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May 12, 2006


Transitional Planning in Mental Health Care: Formidable Challenges to Good Enough Endings

Madness: Suffering To Carry On

Wolves in Sheep's Clothing:

Beginning in the late 1960s and early 1970's, a nationwide movement began to "de-institutionalize" severely mentally ill people. Energized by a growing public perception of the deplorable conditions in many large state psychiatric hospitals and the advent of anti-psychotic medications, the doors of the hospitals were suddenly unbolted. The overtly stated public policy position was that the primary motivation for the de-institutionalization movement was a humanitarian one, specifically people could be prescribed effective medications, then followed by outpatient psychiatrists and clinicians in community mental health centers. However, there was a less humane political motive, namely the wish to begin a drastic reduction of funds provided by the national government in support of mental health services for the American public.

For example, the initial NIMH start-up grants for community-based mental health facilities was 90% or more of the costs for the first year, with supposed commitments for ongoing financial support. In fact, the financial support commonly diminished by 10% each year, leaving the generally impoverished neighborhoods, in which the mental health centers were established, to struggle to meet the financial needs on their own. As a rule, as one might expect, those efforts, doomed from the beginning, were spectacularly unsuccessful.

Cast Them Unto These Mean Streets:

The reality, then, has been disastrous. A relatively small proportion of those persons previously in care was lucky enough to be able to live with some semblance of independence or was able to depend upon long-term care resources living with family members. However, as is so apparent by the sight of those patients wandering the streets of cities across the nation, many could not. Because of the predictable unavailability of sufficient funding for outreach and follow-up programs, a lack of leadership from the medical community, and inadequate structure and support, too many former state hospital patients relapsed.

Despite the development of new medications and the arduous work of advocacy groups such as the National Alliance for the Mentally Ill, the situation remains tenaciously persistent. A very large group of disturbed persons remain untreated, homeless and without services (it is estimated that one-third of the total number of homeless suffer from severe mental illness, usually schizophrenia). Some have ended up in jail (16 to 24 percent of prisoners suffer from psychotic disorders, severe depression or bipolar disorder). Some have been re-institutionalized. Others stay in the community, going into inpatient psychiatric units during acute episodes and being released when they stabilize.

All the while, the “de-institutionalization” movement marches on unabated. This is nowhere more evident than in the field of therapeutic group care for children and adolescents, where transitional services have become the mantra of the past decade. The push to constrict group care services, while pushing for programs that claim to promote independence sounds, as with the earlier “de-institutionalization” of state psychiatric hospitals, like a noble and deeply humane goal. It can be accompanied, however, with a potentially severe emotional cost.

No one can argue against the importance for people to feel autonomous and independent. However, in our sometimes tunnel-visioned focus upon independence, we too easily can become blind to the life invigorating fact that it is just as vital for people in care to be able retain an important, nourishing sense of attachment and connection. Those professionals who organize frequently ill-planned and hastily improvised transitional services often lack a sophisticated understanding of the underlying psychological structures and needs of those for whom they make such plans. They repeatedly are unable to be empathically attuned to one of the major suffering involved in the state of emotional disturbance, specifically that it is a state that almost invariably isolates people and impairs their abilities to form and maintain close, intimate relationships.

In the more desperate of scenarios, the so-called independence is accompanied by neighbors and acquaintances who steal money and cigarettes from them, even sexually victimize them. Autonomy becomes identified with lives too often characterized by fear, boredom and ongoing anxiety. While more independent, they are also much lonelier.

Stubbornly Committed to Working the Trenches:

And what of the lives of those who are committed to working with the marginalized disturbed young people and adults in this difficult atmosphere. One writer has described it this way: "Dealing with clients is easy -- dealing with disgruntled [mental health] workers is hard." They are disgruntled: They earn 20 grand for an intense, high-pressure little-recognized job. "Oh, you are so noble to do the work you do," is what people say. What they really mean is, "Jesus, what fools you are."

You have to be stubborn, willfully blind to the fact that you might be looking at retirement when you're in your 80s with zilch in savings. You have to believe that it's God's work, even if you doubt that he or she exists or gives a damn. You have to be willing to get down and dirty, to be a soldier in the trenches where everybody -- clients, doctors, case managers, concerned family members -- can take potshots at you. Once you're prepared to be in your 40s and still renting, to work in a residence that's nicer than your place, with clients who get more in disability income than you get in take-home, well, step into my office and fill out an application.”

“…our task is to help people be as independent as possible, but in the politicized effort to get state funding and answer to tax
payers, that mission is often translated into a need to demonstrate "movement" toward independence, even if we're not sure it's in the resident's best interest. The …who pay our salaries, are decent, smart people who understand that real life is messy and that it can be difficult to know when someone is ready to move on, to go from a staffed residence (more expensive) to [a less structured setting]. But, inevitably, they feel pressured to lower costs, to provide services as cheaply as possible -- and that in turn becomes a pressure we feel.

Constructing Good Enough Endings

When it comes to creating independent lives, we often have been at best only partially successful. But we need to realize that for many in our care, there many other meaningful roles they can fulfill. Thus, in response to the often overly adamant directive for us to push those in care with us toward positions of independence, we must also pay close attention to the lessons that those for whom we provide care try to teach us about themselves along the way. To fully attend to the detailed messages that they convey to us also means that we need to willing to identify and admit to our own most tender, the weakest, immature and vulnerable parts of ourselves. Our attempt to broaden the scope of their possibilities inevitably requires that we do the same. Further, to a major extent this depends upon our own capacity and willingness to openly admit that at times we know nothing, that aside from the fact of our own mortality, we all must embrace the uncertainty of life.

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