Theoretical Medicine and Bioethics

, Volume 31, Issue 6, pp 411–427 | Cite as

Mental health care and the politics of inclusion: A social systems account of psychiatric deinstitutionalization

  • Enric J. Novella


This paper provides an interpretation, based on the social systems theory of German sociologist Niklas Luhmann, of the recent paradigmatic shift of mental health care from an asylum-based model to a community-oriented network of services. The observed shift is described as the development of psychiatry as a function system of modern society and whose operative goal has moved from the medical and social management of a lower and marginalized group to the specialized medical and psychological care of the whole population. From this theoretical viewpoint, the wider deployment of the modern social order as a functionally differentiated system may be considered to be a consistent driving force for this process; it has made asylum psychiatry overly incompatible with prevailing social values (particularly with the normative and regulative principle of inclusion of all individuals in the different functional spheres of society and with the common patterns of participation in modern function systems) and has, in turn, required the availability of psychiatric care for a growing number of individuals. After presenting this account, some major challenges for the future of mental health care provision, such as the overburdening of services or the overt exclusion of a significant group of potential users, are identified and briefly discussed.


Mental health services Deinstitutionalization Psychiatric reform Social inclusion Social systems theory Niklas Luhmann 



Preparatory research for this paper was conducted during two academic stays at the Universities of Berlin (FU) and Hamburg funded by the German Service for Academic Exchange (DAAD) and the Medical Research Foundation MMA (Spain). I am very grateful to Professor Heinz-Peter Schmiedebach, Dr. Kai Sammet, Professor Rafael Huertas and two anonymous reviewers of this journal, who read earlier drafts of the manuscript and provided valuable critical insights. Finally, I wish to thank Daniel Kim for his terrific editing of the final version.


