L’Institut universitaire en santé mentale de Québec – Deinstitutionalization

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With the development of psychopharmacology in the 1950s came a great wave of deinstitutionalization. The change in the way people thought about mental illness led once again to a new view of the treatments that should be given to those who suffered from it. The human rights movement gave an air of respectability to psychiatric institutions and the aim henceforth was to humanize mental health treatment, first by abandoning confinement in asylums as a means of dealing with mental illness and then by limiting the number and duration of hospital stays. Efforts were made to avoid having patients lose their jobs and their homes. People were only hospitalized if it was absolutely necessary, and people who could do so returned to society.While the true deinstitutionalization movement did not start until about 1960, the early 20th century had its school of thought concerning this issue. Doctor Delphis Brochu, the medical superintendent at Hôpital Saint-Michel-Archange from 1903 to 1923, said that he thought that the mentally ill in hospitals should be prepared for an eventual return to society and accordingly increased the number of discharges of the most lucid patients. With some, he also attempted treatment in their family environment and, if this failed, in families in isolated or very rural areas.1 We can see in this that the first indications of a move towards deinstitutionalization appeared in the early part of the century. (E1)Deinstitutionalization began in 1950 with the implementation of the “open doors” program, which broke up hospital stays with outings such as walks in the park or weekends spent at home. This was also the period when hostels affiliated with the Hôpital Saint-Michel-Archange were recognized; they were mainly used to relieve overcrowding of the health system. However, there was a certain amount of delay in deinstitutionalization in Quebec because this movement required a reorganization of the way mentally ill people are cared for. The emphasis had to shift from the individual patient to his or her family, social and cultural environment.2It was therefore during the 1960s that the real change took place. In 1965, the nuns gave up management of the hospital following the revolution in psychiatry and the beginnings of deinstitutionalization. The hospital became a government-run institution. This was the first phase of deinstitutionalization, instigated in part by the Bédard report. In 1961 the Liberal government formed a commission to study psychiatric hospitals and on March 9, 1962, its report was presented. One of the recommendations in the Bédard report was deinstitutionalization. The report stated: “The Commission is convinced that hundreds of patients continue to live in our mental hospitals when their mental state does not require hospitalization. The Commission concludes its comments with these main recommendations (…):

1. Mentally ill patients must be treated in a location close to their residences to avoid social uprooting;
2. Smaller hospitals (fewer than 500 beds) attached to regional general hospitals providing more adequate services (…);
3. Apart from hospitalization, each psychiatric hospital must provide a range of services: outpatient clinics, day and night centres, emergency teams, etc, with the resulting reduction in number of beds (…).” 3

This first phase had three objectives: regionalization, diversification and a greater number of services in the community.The second phase began about 1975 and, again, mainly changed the way society looked at mental illness. When it was considered in the same light as any other disease, services for the mentally ill began to be integrated into already existing institutions such as general hospitals and medical clinics.The third and final wave of deinstitutionalization started with the 1989 mental health policy. This policy contained five directives for treatment of mental illness:

1. make the individual the prime consideration;
2. enhance the quality of services;
3. distribute resources equitably, based on needs;
4. look for solutions in the patient’s customary environment;
5. form a strong partnership between the individual, public resources and resources in his or her environment.4

Subsequent to the 1989 policy, a system of services in the community (outside of hospitals) was put in place in order to avoid hospitalizations in a psychiatric environment. These community treatment centres were set up in locations that were not set apart from the rest of society. A multidisciplinary team provided services day and night. The specific characteristics of the patients, based on their diagnoses, and the specialization of the employees, who were trained in a particular approach, made these centres locations for treatment that were super specialized in psychiatry.5 Various services were provided at these centres, such as psychiatric day care, a service for centre workers to accompany patients, an emergency intervention service, and home visits.Treatment in the community has changed a great deal since it first appeared. In the 21st century, l’Institut universitaire en santé mentale de Québec (E2) has split up its services into a number of specialized centres in the community. Since the institution reorganized its care and services, these centres are attached to client programs. hypertextlink: http://www.rgiffard.qc.ca/soins_services/soins_psychiatriques/programmes_clienteles.asp The hospital’s guidelines explain that this type of organization consists of a series of interrelated actions taken to arrive at specific objectives, which require human, material, financial and knowledge resources to be achieved, in order to meet the major needs of a particular client group.6 In these client programs, patients are grouped based on the different categories of psychiatric diagnoses. The aims are better needs assessment, greater accessibility of services in the community and better distribution of resources.7 Thus, depending on patients’ diagnoses, they are not hospitalized but treated outside a hospital in a centre that specializes in their type of illness. For example, one of the client programs includes persons with severe personality disorders. These patients receive care at the Faubourg Saint-Jean treatment centre. This client program treats the most severely affected persons in the Quebec City area, who have serious symptoms and require an interdisciplinary approach to improve their mental health. People suffering from emotional problems go to the day hospital to consult the multidisciplinary team and receive treatment. These services are provided to people in a crisis condition who do not present any danger to themselves or others. It is intensive, short-term treatment enabling hospitalization to be avoided. People are most often referred there by the psychiatric emergency department at the Hôpital de l’Enfant-Jésus.8 A number of centres that treat a particular family of diagnoses have been created in the community. We are seeing the results of deinstitutionalization today – greater accessibility of appropriate services for patients to promote better treatment in the community, and the maximum reintegration into society possible. A number of other residential resources in the community of l’Institut universitaire en santé mentale de Québec, such as family resources, have been transferred to the Quebec region’s local community service centre (CLSC). Services and professionals are also following this trend and moving out into the community.

1. Hubert A. Wallot. op.cit., p. 92.
2. Ibid., p. 182.
3. Hubert A. Wallot, op.cit., p. 211.
4. Ibid., p. 391.
5. Ibid., p. 374.
6. l’Institut universitaire en santé mentale de Québec. Guide d’élaboration d’un programme clientèle, mars 2003, p. 10.
7. http://www.institutsmq.qc.ca/index.php?id=25
8. http://www.institutsmq.qc.ca/index.php?id=110