Who Cares for the Mentally Ill?
Hope, Marjorie, Young, James, The Nation
Who Cares for The Mentally Ill?
New York City Mayor Edward Koch's plan to hospitalize, against their will, some of the city's homless who are seriously mentally ill has generated a bewildering battle among lawyers, bureaucrats and assorted professionals. When Joyce Brown, the first street dweller to be involuntarily hospitalized, brought suit against the city, a state court granted her release request; the next day, an appellate court delayed it. Psychiatrists hired by the American Civil Liberties Union pitted their opinions against those of psychiatrists appearing for the city, while state and local officials accused each other of reneging on responsibility for the homeless mentally ill.
Most authorities contend that only a minority of the severely mentally ill need prolonged institutional care. But focusing on the right of mentally ill persons to live on the streets deflects attention from the basic issues. What of their right to comprehensive mental health services? To decent housing? Why is it that so many so-called street people are unwilling to do something as instinctive as come in from the cold? Psychologist Mel Roman observes, "The city's psychiatric wards are miserably overcrowded. Adding twenty-eight beds, as Koch has done, is no solution. Many shelters are dangerous and dehumanizing. More important, if these people had been given adequate mental health services and living supports in the first place, most would not be out on the streets. We need a preventive approach.'
Since colonial days the states have assumed fiscal responsibility for the mentally ill. In the 1960s, however, Federal aid enabled discharged patients to live in the community, and Medicaid began to cover some mentally ill people who could be cared for in nursing homes. States welcomed Federal funds but not the dilution of their power. Another new source of Federal funding and power was the 1963 Community Mental Health Centers Act, which President John Kennedy signed with great fanfare. This "bold new approach' was motivated by the same sense of national purpose as the Federal stand on civil rights--the belief that Washington had to set certain standards to protect citizens in the less enlightened states.
In 1955 state mental hospitals held 558,922 long-term patients; in 1984, approximately 114,000. The movement toward deinstitutionalization was spurred by the development of behavior-altering drugs; by court decisions upholding the rights of patients, including the right to refuse institutionalization unless there is a clear danger to self and others; and by the growing philosophy that most patients should be treated in the least restrictive setting, preferably their own communities.
However, state hospital administrators and employee unions had a vested interest in the status quo. Today there are nearly sixteen times as many mental patients in outpatient facilities as in state hospitals, yet roughly 70 percent of public funds allocated for mental health goes to the hospitals. Deinstitutionalization fosters short-term acute treatment, which is more costly than custodial care, but the fact remains--as James Stockdill, a division director at the National Institute of Mental Health (N.I.M.H.) points out--that few states have transferred state hospital savings to the communities.
The flip side of deinstitutionalization is the emergence of highly restrictive policies of admission to state facilities. Today thousands of mentally ill street people in New York City and elsewhere have never been in a state hospital. Some live outside of institutions because most states forbid involuntary commitment unless the person poses a clear danger to self or others. On the other hand, advocates of outpatient treatment report many cases in which patients, frightened by their inner turmoil, have clearly wanted admission but were denied it. The Central Ohio Psychiatric Hospital, for example, refuses patients not accompanied by an involuntary admission form, as well as those with an alcohol, drug or serious physical problem.
The Community Mental Health Centers have turned out to be anything but comprehensive. There were originally supposed to be 2,000 of them; today they number approximately 870. Because C.M.H.C. planners failed to stipulate requisite rehabilitative services or living arrangements, those remain state and local options. In line with two articles of American faith--local responsibility and reliance on the private sector--the Federal government provided only seed money. As the grants wound down, the centers were expected to become self-sustaining through fees, private insurance, Medicare, Medicaid, Title 20 (the social services block grant) and state and local funds. In 1981 the Reagan Administration lumped funding of all alcohol, drug and mental health programs into one block grant and cut the package by 25 percent. It also slashed Title 20 funds by 30 percent and the Federal portion of Medicaid by 10 percent.
Preparing for the phase-out of seed money, administrators at "public' mental health centers began to scrounge for private support in the form of fees and insurance payments. As one therapist put it, "Our staff meetings began to focus on reaching more clients who could verbalize their problems --and who could pay.' Another therapist said that an her center, staff members are instructed to ask their paying or insured clients to come two or three times a week, even though they may not need more than one weekly visit. Therapists who object are told, Go with the system or lose your job. "You have to make their pockets jingle,' she said.
N.I.M.H. is prodding states to do more work with the severely mentally ill, but it estimates that today only 20 to 30 percent of C.M.H.C. clients nationwide have had inpatient care at a mental hospital. Theoretically, no one in need of treatment is turned away, but "hard to treat' or uninsured clients may be told that there is, say, a three-month wait for an appointment. Sliding-scale fees may correspond to the center's criteria of "ability to pay,' but to low-income clients that may represent an intolerable burden anyway. In addition, the severely mentally ill who require psychiatric treatment are likely to receive little more than medication and perhaps twice-weekly activities. Eventually, many drop out.
Meeting survival needs is fully as important as treatment. Although many states have begun pushing their local mental health boards to fund supportive housing supervised by C.M.H.C.'s, according to E. Fuller Torrey and Sidney Wolfe, in a report issued by the Public Citizen Health Research Group, only 15 percent of the severely mentally ill live in group homes (which must have a trained staff) or foster homes. Moreover, they depend on the good will of the neighborhood and on the generosity of local voters. The U.S. Department of Housing and Urban Development typically confines itself to setting up a few model programs in the hopes of inspiring localities.