  1. 1.
    Freeman, Hugh L., ed. 1999. A century of psychiatry. London: Mosby-Harcourt.Google Scholar
  2. 2.
    Kringlen, Einar. 2003. A contemporary history of psychiatry. In Historia de la psiquiatría en Europa: Temas y tendencias, ed. Filiberto Fuentenebro, Rafael Huertas, and Carmen Valiente, 725–734. Madrid: Frenia.Google Scholar
  3. 3.
    Freeman, Hugh L., Thomas Fryers, and John H. Henderson. 1985. Mental health services in Europe: 10 years on. Public Health in Europe 25. Copenhagen: WHO Regional Office for Europe.Google Scholar
  4. 4.
    Bachrach, Leona L. 1976. Desinstitutionalisation: An analytical review and sociological perspective. Rockville, MD: National Institute of Mental Health.Google Scholar
  5. 5.
    Rosen, George. 1959. Social stress and mental disease from the 18th century to the present: Some origins of social psychiatry. Milbank Memorial Fund Quarterly 37: 5–32.CrossRefGoogle Scholar
  6. 6.
    Bartlett, Peter, and David Wright, eds. 1999. Outside the walls of the asylum: The history of care in the community 1750–2000. London: Athlone.Google Scholar
  7. 7.
    Ballerini, Arnaldo. 2002. La paradoja Italiana: Expansión de la psiquiatría comunitaria y marginación de la psicopatología. Archivos de Psiquiatría 65: 13–26.Google Scholar
  8. 8.
    Gijswijt-Hofstra, Marijke, and Roy Porter, eds. 1998. Cultures of psychiatry and mental health care in postwar Britain and the Netherlands. Clio Medica 49. Amsterdam: Rodopi.Google Scholar
  9. 9.
    Grob, Gerald N. 1991. From asylum to community: Mental health policy in modern America. Princeton, NJ: Princeton University Press.Google Scholar
  10. 10.
    Schmiedebach, Heinz-Peter, and Stefan Priebe. 2004. Social psychiatry in Germany in the twentieth century: Ideas and models. Medical History 48: 449–472.Google Scholar
  11. 11.
    Bennet, Douglas H. 1991. The international perspective. In Community psychiatry: The principles, ed. Douglas H. Bennet, and Hugh L. Freeman, 626–650. Edinburgh: C. Livingstone.Google Scholar
  12. 12.
    Forster, Rudolf. 1997. Psychiatriereformen zwischen Medikalisierung und Gemeindeorientierung: Eine kritische Bilanz. Opladen: Westdeutscher Verlag.Google Scholar
  13. 13.
    Goodwin, Simon. 1997. Comparative mental health policy: From institutional to community care. London: Sage.Google Scholar
  14. 14.
    Barham, Peter. 1997. Closing the asylum: The mental patient in modern society. Harmondsworth: Penguin.Google Scholar
  15. 15.
    Shorter, Edward. 1997. A history of psychiatry: From the age of the asylum to the age of Prozac. New York: Wiley.Google Scholar
  16. 16.
    Becker, Thomas, and José Luis Vázquez Barquero. 2001. The European perspective of psychiatric reform. Acta Psychiatrica Scandinavica. Supplementum 410: 8–14.CrossRefGoogle Scholar
  17. 17.
    Thornicroft, Graham, and Michelle Tansella. 1999. The mental health matrix: A manual to improve services. New York: Cambridge University Press.Google Scholar
  18. 18.
    Allderidge, Patricia. 1979. Hospitals, madhouses and asylums: Cycles in the care of the insane. British Journal of Psychiatry 134: 321–334.CrossRefGoogle Scholar
  19. 19.
    Morrisey, Joseph P., and Howard H. Goldman. 1984. Cycles of reform in the care of the chronically mentally ill. Hospital & Community Psychiatry 35: 785–793.Google Scholar
  20. 20.
    Scull, Andrew. 1989. The asylum as community or the community as asylum: Paradoxes and contradictions of mental health care. In Social order/mental disorder: Anglo-American psychiatry in historical perspective, 300–330. Berkeley: University of California Press.Google Scholar
  21. 21.
    Novella, Enric J. 2008. Theoretical accounts on deinstitutionalization and the reform of mental health services: A critical review. Medicine, Health Care and Philosophy 11: 303–314.CrossRefGoogle Scholar
  22. 22.
    Jones, Kathleen. 1993. Asylums and after: A revised history of the mental health services from the early eighteenth century to the 1990s. London: Athlone.Google Scholar
