Mental Health And Homelessness: Evidence Of Failed Policy?
1989; Project HOPE; Volume: 8; Issue: 4 Linguagem: Inglês
10.1377/hlthaff.8.4.184
ISSN2694-233X
Autores Tópico(s)Homelessness and Social Issues
ResumoBook Review Health AffairsVol. 8, No. 4 Mental Health And Homelessness: Evidence Of Failed Policy?Leslie J. Scallet AffiliationsMental Health Policy Resource Center, Washington, D.C.PUBLISHED:Winter 1989Free Accesshttps://doi.org/10.1377/hlthaff.8.4.184AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSMental healthDeinstitutionalizationPsychiatric hospitalsMental disordersLengths-of-stayMediaMental health servicesAcute careInpatient carePharmaceuticalsThe sight of unkempt individuals, many suffering from apparent mental disorders, roaming the streets with nowhere to sleep and little to eat, is an enduring image of the 1980s. Who could deny the tragedy of their plight? Who could support a policy that caused it?Nowhere to Go is primarily an attack on the policy known as deinstitutionalization; homelessness is touted as evidence of the failure of this policy. This opinion is widely shared among the general public, who see obviously disturbed individuals on the streets and read or watch media reports linking the phenomenon to the dramatic reduction of state mental hospital populations over the past thirty years. Cause and effect seem only too obvious, and author E. Fuller Torrey skillfully uses examples from the media to make his case. The outline of the argument is, essentially, this: (1) the laudable goal of deinstitutionalization was to provide better care for the thousands of seriously mentally ill individuals once warehoused in state institutions; (2) the policy went awry over the years, in response to political forces; and (3) this led to the perverse spectacle of a mental health establishment that promotes the dumping of defenseless, seriously ill mental patients on the streets, while devoting the resources intended for them to clinics for the “worried well.” The trend away from institutions. Deinstitutionalization was initiated in revulsion against the evils of institutional warehousing. If the policy did not turn out as expected, though, the last thing mentally ill individuals need is another set of policies responding ineffectively to the evils of homelessness. While Torrey's eloquent presentation is not a balanced review of the issues and evidence, those interested in pursuing these issues could do no better than Nowhere to Go for a readable introduction to the debate and motivation to become involved in finding a solution to the problem. Like many others, Torrey appears to equate deinstitutionalization with depopulation of the state mental hospitals. However, deinstitutionalization is more properly a process and a direction than a unified policy. The internal inconsistency of its supporters' goals—to improve care, expand services for a broader population, and save money—and the existence of fifty-odd state mental health systems rather than a single national one has guaranteed uneven, often contradictory policy decisions.Movement toward deinstitutionalization has included (1) transferring persons from state mental hospitals into “the community;” (2) expanding community-based mental health and supportive services, including general hospital acute care; and (3) preventing institutionalization by diverting inappropriate hospital admissions and shortening inpatient stays in all psychiatric hospitals. Reduction in state hospital “residents” alone is no proxy for measuring the progress of deinstitutionalization. To what extent did deinstitutionalization, in this broader sense, occur? Essentially, there has been more progress in transferring people out of state hospitals, preventing admissions, and shortening length-of-stay than in creating an adequate system of services and supports in the community. 1 Data suggest that people still are being hospitalized for mental health treatment at about the same rates, but that the nature of hospitalization is changing to focus more on treating and releasing patients rather than on becoming their “residence.” Related to this, state hospitals are no longer the major source of inpatient care, but are increasingly giving way to general hospitals with psychiatric units. 2These elements of deinstitutionalization were implemented with the often vague assumption that community-based services and supports would be available to meet the needs of two basic categories of patients— those discharged after long or short stays from hospitals who needed some form of continuing or periodic care, and those who would no longer be considered appropriate for inpatient care. The latter have become a primary target group for the community mental health center (CMHC) program. While few would argue that the current availability of community mental health services approaches adequacy, the past two decades have seen an enormous expansion in this part of the system.Torrey spends a good part of the book criticizing the CMHCs for failing to serve the first group (the most seriously ill population), which he argues was their primary mission. Controversy continues over this charge. One can criticize the architects of the CMHC program for assuming that more former patients would be able to make it in the community with the types of services provided by the centers than was the case. However, the centers also had a broader mission. They were supposed to be the “seedlings” for a new paradigm in mental health care—a decentralized system focused on preventing casualties, rather than a centralized system focused on caring for the casualties. They were not the only element of deinstitutionalization, and they cannot be held responsible for all of its deficiencies, such as the failure of many state hospitals to do adequate discharge planning.More importantly, deinstitutionalization and the CMHC program began in a time of expanding hope and expanding resources. Few people in any sector (not only mental health) foresaw the squeeze on resources that began in the early 1970s. CMHCs had to adapt just to survive. How many public programs fulfill all their original intentions?It is to the credit of the mental health community that when the problems of deinstitutionalization for seriously mentally ill people became apparent in the mid-1970s, a major effort to address them was established. Torrey mentions the