Are the best days in mental health services behind us?

by Thomas Ellis, PsyD, ABPP on January 30, 2014 · 4 comments

in mental illness,suicide,violence

In a compelling story in a recent episode of CBS’s 60 Minutes, Virginia state Senator Creigh Deeds tells the wrenching story of losing his 24-year old son to suicide, shortly after his son had attacked him with a knife. This occurred the day after Deeds had taken his son to an emergency room, only to be told that there were no hospital beds or appropriate treatment alternatives available for his son.

As a first-year Baylor University graduate student years ago, I never would have thought this would be the state of affairs in mental health all these years later.

Early days

It was 1974, and I vividly recall a mixture of excitement and trepidation as I started my first “practicum” experience at the Community Living Center in Waco, Texas. Our clients at this center all were part of the “deinstitutionalization” movement of the era. This was a period when thousands of patients who had been hospitalized at state hospitals, often for decades, were discharged following a series of court rulings that human beings had a right to be treated in the “least restrictive environment” appropriate to their care, rather than warehoused in facilities where little treatment occurred.

Patients attended the center every day, Monday through Friday, to play dominoes, attend classes on budgeting or nutrition, or go on recreational outings, regardless of ability to pay. There was a true sense of community, with a casual atmosphere and intervention readily available whenever indications of a destabilizing crisis began to emerge. Thus, the need for hospitalization was greatly diminished.

Community Mental Health Act

To put all of this into historical context, recall that the Community Mental Health Act (CHMA) had been passed in 1963, with federal funding for the construction of hundreds of local mental health clinics; this was followed two years later by legislation providing grants that funded staff salaries. It was well understood at the time that vulnerable, hospitalized individuals could not simply be sent out to fend for themselves; community support was essential to reduce the chances of a range of adverse outcomes, from re-hospitalization to suicide.

Over the years, however, federal support was scaled back, with the expectation that states would pick up the costs. For the most part, this has not happened. Community support services like the one where I was trained have mostly disappeared, with mental health professionals moving into other employment arenas (notably, private practice).

So, are people with mental illnesses simply returning to the hospital settings from which they came? The answer is no, because most of the hospitals from which patients were deinstitutionalized in the 1970s have been shut down. Since the enactment of CHMA, fully 90 percent of beds at state psychiatric hospitals have been eliminated.

So where do people with severe mental illness now go? To begin to answer this question, you should know that largest mental health facility in the U.S. is (brace yourself) the Cook County jail in Chicago (Harris County jail isn’t far behind). With a few notable exceptions, modern-day “inpatient facilities” for mentally ill people (especially those without resources) now consist largely of jails, homeless shelters and nursing homes.

The “treatment” that individuals receive in these settings is, to say the least, less than optimal. This state of affairs is even more baffling when you consider that studies have consistently shown that a full range of mental health services that includes inpatient and community support services is not only a more humane alternative, but more cost-efficient as well.

Those heady days of the 1970s, which were full of hope for young mental health workers like me, with every expectation that a new era of enlightenment with respect to mental illness had arrived, are long gone.

How has it come to this? Must we now resign ourselves to listening impassively to the story of a grieving father who lost his son, and nearly his own life, for want of adequate mental health resources?

Sad to say, Mr. Deeds’ story is not uncommon. Fortunately, the Virginia state senator appears determined to improve the mental healthcare system in Virginia in response to this tragedy. Now we just need government leadership throughout our country to follow his example and see to it that people with mental illnesses, and those who love them, receive the quality care to which they are entitled.

Be Sociable, Share!

{ 1 trackback }

The Truth About The War on Drugs (And Mental Health)
March 14, 2014 at 12:29 pm

{ 3 comments… read them below or add one }

George Dawson, MD, DFAPA January 31, 2014 at 12:17 pm

Dr. Ellis,

My professional experience parallels yours and I discuss this story and another on my blog. I see the scaling back of federal support as paralleling the political initiatives that resulted in the institutionalization of managed care. We have solved the financial burden of treating mental illnesses by denying they exist and defunding them. Once it was clear that managed care companies could arbitrarily refuse to pay for treatments that were effective and evidence based, many states jumped on that bandwagon and started to close down bed capacity and CMHC appointments. We now have a situation where there are a large population of people with chronic mental illness cycling in an out of overcrowded emergency departments, inpatient units where the length of stay is so short they leave essentially unchanged, and tenuous housing or homelessness. As you point out that tenuous housing can include jail with the three largest psychiatric hospitals these days probably being county jails.

This process also emphasizes poorly thought out medical interventions over non-medical treatments like psychotherapy, case management, and other supportive services. In some managed care systems people are literally treated on the basis of a depression rating scale rather than a clinical interview. That entire process is cost driven with no consideration of quality.

I am also skeptical of how easily this 30 year trend can be changed. In many states managed care tactics are entrenched right in the state statutes. It is also disappointing to read articles in the news written by journalists who do not have a handle on the problem and who have a tendency to focus on either preventable human tragedy or somewhat sensational articles about the professionals involved. I ws impressed with what Senator Deeds had to say and hope that he gains a national foum to discuss the needed reforms.

Nancy Trowbridge January 31, 2014 at 10:48 am

Dr. Ellis, thank you for sharing your historical context for blog readers. In addition to yourself, Houston Chronicle columnist, Bill King, wrote about mental health needing an investment in the January 30 issue (see editorial pages). In his column, King mentions that he’d visited recently with John Whitmire, a Texas legislator from Houston. Whitmire shared that when he lobbies his fellow legislators for state funding for mental health initiatives “he frequently chides them that ‘if you won’t do it for the right reasons, then do it because it will save us money.'” King goes on to say that not dealing providing for persons with mental illness “is incalculable.”

Clearly far too many individuals with mental illness and their loved ones have paid the price by not having access to affordable mental health care in our communities, not just in Deeds’ state of Virginia or the state of Texas. Hospital care does provide a safe treatment environment when needed. As policy makers and advocates – as communities – let’s look for evidence-based solutions to help our fellow women, men and children who suffer the effects of brain disorders. The good news is that the conversation about mental health issues continues to grow in the open. That’s the first step toward positive change.

Debi Strong January 30, 2014 at 9:32 pm

Dr. Ellis,

Your words ring so true on so many levels. Thank you for putting the situation in an historical perspective so succinctly. When I returned home after my stay at Menninger, I found nothing in the way of community support. I ended up having to create a depression support group affiliated with our local acute psychiatric facility just to help myself! What’s wrong with this picture?? And every week new people tell me that they would really like to attend the group but are afraid of being labeled…
Given the overwhelming evidence that the issues of depression and suicide are becoming increasingly serious all over the world, the time to step up to the plate and apply all the lessons we have learned since the 70s is way overdue! Perhaps Mr. Deeds will start the ball rolling.
Again, thank you for speaking up.


Leave a Comment

Previous post:

Next post: