Introduction

In connection with other vast and profound social and cultural transformations in the Western world, contemporary psychiatry has undergone major changes over the last fifty years. These changes concern not only the development of certain research areas, new therapies, care settings, and legal frameworks but also some of the most significant traits of its internal and institutional organization. As a result of these changes, we now encounter a highly complex and diverse psychiatric landscape that reflects the new demands imposed on psychiatry by our modern societies and the way these societies deal with mental derangement [1, 2].

A major part of these developments must be understood as resulting from the ambitious institutional projects aimed at transforming the face of psychiatry that were launched in the decades following World War II—projects that are now known worldwide as psychiatric reforms. Promoted by the World Health Organization (WHO), and beginning in the mid 1950s in England and the United States and a bit later in Continental Europe and Scandinavia, an international consensus arose about the need for a thorough change in psychiatric care and for new policy strategies for mental health. Above all, the main declared goal of the reforms was to overcome the old asylum-based system of care and establish new community-oriented therapeutic approaches [3]. Since, in many countries, this implied a move away from the traditional institution of the mental hospital and resulted in a considerable increase in the discharge of patients, the term “deinstitutionalization” was coined to refer to this central aspect of the reforms, and it has since become (problematically) more or less synonymous with psychiatric reform as a whole [4].

In most cases, the then flourishing social and community psychiatry provided the programmatic and ideological framework for the reform initiatives. Although interest in the social aspects of mental illness and alternatives to institutional care are as old as psychiatry itself [5, 6], it was only in the post-war period, on the background of a pervasive crisis of the asylum as a social and therapeutic institution, that these old ideas began to exert a remarkable influence and became a prevailing trend in psychiatric theory and practice. The focus on the social and environmental dimension of mental health stimulated by the lessons of war-psychiatry and the then—at least in the US—dominant position of psychoanalysis converged on the assumption that psychiatric patients should not be confined in large, undifferentiated, and isolated mental hospitals but should be actively treated and supported “in” their communities [7–10]. Coupled with a strong emphasis on prevention and rehabilitation and a declared concern for the social integration of the mentally ill, “community care”—ambiguous as the term may be—was on the agenda of psychiatry from the mid 1950s. In a sort of expanding chain reaction, within two decades, all major Western countries underwent a similar process of upheaval in their mental health systems. They experienced similar crises of the old model, discussions of alternatives (often on the background of growing social and media interest), and political involvement with new legislation or national guidelines, including the provision of variable funds for the development of new model services [11–13].

Although these developments were celebrated by many advocates as a “major revolution” or as the outbreak of a “new psychiatric paradigm,” the actual implementation of the reform projects did not fulfill original expectations. Changing the primary locus of care from traditional institutional settings to community-based services proved to be more complicated than it was previously assumed and gave rise to new problems and some important but unanticipated side-effects, particularly among the most severe and chronically ill patients [14]. Due to these developments and other social, economic, and political constraints, by the mid 1980s, the reform movements in most of the countries had lost their initial impetus and seemed to stagnate. Operationalized diagnosis, neuroscientific approaches, and the psychopharmacological boom gradually displaced social psychiatric and psychoanalytic concepts and interests, while psychiatry was forced to face new tasks due to a growing demand on psychotherapeutic advice and treatment [2, 15]. However, many of the structural changes in the care systems that were initiated in the previous decades continued, or even began, to be implemented in some countries. Therefore, recent reports on the situation of mental health care around the globe still speak of the reforms as “ongoing processes” [16, 17].

Notwithstanding all their pitfalls and limitations, the reforms have contributed to a deep transformation in the field of mental health that raises important questions concerning its very nature and long-term implications. In general terms, the broader assessment of the reforms is divided between those authors who consider them to be just one cycle of reform among others [18, 19], and those who conceive the changes of the last half-century as a radical break which deserves closer historical and sociological examination [20]. But given the great interest that large parts of the public and some social and academic sectors have shown while following all these developments, the discussion around the nature and final causes of the reforms has given rise to a storm of essays and studies. In fact, since the very beginning of the reform programs, many explanatory models from various points of view, descriptive levels, and theoretical frameworks have been outlined in order to explain the significant changes in the care strategies for mentally ill persons [21]. And so, for instance, the reforms have been linked over the years to a manifold set of factors, such as scientific achievements (mainly the introduction of modern psychopharmacology [15]), humanitarian concerns [22], professional interests [9, 12], political convenience [23], users’ expectations [13, 24], administrative costs [25, 26], and even the evolution of the labor market [27, 28].

