In the 1970s, when other states were closing mental hospitals, Maryland opened four new ones. The new hospitals were part of the state's plan to move patients out of mammoth crumbling facilities, the oldest of which opened in 1797, and back to their communities. But rather than fund a network of community programs, Maryland built new institutions.
Dr. Stanley R. Platman, the state's top mental health official from 1976 to 1984, said he repeatedly proposed reducing the size of the oldest state hospitals, selling the vacant land and using the money for community programs. Platman said his proposals were torpedoed by a coalition of state legislators, leaders of hospital employe unions and psychiatrists on his own staff.
"You have these antiquated old buildings in this rural environment that are strangely historical," he said, and "an institutional system that is too large, unresponsive and inept in the services it provides."
Gov. Harry Hughes has a different view of the state's deinstitutionalization effort. "I think we've done very well," he said. "There are pressures from both sides. For those still in institutions, you have to provide adequate services or you get sued. One of my principal concerns is that we don't move too fast, that we don't move people out of hospitals before the programs are there."
Critics say Maryland's failure is not releasing patients too fast but failing to provide sufficient programs for those who are discharged. "There has been a helluva lot of good rhetoric," said Michael Millemann, a Baltimore mental health lawyer, "but not a helluva lot of action."
There have been no layoffs at Springfield, one of Carroll County's largest employers, which has a staff of 1,600 but only 900 patients. Last month the General Assembly appropriated $6.2 million to build a new Montgomery County unit but only $3 million for new community programs, the amount requested by Hughes.
In Maryland the pressure to develop such programs collided with the push to improve the quality of state hospitals.
In the late 1970s Maryland began to recruit registered nurses and other professionals aggressively and to funnel young psychiatrists into residency programs at state mental hospitals, particularly Springfield.
Half of the 130 psychiatrists working in state hospitals were replaced, many of them foreign doctors who spoke little English or elderly physicians with few career options. Because well-trained psychiatrists normally eschew the comparatively low pay and considerably lower prestige of public psychiatry, Maryland's transformation attracted national attention.
"Maryland's facilities were worse to begin with than a lot of other places," said Trevor L. Hadley, a clinical psychologist who succeeded Platman last year. "The quality of staffing was worse, and there were traditional and very powerful state hospital fiefdoms."
The impact at Springfield was dramatic. In the early 1970s, the hospital had been reorganized, the old "men's" and "women's" divisions abolished and patients grouped according to jurisdiction to make discharge planning easier. Admission criteria were tightened, and beginning in 1978 discharges accelerated.
At first the policy was greeted with considerable skepticism, especially by psychiatrists. "I thought deinstitutionalization was the stupidest thing I ever heard of," said Dr. Sherrill C. Cheeks, who came to Springfield in 1964 when the hospital had 3,600 patients.
He has changed his mind. "I am convinced that most patients really did not do well with long-term hospitalization," Cheeks said. "The revolving door is better than always being in the hospital, because that way at least people have an awareness and stimulation of another environment."
Once a month, Springfield staff members and workers from seven Montgomery County agencies crowd into an overheated hospital conference room to try to plan the best way to do that for patients who will be returning to the county. They must balance the risk of keeping a patient in the hospital for months after he or she has improved -- the stress of uncertainty possibly triggering a relapse -- with the possibility that a scarce vacancy in a halfway house will occur, often when someone else is rehospitalized.
"I may have worked with somebody for six or eight months, and then a place opens up and they fall apart and aren't ready to leave," said Felicity Swayze, a social worker at St. Luke's House Inc., Montgomery County's largest halfway house program. "It's very intense, very up and down, and you have an investment in that person."
Because of deinstitutionalization, the question is not whether a patient will leave but when. Hospital stays, once measured in years, are generally measured in days.
"We are being asked to do two things," said Dr. V. Rao Inaganti, 33, who heads Springfield's 115-bed Montgomery County unit. "As a medical facility we are being asked to treat people, and socially we are being asked: 'Can these people get out?' "
In Maryland the responsibility for discharged patients is ill-defined. Although the hospital is legally required to draw up a discharge plan for each patient, it is neither obligated nor able to find out what happens once they leave.
Springfield's view, according to social work chief James Slingluff, is that arranging services in the community once a patient is discharged is not the hospital's problem. In many cases "we say this is where you go, this is the number of social services," he said.
Within Springfield, the Montgomery County unit has the reputation of being -- in Inaganti's words -- "a pressure cooker."
"These patients are brighter, more sophisticated and more litigious," he said. "You are looking over your shoulder, and that's an added tension."
Patients who sign voluntary agreements and refuse medication or help in planning commmunity services may be discharged without either. Some are put on a shuttle bus that runs between Springfield and Kensington with a list of unlicensed rooming houses, a month's supply of medication and the name of a clinic. At times the hospital staff makes a "reservation" at a shelter. If a patient refuses or leaves without signing discharge papers, Springfield cannot send his or her records to a county clinic.
Keeping voluntary patients who are no longer considered dangerous means risking a lawsuit, which the staff tries hard to avoid. Sometimes that means doctors discharge a patient knowing that he or she is returning to the environment that helped trigger a breakdown in the first place.
"We struggle with our conscience, and there is an ongoing internal struggle that patients need more than they're going to get," said Slingluff. "The other thing that bothers me is, I know we're going to be blamed when someone leaves here and freezes to death on the streets or stabs someone."