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Abstract
This essay examines the concept and limitations of deinstitutionalization as a principle and practice derived from Western paradigms, and how it has been problematically implemented in non-Western settings, including the Israeli-occupied West Bank. It begins by reviewing the international literature on deinstitutionalization of people with mental health illnesses/disabilities. It then examines the Palestinian experience with deinstitutionalization in the West Bank with an eye to its many limitations, in order to propose alternatives to successfully relocate people with mental health disabilities from hospitals to their communities, and to ensure for them a dignified life. The essay ends with an emphasis on this need in the Israeli-occupied Palestinian territories given the ongoing daily reality of Israeli military occupation and apartheid, which have had dire effects on Palestinians’ mental health.
Acknowledgments
I would like to thank Dr. Samah Jabr, director of the mental health program at the Palestinian Ministry of Health in the West Bank, for reading and commenting on this essay, and for providing valuable insights. I would also like to express gratitude to Dina Kiwan, the principal investigator at the University of Birmingham’s Deinstitutionalisation Under Siege and the network for their support. Time to write this essay was made possible with the financial support of Deinstitutionalisation Under Siege: A network for deinstitutionalisation of persons with disabilities in the Middle East, which is funded by the Arts and Humanities Research Council in the UK (AH/X009467/1), Grant Ref: AH/X009467/1.
Notes
1 Andrew Scull, “‘Community Care’: A Historical Perspective on Deinstitutionalization,” Perspectives in Biology and Medicine 64, no. 1 (2021): 70–81, https://doi.org/10.1353/pbm.2021.0006.
2 This essay does not differentiate between the terms “illness” and “disability,” because its focus is on institutionalization and deinstitutionalization as they relate to mental illnesses, which produce disabilities and require long-term care.
3 Gerald N. Grob, “Mad, Homeless, and Unwanted: A History of the Care of the Chronic Mentally Ill in America,” Psychiatric Clinics of North America 17, no. 3 (September 1994): 541–58, https://doi.org/10.1016/S0193-953X(18)30099-6; Griet Roets et al., “A Critical Exploration of Institutional Logics of De-institutionalisation in the Field of Disability Policy and Practice: Towards a Socio-spatial Professional Orientation,” Social Work and Society 20, no. 1 (2022): 1–17, https://ejournals.bib.uni-wuppertal.de/index.php/sws/article/view/767.
4 Roets et al., “A Critical Exploration of Institutional Logics”; Jim Mansell and Kent Ericsson, eds., Deinstitutionalization and Community Living: Intellectual Disability Services in Britain, Scandinavia and the USA (New York: Springer, 2013), 2.
5 Mansell and Ericsson, Deinstitutionalization and Community Living.
6 Roets et al., “A Critical Exploration of Institutional Logics.”
7 Anindya Das, “The Context of Formulation of India’s Mental Health Program: Implications for Global Mental Health,” Asian Journal of Psychiatry 7 (February 2014): 10–14, https://doi.org/10.1016/j.ajp.2013.09.007.
8 Daniel Yohanna, “Deinstitutionalization of People with Mental Illness: Causes and Consequences,” AMA Journal of Ethics 15, no. 10 (2013): 886–91, https://doi.org/10.1001/virtualmentor.2013.15.10.mhst1-1310.
9 Tatiana T. Salisbury, Helen Killaspy, and Michael King, “An International Comparison of the Deinstitutionalisation of Mental Health Care: Development and Findings of the Mental Health Services Deinstitutionalisation Measure (MENDit),” BMC Psychiatry 16 (December 2016): 1–10, https://psycnet.apa.org/doi/10.1186/s12888-016-0762-4.
10 Yohanna, “Deinstitutionalization of People with Mental Illness.”
11 Scull, “‘Community Care.’”
12 Katherine Teghtsoonian, “Depression and Mental Health in Neoliberal Times: A Critical Analysis of Policy and Discourse,” Social Science & Medicine 69, no. 1 (July 2009): 28–35, https://doi.org/10.1016/j.socscimed.2009.03.037.
13 Das, “The Context of Formulation of India’s Mental Health Program.”
14 Jim Mansell, “Deinstitutionalisation and Community Living: Progress, Problems and Priorities,” Journal of Intellectual & Developmental Disability 31, no. 2 (2006): 65–72, https://doi.org/10.1080/13668250600686726.
15 Roets et al., “A Critical Exploration of Institutional Logics.”
16 Shelley Tremain, “Foucault, Governmentality, and Critical Disability Theory Today: A Genealogy of the Archive,” in Foucault and the Government of Disability, ed. Shelley Tremain (Ann Arbor: University of Michigan Press; 2005), 1–24.
17 Gerald N. Grob, “The Paradox of Deinstitutionalization,” Society 32 (July 1995): 52–59, https://doi.org/10.1007/BF02693338.
18 Caraíosa Kelly, Roy McConkey, and Sarah Craig, “A Case‐Study of Policy Change in Residential Service Provision for Adult Persons with Intellectual Disability in Ireland,” Health and Social Care in the Community 27, no. 5 (September 2019): e760–e768, https://doi.org/10.1111/hsc.12803.
