Towards an acute care hospital

In November 1993 (when Dr Pellegrini was appointed director by the province’s ministry of health), the San Luis psychiatric hospital had between 100 and 120 beds, occupied at 100 %, with an average length of stay of seven and a half years. In 1998 there were eleven beds, occupied at 65 %, with an average length of stay of eight days. The hospital was a classic asylum, a reference point for the centre of the country. To the indefinite number of inmates, typical of asylum institutions, was added committal as an ambiguous notion, with no clear purpose, for an uncertain and arbitrary length of time, left at the mercy of the abuse of power of the professionals in charge of it.

In an Argentina where words emptied of their content are the fashion, Pellegrini is an example of consistency. He always had clearly in mind the difference between saying “we are going to transform” and living through that transformation. That is why he moved into the hospital to live there: he knew, from his earlier experience in Chubut, that he had to move fast; before resistance from the sectors affected could appear, he had to have a base of results with which to defend the process of change.

They began by declaring the hospital in assembly for a week. In a place where clinical files were only very rarely updated, the professionals said they could not attend the assembly because they had precisely those files to update. At the end of those five days it was decided unanimously (with the exception of the former director, who resigned) to turn the hospital into an acute care hospital. That was not the initial plan, but the decision of the people gathered in assembly went no further. For Pellegrini, it was of fundamental importance to generate a process of democratic participation that would allow a movement of opinion.

Two concrete decisions were taken: to stop admitting chronic patients and to take the hospital out into the street. But the main challenge was to transform this institution with the very people who had sustained the asylum for twenty-five years: the professionals, the workers, the patients and the families.

Pellegrini says:

Everyone agreed to close the door to chronic patients, but they kept arriving, and with recommendations that it was recommended not to refuse. They went back to basics: diagnosis, prognosis and treatment. In this way the hospital’s health dimension was restored and its specific task recovered.

The argument “poor man, he has nowhere to go” also weighed enormously — as if he had not come from somewhere. They began to call in the families. An end was put to that great myth of the bad, abandoning family. There were families who abandoned, but others did not. The institution had never helped relatives to help, because it had left them on the other side of the door.

Asylums gradually strip people of everything they can freely decide: inmates do not decide what time they get up or go to bed, nor what clothes they wear, nor how long their hair is; they decide nothing. They become dependent, they become institutionalised, so that every day that passes adds difficulties to social reintegration.

The health of health workers

At first the staff believed that the Monday assemblies were there to talk about the patients and, since the patients were not there… talking about the absent was fantastic. Following Pichon-Rivière, interventions in the assembly had to bear on those present and be made in the first person singular.

It was common to hear interventions that deposited responsibility for the problem outside: “I cannot work in the hospital because they do not give me a secretary, because they do not give me a decent consulting room, because I have no medication.” The assembly, like an operative group, centred on the task and on the actions each member could carry out to make the transformation that had been decided a material reality.

There were four three-walled punishment cells, closed by a sheet of metal, as in prison, and therefore dark. One patient stayed a year and a half in those conditions. In January 1994, Pellegrini proposed closing them. He was in an absolute minority. The nurses defended them and, from another angle, many professionals said it was necessary to establish a system of rewards and punishments.

One day, at two in the afternoon, a woman who was in one of those cells set fire to her mattress. Fortunately, since the cell was airtight, the smoke began to come out from under the door. The nurses did not want to open it, for fear the patient would kill them. They finally opened the door and took the woman to intensive care. Pellegrini put the question back on the table in the assembly and it had to be voted on. The argument of the resistance was: “now the patients will take revenge”; Pellegrini replied: “get ready, because there may be some just revenges”. There was no revenge, there was no violence, and people began to see that another path was possible.

