I am afraid that Rambi is on the planet of Knowing Whereof She Speaks. It is a nice place, you ought to visit it sometime:
Broken Promises: the story of deinstitutionalization
by Pat M. Stubbs
The homeless are ubiquitous. When the percentage of mentally ill are factored in, the problem becomes even more acute and discrete. This paper reviews some of the history involved with deinstitutionalization policies. Do we need to wait for a third task force report to affirm what is already evident? Action, expedient and definitive is needed to resolve the mentally ill homeless problem. Dependent on one's perspective, consumer-based or system-based (psychiatry, social work, etc.) is where the genuine difference lies. Consumers (the mentally ill that use the system) continue to fight with legal issues such as civil rights, advocacy and empowerment concerns, while psychiatry deals with the ethical issues ranging from the "illusion of freedom," to the conflict that arises from principles mandated by their hippocratic oath.
History
The National Institute of Mental Health defines the homeless mentally ill adult population as individuals, age 18 or older, who have long-term severe mental illness and no fixed place of residence (or who are at imminent risk of becoming homeless). Long term severe mental illness is defined as a serious mental or emotional disorder (e.g. schizophrenia, mood disorders, and schizoaffective disorder) that disrupts functional capabilities for primary aspects of life as self-care, interpersonal relationships, and employment or school (Levine & Rog, 1990).
In 1830 there were only four public psychiatric hospitals in the United States and most of the mentally ill were either kept at home or in jails (Torrey, 1988). Some actually wandered the streets begging for meals. As the number of mentally ill and homeless individuals grew, the first almshouses and poorhouses were built. They filled as quickly as they were built. The percentage of mentally ill within these almshouses grew and instigated the building of more public psychiatric hospitals. By 1880, the total number of psychiatric hospitals had grown from four to seventy-five (Torrey, 1988).
Also in 1880, a group of psychiatrists, neurologists, and laypersons formed a group called the National Association for the Protection of the Insane and the Prevention of Insanity (NAPIPI). Their primary goals were to improve conditions within psychiatric hospitals and reverse the apparent growing trend toward insanity. However, by 1884 the NAPIPI disbanded due to internal dissension. Unfortunately, the concept of prevention over treatment has never fully been eradicated from psychiatry.
On February 19, 1909, the National Committee for Mental Hygiene was initiated by Clifford Beers, a graduate of Yale who not so coincidentally had experienced serious mental illness himself as well as hospitalization. With the assistance of William James, Adolf Meyers, and others, the organization was formed. Its goals were to serve as a "clearinghouse for the nation on the subject of mental health, the prevention of nervous and mental disorders, [and] the care and treatment of the insane" (Torrey, 1988). At the time Beers was more interested in hospital reform than prevention, but was eventually persuaded to adopt the then current trend toward the popular Freudian perspective.
Freud believed peoples' lives were dominated not by one's conscious mind, but by the forces within the unconscious mind. Freud also believed that unconscious sexual motives were at the heart of mental illness (Lahey, 1992). Through the theory on "unexpressed sexual motive," he unwittingly encouraged the belief that prevention of mental illness was possible and this fact precipitated a concentration of effort not on treatment but prevention as the paramount issue.
In 1945 there were 3000 psychiatrists working in the United States and 53% worked in the public sector (Torrey, 1988). Mental health was still a growing concern, and on July 3, 1946, the National Institute of Mental Health (NIMH) was formed under the National Institute of Health.
NIMH directives were to: "conduct research, investigations, experiments and demonstrations relating to the cause, diagnosis and treatment of psychiatric disorders; train personnel in matters relating to mental health; develop and assist states in the use of the most effective methods of prevention, diagnosis and treatment of psychiatric disorders" (Torrey, 1988).
In 1948, NIMH began actual operations with 6.2 million dollars of government funding. In 1950, the National Committee for Mental Hygiene modernized to the National Association for Mental Health.
