As usual I always bow to my internal ethics and try to be as open and transparent as possible about the subject at hand, revealing attitudes, biases, views based on long term experience, and an almost “historical view” of the galloping phenomenon of “mental health care delivery reform” thankfully occupying the attention of the country finally. I am old enough to have practiced in the so called mental health age of oodles of resources, and have watched them atrophy, became extinct, go corrupt and get themselves prosecuted out of existence, lose funding for many many understandable reasons, lose their place of importance, watch the ever decreasing number of bright talented younger generations of “would have been social workers, psychiatrists, and psychologists” shy away from the training programs, and our numbers go down especially in child psychiatry. One could take an inflammatory demagogic view and see is as necessary to prevent th abuse and horrors that indeed happened for decades shuttered away out of the light of public review and knowledge and responsible accountability and oversight. But that approach has nearly led to the old saw of “throwing the baby out with the bathwater because something was wrong with the bathwater, too dirty, too hot, whatever. I have seen the inhumane past and still in more restricted corners, inhumane treatment of patients in poorly run state hospitals that made me so mad I thought i would bomb them into the ground they were so bad, but of course after evacuating the helpless patients. I have helped to de-accredite the abominations of such hospitals, a few but enough to see first hand the decades old cultures of isolated facilities with poor faculty, psychiatrists who could work no where else due to histories of alcoholism, just plain bad practitioners and all the rest. I have had close colleagues since my residency days who presided over the deserved federally mandated dismantling of closure of famous hellholes permitted to exist far too long and heard their stories of generations of horror stories.
But in the midst of all this, or in my case in the last quarter of my career, I still know and hold to the somewhat unpopular certitude that state psychiatric hospitals are needed, good ones and now more than every. One simply statistic is that out country’s population and mental health treatment burden has at least doubled if now tripled since World War II. And we have had new mental health phenomenon syndromes, traumatic brain injuries of unforeseen overwhelming magnitude outstripping the abilities of public and private psychiatric-neurological treatment worlds to receive, treat and comprehensively help them out of our IED head rattling new genre of injuries in the Middle Eastern conflicts we have had to enter, police and try to stabilize at little thanks from much of the rest of the concerned world with some exceptions.
State hospitals across the country have been marked for closure and destructions for decades with the trend accelerating greatly in the last 2o years or so. It was thought and expected the the monies saved from funding these “dinosaurs” would be responsibly shifted to the long known need for massive outpatient services for the CMI, chronically mentally ill for which the state hospitals had long existed and served, and served well in a surprising high number of hospitals. Remember the famous Meninnger family of three generations of nationally recognized humane psychiatrists practiced in a state public hospital, Topeka State in Kansas a venerable training and research facility itself.
But the monies supposedly saved were not diverted to outpatient services development. It was like the highway funds of the Eisenhower years allotted for the Great Interstate Highway system got “disappeared” and went elsewhere mysteriously and the desperately massive in size and massively in need infrastructure of the outpatient, outside the hospital mental health care system delivery system was never funded, and never built. So no wonder we have the mess we read about almost every day in small town newspapers to the large national newspapers in the country and the spilling over the walls of management of the CMI much like the broaching of the flood walls of New Orleans from Hurricane Katrina 10 years ago TODAY. I think the analogy is unfortunately not overdrawn.
For policy wonks and those with an irresistible historical curiosity about this phenomenon of state public psychiatric hospital closures, I would refer the reader to a superb book that has the best history and analysis of all this of any of the now many retrospective accounts of this somewhat misguided “solution.” It is entitled: “The Eclipse of the State Mental Hospital: Policy, Stigma and Organization,” by George W. Doudell. I have it linked to its book site URL page on Amazon.com. I must add I am not an “affiliate” of Amazon and do not receive a “Share” of any revenues generated by readers “clicking to it,” or buying it. I offer its site and blurb on Amazon because it has good descriptions of the content, part of which is re-viewable in Amazon’s “Look Inside” feature, and good book reviews by motivated readers and interested citizens. I would also point out it was published in 1996! The issues were forming and growing then and the coming crisis was easily predicable, so it it does make for fascinating reading for those so inclined.
