Deinstitutionalisation

· Este artículo necesita la atención de un psicólogo / experto académico en el tema. Por favor, ayude a reclutar uno, o mejore esta página usted mismo si está calificado. Este banner aparece en artículos que son débiles y cuyos contenidos deben abordarse con precaución académica.. This article is about the replacement of psychiatric hospitals. For the replacement of orphanages, see Deinstitutionalisation (orphanages and children's institutions).  Deinstitutionalisation (or deinstitutionalization) is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability. Deinstitutionalisation works in two ways: the first focuses on reducing the population size of mental institutions by releasing patients, shortening stays, and reducing both admissions and readmission rates; the second focuses on reforming mental hospitals' institutional processes so as to reduce or eliminate reinforcement of dependency, hopelessness, learned helplessness, and other maladaptive behaviours.[1] According to psychiatrist Leon Eisenberg, deinstitutionalisation has been an overall benefit for most psychiatric patients, though many have been left homeless and without care.[2] The deinstitutionalisation movement was initiated by three factors: A socio-political movement for community mental health services and open hospitals; The advent of psychotropic drugs able to manage psychotic episodes; Un financial imperative to shift costs from state to federal budgets.[2] According to American psychiatrist Loren Mosher, most deinstitutionalization in the USA took place after 1972, as a result of the availability of SSI, long after the antipsychotic drugs were used universally in state hospitals.[3] According to psychiatrist and author Thomas Szasz, deinstitutionalisation is the policy and practice of transferring homeless, involuntarily hospitalised mental patients from state mental hospitals into many different kinds of de facto psychiatric institutions funded largely by the federal government. These federally subsidised institutions began in the United States and were quickly adopted by most Western governments. The plan was set in motion by the Community Mental Health Act as a part of John F. Kennedy's legislation This article or section may be confusing or unclear for some readers, and should be edited to rectify this. Please improve the article, or discuss the issue on the talk page. and passed by the U.S. Congress in 1963, mandating the appointment of a commission to make recommendations for "combating mental illness in the United States".[4] In many cases the deinstitutionalisation of the mentally ill in the Western world from the 1960s onward has translated into policies of "community release". Individuals who previously would have been in mental institutions are no longer continuously supervised by health care workers. Some experts, such as E. Fuller Torrey, have considered deinstitutionalisation to be a failure,[5] while some consider many aspects of institutionalization to have been worse. Contents 1 Orígenes 1.1 19th century 1.2 20th century 2 Consecuencias 2.1 Violencia 2.1.1 Victimisation 2.1.2 Misconceptions 3 Mundial 3.1 Asia 3.1.1 Hong Kong 3.1.2 Japón 3.1.3 Nueva Zelanda 3.2 África 3.3 Europa 3.3.1 Italia 3.3.2 Reino Unido 3.4 América del norte 3.4.1 Estados Unidos 3.4.1.1 Criticisms of public mental hospitals 3.4.1.2 Pharmacotherapy 3.4.1.3 President Kennedy 3.4.1.4 Shift to community-based care 3.4.1.5 Changing public opinion 3.4.1.6 Reducing costs 3.5 South America 4 Ver también 5 Referencias 6 Otras lecturas 6.1 Libros 6.2 Papeles 7 disertaciones 8 Bibliography Origins 19th century The 19th century saw a large expansion in the number and size of asylums in Western industrialised countries. Although initially based on principles of moral treatment, they became overstretched, non-therapeutic, isolated in location, and neglectful of patients.[6] 20th century By the beginning of the 20th century, increasing admissions had resulted in serious overcrowding, causing many problems for psychiatric institutions. Funding was often cut, especially during periods of economic decline and wartime. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, ill-treatment, and abuse of patients; many patients starved to death.[7] The first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s. The movement for deinstitutionalisation moved to the forefront in various countries during the 1950s and 1960s with the advent of chlorpromazine and other antipsychotic drugs. The prevailing public arguments, time of onset, and pace of reforms varied by country.