teed-cmh system ch2(1)

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26 CHAPTER ONE Community mental health practitioners are no t value-neutral. Interventions that increase sensitivity to diversity , empowennent, and ready access to needed resources are viewed as desirable, and their opposites are discouraged. Th e ethical principles involved in creating and implementing interventions at all levels are discussed, along with the ethical implications of nonintervention. Th e methods and techniques utilized by practitioner s to concretize the th eory ba se follow. Community men tal health professiona ls consul t with staff of other agen cies, organizations, and institutions in the community, and this consultation allows for both individual- and systems-oriented interventions. Following th e chapter on consul tation, the next technique discussed is research. Th is is consistent with U.S. Surgeon General Satcher 's encouragement that ll interventions in the mental health system be base d on empirical studies. Thus, program evaluation and outcomes assessment tech niques are described. Th e final method concerns how to r eform the system and to develop new pro grams. Frequently, service components need restructuring, and com munity mental health practitioners eed to be aware of the many stra tegies to create change. Th e ability to secure funding through grant-writing is also covered. Th e /inal section projects into the future. Th e elderly populatio n is the fastest growing segment in th e United States and elsewhere. Th e needs of this group and the types of new services to meet their emerging needs ar e explored in a chapter on geron- tology. Th e costs of behavioral care are rising swiftly, and it is likely that managed care and health insurance compani es policies wil l dramatically change during the next ten years to find and fund cost-effective methods of enh ancing the quality of mental hea lth in the community. Th e strategies likely to be adopted are discussed, and the implica tions for how this outcome will affect th e delivery of mental health servic es are consid ered. In its entirety, this text is intended to rovide a more complete awarene ss of the community mental health system and will enable practitioners to navigate the system more effectively. DISCUSSION QUESTIONS 1. What is the community mental health approach? Is it likely that this approach will be effecti ve in producing positive change in the mental health field? If not, what are the impediments? Why did the traditional model of psychotherapy need to be replace d? 2. How would a community mental health interventionist use th e Dohrenwend model to desi gn and im plement a needed program? How might the cultural diversity in the locality affect the way the program i s de signed and put into practi ce? 3. What benefits can communitymental hea lth impart to the mentally ill?What are so me benefits and detriments of applying labels? Are they necessary? Are they helpful? 4. What is the purpose of epidemiological surveillance? 'Why is it important to monitor populati on characteristics? 5. How did the deinsti tutionalization process spur the movement towar d reforming the mental health industrY? "'hat events contributed to the shift? How did the state of behaviora l health care in the past differ from the methods that are commonly used today? How might these methods change if the community psychological approach becomes implemented more fully in the future? CHAPTER Deinstitutionalization OBJECTIVES T his chapter is designed to enable the reader to: Gain a n overview of the history of nstitutionalization. • Identify factors that contributed to the initiation of the institutionalization movement. Identify the role of government in the institutionalization and deinstitutionali zation movements. Describe the "mo ral approach" and its roo ts. • Identify events that contributed to the "psychiatric r evolution" in the 19505. Describe the ways in which a preventative viewpoint contributed to the deinstitutionalization process. Iden tify thre e perspectives from \vruch to view the impact of redu ced ho spi talization. Document the roots of somatic treatments, psychosurgery, and other methods used in the past to treat th e mentally ill. Understand the importance of he Community Mental Heal th Act of 1963 . • Identify diff erent types of antipsychoticdrugs and their importance to demStlt utlOna lizatlO n, alon g with their benefits and side effects. • Understand the bio-psycho-social model of schizophrenia. II Define evidenced-based practice s • Outline the id eas behind the me ntal hygiene movement. II Understand tl,e impact of World War II on th e mental healtll industry. II Gain a general understanding of relevant mental health legislation, on both the state and the fed eral levels . "Those who can110t learn fi'O'll1 · history are doomed to repeat it. " George Santayana 27

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26 CH A P TER O N E

Community mental health practitioners are no t value-neutral. Interventions that

increase sensitivity to diversity, empowennent, and ready access to needed resources

are viewed as desirable, and their opposites are discouraged. Th e ethical principles

involved in creating and implementing interventions at all levels are discussed, along

with the ethical implications of nonintervention.

Th e methods and techniques utilized by practitioner s to concretize the th eory

ba se follow. Community men tal health professionals consul t with staff of other agen

cies, organizations, and institutions in the community, and this consultation allows for

both individual- and systems-oriented interventions. Following the chapter on consul

tation, the next technique discussed is research. This is consistent with U.S. SurgeonGeneral Satcher's encouragement that all interventions in the mental health system be

based on empirical studies. Thus, program evaluation and outcomes assessment tech

niques are described. Th e final method concerns how to reform the system and to

develop new programs. Frequently, service components need restructuring, and com

munity mental health practitioners need to be aware of the many strategies to create

change. Th e ability to secure funding through grant-writing is also covered.

Th e /inal section projects into the future. Th e elderly population is the fastest

growing segment in th e United States and elsewhere. Th e needs of this group and the

types of new services to meet their emerging needs are explored in a chapter on geron-

tology. Th e costs of behavioral care are rising swiftly, and it is likely that managed care

and health insurance compani es policies will dramatically change during the next ten

years to find and fund cost-effective methods of enhancing the quality of mental hea lth

in the community. Th e strategies likely to be adopted are discussed, and the implica

tions for how this outcome will affect the delivery of mental health services are considered. In its entirety, this text is intended to provide a more complete awareness of the

community mental health system and will enable practitioners to navigate the system

more effectively.

DISCUSSION QUEST IONS

1. What is the community mental health approach? Is it likely that this approach will be effective inproducing positive change in the mental health field? If not, what are the impediments? Why did

the traditional model of psychotherapy need to be replace d?

2. How would a community mental health interventionist use th e Dohrenwend model to design and

im plement a needed program? How might the cultural diversity in the locality affect the way the

program is designed and put into practi ce?

3. What benefits can communitymental health impart to the mentally ill?What are some benefits anddetriments of applying labels? Are they necessary? Are they helpful?

4. What is the purpose of epidemiological surveillance? 'Why is it important to monitor population

characteristics?

5. How did the deinstitutionalization process spur the movement toward reforming the mental healthindustrY? "'hat events contributed to the shift? How did the state of behavioral health care in thepast differ from the methods that are commonly used today? How might these methods change if

the community psychological approach becomes implemented more fully in the future?

CHAPTER

Deinstitutionalization

OBJECTIVES

T his chapter is designed to enable the reader to:

• Gain an overview of the history of nstitutionalization.

• Identify factors that contributed to the initiation of the institutionalization movement.

• Identify the role of government in the institutionalization and deinstitutionalizationmovements.

• Describe the "moral approach" and its roo ts.

• Identify events that contributed to the "psychiatric revo lution" in the 19505.

• Describe the ways in which a preventative viewpoint contributed to thedeinstitutionalization process.

• Identify three perspectives from \vruch to view the impact of reduced ho spitalization.

• Document the roots of somatic treatments, psychosurgery, and other methods used in thepast to treat th e mentally ill.

• Understand the importance of he Community Mental Health Actof 1963 .

• Identify different types of antipsychoticdrugs and their importance todemStltutlOnalizatlOn, along with their benefits and side effects.

• Understand the bio-psycho-social model of schizophrenia.

II Define evidenced-based practices.

• Outline the ideas behind the mental hygiene movement.

II Understand tl,e impact of World War II on th e mental healtll industry.

II Gain a general understanding of relevant mental health legislation, on both the state andthe fed eral levels .

