History of Community 2 Jacqueline Maus Feldman

somatization, with trials of magical spells, applica- Introduction tions of body fl uids, use of hallucinogens, and reli- gious retreats to ameliorate these conditions Since antiquity, mental illnesses have proven (Nassar 1987 ) . Hindu religious texts denoted inter- challenging for individuals suffering with them, pretations of mental illness as refl ections of super- for families who wish to support them, and for natural beings imbued with magical powers, or as communities in which they live. Evolution in the a result of the body being out of balance; the reli- development of community services and supports gious community responded with application of has been predicated on the understanding or inter- prayers, herbs, or persuasion (an early attempt at pretation of mental illness, aided by acceptance therapy?) (Bhuga 1992) . Bodily imbalance was and innovation, but often anchored in ignorance, also embraced as an explanation for mental disor- stigma, and short-sightedness. Regardless of how ders by the ancient Chinese; treatment like herbs one de fi nes community psychiatry (by provider, and acupuncture sought to bring these back in by setting, by duration of care, by diagnosis, by alignment (Yizhuang 2005) . Ancient Jewish cul- set of principles, by fi nances/payer of services), tures viewed mental illness as a refl ection of a dis- multiple facets are important in the evolutions of cordant relationship with G-d. Eschewing theories the fi eld. A historical review of community psy- that the etiologies of mental illness were supernat- chiatry is imperative to comprehending the vari- ural or divine in nature, recommended ables that impact the lives of those touched by close observation, accurately described numerous mental illness, and may suggest how systems of mental maladies, noted contributory roles of envi- care should be organized to enhance recovery. ronment, diet, and life style, and suggested treat- As early as the Neolithic era, evidence exists ment be focused on balancing bodily fl uids. that many attempts were made to treat and cure Ultimately, Plato embraced the theory that all mental illness. Skeletal remains with large burr mental illness was predicated on physical prob- holes in their skulls from that era have been specu- lems, and a Greek became the fi rst to lated to re fl ect interventions in brain disorders suggest humane treatment, including releasing agi- (Brothwell 1981 ) . Records from ancient Egypt tated from restraints (von Staden 1996 ) . reported clinical presentations of and During the Middle Ages, the Quran refl ected the need to treat those who were mentally challenged with humane protectiveness; some Muslim physi- J. M. Feldman , MD (*) cians encouraged the development of trusting coun- Patrick H. Linton Professor, Department of Psychiatry seling relationships and developed -centered, and Behavioural Neurobiology, University of Alabama at Birmingham, Birmingham , AL 35294 , USA supportive asylums from 700 to 200 ad (Million e-mail: [email protected] 2004 ) . Unfortunately, such forbearance was not as

H.L. McQuistion et al. (eds.), Handbook of Community Psychiatry, 11 DOI 10.1007/978-1-4614-3149-7_2, © Springer Science+Business Media, LLC 2012 12 J.M. Feldman readily apparent in Europe during the Middle Ages, ago, a city in Belgium, Geel, established a system where interpretation of mental illness again became of community care for those with mental illness tied to a “mixture of the divine, diabolical, magical that has been sustained, in some fashion, through and transcendental” (Million 2004 , p. 38). Humors, this very day. By legend, it is told that in the sixth spirits, and demons were all thought responsible for century Dimphna, the daughter of an Irish king, mental disorders, and the suffering individual was fl ed to the forests of Geel to escape her recently thought to be morally un fi t and suffering from sin, widowed father, who in a grief-stricken , punishment for a lapse in his relationship with G-d, demanded she marry him. Instead of acquiescing, or possessed by the devil. During this time, the she chose to be beheaded; named the patron saint challenge of providing care for these individuals of those with mental illness, the site of her mar- fell to families, although in England the courts often tyrdom became a chapel that witnessed cures of provided additional supports. Others were not so mental illness. Pilgrims seeking miracle cures lucky, and were the target of witch hunts; the overwhelmed the region and the church onsite “more” fortunate were removed (or pushed) from became their housing; at the bequest of the over- family care, shipped off and restrained in alms- whelmed church, villagers from the surrounded houses, jails, or mad houses (Wright 1997 ) . area open their homes, and thus began the tradi- The marked a resur- tion of “integrated, community residential care” gence in the belief that mental illness was predi- (Goldstein and Godemont 2003 ) . These often cated on physical not moral problems, though trans-generational foster families provided men- patients were often seen as wild animals, needing tal health care and support with virtually no for- restraint and physical punishment to ameliorate mal training, and by the late 1930s over 3,800 their animalistic furies. In America in the 1700s boarders were living with Geel families; for the the general medical Pennsylvania Hospital began most part “the role of the family as caretaker, to offer services