In the context of World Mental Health Day 2026, the World Health Organization has released a new practical guide, Supporting the transition to community-based mental health and social care: practical guide to the deinstitutionalization of psychiatric hospitals. The message accompanying its launch is clear: people should not have to surrender freedom, dignity or their place in community life in order to receive mental health support, and countries need to accelerate the shift away from long-term institutional care.
Previous trajectories can make action imaginable under conditions that are never ideal
The guide is ambitious because the task is ambitious. It addresses what psychiatric hospitals themselves can do to reduce long stays and institutional practices, while recognising that deinstitutionalisation depends on much more than hospitals and their managers. Housing, health and social care, employment, education, family support and opportunities to participate in ordinary community life all have to be part of the transition.
I had the opportunity to contribute to the guide as a technical adviser across successive drafts. My involvement included working across versions of the guidance, synthesising international feedback and helping to translate some of the questions raised through that process into more action-oriented material. The aim was to produce something practical: guidance that could orient real action and draw on examples of change rather than ideal models of success. The Transitions team also submitted collective feedback during its development.
One question in particular connects this work with what we are trying to do through Transitions: how can we communicate the complexity of deinstitutionalisation without making transformation appear almost impossible? More precisely, how can what we know about complex reform processes help people begin, deepen work already under way, or restart reform that has stalled?
Comprehensiveness is necessary, and it’s probably one of the first things in your mind when you’re working on this kind of guidance. Psychiatric institutions are embedded in health systems, professional cultures, budgets, legislation, employment arrangements and wider social structures. There is no honest three-step formula for undoing what took decades to put together. But a document that takes this complexity seriously, and that organises it into clear structure can also appear daunting to someone facing a more immediate problem: where do we actually begin?
Within the technical team there was considerable agreement about the overall direction of reform. The much wider international review brought a greater range of experiences and positions into view. Reviewers differed on questions of pace and sequencing, resources, resistance, the role of psychiatric hospitals during transition, the possibility of adverse outcomes and even how to recognise institutionalisation when it no longer takes the form of a large psychiatric hospital.
Some of these questions eventually found their way into a Q&A annex in the final guide, which tries to engage directly with the doubts, objections and practical dilemmas that deinstitutionalisation has always generated. But guidance can only take us so far. The impulse to act often comes from recognising something familiar in another place’s experience, seeing that another institution has confronted a similar obstacle, or hearing from somebody who was there how a seemingly immovable arrangement began to change. This is where trajectories and lived examples of change become especially valuable.
Where does reform begin?
WHO has already done important work documenting concrete examples of person-centred and rights-based community mental health services. Its 2021 Guidance on community mental health services assembled examples of services and networks from around the world and showed how community mental health depends on connections with housing, education, employment and social protection. The new deinstitutionalisation guide also points readers to a much wider body of practical material: Annex 3 brings together resources on mental health policy and legislation, financing, community-based services, stakeholder engagement, discharge planning and workforce development.
The question that interests us here is somewhat different. A strong community service can show what an alternative looks like. It does not necessarily tell us how people got there. What happened before a hospital closed or radically changed? When did people inside a system realise that existing arrangements were no longer defensible? What had to be created outside the institution? Who took the first risks? What happened when reform encountered professional opposition, limited resources or a change in government? Harder to find are detailed accounts of deinstitutionalisation as a process: how reforms began, encountered resistance, changed direction, stalled and restarted. Much of that practical memory remains dispersed across grey literature, different languages, government archives, NGO reports, academic reports and policy briefs, professional networks and personal accounts.
These questions run through Voces y trayectorias: Conversations on Psychiatric Deinstitutionalisation, the open-access audiovisual series we have been developing through Transitions. Its first season consists of eight extended conversations with people who have approached reform from very different positions: policymaking, psychiatric services, research, activism, community work and lived experience, principally in Brazil and Chile. They were never intended as eight models of “good practice”. They are closer to an archive of trajectories.
