Never in their long history of attacks and exposés have the state hospitals faced so uncertain a future as they do today, and never has planning for that future been so difficult or contained so many conflicting influences. These include a large infusion of federal funds, a great proliferation of reports and reviews, a new consumerism, new antipsychiatric attitudes, a renewed antihospital dialectic, and a vivid sensitivity to the civil liberties of patients. This last has produced a steadily mounting series of judicial decisions, laws, and regulations bearing on such issues as the patient's right to treatment, his right to refuse treatment, his right to be treated under the least restrictive conditions, and his right - even his obligation - not to work unless he gets a minimum wage.
Outstanding among new developments has been the extension of the mental hospital's responsibility to include long-term care of the mentally disabled after they are discharged into the community. Today one rarely hears complaints about unjust retention of patients, but injudicious discharge and failure to provide adequate aftercare are major issues. From the point of view of the general public - and this is a viewpoint that I accept - the future of patient care, regardless of location, is the primary question; the future of state hospitals is clearly linked to it but is secondary. The best way to prognosticate this future would be to analyze each of the important new and old factors in the situation, including fiscal and technical elements, and then to project a synthesis of these elements. Such an undertaking, however, far exceeds my capacity or the scope of this article. Instead, I shall review some significant recent events as background, and then attempt a projection based in part on the influences reflected in these events and in part on otheT factors.
THE KENNEDY PLAN AND ITS PROBLEMS
It is now over 12 years since President Kennedy1 formally announced a program to phase out America's large mental hospitals. He outlined a broad plan for a change to community psychiatry, and predicted that, when this had been carried out,
"reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability. ... If we launch a broad new mental health program now it will be possible within a decade or two to reduce the number of patients now under custodial care by 50 percent or more."
Delivered on February 5, 1963, this message came two years after a similar pronouncement by Enoch Powell, then the British Minister of Health, who planned a total rundown of the large British mental hospitals in the next 15 years.2 A scientific report from the minister's medical office in the same year had reached a similar but more tentative schedule by projecting from past experience.3
The British initiative undoubtedly influenced the American action, and both countries have since experienced the predicted major rundown of their mental hospital census. Characteristically, the process has been slower in Britain, which has cut its population by only a third while the U.S. decrease is more than one-half.2,4 Moreover, in the United States the average mental hospital expenditure per them had by 1973 shot up to $254 from the $4 figure that Kennedy had cited for 1962. Kennedy's plan was also vindicated in that there has since been a vast increase of community mental health resources and services; the annual incidence of outpatient psychiatric care is more than twice as great as it was in 1963,5 and it is reasonable to assume that many acute episodes that would once have required state hospital admission are now being treated in general hospitals or on an outpatient basis. It is hard to be sure about this, however, because admissions to the large state and county facilities actually increased until 1971,4 while the initial population decrease dates back to the introduction of phenothiazines in 1954-55.6'7 The question remains without a complete answer, and this uncertainty contributes to the difficulty of interpreting events since 1963 and predicting what may occur in the future.
Other developments in the mental health field did not go according to the Kennedy plan. The community mental .health centers developed far more slowly than anticipated, and even by 1973 only 392 of the planned 2,000 were in operation,·8 they did not become a new type of service but tended to develop along traditional lines;9 and the movement as a whole seemed to lose momentum as time went on. Perhaps the most serious failure of the Kennedy plan concerned the long-stay patients whose successful return to the community was essential to the proposed hospital rundown, since they made up the bulk of these hospitals' census. Kennedy had anticipated that they would be accepted with the "open warmth of community concern and capability." This was a gross miscalculation. Instead of "open warmth," these former patients have too often been received with organized hostility, and communities have been complaining that they do not have the capability to deal with groups of mentally disabled. Thus the Kennedy plan has fallen far short of its real goals with respect to deinstitutionalization; largely as a result of this failure, the whole mental hospital strategy is undergoing a radical reappraisal.
SOME ASSUMPTIONS THAT FAILED
One of the major assumptions of the Kennedy plan was that early, effective treatment would prevent mental disorder from becoming chronic and would cut off the flow of patients into the large mental hospitals. In addition, it was thought that moving chronic cases from the mental hospitals into the community would in itself be therapeutic and would lead to their rehabilitation. It is ironic that 100 years earlier Dorothea Dix had persuaded legislators to create these hospitals in order to prevent chronicity, because she assumed that the patient must be taken from his home and placed in a mental hospital to be cured. Within a century the hospital and the home had traded places as cause and cure (or prevention) of chronicity in mental disorder.