Forthcoming were the pharmaceutical advancements in the treatment of the seriously mentally ill with the introduction of psychotropics. In May, 1954 Chlorpromazine (Thorazine) hit the market and within eight short months it was administered to over two million patients (Isaac & Armat, 1990). Chlorpromazine was discovered in France by Henri Laborit and was initially developed and synthesized in the search for a better antihistamine. Reserpine (Raudixin) was developed in the United States by Ciba Pharmaceuticals (Isaac & Armat, 1990). Currently, Reserpine is infrequently used for the treatment of hypertension. Both drugs were hailed as the effective treatment in controlling the symptoms of psychosis (Torrey, 1988).
The Joint Commission on Mental Illness & Health
The Mental Health Study Act of 1955 was introduced into legislation on July 28, 1955, resulting in NIMH appointing the Joint Commission on Mental Illness and Health to "evaluate the needs of the mentally ill and to make recommendations to Congress for future programs."
The Joint Commission defined positive mental health as: "the attitudes of the individual toward himself; the degree to which the individual realizes his potentialities through action; unification of function in the individuals personality; the individual degree of independence of social influences; how the individual sees the surrounding world; and the individual's ability to take life as it comes and master it" (Torrey, 1988). The Joint Committee performed a six year study entitled Action for Mental Health (Isaac & Armat, 1990). The report, released in 1961, recommended upgrading existing hospitals; putting limits on the number of admissions once a hospital reached its cap, with a maximum cap of one thousand per facility; more usage of general psychiatric wards; and conversion of state hospitals into centers for "the long-term and combined care of all chronic diseases including mental illness" (Isaac & Armat, 1990). It also called for the establishment of community-based treatment centers, perhaps one clinic per fifty thousand area population. However, most importantly stressed was "the concept of prevention was a chimera" (Isaac & Armat, 1990). John F. Kennedy was in the presidential office at that time and was personally interested in enacting mental health legislation, because his sister Rosemary suffered from mental retardation and mental illness, although the latter was not acknowledged at that time, primarily due to stigma. Kennedy appointed a committee to review the "Action for Mental Health" and most of the recommendations were overlooked except for the establishment of community-based treatment centers.
Kennedy misguidedly believed that primary prevention and reduction in state hospitals could be achieved through community mental health centers. In Kennedy's speech THE DREAM, he began with prevention: "Here more than in any other area, an ounce of prevention is worth more than a pound of cure. For prevention is far more desirable for all concerned. It is far more economical and it is far more likely to be successful." Kennedy fostered the belief that the major problem was the existing institutional care of patients, and, in fact, not the disease itself (Isaac & Armat, 1990).
Kennedy promised: "if we launch a brand new mental health program now, it will be possible within a decade or two to reduce the number of patients now under custodial care by 50% or more." Kennedy also promised that "reliance on the cold mercy of custodial isolation would be supplanted by the open warmth of community concern and capability" (Isaac & Armat, 1990).
The Beginning of the End
Thus was born the Community Mental Health Centers Act (CMHC Act). Since there was little, if no, scientific (or otherwise) evidence that prevention was an achievable goal, Congress concentrated on the goal of reducing hospital populations. Unfortunately, no one even thought to ask, Where will all the patients live upon discharge? This is absolutely astounding when one considers that at that time there were no government programs to finance the returning patients, yet no one asked the important question, Where will they go? Deinstitutionalization had officially begun.
In 1962 the government funded Aid to the Permanently and Totally Disabled, (APTD) an early form of SSI (Isaac & Armat, 1990). By the end of October in 1963, John F. Kennedy signed legislation for the creation of Community Mental Health Centers. This act changed the situation considerably because mentally ill individuals within the communities became eligible for federal benefits to pay for rent, food, etc. (Torrey, 1988). In May, 1964, NIMH instituted the guidelines for essential services that would be provided by the CMHCs as:
inpatient services;
partial hospitalization (hospital during the day only);
outpatient services;
emergency services; and
consultation & education services.
An optional second group of services tailored to the chronic patient would make a center more comprehensive (Isaac & Armat, 1990).
Remarkably, none of the guidelines included or mandated a coordination of services or communication between a hospital and the CMHC. This proved to have disastrous results as CMHCs were not informed of patients being released from the hospital. The released patients needed aftercare, minimally for medication and longitudinally for rehabilitation counseling, which would have included locating community resources. Also possible admissions were not diverted to CMHCs (Torrey, 1988).