Nursing facilities, which house another 15 percent of the severely mentally ill, rarely offer the array of special services needed. In many rural areas the mentally ill end up in county homes for indigents, but only if they have lived in the county for a year. Many others dwell alone, in hospitals, on the streets, in jail or in shelters--the asylums of the 1980s.
The presence of so many mentally disabled people on the streets is another index of the fragmentation of services. Dennis Conkin, who does street work with the Tenderloin Self-Help Center in San Francisco, and Tony Hannigan, who helped set up Columbia University's Homeless Project, a drop-in center for people shut out of the treatment system because they are "difficult,' agree that tradditional outpatient services cater to clients with emotional rather than behavioral disorders--those who won't refuse medication, tell workers off or reject the treatment goals. "Ironically,' says Hannigan, "ten or twenty years ago the kind of people we work with were living in S.R.O.s [single-room occupancy hotels], and most were managing to survive.'
As for Medicaid, its very structure fosters fragmentation and inequity. Unlike Medicare, Medicaid is tied to the welfare system; it is for the poor alone and is a Federal-state partnership in which states have enormous discretion, hence the power to control the poor. To obtain Federal cost-sharing, states only need to cover all persons receiving Aid to Families with Dependent Children and most of those receiving Supplemental Security Income, a program designed for the indigent aged, the blind and disabled. While states may extend coverage to the "medically needy,' only one state, Hawaii, covers more than 90 percent of the poor; South Dakota covers 23 percent. Federal regulations also permit requiring copayment and classify only nine services as mandatory; thirty-two are merely optional.
The mental health system, then, is a crazy quilt of conflicting regulations and responsibilities. Medicaid will not pay for room and board in foster homes, halfway houses or group homes, although it may cover admission to hospitals or nursing homes. In most states it pays for the services of freestanding clinics, but only if deemed medically necessary; typically this includes group therapy but not encounter groups. "Day treatment' programs may be covered but not those labeled "socialization,' although the dividing line can be very fine indeed. State discretion is so broad that some states limit mental health clinic visits to eighteen per calendar year, some impose special rate limits and only a few cover treatment for drug and alcohol abuse.
In most places no agency at the state or local level takes responsibility for planning and implementing a system to assure that the mental health and community-support needs of the mentally ill will be met or for monitoring the quality of institutional and community support programs. Nor does the N.I.M.H. assume leadership. An inordinate proportion of overhead is wasted on what one administrator calls "funding gamesmanship.' In sum, the system is not comprehensive, equitable, cost-efficient or preventive.
What directions should mental health care take in the future? One choice is to hobble down the same path, making incremental changes (for example, along the lines recommended by the American Psychiatric Association's Task Force on the Homeless Mentally Ill, which fails to point out the political and administrative changes necessary to achieve an equitable system). Many states and local mental health boards now fund group homes. The Mental Health Planning Act authorizes expenditures of $10 million to encourage states to institute plans for community-based services with special attention to the long-term mentally ill. Integrated programs that meet psychiatric, social, medical, housing and employment needs within one structure do exist, although most rely heavily on private and foundation contributions. The Robert Wood Johnson Foundation of Princeton, New Jersey, has set up excellent models in nine cities. For more than a decade Wisconsin has provided a range of treatment services and a wide-ranging community support network. While advocates hope that this model will inspire other states and communities, it seems not to have.
Another choice could be to privatize mental health still further. The United States seems to be moving quickly in this direction. Already the clear trend is to steer the indigent to public hospitals and privately insured patients to others. Only eighteen states and jurisdictions now fail to mandate that health insurance companies offer some kind of mental health coverage. However, the policy buyer decides whether to accept that option, and only 5 percent of the policies will pay for mental health outpatient services on the same basis as other conditions.
A third way to effect change would be to introduce a comprehensive national health care system that incorporates mental health. Such integration is common both in countries like France and Canada, which follow the universal health insurance model, and in those like Britain and Italy, which offer a national health service. Ironically, under Britain's "socialist' system, doctors enjoy more freedom than their American counterparts. In this country, many doctors feel like employees of the insurance companies.
Can we afford universal health care? The reality is that our privatized approach is the most expensive in the world. A New England Journal of Medicine study, based on 1983 figures, estimates that under national health insurance like Canada's the United States could save $29.2 million a year; under a national health service like Britain's, $38.2 million. Resistance to change would be fierce. But perhaps the real question is, Can we afford not to have it?
Ideally, the concrete shape of a unified mental health system would emerge out of informed national debate. Whatever its final shape, an expanded N.I.M.H. should assume leadership. It would appraise the needs of the mentally ill, set a national budget and guidelines, coordinate the various levels of service and monitor standards. At the same time many decisions could be left to the states and localities. Consumers and other citizens should also have a voice. With adequate planning, our heritage of pluralism can be preserved to some degree within a framework assuring greater equity, access to service and accountability.
Under such a system, C.M.H.C.'s, secure in their status and funding, could employ more staff trained to work with the severely mentally ill, children and the elderly. They could emphasize prevention far more than they now do.
Low-income, chronically mentally ill patients will need comprehensive service, including a spectrum of treatment programs and housing alternatives. This will require a greatly expanded Federal role in coordinating the housing and mental health systems. Beyond that, affordable housing, decent jobs and some basic minimum of economic security should be available to all. In the final analysis, sane mental health policy rests on social policies that create an environment in which people can flourish.…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: Who Cares for the Mentally Ill?. Contributors: Hope, Marjorie - Author, Young, James - Author. Magazine title: The Nation. Volume: 245. Issue: 22 Publication date: December 26, 1987. Page number: 782+. © 1999 The Nation Company L.P. COPYRIGHT 1987 Gale Group.
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