"Those who can110t learn fi'O'll1·history are doomed to repeat it. "

George Santayana

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28 CH A P TER TW O

T he topic of deinstitutionalization can serve as a lens to review the past treatment of

the severely mentally ill. Starting with the history of institutionalization and tracking

its progress can provide a focal point as to why the demsntunonahzanon process

became necessary. It also discloses both positive and questionable outcomes for per-

sons , , ~ t h mental illness. Understanding what produced these neganve events proVIdes

an important lesson in future program considerations. CUI' ' nt practices that utilize

"evidenced-based" psychosocial interventions for the severely mentally iiI offer

renewed hope that those mt h mental illness can achieve no t only symptom reducnon

but also a significant improvement in their quality of ife.

Th e Beginning of Institutionalization

Any discussion of deinstitutionalization must begin mt h an understanding of ho,; the

institutional process itself began. Th e story of the treatment of the mentally III m

America is a troubled one. Th e care of the mentally ill has indeed had a difficult past,

ranging the spectrum from no treatment at all to brain sectioning, or lobotomy. In the

broader picture, it is possible to understand that most attempts to treat the mentally III

were well-intentioned but in many ways doomed. Th e core problem IS that even today

there does no t exist a thorough understanding of what causes severe mental illness.

Schizophrenia affects 1% of the worldwide population, bur the precise etiology and

course remain elusive. Scientists can describe the disorder and Its symptoms and can

indicate what neurotransmitters are askew, but they are yet unable to indicate a cause.Treating a disease symptomatically can be dangerous or ineffective. Severe colds are a

good exanlple. Symptoms include ache:, runny nose, and maybe fever. We can treat

the symptoms in many ways: rest, annbJOncs, flwds, cold remedIes, and so on . the

other hand, good medicine looks to the etiology and treats a c c o r d ~ n g l y . AnnbJOncs

treat bacterial infections but have no effect on viruses, and thus are meffecnve If pre

scribed for a viral a ihnent that is misdiagnosed as bacterial. Psychiatry, similarly, con

tinues to look for a root cause of severe mental illness in an effort to develop an

effective treatment.

People mt h severe mental illness have difficulty functioning in the world. They

often have difficulty thinking, and they may show inappropnate emotions ?r may no t

socialize. In colonial days, without treatment or institutions, the mentally III could be

found in various locations. Th e obvious place was home. Families were called upon to

take responsibility for their loved ones. In many cases, the home setting proved some

what effective. Rothman (1971) desc ribed the home environment for the mentally illas a loving setting where people were looked after and taken care of. Deutsch (1949),

on the other hand, found life for the mentally ill much more difficult. IndJV1duals

would wander freely and mn d up in jails, or be dropped off in differe:'t w,;ns like

unwanted cats. Unfortunately, in today's world, there still eXlst men tally III mdiVJduals

who are homeless or in jail: Th e progress made in over 300 years is q u e s t i o ~ a b l e . Deu tsch (1949) discussed other colonial day practices such as buildmg small reSIden

tial units (in one case, 5 by 7 feet) where the mentally ill would live. Aucnons were held

Deinstitutionalization

to sell off "lunatics" to the highest bidder. Beatings and floggings were common

umented. In spite of this practice, there were people who wanted to help. Alms

or poor houses were designed to help the mentally ill by providing room and

and in some cases by creating employment opportunities. Work in colonial tim

viewed as essential and seen as a way to contribute to the developing society. In

ings of he day, the mentally ill were referred to as "distracted," a reference most

mdlcatmg that they were distracted from work. Colonial Americans implement

English poor laws of 1597 and 1601, which gave communi ty officers the respons

to force families to take care of their sick or assign them to workhouses. Alt

these workhouses were ostensibly for the poor, they were really inhabited by thedeviants of the day, including the developmentally disabled, physically handica

homeless, and mentally ill. Since work was stressed and seen as part of a norma

people who could no t work were stigmatized as being poor and needing help.

Over time, those mt h an illness were separated from the other poor. In 175

first hospital to provide a s e p ~ r a t e unit ,ror the mentally iJJ was opened in the Pen

varna Hospital, m Philadelphia. It wasn t until 1773 that a separate facility for the

tally ill was opened in Williamsburg, Virginia. Interestingly, this public hospita

modeled after the Bedlam Hospital in England, which was originally ca lled "B

hem Hospital." It only later became known as "Bedlam," a word now used in com

parlance to describe out of control activities, such as those that occurred in the htal at that time.

As the 18th century was coming to a close, an international movement fo

treatment of the mentally ill was beginning. Benjamin Rush, the American Fath

Psychiatry, was convinced that mental illness was caused by clogged ce rebral bvessels, and he prescribed bloodletting (a pro cess that drained blood from the ind

ual in the hope that new, "good blood," would form, and consequently the "bad bl

would be eliminated). Meanwhile, a much broader and more enlightened view o

mentally ill was ,taking place in Europe. In France, Philippe Pinel was no t impre

With eIther the mcarceratlon or the treatment approaches of his time. He saw

prac tices as bloodletting and chaining patients as no t only ineffective bur also i

mane. Instead, he sought to work with the patient and to instill hope and confide

HIS work became known as "moral treaonent," words that reflect a weak French tr

lation but had profound effects on the treatment and care of the mentally ill for

dreds of years. This approach, perhaps better called "psychological treaonent," tre

the mentally ill with respect. Pinel was known for removing the chains from the in

c ~ r a t e d mentally ill. His "moral treaonent" began to spread to other European c

tries (Grab, 1994). In Italy and England, respectively,Vmcenzio Chiargui and Wil

Tuke took up the new approach. Most notable was Tuke, who founded the YRetreat in. 1792. His methods relied on assisting patients in gaining self-control

self-restramt. Tuke was a Quaker, and his religious background allowed him to exp

upon the concepts of moral treatment. He often described the treatment of the m

tally ill as akin to the treatment of children. Although the cause of mental illness

not known, Tuke and others saw that their treatment made people well enoug

return home. In effect, they had a workable treaonent approach that utilized a h

pital or an asylum, as they were mown at the time (Grob, 1994). Soon, others in

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30 CHAPTER TW O

United States saw the potential of this approach, and the humane hospital treatment

and a number of hospitals throughout the United States were initiated. Among the

first were Bloomingdale Hospital in New York City, the Public Asylum in Williams

burg, Virginia, and McLean Hospital near Boston, Massachusetts. The excitement

and optimism generated at this time were further enhanced by claims of cure rates that

ranged from 40% to 100% (Quen, 1975). These claims were publicly prononnced and

created quite a positive stir. It would appear, however, such claims were exaggerated

and over time may have led to disillusionment with this new, more humane approach.

Quen (1975) noted that Woodard, in 1834, reported an 82% cure rate and that Galt

and Awl in 1842-1843 reported an astonishing 100% recovery rate, but Quen indicated these claims were impossible and exaggerated. Nonetheless, momentum was

building for the treatment of the mentally ill in settings other than homes and

almshouses. Asylums were developing and in some cases, thriving. States that hereto

fore had avoided the use of tax funds were now beginning to invest in publicly funded

state mental asylmns. Th e initial asylums were mostly privately financed, but both

Massachusetts and New York were working toward developing institutions in the

18205 and 18305. There was a growing feeling that government now could and s hould

take care of he less fortunate. Th e reasons for this shift in thinking were multiple, one

being the desire for government to improve an expanding and emerging society. It was

important for established economic progress to be maintained. It would appear, how

ever, tha t the motivation of government was not as pure and singular as that ofTuke

and Pinel. Early state-funded asylums for the mentally il l were, unfortunately, les s

interested in the moral tre atment approach and instead focused on custodial care. Th e

stated goal was to remove the mentally ill from society. Th e unspoken comm ent wasthat society could get on with its economic production and not be plagued by "dis

tracters." New state asylums in Virginia and Kentucky were underfunded from the ir

inception, and as a result the concept of "moral treatment" was never implemented.