for those with mental illness teacher, natural supportive parent, and behavioral (though in its basement), and colonial Virginia model allows the boarder to function in the nor- opened the fi rst mental health asylum in mal social world” (p. 449). Williamsburg designated speci fi cally for citizens By the 1950s, however, boarder populations with mental illness. Toward the end of the 1700s, began to decline. A study was initiated in Belgium the movement occurred, with in the mid-1960s to study Geel and its mental leadership provided by Phillipe Pinel in France, healthcare system, as its original leader was and Tuke and the Quakers in England. Rees expressing fears that the Colony would dwindle (1987 ) describes Pinel’s philosophy: away. Instead, legislation has elevated the Colony the insane came to be regarded as normal people to autonomous status, and new physician admin- who had lost their reason as a result of having been istrators have inspired evolution in the services exposed to severe psychological and social stress. rendered. More recent research re fl ects the major- These stressors were called the moral causes of ity of boarders are male, ages ranging from 15 to insanity and moral treatment relieves the patient by friendly association, discussion of his diffi culties 75, half are mentally retarded, over 20% diag- and the daily pursuit of purposeful activity; in nosed with . Non-adherence rates other word, social therapy, individual therapy, and are low , and a relatively low incidence of violence occupational therapy (pp. 306–307). is reported. Each family has a psychiatric nurse Before further exploring moral treatment in assigned to them, and hospitalization is available the United States and the evolution of psychiatric if necessary. Of interest, boarders are not kept out care that eventually culminated in expansion of of pubs (taverns), which are “an important part of community psychiatry, a brief sojourn into the community social life” (p. 455). Historically history of Geel is imperative, as it illustrates largely agrarian (which offered boarders opportu- the potential and capacity for a community to nity for farming jobs), Geel is now industrialized; embrace and support people with mental illness boarders still are “given the opportunity to do in a recovery-oriented fashion. Over 700 years meaningful work” (p. 456). Geel 2 History of Community Psychiatry 13

acknowledges and accepts the human needs of the community-based care. The Mental Hygiene boarders and responds to those needs rather than movement was led by Clifford Beers, a brilliant acting on unfounded or exaggerated fears… because of their exposure to and experience with young fi nancier who developed , mental illness, the entire population protects rather attempted suicide and spent 3 terrible years in a than fears members of their community who are state hospital in Connecticut. Against the recom- mentally ill. The living legend of Geel offers an mendation of most of his friends and supporters, opportunity to learn lessons that can encourage effective mental health care—community caring in he felt compelled to document his course of care caring communities (p. 456). (even going so far as to get himself locked down on the freezing violent ward), hoping to improve Unfortunately, communities like Geel were care, demonstrate to the general public that peo- diffi cult to replicate, but dedicated individuals ple with mental illness could recover, and to pre- continued to strive to enhance mental health care vent mental illness and institutionalization. He in America in the mid-1800s. Inspired by was instrumental in the formation of the National Phillippe Pinel, Dorthea Dix promulgated moral Committee on Mental Hygiene, which ultimately treatment reform in America. After failing to evolved into the NMHA, now known as Mental convince the federal government to embrace Health America. This group performed and responsibility for those with mental illness (in published surveys of state hospitals and patient 1854 President Franklin Pierce vetoed a bill that treatment and treatment conditions, and proved would have set up federally funded construction instrumental in changing conditions in state hos- of mental hospitals), Dorthea Dix continued her pitals across the nation (Beers 1981 ) . campaign, begun in the 1840s, to convince state In the late 1940s a clubhouse model of psy- governments “to provide that which many of the chosocial rehabilitation burst on the scene in New ill patients lacked: stable housing, nutritious York City. Based on the belief that those with meals, supportive care in kind and calming envi- mental illness were capable of helping each other, ronment…to provide asylum for those needing The Fountain House (detailed in Chap. 30 ), a support and nurturing to cope with their mental membership organization run for and by persons illness” (Feldman 2010, p. 193). Asylums were with mental illness, was established. It aimed to constructed and patients admitted and “treated” achieve many things for its members that became (with kindness, housing, food, and work). While the backbone of the principle of psychosocial initially capable of providing succor and support, rehabilitation: establishing relationships, increas- the institutions were quickly overwhelmed by an ing productivity and self-confi dence, re-entry in fl ux of society’s less fortunate (those with into society, learning self-advocacy, and fi ghting chronic medical illnesses like syphilis and demen- stigma. It has