Introduction: The narrowing of reform

Psychiatric Deinstitutionalisation (PDI) is widely recognised as a cornerstone transformation in twentieth-century mental health care. It broadly refers to the reduction and closure of large, specialised psychiatric hospitals and the parallel development of comprehensive, community-based residential and treatment alternatives. This shift is often driven by the goal of improving quality of care and expanding rights for people with psychosocial disabilities while challenging traditional roles and practices within mental health care. Historically, the shift emerged from a radical critique of ‘asylums’, perceived as “total institutions” [1], and of institutional psychiatry, viewed as a system organised around the denial of autonomy and citizenship and as a tool of social control and marginalisation [2]. Guided by ethical and political values, reform challenged confinement and segregation as default responses to severe mental distress.

By the late 1980s, however, PDI had begun to lose much of its political and ideological edge in North America and Western Europe. In the USA, reform often took the form of dehospitalisation—understood less as a comprehensive transformation of care systems than as the reduction of long-stay beds and the discharge of patients from psychiatric hospitals [3]. While PDI had originally implied a coordinated shift towards community-based care, including the development of accessible services, social support systems, and alternative residential arrangements, in practice these elements were unevenly realised [4]. Community infrastructures were frequently underdeveloped or fragmented, and responsibility for care was redistributed to families without adequate support. As a result, many individuals experienced discontinuity of care, exposure to new forms of vulnerability, and, in some cases, re-institutionalisation in other settings, while logics of coercion and control persisted in modified forms [5,6]. Rather than a reconfiguration of the relationship between care, community, and citizenship, reform often resulted in a partial displacement of institutional functions.

In parts of Europe, early reform agendas, initially grounded in critiques of institutional psychiatry and oriented towards social inclusion and rights, were progressively reshaped by neoliberal governance and austerity measures [7–9] Policy priorities shifted towards efficiency, fiscal restraint, and accountability, with increasing emphasis on cost containment and service performance. Across both contexts, these developments were accompanied by a redefinition of how deinstitutionalisation was evaluated and governed, with an emphasis on bed numbers, shorter lengths of stay, and lower rates of hospitalisation, rather than the transformation of lived conditions and social relations of care [10,11]. Reorganised around managerial and financial logics, new treatment modalities frequently overlooked the social conditions necessary for recovery. At the same time, the growing centrality of risk management reframed patients as objects of surveillance and control, displacing earlier concerns with subjectivity and social integration [12,13]. This reorientation narrowed the meaning of reform itself, privileging what could be measured, managed, and scaled, and laying the groundwork for the technocratic framings that continue to shape global mental health today.

Yet this trajectory neither exhausted nor defined the possibilities of psychiatric reform elsewhere. In several countries of the Global South, and particularly in South America, psychiatric reform unfolded in close articulation with processes of democratisation, social mobilisation, and the development of distinct traditions within social medicine. These trajectories illustrate different ways in which deinstitutionalisation became entangled with parallel, intersecting projects of political and institutional transformation.

In Brazil, the rise of the Movimento de Luta Antimanicomial in the late 1980s transformed psychiatric reform into a broad-based political project, linking the critique of the asylum to struggles for citizenship, rights, and the construction of a universal public health system [14–16]. Emerging in opposition to the “madness industry” consolidated under dictatorship—characterised by the expansion of private psychiatric hospitals, overcrowding, and systematic neglect [17,18], the movement redefined PDI as a process of deconstruction of the asylum logic [19]. This approach unfolded across multiple dimensions, including legal-political struggles for rights, the development of territorial psychosocial services such as CAPS [Centros de Atenção Psicossocial], and broader sociocultural efforts to transform public understandings of madness [20,21].

In Argentina, reform trajectories were more discontinuous, shaped by cycles of innovation and political repression [22]. Mid-twentieth-century efforts to move beyond asylum-based care, including the development of psychiatric services in general hospitals and experiments with therapeutic communities, were interrupted by state violence during the 1976–1983 dictatorship, which targeted mental health professionals and reinstated custodial and biomedical approaches to care [23]. Following the return to democracy, reforms regained momentum, finding expression in provincial initiatives such as Río Negro’s Law 2440 and the 2010 National Mental Health Law, which established a rights-based framework oriented towards deinstitutionalisation and the integration of care into general hospitals [24,25].

In Chile, reform followed a different trajectory, marked by early attempts to radically reconfigure psychiatry through community-based and politically embedded approaches, followed by authoritarian interruption and later technocratic reconfiguration. In the late 1960s and early 1970s, pioneering epidemiological studies [26] and initiatives such as intracommunity psychiatry sought to shift mental health care beyond asylums and towards collective, socially grounded approaches to care, closely linked to simultaneous political transformations [27,28]. These efforts were dismantled after the 1973 military coup, which reasserted custodial and biomedical models of care and repressed community-based initiatives [29]. Following the return to democracy, Chile implemented a series of national mental health plans that expanded community services and integrated mental health into primary care, achieving significant reductions in long-stay hospitalisation [30,31]. However, this process was embedded within a broader neoliberal model of health system reform, in which policies such as AUGE-GES prioritised cost-effectiveness and standardised interventions, often narrowing the scope of reform and reducing social determinants to individual-level risk factors [27,32].