Most of these available accounts thus point to some aspects of the actual transformations in the mental health field that are certainly relevant and must be taken into account, but they are not free from important shortcomings. Their inadequacies are understandable when considering the multiple dimensions and the interdependence of the complex and multilayered developments in the field. In this sense, one of the reasons for their limited validity lies in the fact that they focus on the influence of one or a few discrete factors and tend to neglect the crucial issue of the emerging social values and contextual requirements that may have inspired these major changes in mental health practice.

At the beginning of the nineteenth century, psychiatry made its generalized appearance as a social and historical actor and established itself as a medical discipline through a set of legal, theoretical, and practical innovations centered on the key institution of the asylum. Paradoxical as it may seem from today’s perspective, the birth of the asylum, which was then widely perceived as the symbol of an enlightened and progressive civilization that no longer ignored or maltreated its dependent mentally ill citizens, was also accompanied by a clear reformist spirit of nearly utopian traits and a broad consensus about the essential role of isolating the patient from the community in the work of recovery [19, 29]. One hundred and fifty years later, it was this very institution of the asylum and the practice of segregation that many mental health professionals and policy makers believed to be the most important obstacles to the realization of psychiatry’s therapeutic commitments. The paradigmatic statement by two prominent researchers of the 1950s that “the worst home is better than the best mental hospital” [30, p. 310] reflects this major opinion shift; their concern was not with the material or human conditions of the asylums but with their therapeutic value. From this point of view, it is logical to conclude that the “drive towards the community” and the subsequent reforms must have been rooted in a broad consensus about certain social values and needs, which any accurate analysis has to account for. It does not seem possible to provide a satisfactory interpretation of psychiatric deinstitutionalization without a theoretical reflection on the requirements that were imposed on the new care devices by a social and cultural order that was, in many decisive respects, completely different from that at the beginnings of the asylum age.

Therefore, the present article intends to outline an alternative account of these developments based on a theoretical framework whose potential has remained unexplored but is nonetheless capable of offering new descriptive tools and explanatory resources. The approach taken here is a social systems theory, more particularly, the theory of society and the description of the modern social order articulated by the late German sociologist Niklas Luhmann (1927–1998). Luhmann’s work provides an extremely rich conceptual inventory that is helpful for grasping the essential traits of particular areas or systems of contemporary society, and his understanding of modernity as centered on the key feature of functional differentiation allows us to introduce distinctive resources for the explanation and contextualization of processes of social change [31–33]. More specifically, Luhmann’s theory of modern society offers two interrelated arguments that may prove very fruitful for considering the phenomena of deinstitutionalization and mental health services reform under a new light: (1) his description of the common patterns of an individual’s inclusion or participation in the different function systems of modern society, and (2) his account of the consequences of functional differentiation for the dynamics of social inclusion and the current fate of individuality and personal identity. Before turning to deal with the recent developments of psychiatry and mental health care, it is necessary to provide a brief sketch of these and other helpful concepts and implications of his theory.

Functional differentiation and the politics of inclusion

Influenced by the structural–functional sociology of Talcott Parsons at the beginning of his career, Luhmann developed over more than 30 years an extremely complex theoretical corpus aimed at introducing systems thinking to sociology. This first took the form of a general theory of self-referential, autopoietic, and operative-closed social systems [34], which was later applied to outline a theory of society as a particular form of these systems. As Luhmann himself declared in his early writings, the development of systems theory was always for him a preparation for the construction of a thorough theory of society. And in 1997, 1 year before his death, the final version of his theory appeared, originally as a German edition, under the title Die Gesellschaft der Gesellschaft (The Society of Society) [35].

