Action for Mental Health Systems Transformation

John Talbott demonstrated remarkable foresight into a future in which we now grapple with many of the troubles he predicted. The staggering increase in the number of homeless persons, our inability to provide high-quality care to patients who have severe mental illness, system breakdowns, and inadequate payment mechanisms were all on Talbott's list of concerns. A critical part of his vision was to shift care from antiquated mental hospitals to the community. With considerable energy, commitment to the most disenfranchised patients, and a willingness to speak out authoritatively and authentically, he defined the issues that are salient to the progress of psychiatry.

The recent report from the President's New Freedom Commission on Mental Health (1) might have been written by Talbott. The authors conclude that today's mental health care system is a "patchwork relic" that frustrates "opportunity for recovery." Only a "fundamental transformation of the Nation's approach to mental health care" that goes beyond "traditional reform measures" will make a difference.

These conclusions echo Talbott's warnings in 1985: "Psychiatry faces a vast array of problems today, including its inability to implement programs for the chronic mentally ill and to apply principles of differential therapeutics, the lack of funds for community services, and the continuing severe fragmentation of the psychiatric delivery nonsystem. Old solutions will not suffice."

As a psychiatrist whose career has spanned this period and who has worked with homeless people for the past 15 years, I am offered, through this commentary, an opportunity to reflect on the circumstances of the most severely ill, stigmatized, and disaffiliated patients, many of whom are homeless. I also speak for a family member who is a consumer of services.

When I first became a psychiatrist, I worked in settings such as public mental hospitals that were like Frederick Wiseman's "snake pits." Private care was sometimes better, but too often it was unavailable to clients with severe mental illness. Providers were often unable or unwilling to address the needs of persons with severe mental illness and those who were homeless.

From today's vantage point, 20 years ago may have represented the heyday of patient care. With the acceptance of psychodynamic theory and a real understanding of the context of patients' lives, providers talked to patients about their experiences and believed in the salutary effect of the relationship. A "trusting relationship" was viewed as the linchpin of treatment. Medication was equally important, working in tandem with "talking therapies." The balance tipped in later years toward medication, a necessary but not sufficient ingredient of treatment. Today, patients languish on inpatient psychiatric units, heavily medicated, with no therapeutic milieu and attended by staff who are too overburdened to spend adequate time talking with them.

Since Talbott wrote about the "shame of the cities," we have witnessed an epidemic of homelessness, with increasing numbers of women and children on the streets. Although the why of homelessness is deeply embedded in structural factors such as the income gap between rich and poor and the crisis in the availability of decent, affordable housing, those who are most affected by these forces reflect our society's prejudices about who is most expendable. Just as in a game of musical chairs, someone is left standing when the music stops. As the characteristics of those left standing have changed over the decades, the record reads as a social history of our biases. Today, women, children, veterans, and persons with severe mental illness and co-occurring disorders are those we disregard the most (2,3).

In the early 1990s, homelessness was regarded as an acute situational crisis. It has evolved into a chronic crisis, with our shelter system and its ancillary services institutionalized and functioning as a poor relation to a fragmented mental health system—but not of such insufficient quality that it is considered an unreasonable disposition for persons with serious medical and mental health problems. Just last month, a colleague described how traumatized his staff was when four women arrived unannounced at their emergency shelter on the same day they had been released from local hospitals with advanced, untreated cancer. Similarly, it is not uncommon for patients to be discharged from psychiatric wards and jails directly to shelters. The spotty progress we have made in the use of assertive community treatment teams and newer antipsychotic medications has not begun to address the larger systemic problems.

Homelessness has changed in another way. Unlike decades ago, when homeless people lived in "skid rows" and deinstitutionalized clients with severe mental illness lived in rooming houses, condominium conversion, gentrification, and lack of a national housing policy has led to a growing population of people who live literally on the streets for extended periods—and not, as former president Ronald Reagan once claimed, "by choice." As this number keeps growing, even in colder climates, we now have the new technology of "street teams" to respond. A majority of these homeless individuals have co-occurring disorders—severe mental illness along with substance use disorders—often coupled with medical problems (3). On the streets, they are preyed upon.

Talbott eloquently described "the shame of the cities" and called for a "national policy." Today, not only do we lack such a policy, but the media describes a phenomenon of "compassion fatigue." Homelessness has become an increasingly accepted feature of our urban landscape.

Disparities in access to health care between the rich and the poor have grown, driving the number of uninsured to a staggering 44 million. Even when people with severe mental illness can get access to care in traditional systems, the barriers are formidable. With managed care dictating shorter stays in psychiatric hospitals, how can complex medication trials be completed or failed medication trials restarted? How can relationships be formed and therapeutic alliances solidified to ensure medication compliance once the patient is discharged? Even with growing awareness of the importance of including patients and their families in the development of individualized service plans and in decision making, such inclusion happens infrequently. Perhaps the sometimes total reliance on medication as a magic bullet has provided a convenient excuse to ignore the role of the therapeutic relationship in the patient's healing process. The shortage of money and personnel has helped make this outcome inevitable.

These difficulties are compounded by bureaucratic fragmentation, diffusion of responsibility, and lack of coordination. Further exacerbating these problems is increased judicial involvement. With the increasingly litigious climate and backfiring of regulations designed to secure human rights, providers sometimes favor caution over the patient's safety and well-being. In this atmosphere, many psychiatric units have become "lockdowns," with the quality of daily life severely compromised. Patients sit around day after day with little to do except converse with their internal demons. Even in this day of neuroscience, the quality of a person's life and recovery still depends on having appropriate surroundings. Patients may continue for months without the luxury of going outside to breathe fresh air. Today, treatment in a psychiatric hospital can be more restrictive than incarceration for a serious crime.

The mandate of those who attend to persons with mental illness has always been shaped by the social, economic, religious, and philosophical temper of the times. This situation is reflected by the history of reform of the mental health system. The pendulum keeps swinging from the hospital to the community and back again; neither the hospital nor the community setting is inherently more humane (4). Although the landscape is different today, the core issues remain the same as outlined by Talbott: patient care, economics, and issues with service systems.

Talbott proposed an action-oriented agenda beginning with destigmatization of mental illness. To transform the mental health system, we must ensure adequate reimbursement, support an infrastructure that responds to patients' needs, and give mental illness parity with physical illness. Talbott called for our profession to spend a sizable amount of time in "legislative lobbying" to guarantee that our patients receive the care they so desperately need. It is our responsibility, he suggested, to create the political will to ensure these changes.

By advocating for the most vulnerable, Talbott reminded us to hone in on the ultimate goal of care and protection of our patients. While serving as president of APA, Talbott declared the primary focus of the 1985 annual meeting in Dallas to be "Our Patients." With strong conviction, he declared that public policy, clinical care, research questions, and training issues could be addressed appropriately only "if we start with the patient…the ultimate purpose of all our work."

I'm sure Talbott would embrace President Bush's declaration that "Americans with mental illness deserve our understanding and they deserve excellent care" (1). By taking decisive action now, we can realize Talbott's vision of comprehensive, patient-centered care available to everyone—especially those who are the most disenfranchised. As he eloquently concluded, "To do otherwise is to continue America's long-standing abandonment of its most underserved and vulnerable mentally ill population and consign one more generation of the mentally ill to oblivion."

Dr. Bassuk is affiliated with the National Center on Family Homelessness, 181 Wells Avenue, Newton, Massachusetts 02459 (e-mail, [email protected]). This commentary is part of a tribute to John A. Talbott, M.D., Editor Emeritus, who served as Editor of Hospital and Community Psychiatry and Psychiatric Services from 1981 to 2004.