Bert Pepper

The Young Adult Chronic Patient: Overview of a Population

A new generation of persistently dysfunctional young adults (aged 18 to 35) has emerged in the community, requiring new programs in community care. This population, which includes a wide range of diagnostic groups, is under study at a suburban New York community mental health center. The center and county are serving 294 such young patients through a variety of programs which include a crisis service, a sheltered workshop, a residential program called the Community Link-Up Experience, an acute day treatment program, an alcohol day treatment program, a case management program, and a Growth Advancement Program that gives patients an opportunity to socialize and share problems with others their age. Residential programs that provide a supportive living situation to young adult chronic patients on both a temporary and a long-term basis are sorely needed and will require an increased outlay of funds. A case study of one young patient who visited the center sporadically over a 12-year period illustrates the treatment problems such patients pose.

Testimony for the neglected: the mentally ill in the post-deinstitutionalized age.

F o r political reasons, public policy and practice always lag behind social change. In the past 25 years we have been witness to a massive social change called deinstitutionalization, itself the result of a new public and professional policy. The first shock wave of this movement was the obvious one: the discharge of state psychiatric hospital patients into the community, in large numbers and over a relatively short period of time. Deinstitutionalization has been increasingly maligned in the public and professional press because of its tragic human fallout and its overwhelming impact upon the services of local governments and their communities. We must bear in mind, however, that these negative judgments upon the policy of deinstitutionalization are fundamentally judgments of how that policy has been implemented. The pejorative use of the term ‘deinstitutionalization’ is as a synonym for irresponsible deinstitutionalization-for that, unfortunately, is what we have seen: the discharge of enormous numbers of patients into our communities without adequate planning for their care and treatment, and without adequate funding for the development of needed community programs of treatment, housing, and support. The policy of deinstitutionalization and its corollary policies, admissions diversion and short-stay hospitalization, are the product of several factors-clinical, social, and economic-which have been catalysts for a change in social policy. These factors include: I ) the discovery and development of medications found to be effective in controlling acute symptoms of major mental illness; 2) legal challenges and landmark judicial decisions, related perhaps to the consciousness-raising of such writers as Szasz and Goffman, which has drawn and reinforced our attention to the civil rights of citizens who happen to become mental patients; 3 ) economic factors that are raising the costs of psychiatric inpatient care to truly astronomical levels; and 4) perhaps most important, the realization within the psychiatric professions, springing originally from experience with open hospitals in England and on the continent. that people have the best chance of achieving their highest level of functioning when they live in the least restrictive environment that is compatible with their safety and their treatment needs. Responsible deinstitutionalization represents a major advance in professional thinking and in social policy. The era of deinstitutionalization is the sequel to the century of the state mental hospital. In that earlier age, compassion for mentally ill persons pointed-as expressed in the efforts of Dorothy Dix and others-to the construction and improvement of state mental institutions as refuges from the demands and dangers of society. In the age of deinstitutionalization, a more enlightened compassion, armed with more advanced therapeutic technology, has directed us to the release of most patients from those same institutions. In the wake of deinstitutionalization-in what has been tongue-twistingly described as the beginning ~~~~~~~ ~ _ _

The role of the state hospital: A new mandate for a new era

AbstractWe are fast approaching a centennial of New York States institutional system, the anniversary of the State Care Act of 1980. This can be evaluated against another important anniversary; the quarter century mark of the current convulsion/revolution of the mental hygiene care system of the entire United States, commonly referred to as deinstitutionalization.The state institutions, which for the past century were built up and maintained as the major locus of care for the chronically mentally ill, no longer occupy that central place in many localities. Yet these hospitals must continue to struggle with overwhelming burdens. Their inpatient populations, although now much smaller, still include many seriously mentally ill patients as well as the essentially non-dischargeable elderly.1 In addition, they must provide for young adults with a new profile of difficult behavior and challenging demands.2 This article is an attempt to redefine the role of the state institution in what has become the new era of community care, and to suggest fruitful new directions for the future which incorporate a contemporary shift in focus: from the concept ofillness to that ofdisability, and from a reliance on afacility or specificprogram to the development of a comprehensive and integratedsystem of treatment and support services.