spawned numerous organizations tia, orphans, and those who were impoverished); locally and has served as a role-model for many battling excessive caseloads and inadequate as they develop their own club-house models funding, humane treatment fl oundered in asy- (Fountain House 2011 ) . lums, and patients were warehoused with little to The use of to treat patients no treatment or care offered (Crossley 2006 ) . with neuroses blossomed in the 1930s and 1940s, Although the introduction of ECT and insulin and the creation of a veteran population affl icted shock therapy ensued, many patients spent the by PTSD in World War II underscored not only remainder of their lives incarcerated in state hos- personal vulnerability to horrendous stress, but pitals. By the mid-1950s, the numbers of patients also the protective power of the unit (commu- housed in American mental institutions peaked at nity), and incentivized the government to step up over 550,000. efforts at treatment (Marlowe 2001 ) . See also In the late 1800s and early 1900s, other Chap. 36 on veterans issues. Until the middle of reforms and treatments in mental health blos- the twentieth century, however, the systems of somed that set the stage for the evolution of care for those with serious mental illness evolved institutional care ultimately transitioning to slowly, and little signi fi cant progress was made 14 J.M. Feldman toward actual treatment of mental illness; instead Act was signed into law; unfortunately, proposed the major focus continued to be segregation of funding for staff was revised downward in 1965, those with mental illness from the general public. and only substantial funding for the building of However, the mid-1950s and early 1960s were community mental health centers remained. Still, the beginning of a massive transition of those these centers were to provide both inpatient and with serious mental illness back into the commu- outpatient services, consultation and education, nity. Although the introduction of the discovery day treatment and crisis services. Centers serving and use of major tranquilizers () rural areas and poor urban areas received addi- has often been touted as the major in fl uence in tional funding. Worried that federal support would de-institutionalization (movement of state hospi- eventually disappear, there was some reluctance talized patients into the community), it is entirely on the part of states to embrace these funds; by the possible that fi nances and politics were major time the program was terminated in 1981, only players as well. Grazier et al. (2005 ) noted: 754 catchment areas had applied for funding. In efforts to transfer responsibility/costs between and addition, many of those staf fi ng mental health among agencies, states and the federal govern- centers focused care on those who were not seri- ment, with persistent funding sources that were ously mentally ill. “These times refl ected the inadequate to meet the kind of resource and service beginning of a philosophical shift in treatment; needs of adults with serious mental illness… resulted in confusion, complexity in access to pay- psychiatric predicated care fell to psychologists, ment for services, created a burden on consumers and effective interventions were thought not be and their families and disincentive from grass root medical or biologic in nature, but to be social providers to meet services needs…what developed or educational, and where it was proffered, that was a lack of consistent national mental health policies…that led to a piecemeal fi nancial system early intervention could prevent mental illness” that diffused accountability, encouraged cost- (Feldman 2010 , p. 194). shifting, and obscured service responsibility result- The passage of Medicaid and Medicare in the ing in vulnerable populations being poorly served mid-1960s offered some provision of care and or abandoned (p. 549). service, although these programs were not State and federal legislation was passed that designed for patients with serious mental illness. moved the development of community -based Without continuous employment, SSDI was not systems of care forward. In 1948 the National available to these patients, and lower payment Mental Health Act created the National Institutes and higher co-pays existed for mental health until of Mental Health with the goal of supporting and recently. IMD (Institution for Mental Disease) sustaining innovative mental healthcare programs restrictions kept (and still keep) patients with and “scientifi c” treatment. In 1958, Congress Medicaid from accessing free-standing psychiat- passed the Mental Health Study Act, which was to ric hospital services. Further elaborations on “provide for an objective, thorough, and nation- funding for mental health care are offered in wide analysis and re-evaluation of the human and Chap. 5 concerning behavioral health fi nancing. economic problems of mental illness” (Public Eventually hospital closures and/or downsizing Law 84-192). A resultant report (Action for Mental meant the state hospital populations went from a Health) delineated necessary funding, staffi ng, high of over 5,50,000 to 62,000 in 1996. In spite of and treatment that President Kennedy used as a promised assistance with treatment, medication, springboard to recommend a National Mental housing, and vocational training, during the 1970s Health Program, calling for the building of 2,000 and 1980s local mental health centers proved at mental health centers to provide comprehensive best inconsistent in providing said treatment, and community-based programs to serve those with patients often found themselves facing “trans- severe mental illness, and adults, children, and institutionalization” (placement in nursing homes, families suffering from stress (Ewalt 1961 ) . In boarding homes, foster care, jails or prisons). 