Taken together, these trajectories show that psychiatric reform unfolds through complex and contested combinations of political mobilisation, institutional experimentation, and technocratic redesign rather than through a single, linear, top-down pathway. Read alongside North American and European experiences, these examples show how different historical relationships between institutional psychiatry, democratisation, social mobilisation, and service reorganisation have produced distinct meanings and pathways of deinstitutionalisation.

In the mid-2000s the “Movement for Global Mental Health” (GMH) pushed for and established a new logic of urgency, prioritisation, and international comparability to mental health policy. This shift was closely tied to the growing influence of the “burden of disease” framework, which uses the Disability-Adjusted Life Year (DALY), a composite measure combining years of life lost (YLL) due to premature mortality and years lived with disability (YLD), to quantify population-level health loss [33]. These metrics made visible the substantial global burden of mental, neurological, and substance-use conditions, and helped establish the “treatment gap”, elevating mental health within global agendas and promoting the “scaling up” of evidence-based interventions in low- and middle-income countries as a moral and technical imperative.

In doing so, they also helped redefine what counted as successful psychiatric reform. Increasingly, progress came to be assessed through indicators such as treatment coverage, workforce expansion, and the delivery of evidence-based interventions rather than through broader questions of institutional transformation. The emphasis on quantification, comparability, and cost-effectiveness privileged forms of knowledge that could be aggregated across contexts, often at the expense of historically and politically grounded understandings of psychiatric reform [34,35]. In this context, the heterogeneous trajectories described above, including those shaped by social movements, democratic transitions, and local intellectual and political traditions, were increasingly folded into a narrative centred on treatment expansion and measurable outcomes [36]. Proponents of this approach often framed the expansion of evidence-based interventions as an urgent matter of equity and human rights, typically emphasising access to psychopharmaceutical and psychosocial treatments [37,38]. While this orientation strengthened global advocacy, it also narrowed the terms through which psychiatric reform was understood, as historically grounded questions of institutional transformation and social relations gradually receded from view [37].

This narrowing has important consequences. The logics of scale and measurement privilege what can be counted and compared, whereas institutional transformation unfolds through slow, contested, and historically embedded processes [39,40]. A sustained engagement with psychiatric reform in South America grounded in social science approaches makes this tension particularly visible, with the region appearing not only as a site of unmet need, as it is often framed within global mental health, but as a space of long-standing intellectual, political, and practical engagement with questions of institutional care, community, and citizenship. The trajectories discussed here embody understandings of deinstitutionalisation that extend beyond the dominant vocabularies of contemporary global mental health, where reform is often framed primarily in terms of scale, coverage, and intervention delivery.

Discussion: Re-engaging with deinstitutionalisation

If renewed calls for action are to succeed, they must be grounded in a richer analytical frame. We propose three interconnected lenses for rethinking PDI in global mental health: attending to context and history; decentring the geography of reform; and foregrounding lived experience. Together, these lenses broaden how institutional transformation is understood and how psychiatric reform is analysed across research, policy, professional training, service organisation, and governance.

Conclusion

PDI is not a closed chapter but a shifting terrain of struggle. The persistence of asylum-based practices, alongside the emergence of new dilemmas, reflects not only gaps in implementation but the limits of how reform has been framed and pursued. As long as reform is understood primarily through technocratic metrics such as beds, coverage, laws and workforce, it will remain difficult to grasp, and address, the transformations it demands.

This is precisely why deinstitutionalisation still matters. Psychiatric institutions have not disappeared; they have persisted, mutated, and, in some contexts, re-emerged through new arrangements of care, coercion, abandonment, and social control. At the same time, decades of uneven reform have generated new contradictions: transinstitutionalisation, fragmented systems of care, the reproduction of custodial logics within community settings, and persistent inequalities in who can access autonomy, support, and citizenship. These challenges cannot be understood through implementation gaps alone. They raise deeper questions about how institutional transformation is imagined, organised, and evaluated. Although contemporary agendas increasingly invoke the language of mental health reform or system transformation, these shifts in terminology do not, by themselves, address the political, ethical and institutional questions raised by deinstitutionalisation. Rather, they risk obscuring the continuing relevance of institutional power, coercion, and citizenship as central concerns of reform.

Re-engaging with PDI therefore calls for a reorientation in how reform is understood and pursued across the multiple sites where it is enacted: research, policy, legal systems, professional training, activism, and everyday practices of care. This includes recognising the diversity of reform trajectories, drawing on intellectual traditions beyond dominant North Atlantic frameworks, and taking seriously the epistemic contributions of lived experience to understanding institutional transformation.

Reclaiming PDI as a political, ethical, and epistemological project is not a matter of returning to past radicalism, but of recovering a richer understanding of institutional transformation—one informed by diverse reform trajectories and open to the forms of knowledge generated through lived experience. Only from that perspective can contemporary mental health reform engage seriously with the enduring questions that processes of deinstitutionalisation continue to pose [45,59,70].