The need to widen the spaces of democratic participation and to open a new programme became obvious; it began in February 1994: “Taking care of the health of health workers”. They started very early in the morning, with massage, relaxation and psychodramatic techniques. They gradually realised that everyone “had their own little garden”; they spoke of the pains in the bodies of the women who did the laundry, of the heavy pots of the cooks, of the scars — from blows — of the nurses. They began to recognise each person’s fears and obstacles; the staff became aware of the cruelty and the damage they had produced with the punishment cells. Something similar happened when those who had applied electroshock perceived that better results were obtained by talking with the patient. They were able to tell how they became attached to patients, how they suffered when they left and wondered what would become of them. Many were ashamed to work in the hospital, where they would not for anything in the world have taken their own children. Later, they learnt to contain a crisis through contact, without medication, and the patients began to speak of what they felt. The institution too was a patient: it had to stand in front of the mirror with its history.

The hospital in the street

At the same time, the hospital in the street began on the very first day. Pellegrini proposed going out with the patients. They were over-medicated patients, who slept twenty hours a day, pale, with wasted muscles. They would walk one or two hundred metres and fall.

The psychiatrists had to review the doses of medication they prescribed, since with those doses one could not walk. In sixty days they reduced the medication by 90 %: out of ten drugs, only one was still given. The patients began to go out further and further. Crossing the road was a discussion that took two assemblies: “we cannot cross the road, they will be run over…”. For Pellegrini, these were overprotective arguments aimed at keeping the asylum from changing.

Pellegrini went out with a few professionals who gradually joined in — the young ones above all — and some nurses. It was demonstrated that one could cross the road, and that one could cross it to come back. From then on, a whole series of arguments that were then discussed in the assembly — and during the compulsory ward round, every day — began to collapse, until it became necessary to discuss the foundations on which the institution rested; and from December a social reintegration plan began, which was what provoked the first great resistance.

It was classic, in the asylum, to think that at Christmas and at birthdays everyone is good. They would celebrate the birthday of a man shut up for years (one of them had been there for thirty-five years). Pellegrini says:

In the first half of 1994 they were already taking the bus. The hospital had a bus, but they wanted to use public transport. At first the patients would get on the bus and the driver looked more in his rear-view mirror than in front of him, while the passengers looked out of the windows. They went to the ice-cream shop, to the cathedral, to radio stations, into the town centre. They wanted to place the problem in the centre of the city, so that no one could say they did not see what they did not want to see.

Among the population there were people who saw them coming and crossed to the other pavement, who looked away; but others watched from a distance, saying “poor man”, “it is so long since I saw him!”; an ice-cream seller offered them ice creams. The community’s position was not univocal. There appeared wishes to deny the problem, disgust, rejection, but also people who wanted to repair what had happened, to help. In April a campaign against the experience began, led by the most reactionary sectors of San Luis. That campaign said: “what is going on, are the madmen wandering about free? madmen are dangerous, bad, dirty, they have no possibility of transforming anything at all”. Those madmen were out in the street and, for five months, none of them did anything dangerous. The campaign began to deflate, but not the resistance to change. Pellegrini says:

A home care system was set up which covers 45,000 km a year — in a province that is nonetheless very small —, which in return generated greater demand. There were people who had lost their place, others who still had one. Families who said: “we have sheets of metal, let us gather some bricks”. Throughout that year 1994 there was a great deal of discussion, but discussions of one hour, then to practice: reality is changed by acts, not by words.

It was very difficult for the psychiatrists and psychologists, especially those with psychoanalytic training, to understand that the problem of a person who has been in the asylum for thirty years is not resolved by an interpretation: in order to be able to leave, that person had to have somewhere to go. The social workers were essential, but there were very few of them. The hospital staff had to be trained in social work. To be trained to help — with the family and the neighbours — to build a wall, to make a roof.

Social reintegration was one thing; throwing patients out of the hospital and then losing interest in them was quite another.

For Pellegrini:

The resistance of the psychiatrists and psychologists to home visits was very fierce. Today it is what is done most. When you enter a house, you perceive whether there is fear or abandonment, you get to know ways of living, the neighbourhood, and you can make a diagnosis that includes what you see, and not only what you are told. Staying in the hospital waiting for the finished product and making the diagnosis on the basis of what you are told is professional naivety.