Some of the rationale for this shortc oming was stated as being due to a lack of funds, a

seemingly endless cry of public facilities. Not all was lost, however, as Massachusetts

was about to develop its first hospital in Worchester (1833). Under the esteemed lead

ership of Samuel Woodward, this asylmn flourished and drew a national reputation for

its care and success in treating the mentally ill. Claiming an 82% cure rate (Quen,

1975), this hospital provided a pilot study for other states to use as justification to

begin developing their own asylums.

Serendipitously, at about the same time, one of the most influential of all mental

health advocates was about to change th e national landscape. Doroth ea Dix made th e

care and treatment of the mentally ill a national issue. In the 1840s, she exposed the

poor quality of care that the mentally ill received in almshouse and jails. She arguedlocal governments could no t afford the proper treatment, and so she called upon the

states to fund the needed care. Her advocacy was impressive. By 1860, 28 of the 33

states had at least one public mental hospital (Rothman, 1971). This surge was based

on a confluence of factors. Th e Pinel-Tuke moral approach, coupled with the Massa

chusetts cure rates and Dix's charm, changed the scope and focus of reatment for hun

dreds of years. This was the trUe beginning of institutionalization. In an amazing show

of confidence, optimism, and perhaps naivet<', the New York State Senate reported

Deinstitutionalization

that "Science, aided by hmnanity, has dispelled ignorance, overcome prejudice

quered superstition, and investigated the causes, character and curability of

dIsease, and had gloriously demonstrated that insanity can be made to yield

power of medicine and medical treatment, and to moral discipline. Th e mystery

once enveloped it has vanished." (New York State Senate, 1856).

Such optimism seemed to be doomed. Or was it? Certainly the intent of g

ment was to help treat the mentally ill in a therapeutic environment, a noble m

that should no t be forgotten. However, a major variable was overlooked. Th e U

States was nndergoing rapid population growth with a significant immigration i

Many of these individuals had difficulty dealing with the stress of a new culture

as a new life. Political groups were concerned and somewhat fearful th at some o

new residents who were strUggling, and perhaps genuinely mentally ill in some

would be dangero.us and perhaps mo re significantly, would be seen as no t contri

to the then boommg economy. Th e appeal to remove those individuals to a pla

would provide "moral treatment" was great-so great, in fact that the institution

population swelled. Th is burgeoning group of hospitalized individuals created

issues from the inception. If the Massachusetts cure rate data were even half-c

what made the model effective were the smaller, more intimate, respectful instit

that could attend to individuals in a beautiful, heartwarming environment.

. Ho:" big is big? Let's jump ahead quickly to the mid-1950s, the peak of i

oonahzaoon, when there were 558,000 people hospitalized (Meyer, 1976). P

State HospItal on Long Island in New York had a population of over 16,000. Im

the magnitude of implementing the respectful moral treatment approach to 1

people. Clearly, the model can be easily lost in a sea of people, staff, and the muaspects of daily life. It appears in hindsight that the concept of moral treatmen

have had ~ a l u e but the enormity of ndividuals in need overwhelmed the approac

It S mterestmg to n o t ~ that as new asylums were being built and expandedthere was a conSIstent archItectural character to the buildings. These developm

however, should be kept in perspective. In less than 50 years, the mentally il

unchamed, moved out of aIls and almshouses, and placed in fine new institution

tings. In New York State, the legislature wanted to insure the finest architectu

paid for world-class architects. Th e Buffalo Insane Asylum was designed by

Richardson, known for many magnificent buildings (including the New York

CapItal) worldWIde . Th e Hudson River Insane Asylum in Poughkeepsie cont

WIth Vaux and Whiters (who designed the Natural History Musemn in New

City) for the buildings, and with Frederick Law Olmstead (Central and Prospect

New York Oty) for the landscape. At some level, it was clear the political winds

supporting the moral treatme nt concept.One of the early asylmn superintendents (today known as the Director o

some cases, the ~ e w b ~ s i n e s s appellation of Chief Executive Officer) b e c a m ~ inoal m helpmg eXlsong msOtuoons expand. Dr. Tho mas Ki rkbride was so influent

fact,. that almost all public hospitals conformed to his conceptual approache

archItectural standards. SImply put, Kirkbride envisioned a central area for staf

"spokes" oflong corridors, emanating from the center. Th e spokes were long re

gular buildings with a hallway that led to a large open area at the end (later blO

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36 CH A P TER TW O

series of nterventions that were troubling yet seemed to be effective in some cases. He

came to call his protocol "malaria therapy." Malaria therapy was based on the ohserva

tion that people with mental symptoms who became ill with typhoid fever would

sometimes shed some of heir psychotic symptoms. Wagner-Jouregg reasoned that the

effects of fever had a palliative effect on memal symptoms (Grob, 1994). American

physicians were quick to apply the new fever therapy to paresis patients. Over time,

subsequent research and outcomes indicated that the procedure was not effective.

During the same period, anothe r somatic observationwas linked to mental symptoms.

Manfred Sakel, a Viennese physician of the 1920s, observed that a dministering insulin

to a point where a seizure or "shock" occurred reduced the symptoms of mental illness.This new "shock therapy" was another attempt to deal with difficult symptoms. Sakel

did not provide a rationale as to why the treat mem worked, and his interventions were

seen as dangerous and risky. Some patients did, in fact, show improvement, but the

mortality rate was as high as 5% (Grab, 1994). Despite this outcome, there was a brief

use of metrozol to induce seizure, which was soon replaced with electroshock. Fever,

coma, and seizure all seemed to effect a change in the brain that was sometimes benefi

cial. Indeed, the rationale for the use of hese extreme measures was that some patients

were improved. However, there were many who expressed concern, s ince there was

little or no understanding of why these intrusive methodologies worked. Of all of the

methods, only electroconvulsive th erapy (ECT) is still in use today. It is given in cases

of severe depression, but with many fewer sessions than were initially used. A "course"

ofECT today could be as low as 8 to 10 "shocks" or treatments, whereas 60 years ago,

individuals may have received up to 100 treatments. Recem literature suggests that t he

seizure produced hy ECT may give the patient a burst of serotonin, the neurotrans-mitter often linked with depression (Sasa, 1999).

Somatic treatments reached their peak with the use of psychosurgery. Both pre

fromal and orbital lobotomies were performed, with mixed results. Although this sur

gery was touted as a lifesaver, many pa tients were left in an emotion less state. It is also

worth noting that the statistical eva luation of treatment outcomes at this time was pre

mature, at best. Many claims of the success of seizures as effective treatme nt were

merely anecdotal. Patiems who were simply emotionally dulled hy the scalpel were in

some cases referred to as "improved. " Other hands-on treatments were tried, but often

yielded poor results. Ho t baths, cold baths, hydrotherapy, sleep, and so on were all

attempts to find, at the very least, symptom reduction; yet it is safe to say individual

treatment before the 1950s provided only minimal improvement for a small number of

patients. State hospitals were overcrowded and understaffed , and abuses were com

mon. Treatment efforts were minimally effective, and the general public viewed the

use of extreme measures (shock, psychosurgery) as proof that people with mental illness were of a different type.

Revolutions in Treatment: Psychotropic Drugs

Revolutions, even psychiatric revolutions, occur only when the timing is right. It was

an opportune time for the introduction of a pill that would help control behaviors and

permit previously hospitalized individuals retur n to the community. Although there

Deinstitutiona lization

were many factors that synergized to make deinstitutionali zation occur, there

none more critical than this new treatment approach: the use of phenothiazines

cially chlorpromazine. In 1952, two French psychiatrists, Jean Delay and

Deniker, noted that chlorpromazine dramatically tranquilized people with s

phrenia. They used the term "neuroleptic" to describe the effects, because it ca

reduction in nervous activity rather than a pa ralysis (drugs before this, such as ba

rates, were but pure sedatives) (Swazey, 1974). Drug companies were quick to re

and began to market these neuroleptics as "antipsychotics." Chlorpromazin

given the trade name Thorazine. Soon, Thorazine was seen as a miracle druO

main contribution of tllis pharmaceutical was its effectiveness in relieving thep ~

symptoms of schizophrenia wit hout totally sedating a person. Shedding thoughturbances allowed patients to function more effectively.

