Will Portugal Copy Our Mistakes?

 The advocacy group Encontrar+SE invited me to Porto, Portugal recently to speak about the closing of our state mental hospitals here in the U.S. This was my third overseas trip, having gone to Iceland and Brazil last year.  

Founded in 2006, Encontrar+SE   is the creation of Filipa Palha, a psychologist, university professor, and determined mental health activist who is trying to make Portuguese health officials accountable.

The government there has announced plans to close all of the nation’s mental hospitals, but it has not allocated any money nor taken any steps to create community-based mental health services.

Sound familiar?

Because Filipa is a gracious hostess, she asked when I arrived if I wanted to tour the coastal city’s many cultural sites. Porto is most famous for its wines, including PORT.  

I appreciated her offer, but asked instead to visit a mental hospital. She arranged for me to tour the Centro Hospitalar Conde de Ferreira, one of the oldest and largest in Portugal and one of the facilities that the government hopes to close.

Whenever I tour a hospital, I look for several things. Cleanliness often reflects on how well a facility is run.  I observe how patients react when they see visitors. Oftentimes, a psychiatrist or a hospital administer will give me a tour and if  he/she is immediately surrounded by complaining patients, I know my tour guide hasn’t been in that ward for a long time. Otherwise, why the mob? Why the complaints? Why the urgency? I also watch to see if patients are engaged in meaningful activities or if they are simply smoking cigarettes and watching television.

The hospital director, its’ chief psychiatrist, a psychologist and social worker were waiting to greet me and each talked proudly about the facility and their therapy programs.

Because of our checkered past in the U.S. when it comes to mental hospitals, many Americans view state institutions with suspicion and automatically assume they are snake pits where people are warehoused, over-medicated and abused.

That’s not what I saw in Porto.

Obviously during a short tour, you are only able to get general impressions. Mine were favorable. The hospital was clean, the workers friendly, and the patients appeared to be getting good care.

I noticed several differences from the U.S. mental hospitals that I have visited. A large number patients were elderly, infirm and suffered from dementia. There were also wards that housed persons with Down’s Syndrome and autism.  The most common mental illness was schizophrenia.  There were no patients who’d been diagnosed with bipolar disorder or major depression.    

In Portugal, the government pays the Roman Catholic Church to operate its mental hospitals. This is because Portugal has a thousand year history, the population is largely catholic and the church has traditionally proved social services for the poor, elderly, infirm and those with mental disorders.

Prior to Filipa creating Encontrar+SE, there were no mental health advocacy groups in Portugal.  There are no consumer run organizations, no civil rights lawyers eager to file class-action lawsuits or support organizations, such as Mental Health America, the National Alliance on Mental Illness or the Depression, Bipolar Support Alliance.

 I’m not sure if this lack of advocacy is because the church has been in charge of caring for persons with mental disorders for so long and the public trusts it or if stigma has kept consumers and their loved ones from organizing.

I noticed in Portugal that people did not seem afraid to send someone to a mental hospital. This is similar to what I noted in Iceland and Brazil. The feeling that I encountered was: where else would someone go for treatment?

Because the hospitals are run by the catholic church, the hospital directors can supplement the bare bones budget that state officials allocate with charity funds, but this is done sparingly.

One of Filipa’s biggest worries is that Portugal’s Ministry of Health does not have a separate budget for mental health. Instead, those services have to compete with other government health programs. How, she asks, will the nation be able to make the transition to community mental health centers if there is no separate budget to fund those services?

So why is Portugal closing its hospitals?

From what I could tell, it’s because of the influence of the U.S. and other nations that have concluded that institutionalization is harmful to people whether they are isolated in hospitals or prisons. Many of Portugal’s psychiatrists were trained in the U.S. and were taught that community based care and inclusion in society are the best ways to help people recover.

But I also suspect that the Portuguese government hopes to save money by shuttering its hospitals. Apparently, even in a socialist country, cutting costs matters.

Filipa asked me to talk about how the U.S. undertook deinstitutionalization –so I spoke about how we had shoved thousands and thousands of sick patients out onto the streets overnight without creating a viable safety net for them. The result was homelessness, lives spent in shabby nursing homes and under-funded assisted living facilities, and a trans-institutionalization for many patients from mental wards to our jails and prisons.

I explained that I am an advocate of community based mental health programs and believe everyone should have the opportunity to recover in a community setting if they are able. But the main thrust of my talk was about how important it is for Portugal to avoid our mistakes and not close its hospitals without first having adequate community services in place.

At a well-attended public meeting held in one of Porto’s largest museums, the government official responsible for shutting down the hospitals became visibly irritated when Filipa used a power point presentation to illustrate how Portuguese officials have been making promises about “psycho-social rehabilitation” (community treatment) without doing anything to actually provide those services.

The official insisted that the hospitals needed and were going to be closed regardless of what Filipa and other prominent psychologists and psychiatrists said. The only way to push the mental health system forward was to close down the hospitals. In the long run, shutting the hospitals would be in the best interests of the patients, he said.

Filipa countered by arguing that the hospitals in Portugal were already part of their respective communities and didn’t need to be closed. Rather, they needed to remain open and be included as part of an overall community treatment program. The hospitals, she argued, would be needed for persons who required long term care.

Their argument made me feel a sense of déjà vu, having heard similar back-and-forth debates when I was a young reporter in the 1970s in Kansas and Oklahoma covering the closing of state hospitals.

I remember one distraught mother from Emporia, Kansas, who had a son with multiple mental and physical problems telling an audience that she couldn’t take care of her son’s needs and there were no facilities in her community where he could go. If the hospital closed, she didn’t know what would become of them both.

When my tour of the Porto hospital ended, the hospital director said: “If we close this hospital, most of these patients, especially the older ones, will have nowhere to go. These are not only patients. They are like my mother and my father. What will happen to them? Where will they go?”

Over the years, I often have thought about that mother and her son in Emporia and wondered what became of them. As I returned home from Portugal, I wondered what would happen to those patients in Porto and whether Filipa will be able to prevent her government from repeating our country’s mistakes in the name of “what’s best for the patients.”

I hope so.

(Next: A story about an innovative and effective program that Filipa launched in Portugal to fight

About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.