I will now turn to what i do know more about first hand. My practice state of NC as noted in a previous post of a few months ago HAD to downsize its state facilities, and had an oddity of two state hospital based within 20 miles of each other through historical almost accidents. one was John Umstead Hospital which was originally built in the 1940’s as the second biggest medical hospital for WWII wounded veterans covering the entire East Coast. After WWII, it was humanely sold to the state of North Carolina for the gracious sum of ONE DOLLAR. It was sorely needed and covered the middle part of the state immediately relieving Dorothea Dix Hospital in Raleigh named after the famous national crusader for mental health services in the lat 1800’s Dorothea Dix. Dix Hospital had covered too much of the state based in Raleigh only 20 miles from Durham for far too long. Each hospital was wisely hooked up FULLY in it training programs in psychology and psychiatry with each of the nearly medical schools, Umstead Hospital with Duke University Medical School as the tiny town Umstead is/was located in is only 18 miles NE of Durham. And Dix Hospital was hooked up fully in its training programs with the University of North Carolina at Chapel Hill School of Medicine psychology and psychiatry departments. One wonderful result was that the attendings of the two state hospitals were for decades almost all University medical school faculty!! The training and therefore the care the patients received and the training the line or ward staff were the same as the patients and staff at the medical school units. It was wonderful and one of the most beneficially unique arrangements in the country in mental health training. By the 1980’s the two medical schools had blended almost totally their teaching seminar series and adult and child psychiatric residencies and fellowships and the cross pollination only made things better.
But all good things could not last and NC suffered the triple economic hits of the early 1990’s I documented in a previous post on introducing mental health reform’s history in NC, the dot com bust of 1999, the first state budget deficit in state history, the incredible economic devastation of Hurricane Floyd in 1999 that devastated a huge portion of eastern NC, devastating the bulk of agribusiness there encompassing the enormous cash crops of tobacco, cotton, corn, cotton, feed grains and pickles of all things as well as the then exploding turkey industry which by then had achieved the state of making NC the second largest Turkey Day supplier of turkeys to America’s Thanksgiving Day dinner tables. Hurricane Floyd cost NC over one billion dollars in a matter of less than a year. Then came the federal lawsuit NC lost over taxing the retirement of federal retirees in the state in 1999-2000 and had to pay back to the federal treasury in one check, over $960B. All this set off budget slashing that still has not been seen anywhere in this country except in California a few years ago. And North Carolina’s financial dilemma then was NO ONE’s fault, not any politicians’, not bad FEMA after crisis help, not for lack of reserves in the state budget as NC had always had huge cash reserves and very cautions open honest money management of its pension funds, reserves, teachers and state employees reserves, highway reserves, disaster monies etc., as opposed to say Illinois; and everyone know what transpired in Illinois in the 90’s with governors left and right going to federal prison for many crimes.
So the state of NC which has a mandatory provision in its state Constitution that it must balance its budget yearly and not resort to borrowing or financial Wall Street shenanigans had to start cutting everywhere. And the state mental health system had to shoulder its due share, of which every little bit hurt greatly but likely no less than all the other quarters of financial maintenance of programs, education, highways, Medicaid, economic development incentives to get companies such as Dell years aback, which we lost, to move to NC etc.
