"Are You Kidding?": Effects of Funding Cutbacks in the Mental Health Field on Patient Care and Potential Liability Issues
Baker, Joyce O., Gutheil, Thomas G., Journal of Psychiatry & Law
Mental health funding cuts and associated reductions in training have exercised a starkly negative effect upon psychiatric patient care in recent years, as reflected in research conducted in the United States and abroad. This article conveys and discusses an illustrative case example with additional reference to appellate and institutional advocacy approaches to the problem.
KEYWORDS: Emergency psychiatry, institutional staffing, mental health funding, correctional psychiatry.
Many reporting on or working in the field of mental health have noted the direct or indirect effects that cuts in mental health funding have imposed on clinicians at all levels during the last two decades and especially during the last decade. Such effects have included decreased staffing, coerced early retirement of senior staff, decreased hiring of new staff, decreased training programs, and so on, all of which necessarily result in the closing of some units and reduced bed availability on the units that remain. According to a recent editorial in the Boston Globe ("Murder," 2011): Deinstitutionalization of the mentally ill proceeded with a fervor in the 1970s. In 1970, the state maintained 12,500 beds in secure state mental institutions. By 1980, that number dropped to 2,200. Now only 626 beds are available in a handful of secure units. And that number could fall by another 100 based on Governor Patrick's latest budget proposal, which includes a $21 million cut to the Department of Mental Health.
Needless to say, while the number of available beds and appropriately trained caretakers has been reduced, the number of persons needing mental health care in various settings has not. As their conditions inevitably deteriorate without the structure and care provided by psychiatric facilities, many of these individuals, either seeking help independently or guided towards seeking help by the medical system or the criminal justice system, end up turning towards these increasingly overwhelmed hospital facilities via emergency rooms and shelters. The stress on the diminishing available treatment centers and appropriately trained staff has been widely noted and commented on, not only across the United States, but also in studies from various countries.
Reviewing the inevitable consequences of such funding cutbacks on practitioners working in the service areas covered by private insurance, HMOs, or even the public sector, psychiatrists Appelbaum and Gutheil (2007) identified "an added inducement to mental health professionals and administrators to abandon understaffed public and publically supported facilities. Those who remain may feel that their hands are tied in trying to provide appropriate care" (p. 266).
In the United Kingdom, Nolan and Smojkis (2003) have cited various studies to the effect that "28% of the nurses in the NHS [National Health Service] were suffering from minor mental health problems, generally identified as anxiety and depression," that "mental health problems were significantly correlated with increasing workload, understaffing, job insecurity and perpetual organizational changes" while "violence against health care staff has been found to have negative mental health consequences" (p. 375), and that, overall, psychiatric workplace violence is generally associated with "overcrowded wards, budget cuts and poor working and patient environments rather than with patient psychopathology" (p. 377).
An online report from the University of Chicago Law School (n.d.) also relates compromises in the support given psychiatric caretakers and facilities to the deteriorating condition of mentally ill patients:
Persons with serious mental illness routinely become disengaged from community care because providers are not funded in a manner which permits them to provide the level and types of services needed to insure continuity of care. The results are predictable: rehospitalization, homelessness, excessive reliance on nursing homes for persons with mental illnesses and even involvement in the criminal justice system. …