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.

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