Some have argued that the real force behind deinstitutionalization came from federal monies because in 1965 the government encouraged the deinstitutionalization process by introducing several programs, primarily medicaid and medicare, which would only provide benefits to patients not in state hospitals (Isaac & Armat, 1990).
In the beginning stages (early 1961) deinstitutionalization did not present much of a problem, because the first wave of patients released were highly functional and had maintained some semblance of closeness with their families, so 2/3 of this wave went to live with family members upon discharge.
The total amount of public funds spent at this time, on the mentally ill was approximately one billion dollars per year. Of that one billion, 96% was spent at state level only. The federal government paid living expenses for a relatively small number of the mentally ill through the Social Security Administration, but "local county and city assumed costs for most patients through welfare, social services, subsidized housing, jails, police and court costs" (Torrey, 1988).
In 1967 the first federally funded CMHC opened. At that time the CMHC directors mistakenly believed that by dealing with social issues such as rent inflation and civil rights, they could get to the heart or cause of mental illness (Torrey, 1988).
Psychiatry had little, if any, knowledge or understanding of community politics. All state hospitals were suspect, under scrutiny, and defined as the problem, with the CMHC being labeled as the solution. The 60's were a time of social revolution, a time when civil rights were asserted for just about everybody and everything.
An important case that had a huge effect on deinstitutionalization was the Lanterman-Petris-Short Act of 1967. "It passed in both Houses without a single dissenting vote" (Republicans saw a way to save money and Democrats saw a way to expand civil rights) and it restricted the grounds for involuntary hospitalization and its length (Isaac & Armat, 1990). So in effect, civil liberty lawyers could also be held responsible to a degree for the acceleration of deinstitutionalization.
The New York Civil Liberties Union saw involuntary commitment as the crux of the state hospital system, and believed that the elimination of commitment laws would precipitate the end of all state hospitals. The civil liberties union sired the Mental Health Law Project, whose primary goal was to "create a doctrinal abyss into which will sink the whole structure of commitment laws" (Isaac & Armat, 1990).
Serving as a catalyst, they aided in the establishment of minimum standards of treatment, including minimum staff to patient ratios. Some states achieved these court-mandated ratios by releasing patients - not by hiring staff. The lawyers helped set "the least restrictive setting" mandate, the "refusal of treatment" mandate, as well as tightened the involuntary commitment laws to "dangerousness to self or others" (Torrey, 1988).
In 1969, NIMH separated from NIH. NIMH saw itself as equal to NIH, although not as a research entity, but rather as an overseer of services (Torrey, 1988). NIMH fulfilled one of its goals of training personnel by using federal funds to begin training programs in existing schools for psychiatrists. Unfortunately they did so without stipulating that upon graduation a doctor would be required to put in one year of service, to the state, for each year of schooling funded. Since there were no provisions to prevent doctors from getting the training and going directly into private practice, that is exactly what they did (Torrey, 1988).
Psychiatry was at its all time low; many state hospital directors and superintendents were reviewed not by their job performance but by the number of empty beds within their respective hospitals. For this reason and others, no one wanted to work in the public sector. Between 1970-75 the number of psychiatrists willing to work in the public sector (including CMHCs) fell by 50% and were replaced by psychologists and social workers (Isaac & Armat, 1990). State hospitals began to be staffed by foreign medical graduates. New immigration laws made it less difficult for professionals from other countries to emigrate to the U.S., especially doctors. Many of the state hospitals initiated residency programs because most of the foreign medical graduates had received little or no psychiatric training within their own country (Torrey, 1988).
Numerous students "were unable to pass state licensing exams due to poor training, lack of competency and language problems" (Torrey, 1988). At least 43 states amended their medical licensing laws by 1971 so that medical students could practice in state facilities on "special state permits" (Torrey, 1988).
CMHCs Fail to Fulfill Their Promise
As deinstitutionalization rates climbed, the proportion of patients treated at CMHC for serious mental illness decreased. Ironically, CMHCs were in the same boat as state hospitals; they were forced to rely increasingly on the foreign born and trained (Isaac & Armat, 1990). It became evident that what CMHCs were doing "was counseling and crisis intervention for predictable problems of living" (Isaac & Armat, 1990). This phenomenon is known as treating the "worried well."