Community Support Program (CSP) with praise but considers it a minuscule effort whose quixotic “purpose is to correct the deficiencies of the $3 billion CMHC program.” Another way to look at this is that the CMHC program expanded to meet the demand for a broad range of “mental health” services and adapted to the loss of federal resources and reluctant state financing by expanding services for people and problems capable of generating private resources. A couple of decades of experience with seriously mentally ill individuals in the community also led to significant learning about the range of their needs and the limitations of mental health services to meet them.The CSP successfully leveraged very small amounts of federal funds into major system change in the states. It was designed not to “correct the deficiencies” of the federal CMHC program, but rather to reshape the priorities of the far larger state mental health programs.Still, Torrey's main point holds considerable truth. Whatever parts of deinstitutionalization have been successful, a primary problem remains—those individuals with serious mental illnesses (those who would have been hospitalized in a previous generation) who are discharged from or never admitted to hospitals. He reserves his most scathing words for the apparent ease with which the mental health establishment “forgot” this part of the mission of deinstitutionalization.Failings of the system.Torrey details the broken promises—the failure to provide appropriate aftercare and follow-up for individuals released from mental hospitals, the abysmal lack of housing and inadequate living conditions in the community, and the shutoff of needed services (including hospitalization) for the sickest people. These are matters on which there is no real debate, and Torrey provides an eloquent description of the consequences. He illustrates with press clippings for the lay audience and study results for the scientific audience; the simplicity and poignancy of the former often tend to obscure the limitations of the latter. What little research information is available is all too easy to overinterpret.For example, Torrey points to the fact that increasing numbers of violent acts are perpetrated by untreated mentally ill individuals, citing (with dramatic examples) increasing press coverage of sensational acts of murder and mayhem committed by persons identified as “former mental patients.” He then cites studies indicating that arrest rates and episodes of personal violence for former patients have increased.What of the ease with which today's communications technology allows the press and media all over the country to pick up such exciting material, feeding the demand of news customers for such titillation? The public impact of such crimes is thus greatly magnified, but this tells us little about their relative incidence in a society where all violence seems to have increased. Other unexplored issues include the vast expansion of the illegal drug problem and the easy availability of street drugs to vulnerable former mental patients; the demographic changes that produced larger numbers of people in the age range known to commit crimes (roughly the same as the typical age of onset for schizophrenia); and the greater ease for police in identifying and arresting mentally ill individuals than other suspects.Similarly, Torrey blames the tightening of legal protection for patients' rights instituted over the past generation for the fact that some seriously mentally ill individuals are suffering because they are not receiving needed treatment and have no adequate alternatives in the community. But, the laws serve many purposes beyond patients' rights—including limiting patient populations in costly institutions. Many people also suffered when the laws made commitment and forced treatment easy. It could be argued that establishment of the legal principle that mental patients have rights as citizens is a major element in the new, assertive role of families and consumers, and also in their ability to persuade professionals and policymakers of their credibility and the justice of their demands for resources.None of these observations, however, negates the essential thrust of Torrey's argument—that the needs of seriously mentally ill individuals have not been met in any remotely satisfactory way under the policies of deinstitutionalization. Torrey tends to blame the mental health establishment for this. The source of the problem, he argues, lies in transmutation of concern about “the mentally ill” into an ever-broadening (in his view, meaningless) concern about “mental health.” Chapters two through six make a case against fuzzy thinking, self-serving grandiosity, and the failure of the medical and governmental establishment to keep their collective eye on the original concern for suffering, seriously mentally ill people.The concept of mental health.Concepts of mental health and illness and the role of mental health professionals in addressing the mental health needs of the public have changed in the past two decades. The dominant current view emphasizes mental illness as a biological phenomenon and touts brain research as the primary appropriate role for the federal government. In the 1960s, when deinstitutionalization began, a different attitude predominated. That period represented a historical effort to shift focus from the negative to the positive, from the failures of treatment to the prevention of illness, from concentrating on the problems/ failures of the individual to concentrating on a broader understanding of the relationship of individuals and the society in which they live. The federal role was concomitantly broad, including service, training, and research on everything from the brain to the origins of racism and poverty. An exploration of the differences in aims, priorities, and emphases during the period in which deinstitutionalization began and today would be a fascinating study. Concern about the “environment” in which people live and its impact on the course of mental problems was an early warning of the problems faced by deinstitutionalized patients returning to the community. Most community-based mental health programs focused on mental health treatment, not on the range of human needs for food, clothing, companionship, and shelter. These required a far more systemic or environmental approach, which had to be invented later in the community support movement. Similarly, studies of homelessness tend to focus on the generic problems rooted in poverty faced by all homeless people and shared by those who are mentally ill, rather than issues specific to any particular homeless population. 