The failure had many causes. Policy makers justified deinstitutionalization in undefined or generic terms—community, reintegration, and rehabilitation—that inevitably got used in contradictory ways. The terms gave the appearance of a progressive, coherent system that bore no resemblance to the reality on the ground. The forces arrayed in favor of depopulating state hospitals were unstoppable, but they lacked an overarching blueprint. The ultimate fragmentation and substandard care were thus the unintended consequences of a largely unplanned process (see Bachrach 1990, Mechanic 1989). In particular, reformers overlooked how housing, income support, and social connections affect the well-being of people with disabling symptoms. The stepwise process by which the state abandoned people with serious mental illness thus produced an entirely new cluster of clinical needs and social dilemmas.
For example, ex-patients and younger people who had never been hospitalized started to receive monthly federal subsidies, and they became a lucrative commodity for entrepreneurs operating nursing homes, group homes, board-and-care facilities, and single-room occupancy hotels. The economics of this business are simple: the less money spent per capita on tenants, the higher the profits. Consequently, people with serious mental illness began to spend part of their lives ghettoized in custodial settings that were smaller but just as untherapeutic as the old state hospitals. A similar logic operated in the private nonprofit agencies that specialized in community psychiatric services. Such agencies captured more federal reimbursements if they treated more individuals, and too often the result was higher caseloads, the hiring of under-qualified providers, and a declining quality of care (Mollica 1983). Because of economic contingencies, the isolation and neglect that characterized the early twentieth century asylum reemerged 70 years later as fundamental aspects of public sector mental health.
COMMUNITY SUPPORT PROGRAMS: ASSEMBLING THE NEW NORM
The undeniable neglect of people with severe mental illness and the reversion to custodial care led to a shift in the policy landscape of the late 1970s. The Community Support Program (CSP) was the major federal response. It rejected the naïve assumption that discharging hospital patients would naturally lead to “community integration” and that facilities like board-and-care homes actually rehabilitate their residents. The program instead began with a cold appraisal of the results of deinstitutionalization (Turner and TenHoor 1978). People with severe mental illness faced enormous obstacles in getting services from general hospitals, social welfare agencies, legal clinics, public housing bureaus, and employment training centers. These institutions simply had no experience with the mentally ill and no specific mandate to serve them. Their staff tried to avoid serving people with the most disabling and chronic symptoms. Federal programs were evaluated on the basis of their efficiency—that is, how cheaply and quickly they could find jobs and independent housing for their clients. As a result, providers preferred to cherry-pick the high-functioning individuals, and they left those with severe disabilities to fend for themselves (see Tessler and Goldman 1982).
The CSP was an ambitious, top-down effort at systemic reform aimed precisely at such problems. It grew out of a series of working conferences at the National Institute of Mental Health, held from 1975 to 1977, that conceptualized the ideal “community support system” needed by mentally disabled adults (see Turner and TenHoor 1978). Participants debated which elements of the current system to keep, the base-line responsibility of the government for individual welfare, and the legitimacy of demands that the mentally ill be productive and independent. Without reaching consensus on any of these issues, the assembled experts nonetheless identified 10 essential functions for community services (Turner 1977):
1 Identification of and outreach to mentally disabled adults, whether in hospitals or the community
2 Assistance in applying for public entitlements
3 Crisis stabilization services in the least restrictive setting possible
4 Psychosocial rehabilitation, including evaluation of strengths and weaknesses, in vivo training in community living skills, and improving employability
5 Supportive services of indefinite duration, including living arrangements and daytime and evening activities
6 Medical and mental health care
7 Backup support to families, friends, and community members
8 Involvement of community members in planning services
9 Protection of client rights through grievance procedures
10 Case management: a single person or team responsible for remaining in touch with clients on a continuing basis.
With this list, the architects of the Community Support Program made a clean break from previous decades of policy. They did not even mention prevention or cure, but focused instead on rehabilitation and ongoing support. Their list thereby acknowledged people’s broad needs for simple survival in the post-asylum era. Often poor, unemployed, and marginalized, this group faced not only the fragmented mental health system but also the dispersal (or nonexistence) of all the other services that once came bundled together in the state hospital. Planners also endorsed the notion that severe mental illness is truly chronic and that some people may need comprehensive assistance for life.
The Community Support Program was the first comprehensive plan to reorganize services after deinstitutionalization. As a distinct program, it was cut short by the fiscal austerity of President Ronald Reagan, which effectively ended the era of national mental health planning that Kennedy began almost 20 years before. The program’s basic orientation, however, continued to drive the development of services at the state and local level, despite the ideology of limited government and the ongoing privatization of health care. In the 1980s, states devised programs that mixed and matched ingredients from the original CSP list of 10 essential functions. Vermont, for example, established regional “community rehabilitation and treatment” agencies that provided vocational training, social support, case management, emergency care, and education for family members (Wilson 1989). Columbus, Ohio, established “community treatment teams” that kept up with clients through all their moves about the city, brokered for services from different agencies, and placed clients in supported housing (Fleming and York 1989).
THE INVENTION AND DIFFUSION OF MODEL PROGRAMS
Building up the apparatus of community-based treatment demanded an enormous amount of improvisation. The problems left in the wake of deinstitutionalization overflowed the bounds of any single mental health specialty (psychiatry, psychology, social work, or nursing). To reconstruct a decent support system for people living in poverty and isolation required gathering resources from different institutions and experimenting with new organizational logics. This open-ended moment of invention, however, soon gave way to an era of precise blueprints and bureaucratic regulation. As new models of treatment were scaled up and woven into state mental health codes, the frontline provider had considerably less room to maneuver. His tasks became spelled out in minute detail, routinized, and audited from above. This tension between the need for improvisation in community services and the strict definition and regulation of clinical roles still pervades daily work in agencies like Eastside Services.
The development of services on the ground demanded the translation of CSP rhetoric into recipes for action with clients. The task often fell to social workers, who by necessity relied on their pragmatic and highly local knowledge to organize programs. The development of Community Support Services in the pseudonymous High County, Kansas, illustrates the translation from policy ideals to the operation of a single local