The differentiation of society has been, at least since the seminal work of Émile Durkheim, a main subject of interest for sociological theory. Yet, in contrast to Pierre Bourdieu and other authors whose approaches tend to focus on the grades and extent of social differentiation [36], Luhmann was mainly interested in establishing and characterizing a limited number of forms of differentiation, which he defined as the relational joint of subsystems within the broader system constituted by society. The primary form of differentiation of a given society is indeed “its main structure, which, when it prevails, determines the system’s evolution and exerts influence on norm formation, further differentiations, system’s self-descriptions, etc.” [35, p. 611]. From this point of view, Luhmann’s concept of differentiation has been regarded as a key tool for the description and comparative analysis of societies, hence representing a major “theoretical offer for ethnologists and historians” [37].

Luhmann identified four basic forms of societal differentiation. The first is segmentary differentiation, which is typical of tribal societies. Segments are characterized by a similar internal structure and stand in an equal relation to one another. The second is differentiation along the principles of center and periphery, which is the case with the classical distinction between city and countryside. The third form is the hierarchical differentiation or stratification typical of classical cultures or feudal societies. Society is then divided into social systems that take the form of classes or castes, each of which stands in unequal relation to the others due to considerations of rank, and each of which provides its own comprehensive context and guidance for the daily lives of its members [38]. In what surely constitutes the central empirical hypothesis of his work, Luhmann described the modern social structure primarily as a functionally differentiated system, and modernization as a process of evolving functional differentiation. According to this theoretical construct, there are today global macro systems like science, politics, economy, mass media, law, and others, which are not different from one another in terms of rank but are differentiated according to the specific functions they fulfill for the whole society (they are equal and unequal at once). Broadly defined, functional differentiation means, therefore, that “specific functions and their communication media tend to be concentrated on a subsystem with universal competence” [35, p. 709].

According to Luhmann, the process of modernization in terms of functional differentiation has had a number of relevant and interrelated consequences. Foremost, modern societies have become “acentric” or “polycontextual” social formations lacking centralized and supra-systemic hierarchies because the specific operative patterns of the different function systems do not allow themselves to be subordinated to a central authority or external criteria. So, for instance, Luhmann argued that there are today inherent limits on the extent to which the political system can effectively regulate other social spheres. On the other hand, the tendency toward universal competence of modern function systems has released a peculiar kind of logic that is both totalitarian and emancipatory when it comes to the inclusion of individuals in society; these systems aim to include and potentially embrace all individuals and thus tend to homogenize their environment. For this reason, “the principle of the inclusion of all individuals in all functions systems” in modern society “is regarded as a postulate, and has increasingly become a matter of fact… accordingly, access to all functional spheres must be granted to every single person depending on his necessities, particular situation, relevant skills or other factors” [39]. In a way that is strongly reminiscent of some influential accounts of the emergence of medicine for the mentally ill [40, 41], Luhmann mentioned the birth of mental asylums and similar institutions on the threshold of modernity as a paradigmatic example of the radical and compulsory character of social inclusion under the evolving conditions of functional differentiation. And, for him, these institutions were a striking feature of a society that did not recognize an “outside” anymore: “Deviant behavior is now no more reason for exclusion, but for special treatment with the goal of inclusion…. Hopeless cases have been transformed into psychiatric subjects, i.e., they are considered as sick persons whose treatment falls under the responsibility of society and has therefore to be institutionally arranged” [42].

However, the counterpart of this development is the fact that modern function systems can only include individuals from their specific and selective functional perspective, so that individuals cannot be fully included in one single system and thus “placed” in society anymore: “individuals can no longer be placed in society, because each function system is oriented toward the inclusion of all individuals, but this inclusion is exclusively restricted to its specific operations” [35, p. 765]. Hence, unlike a hierarchically differentiated society, a functionally differentiated “society does not offer a social status that simultaneously defines what the individual is according to his origins and quality” [35, p. 625]. And consequently, functional differentiation has led to the breakdown of all-inclusive and stable categories of identity, which has now to be constructed ex negativo on the background of an aggregate of roles deriving from all the partial inclusions of the individual in the different function systems (“exclusion individuality”) [43].