Not only had physicians focused on effective treatmem, but government of

also became hopeful that there was a means to decrease costs associated with hos

ization. As mentioned previously, the new antipsychotic is often given major cred

the deinstitutionalization movement. However, there were complications; from

patient's perspective, the new medication was generally well received but no t w

problems. It became evident over time that long-term use of Thorazine-like me

tions (phenotlliazines) had las ting, irreversible side effects. These drugs have a

mon neurotransmi tter effect: they all reduce the amount of dopamine, a

neurotransnlitter that has pathways through the brain 's ftontal lobes and two

motor SJtes. Reducmg the amount of dopamine below sufficient levels impair

motor areas in the substantia nigra, and as a result, certain motor movements be

impaired. Side effects developed that were similar to Parkinson's disease, which rfrom damage to the same motor brain si te areas and is precipitated by low dopa

levels. Motor palsy and "shuffling feet" were becoming common side effects of pe

on phenothiazines for long periods of time. These movement disorders were c

dyskinesias, and because they occurred after long-term use of medications, they termed utardive" dyskinesias.

WIthout question, however, the new medications reinforced the prevai ling

cept that p e ~ p l e could be released/discharged into the community. In addition,

no t yet hospItalIzed could be treated in their natural setting and never need a ho

stay. It should be clearly understood that patients were not "cured,» but rather

had a lesserung of the symptoms to the degree that a hospital stay was not neces

There arose no new knowledge of the cause or etiology of schizophrenia, ju

awareness that symptoms in some individuals could be reduced , thus allowinO' pto be moved to less restrictive settings. b

Bio-Psycho-Social Consideratio ns

Researchers have come to .understand that schizophrenia, one of the major menta

nesses, IS a blO-psycho-soClal dIsorder. All three areas are disrupted to some exten

need attention or repair. Medication management handled some of the biolo

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38 CHAPTER TWO

repair needed, but individuals with schizophrenia had additional personal and inter

personal issues that needed to be addressed. Merely reducing symptoms and expecting

the "psychosocial" skills of people to return was and is naive. In the early 1960s, there

was little thought given to this aspect, and patients were discharged with the hopes

that these skills would return. In some cases, initial placements were made to support

ive living arrangements such as family homes; but to this day, there are not enough

smaller, supportive housing arrangements for all those discharged. Despite this, life

was better from most patients' perspectives. Medication controlled troubling symp

toms, housing was less crowded and more comfortable, and many people believed the

quality of their life had returned. Individuals who returned to the community couldcontinue treatment at outpatient clinics, where they received medication and some

times individual or group therapy. These psychotherapies were found to be helpful in

addressing the psychosocial aspects of the disorder. It wasn't until the 1980s, however,

that specific research on social skill acquisition became available (Liberman, DeRisl &

Mueser, 1989).

The PORT Study

From the latter part of the 1960s on, the programs offered were a result of the Com

munity Mental H ealth Ac t of 1963. There were now a number of community pro

grams that would treat individuals both before and after hospitalization. Communit y

mental health centers held out the promise that mental Illness could be treated m the

community, and only exceptional cases would need long-term hospitalization. Still,

without a full understanding of the disease process, programs and treatments were

designed primarily to treat symptoms. It wasn't until 1992 that both the Agency for

Healt h Care Policy and Research and the National Institute ofMental Health funded

the Schizophrenia Patient Outcomes Research Teams (pORT). The. purposewas to

gather all available scientific evidence related to the treatment of schlzophrema. The

PORT study, which was compiled and published in 1998, paved the way for later

"evidence-based" practice literature (Lehman & Steinwachs, 1998). It made 30 recom

mendations, covering all aspects of a bio-psycho-social approach.Eighteen of he 30 recommendations related to medication usage. These recom

mendations capitalized on advancements in developing medications that had produced

a new series of antipsychotic medications, termed "arypicals." These new antipsy

choties provided both positive symptom abatement and, in some cases, a therapeutic

effect on negative symptoms, all without producing dyskinesias. These drugs aVOIded

the mo tor pathways when reducing dopamine, thus lessening or negating any motor

involvement. The most prominent of the new arypicals was Clozapme. Clozapme

became an important treatment alternative, especially for treatment refractory

patients (those no t responding to previous medication trials) as well as panents who

displayed violent behavior. It was also a boon to panents who developed motor SIde

effects from the more rypical antipsychotics.Recommendations 19-2 1of he PORT study related to the use of electroconvul

sive therapy (ECT). The study reported there was sufficient evidence to .show ECT

reduced acute symptoms of schizophrenia, yet it was also noted the posmve effects

Deinstirutionalization

were short-lived. The number of treannents was ideally listed as 12, as studies

shown no significant change with more treannents. Recommendations 22 an

reported individual and group therapy were supportive and had shown some be

but that psychodynamic therapies should not be used in the treannent of persons

schizophrenia. Recommendations 24-26 suggested patients who had ongoing co

with families should be offered an intervention that was education and skill-Iear

based, and these interventions could be given to families that had high "expr

emotion" (EE). There were, in the literature, reports that families with high expre

emotion (family members who were hyperactive,loud, etc.) were no t suitable for

ple recovering from schizophrenia (Butzlaff & Hooley, 1998). As the "high EE"cept was discarded (Cheng, 2001), so was the notion of the anxious family.

Recommendations 27-28 gave public credibility to the positive impact of v

tional rehabilitation. Vocational rehabilitation was recommended for people who

an interest in working, a history ofwork, and the potential for good work skills.

vided opportunities would include prevocational, transitional supported employm

and vocational counseling. The last two recommendations made two service sy

recommendations-assertive case management and assertive community treatm

Both service components had evidenced positive outcomes by molding p r ~ g r a m oings to the patient and not making the patient fit a program mold or be turned aw

Evidence-Based Practices

These 30 recommendations were well received by the mental healt h community

public programs began, albeit slowly, to modify treatment and program offeringsAlthough there was heavy reliance in the PORT study on the biology of sc

phrenia, all the components of a bio-psycho-social model were addressed, giving

dence to the concept that schizophrenia involves all aspects of the bio-psycho-s

continuum. It follows that curre nt day treatment approaches address all aspects o

bio-psycho-social continuum. This positionwas supported bya meta-analysis of e

tive community-basedtreatments for schizophrenia (Mueser, Bond, & Drake, 200

study indicating psychosocial interventions and psychosocial treannents have pos

treatment outcomes. These interventions provide to the clinician a number ofva

treannent practices research has found to be effective. These practices, as menti

earlier, are generally referred to as "evidence-based practices."

A number of observations are worth noting:

• Currently accepted practices for the treannent of lle severely mentally il l pro

positive outcomes. These results and subsequent reconfirmations give new to individuals and families who have dealt with mental disease for generation

• Effective treannents support a bio-psycho-social model. Ne ither medicatio

skills-building alone will return a person to a bette r qualityof ife.

• Clinicians are now more research- and evidence-based. Previous prac

(lobotomies, insulin, shock, etc.) that were drastic attempts at symptom re

tion have been replaced with workable, effective interventions that deal wi

aspects of functioning and greatly improve quality of ife.

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40 CH A P TER TWO

Currently, there are six areas ofpractice where research evidence has indicated pos

itive treannent outcomes with the severelymentally ill (Mueser, Bond, & Drake, 2001).

