Policy makers and workers in the field of mental health said at a national conference in Washington recently that they were wrong to place thousands of mental patients in community care facilities without first planning and providing the services needed to take care of them.
After nearly 30 years of emptying public mental institutions, speakers said, the professionals have failed to provide a coordinated community mental health system that gives poor and chronically ill outpatients the housing, medical care, jobs, social training and other support services they need to successfully reenter the community.
These and other conclusions were discussed at a two-day meeting of 173 mental health professionals at the Hyatt Regency Hotel. The conference on patient reentry into the community featured more than a dozen panelists and was sponsored by the National Association of Private Psychiatric Hospitals, an organization of 176 hospitals.
Speakers said priority should now be placed on developing community support services along with institutional programs that help chronically ill outpatients who need occasional confinement because they are "better but not well."
Before the 1970s, nearly 70 percent of the patients released from institutions were independent. They had homes, family, money and other support services to help them in the community, Max Silverstein, an organizer of community programs, said in an interview. That trend has been reversed, said Silverstein a former professor of social work at the University of Pennsylvania.
"Now we're sending out people without resources, family, jobs - and people (neighbors in communities) hate them," Silverstein exclaimed. He said that while the courts and policy makers were good at legislating reform, "you can't legislate love."
In Washington, the rethinking of deinstitutionalization comes after a 1978 U.S. District Court decision ordering city officials and St. Elizabeths Hospital, a local mental institution, to devise a plan for placing thousands of patients in community facilities. The order was the result of a 1974 suit filed by attorneys with the Mental Health Law Project who charged that thousands of long-term patients had been needlessly confined in St. Elizabeths.
Joel Kline, a Washington attorney who worked with the Mental Health Law Project in the St. Elizabeths suit, said he and other "well-intended but misguided attorneys" now realize they may have acted in haste. He said Washington, like many other cities, does not have adequate community programs to help outpatients. As a result, many endure isolated lives in rundown boarding houses or aimlessly roam the streets, he said.
"Unsafe" foster care homes, such as the District home where 10 mental outpatients died in a fire last April, have opened across the country, according to several speakers at the conference. The home on Lamont Street NW had a city license to house 51 people, although it lacked a fire escape, smoke detectors and working fire extinguishers.
"For so long, people in mental health care delivery systems have been beat back by lawsuits," Kline said. He appealed to the audience "to fight back" and be "less cowardly," for the sake of the patients.
The Department of Health, Education and Welfare has reported that since 1955, the inpatient population of mental institutions has decreased about 65 percent, from 559,000 patients to 160,000. Placements in community facilities were advanced by the development of behavior-controlling drugs, by decisions in civil rights suits that required deinstitutionalization and by the promise that community programs were less expensive than the institutions.
Now the experts say they're not sure whether some of the community programs are less costly or more humane than the "'snake pits' of state hospitals," as one federal official called the hospitals, which brought about the reforms.
The revelations come during a period of tight money and in the wake of a 1977 General Accounting Office report that studied deinstitutionalization. Several panelists said the study concluded that many of the nation's community mental health programs were inadequate and poorly planned and that patients were discharged from state hospitals before adequate support services, such as housing or jobs, were provided.
David Williamson, director of a new $800 million federal program operated by the Department of Housing and Urban Development (HUD) to create housing for the physically and mentally disabled, said, "That GAO report is kind of like a kick in the seat of pants for HUD."
Othe panelists agreed that the GAO report, public reaction to newspaper and television reports as well as outpatients who have difficulty living in the community have forced mental health professionals to rethink their deinstitutionalization decisions.
Throughout the two-day conference, the mental health experts and federal policy makers expressed gloomy opinions as to reasons for the outplacement failures.
"We moved too prematurely," said Silverstein.
Richard Heim, director of the national Medicaid program, and Mary Hastings, director of the state mental health agency of Illinois, blamed conflicting public policy.
Heim explained that Medicaid policy differs from state to state, and regulations of the $20 billion national program often cause conflicts. For example, in most states, Medicaid pays for mental health services for patients living in hospitals or large nursing homes but does not pay similar costs for community programs, such as small halfway houses, he said.