From the point of view of the dynamics of inclusion or participation of individuals, Luhmann described the differentiation of function systems as a process involving a typical sequence of steps. It begins with isolated communicative situations with a certain degree of functional specificity; it continues with the genesis and institutionalization of specialized roles, which serve to define and identify a functional frame of reference; and it ends with the development of public or complementary roles, which regulate the inclusion of the whole population in the evolving social system through different forms of participation [44]. By the end of this process, the public becomes categorized in a threefold sense. First, the public is generalized, i.e., it is conceived without regard to specific social and personal attributes or particularities. Second, it is considered from a universalistic point of view, i.e., every single person is a potential target of the various function systems. And, finally, its status is respecified as being constituted by numerous complementary roles (consumer, patient, voter, etc.) that are thought to be independent from one another. To sum up, generalization, universalization, respecification and the implicit assumption of an individual’s sequential participation in the different function contexts define in Luhmann’s view the framework for social inclusion under the structural conditions of functional differentiation.

Given these considerations, the progression of modernity by means of functional differentiation and the associated principle of inclusion of all individuals in all function systems had to face two major traditional forms of exclusion during the early modern age. The first was the pre-modern tendency of regulating the access or participation of individuals in the different spheres of society in classist-hierarchical terms, while the second was the explicit marginalization of generic population groups like the poor, vagrants, homeless, and, certainly, the mad. In Luhmann’s view, these two forms of exclusion seem to have been perceived separately in the early modern period, but both started to become unstable in the course of the eighteenth and nineteenth centuries, as reflected respectively in the development of the semantics of nations and citizens (or what he calls “class-independent generalizations” [35, p. 739]) and in the introduction of different institutional forms of social aid and welfare programs. However, with the further advance of functional differentiation during the twentieth century, these two kinds of handicaps to the principle of inclusion of all individuals in all function systems began once and for all to erode. Within the framework of Luhmann’s sociology, this was a logical consequence of the very dynamics of inclusion in modern function systems because “the generalizations and respecifications with which they embrace their public and ascribe their complementary roles are not compatible with hierarchical differentiations or with the explicit exclusion of marginal population groups” [44]. In other words, under the fully developed conditions of functional differentiation, there are no legitimate reasons for preventing anyone from using money, belonging to a nation, visiting a university, getting married, etc. But, on the other hand, “there is no exclusive inclusion anymore. Nobody loses his legal capacity if he gets married or sick; he may perhaps just risk his fortune” [45].

Taking into account the main lines of this understanding of modernity and its consequences, the following sections will seek to determine if a reappraisal based on it is able to provide an adequate characterization and explanation of the recent transformations in the patterns of mental health care. And, as will soon be apparent, this theoretical perspective will lead indeed not only to a renewed description of this striking development in contemporary health care policies, but also to a broader understanding of psychiatric deinstitutionalization within the context of the extraordinary social and cultural changes experienced by Western societies in the decades following World War II. Finally, some major challenges for the current state and immediate future of mental health care provision will also be identified and briefly discussed.

New values, new users, new failures

Following the onset of the psychiatric reform processes, and as evidenced by different comparative studies and reports [11–13, 46–50], a number of new patterns and trends in mental health services have emerged across Western Europe and North America in the second half of the twentieth century.

The first substantial feature of the new psychiatric landscape which calls for attention is thus the widened scope of psychiatric institutions, i.e., the growth in the amount of global services and treatment episodes and the fact that today’s psychiatry reaches or embraces many more people. This contemporary expansion has been closely intertwined with profound changes in the distribution of clients attending psychiatric institutions so that the current focus of mental health consultations tends to be concerned with less severe disorders and adaptive problems.

Furthermore, there has been a general trend away from reliance upon long-term incarceration in the old asylums and toward a more varied and more community-based pattern of care and treatment. Mental hospital bed space in each country has tended to reach a peak, and subsequently, decline. Many of the older hospitals have been substantially run down or closed, while at the same time, new psychiatric departments in general hospitals have been established. There has also been the development of outpatient and day patient services. Outside the hospital, a wide range of new community-based treatment facilities have developed. These include community mental health centers and multidisciplinary community-based psychiatric teams involving general practitioners, community psychiatric nurses, psychiatrists, psychologists, and other staff groups. These developments in services have frequently taken place within a more general shift towards sectorized community psychiatric services.

