Alternatives to Hospitals
The reduction in the number of hospital beds, since the 1950s, has provided the opportunity for the development of a number of alternatives to the hospital for acute psychiatric treatment. Small, non-coercive, open-door, domestic settings providing essentially the same services as a psychiatric hospital unit have been operating for decades in many places around the world including Boulder, Colorado; Vancouver, British Columbia; Trieste, Italy; and cities in the Netherlands. These alternative settings are in the same tradition as the York Retreat – small, normalizing facilities that are open-door and genuinely in the community, allowing the user to stay in touch with his or her friends, relatives, work and social life. They are more flexible and non-coercive than hospitals and often based more on peer relationships than on hierarchical power structures. They can offer opportunities to residents to be involved in the operation of the treatment environment. If costs can be kept lower than hospital care, the pace of treatment in the alternative setting need not be as rapid and it becomes more possible to offer a more quiet form of genuine asylum.
The recent growth in the use of alternative settings of this type in Britain is an important trend which has been made possible by the closure of psychiatric hospitals and encouraged by the precepts of the Recovery Movement. The Recovery Model has emphasized the importance of patient empowerment and interpersonal support, and in line with this focus, hospital alternatives offer a treatment approach in which paternalism and coercion are reduced and peer support is emphasized. They provide a different treatment atmosphere with more autonomy for staff and residents. Their cost-effectiveness, greater emphasis on human interaction rather than medication, and improved user-satisfaction are important benefits. We should be aware, however, that, especially in the U.S., there is often a drive to increase the size of such facilities, lock the doors, and introduce the use of restraints and seclusion, reflecting the dynamic tension between the drive to security and cost-efficiency, on the one hand, and human-scale, personalized care on the other.
Small, normalizing facilities that are open-door and genuinely in the community.... offer opportunities to residents to be involved in the operation of the treatment environment.