In February 1994 it became obvious that they had to study patient by patient — one hundred and thirty people at that moment — and diagnose them. The diagnoses dated from their admission, some from 1982. Pellegrini says:

The absolutely predominant diagnosis was “social and family abandonment, institutionalisation”. That was what had to be operated on, and not the paranoid schizophrenia diagnosed in 1982 which, at that stage — if it persisted — was a residual situation. If the institution moves, everything moves; and one has to begin by moving the heads of those who work in it.

Building networks

There is no human being who has no one; what happens is that no one looks. To reintegrate socially, one must gradually build a system of social points of support: the periodic visit of the hospital team must be articulated with some form of social holding.

The question of the unions was very difficult, because professional roles and everyone’s prerogatives were called into question. The professionals argued about guarding sectoral privileges, whereas prerogatives should be discussed in terms of the task. No one knew how to do community social work, starting with the social workers, used to the office and the telephone. They had to go and work in the street. The psychologists were not prepared for it, but they had to go. Today twenty home visits a day are made. Many patients in crisis have a containing family and are hospitalised at home. Others leave, but need support at home. The team is made up of two nurses, two psychologists, an occupational therapist and — if necessary — a psychiatrist.

25 % of long-stay patients needed to be readmitted. They were readmitted for eight or ten days, then left again. But the periods between one admission and the next grew longer, because they began to have supports in the community. In August 1997 there remained ten patients for whom no support could be found, no family, institutional or neighbourhood reference. The system of subsidised host families was then created, and not halfway houses. A decree was signed, in whose preamble the provincial State acknowledged having generated this damage and having the ethical and institutional obligation to make reparation to these ten people. They were not creating a programme with a variable number of beneficiaries, which would then end up being bigger than the hospital: the resolution applied to those ten, who belonged to the “chronic ward” of a hospital which had itself been transformed.

They went to two houses, with people trained by the hospital staff. They were human beings autonomous in the gestures of daily life, in a situation of social and family abandonment. The result was excellent. In a house one can choose, and social skills are gradually recovered. One of them joined the club, another began working in a bakery; little by little they entered the neighbourhood.

Today the average length of stay is seven and a half days. It has been established that, for San Luis, the demand for beds that has proved effective is five beds for men, five beds for women and one individual bed for people in crisis.

In the old model, the hospital was a funnel: every patient who fell ill in the province was sent there. With the transformation came the development of work with the community, workshops on AIDS and the Institutional Groups on Alcoholism, in the hospital as well as in schools; and the number of consultations increased. The working model was reproduced across the province: beds for brief psychiatric admission appeared in other institutions and the municipalities began to consider specific solutions for each case, generating in the province a mental health network of home care for which the hospital is the reference.

The judiciary

Complaint and paralysis also had to do with other institutions. In the assembly it was usual to hear: “that patient, we cannot discharge her because it was judge so-and-so who had her admitted”, “the judges never come and see”, “why would they come? can’t you see they think they are gods?”. Once again, they were talking about someone who was not there: the obstacle was deposited outside. Those present bore no responsibility. The court order said “admit”.

The principle of saying neither good nor ill of the absent, of waiting until they are there and answer for themselves, put an end to corridor gossip and tale-telling. Health professionals thought they were gods too: they did not go to the courthouse either.

They decided to go to the courts, but first they had to know who the person they were going to talk about was. It was not a matter of going and saying: “we have sixty inmates, we want sixty discharges”. Putting things case by case forced them to study, to know who this person was — and they began to personalise treatments. It was no longer enough to hand out haloperidol and Artane in bulk.

A patient turned up whose reason for consulting, eight years earlier, had been a headache. He did not know why he was in hospital. Going to where he had lived, they discovered that he had owned a plot of land, since crossed by a road, whose value had increased enormously. The land had already been sold. There was a family… a police superintendent, a lawyer and a judge.

Another patient — who, twelve years earlier, had had a schizo-paranoid episode — had killed his brother and pulled the trigger against his mother’s head, but the weapon had jammed. It was not simple: the case had had a great deal of coverage in the media. It could not be spoken of without serious argument.

