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Our first generation of young adult chronic psychiatric patients since deinstitutionalization has emerged in the community. Updated research results and case studies show different patterns of emergence but similar indications for clinician response.
The myriad of community problems created by the deinstitutionalization of psychiatric hospitals can be attributed to inadequate administrative planning rather than any lack of technical expertise in working with the mentally ill. In planning, administrative goals were emphasized over treatment concerns, community systems and environments were poorly conceived, and the difficult realities of treating chronic mental patients in the community were not acknowledged. Some of the failures in planning can be attributed to a lack of a client, community, and treatment personnel acknowledgement and involvement. Empowering these groups in the decision making process would improve community services, as would organizing clients into an active social, political, and consumer force.
The crisis in community care for the seriously mentally ill (SMI) stems from organizational and financial difficulties as well as from deeply embedded structural factors. The analysis shows a preference for medicalizing and individualizing the problems of SMI rather than viewing them as structural social welfare issues. The author discusses problems of deinstitutionalization, homelessness, service provisions, financing, accounting and reporting, employment, bureaucratic skimming and burden to families and points out the ambivalent ideology and the inherent contradictions within the mental health service system. Finally, the centrality of social control and the maintenance of orderly social life in public policy and program development is illuminated.
Although the era of deinstitutionalization of the aged from state mental facilities and of the rapid growth of the nursing home industry appears to have ended, the question remains of the extent to which nursing home care is substituted for psychiatric care. To study this question, the numbers per capita of Medicaid program recipients of inpatient psychiatric care for each state in the period 1979-82 was regressed on numbers per capita of Medicaid nursing home recipients, numbers of nursing home beds per capita, and the percentage aged. As expected, psychiatric care is negatively related to bed supply, positively to nursing home recipients and to percentage aged; and the relationship to nursing home recipients is stronger in states with undersupplies of beds. These findings are interpreted to show that nursing home care is substituted for inpatient psychiatric care, depending on bed supply, the generosity of the Medicaid program, and the level of demand for care.
Archival data from daily logs maintained at a private proprietary home were tracked from four to 29 weeks prior to psychiatric rehospitalization for ten deinstitutionalized adult females and ten nonhospitalized controls. Three raters coded behavioral incidents into ten categories. The rehospitalized women had significantly more incidents than did the controls, including more affective disturbances (depression, anxiety, anger, and interpersonal concerns) and more attempts to secure psychiatric rehospitalization. The rehospitalized groups also exhibited symptomatic behavior for a greater number of weeks than did the control group, suggesting that the symptom pattern was probably detectable long before rehospitalization was necessary. Peaks in incidence frequency often occurred several weeks prior to rehospitalization.
In this paper, the relative merits and limitations of two models of case management (CM) are compared: "aggressive" and "problem-focused". Although aggressive CM has a well-established history of improving the community tenure of deinstitutionalized patients, individuals participating in this treatment are likely to become dependent on health care providers and hence require indeterminate assistance. Problem-focused CM teaches patients how to identify and resolve community-based predicaments thereby making them relatively more independent of the mental health system. Patients receiving problem-focused CM, however, need reasonably competent cognitive functions thereby ruling out participation of the most severely disabled individuals. An interaction of the two approaches is proposed in which aggressive and problem-focused CM is selected depending on the patient's current needs, cognitive deficit, and level of social support.
This study examines the views of community mental health practitioners toward aftercare services and deinstitutionalized patients. A survey of 361 practitioners in Allegheny County, Pennsylvania, finds that these views are related to practitioner experience in psychotherapeutic practice, professional affiliation, educational level, and amount of specialization in aftercare. Implications are drawn for staffing and structuring community mental health aftercare services in ways that are likely to enhance practitioner committment to aftercare.
The failure of deinstitutionalization and the community mental health movement to improve the treatment of chronic psychiatric patients, particularly schizophrenics, is described. Problems with the current treatment paradigm include unrealistic expectations concerning the rehabilitative effects of antipsychotic medications, inadequate funding of the community mental health system, and the predominance of the "infectious disease model," rather than the more appropriate "chronic disease model" of mental illness. A model for the comprehensive treatment of chronic mental illness is proposed that includes: treatment, rehabilitation, social services, and continuity of care. The need for an integrated community approach to rehabilitating chronic psychiatric patients is stressed, and some of the specific ingredients essential to such a program are identified.
Thinking regarding the needs of the chronically mentally ill has changed substantially in the post-deinstitutionalization period. Increasingly, the heterogeneity existing within this population has been recognized along with the need for an integrated continuum of residences and services. At a state level, this realization has stimulated the development of planning models which are used to predict the number and types of residential/service slots needed by the chronically mentally ill. In Colorado, a model was developed which uses data-based client profiles to predict needs along a continuum of services ranging from inpatient treatment to independent living with mental health support. In this paper, we discuss the development of the model and present the results of implementing it for a sample of 5,017 chronically mentally ill clients. The practical and heuristic value of the model is featured as well as its implications for further research.
Previous research has reported prevalence rates of mental health problems among homeless individuals that range from 20% to 90%. Attempting to validly verify prevalence rates is important because of the implications concerning both deinstitutionalization and developing an appropriate mental health policy over the next decade. In the present research, which used as its sample the largest homeless sample assessed to date, prevalence was found to fall at the lower range of previously cited data. Despite the fact that the prevalence of mental health problems among the homeless population was found to be relatively low, it was found that homeless people with mental health problems are, at best, only marginally served by the mental health system. Implications for community mental health policymakers and program designers are discussed.