[7] En los Estados Unidos, class action lawsuits and the scrutiny of institutions through disability activism and antipsychiatry helped expose poor conditions and treatment. Sociologists and others argued that such institutions maintained or created dependency, passivity, exclusion, and disability, which caused people to remain institutionalised. Rosenhan's experiment in 1973 "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible."[8] A prevailing argument claimed that community services would be cheaper and that new psychiatric medications made it more feasible to release people into the community.[9] Mental health professionals, public officials, families, advocacy groups, public citizens, and unions held differing views on deinstitutionalisation.[10] A key text in the development of deinstitutionalisation was Asylums by Erving Goffman.[11] Consequences Community services that developed include supportive housing with full or partial supervision and specialised teams (such as assertive community treatment and early intervention teams). Costs have been reported as generally equivalent to inpatient hospitalisation, even lower in some cases (depending on how well or poorly funded the community alternatives are).[7] Although deinstitutionalisation has been positive for the majority of patients, it also has severe shortcomings.[12] Expectations that community care would lead to fuller social integration have not been achieved; many remain without work, have limited social contacts, and often live in sheltered environments.[13] New community services are often uncoordinated and unable to meet complex needs. Services in the community sometimes isolate the mentally ill within a new ghetto, where service users meet each other but have little contact with the rest of the public community. It has been said that instead of "community psychiatry", reforms established a "psychiatric community".[7] Existing patients are often discharged without sufficient preparation or support. A greater proportion of people with mental disorders become homeless or go to prison.[7] Families can often play a crucial role in the care of those who would typically be placed in long-term treatment centres. Sin embargo, many mentally ill people are resistant to such help due to the nature of their conditions. The majority of those who would be under continuous care in long-stay psychiatric hospitals are paranoid and delusional to the point that they refuse help, believing they do not need it, which makes it difficult to treat them.[14] Violence Victimisation Moves to community living and services have led to various concerns and fears, from both the individuals themselves and other members of the community. Over a quarter of individuals accessing community mental health services in a US inner-city area are victims of at least one violent crime in a year, a proportion eleven times higher than the inner-city average. The elevated victim rate holds for every category of crime, including rape/sexual assault, other violent assaults, and personal and property theft. Victimisation rates are similar to those with developmental disabilities.[15][16] Misconceptions Despite perceptions by the public and media that people with mental disorders released into the community are more likely to be dangerous and violent, a large study indicated that they are no more likely to commit violence than others in their neighbourhoods, which were usually economically deprived and high in substance abuse and crime.[17] Findings on violence committed by those with mental disorders in the community have been inconsistent and related to numerous factors; a higher rate of more serious offences such as homicide have sometimes been found but, despite high-profile homicide cases, the evidence suggests this has not been increased by deinstitutionalisation.[18][19][20] The aggression and violence that does occur, in either direction, is usually within family settings rather than between strangers.[21] Worldwide Asia Hong Kong In Hong Kong, a number of residential care services such as half-way houses, long-stay care homes, supported hostels are provided for the discharged patients. Además, community support services such as rehabilitation day services and mental health care have been launched to facilitate the patients' re-integration into the community. Japan In Japan, the number of hospital beds has risen steadily over the last few decades.