The consequences of these developments for service users have been substantial. The length of time for which patients are admitted have fallen, and the numbers admitted on a voluntary basis have notably increased. An increasing number of admissions are made to locally based and recently created psychiatric departments in general hospitals, rather than to the older mental hospitals. In general, the overall number of admissions has increased sharply in many countries.

These changes in the activities and functions of psychiatric services have resulted in a considerable reduction in the availability of care within the older, established services. The loss of beds and the reduction in the average length of stay means that many people with mental illness find themselves living in community settings when previously they might have been institutionalized. To replace this shortfall, there has—to varying degrees—been an increase in the supply of residential homes, day care, social work support, domiciliary services, and a variety of other facilities to help support service users in the community. In a number of countries there has been a large-scale transfer of patients to nursing and residential homes, many of which are in the private and voluntary sectors and are frequently poorly staffed and equipped. Moreover, a significant number of former or potential users of mental hospitals have become homeless or landed in inadequate settings such as boarding homes or even prisons. Finally, the shift toward a more community-oriented model of care has resulted in greater emphasis being placed on the role of lay help and support, particularly of family members of service users.

Considering the important therapeutic developments of the period and the evolution in psychiatry’s internal specialization, there has been in the last decades a marked change in the way mental health patients are treated and cared for in Western European and North American countries. And, as I have argued elsewhere, the analysis of the available empirical evidence suggests that the recent transformations mainly represent the transition from a pattern of care based on less differentiated long-term interventions in large and isolated asylums to an extended and more differentiated (according to age, diagnosis, therapeutic technique, chronicity, various social problems, etc.) model centered on short-term interventions in small and—when possible—community-proximate institutions [50].

From the perspective of Luhmann’s social theory, then, the essential aspect of this recent shift from asylum to community care may be grasped by looking precisely at the changing pattern of inclusion or participation of individuals in the mental health care systems. Accordingly, the asylum model of care can be described as “hyper-inclusive.” This term, which has recently been proposed in the social systems literature [51], does not refer to an exaggerated form of inclusivity where all people are included as part of a community but, rather, defines a strict and total integration of the individual into an institution such that his access to and participate in other functional areas of society are notably reduced. The shift, then, is from this hyper-inclusive model to a community-oriented model in which inclusion is determined by the usual criteria of modern society’s function systems. Put differently, in the new model of care the public has been respecified into a complementary role (in relation to that of the psychiatric patient) that has to be performed in a punctual way in order to facilitate the patient’s access to other functional contexts. From this point of view, the goal of maximizing a patient’s availability to participate in the other functional spheres of society is the reason why psychiatric interventions today have a selective and punctual character and why they tend to take place, according to the hegemonic postulates of community care, as close as possible to the patient’s place of residence; psychiatric interventions thereby allow patients sequentiality in the performance of their individual roles, which Luhmann considers to be typical of our current social order. Put yet another way, the mentally ill no longer have the lower and marginal status that previously excluded them from regular participation in most relevant areas of society; instead, they now have a role, which is to be a mental health services user, and their passage through the care system should not prevent them, if possible, from performing the bulk of their other individual roles. Considering this formulation, this alternative description may seem quite theoretical at first glance, but it fits exactly with most declarations of the basic principles that seek to guide the modern organization of services for persons with mental disorders. So, for instance, the pioneer of English social psychiatry, Rudolph Freudenberg, once stated that “community psychiatry is based on the assumption that persons with mental disorders may be best helped when the bonds with the family, friends, work and society are maintained” [17]. And similarly, according to a recent WHO report, these persons

should always be treated and cared for in settings having the lowest impact in their personal freedom, status and social rights, including their ability to continue working and conducting their daily lives. In practice, this means promoting community-based attention and to resort to institutional treatments only in exceptional cases [52].

As some authors have rightly pointed out, this philosophy of care reflects to some extent the adjustment of mental health services to the needs of new users who seek help for milder problems than those that affected the inmates of former asylums [12, 13, 53]. However, this has also been responsible for the new community psychiatry’s deplorable shortcomings in dealing with chronicity and disability [9, 14, 25].