The question of the judiciary was a very great learning experience. They went there in delegations of twenty people, but not to offend nor to threaten: they were keen that the judge should hear what the nurse of each of the teams said about the patient. They took the patients along — seeing a file is one thing, seeing the person is another —, then they explained, then they looked for alternatives. At first it was very hard, because there was a great deal of resentment, too much stupid professional pride — among the lawyers as much as among the health professionals. Then, when both sides saw that things could be modified, they began to have a different relationship. In 1999 the last patient placed by the courts left the hospital.

By recovering the person, by putting an end to the herd, by carrying out different treatments, by recovering — or not — the family, by seeing that the neighbourhood accepted them, depersonalisation and massification came to an end. It took three years; people began to appear for the judges too: they were no longer the sixty men stuffed into the psychiatric hospital. But every decision had to be argued for, not as an academic debate, but in the form of practical proposals for each case. It was a work of great perseverance, which watched over not only the human rights of the patients but also those of the professionals, who were not jailers.

Very interesting formulas have gradually been tried out. There are patients who are at home under a court decision obliging the family institution to take charge. The hospital was no longer solely responsible. There was one judgment that represented a year of work. A woman who had been in hospital for a long time had a house she shared with her husband, who had set up home with another woman. The woman had been discharged. The judgment obliges the husband to pay her a monthly allowance thanks to which her place in a host family is guaranteed.

The backlash

When, in eight months, this process began to reintegrate half of the patients deposited there, a very violent bombardment began. Two criminal complaints were filed, one against Pellegrini and the other against the technical team, for abandoning patients. Members of parliament who had never set foot in the hospital started defending patients’ right to be cared for.

In that hospital there were women who, during their stay, had had three children by three different fathers, unknown but suspected; there had been homicides between patients; living conditions were sub-human and a good part of the discharges were by death — but at that time there were no human rights. When the situation began to be transformed, the management was summoned before the legislative assembly. The hospital as a whole decided to defend the experience together with the families and the patients.

It is usual, in Buenos Aires, for people to say to Pellegrini with a smile: “that can be done because it is a small town, but here it is extremely difficult”. San Luis has 150,000 inhabitants; in a small town, not even an infidelity can be hidden. There, a discharge from hospital cannot be concealed: at once, the telephones would start. “There goes mad Pérez… how could they have let that one out?” In the city of Buenos Aires, no one knows the past of the man sleeping under the motorway; there, everyone knows who he is, what he does, what past he has, the man sleeping in the square — and consequently the impact of a process of transformation is very great. At the supermarket, the hospital staff run into the families, who insult them or thank them. That began to break the “the madman is yours”: “he is your father, your husband or your son; what are you going to do?” It is a matter of sending back the social pressure to accept the deposit, of sending it back with support.

Within the walls

There were other changes that altered the life of the hospital for good. In 1997 a single-specialty hospital was turned into a general hospital. The hospital is located in a community of 25,000 inhabitants. A wing left free in the course of the transformation was renovated; consulting rooms were opened there for a dentist, a paediatrician, a general practitioner, a medical analysis laboratory, three nurses and two health agents, and work began on the population’s demand for health care. Pellegrini remembers:

The works cleared the corridors of their security doors; and the kitchen, which in the previous period was a kind of inaccessible bunker that could only be reached from outside, became a place integrated into the hospital.

Since 1998, patients in crisis are admitted together with their family, which required transforming part of the hospital; but they eat there, family therapy begins in the midst of the crisis, the relatives know what being in hospital is, they do not leave the problem behind and go away, and they stay involved. If they come expecting a deposit, they have to deposit themselves along with the patient. This situation makes it possible to understand family dynamics that occur from the first day, to hear conversations that take place from the first day.

Finally, it should be mentioned that the hospital, today a teaching hospital, has a fruitful teaching activity which includes, among other things, a placement scheme with board and lodging. (Hospital Escuela de Salud Mental, hospimen@sanluis.gov.ar)