The authors’ diagnosis begins with an observation about language. When deinstitutionalisation re-emerged on the global mental health agenda in recent years, it did so largely because investigators and advocates documented the persistence of long-term institutionalisation and serious human rights abuses inside psychiatric facilities, from locked wards in high-income countries to large custodial complexes in low- and middle-income settings. Yet the responses that followed, they argue, have been framed overwhelmingly in managerial and technocratic terms. Reform is described as a matter of service coverage, of reducing bed numbers, of expanding the mental health workforce, and of designing interventions that can be scaled across diverse health systems. These are legitimate operational concerns, but the authors warn that when they become the entire vocabulary of reform, they obscure the institutional, political and social conditions through which psychiatric care is actually organised.

That narrowing has consequences. A policy framework that measures success in beds closed and patients reassigned can coexist comfortably with practices that reproduce segregation under new names. The essay points to transinstitutionalisation, the well-documented drift of institutionalised people from psychiatric hospitals into other custodial or quasi-custodial settings such as nursing homes, shelters, forensic facilities, private care homes and the streets, as evidence that closing a hospital does not by itself dismantle the logic of confinement. It also points to fragmented systems of community care that, in the absence of adequate housing, income, work and social support, leave former patients circulating between emergency departments, police cells and short-stay units. Most insidiously, custodial and segregationist logics can persist inside nominally community-based services, where group homes and day centres may replicate the routines, hierarchies and restrictions of the wards they replaced.

To recover the fuller meaning of reform, the authors turn to history, and specifically to South America, a region they argue has been systematically marginalised in the geographies of mental health reform knowledge. The dominant narrative of deinstitutionalisation, built around Basaglia’s Italy and the community psychiatry movements of the United States and Britain, treats the Global South as a latecomer importing models developed elsewhere. The South American record tells a different story. In Brazil, the psychiatric reform movement that emerged in the late 1970s and 1980s was inseparable from the struggle against military dictatorship and the broader democratisation of society. Mental health workers, users and families organised politically, and the movement’s demands were written into law: the 2001 Brazilian mental health law oriented the national system toward the substitution of hospitals with open, community-based psychosocial care networks. Deinstitutionalisation there was not a health-sector technical adjustment but a citizenship project, contested in congresses, conferences and the streets.

Argentina offers a parallel trajectory with its own inflections. The Argentine movement, likewise entwined with human rights activism that gained urgency after the return to democracy in 1983, culminated in a 2010 national law that explicitly framed mental health care in rights-based terms, declared the goal of reducing hospitalisation and established the presumption of capacity for people with mental health conditions. In both countries, the authors suggest, the relationship between institutional transformation, democratisation, social mobilisation and citizenship was constitutive rather than incidental: the shape of psychiatric reform reflected the shape of the political order being fought for. These histories demonstrate that deinstitutionalisation has developed through distinct national configurations rather than a single exportable blueprint, and that the direction of reform depends on who holds power over the definition of madness and its treatment.

The South American experience also furnishes cautionary lessons. Even where legal frameworks are ambitious and substitute services exist, implementation has been uneven, funding fragile and hospital sectors resilient. Brazil’s psychosocial care network, despite its international reputation, has faced periods of retrenchment and political contestation, and large psychiatric hospitals have proved difficult to close in practice. The persistence of custodial arrangements, including privately run therapeutic communities and faith-based asylums that have grown in some contexts, illustrates the authors’ point that institutional logics migrate and mutate rather than simply disappear. Reform, on this reading, is never a milestone reached but a horizon that must be actively defended against regressive pressures, a framing that explains why the authors describe deinstitutionalisation as a contested horizon rather than a legacy.

From this analysis the essay derives three lenses for re-engaging with psychiatric deinstitutionalisation. The first is attention to context and history: reform proposals should be read against the specific political, economic and institutional conditions of the places where they are applied, rather than evaluated against a universal template derived from a handful of canonical cases. The second is the decentring of dominant geographies of reform, which means treating South America, and by extension other regions outside the usual centres of knowledge production, as sources of theory and strategy rather than merely sites of implementation. The third is the foregrounding of lived experience, which places the knowledge of people who have been institutionalised, and of their families and movements, at the centre of what counts as evidence about care, coercion and community.

These lenses are not merely interpretive; they redirect attention to the concrete sites where reform is produced. The authors enumerate them across research, policy, professional training, activism and governance. What researchers choose to measure, what curricula teach future psychiatrists and psychologists about the history of their institutions, what advocacy coalitions demand, and how governance structures distribute authority over mental health budgets all shape whether reform deepens or stalls. A technocratic framing tends to concentrate these decisions among planners and funders; a political framing recognises that the boundaries of the psychiatric institution are negotiated in legislatures, courtrooms, user movements and neighbourhood clinics. The essay’s contribution is to insist that these sites, and the social struggles that play out within them, are proper objects of global mental health scholarship rather than background noise to service-design questions.

