APPROACHES TO ESTABLISHING COMMUNITY SERVICES FOR THE MENTALLY DISABLED A. Anthony Arce, M.D.

INTRODUCTION Deinstitutionalization has become a major movement in American psychiatry. The courts, the legislatures, and the mental health professionals all agree that mentally disabled individuals need not be and should not be kept in institutions when they are capable of functioning in the community. The inpatient population of mental institutions has been steadily declining through increased discharges, more restrictive admission criteria, and the impact of civil rights legislation. In 1955, there were 550,000 inpatients in psychiatric hospitals. By 1976, the number had decreased to under 200,000. This change in the locus of care from institution to community has brought the mental health services delivery system and other human service agencies face to face with a new set of issues surrounding the care these communitized patients receive and the kinds of lives they lead. Chief among these issues have been (1) the need for suitable residential facilities to meet both the short-term and the long-term needs of this chronically ill population and (2) the need for a wide range of supportive and rehabilitative services without which the odds of these chronically ill patients remaining in the community are zero. The lack of supportive residential programs in coordination with extensive rehabilitation services has placed severe burdens on the many urban communities to which the chronically ill patients are discharged or to which they tend to gravitate. The influx of such patients into neighborhoods because of the establishment of either residential or treatment facilities causes great alarm and consternation among the residents of those neighborhoods. While the public in general is fairly well informed about mental illness and willing to accept it as a medical problem, a major portion of the public

Dr. Arce is Director, H a h n e m a n n Community Mental Health Center, Philadelphia, Pa., and Professor o f Psychiatry, H a h n e m a n n Medical College and Hospital. 264

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continues to be frightened by mental patients because of their occasional bizarre behavior and presumed unpredictability and dangerousness. Attempts at establishing residential or treatment facilities in most neighborhoods often encounter strong opposition. Community residents have expressed concern over depreciation in property values, increases in crime rates, the dumping of patients without adequate supervision or available services, and the possibility that acceptance of one service will lead to a flooding of the neighborhood with others. Such opposition notwithstanding, increasing numbers of clinics, day treatment centers, and other treatment facilities as well as halfway houses, hostels, foster homes, and other group-living arrangements are being established in communities throughout the nation.

APPROACHING THE COMMUNITY There are basically two methods of approaching this issue of establishing a community services project, whether residential or nonresidential. One is through a lengthy process of community education and organization aimed at enlisting the support of influential citizens and other organizations leading to community acceptance of the project. The other method is a low-profile approach in which the agency neither announces its intentions of setting up shop nor prepares the community for it, but hopes that once the project is afait accompti it will be allowed to stay. This approach, however, may generate considerable resentment on the part of the neighbors and make it harder for staff and patients to achieve a modicum of acceptance by them. The two vignettes that follow are examples of the successful application of the two approaches. The first case illustrates a community organization approach in establishing a nonresidential treatment service; the second case, a low-profile approach in establishing a residential facility.

The South Shore-Rockaway Program T h e South Shore-Rockaway catchment area comprises the Rockaway Peninsula and the south shore of Jamaica Bay, all part of the borough of Queens. The population of approximately 136,000 is socially and economically heterogeneous, ranging from very poor to upper middle class. The eastern section of the peninsula, where the program is located, is the most populated area and has the greatest diversity of economic, ethnic, religious, and social groups. At the time, the area had been given, by the city, the highest priority for the development of community mental health services. In 1969, three agencies, one private and two state, embarked on a joint effort to establish a community mental health service for the area. The sponsoring agencies were the Catholic Medical Center of Brooklyn and

