The Dawn of a New Era in Behavioral Healthcare

As found in The USPRA Recovery Update Oct. 10, 2012

The Behavioral Health Care system is entering a new era in which it will be defined by multiple stakeholders, each with their own agendas and principles. Although the final design is yet to be written, it is becoming clear that the principles of recovery, cost containment, self-determination, and care management will compete for leading roles. If realized to its fullest potential, this new system will be comprehensive, integrated, efficient, and outcome-driven, as it is being designed to help control the spiraling costs of entitlements.  Regardless of your role in the system—consumer, provider, oversight or funder—your success in this new era will depend on how well you prepare for the changes now.

Across the country, sweeping changes are underway in service provision to persons with a behavioral or developmental disability.  The extent to which these changes are being implemented vary from state to state.  Some states are near a final implementation of their planned changes, while others are still in a discovery phase and trying to understand what the Affordable Care Act will mean for them.  Despite this disparity, we as a nation—particularly as a community of human service entities, participants, significant others, family, providers, and other invested parties—are well into a time when individual stakeholders need to prepare for the future.  To do this one needs to develop insight into how the new era may operationalize.

 “You have to know the past to understand the present.”  – Dr. Carl Sagan

Our discussion of the future of Behavioral Health Services begins with a brief look at where we have come from to be here today.  For illustration purposes, let us look at the history of Mental Health Reform, its movements, and points of focus to learn a little about where we may be heading and what we hope to accomplish.  Although not encompassing all the nuances of reforms faced by each behavioral health disability, the following overview will provide us with structure of reform focus points that cross many disabilities.

The Eras of Mental Health Reform can be divided into four historical periods (Morrissey and Goldman, 1984) and one emerging movement.  Change happens when an external or internal force gains enough momentum to redefine what exists.  If we look at the historical four eras of mental health reform, we learn that although the creators of each movement may have felt the change they helped fashion would solve all the issues, oftentimes new and challenging forces, both internal and external, would emerge.  Changes in acceptable moral standards, economic fluctuations, and self-realization created environments of change that leaders and believers were able to harness into a movement and the development of a new era.  Often these eras were highlighted by people, places and practices that seem primitive and often barbaric by today’s standards, but in their time they were revolutionary, each movement giving us something of value to build on.

The Moral Treatment Era (Morrissey and Goldman, 1984), often known as the Era of Asylums, is unimaginable in today’s world, but at the time it was seen as revolutionary for its incorporation of humane and restorative services in a world of abuse and disdain.  During this period of time, there was a belief that the isolation of individuals in large asylums that provided a “moral and religious” environment would cure an individual and enable his or her return to society.  This focus on humane treatment and curing individuals was indeed an admirable mission; however, the era is remembered as one of overcrowded asylums that focused on custodial care and not treatment.  Internal pressure from within the world of Psychiatry, along with external pressure from growing community discourse about the inhumane conditions, as well as a champion for change in Clifford Beers, led to a gradual new reform.

 This new era known as the Mental Hygiene Era (Grob, 1991), aka the Progressive Era, introduced scientific orientation and prevention.  Psychopathic hospitals, children’s clinics, and outpatient treatments were introduced as new and progressive approaches.  However, a large influx of immigrants to the United States, many of whom had serious behavioral health issues as well as declining resources and a misguided focus on treating only the symptoms of chronic illness, led to overcrowded conditions in state hospitals and a return to custodial care. The Mental Hygiene Era left behind some of the most crucial residual effects, including the establishment of psychiatric social work, psychology, and counseling as important professional practices in the system of care.  A legacy of the era was also a shift in responsibility to governments, in this case state governments, for the care for this population.  Similar to what happened during the previous reform era, external forces and internal unrest created new hope for change.  Oddly enough, it was the success of brief psychological and psychiatric interventions during World War II and the use of psychotropic medications that created a new hope for success inside the system.  This new hope inside the system, coupled with a new growth in discourse from community stakeholders, as well the financial crisis caused by the maintenance of these large state hospitals, created the conditions for what would become the third era of reform.

