The Role of the State Hospital in the Twenty-First Century

The place of state hospitals in the overall system of mental health care has been a constant focus of debate, from views championing the establishment of such hospitals in the 19th century to those advocating their demise in the 20th. It appears that we are now ready to move from the question of yea or nay for state hospitals to considering how this kind of facility can best work as part of a system of services for those who suffer from serious mental illness. Given this framework, I have asked four current or recent state mental health commissioners to review The Role of the State Hospital in the Twenty-First Century, edited by William Spaulding. The commissioners, Dr. Mayberg, Dr. Barrett, Ms. Sudders, and Dr. Lippincott, represent three disciplines as well as four states that are at different points in the evolution of their health systems.— Jeffrey L. Geller, M.D., M.P.H.

What Happens After the Metamorphosis?

Stephen W. Mayberg, Ph.D.

Without question, the role of the state hospital in the public mental health system has undergone a considerable metamorphosis in the past two or three decades. Many states have downsized their facilities, while other states have developed new facilities. However, as better treatment options have become available in the community, almost every state has begun to look systematically at what kinds of individuals are most appropriately served in the state hospital and what kinds of treatment programs work best for them.

It is clear that determining the role of the state hospital is a complex issue driven not only by treatment considerations but also by economics, politics, and history as well as by new delivery systems, new technologies, and changing knowledge about mental illness. Understanding the forces that shape change while also paying attention to history is essential in developing any conceptions about the future role of the state hospital.

In this book William Spaulding, professor of psychology at the University of Nebraska-Lincoln and a clinical psychologist in the community transition program at the Lincoln Regional Center, presents a series of papers analyzing the issues confronting state hospitals. The book is divided into two parts. The first part, on policy, uses, as the editor notes, a top-down approach, beginning with broader perspectives. Leona Bachrach's lead essay, "The State of the State Mental Health Hospital at the Turn of the Century," clearly frames the history and variability of programs and opinions nationwide and several of the overarching, critical questions. Bachrach's long experience in analyzing services for chronically mentally ill patients provides a credible platform for discussion of many of the issues related to deinstitutionalization.

Richard Hunter follows with "Public Policy and State Psychiatric Hospitals," a concise history of the interaction of politics and the state hospital movement. The next two papers are case studies of state-hospital-based rehabilitation programs.

In the second part, on the new technologies, Mario Scalora's opening chapter, "No Place Else to Go: The Changing Role of State Hospitals and Forensic Mental Health Services," discusses the ever-increasing importance of forensic populations. Other contributors cover three areas that currently have a strong impact on state hospitals: the concept of therapeutic jurisprudence, community-based technologies such as various kinds of intensive case management, and information management technology. Spaulding ends with a formulation of the future roles and functions of state hospitals, drawing on the contributors' chapters.

Although Spaulding's organizational approach from macro to micro issues is laudable, one needs to remain aware of the dramatic differences in state hospital utilization among states. The chapters that deal with the bigger picture tend to be more relevant and helpful as a context for discussions about the future of the state hospital. It is critical to remember that every state mental health system is unique and that state-to-state variability is huge.

For instance, among the states, community alternatives have been developed with varying degrees of application and success. We have all learned from previous cycles of deinstitutionalization that the absence of a strong community system to receive persons discharged from the state hospital guarantees failure.

Unfortunately most of the micro-level articles about policy and technologies have been written by individuals who teach or work in a single system, the Nebraska mental health system. Although in context the articles illustrate their points, their applicability to other states is not always as readily apparent. That said, however, the issues addressed here are important for anyone working in a state hospital system to understand. State hospitals are no longer islands unto themselves, and failure by hospital administrators and staff to pay attention to the external forces that shape change will have serious ramifications for the hospital's future.

Clearly this book cannot be seen as a definitive treatise on the future role of the state hospital, nor as a cookbook for understanding state hospital issues. However, the issues identified and the solutions offered by the authors of each chapter are worth considering in attempting to understand the problems that affect the evolution of the state hospital system. Failure to take into account the myriad forces for change as well as the forces that reinforce the status quo has had negative consequences for some hospitals and states.

