In describing the difference between people who are mentally ill and ones whose behavior is odd but tolerable, Richard Antonelli, the director of the Washington County community mental health center, thought back to his boyhood and the local mailman: "He used to talk to himself. It was accepted. Maybe jokes were made and kids sometimes teased him. But he got along pretty well. When I began working in mental health, I knew what he was experiencing -- auditory hallucinations.
"He was hearing voices and he would respond to them . . . He lived with two sisters, older than he. They tolerated him. When they died, he went off to the state mental hospital . . . It was a social situation. There was no longer anyone who would be tolerant of this fellow."
The commitment of Antonelli and the psychiatrists, counselors and other workers at this well-regarded facility in southern Rhode Island is to create a climate of tolerance. The effort, which is succeeding and is well worth national attention, is to provide therapy for the hallucinating mailman -- or the schizophrenic lawyer, the manic-depressive secretary or anyone else who is mentally disabled -- in the neighborhood, not the state hospital.
This approach was established by the Community Mental Health Centers Act of 1963. It was as revolutionary a shift in thinking as the one in 18th-century England when the raving lunatic was unchained from his Bedlam snakepit and treated as a person, not a degenerate. In 18 years, deinstitutionalization programs have seen a half-million patients leave some 300 state hospitals, with well over 2 million in all being served by the national network of community mental health centers.
The 1963 law, intended to close the debate on the best methods of treating the mentally disabled, has instead -- and unwittingly -- sparked new arguments among medical and legal observers. The voices of the patients themselves, as well as their new neighbors near the community facilities, have also been heard. It is as if the law -- compassionate, cost-effective and overdue -- were too lofty an ideal for mere mortals to carry out in the workaday world.
The failures are well known:
Large cities now have subcultures of the liberated mentally ill. They are the dumped people who wander the streets free from the institutional structure of the hospital but victimized by the indifference of social institutions to their pain.
Neighbors, often the well-off and seemingly educated, fear the presence of "madmen" and pressure for zoning laws to keep out the former patients.
Officials at the hospitals and the centers often operate separate empires, with cooperation seldom replacing competition.
And now, a 25 percent reduction in federal funds for the centers has been voted. The states, few of which were ever concerned with this issue, will receive the mental health money, instead of individual local programs.
The worthiness of the mental health center in Charlestown is in the example it sets. The message from here is that the ideal can be achieved. If everyone involved becomes committed to the goal of community care and keeps alive the zeal one day after another, then the patients can be served and the law fulfilled.
At Charlestown, nothing is fancy. The basics count. A day treatment program serves patients by offering instructions that range from cooking skills, job interviews and appropriate dress. If needed, continuous supervision is provided. The local community is kept involved with educational programs that help dispel the myths about the mentally ill. The public is consulted through a large advisory board. Officials at the state hospital are seen as partners, not opponents. Through "case management," each patient is served individually by one of 50 staff professionals.
Without all of these forces at work all the time, it is hard to imagine how any community mental health center can succeed. It can be agonizingly difficult work.
But why should it be easy? No cure has ever been found for any mental illness, whatever its form. At best, the symptoms are controlled or the pain relieved.
We are still groping -- healers, patients and families of those who are ill. It's now thought that the local community is therapeutic. No one is promising a rose garden, only a neighborhood.