Leona L. Bachrach

The challenge of service planning for chronic mental patients

The articles included in this special issue of the Community Mental Healthdournal adopt a variety of approaches to service planning for chronically mentally ill individuals. They treat this general topic from both research and theoretical perspectives, and they deal with a wide array of issues, such as state mental health system interventions, homelessness among chronically mentally ill individuals, the needs of families of chronically mentally ill patients, political overtones of service delivery, and problems in program design and program evaluation. Those whose lives are directly touched by the chronically mentally ill--service providers, service planners, relatives, researchers, and legislators-clearly have a variety of concerns and interests. That these individuals sometimes fail to communicate with one another is hardly a surprise. On the other hand, the fact that such varied interest groups share considerable common ground in their concern for the chronically mentally ill is cause for optimism. Despite the diversity in approaches, certain common themes emerge from the papers in this volume. Together, they stress and underscore the fact that, irrespective of ones specific position, service planning is regarded as most efficient when it allows for continuity in the care of members of this patient population and when it encourages the provision of a full array of comprehensive services. In this brief article I shall explore some of the dimensions of continuity of care and comprehensiveness of services as they apply to service planning for chronic mental patients. Like many other psychiatric service system planning concepts (Bachrach, 1985), both terms are generally used without adequate or precise definition, and much of their subtlety has been lost.

CONCEPTUAL ISSUES IN THE EVALUATION OF THE DEINSTITUTIONALIZATION MOVEMENT

Publisher Summary There are marked discrepancies between the knowledge of the principles of effective community-based treatment for persons afflicted with chronic mental disabilities and the implementation of these principles. The chapter discusses the philosophical underpinnings of deinstitutionalization. Deinstitutionalization is a dynamic and continuing series of adjustments involving all the elements of service delivery system. Although it is possible to find isolated programs that provide humane and relevant services for portions of the target population of deinstitutionalization, there is ample evidence that the movement has yielded results that are, in a global sense, less than satisfactory. Existing evaluation studies tend to focus on one program at a time and to assess exclusively that programs outcomes for the isolated portion of the target population that it serves. The result is a corpus of discrete evaluation studies that pertain to a variety of local mental health and human services efforts on behalf of the chronically mentally disabled. The deinstitutionalization movement is an entity in which the whole is different from the sum of its parts.

General hospital psychiatry and deinstitutionalization: A systems view

The shift in responsibility for the care of chronic mental patients has generated a variety of problems for general hospital psychiatry. In response to these new demands, general hospital psychiatry has evolved a variety of effective strategies. Nevertheless, widespread concern over the appropriateness of serving chronic patients in an acute care setting persists. The level and direction of general hospital psychiatrys involvement with chronic mental patients will vary according to the specific characteristics of a communitys patient population, its goals for those patients, and the resources at its disposal for realizing those goals. General hospital psychiatry must make a serious effort to minimize its being forced into a reactive position by deinstitutionalization policies generated by distant authorities. It must assume, instead, its rightful position as an autonomous, but fully cooperative, element within the psychiatric service system. Only then can its responsibility to the chronically mentally ill, to other patients, and to its own integrity be assured.

The Urban Environment and Mental Health

ion from the most general to the most specific. The homeless population A first major point to be made regarding the homeless population is that we currently lack consensus about its basic dimensions. Homelessness is a confusing and poorly defined concept, and debates occur as to whether a cardboard box, or a reed hut, or even an automobile might reasonably be construed as a home particularly under benign climatic conditions like those that prevail in Tucson. There are similar debates over whether a simple lack of shelter is by itself sufficient to render an individual homeless. In fact, some advocacy groups in Great Britain have attempted to clarify the definition of homelessness by introducing the concept of ‘houselessness’ (Bailey, 1977). To these advocates, the term houseless implies only a simple lack of physical residence for example, something that might befall a person whose house burns down. But the term homeless is reserved for conditions of more generalized deprivation, and it implies social isolation or disaffiliation as well. In fact, disafhliation that is, an absence of affiiiative attachments and supportive social relationships is widely considered to be basic to homelessness (Bachrach, 1984). It suggests that homeless people, in addition to having no residence, also lack the skills and resources the social margin, if you will to move out of their circumstances. It implies that the lives of these people have become stalled and hopeless. Homeless people may be found in many different places, if one knows where and how to look for them. They may be found on sidewalks, in the middle of streets, in automobiles, under automobiles, in parks, in libraries, in doorways, in subways, and in general hospital emergency rooms. In many parts of the United States homeless people live in railroad stations, bus stations, and airports. Some reside in jails, and others in large mental hospitals. So a second observation concerning the homeless population is that it is extremely diverse and that it consists of many different subgroups. Not only do its members live in very different places, but they get to those places by very different routes. Many combinations of events dispose people toward homelessness. A third observation about this population is that it appears to be undergoing extensive demographic changes in the United States at the present time. Whereas homeless populations in the past consisted largely of middle-aged alcoholic men, today’s homeless population contains large and growing numbers of younger individuals of both sexes.

The state of the State Mental Hospital at the turn of the century

There is a core of services whose specific content varies from place to place that still appears to belong to the state mental hospital.

The homeless mentally ill in the general hospital: A question of fit

The evolution of general hospital psychiatry and the growth of the homeless mentally ill population in the United States have coincided temporally. Although the two have many points of confluence, their interaction has largely been of a last-resort variety, sometimes occurring by default and rarely adequately planned. The general hospital psychiatric unit has an important role to play in serving the homeless mentally ill--a role that is consonant with its mission of providing care to individuals whose service needs include special treatment interventions in short-term settings. That role may be most effectively implemented in a pluralistic service system, where the general hospital psychiatric unit is one of many facilities responding appropriately, but differentially, to the needs of individual members of the homeless mentally ill population.

Homeless Mentally Ill Women: A Special Population

Homeless mentally ill women clearly constitute what the President’s Commission on Mental Health (1978) in the Carter years termed a “special population”—a subpopulation of American citizens who experience extraordinary and often unremitting barriers to care. Indeed, several areas of “specialness” converge to affect the access of homeless mentally ill women to needed services.

Administrative Psychiatry: What Sort of Job is This For a Woman?.

A survey of male and female psychiatric administrators revealed that men often fail to realize that women are disadvantaged by such things as lack of mentors, sexism, and inflexible laws. The authors suggest several approaches to investigate the number of qualified women in administration and call for additional research to better understand such career choices.