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