• Medication: It is und erstood individuals with severe mental illness have a chem

ical neurotransmitter imbalance. Whether it is toO much dopamine or gluta

mate or too little serotonin remains to he determined. However, there is

sufficient evidence to indicate that following medication guidelines leads to an

increased chance of positive change (often symptom reduction) over a short

period of time.

• Illness seifmanagement training: Perhaps better labeled "wellness self-management," it involves several sub areas. Psychoeducation, another term needing

some redesign, is at the cornerstone of self-management. Nothing is more

empowering than understanding the impact that actions have on future behav

ior, and stressing an individual's ability to exercise personal control in order to

avoid negative consequences. Th e literature is now consistent in reporting that

conveying basic information about psychiatric disorders, including their history,

course, symptoms, methods of relapse, and prevention, as well as knowledge of

medication effects and side effects, has reduced relapse and ha s improved the

quality of life for many (Mueser, Bond, & Drake 2001). Social skills training has

been a staple of treaonent for some time, with patients being taught social ski lls

that either were forgotten or never learned. Social interaction while hallucinat

ing is difficult at bes t, and short circuits valuable life experiences. Ski ll develop

ment can be achieved through role-playing, modeling, social learning pr inciples,

and other methods (Lieberman, Derus; & Mueser \989). Cognitive remediationis an additional sub area and a relatively recent development. Beck (1979) suc

cessfully demonstrated the use of cognitive therapy for the ameliorati on of

depression, and this therapy is now also being appli ed to the treannent of psy

chotic disorders. Working with individuals to change their thinking about both

themselves and their options in life can have a positive effect (Chadwick, Birch

wood, & Trower, 1996).

• Case management and assertive community treatment (ACT): ACT is a modification

of ypical case management highlighted by the offering of services in natural set

tings, around the clock/seven days a week availability, direct service provision (as

opposed to the prescription of services), team rather than individual caseloads,

and low ca seloads (as low as 10 in some programs). Additionally, some ACT

teams are incorporating concepts of empowerment and individual responsibility

as philosophical s ubstrates in what is termed "the road to recovery" ACT teams

and services have been extensively researched since the initial programs weredeveloped in the 1980s (Stein & Test, 1980). Research has continually found

ACT teams reduce hospitalization (Mueser, Bond, & Drake, 1998).

• Family psycboeducation:As fewer individuals are hospitalized and therefore spend

more time in the community, it is more common for families to be involved with

the severely mentally ill. Talbott (1984) reported that between 30 to 60% of the

severely mentally ill at this time lived with their families. A number of interven

tions have proven effective, especially at preventing relapse and maintaining

Deinstitutionalization

community living. McFarlane, Lukens & Link (1995) reported lowered r

rares with multiple family groups. These are group sessions in which a n

of families constitute the meeting, and family members eventually learn t

vide support to each other as they deal with the illness.

• Supported employment: Th e current approach to employment is a rad ical c

from previous years. It was originally though t tha t prevocational experienc

training were necessary before a person entered an employment posi tion

rent thinking moves individuals into competitive employment directly an

vides supports at the work site. Bond, Drake & Mueser (199 7) found supp

employment programs show superior levels of competitive employmentversus 21 % seen with mOre traditional approaches.

• Integrated substance abuse treatment: Individuals with severe mental illness

been frequently known to develop substance use disorders and thus be

diagnosed. Common treatment approaches in the 1980s would treat each

der separately and sequentially. A review of the literature by Drake, M

McFadder & Mueser (1998) indicates integrated treannent, in which

disorders are simultaneously treated, has positive clinical outcomes. Acco

to Drake, these programs "lead to amelioration of both mental illness and

stance use disorder, and reduce the risks of negative outcomes that haveassociated ,vith dual disorders."

The Community/OrganizationPerspective

As was discussed, the first asylums, such as McLean, the Hartford Retreat,

Bloomingdale Hospital, were all initiated through the use of private and/or corp

funds. It wasn't until after the 1820s that individual states began to consider t

selves responsible for the care and treannent of the mentally ill. Policy makers, a

were no t responding solely to humanistic concerns; from their view, the menta

were a problem m that they were no t able to work or participate in the expan

economy. In order to fully understand the import of community organization

necessary to review the influence of governments in the establishment of programthe mentally ill.

. Individual states such as New York and Massachusetts led the way in es tablis

pubhcly funded mental hospItals. Dorothea Dix, in the 1840s, advocated for all s

to h ~ v e publicly funded state asylums. Her arguments, as touched on previously,

predIcated on the deteriorating condition in the poor or almshouses that provided

Idence for many mentally ill individuals.As early as 1806, the New York State Legture appropnated money to erect an asylum for "lunatics." These dollars

unspent, bur t h ~ concept was revisited in 1830 when Governor Throop called a

tion to the legIslature that there were "345 lunatics in the various counties u

counted for . . " (New York State Senate, 1856). Th e background was set for

concerns, most notably the idea that counties could not afford to care for the incr

ing number of mentally ill in almshouses. Hence began a complex dance of accou

bility and responsibility for the mentally ill. County, state, and eventually fed

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42 CHAPTER TWO

involvementall had a role in leadership or lack thereof. Dix specifically requested that

five million acres of federal land be given to the states for the purpose of building asy

lums. Although Congr ess passed a bill in 1854 allocating ten million acres, t hen Pre si

dent Pierce set a precedent for years to come when he vetoed the bill (Grab, 1994).

This veto kept the federal government Out of financing for the mentally ill for almost a

full century. Some states forged ahead despite this setback. In 1873, New York created

the State Commission of LtUlacy. Th e goal of this group was to send all of the current

mentally ill persons in almshouses to a centralized state asylum. In terestingly, the state

required the counties to contribute to the cost. This process became formalized when

in 1890, the New York State Care Act was passed, requiring the mentally ill to be sent

to the state asylums. An immediate result of his action was a large increase in the pop

ulation of exis ting asylums but without sufficient funds for expansion. T his began an

unfortunate trend that followed the history of public mental institutions, perhaps even

to this day.

As was mentioned, Adolph Meyer was an influential psychiatrist at the turn of

the 19th century who developed a number of interesting inpatient treatment

approaches. He stressed the professionaIization and medicalization of psychiatric care.

In addition to his more personalized approach to the individual, he was also responsi

ble for developing a new approach to community treatment, the aftercare clinic.

Meyer envisioned that some state hospital patients could in fact be discharged and yet

still get care at a community clinic. Thi s idea was not well received, since other hospi

tal superintendents saw this as a threat to their jobs. Hence, the aftercare clinic con

cept was never fully implemented, since the larger state h ospitals held considerable

political influence.The

clinic concept did continue despite this outcome , through anumber of privately funded, mostly child guidance clinics. Unfortunately, a number of

practices were allowed to flourish that eventually became problematic. To begin with,

hospitals used the term "parole status" for those who could leave the hospital and

attend aftercare clinics.This term formed a link between the mentally ill and the crim

inal justice system that persists until this day.

In another questionable practice, it was not uncommon for patients to be "put in

charge" of other patients, to aug ment increasingly lower levelsof staffing. Superinte n

dents were reluctant to release patients to aftercare status because they could utilize

the help that the patients provided.