As Kennedy hoped, the census of the large mental hospitals has indeed been reduced by more than half. For a time it was said by some that the decrease was brought about by the creation of the community mental health centers; but, as mentioned above, the mental hospital population reduction began seven years before the Kennedy message, and by 1973 only a fifth of the planned centers had been opened. Some observers have sought to explain the fall in the mental hospital population by the fivefold increase of outpatient services and psychiatric units of general hospitals since 1955. 5 If so, it could have been achieved only if they had brought about a decrease in state hospital admissions, an increase in discharges, or both. But state hospital admissions did not decrease until 1972; instead, they doubled between 1955 and 1961.4,9
Nor is there good evidence that the new community facilities encouraged the discharge of mental hospital patients by providing aftercare. We lack statistics on this point, but it is well known that these facilities have generally not dealt with the more severely handicapped, including former mental hospital patients, partly because these patients did not come forward for treatment and partly because the new facilities have been flooded with more treatable community cases that had previously received no care. In particular, these facilities have resisted admitting patients with organic disease, alcoholics, geriatric patients, chronic severe psychotics, and delinquent acting-out patients. Thus the mental hospitals themselves have had to provide their discharged patients with whatever help they could, and this explains why current criticisms about lack of aftercare for the mentally disabled in the community are directed against the large hospitals and not against the community facilities. Unfortunately, there have been no large-scale studies about what has happened to all the patients (particularly those with significant chronic disability) who have left the state hospitals, but the studies we do have indicate that these patients have had little or no help from anyone.2,10-12
Some mental hospital authorities have maintained that the care and treatment of discharged patients is a community responsibility, that appropriate community facilities will not develop unless a need is created, that communities will respond to the stimulus of need, and that thus, in the long run, patients will gain by community placement. They strongly support the position that community placement is therapeutic in itself, while the mental hospital is antitherapeutic and is a prime cause of dependency and chronicity.
In the light of experience, this appears to be oversimplified reasoning. It ignores the very large numbers of persons who do recover under state hospital treatment, and the fact that community services have not developed to meet the needs of discharged patients. Finally, it is clear that many persons with chronic mental disability have not benefited from the simple fact of being in the community. Instead, a backlash has developed against this type of placement, and the public, the press, and the professions have joined in complaining that chronically disabled persons have in reality been "dumped" to live on welfare allowances in low-grade accommodations with inadequate food and no medical care or rehabilitative services. Examples are cited where these accommodations are concentrated in deteriorating and dangerous slum areas, with the former patients living alone in tiny rooms, in fear, neglected, victimized by unscrupulous landlords, attacked and robbed by lawless .neighborhood elements, and in sum not so well off as they were in the hospitals.13"15 In one section of Los Angeles, 1,100 such persons recently discharged from a state hospital are said to be congregated in a 20-block area.10 On the other hand, there are equally vigorous complaints that some former patients are disruptive, frightening to women and children, and actively psychotic; that they annoy and alarm others by begging and behaving in a bizarre and sometimes threatening manner; and that they impose an undue stress on their own families.16,17
OTHER PROBLEMS AND DILEMMAS
All this is not to say that there is any support for a return to previous policies. A very strong civil-liberties lobby is actively working in the courts and legislatures with the stated aim of further accelerating discharges and putting more restrictions on hospitalization.18,19 It is also moving to upgrade the hospitals through a series of lawsuits based on the doctrine of "the right to treatment." In response, the courts have now begun to set such minimum standards for care and treatment. This has raised hospital costs, and in several states the increased cost has forced a decrease in the number of patients; in Alabama, for instance, the number dropped by 60 per cent following intervention by the courts. One leader in the movement has stated publicly that he hoped to make mental hospital care so expensive that it would have to be abandoned.20
In the meantime, it has been amply demonstrated that simple hospital discharge is not enough, and a civil-liberties group is planning "a second generation of lawsuits" aimed at having the courts set standards for care and treatment in the community.21 This calls for guarantees of good housing, adequate social assistance, and complete mental health services. It amounts to a continuation of full mental hospital services to the chronically disabled, but on a dispersed basis. No one yet seems to have addressed the problem of those patients who cannot cooperate and will not accept treatment, and our experience is that such cases are numerous.