  23. 23.
    Leifer, Ronald. 1969. In the name of mental health: The social functions of psychiatry. New York: Science House.Google Scholar
  24. 24.
    Wedel-Parlow, Ursula. 1991. Gemeindenahe Psychiatrie: Bearbeitung und Transformation eines sozialen Problems. Frankfurt a.M.: Peter Lang.Google Scholar
  25. 25.
    Scull, Andrew. 1984. Decarceration: Community treatment and the deviant, 2nd ed. Cambridge: Polity.Google Scholar
  26. 26.
    Brown, Phil. 1985. The transfer of care: Psychiatric deinstitutionalization and its aftermath. London: Routledge & Kegan Paul.Google Scholar
  27. 27.
    Ralph, Dianna R. 1983. Work and madness: The rise of community psychiatry. Montreal: Black Rose.Google Scholar
  28. 28.
    Warner, Richard. 1994. Recovery from schizophrenia: Psychiatry and political economy, 2nd ed. London: Routledge.Google Scholar
  29. 29.
    Schrenk, Martin. 1967. Zur Geschichte der Sozialpsychiatrie: Isolierung und Idylle als Therapeutik der Seelenstörungen. Nervenarzt 38: 479–487.Google Scholar
  30. 30.
    Cumming, Elaine, and John Cumming. 1957. Closed ranks. Cambridge, MA: Harvard University Press.Google Scholar
  31. 31.
    Baraldi, Claudio, Giancarlo Corsi, and Elena Esposito. 1997. GLU: Glosar zu Niklas Luhmann Theorie sozialer Systeme. Frankfurt a.M.: Suhrkamp.Google Scholar
  32. 32.
    Reese-Schäfer, Walter. 1999. Niklas Luhmann zur Einführung, 3rd ed. Hamburg: Junius Verlag.Google Scholar
  33. 33.
    Stichweh, Rudolf. 1999. Niklas Luhmann (1927–1998). In Klassiker der Soziologie, ed. Dirk Kaesler, Vol. 2, 206–229. Munich: CH Beck.Google Scholar
  34. 34.
    Luhmann, Niklas. 1984. Soziale Systeme. Grundriß einer allgemeinen Theorie. Frankfurt a.M.: Suhrkamp.Google Scholar
  35. 35.
    Luhmann, Niklas. 1997. Die Gesellschaft der Gesellschaft. Frankfurt a.M.: Suhrkamp.Google Scholar
  36. 36.
    Kneer, Georg. 2004. Differenzierung bei Luhmann und Bourdieu. Ein Theorienvergleich. In Bourdieu und Luhmann. Ein Theorienvergleich, ed. Armin Nassehi, and Gerd Nollmann, 25–56. Frankfurt a.M.: Suhrkamp.Google Scholar
  37. 37.
    Tyrell, Hartmann. 2001. Gesellschaftstypologie und Differenzierungsform. Segmentierung und Stratifikation. In Sinngeneratoren. Fremd-und Selbstthematisierung in soziologisch-historischer Perspektive, ed. Cornelia Bohn, and Herbert Willems, 511–534. Konstanz: Universitätsverlag Konstanz.Google Scholar
  38. 38.
    Dumont, Louis. 1980. Homo hierarchicus: The caste system and its implications. Chicago: University of Chicago Press.Google Scholar
  39. 39.
    Luhmann, Niklas. 1980. Gesellschaftliche Struktur und semantische Tradition. In Gesellschaftsstruktur und Semantik. Vol. 1, Studien zur Wissenssoziologie der modernen Gesellschaft, 9–71. Frankfurt a.M.: Suhrkamp.Google Scholar
  40. 40.
    Gauchet, Marcel, and Gladys Swain. 1980. La pratique de l’esprit humaine: L’institution asilaire et la révolution démocratique. Paris: Gallimard.Google Scholar
  41. 41.
    Weiner, Dora B. 1999. Comprendre et soigner. Philippe Pinel (1745–1826): La médecine de l’esprit. Paris: Fayard.Google Scholar
  42. 42.
    Luhmann, Niklas. 1995. Jenseits von Barbarei. In Gesellschaftsstruktur und Semantik. Vol. 4, Studien zur Wissenssoziologie der modernen Gesellschaft, 138–150. Frankfurt a.M.: Suhrkamp.Google Scholar
  43. 43.
    Luhmann, Niklas. 1989. Individuum, Individualität, Individualismus. In Gesellschaftsstruktur und Semantik. Vol. 3, Studien zur Wissenssoziologie der modernen Gesellschaft, 149–258. Frankfurt a.M.: Suhrkamp.Google Scholar
  44. 44.
    Stichweh, Rudolf. 1988. Inklusion in Funktionssysteme der modernen Gesellschaft. In Differenzierung und Verselbständigung: Zur Entwicklung gesellschaftlicher Teilsysteme, ed. Renate Mayntz, 261–293. Frankfurt a.M.: Campus.Google Scholar
  45. 45.
    Luhmann, Niklas. 1995. Inklusion und Exklusion. In Soziologische Aufklärung. Vol. 6, Die Soziologie und der Mensch, 237–264. Opladen: Westdeutscher Verlag.Google Scholar
  46. 46.
