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Insights and Innovations in Community Mental Health The Erich Lindemann Memorial Lectures organized and edited by The Erich Lindemann Memorial Lecture Committee hosted by William James College Table of Contents Foreward .................................................................................................................................4 Carving Mental Health Out of Health Care: What Becomes of Community Mental Health? .................................................................................................................................... 5 Introduction by David G. Satin, MD ..................................................................................6 William Dalton .................................................................................................................. 8 Introduction by David G. Satin, MD .......................................................................... 8 William Dalton ........................................................................................................... 9 Nancy Langman-Dowart, RN, MS, MPH ......................................................................... 18 Introduction by David G. Satin, MD ......................................................................... 18 Nancy Langman-Dowart, RN, MS, MPH.................................................................. 18 Community Mental Health Centers: Ideology, Practice, and Politics .................. 19 The Shift to Privatize ............................................................................................ 21 Current Models of Private Sector Managed Mental Health Care ........................ 22 The Emergence of “Carve Out” Mental Health Programs ................................... 23 What’s Ahead in Health Care Delivery? .............................................................. 24 The Future of CMHCs: Integration and Collaboration ....................................... 26 Conclusion ............................................................................................................ 27 References ............................................................................................................. 27 Nasira A. Khan, MD ........................................................................................................ 30 Introduction by David G. Satin, MD ........................................................................ 30 Nasir A. Khan, MD ................................................................................................... 30 What is Meant By Carve Out ................................................................................ 31 Why Did This Occur? ............................................................................................ 31 Advantages of Mental Health Carve Out ............................................................. 32 Disadantages of Carve Out of Mental Health from General Health Care: .......... 33 Insights and Innovations in Community Mental Health | Lecture 18 | May 5, 1995 2 Managed Care in the Public Sector .......................................................................35 The Future ........................................................................................................... 36 Joyce Burland, PhD......................................................................................................... 38 Introduction by David G. Satin, MD ........................................................................ 38 Joyce Burland, PhD ................................................................................................. 38 Discussion ........................................................................................................................43 Insights and Innovations in Community Mental Health | Lecture 18 | May 5, 1995 3 Foreward The Erich Lindemann Memorial Lecture is a forum in which to address issues of community mental health, public health, and social policy. It is also a place to give a hearing to those working in these fields, and to encourage students and workers to pursue this perspective, even in times that do not emphasize the social and humane perspective. It’s important that social and community psychiatry continue to be presented and encouraged to an audience increasingly unfamiliar with its origins and with Dr. Lindemann as a person. The lecturers and discussants have presented a wide range of clinical, policy, and historical topics that continue to have much to teach. Here we make available lectures that were presented since 1988. They are still live issues that have not been solved or become less important. This teaches us the historical lesson that societal needs and problems are an existential part of the ongoing life of people, communities, and society. We adapt ways of coping with them that are more effective and more appropriate to changed circumstances—values, technology, and populations. The inisghts and suggested approaches are still appropriate and inspiring. Another value of the Lectures is the process of addressing problems that they exemplify: A group agrees on the importance of an issue, seeks out those with experience, enthusiasm, and creativity, and brings them together to share their approaches and open themselves to cross-fertilization. This results in new ideas, approaches, and collaborations. It might be argued that this apparoach, characteristic of social psychiatry and community mental health, is more important for societal benefit than are specific new techniques. We hope that readers will become interested, excited, and broadly educated. For a listing of all the Erich Lindemann Memorial Lectures, please visit www.williamjames.edu/lindemann. Insights and Innovations in Community Mental Health | Lecture 18 | May 5, 1995 4 The Erich Lindemann Memorial Lecture Committee presents THE EIGHTEENTH ANNUAL ERICH LINDEMANN MEMORIAL LECTURE Carving Mental Health Out of Health Care: What Becomes of Community Mental Health? “Carving out” (segregating) support and control of mental health services, and managed care affects community mental health and comprehsneive health by stigmatizing mental health problems, care, and caregivers. It also undermines the comprehensive, integrated approach to health promotion and illness treatment. How can different authorities and rules address community mental and physical health, and what support will mental health receive under these conditions? Lecturer William Dalton: Commissioner of Mental Health and Mental Retardation, State of Vermont Discussants Nancy Langman-Dorwart, RN, MS, MPH: Director of Mental Health, Blue Cross and Blue Shield of Massachusetts Nasir A. Khan, MD: Director, Bournewood Hospital; Clinical Psychiatrist Joyce Burland, PhD: Alliance for the Mentally Ill of Vermont Moderator David G. Satin, MD, FAPA: Assistant Clinical Professor of Psychiatry, Harvard Medical School; Assistant in Psychiatry, McLean Hospital Friday, May 5, 1995, 2:30 – 5:30 pm Massachusetts School of Professional Psychology 221 Rivermoor Street, Boston, MA 02132 Insights and Innovations in Community Mental Health | Lecture 18 | May 5, 1995 5 Introduction by David G. Satin, MD Let me welcome everybody to the 18th Annual Lindemann Memorial Lecture, this year titled Carving Mental Health out of Health Care: What Becomes of Community Mental Health? A brief introduction to the topic. What does it mean when a group of people or a human activity is segregated from the rest of the community? The metaphor that we have here common today of carving out things to me has a particularly brutal and bloody connotation. Exclusion often means isolation from the fabric of society, and sometimes subjection to separate standards and treatment. The intention may be to give special care and added resources, but historically it is often been associated with devaluation, limited opportunities and ultimate rejection from society. This is why democratic societies resist segregation of population groups in favor of equal opportunity and equal treatment. Of course exceptions are made, even in democratic societies and for people in special need, such as the young and the infirm, or those who present a special danger, such as those with infectious diseases or dangerous criminals. These are segregated out of society. The mentally ill and mental illness have often been targeted for bad repute and bad treatment. They more often have been seen as witches, maniacs or disturbers of the public tranquility than those who have been specially favored by the gods. Thus reform movements have most often sought to have lunatics or the insane treated like others of God’s creatures, or like other sick people. For these reasons carving out mental health and the mentally ill might well raise apprehension. Why is mental health being carved out of health care now? This is an era of economizing of expense, and, as a consequence, reducing societal caregiving. Surely much effort is going into reducing public expenditures and tax contributions to government programs. Health care, welfare, veterans administration medical services, Medicare, nutritional programs all have been reduced or future reductions are taken for granted. State mental hospitals have been emptied and closed. Deinstitutionalization means reduction of state mental health budgets under the guise of community care. Both the number and level of expertise of mental health clinicians is being reduced to the minimum. Funding for psychiatric treatment has always been below that for physical

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