Mental health and homeless

By tk
Saturday, January 18, 2003

The emptying of hosptitals began in the 1970's

Ronald Reagan and the Commitment of the Mentally Ill:
Capital, Interest Groups, and the Eclipse of Social Policy

http://www.sociology.org/content/vol003.004/thomas.html

http://www.ohiou.edu/~ridges/history.html

Simultaneous with the breakthrough in medical treatment, the community mental health movement became a centerpiece of President John F. Kennedy’s congressional program. There were concurrent shifts in insurance coverage for the mentally ill provided by the Comprehensive Mental Health bill in 1964, and the Medicare and Medicaid Acts in 1966. All of these national movements led to a reduction of the use of existing mental health hospitals and an explosive growth in private hospitals, general hospitals with psychiatric wings, and community  mental health centers. As a result states greatly restricted long-term, full care services in state mental institutions in the late 1960s and early 1970s.

In 1972, a federal court ruled that patients in mental health facilities could no longer work at these institutions without pay. The impact of this ruling further changed the nature of the Mental Health Center, for now the remainder of the agricultural pursuits and dairy farming had to go, as well as the upkeep of much of the grounds. The institutions didn’t have enough money to pay the patients for their contributions and also didn’t have adequate money or staffing to occupy patients with abundant much free time. The costs of housing patients increased dramatically, patients became bored and felt they lacked the purpose they once clung to, thus the need to de-institutionalize was more prevalent then ever. 

http://www.macon.com/mld/telegraph/2555682.htm

Lanterman-Petris-Short Act, adopted by the California Legislature in 1967, effective in 1969. It became the model for mental illness commitment laws throughout the United States. At roughly the same time, the federal courts became increasingly insistent on certain standards of procedure and proof for committing people to mental hospitals for indefinite periods of time.

Olmstead v. L.C and E.W.

Mentioned in:
http://www.accessiblesociety.org/topics/ada/olmsteadoverview.htm

http://www.city-journal.org/html/7_3_a2.html

For example, in 1963, when deinstitutionalization was getting under way, state and local government contributed 98 percent of the total cost for support and services for persons with mental illnesses, and the federal government contributed just 2 percent.

All that changed in the 1960s, when Washington made mentally ill individuals who had been discharged from state psychiatric hospitals eligible for a variety of federal programs. Funds from Medicaid, Medicare, Supplemental Security Income (SSI), the Disability Insurance Trust fund (SSDI), food stamps, and housing programs all became available to those with serious mental illnesses. States quickly learned how to shift the costs and the responsibility for providing public psychiatric services to the federal government, so that by 1994 the state and local share of total costs had decreased from 98 to 38 percent, while the federal share had increased from 2 to 62 percent. As the discharged psychiatric patients increasingly fell between the cracks in the treatment system, the states increasingly disavowed responsibility for them.

 With the repeal of the Mental Health Systems Act by the Reagan administration in 1980, the amount of federal dollars allocated to community mental health agencies declined. To explore problems and issues in mental health service delivery in the 1990s, 272 mental health administrators in county-level, public sector organizations from Wisconsin and Michigan were surveyed. Budget effects on service, staff and administration are discussed (authors).

Mental Health Systems Act  

THINK ABOUT THE NEXT 25 YEARS

ADVICE FOR THE PRESIDENT'S COMMISSION ON MENTAL HEALTH

By
Michael B. Friedman, CSW
Mental Health News Fall 2002

President Bush recently announced the formation of a Commission on Mental Health to develop recommendations for changes in mental health policy in the United States-a remarkable event if only because major Federal Commissions on Mental Health are so rare. In the second half of the 20th century, there were only two of them. The first was created by The Mental Health Study Act of 1955. That Commission issued a report in 1960 which became the basis of The Community Mental Health Act of 1963. It triggered massive Mental Health Systems Act deinstitutionalization of State mental hospitals and contributed to the development of mental health services in the community. The second Commission was established by President Carter in 1977 and produced recommendations that led to the passage of the at the very end of his administration. Although the Reagan administration never implemented the Systems Act, its central idea-that the mental health system is a fragmented non-system that must be reorganized-has been a driving force in mental health policy for the past twenty-five years.