The authors studied 58 different types of accommodation belonging to various classifications (Psychiatric Wards, Asylums, Hostels, Sheltered Homes, Apartments and Boarding Houses) which housed 613 chronic mental patients from the province of Valencia. The "Hospital Hostel Practices Profile" was used to test the reliability (internal consistency) of the Spanish translation. A profile of different types of practice in the accommodation was obtained by assessing restrictive practices in the patient's areas of activity, personal possessions, meals and drinks, health and hygiene, residents' rooms and services. Significant differences were observed between psychiatric wards and self-contained apartments and also, to a lesser degree, sheltered homes. The usefulness of H.H.P.P. for the analysis of restrictive practices in the accommodation of deinstitutionalized people is discussed in order to highlight the most suitable type of resettlement for the patients.
In 1935, in 1965, and in 1972, the original Social Security Act and amendments to it were used by states to deinstitutionalize. In each instance a private, profit-making nursing home and board and care industry was stimulated. Poor care in such facilities was an unintended consequence of the legislation. Neither the Congress nor evaluators have clear concepts of what constitutes a life of decency and dignity for the chronically dependent. Behaviorally oriented social scientists and legislators have in common the difficulty of dealing with soft variables such as decency and dignity. In the absence of clear goals, care drifts below a lower threshold of acceptability and is corrected to some extent following public scandal. Social scientists need to learn to develop concepts and measurements suitable to monitoring the implementation of humane ideals.
Deinstitutionalization of the chronically mentally ill has only recently been recognized as a phenomenon which may not be in the best interests of the patients involved. The reasons for this include the lack of adequate community-based resources for domiciliary, treatment, and rehabilitative services, plus the response of society to deviant behavior. However, the most fundamental problem is likely to be the severity of the illnesses with which we are concerned, so that the solution cannot be as simple as the sending "home" of the long-term patients. Prevention of institutionalization is seen as a more feasible goal than its cure. This requires a comprehensive program incorporating, among other things, a recognition of the necessary role of the mental hospital, and the need to improve the quality of care provided therein.
In sociocultural perspective, this paper traces the impact of deinstitutionalization and the community mental health movement on the mental health service delivery system and subsequent effects on psychiatric training. Examples are given of changes at the national, state, and local levels. The current need is for new initiatives to interest residents in public sector psychiatry and in work with the chronic patient. Issues discussed include new conceptions of the parameters and roles of psychiatric treatment, involvement of families and other support groups in patient care, comprehension and applications of cultural values, and new functions of the state hospital in the continuum of care as locus of specialized services and of professional training and research.
In this article movements from institutional to community care for psychiatric patients in various European countries are discussed. Programs considering the welfare of afflicted persons, diminution of psychopathology and improvements of functioning, as well as the costs of deinstitutionalization are reviewed. The review first deals with the prevention of admissions prior to referral to inpatient facilities, looking at the role of general practitioners and ambulatory services in preventing admissions. Secondly, alternatives for hospital care are considered. Thirdly, consideration is given to the possibilities of shortening the time patients stay in hospitals. Next, experiences in discharging long stay patients to alternatives for continued care in psychiatric hospitals are reported. Finally, the advantages are shown of integrating all regional mental health services under one administration. Selected national policies are described as well as the success of present programs are discussed. With few exceptions only European studies are reported.
Laws and policies governing the care and treatment of the mentally ill are in part shaped by the sociopolitical climate in which they are formulated, and their outcomes are similarly shaped by the context in which they occur. Civil commitment laws were narrowed in a liberal era but later broadened in response both to the outcome of the initial reform and the trend toward social and fiscal conservatism which emerged in the late 1970s and 1980s. This study, which reports on the evolution of commitment law in the state of Washington, indicates that while recent changes in these laws mandate greater use of state hospitals, the retention of the procedural safeguards set in place by the initial reform coupled with limitations on resources available to state mental health systems will prevent a return to the state hospital as it appeared prior to the deinstitutionalization movement. These factors may promote the search for non-institutional alternatives, such as efforts underway in Washington and elsewhere to implement civil commitment of community-based services.
We are fast approaching a centennial of New York State's institutional system, the anniversary of the State Care Act of 1980. This can be evaluated against another important anniversary; the quarter century mark of the current convulsion/revolution of the mental hygiene care system of the entire United States, commonly referred to as deinstitutionalization. The state institutions, which for the past century were built up and maintained as the major locus of care for the chronically mentally ill, no longer occupy that central place in many localities. Yet these hospitals must continue to struggle with overwhelming burdens. Their inpatient populations, although now much smaller, still include many seriously mentally ill patients as well as the essentially non-dischargeable elderly. In addition, they must provide for young adults with a new profile of difficult behavior and challenging demands. This article is an attempt to redefine the role of the state institution in what has become the new era of community care, and to suggest fruitful new directions for the future which incorporate a contemporary shift in focus: from the concept of illness to that of disability, and from a reliance on a facility or specific program to the development of a comprehensive and integrated system of treatment and support services.
This paper examines the role of the police in supporting community based mental health services for the chronically mentally ill in a mid-sized midwestern city. Cooperation between the police and mental health system, as reflected in training and procedural agreements for emergency evaluations and hospitalization, achieves the conversion of the police to a medical model view of mental illness which stresses the importance and effectiveness of medication compliance so that the police will act upon this belief in their handling of the mentally ill. However, police recognition of the limits of the medical model and organizational change impacts upon cooperative police practices. Police experience conflict over the assumed therapeutic goals of community treatment and the important gatekeeping function community mental health systems perform under deinstitutionalization. Erosion of the police belief in the effectiveness of community mental health, and the resulting change in practices, may provide an important, yet partial, counterbalance to the control exerted by the medical model. The availability of police authority to assure compliance, or in some cases to reinforce the consequences of non-compliance with medication, raises questions about police-mental health relationships that are too cooperative.