Mauricio Gómez Chamorro, a psychiatrist who has played a central role in Chilean psychiatric reform, including as director of El Peral Psychiatric Hospital and later as head of the Mental Health Department at the Ministry of Health, remembers a crucial point in efforts to transform El Peral in Santiago. In our conversation, interviewed by Sofía Bowen and me, he recalls how, during the 1990s, those leading Chile’s psychiatric hospitals looked closely at who was living in them and why. The result was an institutional diagnosis as much as a clinical one:
“The final diagnosis was that it was really serving no one. Because those who could leave had no reason to be there, and those who were there because they needed a clinical space were not receiving the necessary support. And that, for us, became the basic blueprint for the transformation.”
There is something useful in the ordinariness of this moment. Reform did not begin because a complete alternative system had already been designed. It began by examining, with some honesty, what the hospital was actually doing, whose interests and wellbeing it was serving, and with what results. The picture was stark, but also familiar: some people remained because there was nowhere else for them to live; others were receiving the wrong kind of support. The institution was simultaneously containing social problems and failing clinically.
Fernanda Nicácio, an occupational therapist and long-standing figure in Brazilian psychiatric reform who was directly involved in the internationally recognised Santos experience, recalls a different kind of beginning. In our conversation with her and Cláudia Braga, interviewed by Delia Da Mosto and Felipe Szabzon, she looks back to the municipal intervention in the Casa de Saúde Anchieta in 1989. The intervention followed the exposure of severe neglect and abuse inside the private psychiatric hospital and quickly became something more ambitious than an attempt to improve conditions. The aim was to dismantle the asylum and build a substitute system across the city: five open, 24-hour territorial services, supported housing, work initiatives and, eventually, a cooperative.
“The Santos experience with the intervention demonstrated a fundamental issue: the responsibility of public authorities for citizens’ health... the construction of a network, five 24-hour services, housing, work, which later produced the first cooperative... it marked the possibility that it is possible.”
Santos became important well beyond the city because it showed, in practice, that a psychiatric hospital could be closed while alternatives were built around it. That final phrase is therefore more than rhetorical. One function of carefully approaching previous experience is precisely to show that another arrangement can actually be built.
Reform is made through institutions and politics
The conversations also remind us how misleading it can be to imagine implementation as something that begins once the policy questions have been settled.
Benedetto Saraceno, psychiatrist and former Director of WHO’s Department of Mental Health and Substance Abuse, has been involved in psychiatric reform across local, national and international settings for several decades. In our conversation, interviewed by Delia Da Mosto and Felipe Szabzon, he reflects on a problem familiar to anyone involved in health-system change: reform driven only from the top does not work, but isolated bottom-up innovation rarely transforms a whole system either. Lasting change, he argues, requires political and institutional direction alongside local actors capable of turning that direction into practice in particular places.
Once we move closer to particular histories, however, even that relatively neat formulation becomes messier.
Gómez, drawing on his own experience, is unusually frank about what changing El Peral demanded from the people involved. Psychiatric hospitals, he argues, do not transform simply because an authority instructs them to. Those trying to change the hospital “burned themselves” in the process, and some paid heavily through dismissal, threats or persecution.
This too is part of deinstitutionalisation. Institutions are made not only of buildings and budgets, but of professional identities, hierarchies, routines, interests and assumptions about what is safe, necessary or possible. When people are placed in positions of prolonged passivity, a whole world of expectations and practices takes shape around them, often more durable than the language of reform itself. Institutional change can therefore threaten established roles and forms of authority, including among people who would not describe themselves as defending institutionalisation.
The Brazilian and Chilean trajectories repeatedly show that reform depends on encounters and combinations that are hard to reduce to a universal sequence: political openings, local experiments, municipal leadership, social movements, professional dissent, new legislation, public financing and people willing to remain with an institutional problem for years. This makes reform difficult to reduce to a neat sequence of actions. It also makes these histories particularly useful for those trying to act in imperfect conditions.
Lived experience as knowledge of reform
This year’s World Mental Health Day theme, “Lived experiences heard: real voices, real change”, is particularly relevant to deinstitutionalisation. WHO’s launch of the new guide emphasises that people who have experienced institutional care need to be active partners in reshaping systems. This is something we have also discussed in a recent essay in PLOS Mental Health.