The argument lands at a moment when the global mental health field is expanding rapidly, driven by the enormous burden of mental disorders, the scale-up agendas of international agencies and a growing rights discourse exemplified by the United Nations Convention on the Rights of Persons with Disabilities. That convergence creates both an opening and a risk. The opening is that a new generation of practitioners and policymakers is asking, many for the first time, what should be done with the large institutions that still hold hundreds of thousands of people worldwide. The risk is that the answer defaults to a narrow toolkit of bed reduction and task-shifting that leaves the underlying architecture of exclusion intact. Montenegro and colleagues’ intervention is a reminder that the founders of deinstitutionalisation were not primarily optimising service delivery; they were contesting the power of the asylum and asserting the full citizenship of its inmates.

Reclaiming that horizon, the authors conclude, means accepting that deinstitutionalisation is not a policy that was tried and found wanting, but a project that remains incomplete and continually contested. The South American trajectories, with their fusion of clinical innovation, legal transformation and social mobilisation, show that another relationship between mental health care and the state is possible, and also that gains can be reversed when the political conditions that produced them erode. For a field increasingly fluent in metrics, the essay’s most provocative claim is that the most important outcomes of psychiatric reform, dignity, autonomy and belonging, are precisely the ones that resist measurement by bed counts and coverage targets, and that the future of global mental health will depend on whether it can learn to see them.

Subject of Research: Psychiatric deinstitutionalisation and the politics of mental health reform in global mental health

Article Title: Why deinstitutionalisation still matters: Reclaiming a contested horizon in global mental health

Article References: Montenegro, C., Szabzon, F., Bowen, S., & da Mosto, D. (2026). Why deinstitutionalisation still matters: Reclaiming a contested horizon in global mental health. PLOS Mental Health, 3(9), e0000699. https://doi.org/10.1371/journal.pmen.0000699

Image Credits: AI Generated

DOI: 10.1371/journal.pmen.0000699

Keywords: deinstitutionalisation, global mental health, psychiatric reform, human rights, South America, community care, transinstitutionalisation, citizenship, mental health policy, social mobilisation, institutional reform, lived experience

The study, published in April 2026, is built on semi-structured narrative interviews conducted between July and November 2025, including an on-site return to Leros itself. Baldi, trained in Franco Basaglia’s Department of Mental Health in Trieste, served between 1990 and 1995 as scientific consultant and training coordinator for the Italian team charged with dismantling the Leros State Hospital under European Community funding. The methodology deliberately preserves her first-person voice, following principles of narrative inquiry and the COREQ reporting guidelines, and pairs the testimony with photographic documentation of the hospital’s decaying pavilions. The researchers frame the account through Judith Butler and Athena Athanasiou’s concept of dispossession and through Basaglia’s principle of institutional negation, the idea that the asylum itself, not merely its conditions, must be abolished.

What Baldi found when she first entered the wards in early 1990 defies easy description. More than 1,200 people were confined in the hospital, many of them deported decades earlier from overcrowded mainland asylums, some transported by military ships with numbered tags pinned to their chests that the wind had blown away, erasing their identities forever. Clinical records frequently contained question marks instead of names. Patients lived naked or in rags, unwashed, malnourished and anemic, crowded around a single stove in winter. Food was sometimes poured directly onto tables without plates or cutlery. In Ward 2 for women, Baldi witnessed three naked women crouched under a table, embracing, one of them throwing her own feces against a window. A visiting Irish priest fled the ward and fell to his knees outside, screaming at the sky. Baldi herself walked to a nearby beach and screamed into the waves.

The historical stratification of the island explains how such a place could exist at the heart of late twentieth-century Europe. Italian from 1912 to 1946 and transformed by fascism into a military stronghold, Leros passed to Greece in 1947 and was repurposed for successive waves of confinement: re-education schools for thousands of children of civil-war dissidents in 1949, a colony for psychiatric deportees from 1958, and a detention camp for roughly 4,000 political prisoners under the Colonels’ dictatorship between 1967 and 1974. The psychiatric population swelled from 650 beds to nearly 2,750 by 1981. The scandal finally broke in the 1980s through young doctors’ denunciations at international conferences, a 1982 documentary titled Azititi, and an Observer investigation in 1989 headlined Europe’s Guilty Secret, prompting the European Parliament to consider sanctions against Greece.

The deinstitutionalization project that followed was anything but smooth. An earlier EEC-funded reform in 1984 had produced almost nothing: barely a fifth of the money was spent, patients were merely sorted into diagnostic wards, and NGO-run hostels selected the quietest, most manageable inmates while leaving roughly a thousand untouched. The Trieste team, working with Greek psychiatrist Theodoros Megaloeconomou, secured a separate project covering the notorious Pavilions 11 and 16, funded at 465 million drachmas, about a third of the first program’s budget. Their approach clashed fundamentally with a rival conception of reform. Where English and Dutch teams defined humanization as cleaner walls and adequate food within the hospital enclosure, the Italians insisted on what they called deinstitutionalization: the negation of the asylum as such, the restoration of legal rights, freedom of movement, work, biographical identity and self-determination.