[7] New Zealand New Zealand established a reconciliation initiative in 2005 to address the ongoing compensation payouts to ex-patients of state-run mental institutions in the 1970s to 1990s. A number of grievances were heard, Incluido: poor reasons for admissions; unsanitary and overcrowded conditions; lack of communication to patients and family members; physical violence and sexual misconduct and abuse; inadequate mechanisms for dealing with complaints; pressures and difficulties for staff, within an authoritarian hierarchy based on containment; fear and humiliation in the misuse of seclusion; over-use and abuse of ECT, psychiatric medications, and other treatments as punishments, including group therapy, with continued adverse effects; lack of support on discharge; interrupted lives and lost potential; and continued stigma, prejudice, and emotional distress and trauma. There were some references to instances of helpful aspects or kindnesses despite the system. Participants were offered counselling to help them deal with their experiences, along with advice on their rights, including access to records and legal redress.[22] Africa Template:Expand section Uganda has one psychiatric hospital.[7] Europe In some countries[specify] where deinstitutionalisation has occurred, "re-institutionalisation", or relocation to different institutions, has begun, as evidenced by increases in the number of supported housing facilities, forensic psychiatric beds, and the growing prison population.[23] Some developing European countries[specify] still rely on asylums. Italy See also: Psychiatric reform in Italy Italy was the first country to begin the deinstitutionalisation of mental health care and to develop a community-based psychiatric system.[24] The Italian system served as a model of effective service and paved the way for deinstitutionalisation of mental patients.[24] En 1978, the Basaglia Law had started Italian psychiatric reform that resulted in the end of the Italian state mental hospital system in 1998.[25] The reform was focused on the gradual dismantlement of psychiatric hospitals, which required an effective community mental health service.[26]:665 The object of community care was to reverse the long-accepted practice of isolating the mentally ill in large institutions and to promote their integration in a socially stimulating environment, while avoiding subjecting them to excessive social pressures.[26]:664 United Kingdom See also: Care in the community Template:Empty section North America United States The United States has experienced two waves of deinstitutionalisation. The first wave began in the 1950s and targeted people with mental illness.[1] The second wave began roughly 15 years later and focused on individuals who had been diagnosed with a developmental disability (p. ej.. retraso mental).[1] Deinstitutionalisation continues today, though the movements are growing smaller as fewer people are sent to institutions. Numerous social forces led to a move for deinstitutionalisation; researchers generally give credit to six main factors: criticisms of public mental hospitals, incorporation of mind-altering drugs in treatment, support from President Kennedy for federal policy changes, shifts to community-based care, changes in public perception, and individual states' desires to reduce costs from mental hospitals.[1] Criticisms of public mental hospitals The public's awareness of conditions in mental institutions began to increase during World War II. Conscientious objectors (COs) of the war were assigned to alternative positions which suffered from manpower shortages.[1] Alrededor 2,000 COs were assigned to work in understaffed mental institutions.[1] En 1946, an exposé in Life magazine detailed the shortfalls of many mental health facilities.[1] This exposé was one of the first featured articles about the quality of mental institutions.[1] Following WWII, articles and exposés about the mental hospital conditions bombarded popular and scholarly magazines and periodicals. The COs from the 1946 Life exposé formed the National Mental Health Foundation, which raised public support and successfully convinced states to increase funding for mental institutions.[1] Five years later, the National Mental Health Foundation merged with the Hygiene and Psychiatric Foundation to form the National Association of Mental Health. During WWII, it was found that 1 fuera de 8 men considered for military service was rejected based on a neurological or psychiatric problem.[1] This increased awareness of the prevalence of mental illnesses, and people began to realize the costs associated with admission to mental institutions (es decir. cost of lost productivity and of mental health services).[1] Since numerous individuals suffering from mental illness had served in the military, many began to believe that more knowledge about mental illness and better services would not only benefit those who served but also national security as a whole.