1963, the Mental Retardation Facilities and While President Nixon was successful in with- Community Mental Health Center Construction drawing some public support of mental health 2 History of Community Psychiatry 15 care, in 1977, President Carter empowered a Declared the decade of the Brain by President Commission on Mental Health to review services George HW Bush, the 1990s did re fl ect a revival and funding across the nation. It discovered that in interest in biological treatment of serious men- community services had increased over the last tal illness, and ushered in a plethora of new medi- 15 years, but that substantial numbers of cations, including the atypical antipsychotic populations (ethnic minorities, the urban poor, medications, which were touted as being superior women, children, veterans, those with physical to older antipsychotic medication; they did seem handicaps, adults with chronic mental illness) to have a reduced (though still present) probabil- were underserved, living without basic necessi- ity of causing tardive dyskinesia, a dramatic ties, limited aftercare or medical care, and movement disorder side effect. However, as a increased rates of hospital recidivism. The report class they also carried with them a propensity for encouraged the development of services for those placing patients at risk for weight gain, and devel- with chronic mental illness, proposing federal opment of diabetes, hyperlipidemia, and/or meta- grants for said development; the National Mental bolic syndrome. While promising to enhance Health Service Systems Act of 1980 called for treatment, these new medications also imposed and funded a massive overhaul of the nation’s huge fi nancial burdens on formulary costs, and mental healthcare system to focus priorities on “opened the door for massive infl uence by services for these underserved populations. pharmaceutical companies” (Feldman 2010 , Unfortunately, it was underfunded by President p. 196). The Medicaid Rehabilitation option did Reagan and by 1981 deleted entirely by the encourage a focus on those with serious mental Omnibus Budget Reconciliation Act, decimating illness, and encouraged development of a broader years of federal leadership, serving to further dis- array of services by offering payment for sup- mantle the regional impact of NIMH, and reduc- ports such as case managers, day treatment, and ing staff and services at local mental health ACT (assertive community treatment teams). centers. Criteria for SSDI also changed then; Many mental health centers utilized Medicare while patients with serious mental illness made up funding to provide partial hospitalization services 11% of SSDI recipients, they were 30% of those in an attempt to minimize hospitalization and who lost program eligibility (Feldman 2010 ) . rehospitalization. It should be underscored that The 1980s and 1990s were also decades of the focus of treatment during this time was on imposition of managed care on the service provi- symptom control. sion for mental health patients in the community. By the early 1990s, there were limited tool Capitation systems were put in place, ostensibly kits to guide clinical interventions, primitive evi- to maintain quality services while controlling dence-based practices, few nuanced outcome costs. Standardization of assessments and treat- measures, and an increasing demand for service ment, limited enrollment rates, risk-sharing, and in the face of an underdeveloped psychiatric external regulation (all often predicated on mini- workforce. In response, the federal government mization of hospitalization) placed enormous in 1992 directed NIMH to be reorganized under burdens on local MHCs. But “managed care, NIH (the National Institutes of Health) and which fostered a system in which choice was lim- CMHS (Center for Mental Health Services) to be ited, care was managed to decrease costs, and moved under SAMHSA (Substance Abuse continuity was threatened, was particularly trou- Mental Health Services Administration), which blesome for individuals with socially stigmatized, sought to encourage and support mental health- poorly understood illnesses that had traditionally care research and workforce development. The been treated separately from standard medical philosophy of a community supports system was care” (Feldman 2010 , p. 196). Many state sys- embraced. Forays into vocational rehabilitation tems of care funded by Medicaid were decimated, blossomed. Psychosocial and psychiatric reha- and equivocal results from this experiment bilitation models were developed by William continue to be reported. Anthony and his colleagues which emphasized 16 J.M. Feldman the development of vocational rehabilitation relapse prevention, consumer-centered treatment plans; they focused on characteristics of work planning, and strengths-based assessments. that were desired, the skills and knowledge nec- Involvement and engagement with families as essary to perform the work successfully, the cur- collaborators has occurred. NAMI’s use of family- rent level of readiness, and the methods to be to-family techniques has proven dramatically its used to help close the identifi ed gaps (Wallace