 The Community Mental Health Era (Goldman Morrissey, 1985) of the mid-20^th century was highlighted by a belief in social integration and deinstitutionalization, which for its time were creative, moral, and cost-efficient goals.  It was a period when responsibility shifted from the state and individuals to the federal government and hospital-based institutional care gave way to more community-based outpatient care.   New treatment technologies began to flourish and there was a great reduction in hospital census.  However, this rapid reduction of hospitalized patients occurred without proper planning or the adequate development of community supports; so what started with such great hope ended with homelessness, street wandering, and socioeconomic disaster for many of those it intended to help. Despite the negative consequences, there were many positive ones as well: the solidification of the federal government’s responsibility as well as the proliferation of new practice approaches, new medications, and an increase of community mental health centers.  New governmental policies, as well as the establishment of governmental agencies whose responsibilities were primarily associated with behavioral health care, helped to champion the next new era (Morrissey and Goldman, 1984).

The Community Support Movement of the mid 1970s, which continued into the 21st century, brought us a belief that mental illness should be attacked as a social welfare problem. This is a period highlighted by the development of environmentally based programs like employment services, social clubs, and new housing opportunities.  It was a time of tremendous development in new and larger outpatient programs, clinics and psycho-social clubs, day treatment, partial hospitals, and rehabilitation programs (Bob Smucker, Promise, Power and Pain).  There was unprecedented growth in residential opportunities, first in congregate care settings and more recently in the development of independent housing opportunities.  However, as in so many periods before it, the development was hap-hazard at best; programs were added on top of other programs, and services created silos of care.  There was a lack of real coordination and integration, which meant that access to essential services outside the behavioral health world became nonexistent to most people. Whereas people were once institutionalized in asylums and hospitals, they now became institutionalized in day programs, adult homes, and community residences.

The period was not without great advances in both thinking and treatment.  The creation and development of best practices in behavioral health care, new and innovative psychotropic medications, the establishment and infusion of rehabilitation practices, and the development and organization of the peer movement have had and will continue to have a major impact on the behavioral health care system.  However, the single greatest contribution of the era was the work of those individuals who championed the belief that people with behavioral health issues can recover and can become members of the same society as anyone else, and that persons with lived experience not only have a place as consumers in the system but should be the leaders and providers in the system.

So, today we stand at the threshold of another era—one we hope will be the right one, the just one, the final one.   What are some of the lessons learned from the past that we need to take forward?  There will be financial constraints, and the system must build from the start recognizing this. Seed money and start-up grants are nice, but there must be long-term financial commitment to ensure long-range fiscal viability.   Governments will be involved, and governments change.  The system must be built to withstand political pressures and politics of the day.  Societal involvement has been an area of oversight since the behavioral reform began. The system must take into account the expectations of society as whole and the potential for social discourse if those expectations are not met.  Innovation is critical to long-term success.  New ideas, new practices, and new hopes should be embraced and encouraged.  The hardest lesson to plan for is the knowledge that there will always be unintended consequences and unanticipated events. Planning in this new era must take into account effects on all stakeholders, including those not directly in the system like social service agencies, local bus companies, and employers. There must be flexibility in the design so changes can occur, and be addressed without complete disruption.

“For every problem there is one solution which is simple, neat, and wrong.” – H.L. Mencken

The solutions to the problems we face today will not be easy.     The next era of mental health reform must tackle complicated issues that will take a multidimensional solution.

What will the new era bring?  Depending upon one’s point of view, we are in the midst of this new era already.  To some it is an era of recovery, self-determination, person-centered planning, evidence-based practice, and more; to others it is the era of fiscal reform, cost reduction, and service delivery efficiency.  In reality, we are in the midst of many reforms. This historical paradigm shift creates many questions: where the services are going to be provided, what services will be provided, who should provide the services, who gets to access to what, how they get paid, and many other questions.  Each of the components of the new system will hopefully act as a balance and check so no single area can create an issue that the system cannot recover from.

Here are 7 things we can expect:

• We can expect over time that access to care will be facilitated through a care managed/cost-contained system.  This will create a central point of accountability long overdue in the behavioral health world.  We will have coordinated plans of care and the potential use of nontraditional highly successful service approaches.
• There will be a recovery based system. The arguments about whether people can recover should be finished and the attention focused on how systems as large as the behavioral health care system can focus on each individual while maintaining a fiscal balance. Peer services, rehabilitation services, and innovative treatments, coupled with new access to health care, are a viable starting point and should be a part of whatever the final system of care will look like.
• Success will be assessed by outcomes. Life roles such as independent housing, education, social integration and employment will be the expectation and not the exception, as will reduced hospitalization, lower recidivism, and integrated care models that will bring together behavioral health services and general health treatment.
• Evidence and proven practices will become common practice.   Innovations in hospital diversion, relapse prevention and creative practices will become more readily available.
• Data, data, and more data will be needed to manage a complex care system.  Electronic access to health information, both within care systems and across systems of care, will become critical to ensuring that care managers have the information they need to make clinically appropriate decisions.
• The locus of care and the service models of today will not be sufficient or viable in the new era.  Care will shift from places to people.  Peer services, rehabilitation practices, and alternative care models will become common interventions for program participants.
• There will also be limited resources and the potential for rationing of services as well as a possibility that decisions of care would be based upon resources and not individual needs.

Even if all the hopes and dreams of those who influence the next era are met, there remain concerns about the ability to achieve the paradigm and maintain the reform.  What can be done with the existing locus of care? The current system is based upon bricks and mortar, and with that comes great expense and a reluctance to change. We have a workforce that is not trained for the approaches of tomorrow, so a retooling of the staff will be mandatory.  As vast as the infrastructure is in behavioral health, the question of whether it is adequate for the new era remains to be seen. Do the existing data systems at all levels have the necessary functionality to adequately support the reform movement?  And will the finances support it adequately in the long term? Committed resources that can withstand the winds of change are essential to the new era’s success.  This is by no means a complete list, but is intended to stimulate thought and creative solutions.

No matter what role you play in the behavioral healthcare system, your success will depend upon your readiness for the change.   Data, Information, and Knowledge are keys to being prepared.  The ability to obtain all the appropriate data and organize it so it is understandable and informational will allow you to possess the knowledge to prepare for the future.  Preparation will not be easy—it will require reconfiguring human and physical resources, creating a new locus of care, adjust attitudes require information and knowledge.

“A small body of determined spirits fired by an unquenchable faith in their mission can alter the course of history.” – Mahatma Gandhi

Now is the time to start preparing. Are you ready?

Sources of information and works cited

Morrissey JP, GoldmanHH, Cycles of reform of the chronically mentally ill. Hospital and Community Psychiatry

Bush, C. T. (2000), The Surgeon General’s First-Ever Report on Mental Health Carol T. Bush, PhD, RN. Journal of Child and Adolescent Psychiatric Nursing, 13: 89–90. doi: 10.1111/j.1744-6171.2000.tb00082.x

Grob, Gerald N. From Asylum to Community: Mental Health Policy in Modern America. Princeton: Princeton University Press, 1991.

Humphreys, K., & Rappaport, J. (1993) From the Community Mental Health Movement to the War on Drugs: A Study in the Definition of Social Problems. American Psychological Association, 48, 892-901

Jones, K. (1972) A History of the Mental Health Services. Routledge & Kegan Paul. London.

Kennedy, E. (1990) Community Care for the Mentally Ill: Simple Justice, American Psychologist, 45, 1238-1240

Morrissey, J., & Goldman, H. (1986) Care and Treatment of the Mentally Ill in the United States: Historical Developments and Reforms. ANNALS of the American Academy, 484, 12-27.

Bassuk E, Gerson J: Deinstitutionalization and mental health services. Sci American 1978; 238:46-53.

Rose S: Deciphering deinstitutionalization: complexities in policy and program analysis. Milbank Mem Fund Q 1979; 57:429-460.

Gruenberg E, Archer J: Abandonment of responsibility for the seriously mentally ill. Milbank Mem Fund Q 1979; 57:485-506.

Bachrach LL: Deinstitutionalization: An Analytical Review and Sociological Perspective. Rockville, MD, National Institute of Mental Health,1976.

Lamb HR: What did we really expect from deinstitutionalization? Hospital Community Psychiatry 1981; 32:105-109.

Lamb HR: Deinstitutionalization and the homeless mentally ill. Hospital Community Psychiatry 1984; 35:899-907.

Smucker , B., Promise, Progress, Pain: A Case Study of America’s Community Mental Health Movement From 1960 – 1980, http://mentalhealthhistory.org/Promise_Progress_Pain.pdf, (date unknown)

Deutsch, Albert, Shame of the States (New York: Harcourt, Bruce & Company, 1948)

Koyanagi C, Goldman H. Quiet success of the national plan for chronic patients. Hospital Community Psychiatry. 1991;42:899–905.

Goldman HH, Morrissey JP. The alchemy of mental health policy: homelessness and the fourth cycle of reform. Am J Public Health. 1985;75:727–731..