In 1975 relatively few CMHCs were in compliance with the first five essential services originally created by NIMH in May 1964; 50% had no beds, and little or no emergency services. Only 6% had day treatment, and almost all were poorly staffed (Torrey, 1988).
In fact, most of the CMHC staff found the serious mentally ill to be onerous and difficult to work with. The CMHC Bill was revised and passed with the same original five services plus seven more. The seven new services were:
screening of patients prior to admission to state hospitals;
follow-up care for those released from mental hospitals;
developing transitional living facilities for the mentally ill and providing specialized services for:
the child;
the elderly;
drug abusers; and
alcohol abusers (Torrey, 1988).
In 1977, the Secretary of the Department of Health, Education and Welfare established a Task Force on Deinstitutionalization of the Mentally Disabled, because it had become obvious to almost everyone that CMHCs were not working and were being used for the worried well. As one senator put it, "no one discounts the pain of the worried well, but congress and taxpayers did not intentionally fund a national counseling service; it intended to fund a program to substitute for state hospitals in caring for the seriously mentally ill" (Isaac & Armat, 1990).
Based on this Task Force report the Community Support Programs (CSP) began "for one particularly vulnerable population -- adult psychiatric patients whose disabilities are severe and persistent" (Torrey, 1988). NIMH established CSPs recognizing the failures of the CMHC program, but far from acknowledging it (Isaac & Armat, 1990).
The following guidelines were set by NIMH for CSPs: "medical and mental health care; crisis stabilization in the least restrictive setting possible, with hospitalization available when other options are insufficient; psychosocial rehabilitation services; backup support to families, friends, and community members; involvement of concerned community members in planning and offering housing or work opportunities; supportive services of indefinite duration, including supportive living and working arrangements and other such services for as long as they are needed" (Torrey, 1988).
In 1979 the National Alliance for the Mentally Ill (NAMI) was formed and shortly thereafter (approximately 1980) was the inception of the National Mental Health Consumers Association (NMHCA). Both consumer advocacy groups have national as well as regional offices. It is the position of this writer that the emergence of consumer-based advocacy groups was precipitated by the failure of the current mental health system, including but not limited to, the government, psychiatry, CMHCs, and other official organizations that consider themselves to be primarily dedicated to the treatment of the mentally ill.
In 1987 the Stewart B. McKinney Homeless Assistance Act (Public Law 100-77) was passed. This act provided the first federal funds allocated specifically for the homeless population (Levine & Rog, 1990). Under Title VI, Section 611 and 612 are particularly relevant to the mentally ill homeless.
Section 611 authorizes a non-competitive block grant program that is designed to provide an "infusion of funds to state level for five services: outreach, case management, mental health treatment, support and supervisory services in housing for homeless mentally ill persons and training for service providers" (Levine & Rog, 1990).
Section 612 authorizes a competitive block grant program where "innovative service initiatives" are emphasized. The same array of mental health services were required for each accepted program, including: outreach services in nontraditional settings; intensive, long-term case management; mental health treatment; staffing and operation of supportive living programs; and management and administrative activities (Levine & Rog, 1990).
Conclusion
In conclusion, more than three decades of deinstitutionalization policies have resulted in at least two task force reports (one in 1985 by the American Psychiatric Association and another in 1992 by the U.S. Department of Health and Human Services) as well as numerous books and articles addressing homelessness and the mentally ill. Although many different recommendations have been made by many people, little has been accomplished to implement these recommendations on a large scale. This may be due to several factors including waiting for the ideal to occur.
The ideal is defined as wanting to have a comprehensive and coordinated mental health system that would induce and engage the homeless mentally ill to voluntarily accept treatment and appropriate living arrangements. But... we can no longer wait for this ideal system to be established.
The homeless mentally ill problem has given rise to issues ranging from legal to ethical -- the answer may lay in a simple, straightforward large-scale values clarification by asking ourselves the question, Can we as an advanced, wealthy nation afford to allow the problem to continue?
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