Structural changes and their consequences in a "natural" psychiatric sector: Gotland 1976-1981

In recent years discussions about the development of psychiatric care internationally and in Scandinavia have been focused on principles of opening and sectorizing, sometimes at the cost of existing differentiated and effective psychiatric in-patient care-programs. During the last 6 years a process of strengthening and opening psychiatric care was started on the Swedish island of Gotland (55 000 inhabitants), based on an existing mental hospital, utilizing the existing personnel, maintaining existing effective structures of institutional care and developing new ones in out-patient care. The intention was to combine principles of subspecialized psychiatric in-patient are treatment with ideas of sectorization, accessibility and openness. Our results seem to show that it is well possible to reach positive results, optimizing and opening up an existing institution, using a basic psychodynamic, synoptic and eclectic ideology, offering differentiated treatment programs and without the immediate use of sectorizing principles. Sectorization and accessibility without qualified treatment programs of in-patient care may not be a sufficient solution to all the problems we find in psychiatric organisations. On the other hand, our achieved positive results have probably the naturally sectorized character of the island of Gotland as a presupposition. Principles of sectorization and differentiation seem in psychiatry not to be contrary but complementary. However, it seems to be legitimate, possible and effective to start a process of psychiatric evolution transforming an existing old-fashioned mental hospital.