A Better Mental Health System, Imagined

 

    This might not be my most popular opinion but I think it needs to be shared.

    About thirty years ago, most state hospitals for mental health were closed. Deinstitutionalization started in the 1950s and 1960s, spurred by the harsh, inhumane conditions patients were being kept in. This was supposed to help people with mental illness live in the community at a level they could manage with help, while decreasing the amount of money the government had to pay.

    Sounds nice, right? We want our clients to do well, we want them to live their lives like anyone else. What could go wrong?

    A lot, it turns out.

    I am most familiar with Mayview State Hospital I. Pennsylvania. I’ve spoken to both past patients and staff members, all of which remember it fondly. Most of the patients I spoke with said they were the happiest they’ve ever been while living there.

    Mayview State Hospital had 3,785 patients and 1,200 employees at its peak in 1967. If my (very poor) math is correct, that’s about 1,015 residents under ratio, if you’re going by today’s ratios of 4 patients to 1 nurse. Seems reasonable and not unmanageable, although I completely understand that it can depend on the day, who you have, and how they are behaving. (Disclaimer: my math is very bad, please let me know if I’ve messed this up).

    There were 335 acres with 39 buildings, including a self-sufficient farm, a railroad to transport food in and out, and jobs for the patients to do, as well as a theater and some stores for the patients to visit. The nurses I spoke to told me that they never saw or heard of any abuse to the patients; however, in that big of an operation, it could have been occurring and those nurses had simply never seen it. They said that they had run into some aggressive and violent patients but “there weren’t as many as you might think.”

    When the facility started closing in 2007, patients were devastated. This has been their home, for many of them, for years. Sometimes decades. Patients were sent to community-based services or other state hospitals. Some previous patients have suggested that they were kind of just… set free with no real plan. I take this with a grain of salt, as sometimes our clients get confused or are unsure, but it should be mentioned.

    It had been determined that the hospital would be completely closed by 2008 but the closure was halted at the end of 2007. Two previous patients had died, one having either jumped or fallen from a bridge and the other had been walking on train tracks and was struck by a train.

    Deinstitutionalization was a decent, but half-baked idea. There were other levels of community-based living but none of them fit quite right. There were (and are) still people falling through the cracks of a system with guidelines that were too rigid. Thirty years later, we are learning that some of these levels of care are not helping.

    For example, data on DAS/RTP programs (Diversion and Acute Stabilization/Respite Treatment Programs) over the past thirty years has shown that they are often not successful. These voluntary programs are a step below the hospital and are typically used to stabilize clients on their medications until they are ready to be released… or their 30 days is up. The same clients cycle over and over again. In my experience, this is due to those clients not having appropriate housing or supports when they are discharged. What makes it more difficult is that DAS/RTP is only supposed to be a 30-day program. What good does that even do if they’re leaving stabilized with nowhere to live?

    I have had residents in long-term structured residential facilities (LTSR) in limbo. These involuntary facilities have the goal to reintegrate residents back into society after a long period of stabilization (which can sometimes last the rest of their lives). I have not heard of many people accomplishing and maintaining a less restrictive environment from a long-term facility, maybe one or two.

    The geriatric-only LTSRs struggle even more. Residents typically only leave the facility when they are physically too ill to stay. There are nurses on site but they do not have the equipment that nursing homes do. When a resident gets sick, they have to be discharged to the hospital to wait for a nursing home bed. There are not many nursing home beds, so the resident sits in the hospital for months and months. They refuse their medications, as is their right to do in a less restrictive environment, and end up right back in the hospital. The cycle begins again.

    I think the whole mental health system needs to be changed. Again.

    I think that closing the state hospitals was a bad idea. I think they needed to be reworked. As sad as it is to think this, there are people out there who need 24/7 mental health hospital-level care to be safe and happy. There are people who will reach complete recovery and there are people who will not. I think the people who will not recover fully require a better option than a nursing home or an LTSR, where they will not receive mental health and physical health treatment at the same time.

    If I have a resident who goes to the hospital because they are sick, and part of the reason they are sick is because they refuse to take their medications (and at any level outside the hospital, medications are not allowed to be forced), we are only putting a bandaid on the problem. The second they leave and are no longer on a forced medication protocol, they will stop taking their medications again. Eventually, they will end up back in the hospital because the level of care they are in is not equipped to help them.

    It makes so much more sense in my mind to have multiple state hospitals with a lot of land.

    There would be a full hospital for both mental health and physical health concerns so both could be addressed appropriately. This would take a ton of strain off of outside hospitals, who rarely have time to deal with mental health patients on top of all of the other work they already do.

    There would be a long-term residential unit, where people who need to stay for a long time can reside if and when they are ready to move on.

    There would be a forensic unit where people who are mentally ill and have committed crimes stay, for a time or indefinitely.

    There would be a diversion and acute stabilization unit so that clients could adjust to their medications before moving to a less restrictive care environment.

    There would be other more specific less restrictive units such as intellectual disability, community integration with socialization, and drug and alcohol recovery. Here, people with these issues would learn how to reintegrate back into society by learning activities of daily living. How to cook, how to clean, how to get on a schedule for medications, how to obtain transportation, how to schedule and attend appointments, how to socialize appropriately, the list goes on.

    There would be access to group and individual therapy on an inpatient and outpatient basis, all in the same building. There would be no need to worry about transportation, as most of your clients would live on-site or within walking distance.

     On the grounds, there would be supportive housing. Unstaffed housing where the people who live there would be checked in on a few days a week in-person, making sure that they are taking their medications as prescribed and that they are attending all appointments, as well as remaining clean from drugs and alcohol. If there was a change in the client leading to hospitalization, it would be noticed much more quickly and could be addressed faster.

    Right outside the grounds, there would be a few neighborhoods with reduced housing prices. This would be housing for people who had recovered from drug and alcohol addiction or who had their mental health symptoms under control and well-treated. Staff would be assigned to these houses to ensure that things were still going well. Again, if there was a change in the client leading to hospitalization, it would be noticed much more quickly and could be addressed faster.

    I have noticed that there is a lot of disconnect between the different services, such as service coordination. If they were employed by the same company, it would be easier to determine if work is being completed appropriately. The service coordinators would have an easier time placing people, as they would be placing them within the same company in the same area.

    If someone needed to be hospitalized, it wouldn’t be nearly as traumatizing as someone calling the ambulance. You might be able to just walk across the lawn to receive help. If you needed to change levels of care, it would be significantly easier. You’ve already been there, you’re just moving to a different unit, for now or forever. If someone was sick, they could just move from one floor to another.

    It is important to me that my clients are as happy and healthy as they can possibly be. I think that consistent care is part of that process. This would be an endeavor that would need to be fully staffed and paid attention to, not something that has no oversight. This feels like it would be the best way to make sure that clients remained safe.

    What are your thoughts?