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Queens, the New York State Bureau of Aftercare Services, and Creedmoor State Hospital. The proposed program was to provide a broad range of clinical outpatient services including aftercare for patients discharged from state hospitals, and consultation to general hospital emergency services and other city agencies. The long-range objective was for the program ultimately to become the nucleus around which a community mental health center could be organized. An undercurrent of resistance to mental health programs had been perceived by us during exploratory contacts with some individuals and civic organizations. It was decided that community organizational work was necessary and an experienced social worker was hired as coordinator of community affairs. He began meeting with larger community groups and local political leaders to explain the proposed program. They were told that the program would be treating aftercare patients from the Rockaway community at first, would soon offer emergency and walk-in services, and then would try to meet other community needs. Because of the desperate need for services, these proposals were received favorably and publicly endorsed by community leaders. T h e y were kept continuously informed on the progress. They actively supported the program and gave valuable advice on strategies for introducing it into the Rockaways. On their advice, for instance, a public relations program was mounted to prevent community hostility. At the time, local residents were picketing another mental health program, a residential facility for substance abusers, that was planning to open in the area. Also on the advice of community leaders, early contacts were made with influential community groups, individuals and service agencies who could help if opposition arose. These efforts ultimately led to a unanimous statement of support from twenty-six member agencies of the Rockaway Health Council, a voluntary association of health, education, and welfare agencies. The net result of this community organizational work was that no opposition to the program was encountered. The ultimate stamp of approval came with the acquisition of a site as a direct result of the collaboration between community representatives and the Chamber of Commerce. Public relations energies were then channeled into the area of making the program viable and community oriented through collaborative agreements with local police, emergency rooms in general hospitals, schools, etc. Today, a much expanded program continues to operate in the neighborhood and is regarded by residents as an integral part of their community services system. Genesis House

Meyer-Manhattan Psychiatric Center is one of the three autonomous facilities created in 1970 through the unitization of Manhattan State Hospital. It serves a geographical area approximately equal to the northern third

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of Manhattan. The population served numbers approximately 570,000, residing in four mental health center catchment areas: Inwood, Washington Heights, Harlem, and Morningside. In 1971, Meyer had an inpatient population of nearly 1,000 and provided aftercare services to an additional 600 patients through its outpatient clinic located in the Morningside area. Other community resources to deal with the mental health needs of the community, especially ambulatory care services and alternatives to hospitalization, were at that time virtually nonexistent. Between 1971 and 1973, the inpatient population at Meyer had been reduced by 50 percent, and the outpatient work load had been tripled. To aid patients in the transition from institution to community, a self-care unit had been established at the hospital for patients requiring minimal supervision who were in the process of preparing for return to the community. Unfortunately, many of them ended up in unsupervised single-roomoccupancy hotels where they were victimized and rapidly decompensated. Our concern over the plight o f the chronic patient was shared by the Director of Psychiatry of the New York City Department of Social Services. He had expressed vociferously and repeatedly his consternation at the ever increasing numbers of patients released from many state hospitals into the city to be supported on public assistance but without any available treatment services. We agreed on the need for establishing a more structured supervised setting where chronic patients could reside for varying periods of time before ultimately moving into group apartments. In the course of these discussions, an opportunity arose to develop such a residence. The drug-free treatment programs for d r u g addicts in New York City were being closed for lack of patients. A small tenement, which had been partially renovated by the Phoenix House Drug-Free Rehabilitation Program, was being vacated. The landlord was approached with the following proposal. The hospital would undertake to maintain the residence fully occupied and to ensure that rents would be paid on time, that cleanliness would be maintained, and that the property would not be destroyed. In return, the landlord agreed to invest his own money in rebuilding bathrooms, refurbishing and equipping bedrooms, and providing each floor with a fully operating kitchen. Over time, given the assurances of full occupancy and maintenance of the building in good condition, the landlord would recover his investment at a profit. To complete the program, it was agreed that Meyer-Manhattan would provide supervising staff on a twenty-four-hour basis and the Department of Social Services would expedite the processing of public assistance applications ensuring that patients would be able to obtain all possible permissible benefits. Genesis House opened on October 15, 1973, one floor at a time, over a period of two months, until its capacity of 65 residents was reached. The community was not aware of the change that had taken place in the building's population from substance abusers to chronic mental patients. However, some nine months later, when another hospital attempted to

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replicate the project one block away across Broadway, neighbors mounted a campaign in opposition in the local press and television, and the hospital had to withdraw.

COMMENT Neither approach guarantees either success or failure. Besides the many demographic differences among communities---ethnic-social composition, economic level, urban, suburban or rural locations, etc.--there is also the unpredictability of community acceptance of residential vs. nonresidential services. Moreover, programs for developmentally disabled patients encounter on the whole less opposition than programs for the mentally ill. Given all the variables that should be considered in establishing services for the mentally disabled in communities, the community organization approach, while lengthier and more arduous, offers the greater chance of success.

Approaches to establishing community services for the mentally disabled.

APPROACHES TO ESTABLISHING COMMUNITY SERVICES FOR THE MENTALLY DISABLED A. Anthony Arce, M.D. INTRODUCTION Deinstitutionalization has become a major...
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