The new custodians: Spinning wheels in mental health services for the chronic client

The custodial nature of the asylum evolved over time in response to the needs of the clientele which included the patients, the community and the families of the ill. An outpatient program designed to provide co-ordinated, comprehensive, continuing care to clients with a diagnosis of schizophrenia similarly evolved over the years 1980-1988 in response to the needs of the sponsoring hospital, the community and the government Ministry of Health. The program began in conditions of resource scarcity and was unable to secure funding to provide the range of services necessary to facilitate rehabilitation and community integration for the clients. Maintenance in the community and supportive services to the families and clients met the goals of the decision makers and funders, but not the goals of the program founders, their clients or the clients' families. Participant observation research over a three and a half year period and document analysis of the history of the program were used to discover the process of cycles of change in the program's development and the clinician's initiation of and responses to those developmental changes. The chronological ethnography of the work of mental health workers in the 1980's reveals that many of the problems they face in instituting adequate systems of service to the chronically mentally ill are embedded in social structures and cultural values which have not changed, despite changes in the locale of treatment and containment, since the policy of deinstitutionalization was implemented.