There are a number of lessons the current Commission should learn from the prior two experiences.

First, the Commissions have been convened a quarter century apart. This Commission, therefore, needs to project mental health policy for the next twenty-five years.

Second, however thorough and complex their reports are, Presidential Commissions end up being known for, and driving, a very few simple ideas. The first Commission drove the transformation of the public mental health system from an institutional system to a community system. The second President's Commission contributed to the expansion of the community support program and lent credence to the belief that reorganization could solve our problems.

Third, there is a very sharp divide between idea and implementation. The initial phases of deinstitutionalization were tragic for a great many people with serious mental illnesses and their families. Nearly forty years have passed since the Community Mental Health Centers Act was passed. Many people are faring better now, but we still do not have a fully adequate community mental health system. Unlike deinstitutionalization, the ideas behind the Mental Health Systems Act have not had tragic consequences. In fact some of the efforts that have emerged-such as case management-have been helpful to people with mental illnesses and their families; and the management of mental health has improved. But many of the most brilliant ideas about systems change have either foundered on the rocks of reality, led to remarkable but unduplicable model programs, or been turned into humdrum bureaucracy.

History, then, suggests that The President's Commission on Mental Health needs to think about the needs of the next quarter century and seek a few clear, central ideas that can be the basis of changes in practice that take into account the pitfalls of implementing great ideas.

Here is one suggestion. The Commission should focus first on the mental health needs of people rather than on the needs of the "system." Who will need mental health services over the next twenty-five years? What kinds of services will they need? What research should be sponsored to determine service need and effectiveness? Who will provide services? Only after answering these questions should the Commission ask how to organize and finance mental health?

Who are the people who need mental health services in the foreseeable future?

Post-Deinstitutionalization Populations: Clearly there are a number of populations who still are not adequately served after years of deinstitutionalization. One critical population consists of people with severe and recurrent mental illnesses who live on the edge in the community and tend to reject traditional mental health services. The other critical population consists of people who have been "transinstitutionalized." Of primary concern are people in adult homes and those in jails and prisons. Just over the historical horizon are those who have been transferred to nursing homes with inadequate mental health services.

Children and Adolescents: Promises to address the mental health needs of children and adolescents go back at least a quarter of a century. There have been some accomplishments, but nothing that approaches fulfilling the promise to develop an adequate community-based mental health system for kids. It is time to keep that promise while keeping in mind the fundamental lesson of the deinstitutionalization of adults. Don't take down the institutional elements of care without developing adequate alternatives first.

It is also critical to be clear that the goal is to help kids with serious emotional disturbances wherever they are, not just those who turn up in formal mental health settings. There are more kids with mental health needs in child welfare, education, and juvenile justice than are served by formal mental health providers. Public mental health authorities have done far too little to help these children.

Changes in Demography: Over the next twenty-five years there will be vast demographic shifts in the United States. There will be tremendous growth of older adults (who will be more likely to seek mental health services than the current generation of older adults), and there will be tremendous growth of minority populations (who together may constitute a majority of the American population.) Mental health services for aging Americans living in diverse settings will be a critical challenge during the next quarter century. And the development of cultural competence must go beyond politically correct lip-service if this nation is to be able to meet the mental health needs of a majority of its citizens in the future.

It may well be that if the President's Commission devotes its attention to all the populations I have noted, its work will become too complex and diffuse. Perhaps it should set sharper priorities. But it is surely critical that the Commission anticipate the needs of diverse populations over the next twenty-five years, and those findings-rather than findings about organization and finance-should drive its deliberations.


