The disoriented chronically mentally ill in our cities, wandering aimlessly and commonly homeless, is a focus of public policy susceptible to fierce emotions and forceful mythology. A growing chorus blames the victims and condemns the policies that prevent their incarceration. The media increasingly gives prominence to crimes committed by the mentally ill despite the evidence that the vast majority are harmless and pose no greater risk than any other citizen.
The tragedy of deinstitutionalization is twofold: first, the lack of leadership to implement proven models of effective community care for chronic patients, and second, the entrenched bureaucratic and economic interests that have made it so difficult to organize and finance appropriate programs to maintain patients' levels of functioning and quality of life.
Community mental health care is correct in concept and can be implemented in practice. The vast majority of chronic patients prefer community residence to institutional care despite the deprivations and hardships that currently characterize their daily lives.
Their lack of contact with social services tells us more about the inadequacy of care than their lack of cooperation, although resistance to treatment occurs.
Their homelessness tells us more about poor urban planning, gentrification and entrepreneurship run wild than a willingness to accept decent shelter. Resistance to public shelters tells us more about the paucity and frightening quality of what is provided than patient recalcitrance.
There is overwhelming evidence that programs which consolidate services and meet a spectrum of needs enhance quality of life more than is possible with institutional care. At a minimum, these needs include maintenance of health, appropriate medication monitoring, decent nutrition and shelter, and development of skills required in everyday life.
A small number of chronic patients require asylum but most do not. Satisfactory community care, however, means that funds must follow the patient and that an equitable distribution between funding for community care and hospital services must occur. Community services are not only superior in performance, and preferred by patients, but also are cost effective.
Failure to build effective community services is due to fragmentation of funding and responsibility, inconsistencies in eligibility criteria for many of the programs on which these patients' welfare depends, and a lack of coordination and cooperation among central components of the services system. A prerequisite for developing appropriate and effective systems of care is to focus clear responsibility and organizational and financial authority in an agency having the support of varying levels of government.
Such an authority, whether organized as a public entity or a nonprofit corporation, would be responsible for defined populations of patients and the expenditures made on their behalf for medical and psychiatric care, social and rehabilitation services, and basic sustenance and shelter.
Budgetary control provides the ability to assess tradeoffs and make cost-effective decisions. Implementation requires cooperation between varying levels of government and a willingness of each to yield some of its limited and inadequate discretion.
Deinstitutionalization as it has developed has served the fiscal interests of states more than the welfare of patients and their families or the community. Deinstitutionalization simply provides a context for care or neglect.
We understand how to build effective programs, but have yet to harness the political and public support essential for implementation. It is difficult to accept that a society with the scientific, technological and organizational capacity to conquer space and transplant hearts could not adjust organizational arrangements to make deinstitutionalization something more than a false hope.