My state hospital had to reduce its census literally by 500 hundred beds from 790 or so to 292 beds. Each of the hospital endured and underwent massive similar cuts. Outpatient groups homes went under and the systemic reform and budget cutting begun in 2000 as it HAD TO, started the rapid declines in services and tragedies and suicides went up, up, up. The homeless multiplied, and the jails started their pattern of being the often final repository for the CMI [chronically mentally ill} whose depot monthly anti-psychotic shots could not be subsidized, outreach workers could not supervise and ensure their reception of their doses, all went down the economic drain. Great hue and cry ensured and everybody blamed everybody else. It did not help that initial reform organizational models were imported from others states, like Michigan, by a merry band of planners and nonclinical administration bureaucrat types, and in the South those types are still regarded as lower than the reviled “Carpetbaggers” of the Reconstruction period of history of the South after the civil war. Their models did not work, did not fit down here, destroyed the prior infrastructure and things went from bad to really really worse. Services were silo’ed, local counties lost their country mental health clinics accessible to the rural citizens, business efficiency requirements were imposed that had ot have at least 200,000 persons, offices were, closed, small counties had to have patients in need not only commute distances to the now new clinics one of two counties away, if they had emergency services, they had to call toll free 800 numbers staffed by outsourced referral “companies” who at first really did not know the geography of North Carolina. it was a total mess. Then some corruption hit and two heads of the new several county mental health services agencies, acted like the new Russian oligarchs in post Soviet Russia, paid themselves exorbitant salaries, i.e., over $300,000 and had sweetheart deals wheeling and dealing the old mental health centers’ real estate holdings, clinic buildings etc. They got canned and legally taken to task…
Gradually the state planners started to catch up in the mid 2000’s and helpful and growing sensible services and structures started to emerge. Services that had been silo’ed and isolated from each other both state and region wide, and, locally, were mandated to work together and coordinate and plan together outpatient services for patients. So our agenices now talk to each other better than the FBI, and Homeland Security people do. Sometimes I say our patients are safer and better provided for than WE are from the Taliban….
And lastly the saga of the state hospitals has come full circle. Early one for 2002 stories were emerging that as ALL of us practicing clinicians predicted, the drastic reduction of state hospital beds resulted in ungodly waiting times for grievously ill mentally ill to wait in ERs all over the state for dangerously long periods of time, from a week or so tow WEEKS. Community hospitals without area psychiatrists, i.e., whole counties in NC that do NOT have a single practicing psychiatrist, and never have had, managed out of control, suicidal, overdosed, self injurious, escaping, assaultive psychotic patients the best they could. Our state hospital started informally designating a psychiatrist to head up admissions, triage admissions, and spend good portions of each and every work day, consulting, advising and guiding community docs in how to manage and treat these patients to start treatment in the outlying community hospitals and extend ourselves as best we would.
As a result Dix Hospital was closed as it had long been slated to and it and Umstead state hospital were merged into and enlarged and covered their broad catchment area better than ever. The eastern state hospital was also being replaced by a brand new hospital slated to open in a year or two. My state hospital covering the western part of NC and the largest area, is being replaced by a similar state of the art new hospital. All of them will have state of the art information systems, care robots, better architectural safety, more programming for patients and on and on. My hospital will for instance add at least a 100 beds the first years and is slated in the coming few years to add a hundred beds annually to get us back to where we were less than 10 years ago, 800 or more beds. And we will have a new forensic unit to supplement the overburdened services in the state capital Raleigh at it relatively new forensic psychiatry hospital unit for the big Central Prison of the whole state to begin to handle the national phenomenon of the prisons being filled with at least 25-50% mentally ill inmates.
And furthermore the state of NC is considering in future building another statue psychiatric hospital that services the biggest MSA [metropolitan statistical area] of NC, the Charlotte area and a few of its adjacent counties that need a facility of its own. All of this is occurring I am proud to say in the setting of the slow recovery, and a conservative Republican Governor and legislature who slowly and quietly have been moving more and more to doing more and more helpful things for the mentally ill under years of stress and mistakes and failed experiments yet persevering through it all. And I might add in great contrast to many other states all too obvious in the media if you set your Google search-bots to these topics.
As usual in our federated system of national and state governements, each state’s situation and approach and means are different. Please feel free to comment should your region and areas’s/state’s approach offer something unique and different. Your thoughts and ideas are most welcome.
The Mental Health Reform Blog 