TheMental Hygiene Movement

It would not be until the 1960s that aftercare clinics would return in full form as anadjunct to state hospital care. Meyer's ideas, which included treating an individual in

the community before the person became severely ill, became known as the menta l

hygiene movement . Th is word "hygiene" became associated with prevention and

eventually moved psychiatrists from working in solely inpatient settings to community

seltings. It was this community prevention focus that also ushered in the beginning of

what we now call advocacy. Through the efforrs of Clifford Beers, a former hosp ital

Deinstirutio nalizarion

patient, a more critical view of the provision of care was begun. Beers chronic

mental illness (he experienced grandiose delusions and had symptoms that woul

likely be associated with bipolar disorder) for others to read. He wasYale educat

was able at times to speak eloquently about his treatment and mistrea tment. He

tually wrote a book, A Mind That Found Itself (Beers, 1908), that started a c

reform. Beers wanted to start a national organization that would promote his ide

calls for reform. He spoke with Meyer, who also wanted such an organizatio

under the sponsorship of "professionals." Meyer convinced Beers that to foc

mental hygiene would be the best option for people with mental illness. In 190

Connecticut Society for Mental Hygiene wa s formed . Beers and Meyer did prmental hYgIene, but soon would break apart, and in 1909 the National Committ

Mental Hygiene was founded. Its purpose was to "protect ti,e public's mental

and promote research into the etiology ofmental illness" (Johnson, 1990), goa

the group held for many years, although the research outcomes were slim.

The psychiatry specialty's organization, which before 1921 was known

A m ~ r i c a n Medico-Psychological Association, became the American Psychiatric

c I ~ t l o In that year. The American Psychiatric Association was to some extent a

ghng enmy, as Its place WIthIn the American Medical Association (AMA) was of

question. In 1931 , the AMA decided to formalize the approach to institutionaliz

and through the efforts of J ohn Grimes, a non psychiatr ist physician, formed a

1111ttee to review the conditions at state hospitals. Grimes and three co lleagues v

600 of he 631 state mental hospitals (Johnson, 1990) and also supplemented the

with a written evaluation by the hospital superintendents. Grimes found that as h

preparing his report, word had leaked out that his findings would expose terriblembarrassing conditions, and members of the American Psychiatric Association

bied to have him revise it. His reluctance led to his termination. Determined, G

prepared his report despite this, and he provided new information on the wors

c o n d l t 1 o ~ s . He wrote that hospItals were overcrowded, that patients basically w

for h o s p l t ~ 1 staff, and that others were locked up for staff convenience. Of mOSt im

tance, GrImes was offended that so-called "hospitals" were no t providing

ment but rather mere reSIdence. HIS recommendation was prophetic. As Joh

(1990) states, "he proposed what he called 'deinstitutionalization' to include imm

ate parole of all suitable patients to aftercare clinics where they would be seen by s

workers under medical supervision." His other recommendations were eq

prophetlc: converSIOn of state hospItals to acute care facilities teachin" of ski

daily living, and development of mutual arrangements with corr:munity :genciesconcepts were to be realized, but not for over 30 years.

Needless to say, his recommendations were not heeded, and hence overcroing, physical plant deterioration, and somewhat drastic attempts at new treat

"cures" (shock therapy, psychosurgery) prevailed. This was, however, the beginni

a movement shIft care to the community. Karl Menninger, a well-respected

popular phYSICIan of the tlme, was supportive of community care, and his vo ic

1945, prompted others to listen. Things took a different turn, however, as psychiarwere about to be SIdetracked by theIr Involvement in World War II.

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44 CH A P TER TW O

The Impact of World War II

Th e economic depression of the 1930s and the impending World War proved to be a

devastating time for the state hospital system. Deprived of capital dollars to eIther fix

or expand huildings, the wards continued to fill . Overcrowdmg was exacerbated by a

shortage of doctOrs, about 1 doctOr to 500 patients, and an even greater shortage of

nurses, about 1 nurse to 1,320 patients (Group for the Advancement of Psychiatry,

1946). Unfortunately, this was a trend that would no t easily abate. Inc:eased pressure

was developing to allay symptOms and to create improvement suffiCIent enough to

warrant discharge. Despite th e now worsening conditions and drastlc treatment meas

ures, the policy of nstitutionalization continued to be supported. In 1945, the Mental

Hospital Survey Committee Gointly created by the Amen?an P s y c h i a t n ~ AsSOClatlon

and the U.S. Public Health Service in 1936) began to Identlfy concerns WIth state hos

pitals and overcrowding, bu t the ~ o m m i t t e e . reported .optimistically on the Impact of

the new somatic treatments WIthin mstltutlonal settmgs (Grob, 1994). Hence, the

impact of World War II and its effect on the treatment of the mentally III was sIgrufi-

cant and yet often unrecognized. . 's mentioned in Chapter 1, psychiatrists were involved II I the screerung and

assessment of recruits to help determine whether individuals were smted for acove

duty. As war unfolded, the effects of stress were wimessed and studIed . Th e relaoonship

between stress and mental deterioration was seen as a SIgnIficant vanabie. II I the treat

ment of he mentally ill. Environmental factors, if controlled, were recognIzed as some

thing that could potentially limit the severity of illness. A new t h e o r e t l ~ a l model of

community treatment was developing. The concept was simple: p r e v e n ~ Clrcumstanttal

stress from occurring in the community and individuals would no t detenorate to su?h a

degree that hospitalization was necessaty. Government response was not far behind.

After World War II the U.S. health care system reemphasized research. Robert Felix,

who was trained in ilie public health approach to mental illness, i n i t i a t ~ d an effort to

rekindle federal involvement in the mental health field. Although psychiatry was not a

major influence at this time, research in the medical arena pointed to success WIth con

trolling such diseases as smallpox. As such, a wave of ~ e n t i m e n t f o r preventlon programs

was pervasive. On the basis of the new medical findings, PresIdent Truman p a ~ s e d the

National Mental Health Act of 1946, which provided funds for research, tramlllg, and

grants to states instituting pilot projects dealing with prevention and treatment of men

ta l disorders. Th e National Institute of Mental Health (NIMH) was estabhshed to

carry out the mandate. Felix had orchestrated the support of the f ~ d e r a l government on

the conceptualization that mental disorders were a public health Issue. The Immediate

outcomes of the new funding policies were such that by the 1950s, many states had lrutiated community-oriented prevention programs. NIMH conducted a s ~ r v e y III the

mid-1950s and found that nearly 1,300 outpatient chrucs were m operatlo.n (Bahn &

Nonnan, 1957). Th e popular therapeutic approach centered on. early detecoon, but lit

tle data or supportive evaluation revealed program effectlveness. A communIty

approach was becoming particularly common as well. Then Senator John F. Kennedy

cosponsored a bill, the Menta l Health Study Act of 19 55, to study the treatment of the

mentally ill. Th e bill established the J OInt CorrurusslOn on Mental illness and Health

Deinstitutionalization

(note the tag word "Health"), which completed a major study in 1961. This repor

cluded that "the nation could more than double the nmnber of chronically ill m

patients returned to the community" Gohnson, 1990). Sentiment and action wer

moving toward changing the state hospital system. Mary Jane \¥ard's The Sna

(1947) and Albert Deutsch's The Shame of he States (1948) were popular expose

compelled the public and politicians to take action.

Also as mentioned in Chapter 1, Kennedy, who was by then the President

the Joint Commission report and developed a task force to draw up recommend

to implement the suggested recommendations. The task force had wide represen

from individuals both within the field and outside, including representatives fro

Defense Depa rnnent and American Legion. An ideological split developed with

task force, thereby leading, perhaps more than any other aspect, to the negativ

comes of deinstitutionalization.The issue at stake was the role of tl,e state hospi

was a crucial time that necessitated a clear direction, either advocating a continue

for state hospitals or calling for tl,eir abolishment. Unfortunately, there was no co

sus, and thus an opportune time to develop a progressive policy for the severely

tally ill was lost. A large contingent of the committee felt that the conc

prevention was so strong that the need for long-tenn care would not be necessa

hindsight, the committee failed to either understand or appreciate the needs

severely mentally ill. They failed to consider these conditions affect an individ

many different spheres and that patients require support and treatment throu

much of their life. Again, in retrospect, it is clear a comprehensive community pro

for long-term patients was needed but not considered. \¥hat did develop fro

committee was a program based on prevention and on the acute treatment of millness. Th e role of he state hospital was simply to "ge t smaller." Th e commuuity

tal health program that developed was designed for the more acute cases, and the

term patients were returned to a system that was no t designed to meet their

Over 50 years later, there is still discussion of the severely mentally ill and their n

an opportunity was lost, and attempts are still being made to rectify a flawed p

Without a clear policy direction, state hospitals survived but were to be of dinlin

use. Some state hospital closures were rapid. In 2003, Th e Olympian, a popular W

ington State newspaper, reported that over forty state hospitals were closed be

1990 and 1997 alone. Closures were precipitated not only by fuzzy philosophy bu

by federal reimbursement policy, the "institution for the treatment of mental dis

or IMDs, which would exclude federal reimbursement to state hospitals.

