EDITORIAL
ESTABLISHING
COMMUNITY
SERVICES FOR THE MENTALLY ILL
The most vexing and pressing problem for p u n i c psychiatry and indeed all psychiatry is the care and treatment of the chronically mentally ill. While in colonial America such care was provided at home, with time, a series of institutions (almshouses, county poorhouses, state hospitals, psychopathic hospitals and general hospitals, etc.) came into existence. It had only been in the last twenty years that alternatives to institutions have been utilized for the treatment and care of the chronically mentally ill population. And while day hospitals and crisis services have achieved some prevalence, more recent attempts to establish other settings in the community (e.g. group homes, halfway houses, apartment programs) have resulted in too few such alternatives to hospital care. The principal reasons why the deinstitutionalization movement was such a disaster are (1) that money has not followed patients from institutional to community settings and (2) that there is not at present a sufficient number and range of graded, adequate and appropriate community settings in place. Both are the direct result of the failure of government to plan adequately for and implement the shift in locus from state hospital to community care. As a result, we are faced with a situation where in 1976 the largest share of the health dollar (30 percent) is directed to the most inappropriate alternative to the state hospital--the nursing home, while we have only 232 of the most appropriate settings halfway houses. Thus, fewer than 9,000 o f the estimated 900,000 schizophrenics living in the community can avail themselves o f this opportunity. T h e reasons for the lack of an adequate n u m b e r and range of community services and settings are many. These include: the historical bias toward institutional care; the vested political interests that prevent state facilities from transferring their resources to community care; the economic incentives to inpatient care and disincentives to ambulatory care, income production and functional maintenance; the lack of money to fund community services and settings; the tangle of bureaucratic restrictions, entitlements and regulations preventing utilization of what funding does exist to apply to real patients; and the realistic difficulty that mental health professionals and their allies have in establishing services and settings in the community to care for the severely and chronically mentally ill. O f late there has been increasing interest in the problems of establishPSYCHIATRIC QUARTERLY, VOL 50 (4) 1978 0033-2720/78/1600-0251500.95 ~) 1978 Hmnan Sciences Press
251
252
EDITORIAL
ing community mental health services and the National Institute of Mental Health recently funded a national conference on this subject sponsored by the Horizon House Institute of Philadelphia. Undoubtedly, this effort, which will continue for several years, will highlight the problems in establishing such services and care and help those attempting to do so to realize their goals. The special section featured in this issue of Psychiatric Quarterly is devoted to this topic. It represents the outcome of a conference on community care held last year at Cornell University Medical School, cosponsored by the New York Hospital, Westchester Division, and the Harlem Valley Psychiatric Center. The conference was based on the assumption that there are certain common problems in establishing community services and that an examination of several successful programs contrasted with several that were unsuccessful would bring out the themes common to programs that worked or didn't work. In this special section we begin with a review of the literature on community residences. This is followed by case examples of three successful and three unsuccessful attempts to establish community services. Finally, two members of the steering committee which planned the conference summarize the themes and elements common to success or failure in establishing sueh services. For too long, too many of us have labored in ignorance of each other's efforts and experience. This special section hopes to help remedy this information gap relating to the establishment of community care for our most deserving patient population. John A. Talbott, M.D.
ESTABLISHING
COMMUNITY
SERVICES FOR THE MENTALLY ILL
The most vexing and pressing problem for p u n i c psychiatry and indeed all psychiatry is the care and treatment of the chronically mentally ill. While in colonial America such care was provided at home, with time, a series of institutions (almshouses, county poorhouses, state hospitals, psychopathic hospitals and general hospitals, etc.) came into existence. It had only been in the last twenty years that alternatives to institutions have been utilized for the treatment and care of the chronically mentally ill population. And while day hospitals and crisis services have achieved some prevalence, more recent attempts to establish other settings in the community (e.g. group homes, halfway houses, apartment programs) have resulted in too few such alternatives to hospital care. The principal reasons why the deinstitutionalization movement was such a disaster are (1) that money has not followed patients from institutional to community settings and (2) that there is not at present a sufficient number and range of graded, adequate and appropriate community settings in place. Both are the direct result of the failure of government to plan adequately for and implement the shift in locus from state hospital to community care. As a result, we are faced with a situation where in 1976 the largest share of the health dollar (30 percent) is directed to the most inappropriate alternative to the state hospital--the nursing home, while we have only 232 of the most appropriate settings halfway houses. Thus, fewer than 9,000 o f the estimated 900,000 schizophrenics living in the community can avail themselves o f this opportunity. T h e reasons for the lack of an adequate n u m b e r and range of community services and settings are many. These include: the historical bias toward institutional care; the vested political interests that prevent state facilities from transferring their resources to community care; the economic incentives to inpatient care and disincentives to ambulatory care, income production and functional maintenance; the lack of money to fund community services and settings; the tangle of bureaucratic restrictions, entitlements and regulations preventing utilization of what funding does exist to apply to real patients; and the realistic difficulty that mental health professionals and their allies have in establishing services and settings in the community to care for the severely and chronically mentally ill. O f late there has been increasing interest in the problems of establishPSYCHIATRIC QUARTERLY, VOL 50 (4) 1978 0033-2720/78/1600-0251500.95 ~) 1978 Hmnan Sciences Press
251
252
EDITORIAL
ing community mental health services and the National Institute of Mental Health recently funded a national conference on this subject sponsored by the Horizon House Institute of Philadelphia. Undoubtedly, this effort, which will continue for several years, will highlight the problems in establishing such services and care and help those attempting to do so to realize their goals. The special section featured in this issue of Psychiatric Quarterly is devoted to this topic. It represents the outcome of a conference on community care held last year at Cornell University Medical School, cosponsored by the New York Hospital, Westchester Division, and the Harlem Valley Psychiatric Center. The conference was based on the assumption that there are certain common problems in establishing community services and that an examination of several successful programs contrasted with several that were unsuccessful would bring out the themes common to programs that worked or didn't work. In this special section we begin with a review of the literature on community residences. This is followed by case examples of three successful and three unsuccessful attempts to establish community services. Finally, two members of the steering committee which planned the conference summarize the themes and elements common to success or failure in establishing sueh services. For too long, too many of us have labored in ignorance of each other's efforts and experience. This special section hopes to help remedy this information gap relating to the establishment of community care for our most deserving patient population. John A. Talbott, M.D.