We must remember that asylums and state hospitals were originally sited away from urban areas to avoid the stresses of urban life. Many of these institutions were designed to be self-sufficient, with their own farms and dairies. They developed their own culture and identity as well as a certain degree of isolation. This insular approach is not helpful now, and Spaulding's book critically emphasizes the need to be aware of the past and to look to and embrace the future and the changes it inevitably brings.

The Future of the Public Mental Health System

Thomas Barrett, Ph.D.

This book is really about the future of the public mental health system in the United States. And that is as it should be. No discussion of the nation's state hospital system would be complete without consideration of where the boundary lies between those who can be treated effectively in the community and those who need the services that only a state hospital can provide effectively.

The book is divided into two parts. Part 1 is devoted to the perspectives of "observers and participants" from various levels within the system. The opening chapter is by Leona Bachrach, longtime observer of the system of care for individuals with serious and persistent mental illness. She examines critical questions about the roles of the state hospitals, including "What has been the fate of those mentally ill persons who are no longer served in state mental hospitals?" Her analysis suggests that some people with mental illness who are homeless or in jails and prisons would have been in state hospitals before deinstitutionalization. The chapter concludes by calling for "unified systems of care," which are difficult to argue against but equally difficult to implement.

The remaining chapters of part 1 include a politically naive analysis of the impact of politics on the mental health system and an interesting case study of the transition of a state hospital system into a rehabilitation-focused system of care. The latter is an honest story about the successes and difficulties one state hospital experienced in making this transition.

Part 2 is intended to address the role of new technologies in the future of state hospitals. "No Place to Go" focuses on the problems associated with hospitalizing people from the criminal justice system who are judged to be dangerous to society. Inevitably, the discussion leads to questions about whether the United States is going back to a system of care that criminalizes people with mental illness. This chapter and the next suggest that mental health professionals need to be involved in developing social policy related to rehabilitation and safety issues.

The roles of assertive community treatment programs and clinical decision support systems are discussed in the next chapters. The former discussion is an insightful meta-analysis of what assertive community treatment programs can and can't do and the implications for state hospitals, which is to serve those who cannot be effectively served in these programs. The discussion of clinical decision support systems seems misplaced in this book: the tracking of clinical data and outcome data is an important issue, but this book focuses on systems-of-care issues.

Overall, the book addresses the important issue of how the U.S. public mental health system will evolve in the 21st century to address serious societal and systems-of-care problems. One of the challenges is how to inform the general public about safety and rehabilitation issues without using the head-in-the-sand mentality so often employed by the public mental health system in the past century. The final chapter, which formulates future roles and functions of state hospitals, could serve as a prologue to a subsequent book that attempts to lay out a blueprint for social policy and public mental health services for the 21st century.

Defining the Appropriate Role for the Hospital

Marylou Sudders, A.C.S.W.

In a perfect world where mental health is fully integrated within a well-articulated, and well-financed, health care system, public psychiatric hospitals would be an anachronism. But the reality is that mental illness is relegated to the rear of our health care system and our societal consciousness.

This book is a compendium of articles organized in two parts. The first part addresses the historical and changing roles of state hospitals as well as the perspectives of the authors. The second part discusses the future role of state hospitals. Not surprisingly, forensic mental health and computerized data management systems dominate the discussions.

Unfortunately, with two exceptions, not much new territory is explored. "State Hospitals in the New Millennium: Rehabilitating the 'Not Ready for Rehab Players,'" by Paul Stuve and Anthony Menditto, chronicles the transformation of a Missouri forensic hospital into a rehabilitation facility, preparing forensic patients with serious mental illness for eventual community discharge. This pragmatic and thorough chapter clearly shows that progressive change can occur within a public institution that many believe is immune to change. The authors compellingly present the case that highly individualized treatment is possible and has a significant impact on patient outcome. Given the increasing proportion of forensic populations in public psychiatric facilities, this article is a must-read for public officials struggling with the issue.

The other noteworthy chapter is by Leona Bachrach. "The State of the State Mental Hospital at the Turn of the Century" chronicles the state hospital's role in a historical context and reviews the either-or debate, otherwise known as the hospital-versus-community debate. Dr. Bachrach puts aside the debate and revisits a theme familiar to many involved in community mental health over the years: unified systems of care. She suggests that state psychiatric hospitals have a legitimate role as one component of a unified system of mental health care. Given the situation outlined in the opening paragraph of this review, I can only concur with her opinion.