The conversations with Lorena Berríos and Fabiane Valmore make clear why lived experience matters here as a form of knowledge, rather than simply as testimony to be added after the main decisions have been made.
Berríos is an expert by experience, psychiatric survivor and activist for the rights of people with psychosocial disabilities. She is part of RedEsfera Latinoamericana and has been active in the Mad Pride movement in Latin America, working around autonomy, mutual support and human rights. Interviewed by Sofía Bowen and me, she describes the movement from individual experience towards collective analysis in striking terms. Mutual support may begin with telling what happened, she says, even with “vomiting the rage”. But something changes as people begin to recognise their experiences in one another:
“Then you politicise the rage, and that is a process... You realise, when you hear so many voices with the same story, that they correspond to something we do not see but that exists... a system that dominates. And when we understand that, we politicise it, and realise that the only strategy that can exist to confront it is organising.”
That is a demanding understanding of participation. Lived experience does not simply make a service more responsive to individual preferences. Shared experience can reveal patterns that are difficult to see from within professional or administrative categories. It can change how the problem itself is understood.
Berríos also points to the distance that can remain between formal commitments to participation and actual redistribution of authority. Discussing Chile’s 2021 mental health law, she notes that recognition of experts by experience has not necessarily translated into people with lived experience occupying positions from which they can design, plan or evaluate policy.
Fabiane Valmore is a sociologist, political scientist and activist in Brazil’s movimento antimanicomial — usually translated as the anti-asylum movement, referring to the movement against psychiatric asylum-based care and institutionalisation. Her work is inspired by the legacy of Nise da Silveira. She is a member of the Transitions Academic Advisory Committee and has been closely involved in promoting user participation in Brazilian mental health policy, including through the National Free Conferences of RAPS Users. Interviewed by Delia Da Mosto and me, she reflects on conversations about deinstitutionalisation with people who had experienced long-term psychiatric hospitalisation. She recalls one participant making an unsettling comparison with the abolition of slavery:
“He said: ‘It is like what they did when slavery ended: they freed the slaves. Where did they go?’ ... When a person who has experienced long-term institutionalisation compares opening the doors of the asylum with opening the doors of the senzala [slave quarters], this needs to be spoken about and thought about seriously.”
The comparison is intentionally difficult. Its force lies in refusing to equate release from confinement with the material conditions of freedom. Leaving an institution matters enormously, but it immediately raises other questions: where does someone go, with what income and housing, with what relationships and recognition, and with what protection from violence? In Brazil, these questions are inseparable from longer histories of racial inequality and exclusion.
This is one reason lived-experience knowledge is so important to deinstitutionalisation. It also reminds us that lived experience is never detached from the social and political context in which it is formed. Fabiane and Lorena speak from Brazil and Chile, societies marked by histories of state violence, authoritarian rule, struggles for democracy and persistent inequality. Concepts such as participation, citizenship, community and freedom therefore carry histories that extend well beyond mental health services. Their accounts draw attention to the continuities that can exist between life inside and outside formal institutions, to the new forms of dependence that can follow discharge, and to the difference between being physically present in the community and having a meaningful place within it.
What are we trying to produce outside the institution?
The question raised by Fabiane — what kind of freedom follows the opening of the institution’s doors? — appears from another angle in the reflections of Cláudia Braga, professor of Occupational Therapy at the University of São Paulo and a former PAHO/WHO mental health consultant. Interviewed by Delia Da Mosto and Felipe Szabzon, Braga reflects on psychosocial rehabilitation in Brazil and argues that it has to involve rebuilding a person’s power in actual social relationships. It cannot be confined to the interaction between a professional and a service user, or even to activities taking place within a community mental health centre:
“This process necessarily involves reconstructing the person’s power in relationships and real-life settings... it cannot take place only inside a mental health service... it needs to happen where life happens... in social relationships, work, schools, housing and everyday life.”
