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Deinstitutionalisation of Mental Health Patients in Argentina Not Enough

BUENOS AIRES, Jun 1 2012 (IPS) - A new approach to mental health care is slowly making headway in Argentina, against heavy resistance. Based on short-term hospitalisation, fewer psychiatric hospitals, and more services to strengthen the social integration of patients, it is aimed at eradicating inhumane treatment of the mentally ill.

In the last four years, Argentina ratified the United Nations Convention on the Rights of Persons with Disabilities and passed a law on mental health that is in line with the international convention and protects the rights of people with psychiatric problems.

The new law states that mental health services must be community-based, and promotes interdisciplinary action involving psychiatrists, psychologists, social workers and other professionals. According to the law, admission to institutional health facilities is a last resort.

But implementation of the law is going slowly. “Some practices are being modified in an isolated manner, but there have been no concrete institutional changes yet,” Macarena Sabin, the psychologist who works with the Centre for Legal and Social Studies (CELS), told IPS.

CELS was one of the human rights groups that pushed for passage of the mental health law in 2010. Three years earlier, it had published the report “Vidas arrasadas: La segregación de las personas en los asilos psiquiátricos argentinos” (Ruined Lives: Segregation from Society in Argentina’s Psychiatric Asylums) denouncing the abuse and negligence to which some 25,000 institutionalised mental patients were exposed in this South American country.

The report documented punishment in isolation cells, physical and sexual violence against patients, lack of medical attention, rehabilitation and treatment, unhygienic living conditions, overcrowding, and deaths that were never investigated.

According to the study, 80 percent of people hospitalised in psychiatric wards at the time had been there for over a year, and between 60 and 90 percent of them were “social patients” – in other words, people held in the institutions because they had nowhere else to go.

In its annual report published in May, CELS said the ratification of the convention and the approval of the new law indicated that things had started to change. But the group still pointed to an enormous gap between what is on paper and the reality on the ground.

Grave violations of the human rights of people with mental disorders persist, says the new report, which adds that patients in psychiatric hospitals are still the most vulnerable.

Sabin said that in the eastern province of Buenos Aires, where most of the country’s mental health patients are concentrated, “the application of the new law has been overacted, with an increase in the number of discharges of chronically ill patients.”

She said this is being done to prove that the process of deinstitutionalization of the mentally ill is moving forward. But without intermediate care facilities to attend to their needs, many of the recently discharged patients merely end up being hospitalised again, she added.

“It’s the revolving door phenomenon in psychiatric hospitals,” Sabin said. “The number of occupied beds in the chronic care wing goes down, but there is overcrowding in admissions, where patients are overmedicated to return them to a supposedly normal state.”

This problem is at its worst in the capital.

Socialist city lawmaker Virginia González Gass, chairwoman of the mental health commission in the Buenos Aires legislature, told IPS the situation “is disastrous” and many of the discharged mental health patients end up in homeless shelters.

“There are no halfway houses or ambulatory programmes to help them rebuild ties with their families or rejoin the labour market. The patients, without any support, end up in shelters where they aren’t even visited by a doctor,” she said.

There are three psychiatric hospitals in the capital: for men, women and adolescents. But no institutions have yet been put in place to help patients make the transition from hospitalisation to full integration with the family and the community.

Moreover, services created by patients themselves along with civil society organisations to help forge links between the hospitals and the outside world have been shut down. These included a bakery as well as carpentry and art workshops, Sabin said.

“Many doctors are opposed to the law,” the psychologist said. “They don’t allow patients to exercise their right to a lawyer. Hospital staff who allow legal defenders access to the patients are threatened with penalties.”

Under the new law, the National Public Defenders Office created a mental health unit, made up of 22 professionals, including psychiatrists, psychologists, lawyers and social workers, coordinated by Mariano Laufer, an attorney.

Laufer’s task is to keep patients from being hospitalised against their will. And in cases in which hospitalisation is inevitable, the team works to guarantee that it is brief and that the patients have agreed to the treatment they receive.

“The law is a tool in a slow, gradual process of reform that will take years,” Laufer told IPS. But, he added, “The legislation has radically changed the way the justice system treats these cases.”

In the 10 months since the mental health unit that he leads began to operate, it has helped some 1,700 people, he said. “Seventy percent of them were discharged or their hospitalisation was transformed into voluntary or ambulatory treatment.”

The lawyer said that before the convention was ratified and the new law passed, the approach to the mentally ill was “tutelary and paternalistic…Patients were not the subjects of rights, but objects of state protection or tutelage.”

“People with mental problems were legally stripped of their capacity to exercise their rights, in order to be protected. But what that caused was greater passivity, the annulment of the patient as a person, and their death in terms of civil rights,” he said.

Under the new approach, the patient has full rights, and involuntary hospitalisation, which was commonplace in the past, “is seen as equivalent to the deprivation of liberty” if it does not meet the requisites and guarantees required by law.

A judge must be informed when a patient is involuntarily hospitalised, and the hospitalisation must be brief and must only occur in cases in which there is a risk to the patient or to others, he explained. The judge must also periodically monitor the treatment received by the patient, to make sure it is in line with the law, he added.

In the past, the psychiatric patient remained isolated from the family after hospitalisation, unable to receive visits or phone calls. Many ended up staying in the hospital for months or years, and were subjected to treatment against their will.

But Laufer said the new conception has run up against resistance. Under the new system, “Information and knowledge is democratised, and is no longer in the hands of just one psychiatrist. In addition, our team is multidisciplinary and gets involved with a close understanding of the case in question,” he added.

But he concurred with CELS that “without halfway homes or alternative facilities, the process of deinstitutionalisation is very difficult to carry out. The law is one tool, but public policies are also needed.”

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