Community Mental Health Act of 1963Th e Community Mental Health Act of 1963, the direct result of the commi

report, was developed essentially around a strong public health orientation. I

predicated on local development of services provided to a geographic section of 7

to 200,000 people. Th e Communiry Mental Health Act of 1963 mandated the

sion of five essential services: inpatient acute care, outpatient care, partial hospi

tion, emergency care, and consultation and education.

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48 CHAPTER TW O

direction for the state hospital system. As recently as 2004, the New York State Public

Professional Union sponsored a full-page newspaper ad opposing closure of a state

hospital. The stated concern was to not inconvenience families to have to travel an

additional 50 miles to the next state hospital. State hospital policy aside, current publichospitals have begun to incorporate, on a national level, evidence-based practices.

Political and Social Policy Perspective

As mentioned earlier in the chapter, the role of the federal government has changedover the years. President Pierce was the most outspoken opponent of federal intervention or direction, as he believed mental health policywas a state issue. He vetoed legis

lation that Dorthea Dix had advocated, and he stated, " . . I cannot find any authority

in the Constitution that makes the federal government the great almoner of publiccharity throughout the United States" (Foley & Sharfstein 1983, p. 647). The federal

movement toward prevention and public health in the ea rly 1950s helped rekindle the

political role of federal government. In 1954, President Eisenhower passed Title II of

the Social Security Act: the Disability Income Program. This title would be the

groundwork for further titles: XVIII, Medicare; XIX, Medicaid; and XVI, Supplemental Security Income Program. These would ensure federal financial involvement forprograms for the mentally ill for future years. Eisenhower spoke at his State of the

Union Address in 1955, " . . I shall propose rigorous steps to combat the mis ery andnational loss involved in mental illness" (Sharfstein, 2000). Up to this time, few states

had authorized funds for community service. The first attempt to fund communitycare by the states came in 1954 when New York State passed the Community MentalHealth Service Act, which proposed state fiscal support for local communities todevelop community programs. Governor Thomas Dewey's state budget messagealluded to reducing the state fiscal commiunent to inpatient care (Johnson, 1990).

The cost to the states for institutionalized care has become enormous. The

median annual cost per patient in a mental hospital in the nation was $246 in 1939 and$636 in 1949 (Johnson, 1990). As discussed, in 2004 the estimated cost per adult person per year was $237 ,6 15 (Rifton, personal communication, 2004). This enormous

fiscal burden forced government officials to look for cost-cutting measures, as New

York State did in the 195 Os.

The fiscal policy issues that states face today relative to funding mental health

programs were determined over 40 years ago. The first significant legislation thatbegan to impact the mentally ill was in 1960, when the federal government agreed to

subsidize general and chronic hospital care through medical assistance to the aged,which today is called Medicare. This regnlation was incorporated under Title 1 of theSocial Security Law and exempted from state-run institutions reimbursement (theIMD exclusion). The exclusion of state-run institutions would be a significant over

sight for the future of many individuals with severe mental illness. The exclusion concept was carried forward to 1965 under Title XIX and Title XX of the Social SecurityLaw, which provided for Medicare and Medicaid, a new reimbursement mechanism

Deinstitutionalization

for the poor. Medicaid is now the nation's largest public insurance program (Rbaum & Teitelbaum, 2002). The enacunent ofMedicrud included an exclusion k

as "Medicaid IMD exclusion." The exclusion bars federal coutributions to the c

medically necessary inpatient care incurred in treating Medicaid beneficiariesages 21 to 64 who receive care in certain institutions that fall within the definitan "institution for mental disease" (Rosenbaum & Teitelbaum, 2002). An "instit

for mental disease" is defined as "a hospital nursing facility or other institution of

than 16 beds that is primarily engaged in providing diagnosis, treaunent or care osons with mental disease, including medical attention, nursing care and relatedices." It should be noted that in subsequent legislation, Medicare provided fundinthe under 21 and over 65 population, bu t the IMD exclusion remained.

This fiscal incentive to release long-te rm state hospital patients into the com

nity was significant. States moved quickly (although in hindsight, not quickly eno

to develop community housing and programs. Generally speaking, the federal goment paid between 50% and 78% of the costs on Medicrud eligible individuals. Gsuch fiscal incentives, states looked to shift the financial burden to the federal go

ment by moving long-term patients from state hospitals with no federal reimb

ment, to other institutions (often nursing homes) that were Medicaid eligible.Cbicago Tribune reported that the State of Illinois "dumped thousands of menta

patients into nursing homes in order to collect Medicaid, which paid half the

(Berens, 1998). The article goes on to say that state workers "quietly reclass

many patients to disguise the portion who were mentally ill. This transinstitutionation resulted in the state's receiving an additional $50 million from Medicaid.Thi

based on the early promise that the adult ages 21 to 64 population should be excfrom reimbursement for public institutions. It was hoped that all individuals ingroup would move to community settings.

To compound m a l ~ e r s , Medicaid was originally a medically based service. In words, all reimbursable services were to be prescribed by a physician, andphysician-based services were not reimbursed. As previously illustrated, services surehabilitation, self-help, case management, and so on are essential elements in the tment regime for the severely mentally ill. These services are often provided by prsionals, but not necessarily by physicians. Program priority was directed toreimbursable services, and thus some of the evidence-based services (assertivemanagement, etc.) were slighted. More recently, states have reversed this tren

mcorporatmg some of hese services under the reimbursable rehabilitation designaAs has been repeatedly shown, the lack of vision for a coordinated treat

approach to the mentally ill created a void filled by other opportunistic fiscal and p

Ical agendas. In 1972, another federal amendment aided this trend . The Social Srity Amendment of 1972 was a new entitlement to provide a certain lev

~ a r a n t e e ~ income called SS!. SSI eligibility was generously applied to people wdIsabIlity that prevented them from entermg the workforce. Unlike Medicaid, w

was only half-supported by the federal government, 5SI was 100% federal fu

altllOugh states were allowed to supplement the amount if they felt it was necesStates saw thIS enntlement as yet another vehicle to help institutionalized per

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50 CHAPTER TWO

return to the community. Armed with sufficient funds and with new reimbursable pro

grams available in the community, a "push" was evident. In 1974, the first year SSI was

available , states saw the largest decrease in state hospital population (13.3%) of any

single year Gohnson, 1990). SSI has been a mixed blessing. In a similar fashion as fee

for-service, reimbursement methodologies in which repeated visits are rewarded

financially, SSI created an uncomfortable dependency. There was no incentive to

recover or to return to the workforce. Also, the money savings of the Social Security

programs of 1965 and 1974 gave no attention to the treatment needs of the severely

mentally ill . Th e hope was that if the locus of care shifted to the communi ty and peo

ple had enough money to live, they would be "better off." As has been indicated, it is

not the locus of care but the attention to the disorder and application of evidence

based treatments that are necessary (Geller, 2000).

Another significant yet unfortunate outcome of the new federal policy was a lack

of accountability for treatment implementation. As patients left the institutions, there

was no consistent management of the ongoing treatment, something that is essential

to recovery, and no assurance of the critical interface between hospital , community

treatment, and individual needs.