So, for instance, it is not surprising that a clear operative displacement toward more restrictive conceptions of treatments has frequently led to long-term interventions and most rehabilitative tasks being delegated to different auxiliary facilities—the so-called complementary sector—such as unspecified nursing and boarding homes or even overtly extra-systemic organizations like prisons [26]. Similarly, it also seems logical that the new forms of exclusion that many mental health patients are now facing have less to do with the phenomenon of hyper-inclusion or incarceration than with the consequences of a limited inclusion, i.e., with situations in which an insufficient consideration—and hence inclusion—on the part of the mental health services ends up significantly reducing the options for routine participation in other functional spheres of society. Furthermore, the explicit avoidance of hyper-inclusive practices as prescribed by the current philosophy of care has logically led to new coercive measures that many countries are now on the way of approving [54]. After all, intensive interventions through hospitalization, admission in long-stay centers, etc., which limit a patient’s social access and free mobility in his environment, are precisely what these coercive measure, such as compulsory intake of certain drugs or obligatory attendance at outpatient units, are trying to avoid. In this sense, and apart from its clinical usefulness, the notable preeminence of drugs in current treatment plans also needs to be seen on the background of their extraordinary compatibility with the new patterns of intervention in mental health care systems [55]. In terms of selectively controlling the most problematic and disruptive symptoms (and shortening the periods of hospitalization), more easily handling ambulatory contexts, reducing the need for the interventions of professionals to occasional clinical visits, and being able to be potentially used by almost all individuals, there is no doubt that drugs are better suited than any other means to an operative model that is now based on universality, selectivity, and punctuality (i.e., potentially embracing the whole population, offering specialized treatments, and performing interventions of short duration).

To sum up, the recent move from a model centered on the integral care of a limited number of patients in large and isolated asylums to a model oriented to providing punctual treatment for a greater number of individuals in community-proximate settings—or in other words, the move from the medical and social management of a lower and marginalized group to the specialized medical and psychological care of the whole population—points to a decisive operative shift within the mental health field. Consequently, public and professional ideas and practices of what constitutes good-quality services have, to a considerable degree, been turned on their heads in a relatively short period of time. Yet the question that arises, which will be our main focus in the next section, is, why has this occurred? What forces, in what combination, led to such a widespread and remarkable change?

The duties of emancipation

It remains, therefore, to be clear about what constellation of circumstances caused, made possible, or forced this paradigmatic shift in a system that, in spite of being subjected for decades to multiple controversies and assaults [14, 15, 25], had kept its essential features unaltered up to the second half of the twentieth century. Approaching this task certainly means entering a fairly speculative field. But, as I have already suggested and will now try to show, Luhmann’s description of modern society in terms of functional differentiation may offer distinctive clues to a proper understanding of this striking shift that occurred within the context of the deep social and cultural transformations experienced by Western societies in the aftermath of World War II.

The psychiatric reform programs officially began taking place in most Western countries between the 1950s and 1970s, when diverse legislative initiatives established the basis for what the new postwar societies expected from future systems of mental health care. Some emblematic landmarks of this process include, for example, the passing of the Mental Health Act of 1959 in the United Kingdom; the signing by J. F. Kennedy of the Community Mental Health Centers Act of 1963 in the USA; the publication at the end of 1975 of the voluminous report of the German Enquête-commission; and the passing in 1978 of the notorious Italian Law 180, popularly known as Basaglia’s Law [12].

Significantly, the global picture of these three key decades (1950–1980) reveals that they were a time of radical breaks in the political, economic, social, and cultural order or, in other words, a period when some of the most outstanding aspects and correlates of our current social order spread more rapidly and with more universality than in previous decades [56, 57]. This is surely not the place to evaluate or even recount the profound consequences of the immense economic expansion, the unstoppable social revolution, or the deep cultural changes of this period, which led the influential British historian Eric Hobsbawm to define it as the “golden age” in which Western societies nurtured the “dream of an ever-growing prosperity” [58]. Yet what is highly interesting in the context of this article is the fact that these decisive transformations favored and went hand in hand with an increasing interest in the social integration of those population groups that were previously marginalized and subordinated. This is evidenced by the influential series of egalitarian movements for the emancipation of colonial populations, women’s rights, abolishment of racial discrimination, and, certainly, the situation of mental health patients. And, in most countries, the emergence of psychiatric reform projects and movements was indeed closely linked to a general climate of societal reform and an explicit public concern over the situation of marginal population groups [9, 10, 59, 60].