This makes “community” considerably more demanding than a change of address. A service can sit in the middle of a neighbourhood and still reproduce passivity and dependency. Braga gives the deliberately ordinary example of programmes in which people spend their days making ashtrays, crocheting or watching films chosen by professionals. The physical setting has changed, but few exits into work, relationships or ordinary social roles have been created.
Her account of one of the central achievements of Brazilian psychiatric reform brings the argument back to a deceptively simple idea:
“The greatest success is freedom. The greatest success is care in freedom. The greatest success is the many people who were institutionalised in psychiatric hospitals and today live in freedom, are cared for in freedom. The greatest success is the many children and adolescents who will never know, we hope, the reality of a psychiatric hospital because they will only know care in freedom.”
That formulation, cuidado em liberdade — care in freedom — says something that is difficult to reduce to service location or bed numbers. Freedom becomes part of the organisation of care itself rather than a reward following successful treatment.
And this is precisely where trajectories also help us remain cautious. Margarita Machuca, an adult psychiatrist specialising in mental health service networks and the integration of mental health into general hospitals, currently leads the Mental Health Clinical Support Unit at Hospital El Pino in Santiago. Interviewed by Sofía Bowen and me, she describes people discharged from long-term psychiatric institutions who then move repeatedly between short-stay wards, shelters, general hospitals and periods of homelessness. From the perspective of the health system, they have left the psychiatric hospital. From the perspective of their lives, however, the fragmented network itself can begin to reproduce an institutional logic.
The question is therefore not simply whether someone is outside. It is what kind of life becomes possible there.
An ongoing archive of South American ideas and practices of reform
There is a broader reason for making these conversations available in English as well as Spanish and Portuguese. South America is increasingly mentioned in international discussions as an important site of psychiatric reform. Yet the region can still appear through a handful of shorthand references: Brazil and the anti-asylum movement, the Caracas Declaration, perhaps Santos or Rio Negro in Argentina, sometimes Chile’s development of community and primary mental health care. These reference points matter, but they only begin to capture what has accumulated across several decades of reform.
In Voces y trayectorias, Benedetto Saraceno describes what happened when European anti-institutional ideas encountered Latin American traditions of social medicine and health systems operating under very different social conditions. He puts it provocatively:
“The Latin Americans had an important light that we did not have, which was social medicine... The main lesson learned from Latin America was how mental health framed in poverty can help the poor psychiatry of the rich countries.”
The point is not to romanticise scarcity. Saraceno is referring here to a longer Latin American tradition of social medicine, which has treated health and illness as inseparable from social relations, political economy and collective life, and which developed in close dialogue with struggles over democracy, inequality and public health. These reforms unfolded in contexts marked by inequality, uneven resources and major political change, and those conditions shaped distinctive ways of thinking about primary care, community work, citizenship and the relationship between health services and social life.
Brazil and Chile also followed markedly different trajectories. Brazilian reform became entwined with democratisation, the construction of the Unified Health System, the anti-asylum movement and experiments in territorial psychosocial care. Chile developed a substantial community and primary-care architecture while long-stay psychiatric institutions proved much harder to displace. Neither history offers an uncomplicated model, and neither is finished.
That is why we called the series Voces y trayectorias — voices and trajectories.
The first season contains eight conversations. Some participants were responsible for major policy and institutional decisions. Others entered this history through activism, research, everyday service work or their own experience of psychiatry. They disagree about important things. They remember events differently. They emphasise different achievements and unfinished problems. This is not a weakness of the archive. It is part of what makes it useful.
The new WHO guide provides an important framework for countries, hospital leaders and reform teams seeking to move away from long-term institutional care. Voces y trayectorias offers another way into the accumulated practical memory of reform, through the words of people who have tried to change institutions, build alternatives, organise collectively and live through the consequences.
Guidance can help organise the work. Previous trajectories can make action imaginable under conditions that are never ideal. Sometimes recognising one’s own problem in another place’s unfinished experience, and hearing in some detail what people actually did, is what makes beginning, persisting or beginning again seem possible.