Historically, state hospitals have been driven by ideology and societal mores rather than by evidenced-based research, state-of-the-art clinical treatment, and rehabilitation. State hospitals and their roles have changed as a reflection of public attitudes and demands. Facility costs and budgetary constraints also have been dominant factors in the quality of inpatient treatment.

Unfortunately, none of the articles include discussions of the growing role of consumer empowerment and the incorporation of recovery models in state hospital systems. These factors will leave an indelible mark and will fundamentally change the role of inpatient treatment in public psychiatric hospitals.

Finally, it is clear that the role of state hospitals has changed in reaction to societal demands, ideological debate, and economic constraints. In the 21st century, how novel it would be if mental health policy makers and key mental health constituencies defined for themselves the appropriate role of public psychiatric hospitals!

The Resources and the Will for Community Service

Richard C. Lippincott, M.D.

I read this New Directions for Mental Health Services text with considerable interest, as the topic is near and dear to my heart. The book's intent is to address the debate about the definition, service potential, and future of the state hospital. The text, a collection of chapters focusing on different aspects of this debate, is written by individuals of various disciplines and edited by William Spaulding, Ph.D., professor of psychology at the University of Nebraska-Lincoln. Many of the concepts are clear, well articulated, and enthusiastically expressed. The extensive references provide substantial support, and several presentations are worthy of special note.

Leona Bachrach's chapter, "The State of the State Mental Hospital at the Turn of the Century," provides an excellent, thorough review of the subject. Dr. Bachrach raises and answers four important questions: how has the prevailing view of state mental hospitals changed, who is being served, what has happened to individuals discharged or no longer served by state hospitals, and what is an appropriate role for hospitals today.

Throughout her chapter, Dr. Bachrach makes two important points relevant to the last question. The first is that community-based service adequacy "is not so much whether the community has the potential for providing a full array of services but rather whether it possesses the resources and the will." The second is that, quoting John Wing, it is the "quality of life lived" by the patient that is the criterion by which services should be judged. Dr. Bachrach believes there is a "core of services" that still belongs to the state mental hospital and that change will take "great effort and cooperation from the political powers." These arguments are hard to refute.

The discussions about the role, place, and usefulness of psychosocial rehabilitation services are also important. The concepts that the state hospital environment can be enhanced and can be effective in providing rehabilitation services and that all individuals with mental illness are "rehabilitation ready" are key. Contributors make a substantial argument that long-term rehabilitation technologies provided within the state hospital environment are more effective for some patients than those provided in the community.

The chapter devoted to data management for clinical decision support in state hospitals is up to date and relevant. It offers highly contemporary material, a flow chart for managing treatment decisions, and information about developing a clinical decision support system. This material would do even the most committed enthusiast of problem-oriented treatment proud.

I was somewhat disappointed with the overall presentation, however, as many important points are not covered. The movement toward integration of services, the importance of program continuity, and the need to shift resources toward community-based programs are not given a clear voice. Discussion of the role of psychiatric leadership is missing, and expanded comments about different regions of the country and different approaches would have been welcome.

There is an unfortunate lack of discussion about the truisms that "all decisions are political" and that "budgets are not based on quality and on what is needed but on what the governor wants to give." This situation is the heart of state mental hospital existence, and a significant body of data about the impact of state politics on state hospital programs is available.

Finally, some recognition of the effectiveness of patient empowerment, the importance of dealing with real-life challenges in psychosocial rehabilitation, and the need for patients to develop confidence in their own ideas would seem appropriate. After all, "recovery" is a principle now quite widely accepted as a basis for development of individualized treatment plans.

Despite these concerns, I found the text a very readable and meaningful attempt to view the challenges of the roles of both the state hospital and community-based services in relation to what may be best for the individuals served. I hope that a follow-up within the New Directions series will present other aspects of this extremely important issue with similar clarity.

Dr. Mayberg is director of the California Department of Mental Health.