The Origin of Community-Based Mental Health Treatment

Source: Image by 政徳 吉田 from Pixabay

My intention in writing these posts is to share the experiences that I went through with my son, starting with the first manifestation of his illness and our journey through numerous subsequent episodes. It's also to provide commentary as a parent and psychiatrist on issues that these experiences bring up, such as how the diagnostic process works in mental health, and how to work with treatment providers and medication issues. My hope is that reading this may be helpful for people with mental health issues and also their families and friends.

The origins of community-based treatment: From asylum to state hospital to deinstitutionalization

To understand the rise and fall of the Dane County (Wisconsin) mental health system, it is first necessary to understand the history of the asylum and of deinstitutionalization. In the 19th and early 20th century, mental asylums were created as the main form of care for patients with severe mental illness. Dane County originally had a state psychiatric institution, which opened in the 1800s as the Wisconsin Hospital for the Insane, and then later the Mendota State Hospital and the Mendota Mental Health Institute (MMHI). Patients received custodial care and typically lived all aspects of their life in a psychiatric hospital with limited access to the outside world.

Originally, state hospitals were asylums developed to provide care and shelter for the seriously mentally ill run at the state level. The total number of residents at state hospitals peaked nationally in 1955 with 560,000 inpatients and fell to 47,000 by 2003. Factors responsible for this depopulation included extreme understaffing and overcrowding, the development of the National Institute of Mental Health in 1949, and the development of psychiatric drug therapy, with chlorpromazine first introduced in 1954, and the subsequent development of new neuroleptics.

Increased awareness of neglect and abuse of patients in state hospitals also catalyzed social concern and led to new laws pertaining to the confinement and treatment of state hospital inpatients. Two important legal policies established the right to due process regarding involuntary commitment and the right to treatment in facilities that met newly-established minimally adequate standards of care. The failure of state hospitals to meet judicially mandated required care led to discharge of thousands of state psychiatric patients.

Another factor was the shift in funding for services from the state to the federal government with the Community Mental Health Centers Act of 1963 and the creation of Medicaid and Medicare in 1965, providing financial incentives for states to move patients out of non-federally funded state hospital and into federally-subsidized settings such as psychiatric wards of general hospitals and residential homes. The Omnibus Budget Reconciliation Act of 1981 ended direct federal funding of community-based mental health services, reallocating costs back to the states. The states in turn shifted the responsibility to provide care to the counties. In Wisconsin, Mental Health Boards were established with the responsibility for providing care for mentally ill in the community.

Program of Assertive Community Treatment (PACT)

The funding for community care came from decreasing the number of hospital beds and using the money to fund community programs. These funds provided fee-for-service care both to individuals and to community care teams. In the late 1960s and early 70s, the PACT (Program of Assertive Community Treatment) model was developed at Mendota by two pioneers of mental health services, Leonard Stein and Mary Ann Test. In collaboration with NAMI, they were able to get the legislature to set aside part of the money freed up by deinstitutionalization and the emptying of Mendota for community mental health services.

The PACT model, a community-based treatment, rehabilitation, and supportive-services program aimed at helping those with severe and persistent mental illness avoid psychiatric hospitalization and live independently in the community, was the forerunner of other similar programs throughout the world. It included day treatment programs and outpatient mental health clinics, as well as supported housing resources, some entailing monetary assistance and some also with on-site mental health supervision, job skills training, and supported work, in which the work role is backed up by a mental health professional.

In 1974, MMHI received the Gold Achievement Award for the program, also known as the “Madison Model.” By 1975 the patient population at Mendota MHI and the other Wisconsin mental health institute, Winnebago Mental Health Institute, had dropped to a third of their previous capacity. With money set aside for community services, a spectrum of care was able to be developed, including transitional facilities and step-down facilities as well as community mental health services, job rehabilitation programs, and supportive housing.

The most challenging aspect was the provision of long-term housing, especially for those who needed medication support. In part this gap was filled by community-based residential facilities, licensed to distribute medication; however, there were simply not enough of these facilities to accommodate the demand. Further, many patients (like my son) rejected what they regarded as an overly restrictive living environment with multiple rules and curfews. During his many illness episodes, Bill was able to spend less time in the hospital because as he became less acutely ill he was able to stay in facilities that are essentially partial hospitalization, with 24-hour staffing and the ability to dispense medication. The facility he was most frequently in was Recovery House, which he much preferred to being in the hospital. He found the staff there to be supportive and he enjoyed socializing with the other patients.

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Whether this was the best option for his recovery is debatable. Being in the “least restrictive” environment is very much part of our culture of individual freedom and certainly supports the notion of offering more choice. However, this needs to be balanced against the cost of this level of care: The staff at these facilities are not formally trained to recognize the earliest signs of worsening illness, particularly if patients are good at covering up their symptoms. Arguably, for some patients, a longer stay in a hospital with sufficient time to stabilize and more time to adjust medication dosage might be a better alternative.