The practical mechanics of that transformation, recounted in granular detail in the testimony, read like a manual of radical patience. Team members entered the wards daily with cigarettes, biscuits and chocolate, washing and dressing patients who had not spoken in years, teaching them to use cutlery and to dress themselves. They battled the administration over padlocked personal wardrobes, bought padlocks with their own money when tenders stalled, and repaired punctured wheelchair tires every morning until the attendants understood the point being made. Medication, previously administered in massive doses, was gradually and almost entirely eliminated to avoid rebound effects. Former inmates were moved into officers’ villas and later into twenty apartments and small prefabricated houses across the island, supported by an agricultural cooperative, ceramics and painting workshops, and a theater group that performed at the Aegean Theater Festival. In one emblematic scene from Easter 1994, the Greek Deputy Minister of Health joined the cast on stage, chanting a refrain from the independence struggle: better one hour of free life than forty years of slavery.

The study is equally candid about the political economy that resisted every step. The hospital was the island’s economic engine, employing more than 900 attendants, and a network of suppliers, politicians and administrators profited from the status quo. The first hospital board obstructed the Italian team, denied resources, personally attacked the workers and even threw their scooters into the sea. Tourism operators feared the sight of former patients would repel visitors. Only when former inmates began frequenting taverns and shops, redistributing hospital money into the local economy, and when attendants realized that small community residences meant better working conditions, did the opposition crumble. Follow-up evaluations three to four years after the team’s departure revealed the limits of what five years could achieve: 92.6 percent of former patients reported satisfaction with their new lives, but 62.1 percent had no family contact and only 31.6 percent were employed, a measure of how profoundly decades of institutionalization had damaged the capacity for autonomous social life.

The bitterest irony anchors the study’s contemporary argument. When Baldi returned to Leros in 2015 for a twentieth-anniversary conference, she found the island beautified by tourism, and on a hill above the bay, a gleaming new structure built to hold two thousand migrants. The island of deportation had become, once again, a site of confinement, now hosting a massive migrant detention center. Drawing on Butler and Athanasiou, the authors argue that territories made economically dependent on managing confined populations will seek replacement populations when one group is liberated, and that dispossession operates relationally, with precarious communities participating in the confinement of those more vulnerable still. The asylum closes; its function is dispersed and renamed, surfacing in repatriation detention centers, forensic psychiatric units, involuntary treatment orders, mechanical restraint still practiced in European wards, and community mental health services that increasingly select patients by narrow diagnostic thresholds while excluding those whose suffering does not qualify as severe.

This displacement, the authors contend, falsifies the progressive narrative that the closure of the asylums represented irreversible humanitarian progress. During the COVID-19 pandemic, Italy extended involuntary psychiatric treatment to adolescents in acute crisis, a departure from the principles of Law 180 of 1978, the Basaglia Law that abolished Italian asylums. Baldi’s testimony defends that law fiercely, arguing that its apparent failures stem from political under-implementation and chronic underfunding of territorial services rather than from its principles, and that the Trieste department remains a World Health Organization collaborating center. What the Leros case demonstrates, technically and politically, is that deinstitutionalization cannot succeed as a purely clinical or administrative operation. It requires confronting the local political economies, the mafia-like supplier networks, the employment dependence, the cultural fear, that make total institutions desirable to the communities that host them, and it requires transforming economic and social relations so that territories no longer need confined populations to survive.

The study closes without romanticizing its own history. Baldi acknowledges what remained unfinished: legal status could not be changed, since discharge meant losing all assistance, so the hospital administratively persists, caring today for roughly seventy people from those years in small residential houses. Some stories ended in tragedy, including a young man who, after losing the friend who had anchored him, hid his medications and let himself die. Yet the testimony insists on what was proven possible, in Basaglia’s own phrase, that the impossible is possible when collective action is sustained by ethical commitment. As new walls and barbed wire rise across Europe around migrants, the poor and the diagnosed, the Leros archive stands as both warning and evidence: institutional violence is not a relic that progress buried, but a capacity that societies re-activate whenever collective trauma goes unprocessed and disposable populations remain economically useful to confine.

Subject of Research: Narrative testimony on the deinstitutionalization of the Leros psychiatric hospital and the persistence of institutional violence in Europe

Article Title: Beyond the Total Institution? Narrative Testimony from Leros Psychiatric Hospital Deinstitutionalization (1990–1995) and the Persistence of Institutional Violence in Contemporary Europe

Article References: Baldi, C., & Carbone, A. (2026). Beyond the Total Institution? Narrative Testimony from Leros Psychiatric Hospital Deinstitutionalization (1990–1995) and the Persistence of Institutional Violence in Contemporary Europe. Trends in Psychology. https://doi.org/10.1007/s43076-026-00514-x

Image Credits: AI Generated

DOI: 10.1007/s43076-026-00514-x

Keywords: Leros, deinstitutionalization, institutional violence, Franco Basaglia, psychiatric reform, total institution, migrant detention, dispossession, narrative testimony, community mental health, Greece, Trieste