In brief, the discharge policy of the mental hospital is criticized for being at the same time too free and too restrictive. The dilemma is still further intensified because the only solution seems to be a vastly increased system of services to a dispersed population, which calls for increased financial backing over which the hospitals have no control. An obvious answer appears to be the transfer of funds from inpatient to outpatient services, but at this moment the remaining inpatient services are in general too scantily financed, by current standards, to permit any major diversion of resources to extramurai operations. Regardless of fiscal or other considerations, however, the public now demands that the state accept a continuing responsibility for these patients, and in New York this demand has been met by a new law that provides support for long-stay patients after discharge and relieves the local communities of the financial burden. Incidentally, this law has so far had no perceptible effect in increasing community acceptance of such patients. In addition, New York State is now moving to set up minimum standards of its own for group residences that serve the mentally disabled in the community.
It is interesting to note that, in spite of all the defects and limitations in the large-scale process of deinstitutionalization, there was no public reaction and only a limited professional criticism for seven or eight years. The first important move to protect patients from improper placement appears to have come not from the courts or legislatures, or from the mental health professions, but as a public reaction when, in January, 1973, California announced that all its state hospitals would be closed within five years and the state schools in 10 years. This state had without major incident already reduced its state hospital census to 7,000 from a maximum of 50,000, but the scheduled final closing precipitated a sudden reaction, with a legislative inquiry and newspaper exposés.10,14 California then decided to reopen two hospitals and abandon the scheduled closings. In the meantime, similar reactions had appeared in other states. Massachusetts, for example, published a plan for deinstitutionalization in November, 1973, after almost two years of preparation, but popular protest and a press campaign were followed by resignation of the commissioner in early 1975 amid now familiar charges of patient dumping.
New York State, too, underwent a change of commissioners at about the same time in the context of similar complaints. There had been previous scattered protests by professionals and by community leaders about the plight of many former patients in the community. Then, in 1974, the public press became interested, and even the traditionally liberal and highly influential New York Times entered the field and carried on a vigorous campaign of criticism.15 In the meantime, community sensitivities had been roused, and several local governments passed laws and applied other pressure in an attempt to stop placement of former mental hospital patients in group accommodations. This was in part, at least, the expression of an attitude of rejection towards the mentally disabled, but the stated aim was to protect both the patients and the community. Although the courts have not upheld these restrictive laws, the litigation has drawn further attention to the lack of housing and aftercare. As a result of this controversy, the press, which had for some years been supportive of the mental hospitals, has now become generally critical; antisocial acts of former mental patients are again featured in the headlines, and traditional attacks on many aspects of hospital operations are again commonplace.
The hospitals are also facing a new dilemma because of the application of liberal policies to mentally ill persons who have been accused of crimes. In 1967 about 5 per cent of hospital admissions were of mentally ill offenders, and the number has risen since then.22 Here, as in the California experience, we have observed a sort of threshold reaction. There had been no public criticism in 1966, when 1,000 such patients were transferred from New York correctional psychiatric facilities to civil state hospitals as a result of the court decision in the Baxstrom case.23 But in 1974 a similar move, of a far smaller group of patients, led to public outcry and a sudden demand for increased mental hospital security on the ground that some of these patients had committed serious crimes. Thus the same liberal trends that originally led to the creation of the open hospital are now bringing maximum-security sections back into civil menial hospitals. One solution to this problem is parole or probation on the condition that the patient cooperates in treatment. This is particularly important in cases of character or conduct disorder, where the legal dichotomy of "mad or bad" is quite impractical.
One naturally asks why longstanding policies on release that have had public support, or at least no effective opposition, for years should suddenly become a target for widespread criticism at the very time when they have been built into laws, regulations, and judicial decisions. The answer probably has to do with the public mood, a problem outside our field. But it now appears that we cannot rely on increased public tolerance of deviant persons in the community. If anything, such tolerance is diminishing, while judicial and legislative trends are becoming more liberal.
WHAT OF THE FUTURE?
On the basis of past experience, we might venture some predictions concerning the immediate future:
1. Thinking about state mental hospitals separately from other mental health services is likely to lead to serious errors. The mental hospitals are part of a continuum of human services, and movement in any area influences others. For example, the trend to limit geriatric admissions in state hospitals was associated with a spectacular rise in nursing and personal-care home populations from 554,000 in 1963-64 to 815,000 in 1969; at the same time, the number of their mentally ill residents rose from 222,000 to almost 427,000. 12 We may, incidentally, expect repercussions in the state mental hospitals from the recent nursing-home exposés and scandals.