[1] Congress passed the National Mental Health Act of 1946, which created the National Institute of Mental Health (NIMH). NIMH was pivotal in funding research for the developing mental health field.[1] Pharmacotherapy During the 1950s, new drugs became available and were incorporated into treatment for the mentally ill. The new drugs effectively reduced severe symptoms, allowing the mentally ill to live in environments less stringent than institutions, such as half-way houses, Asilos, or their own homes. Drug therapy also allowed many mentally ill to obtain employment.[1] President Kennedy In 1955, the Joint Commission on Mental Health and Health was authorised to investigate problems related to the mentally ill. President John F. Kennedy had a special interest in the issue of mental health because his sister, Rosemary, had been lobotomised at the age of 23 at the request of her father.[1] Shortly after his inauguration, Kennedy appointed a special President's Panel of Mental Retardation.[1] The panel included professionals and leaders of the organization. En 1962, the panel published a report with 112 recommendations to better serve the mentally ill.[1] In conjunction with the Joint Commission on Mental Health and Health, the Presidential Panel of Mental Retardation, and Kennedy's influence, two important pieces of legislation were passed in 1963: the Maternal and Child Health and Mental Retardation Planning Amendments, which increased funding for research on the prevention of retardation, and the Mental Retardation Facilities and Community Mental Health Centers Construction Act, which provided funding for community facilities that served people with mental disabilities.[1] Both acts furthered the process of deinstitutionalisation. Shift to community-based care In general, professionals, civil rights leaders, and humanitarians saw the shift from institutional confinement to local care as the appropriate approach.[1] The deinstitutionalisation movement started off slowly but gained momentum as it adopted philosophies from the Civil Rights Movement.[1] During the 1960s, deinstitutionalisation increased dramatically, and the average length of stay within mental institutions decreased by more than half.[1] Many patients began to be placed in community care facilities instead of long-term care institutions.[1] Changing public opinion While public opinion of the mentally ill has improved somewhat, it is still often stigmatised. Advocacy movements in support of mental health have emerged.[1] These movements focus on reducing stigma and discrimination and increasing support groups and awareness. The consumer or ex-patient movement, began as protests in the 1970s, forming groups such as Liberation of Mental Patients, Project Release, Insane Liberation Front, and the National Alliance on Mental Illness (NAMI).[1] Many of the participants consisted of ex-patients of mental institutions who felt the need to challenge the system's treatment of the mentally ill.[1] Inicialmente, this movement targeted issues surrounding involuntary commitment, use of electroconvulsive therapy, anti-psychotic medication, and coercive psychiatry.[1] Many of these advocacy groups were successful in the judiciary system. En 1975, the United States Court of Appeals for the First Circuit ruled in favour of the Mental Patient's Liberation Front of Rogers v. Okin,[1] establishing the right of a patient to refuse treatment. A 1975 award-winning film, One Flew Over the Cuckoo's Nest, sent a message regarding the rights of those committed involuntarily. Ese mismo año, estados unidos. Supreme Court restricted the rights of states to incarcerate someone who was not violent. This was followed up with a 1978 ruling further restricting states from confining anyone involuntarily for mental illness. NAMI successfully lobbied to improve mental health services and gain equality of insurance coverage for mental illnesses.[1] En 1996, the Mental Health Parity Act was enacted into law, realizing the mental health movement's goal of equal insurance coverage. In 1955 for every 100,000 US citizens there was 340 psychiatric hospital beds. En 2005 that number had diminished to 17 per 100,000. Reducing costs As hospitalisation costs increased, both the federal and state governments were motivated to find less expensive alternatives to hospitalisation.[1] los 1965 amendments to Social Security shifted about 50% of the mental health care costs from states to the federal government,[1] motivating the government This article or section may be confusing or unclear for some readers, and should be edited to rectify this. Please improve the article, or discuss the issue on the talk page. to promote deinstitutionalisation. The increase in homelessness was seen as related to deinstitutionalisation.