    Mangen, Stephen P., ed. 1985. Mental health care in the European community. London: Croom Helm.Google Scholar
  47. 47.
    Breemer Ter Stege, Chris, and Martin Gittelman. 1987. The direction of change in Western European mental health care. International Journal of Mental Health 16: 6–20.Google Scholar
  48. 48.
    Thom, Achim, and Erich Wulff, eds. 1990. Psychiatrie in Wandel: Erfahrungen und Perspektiven in Ost und West. Bonn: Psychiatrie-Verlag.Google Scholar
  49. 49.
    Rössler, Wulf, Hans-Joachim Salize, Ulrich Biechele, and Anita Riecher-Rössler. 1994. Stand und Entwicklung der psychiatrischen Versorgung. Ein europäischer Vergleich. Nervenarzt 65: 427–437.Google Scholar
  50. 50.
    Novella, Enric J. 2010. Mental health care in the aftermath of deinstitutionalization: A retrospective and prospective view. Health Care Analysis 18: 222–238.CrossRefGoogle Scholar
  51. 51.
    Göbel, Markus, and Johannes Schmidt. 1998. Inklusion/Exklusion: Karriere, Probleme und Differenzierungen eines systemtheoretischen Begriffspaares. Soziale Systeme 4: 87–117.Google Scholar
  52. 52.
    World Health Organization. 2003. Mental health legislation and human rights. Geneva: World Health Organization.Google Scholar
  53. 53.
    Busfield, Joan. 1986. Managing madness: Changing ideas and practice. London: Unwin Hyman.Google Scholar
  54. 54.
    Sheehan, Kathleen A. 2009. Compulsory treatment in psychiatry. Current Opinion in Psychiatry 22 (6): 582–586.CrossRefGoogle Scholar
  55. 55.
    Healy, David. 2002. The creation of psychopharmacology. Cambridge, MA: Harvard University Press.Google Scholar
  56. 56.
    Mammarella, Giuseppe. 1995. Storia d’Europa dal 1945 a oggi. Roma: Laterza.Google Scholar
  57. 57.
    Judt, Tony. 2005. Postwar: A history of Europe since 1945. New York: Penguin Press.Google Scholar
  58. 58.
    Hobsbawm, Eric. 1994. Age of extremes: The short twentieth century 1914–1991. London: Michael Joseph.Google Scholar
  59. 59.
    Basaglia, Franco. 1968. L’istituzione negata. Torino: Einaudi.Google Scholar
  60. 60.
    Kersting, Franz-Walter, ed. 2003. Psychiatriereform als Gesellschaftsreform. Die Hypothek des Nationalsozialismus und der Aufbruch der sechziger Jahre. Paderbor: Verlag Ferdinand Schöningh.Google Scholar
  61. 61.
    Stanton, Alfred H., and Morris S. Schwarz. 1954. The mental hospital. New York: Basic Books.Google Scholar
  62. 62.
    Caudill, William. 1957. The psychiatric hospital as a small society. Cambridge, MA: Harvard University Press.Google Scholar
  63. 63.
    Goffman, Erving. 1961. Asylums: Essays on the social situation of mental patients and other inmates. New York: Anchor Books.Google Scholar
  64. 64.
    Roelcke, Volker. 1999. Krankheit und Kulturkritik: Psychiatrische Gesellschaftsdeutungen im börgerlichen Zeitalter. Frankfurt a.M.: Campus.Google Scholar
  65. 65.
    Giddens, Anthony. 1991. Modernity and self-identity: Self and society in the late modern age. Stanford, CA: Stanford University Press.Google Scholar
  66. 66.
    Zaumseil, Manfred, and Klaus Leferink. 1997. Schizophrenie der Moderne - Modernisierung der Schizophrenie. Lebensalltag, Identität und soziale Beziehungen von psychisch Kranken in der Grossstadt. Bonn: Edition Das Narrenschiff im Psychiatrie-Verlag.Google Scholar
  67. 67.
    Rieff, Philip. 1961. Freud: The mind of the moralist. Garden City, NY: Doubleday Anchor.Google Scholar
  68. 68.
    Castel, Robert, Françoise Castel, and Anne Lovell. 1982. The psychiatric society. New York: Columbia University Press.Google Scholar
  69. 69.
    Dörner, Klaus. 1979. Psychiatrie und Gesellschaftstheorien. In Psychiatrie der Gegenwart, eds. Karl-Peter Kisker, Hans Lauter, Joachim-Ernst Meyer, et al., 771–809. Berlin: Springer.Google Scholar
  70. 70.
    Grove, Bob. 1994. Reform of mental health care in Europe. British Journal of Psychiatry 165: 431–433.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2010

Authors and Affiliations

  1. 1.Centre for Human and Social Sciences (CSIC)MadridSpain

Personalised recommendations