Because of the interrelatedness of all types of psychiatric services, it is meaningless to ask how many state hospital beds are needed to serve a given number of people unless we are able to specify what alternatives are envisioned. We can, however, ask a fundamental and still unresolved question, "What is the total need for beds for all psychiatric patients, including those with chronic disability?" On this point the best information appears to be developing in Britain.2,11,18,24,25 The data are still conflicting, but I would judge that the figure will be in the neighborhood of 150 per 100,000, most of these being needed for intermediate and long-term cases. It appears certain that under existing conditions many of these beds will continue to be in the large mental hospitals, and the American Psychiatric Association has issued a formal statement to the effect that there is still a need for the mental hospital.2* A similar statement about psychogeriatrics has been issued by the British Geriatrics Society and the Royal College of Psychiatry.27
2. It now appears that chronicity among mental patients has not been abolished, that much of it is not reversible by current methods, and that we cannot rely on existing methods to prevent the development of "new chronics." This is most obvious with respect to organic states such as alcoholism, which is increasing, but it also applies to schizophrenics and a considerable number of persons who suffer from a combination of mental disabilities. Only a new advance in the technical aspects of psychiatric treatment is likely to make a change in this situation.
3. We are currently engaged in a nationwide trial to determine how many of these persons can be maintained in alternative community facilities. Within a few years we should have firm data on the methods, the results, and the cost of such a policy, but we have none of these yet.28 We know only that a society accustomed to mental hospital services will use social and political means to resist when such services are reduced below a certain point that is still undetermined. The public reaction in Britain is more muted but seems parallel to our own.2,24,25
4. A new and unsolved problem is that many communities have become so sensitized to the "ex-mental patients" that they have broadened the category to include a considerable number of other persons who have never been in a mental hospital but are deviant in appearance or behavior. This group includes especially alcoholics, vagabonds, and many feeble aged persons, the homeless, rootless, friendless people nobody wants. In a sense the public is right, because many of these people require much the same kinds of services as do former mental patients. It seems unlikely that they can or should be excluded very long from new plans for services to former patients.
5. It has in the past been highly unacceptable to give overt consideration to questions of cost in health matters generally, but our denial has been of no use. Cost has always influenced the structure of mental health services, and cost effectiveness promises to be more influential in the future, especially since the current economic downswing may give cost considerations a measure of respectability they previously lacked.
6. Because alternatives are not available in many areas, we can expect that many persons with acute episodes will continue to go to large mental hospitals for treatment. This is especially true for patients who need a longer stay than a week or two, and for them there are important advantages in the greater space and special facilities of the large hospitals.
7. Many of the chronically disabled will probably remain in the state facilities; to accommodate their needs, some state hospitals have converted certain living quarters no longer operated as psychiatric facilities into congregate community residences. It seems quite likely that, for important legal and administrative reasons, such conversion will be more widely applied in the future, leaving only a part of many facilities to be run as mental hospitals.
8. We can also expect that many more patients with milder disabilities will be dispersed into hostels, family-care homes, etc., and that the hospital services will follow them. For this to be fully effective, we shall require special regional transportation systems, analogous or even associated with school bus systems, to bring these people together for social, recreational, and rehabilitation programs.
9. For a long time it was thought that a universal welfare allowance would by itself free virtually all persons from long-term dependence on the state hospital. We now know that many are unable to utilize the resources provided. The confused aged, withdrawn schizophrenics, and irresponsible alcoholics all require protection from their own weaknesses and those of others, and their regular monthly check is an open invitation to the unscrupulous. A system of conservatorship could ensure that these persons get the full benefits of their allowances, and at the same time provide ongoing supervision of their needs. Such a system is available in theory, but so far it has been little applied.
The future of the large mental hospital appears likely to remain related to the future care and treatment of persons who have significant chronic mental disability. These hospitals also serve many other types of patients, with serious mental disorders for which other services are not available. Nationwide these cases account for some 400,000 admissions annually, almost all of them very short-term. But the emphasis in any discussion about state mental hospitals must still remain on the long-stay patients, because they make up the bulk of the total hospital population.
Efforts to develop acceptable alternatives to hospital life for as many of these persons as possible have a very high priority in American psychiatry today, and it appears that the mental hospitals will continue to take a leading role in this work. In fact, it is likely that, given sufficient time and start-up money, the state hospitals could metamorphose into a dispersed system, and we may hope that the final total cost will be lower than that of mental hospital care, though this is by no means certain. It does seem inescapable, however, that during the transitional period society will have to pay for both systems to the extent they run parallel.
