Mojca Urek, Juš Škraban

Roberto Mezzina

Long term institutions have been for many years considered as relics of the past, but they still absorb the majority of economic resources of mental healthcare and are vehemently resisting to change. Most reforms in Europe are now trying to develop community services, which are integrated within welfare systems and social networks, but they are loosely coupled with a radical institutional transformation. Deinstitutionalization is mentioned in many international charters and documents, as the WHO Report and the UN Committee for Convention on the Rights of Persons with Disabilities. While there is a substantial agreement on the basic definition as far as it is referred to patients (e.g., the release from the institution), nonetheless the process is widely misunderstood. It regards not just the downsizing, and final closure of total institutions, or the discharge of their patients, but a whole system change and moreover a full transformation of psychiatry towards community mental health. Deinstitutionalization must be seen as the main strategy to overturn old forms of oppression of people with mental health conditions and disabilities and to mobilize resources and supports for their recovery and social integration. Community-based services can promote the response to needs and the fulfillment of citizenship rights by catalyzing resources and opportunities. The Italian experience, and especially the one in Trieste, is a demonstration that this is possible, by acting in a way that fosters subjectivity, empowerment, recovery and social inclusion, while embracing a human rights approach (e.g. principles of open door, no restraint). To complete deinstitutionalization of mental healthcare, we thus need the convergence of human rights, person-centered and recovery approaches with comprehensive, strong, and responsive community-centric services.

Juš Škraban

This article draws on a three-year action research project to transform a secure unit in a special social care institution into community-based services. The article presents the findings of the research, which relate to key aspects of the procedures for admission and discharge from the secure unit. Degradation ceremonies and the almost unchallengeable authority of expert opinion play the key role in the admission process. A relatively low number of discharges is due to factors related to the concept of dangerousness, notion of responsibility, embeddedness of secure unit in the social care system and staff mindset. The author suggests that, in practise, admission to a secure unit can be understood as providing access to care, but that this is (wrongly) conditioned with placement of user. Social work methods provide good grounds for changing the current situation in accordance with human rights and for more productive risk management outside the institution.

Joanna Fox, Shulamit Ramon, Raf Hamaizia

Although UK Mental Health services have been de-institutionalised since the end of the 20th century, women with (borderline) personality disorder are often admitted compulsorily to closed psychiatric wards due to high level of self-harm. The paper focuses on the evaluation of introducing innovative intervention methods, alongside dialectical behaviour therapy, in the Daffodil ward which promoted the agency and self-responsibility of service users in managing their mental health. The evaluation reported in the article includes individualised photovoice followed by interviews of the inpatients, and in parallel receiving providers’ reports about every three months. The photovoice method enabled service users to take photos representing their experiences on the ward; this provided a basis for interview content. The new interventions promoted the recovery and empowerment of service users and utilised the transformative role of peer support and experts by experience in improving ward culture. The interim findings highlight how the impact of an effective culture of experts by experience involvement and the introduction of a new service model can provide a context for deinstitutionalisation from within an institution, providing a template for future hospital service delivery.

Vito Flaker

Users’ involvement and inclusion are the main purposes in the transformation of the residential institutions and its main vehicle. However, it is on the account of other undertakings of the organisation, mostly left aside in the process. Inclusion is the negation of the exclusion, which by total institutions homogenise the society and craft devalued, deviant roles. Inclusion can vary in intensity from mere presence and participation to attachment and identification, affiliation to a group and takes place on personal, organisational and community levels. Assemblies (therapeutic communities) are among the most prominent ways of how to enable involvement of users in the process of transformation. However, they need to, in order to achieve their mission – self-governance and personal affirmation of participants – be open, democratic and really decide on truly important issues, otherwise they remain mere ceremonies, or worse, instrument of control, discipline and manipulation. This way of decision making and participation must persist also after the resettlement and dispersion of residents and include the community and thus contribute to it. Inclusion of users into the community represents also adding the necessary collective, communal dimension to the otherwise individualised care and enables the community to become an agent of care (and not just adverbial clause of place). The role of the professionals is to facilitate such processes while providing support to users to do so. At the same time, the previously excluded by inclusion make the community more real. Four faces of inclusion can be decoded: self-management of care, support in inclusion, renewing and strengthening the networks and community action. These must be considered and enacted simultaneously, since alone they do not suffice as they complement and strengthen each other.

Katarina Mauch

One of the key issues of deinstitutionalization is often where people will live in the community after resettling from institutions. In the past, in Slovenia, residential group homes have been established as one of the most common (organised) forms of resettlement from institutions. Although initially intended solely as a transitional form or an intermediate step between life in an institution and independent living in the community, experts and users point out that residential groups are not the most suitable way to create living in the community for people returning from institutions, as they often reproduce institutional culture. This raises the question of what types of places are more appropriate and how to create them. The article presents the users’ perspective of residents on an institution, who were involved in the “Dom na Krasu” project and were part of the deinstitutionalization process, and on decision-making regarding the relocation to the community in various ways. Although these individuals were expected to play a key role in the deinstitutionalization process, relocations in the project often occurred without their real participation and without opportunities to decide where, with whom, and how they would live. The article emphasizes that inclusive and suitable spaces for people resettling from institutions are only those that are created together with the users.

Bojan Šošić, Esmina Avdibegović, Nejra Tinjić, Vahid Djulović

Following the end of the war in Bosnia and Herzegovina (1992–1995), the process of reforming mental health services began, focusing on the development of community mental health centers as the backbone of deinstitutionalized care for individuals with mental health issues. During this period, several user associations were established with the aim of amplifying the voice of service users in shaping the conditions for their improved status and full participation in society. The aim of this paper was to analyse challenges and perspectives in the development of the user-led organizations and user-led initiatives in Bosnia and Herzegovina as a post-conflict and transitional community. The authors of this paper attempted to answer exactly how and to what extent post-conflict and transitional circumstances provide an opportunity for the development of the user-led initiatives. In searching for the answer, the case study method of a user-led organization with a twenty-five years experience was used. The findings show that in using opportunities and coping with challenges the key lies in the independence, mutual assistance skills, democratic management of the organization, involvement of all the users in the development and implementation of initiatives, openness to cooperation, inclusion in the social network and willingness to learn and share knowledge.

Jošt Cafuta Maček

The article is based on a study practice carried out by students of the Faculty of Social Work, University of Ljubljana, in the 2015/16 academic year at three camps in Serbia, in three different institutions for people with mental health issues. It shows the connection between the democratic principles of deinstitutionalization and the need to introduce them into the higher education system. The emphasis is on a specific form of teaching and creating knowledge about, and for deinstitutionalization, at deinstitutionalization camps. Special attention is paid to the impact of camps on the process of deinstitutionalization and to camps as a method of teaching social work. It shows how insights into the democratization of relationships and knowledge creation in the community can also be used in the development of social work education.

Nataša Novak

The article describes the personal circumstances of the user and the events surrounding the resolution of housing issues within the community. It describes how and why the coordinator took on more and more responsibilities, as no other assistants were available, while still respecting the integrity and independence of the user, who played an important role in deciding on the renovation process and raising funds. As a result of their cooperation and individual planning, the user managed to save enough money in three years to renovate the water and electrical systems, windows, and chimney, thanks to applications for tenders, donations, and government subsidies for epidemiological measures.

Tone Vrhovnik Straka

Suzana Oreški

Andraž Rožman