America's Mental Health System Needs Improvement, But Gains of the Past Give Hope for the Future

When a leading mental health advocate says, "The infrastructure for the public mental-health system is in the worst shape it's been in 40 years," I wonder what he's thinking. Maybe it's just rhetorical flourish, but it is false and counterproductive.
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There's little doubt that the American mental health system could be better. But it is not necessary to trash the developments of the last half century to make that point. In fact, given all the effort that has gone into making the mental health system better, it would be profoundly discouraging to think that the system is no better than it used to be.

So, when a leading mental health advocate says, "The infrastructure for the public mental-health system is in the worst shape it's been in 40 years," I wonder what he's thinking. Maybe it's just rhetorical flourish, but it is false and counterproductive.

I don't know where he was 40 years ago, but I was working in one of the few psychiatric rehabilitation programs that existed at the time. It was on the west side of New York City, and it was devoted to helping people who were being pushed out of state hospitals at a very rapid pace to live safely in the community. Because there were so few decent services and housing alternatives in the community, our work was a great challenge.

It was 1973. New York's aggressive policy of de-institutionalization had been in effect for five years. The population of state hospitals in NYS had been reduced from about 80,000 to 44,000. [1] [2] Most people who would have been in state hospitals returned to families that were unprepared to have them back at home. A great many people were transferred to nursing homes and to adult homes -- facilities originally intended for the frail elderly, beginning the process of transinstitutionalization that remains a problem today. And many more people moved into housing for poor people, often single-room occupancy hotels (SROs) that were squalid and dangerous. Murders of people with mental illness, while not an everyday occurrence, made disturbing headlines from time to time.

Discharge planning from state hospitals was exceedingly limited, often a 30-day supply of medication, the address of a state aftercare clinic, the address of the local welfare office -- which would arrange housing and income and one bus or subway token. The state aftercare clinics were notoriously over-extended and provided poor quality care. At the time, it was hard to find an English-speaking psychiatrist. Treatment was often a 10-minute visit each month or two, basically to renew prescriptions for anti-psychotic medications that quelled symptoms of acute psychosis but often had awful side effects.

State hospitals at the time were generally dreadful places, themselves often unsafe. The hospital that I visited once a week to meet people who might be able to live in the community housed people barracks-style in an open ward of 50 people. Most patients did nothing but sit in the "dayroom" all day. Life was so unpleasant in these hospitals that the former patients I knew in the community preferred to live in dangerous, shabby SROs than to go back to the hospital. As someone once said to me, "At least they have to break down my door if they want to beat me up."

In 1973, mental health services for people with severe, long-term mental illnesses were generally incredibly inadequate even by the standards of the day. The Community Mental Health Centers Act of 1963 had envisioned the widespread development of community-based mental health services that would include crisis services, inpatient services in local hospitals, outpatient treatment, day programs, and community education. And there were model programs here and there. But fewer than 50 percent of the programs envisioned when the Act was passed ever came into existence. [3] [4]

That is what the mental health system was like 40 years ago. To say that the infrastructure of the mental health system is worse today than it was then is ludicrous.

What has happened since? In 1978 the Community Support Program (CSP) was introduced by the National Institute of Mental Health and gradually spread across the country. It called for the development of community housing for people with severe, long-term mental illness, for a vast expansion and improvement of outpatient treatment services, for expansion of inpatient services in local hospitals, for expansion of psychiatric rehabilitation services, and for case managers to help people to negotiate the complex mental health and social welfare systems.

As a result, there are now tens of thousands of housing units, thousands of rehabilitation programs, many more outpatient programs, and more psychiatric beds in local hospitals. The few state psychiatric hospitals that remain are both smaller and far better than they were even 25 years ago.

In addition, laws regarding discharge planning and patients' rights have added important protections against abuse and neglect.

Similar developments with regard to children's mental health have resulted in significant improvements since 1973, when very few child mental health services had any public support.

Is it enough? Of course not! But what we have achieved, rather than being a source of shame because it is inadequate, should be a source of pride in the vast improvements that have taken place over the past 40 years. And it should be a source of hope for the improvements that can be made over the next 40 years.

For more by Michael Friedman, L.M.S.W., click here.

For more on mental health, click here.


[1] "1869 to 1994 Trends in Inpatient Workload," NYS Office of Mental Health, Bureau of Planning Assistance, Mental Health Information Unit, October 1984

[2] Statement of James A. Prevost, M.D., Commissioner, Office of Mental Health, Legislative Budget Hearing, March 4, 1981

[3] Mechanic, David. Mental Health and Social Policy, 5th Edition, Pearson 2008.

[4] Mechanic, D., McAlpine D., and Rochefort, D. Mental Health and Social Policy, 6th Edition, Pearson 2013.

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