The final result could be a system based on small multipurpose state hospital-type facilities that would still retain the residual or backup function of the traditional state facility and, in addition, be the base of operations for personnel serving disabled persons living in various supervised community groups. Defined in this way, some hospitals could emerge as community mental health centers, as a few have already done. Other jurisdictions might follow the pattern developed in the Netherlands, where all disabled persons (both physically and mentally handicapped) are served in nonsegregated fashion with no pressure for full rehabilitation, and indeed no expectation that this will be reached by all of them.
The state hospitals will continue to take a leading role in the process of deinstitutionalization, whose only legitimate aim is not simply to reduce the number of mental hospital beds but to reduce the need for such beds by providing better alternatives and more effective treatment. The earlier procedure of radical deinstitutionalization for its own sake has been rejected as a failure. The open warmth of community concern may still develop, as President Kennedy anticipated, but first we shall have to provide effective capability from other sources.
1. Kennedy, J.F. Message from the President of the United States. 88th Congress, 1st Session. Document 58, Feb. 5, 1963. Washington, D.C.: U.S. Government Printing Office. 1963.
2. "Coordination or Chaos: The Rundown of Psychiatric Hospitals." London: Mind Report 13. Bookstall Services, 1974.
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8. Comptroller General of the United States. Report to Congress B-1 64031 (5). Washington, D.C.: General Accounting Office. 1974.
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10. Alquist, Sen. A.E, Final Report. Senate Select Committee on Proposed Phaseout of State Hospital Services (mimeograph). Sacramento, Calif., 1974.
11. Letemandia, F.J.J. , and Harris, A.D. Psychiatric services and the future. Lancet (Nov. 3, 1974), 1013-1016.
12. Redick, R.W. Patterns in use of nursing homes by the aged mentally ill. NIMH Statistical Note 107, June, 1974.
13. Lamb, H.R., and Goetzel, V. Discharged mental patients - Are they really in the community? Arch. Gen. Psychiatry 24 (Jan., 1971), 29-33.
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15. Schumach, M. "Proprietary Homes Called Snake Pits." New York Times, Aug. 5. 1974.
16. "Reaction of Family Studied in Schizophrenic's Home Care" (report on study by Hoening, J., and Hamilton, M.W.), Psychiatric News (Aug. 15, 1973), 22.
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18. Graenbtatt, M. Class action and the right to treatment. Hosp. Community Psychiatry 25:7 (1974), 449-452.
19. Stickney, B.S. Problems in implementing the right to treatment in Alabama: The Wyatt v. Stickney case. Hosp. Community Psychiatry 25:7 (1974), 453-460.
20. Schwartz, LH. Litigating the right to treatment. Hosp. Community Psychiatry 25:7 (1974), 460-463.
21. "The Next Generation of Litigation Will Involve Community Services." Innovations (Winter, 1974), 13-15.
22. Scheidenandel, P.L., and Kanno, CK. The mentally ill offender. Joint Information Service of the American Psychiatric Association. Washington, DC: Garamond/Pridemark Press. 1969.
23; Steadman, H.J., and Keveles. G. The community adjustment and criminal activity of the Baxstrom patients 1966-1970. Am. J. Psychiatry 129:3 (1972), 304-310.
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25. "Homeless Single Persons" (Editorial). Lancet (May 19, 1973), 1101.
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27. British Geriatrics Society and Royal College of Psychiatry. Joint Report on Matters Relating to Care of Psychogeriatric Patients. Br. J. Psychiatry (suppl.; Aug.. 1973). 2-3.
28. Caplan. R.B.. and Caplan, G. Psychiatry and the Community in 19th Century America. New York: Basic Books, 1969.
Eisenberg, L. The future of psychiatry. Lancet (Dec. 15, 1973), 1371-1375.
Leighton, A. "The Other Side of the Coin" (Editorial). Am. J. Psychiatry 727:11 (1970). 1547-1549.
Murphy. H. B. M., et at. Foster homes: The new back wards? Canada's Mental Health Supplement No. 71 (Sept.-Oct, 1972), 1-17.
"From Custody to Compassion" (report of address by Dr. Bertram S. Brown). Psychiatric News (Aug. 15. 1973). 11.