This unfolding myopic approach to the severely mentally ill did no t go unno

ticed. David Mechanic spoke frequendy about the "need to overcome the debilitating

efforts of decenrralization of an uncoordinated system of treaonent, care and financ-

ing" (Grab, 1994, p. 305).

Th e National Institute of Mental Health was also aware of he existing fears, and

given its mandate to promote research, launched a community support program in

1977. In some ways it was an add-on to the original 1965 legislation, as it added components for housing, income, psychiatric and medical treatment, and support services,

including vocational rehabilitation. Th e CSP, as previously menti oned, was to be a

partnership with the states, and was designed to fill in gaps, where needed, for those

who were no longer in state institutions.

In many ways, CSP was successful. It provided a renewed focus on the individual

and his or her needs. For states that took advantage, such as WIsconsin, it provided the

necessary impetus for better, more coordinated treatment.

Th e WIsconsin model, through the foresighted effortS of researchers such as

Leonard Stein and Mary Test, suggested it was possible for highly impaired persons to

be able to not only survive in the community but also to be satisfied with services

involving less hospitalizations (Stein & Test, 1980). A number of replications of this

model were attempted throughout the United States, and the most consistent. out

come was that the "assertive community care" did reduce hospitalization. As Illus

trated, Assertive Community Treatment (ACT) teams have been demonstrated to bean evidence-based practice for the treatment of he severely mentally ill.

To some degree, it is unfortunate the motivation to implement such programs was

left to the states. President Reagan's repeal of the Mental Hea lth Systems Act of 1980

contributed to this outcome. Yet another attempt to force states to at least plan for the

SMI was enacted in 1986, as d,e Comprehensive Mental Heal th ServiceAct (CMHS).

This Act required states to plan and implement a comprehensive, community-based

program of care for the severely mentally ill. Failure to do so jeopardized other funding,

Justice

Deinstitutionalization

and as a result, states included annual plans to the federal govenunent to ensure f(Geller, 2000).

From a financial perspective, there has been litde change in the role of th

eral govenunent. There is still no clear accountability for patient care. The

however, a vast number of uncoordinated fiscal incentives that mayor may not

tate evidence-based practices.

There have been significant changes in the mental health commitment laws in

years. One of the first laws to address involuntary commitment was in Californ

Lautennan-Petris Short Act of 1968. This legislation dealt with the civil rights o

chiamc patients being hospitalized against their will, and made hospitalization

difficult. In addition, it challenged the renewed commitment once someone had

admitted. This Act was a follow-up to the 1966 judicial decision, Lake v. Camer

which an appellate court ruled that a person could be admitted to an institution

a less restrictive facility could not be found. These two rulings drastically chang

admission.policies of all state hospitals and, of course, could be used no t only to

tect cml nghts but also to foster cost-savings measures that some states craved.

Along with these new admittance protocols, the thrust of civil rights prote

for the mentally ill continued. In 1970, the lfJatt vs. Stickney (ruled by st

Alabama) ruling mandated adequate and effective treatment in public psychiatric

pitals. In addmon, It mSlsted on a humane psychological and physical environmenenough staff to administer adequate treatment, including individualized trea

plans. This statute was significant for many states. Those individuals who remain

hospitals ~ o w had a civil right to effective and humane treatment with ade

staffing. It S mteresnng, that thiSconnnued the process of discharging more and

patients to the community, as the cost to provide care for those remaining beca

fiscal burden. Still, further protection continued to be granted. In 1972, in Lessa

Schmidt, the court ruled persons facing involuntary commitment were guara

legal procedure safeguards similar to those for someOne who was charged with a c

In effect, each involuntary committed person had a right to legal aide. In New

State, attorneys were assigned to state hospitals to implement such a mandate a

meet with.each admitted individual. Another suit had a quiet but significant impa

state hospitals and discharges. In 1973 , in Sauder vs. Brennan, the court ruled pat

workers are covered by the Federal Fair Labor Standards Act, entiding them t

muumuffi.wage and overOme compensation. Parientworkers were , for many hospa euphenusm for "free help." Many long-stay patients who were relatively stable

become part of the working fabric of the hospital, so much so that some patients

often confused with staff. These workers "earned their keep," socialized with staff

worked long and hard. Generally, patients in these positions did not want to leav

hospital, as this had become their "real" home where they felt protected and pro

nve. Th e Sauder Act changed that, and vocational rehabilitation became a mtreatment-ori ented element in hospital practice.

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52 CH A P TER TW O

In Donaldson vs. O'Connor (1974), and later confirmed by the Supreme Court

(1975), it was ruled that a state cannot confine a nondangerous individual who is capa

ble of iving by him or herself or with a family member. This significant act again made

involuntaryhospitalization more stringent. It added to J1)!att vs. Stickney and made the

admitting criteria to hospitals what they are today; evidence of a mental condition that

cannot be t reated in a less restrictive environmentand/or evidence the person is a dan

ger to self Or to others as a result of such mental condition.

Although not impacting hospitals directly, in 1976, Tarasoffvs. Regents of he Uni

ve-rsity ofCalifo172ia ruled, "if a patient presents a serious danger of violence to another,

the therapist incurs an obligation to protect the intended victim against the danger"(Geller, 2000). Although at the time it was thought that this ruling would greatly

impede the therapeutic alliance, generallyspeaking, this has not been t he case.

In 1990, more import ant legislation that helped protec t those with mental illness

was passed. Th e American with Disabilities Act (ADA) pushed to eliminate discrimi

nation against disabled persons. For the mentally ill, this legislation was an important

boost for those entering the competitive job market.

In 1996, advocacy groups that argued on behalf of psychiatric coverage as part of

health insurance were rewarded with the Domenici Wellstone Mental lilness Parity

Amendment. This amendment forced employers of more than 50 workers to provide

coverage for mental illness.

Lastly, in 1999, 30 years after Lake vs. Cam.,.on , the Supreme Court ruled in

Olmstead vs. LC and E.W that the ADA would mandate states to provide community

placement for persons with mental disabilities. This was a somewhat belated recogni

tion that without supported community pIacement, successful community placementwas compromised.

Conclusion

The history of treatment interventions for the mentally ill has shown movement from

a focus on institutionalization to community-oriented, evidence-based practices. Th e

deinstitutionalizationmovement helped foster a more community-oriented approach,

although not without some negative consequences. Current evidence-based practices

and the psychosocial interventions they provide offer new hope for an emerging

recovery-oriented field.

D I S C U S S IO N Q U E S T I O N S

1. What was the state of mental health inpatient care in the 1950s? How did this differ from the standard of care commonly given in the 19th century? VVhat contextual factors contributed to a shift in

mental health care administration?

2. How has the treatment of the mentally ill changed since the 1950s? What prompted these changes?

How has the ro le of the state hospital changed during this time period?What sociopolitical eventsin modem times might be contributing to the state of the current mental health system?

DeinstitutionaJization

3. Why have menta] health programs rraditionall been d' ddisorder? Has thisprotocol changed? If not wh;t uld ~ , g n e h

otreat only the symptom

. ' wo ave to appen to cause It to chan

4. OutlIne some of the contributi n th Ad ] h Mthe way in which these c o n t r i : u ~ o n : t m a ~ f e s t ' eyer ad e to the treatmentof he mentallcontribute to the design of community m tal h

m]mth° ern trehatmem protocols. How did h

en ea approac es?

5. How have admittance procedures changed over th ) ~ ' h tributed to this shift' \Vhat . years. \ at were some social issues th

whom were these h ~ g e s b : ~ ~ C ~ ~ l ~ a : ; ! ~ ; ~ a n t pIeces of legislation that affected this cha