19 Das, “The Context of Formulation of India’s Mental Health Program.”
20 Inge Petersen et al., “Planning for District Mental Health Services in South Africa: A Situational Analysis of a Rural District Site,” Health Policy and Planning 24, no. 2 (March 2009): 140–50, https://doi.org/10.1093/heapol/czn049.
21 Rafael H. Candiago et al., “Shortage and Underutilization of Psychiatric Beds in Southern Brazil: Independent Data of Brazilian Mental Health Reform,” Social Psychiatry and Psychiatric Epidemiology 46 (2011): 425–29, https://doi.org/10.1007/s00127-010-0207-1.
22 Akmal A. Aliev and Tatiana T. Salisbury, “Recommendations for Mental Health Reforms in Uzbekistan: A Policy Report,” Central Asian Journal of Global Health 9, no. 1 (2020): e513, https://doi.org/10.5195/cajgh.2020.513.
23 World Health Organization (WHO), Mental Health Gap Action Program: Scaling Up Care for Mental, Neurological and Substance Use Disorders, 2008, https://apps.who.int/iris/bitstream/handle/10665/43809/9789241596206_eng.pdf.
24 Aliev and Salisbury, “Recommendations for Mental Health Reforms in Uzbekistan.”
25 While such Western-led deinstitutionalization programs were designed for implementation in the West Bank and Gaza Strip, this essay focuses on events taking place in the West Bank. Further research is needed to investigate events taking place in the Gaza Strip.
26 WHO, Mental Health Gap Action Program.
27 John A. Talbott, “Deinstitutionalization: Avoiding the Disasters of the Past,” Psychiatric Services 55, no. 10 (October 2004): 1112–15, https://doi.org/10.1176/appi.ps.55.10.1112.
28 Grob, “Mad, Homeless, and Unwanted.”
29 J. Aa. Nøttestad and O. M. Linaker, “Psychiatric Health Needs and Services before and after Complete Deinstitutionalization of People with Intellectual Disability,” Journal of Intellectual Disability Research 43, no. 6 (December 1999): 523–30, https://doi.org/10.1046/j.1365-2788.1999.00236.x.
30 Dixon Chibanda, “Programmes that Bring Mental Health Services to Primary Care Populations in the International Setting,” International Review of Psychiatry 30, no. 6 (2018): 170–81, https://doi.org/10.1080/09540261.2018.1564648.
31 Julian Leff, “Why is Care in the Community Perceived as a Failure?,” The British Journal of Psychiatry 179, no. 5 (November 2001): 381–83, https://doi.org/10.1192/bjp.179.5.381.
32 Yohanna, “Deinstitutionalization of People with Mental Illness”; Lisa Davis et al., “Deinstitutionalization? Where Have All the People Gone?,” Current Psychiatry Reports 14, no. 3 (June 2012): 259–69, https://doi.org/10.1007/s11920-012-0271-1; Joav Merrick, Peter Uldall, and Jakob Volther, “Intellectual and Developmental Disabilities: Denmark, Normalization, and De-institutionalization,” Frontiers in Public Health 2 (2014): 1–3, https://doi.org/10.3389/fpubh.2014.00161.
33 Scull, “‘Community Care.’”
34 Yohanna, “Deinstitutionalization of People with Mental Illness.”
35 WHO and Gulbenkian Global Mental Health Platform, Innovation in Deinstitutionalization: A WHO Expert Survey, 2014, https://apps.who.int/iris/bitstream/handle/10665/112829/9789241506816_eng.pdf.
36 Mansell and Ericsson, Deinstitutionalization and Community Living.
37 Dale Gavlak, “Learning to Heal Minds in the Eastern Mediterranean,” Bulletin of the World Health Organization 94, no. 10 (2016): 714–15, https://doi.org/10.2471/BLT.16.021016.
38 Das, “The Context of Formulation of India’s Mental Health Program”; Kelly, McConkey, and Craig, “A Case‐Study of Policy Change”; WHO and Gulbenkian, Innovation in Deinstitutionalization.
39 Gordon Chit-Nga Shen, Global Mental Health Policy Diffusion, Institutionalization, and Innovation (Berkeley: University of California, 2013).
40 Ann Hamden et al., “Is Deinstitutionalization Working in Our Community?,” International Journal of Mental Health Nursing 20, no. 4 (August 2011): 274–83, https://doi.org/10.1111/j.1447-0349.2010.00726.x.
41 Chibanda, “Programmes that Bring Mental Health”; WHO and Gulbenkian, Innovation in Deinstitutionalization; Julian Leff, “Why Is Care in the Community Perceived as a Failure?,” British Journal of Psychiatry 179, no. 5 (2001): 381–83, https://doi.org/10.1192/bjp.179.5.381.
42 Das, “The Context of Formulation of India’s Mental Health Program”; Petersen et al., “Planning for District Mental Health Services in South Africa.”
43 Alexander Gralnick, “Build a Better State Hospital: Deinstitutionalization Has Failed,” Hospital & Community Psychiatric 36, no. 7 (July 1985): 738–41, https://doi.org/10.1176/ps.36.7.738.