3 However, the emphasis on federal policy and professional roles should not obscure the role of the states. Mental health care in this country remains primarily a state responsibility. Despite the fact that the great majority of patients (including many of the most seriously mentally ill individuals) now receive care “in the community,” and that financial support for community-based mental health services has increased significantly since 1964, the bulk of state mental health resources are still spent on state hospitals. Only nine states allocated less than 50 percent of their mental health budgets for state hospitals in 1985. 4Link with homelessness.A significant problem in making a connection between deinstitutionalization (even in the limited sense of depopulation of state institutions) and homelessness among mentally ill people is that most of the reduction in resident hospital populations had occurred by the mid-1970s. Homelessness did not emerge as an issue until the 1980s. What was different? One major change was the squeeze on public resources for generic income support, housing, and medical care that began to be felt in the mid-1970s and accelerated in the 1980s.Persons with severe mental illness tend to be vulnerable along all three major dimensions that influence homelessness. Their incomes are low. Affordable housing is scarce, and they are further disadvantaged because they sometimes require special housing, which is in even shorter supply. They may also lack the skills and social supports to manage their limited income and obtain assistance from family and friends. This last factor is in fact one of the elements defining the severity of their illness.While they share these problems with other low-income individuals, they may be at particular risk of homelessness because of the combined impact. Also, hospitalization or an acute episode of illness may result in the immediate loss of whatever housing they had found.Torrey devotes a mere paragraph to the Reagan administration's policies of drastically reducing the programs that provided thousands of mentally disabled people housing alternatives and the income to pay for them. Deinstitutionalization assumed that these generic poverty programs were available to former patients who were poor. One is left with the impression that somehow the National Institute of Mental Health and the CMHCs should have foreseen this event and been ready to provide whatever was needed.It may be true that if deinstitutionalization had never begun, many of the individuals currently mentally ill and homeless would have had a roof over their heads— the state mental hospital. But, the major reduction of state hospitals occurred several years before homelessness appeared. Mental health policy concerns had little to do with the economic and political developments of the 1970s and 1980s, which negated the assumptions on which deinstitutionalization was based and allowed particularly vulnerable individuals to fall through the cracks into homelessness.Addressing the problem. Torrey asks many of the right questions: Where does all the money go? What have we learned from the past thirty years of deinstitutionalization? Who will provide leadership? What is needed now? He argues that more money is not what is needed, except for research. He identifies elements that, in combination, would begin to address the problems: (1) giving the seriously mentally ill first priority for public psychiatric services, (2) making psychiatric professionals and governments accept real responsibility for the seriously mentally ill, (3) changing laws to focus on treatment needs rather than individual autonomy, and (4) expanding two key funding areas—housing and research. These would shift priorities within the mental health field to focus exclusively on illness, on treatment priorities, and on the most severe cases, and to rely absolutely on research to find answers. No attempt would be made to prevent mental problems or to address problems other than the major illnesses, presumably schizophrenia and depression. The book ends with an inspiring vision of what life would be like if these recommendations were carried out. But, where would the line be drawn between “serious” mental illness and other severe and more or less disabling conditions causing individual suffering? How do advocates maintain interest and concern once the most heart-rending cases are no longer visible? Are the most seriously mentally ill the only concern of the field? If we do not study “normal” behavior, how can “abnormal” be understood? If one keeps these concerns in mind, Nowhere to Go is highly recommended as a constructively provocative challenge. One cannot come away without a sense of shame that our society permits such suffering, or without a sense of frustration with the pragmatism and incrementalism of public policy. Both are valuable reminders for those who may too easily distance themselves from the plight of people with serious, disabling mental illness. NOTES1. Scallet L.J. , Marvelle K. , Needleman J. , Deinstitutionalization and Homelessness ( Washington, D.C. : Policy Resources, Inc. , 1989 ). Google Scholar 2. National Institute of Mental Health , Mental Health, United States, 1987 , ed. Manderscheid R.W. , Barrett S.A. , DHHS Pub. no. (ADM)87-1518 ( Washington, D.C. : U.S. Government Printing Office , 1987 ). Google Scholar 3. Institute of Medicine , Homekssness, Health, and Human Needs ( Washington, D.C. : National Academy Press , 1988 ). Google Scholar 4. Finai Report: Funding Sources and Expenditures of State Mental Health Agencies ( Alexandria, Va. : National Association of State and Mental Health Program Directors , July 1987 ). Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 1 History Published online 1 January 1989 InformationCopyright © by Project HOPE: The People-to-People Health Foundation, Inc.PDF downloadCited bySocial determinants of mental health care systems: intensive community based Care in the Veterans Health Administration28 August 2020 | BMC Public Health, Vol. 20, No. 1
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