On May 14, the American Psychological Asociation is encouraging members to blog on subjects related to mental health and mental illness. This is an opportune time for me to reflect on what has been accomplished in the nearly forty years I’ve been working in this field, and what still needs to be done.
As a society, we’ve made a great deal of progress in de-stigmatizing mental illness over the past fifty years or so. However, there is still room for improvement; and, further, we need to back up our good intentions with action to make mental health care and treatment more affordable and accessible to all.
While we’ve made great strides in understanding and treating mental illnesses, and while advocacy organizations such as the National Alliance for Mental Illness have helped encourage support and diminish stigma for individuals and families impacted by mental illness, we still hear too often about these individuals in a context of fear, sensationalism, or blame. Mass shooting incidents in particular, have focused attention on mental illness in the past few years, seemingly as a way to take the focus off the easy availability of assault-style weapons.
At the same time, our systems for delivering mental health treatment (including prevention, intervention, and rehabilitation services) have become fragmented and funding has been lost with each passing budget crisis at the federal and state levels. Treatment funding was shifted onto the Medicaid system, which had the result of making mental health treatment a poverty- based system in many states.
When I began working in the field of mental health in 1976, I was a mental health worker and discharge planner on the psychiatric unit of a general hospital on the north side of Chicago. For the previous decade, the process of “de-institutionalization” had been underway in Illinois. Many patients who had been placed into state-run long-term mental hospitals years before were suddenly placed into communities, in either independent living settings or what were sometimes called “halfway houses,” but which were actually licensed as nursing homes. This move created large urban areas that effectively became “psychiatric ghettos” in Illinois. Many formerly institutionalized people lived close to the Lake Shore in Chicago, from Lincoln Park to the northern city limits. Improved psychotropic medications were the key to unlocking the doors of the state mental hospitals and making possible the provisions of the Community Mental Health Act signed by President Kennedy.
The good part of this effort was the intentionally seamless network of programs, facilities, funding, and case coordination that was put in place under the state agencies like the Illinois Department of Mental Health. Each neighborhood had a community mental health center, from which neighborhood residents could receive appropriate services. Inpatient care was provided through “purchase of care grants” to community hospitals, in order to provide stabilization and intensive hospitalization before patients were stepped down to a lower level of care. The state still ran inpatient facilities, but they were divided into short, medium and long term programs.
Most individuals with mental illnesses were to be cared for in the CMHC’s through medication management, day treatment, and outpatient care.
This system always had its weaknesses, including how to handle an influx of young adult chronic patients who had never been institutionalized, but instead blended into a “street culture” that arose when the youth rebellion of the 1960’s and 1970’s was at its height. These individuals were generally less compliant and therefore less able to be reached through the tidy Community Mental Health system.
In later years, funding at the state and federal level began to be a point of conflict and contention,with the public usually accepting cuts in services as an option to avoid higher taxes. Medicaid (fee-for-service) funding began to replace grants and other comprehensive programs. One result of this was that individuals who weren’t covered on private insurance had to become disabled and indigent in order to qualify for services.
The “psychiatric ghettos” in Chicago were displaced by gentrification of the North Side, and many of the residential facilities were closed. People with chronic mental illnesses were scattered around the city and suburbs, staying with family members when they could, in single room occupancy hotels where they still existed, in group homes when they were available, and on the street or in jail when no other options existed.
Currently, in Illinois, we have a patchwork of agencies, funded through the United Way, Medicaid, donations and fundraising, and grants. These agencies serve as many people as they can, and generally do a very good job. But some have been forced to consolidate or close their doors.
At the same time, we have newer medications that show promise of restoring people to fulfilling and productive lives, especially when combined with psychosocial rehabilitation services. Those with private insurance have had access to these treatments for some time, and now people who qualify under the provisions of health care reform will be able to access these treatments as well – provided we work to assure that behavioral health (mental health and substance abuse) treatment is part of every plan and integrated into the “Accountable Care Organizations” being created.
The subject of stigma is a little tougher to handle. One thing we must do is avoid thinking of people with mental illness as dangerous – in fact they are, on average, no more dangerous than any other group of people – and to recognize that treatment can help. Parent and family advocacy (through NAMI, the Depression and Bipolar Support Alliance, and Mental Health America of Illinois) can also help foster understanding and compassion for those with mental health problems. Many of us, at some point in our lives, could meet the criteria for having a mental health disorder. We need to remain aware that those with longer-lasting or more serious disorders are people who are just like ourselves, caught in the grip of a health problem that can be successfully treated like any other.