[27][28][29] Studies from the late 1980s indicated that one-third to one-half of homeless people had severe psychiatric disorders, often co-occurring with substance abuse.[30][31] A process of indirect cost-shifting may have led to a form of "re-institutionalisation" through the increased use of jail detention for those with mental disorders deemed unmanageable and noncompliant.[32][33] When laws were enacted requiring communities to take more responsibility for mental health care, necessary funding was often absent, and jail became the default option,[34] being cheaper than psychiatric care.[32] In summer 2009, author and columnist Heather Mac Donald stated in City Journal, "jails have become society's primary mental institutions, though few have the funding or expertise to carry out that role properly... at Rikers, 28 percent of the inmates require mental health services, a number that rises each year."[35] South America Template:Expand section In several South American countries,[specify] the total number of beds in asylum-type institutions has decreased, replaced by psychiatric inpatient units in general hospitals and other local settings.[7] See also Community mental health Community mental health services Deinstitutionalisation (orphanages and children's institutions) Discharge planning Habilitation Homelessness Homeless mentally ill Institutional release Institutional syndrome Involuntary commitment Mainstreaming Obligatory Dangerousness Criterion Outpatient commitment Partial hospitalization Rehabilitation Right to treatment References ↑ Jump up to: 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 Stroman, Duane (2003). The Disability Rights Movement: From Deinstitutionalization to Self-determination, University Press of America. ↑ Jump up to: 2.0 2.1 [[Leon Eisenberg|]] (Agosto 2010). Were we all asleep at the switch? A personal reminiscence of psychiatry from 1940 Para 2010. Acta Psychiatrica Scandinavica 122 (2): 89–102. ↑ Mosher, Loren (1999). Letter Mosher to Goodwin. Psychology Today 32 (5): 8. ↑ Szasz, Tomás (2007). La coerción como cura: a critical history of psychiatry, 34, Publicadores de transacciones. ↑ Torrey, E. Fuller (2010 Verano). Documenting the failure of deinstitutionalization.. Psiquiatría 73 (2): 122–4. ↑ Wright D (Abril 1997). Getting out of the asylum: understanding the confinement of the insane in the nineteenth century. Social History of Medicine 10 (1): 137–55. ↑ Jump up to: 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 (Agosto 2007). Deinstitutionalization and reinstitutionalization: major changes in the provision of mental healthcare. Psiquiatría 6 (8): 313–316. ↑ Kornblum, William (2011). Sociology in a Changing World, 9el, Cengage learning. ↑ Rochefort, D.A. (Primavera 1984). Origins of the "Third psychiatric revolution": the Community Mental Health Centers Act of 1963. Journal of Health Politics, Policy and Law 9 (1): 1–30. ↑ (Septiembre 1979). Deinstitutionalization in the absence of consensus. Hosp Community Psychiatry 30 (9): 599–604. ↑ Mac Suibhne, Séamus (7 Octubre 2009). Asylums: Essays on the Social Situation of Mental Patients and other Inmates. Revista Médica Británica 339: b4109. ↑ Torrey, E. Fuller (1997). Deinstitutionalization: A Psychiatric "Titanic". Out of the Shadows: Confronting America's Mental Illness Crisis. Juan Wiley & Hijos. URL a la que se accede en 21 Octubre 2011. excerpted by Frontline (pbs.org). ↑ Fuller, Torrey.E Deinstitutionalization: A Psychiatric "Titanic". ↑ Torrey, E. Fuller (2008). The insanity offense: how America's failure to treat the seriously mentally ill endangers its citizens, 1c, Nueva York: W. W.. Norton. ↑ (Agosto 2005). Crime Victimization in Adults With Severe Mental Illness: Comparison With the National Crime Victimization Survey. Archivos de Psiquiatría General 62 (8): 911–21. ↑ Petersilia, Joan R (2001). Crime Victims With Developmental Disabilities: A Review Essay. Criminal Justice and Behavior 28 (6): 655–94. ↑ (Mayo 1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archive of General Psychiatry 55 (5): 393–401. ↑ Sirotich, F. (2008). Correlates of Crime and Violence among Persons with Mental Disorder: An Evidence-Based Review. Brief Treatment and Crisis Intervention 8 (2): 171–94. ↑ Estuardo, H. (Junio 2003). Violence and mental illness: una visión general. World Psychiatry 2 (2): 121–4. ↑ (Enero 1999). Homicides by people with mental illness: Myth and reality. Br J Psychiatry 174 (1): 9–14. ↑ (Enero 2005). Family violence among adults with severe mental illness: a neglected area of research. Trauma, Violencia, & Abuse 6 (1): 40–54. ↑ Report of the Confidential Forum for Former In-Patients of Psychiatric Hospitals. Department of Internal Affairs, New Zealand Government. ↑ (Enero 2005). Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. Revista Médica Británica 330 (7483): 123–6. ↑ Jump up to: 24.0 24.1 (Abril 2009). Dismantling asylums: The Italian Job. London Journal of Primary Care. ↑ Burti L. (2001). Italian psychiatric reform 20 plus years after. Acta psychiatrica Scandinavica. Supplementum 104 (410): 41–46. ↑ Jump up to: 26.0 26.1 Tansella, M. (Noviembre 1986). Community psychiatry without mental hospitals – the Italian experience: una reseña. Revista de la Royal Society of Medicine 79 (11): 664–669. ↑ Scanlon, John (2 Octubre 1989). Homelessness: Describing the Symptoms, Prescribing a Cure. Backgrounder. 729. ↑ includeonly>Frotar, Lillian B.. "Sand Castles and Snake Pits: Homelessness, Política pública, and the Law of Unintended Consequences", Otoño 2007. ↑ includeonly>Friedman, Michael B.. "Keeping The Promise of Community Mental Health", 8 Agosto 2003.[enlace muerto] ↑ (Mayo 2003). Challenges for psychiatry in serving homeless people with psychiatric disorders. Psychiatric Services 54 (5): 669–76. ↑ Feldman, S. (Junio 1983). Out of the hospital, onto the streets: the overselling of benevolence. Hastings Center Report 13 (3): 5–7. ↑ Jump up to: 32.0 32.1 Torrey, E. Fuller (1992). Criminalizing the Seriously Mentally Ill: The Abuse of Jails as Mental Hospitals. URL a la que se accede 12 Noviembre 2010. ↑ (Octubre 2004). Cost Shifting to Jails after a Change to Managed Mental Health Care. Health Serv Res 39 (5): 1379–401. ↑ includeonly>Roche, Timothy. "The Chief and His Ward", 10 Julio 2000. Recuperado el 12 Noviembre 2010. ↑ includeonly>Mac Donald, Heather. "The Jail Inferno", 'City Journal'. Recuperado el 27 Julio 2009. Further reading Books Ager, Un., Emerson, E., Mansell, J., Beasley, F., McConkey, R., Lewis, D. R., et al. (1990). Community integration, adjustment, evaluation and costs. Florencia, KY: Taylor & Frances/Routledge. E. Fuller Torrey(1997)Out of the Shadows: Confronting America's Mental Illness Crisis New York: Juan Wiley & Hijos, . Papers Evidence to the House of Commons Social Services Committee on community care, with special reference to the adult mentally ill and mentally handicapped. (1984).): Bulletin of the British Psychological Society Vol 37 Nov 1984, 378-380. Agostinelli, N. (1980). Mental health services in the Rome Italy metropolitan area: Lavoro Neuropsichiatrico Vol 67(3) Nov-Dic 1980, 339-358. Albee, G. W. (1977). Review of The new volunteerism: A community connection: PsycCRITIQUES Vol 22 (7), Jul, 1977. Albee, G. W. (1997). The Radicals Made Us Do It! Or Is Mental Health a Socialist Plot? : PsycCRITIQUES Vol 42 (10), Oct, 1997. Alisky, J. M., & Iczkowski, K. Un. (1990). Barriers to housing for deinstitutionalized psychiatric patients: Hospital & Psiquiatría Comunitaria Vol 41(1) Ene 1990, 93-95. Allen, D. (1989). The effects of deinstitutionalisation on people with mental handicaps: Una reseña: Mental Handicap Research Vol 2(1) Ene 1989, 18-37. Altman, R. (1992). Diary of a Normalization Experiment: PsycCRITIQUES Vol 37 (11), Nov, 1992. Altschuler, D. M., & Brash, R. (2004). Adolescent and Teenage Offenders Confronting the Challenges and Opportunities of Reentry: Violencia Juvenil y Justicia Juvenil Vol. 2(1) Ene 2004, 72-87. Amaro Gonzalez, G. (1987). Deinstitutionalization, the sheltered rehabilitation center with boarding facilities and a family doctor: Revista del Hospital Psiquiatrico de La Habana Vol 28(3) Navidad-septiembre 1987, 455-465. Anderson, E. Un., & Lynch, M. M. (1984). 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Aubry, T., & Myner, J. (1996). Community integration and quality of life: A comparison of persons with psychiatric disabilities in housing programs and community residents who are neighbours: Canadian Journal of Community Mental Health Vol 15(1) Spr 1996, 5-20. Avgoustidis, Un. G. (2001). Cooperation of psychiatry and the church as a deinstitutionalization project: International Journal of Mental Health Vol 30(4) Victoria 2001-2002, 42-48. Axelsen, E., & Ronbeck, K. (1981). "From living in herd to living in group." Alternatives to hospitalization of young longterm patients: Revista de la Asociación Noruega de Psicología Vol. 18(5) Mayo 1981, 249-256. Bachrach, L. L. (1983). New directions in deinstitutionalization planning: New Directions for Mental Health Services No 17 Estropear 1983, 93-106. Bachrach, L. L. (1983). An overview of deinstitutionalization: New Directions for Mental Health Services No 17 Estropear 1983, 5-14. Bachrach, L. L. (1984). 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