(Michael B. Friedman is the Public Policy Consultant for The Mental Health Associations of New York City and of Westchester County. The opinions expressed here are his own and are not necessarily shared by the Associations.)

This "Mental Health E-News" posting is a service of the New York Ass'n of Psychiatric Rehabilitation Services, a statewide coalition of people who use and/or provide community mental health services dedicated to improving services and social conditions for people with psychiatric disabilities by promoting their recovery, rehabilitation and rights.
To join our list, e-mail us your request and, where appropriate, the name of your organization to NYAPRS@aol.com. 

Last Updated on 09/12/02   webmaster@namiscc.org

http://www.archives.nysed.gov/a/researchroom/rr_health_mh_timeline.shtml

NY mental health timeline excerpt:

• 1977: Jimmy Carter formed the President's Commission on Mental Health.

• 1977: The New York State Mental Hygiene Law was recodified and the DMH's responsibilities were broken down and assigned to three autonomous offices: the Office of Alcohol and Substance Abuse, the Office of Mental Retardation and Developmental Disability, and the Office of Mental Health (OMH).

• 1978: The Civil Service Employees Association’s advertising campaign resulted in an executive-office policy directive instructing the OMH to increase staffing levels in state psychiatric centers.

• 1978: The OMH created the Community Support System, a program designed to furnish treatment and support services to the seriously mentally ill.

• 1979: The National Alliance for the Mentally Ill (NAMI), a new advocacy group for people with serious mental illness and their families, was formed.

• 1980: The National Mental Health Systems Act, which asserted that the federal government would continue to shape mental health policy but assume less of the burden of paying for treatment, is passed.

• 1980: The New York State Insanity Defense Reform Act increased the OMH's responsibility for caring for and evaluating criminals deemed not responsible by reason of insanity.

• 1980's: The OMH created new initiatives designed to meet the specific needs of mentally ill African-Americans and Latinos, develops outpatient programs for the elderly/Alzheimer patients, mentally ill criminals, and people with AIDS.

• Early 1980's: Seeking to cut federal expenditures, the Reagan administration directed the Social Security Administration to pare the SSI and SSDI rolls. Social Security administrators responded by developing definitions of mental illness that diverged from those used in the past and those employed by mental health professionals. The resulting dislocations ultimately produced a public outcry that compelled the administration and Social Security to back down.

• 1981: The 1981 Omnibus Budget Reconciliation Act repealed the provisions of the National Mental Health Systems Act, cut federal mental health and substance abuse allocations by twenty-five percent, and converted them to block grants disbursed with few strings attached. New York State, which used block-grant monies to fund community-based programs, and other states have to cut mental health programs.

• 1981: The President's Commission on Mental Health issues its final report, albeit without fanfare.

• 1984 New York’s inpatient population was 32,000

• Mid-1980's: Federal support for mental health treatment increased as advocacy groups protest against funding cuts and Democrats in Congress buried funding allocations in omnibus budget bills.

• 1986: The federal State Comprehensive Mental Health Plan Act compelled states to devise detailed service plans that emphasized the needs of the seriously mentally ill in order to remain eligible for federal block grant funds. In its emphasis upon planning, it closely resembled New York State's efforts to insure that seriously ill people receive adequate care.

• 1986: New York State served 500,000 people via the deinstitutionalized approach. New York State has 33 mental health facilities: 23 psychiatric centers for adults; 6 psychiatric centers for children; 2 forensic psychiatric centers, and 2 research facilities

• 1992: The federal Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act abolished the ADAMHA and replaced it with the Substance Abuse and Mental Health Services Administration (SAMHSA). During the Bush and Clinton administrations, the SAMHSA emphasized information provision and administration of block grants, which had more restrictions than they had in the past.

• 1993: The Clinton administration's efforts to create a national health insurance program were  notable for their relatively generous provisions for mental health care. However, Republicans and many Democrats in Congress rejected the plan and the administration shied away from advancing any other bold policy initiatives.