Seen from a social systems perspective, and as has been already pointed out, the eruption of these movements was a clear sign of the gradual abolition of an important historical obstacle to the principle of inclusion of all individuals in the different functional spheres of society (prescribed by the advance of functional differentiation and its normative correlates of freedom and equality). The extension of these typically modern postulates to traditionally marginalized population groups or, in other words, the collapse of the hierarchical order in those sectors of society where it had previously prevailed, forced the final recognition of the right of all individuals to take part without mediation in any functional areas of society. And hence, it can easily be seen how the decades following World War II overcame, in this decisive way, the historical and social context that had invented the old mental hospital.

Indeed, at the very moment when these processes of social change forced the majority recognition of full civil rights for mentally ill patients, the asylum—a hyper-inclusive space that widely limited the ability of its inmates to participate in other functional contexts [30, 61–63]—was uncovered as an obsolete institution that was incompatible with the values inspired by the new social order. Provided that, paraphrasing Luhmann, society no longer had any reasons to prevent psychiatric patients from using money, getting married, going to universities, voting, or reading newspapers, the practice of long-term internment of patients in large asylums isolated from the outer world became completely unjustifiable and even scandalous. And consequently, various countries hurried to reorganize their care networks according to the principles of community psychiatry, i.e., according to programs that were more suited to the normative pattern of inclusion or participation of all individuals in the different functional spheres of society.

But, beyond all these decisive changes in the social status of mental health patients, there is another important factor directly related to the consequences of the thorough modernization of Western societies that seems to have had a strong causal impact on the genesis of psychiatric deinstitutionalization. As has already been mentioned, the demand for psychiatric services among the general population has not stopped increasing in an exponential way in the last half century. This suggests that the social and cultural transformations in recent decades must have created a series of structural conditions that increased the demand for psychiatric treatment and care by a growing number of individuals. And, given that people presenting to psychiatric institutions in more recent years have sought help for much milder problems than those that affected the inmates of former asylums, the profile of these new users probably played a major role in the wide discrediting of the asylum order and the final establishment of the psychiatric reform projects. But, how could these recent processes of social and cultural change be responsible for promoting and increasing the use of psychiatric services, i.e., for generating new cases for psychiatry and even turning every single person into a potential user of mental health services?

The assumption of an intimate link between modernity—or even civilization—and mental illness has a long history that goes back to the foundational periods of psychiatry. This assumption provided the incipient asylum order with one of its most outstanding ideological principles [5, 29, 64]. But this link is also frequently postulated by an old and rich tradition going back to the founding fathers of sociology, which stresses the debilitating effects of modern life and institutions on self-experience and the emotions. Indeed, the analyses of Karl Marx on the alienating consequences of modern economic structures and relationships; Max Weber on the growing rationalization, secularization, and bureaucratization of modern life; and Émile Durkheim on the juggernaut of industrialization and the growing reflectiveness that have caused traditional values to lose their quasi-natural status have inspired manifold variations on this thesis. Their central argument could be synthesized as follows: in the course of a striking process of “general mobilization” (a term coined by Karl Deutsch), modernity breaks down the protective framework of the small community and tradition and replaces them with much larger, impersonal organizations; the individual feels thus bereft and alone in a world in which he lacks the support and the sense of security provided by more traditional settings, and this leads to the development of emotional disturbances or overt mental derangement [65, 66].

But, although these diagnoses have surely to be taken with some caution, there can be no doubt that modernity has provoked a remarkable internalization of behavioral control and the spreading of a pervasive ideology of self-contemplation, enhancement, and manipulation; it has witnessed the emergence of what the American essayist Philip Rieff once called the “modern psychological man” [67]. The generalization of this pattern of self-experience based on reflexivity and the promotion of interiority—i.e., the deployment of what may broadly be defined as the modern culture of subjectivity—has thus created the conditions in which a previously amorphous conglomerate of experiential and behavioral phenomena are now categorized as psychological distress and considered as states requiring specialized advice and treatment. In this context, it is not surprising that the concepts of psychiatry and psychology have finally penetrated nearly all spheres of daily life, and the strong upheaval of this process during the last decades has even led some commentators to speak of the recent emergence of an “advanced psychiatric society” [68].

