From asylum to community. The threatened disintegration of public psychiatry

Before 1950, publicly supported psychiatric services (i.e., those of so-called public psychiatry) were provided primarily at state hospitals. Over the past 30 years public psychiatry has shifted its emphasis away from long-term custodial care to outpatient and community-based services. Paradoxically, this broadening of focus has become associated with both an expanded use of psychiatric services and a threatened decline in clinical standards and treatment goals. Five areas of policy confusion and contradiction threaten the stability of public mental-health services: the shift in emphasis from public to private services, the issue of rehabilitation and reintegration into society versus custodial care, the differential treatment of the lower-class patient, the demedicalization of public services, and conflict between professionals and blurring of roles within the psychiatric profession. These problems reflect public psychiatry's overemphasis on social reform and political rather than clinical definitions of treatment, its lack of specific treatment and of defined treatment goals, and its inability to change psychiatry's (and society's) historical assignment of low status to the public patient.