44 Harvey Gordon and Ibrahim Murad, “Psychiatry and the Palestinian Population,” Israel Journal of Psychiatric 42, no. 2 (2005): 73–80, https://cdn.doctorsonly.co.il/2005/03/2005_2_3.pdf.
45 Richard Keller, “Madness and Colonization: Psychiatry in the British and French Empires, 1800–1962,” Journal of Social History 35, no. 2 (2001): 295–326, https://www.jstor.org/stable/3790190.
46 Ibrahim Murad and Harvey Gordon, “Psychiatry and the Palestinian Population,” Psychiatric Bulletin 26, no. 1 (2002): 28–30, https://doi.org/10.1192/pb.26.1.28.
47 Rita Giacaman et al., “Mental Health, Social Distress and Political Oppression: The Case of the Occupied Palestinian Territory,” Global Public Health 6, no. 5 (2011): 547–59, https://doi.org/10.1080/17441692.2010.528443.
48 “Bedlam,” Britannica, last modified September 13, 2013, https://www.britannica.com/topic/Bedlam.
49 “Bedlam,” Britannica.
50 Eugene L. Rogan and Avi Shlaim, eds., The War for Palestine: Rewriting the History of 1948, vol. 15 (Cambridge: Cambridge University Press, 2001).
51 Giacaman et al., “Mental Health, Social Distress and Political Oppression.”
52 Yaacov Lerner, “Mental Health Services in the Changing Israeli Society,” Palestine-Israel Journal of Politics, Economics and Culture 10, no. 4 (2003): https://pij.org/articles/60/mental-health-services-in-the-changing-israeli-society.
53 Giacaman et al., “Mental Health, Social Distress and Political Oppression.”
54 World Health Organization (WHO), Community Mental Health Development in the Occupied Palestinian Territory: A Work in Progress with WHO, September 30, 2006, https://reliefweb.int/report/occupied-palestinian-territory/community-mental-health-development-occupied-palestinian, 7.
55 Palestinian National Authority Ministry of Health, WHO-AIMS Report on the Mental Health Systems in the West Bank and Gaza (Geneva: WHO, 2006), https://extranet.who.int/mindbank/item/5904.
56 Bassam Al-Ashhab, “An Update on Mental Health Services in the West Bank,” Israel Journal of Psychiatry 42, no. 2 (2005): 81–83, https://cdn.doctorsonly.co.il/2005/03/2005_2_4.pdf.
57 Mohammad Marie, Ben Hannigan, and Aled Jones, “Mental Health Needs and Services in the West Bank, Palestine,” International Journal of Mental Health Systems 10 (2016): 1–8, https://doi.org/10.1186/s13033-016-0056-8.
58 Marie, Hannigan, and Jones, “Mental Health Needs.”
59 Samah Jabr et al., “Mental Health in Palestine: Country Report,” Arab Journal of Psychiatry 24, no. 2 (2013): 174–78, https://doi.org/10.12816/0001376.
60 Marie, Hannigan, and Jones, “Mental Health Needs.”
61 Information obtained from Dr. Samah Jabr, director of the mental health unit of the Palestinian Ministry of Health.
62 UN, “Palestinian Ministry of Health Launches 5-year Mental Health Strategy with EU and WHO Support,” news release, June 15, 2015, https://www.un.org/unispal/document/auto-insert-198619/.
63 Ola Aker, National Health Strategy 2017–2022 (Ramallah: Palestinian Ministry of Health, October 2016), https://andp.unescwa.org/sites/default/files/2020-10/National%20Health%20Strategy%202017-2022.pdf.
64 “Institutions that Care for the Affairs of the Elderly” [in Arabic], Wafa News Agency, accessed April 10, 2023, https://info.wafa.ps/ar_page.aspx?id=3204.
65 A list of these institutions was provided by the Center for Lebanese Studies, which documented institutions supporting people with mental illness in Lebanon, Jordan, and the occupied Palestinian territories.
66 “Justice for Some by Noura Erakat,” Arab Center Washington DC, May 14, 2019, https://arabcenterdc.org/resource/book-review-justice-for-some-by-noura-erakat/.
67 Awad Mataria et al., “The Health-Care System: An Assessment and Reform Agenda,” The Lancet 373, no. 9670 (April 4, 2009): 1207–17, https://doi.org/10.1016/S0140-6736(09)60111-2.
68 “Bedlam,” Britannica.
69 Elena Portacolone et al., “A Tale of Two Cities: The Exploration of the Trieste Public Psychiatry Model in San Francisco,” Culture, Medicine, and Psychiatry 39 (2015): 680–97, https://doi.org/10.1007/s11013-015-9458-3.
Additional information
Notes on contributors
Rita Giacaman
Rita Giacaman is professor of public health at the Institute of Community and Public Health, which she founded in 1978 at Birzeit University, in the Israeli-occupied West Bank. As a researcher and practitioner, Giacaman played an important role in the development of the Palestinian primary healthcare model, in the establishment of the first women’s health program, and in building the Palestinian community-based disability rehabilitation network. Her ongoing work entails the development of measures to assess context-appropriate psychosocial health programs to generate capacity to endure and resist ongoing war-like conditions, especially among youth.