Now bearing in mind the main lines of Luhmann’s comprehension of modern society, both mobilization-emancipation and subjectivization-individuation can be understood as two important correlates of what the primacy of functional differentiation has meant for particular individuals. Then, on the one hand, as has been already suggested, the progress of functional differentiation (i.e., the saturation of the individual with a multiplicity of roles that are increasingly disparate and his release into the high behavioral demands that are generated by the inflationary dynamics of the various function systems), has surely increased the “visibility” and perhaps the number of persons lacking the required initiative and self-reliance [69]. But, on the other hand, if functional differentiation makes the inclusion of individuals in a complete and exclusive way impossible, the individual has been liberated and emancipated from a good part of the bonds and constrictions of tradition; but he has in turn been forced to reflexively construct himself as a sort of remainder of all his partial inclusions in the different function systems. Consequently, under the structural conditions imposed by functional differentiation, the individual “can no longer feel himself as a firm and final point of reference, and, in order to be himself, he is always needing a further effort to achieve self-realization” [32].

According to Luhmann, then, the problems of individuality—as well as the contemporary environmental challenges—have to be seen as issues which are closely intertwined with the development of modern society as a functionally differentiated system: “the environmental problems caused by technology and overpopulation [and] the increasingly individualized and self-based expectations towards happiness and self-realization… are, as it is easy to see, a direct or indirect effect of modern social evolution, i.e., of the transition to functional differentiation” [35, p. 795]. But, moreover, they constitute two of the most important sources of the extraordinary “irritability,” the somewhat chaotic dynamism, and the feelings of omnipotence and insufficiency and of chance and despair that are characteristic of today’s society: “Today’s society offers topics like ‘identity’, ‘emancipation’ or ‘self-realization’ that promote the dismantling of social barriers, but it does not touch upon the issue of how individuals may take advantage of the available freedom and establish a satisfactory and meaningful relationship with themselves” [35, p. 805].

Concluding remarks

Accepting that as a result of the transformations of the last decades, psychiatric institutions have moved from taking charge of the medical and social care of the mad and the severely mentally ill—i.e., from administering and managing those with a marginal status in society—to dealing with the specialized (medical and psychological) care of the whole population, it is undeniable that this mutation points to a notable socialization and democratization in the patterns of mental health care provision. The function fulfilled now by psychiatry is, in this sense, much less intensive and is not limited to a hierarchically lower group of society but, rather, exists in the egalitarian plot of modern society. The mental patient, finally, has thus become an affected person or a sick citizen, a user, ultimately, to whom certain rights have been awarded but to whom the current systems of care can only offer punctual and specialized treatment. And, as we have seen, everything suggests that this new pattern of intervention is well-adjusted to the problems of relatively well-integrated individuals who, while consulting mental health services, are capable of keeping a job, a family, or other personal or social resources. But chronic and disabled patients, who may eventually require interventions that cannot be limited to punctual and selective care, clearly do not fit as well into the system’s modus operandi.

These considerations and the presented account on the recent evolution of mental health care thus lead to a forecast on its future prospects that is widely coincident with the one advanced by other authors [12, 13] and is certainly not encouraging. One concern is the fact that the overall demand on mental health services is likely to continue increasing and may soon overwhelm the system’s ability to meet them. But beyond the fate that seems to await certain resources or therapeutic means, the most problematic and worrying concern is that the structural conditions imposed by the new short-term and treatment-centered patterns of intervention will tend to maintain, and probably further accentuate, the unfavorable situation, or even the overt exclusion, of a good part of patients who are affected by chronic or severe mental disorders. As stated in a recent review of the evolution of psychiatric care in the European Union, the bitter irony of the whole project of deinstitutionalization and reform of mental health services of the last few decades is precisely that it was a response, in part, to societal concerns about the conditions experienced by long-term residents of the old mental hospitals. But “now it is clear that this group, who was supposed to benefit most from the closure of institutions, has in many cases fared worst” [70]. And a probable consequence of this may be the maintenance or the future creation of new total institutions that, this time, will be beyond the reach and control of psychiatry and one day be even more difficult to reform than the old asylum system was.