effi cacy. Addressing co-occurring disorders (sub- 1993; Lamb 1994; Liberman 1992 ) . A wide vari- stance use/abuse/dependence and medical ill- ety of skills training, family psycho-education, nesses concomitantly with mental illness) is and supported employment modules have been proving challenging and yet without addressing developed since then (see Chap. 25 covering sup- these co-existing illnesses, patients will continue ported employment). Barton ( 1999 ) reported that to be at higher risk for relapse and rehospitaliza- multiple programs focusing on empowerment, tion. Cognitive behavioral therapy, dialectical competency, and recovery had proven helpful: behavioral therapy, and peer support (utilization “the range of social, educational, occupational, of consumers as peer specialists, bridge programs) behavioral and cognitive training has improved have offered consumers innovative therapies that the role performance of persons with serious can enhance recovery. Community psychiatry has mental illness, and noted an average of 50% entered an era that seeks to endorse and support decrease in cost of care due to reduced hospital- rehabilitation and recovery, often increasing the izations” (p. 526). use of assertive community treatment teams to The report of the U.S. Surgeon General in reinforce and support the skills sets necessary for 1999 (U.S. Department of Health and Human recovery. Attention to the imperative issue of sta- Services 1999 ) denoted the gap between research ble housing has moved to the forefront, with mul- and practice, and made recommendations tiple models of housing (dry vs. damp vs. wet; “emphasizing a scienti fi c base, overcoming housing fi rst, transitional housing, permanent stigma, public awareness, adequate services, cul- housing) being attempted. tural competence, and real parity” (Cohen et al. Several salient court decisions have had a tre- 2003 , pp. 467–468). President Clinton’s attempt mendous impact on the development of improved at healthcare reform, which included parity services for mental health patients. These are between medical and mental health, proved well summarized on a time-line in Chap. 6 on unsuccessful. It was not until 2008 that Congress advocacy. Suf fi ce it to say, each federal ruling ultimately passed legislation requiring parity. underscores the movement along the spectrum of More recently, tool kits and clinical guidelines the right to receive the least restrictive treatment have suggested evidence-based treatment inter- by those committed to the states for mental health ventions (APA practice guidelines), and since care. Recent legislation continues to affect com- 2000 there has been increasing support for the munity psychiatry. The Medicare Modernization development of means to assess effi cacy of treat- Act of 2005 proffered means by which those who ment and the push for evidence-based practice. had Medicare were able to purchase their medi- During the latter part of the 1990s and into cation, including psychiatric medication. In 2008 2000 and beyond, the major focus of treatment the Parity Act was passed that legislated that pay- has shifted from symptom control to rehabilita- ment (and limits) for mental health and provision tion to recovery, “with the goal to help people of mental health services (including substance pursue independence, self-management, person- abuse services) had to be essentially equivalent ally meaningful activities and better quality of for medical and mental health care. Despite life” (Drake et al. 2003 , p. 427). Core guidelines concerns that costs would rise precipitously, for recovery-oriented services included research re fl ects little impact on utilization, cost, development of trusting consumer/professional or quality of care (Azzone et al. 2011 ) . Healthcare partnerships less focused on hierarchy than reform, passed in 2010, offers a unique on shared decision-making, psycho-education, opportunity for the provision of mental health 2 History of Community Psychiatry 17 care; however, ongoing challenges exist regard- coordinated) and the consumer supported in the ing the limitations of the mental healthcare work- community, any success is fl eeting. Stigma con- force and the interface between mental health and tinues to hold powerful sway over law makers primary care (please see Chap. 14 for detailed and common citizens, and fi nancial systems discussion). (given the recession of 2008–2011) feel com- In 2003, President George W. Bush assembled pelled to decrease funding for many things, the New Freedom Commission on Mental Health. including mental health. Perhaps the lives of This group of healthcare practitioners was those with mental illness can surmount the extant empowered to survey services across the United disparities to reach futures headed for recovery. States, identifying programs that were particu- These hopes are best summarized (though cer- larly successful: “It reviewed the science of men- tainly not mandated or funded) by the President’s tal health, and mental health services, (and New Freedom Commission ( 2003 ) : “to achieve offered) an indictment of the mental health ser- the promise of community living for everyone, vice system, which included fragmentation/gaps new service delivery patterns and initiatives must in care for children and adolescents, increased ensure that every American has easy and consis- unemployment and disability (in those with tent access to the most current treatment and best SPMI) and noted that neither mental health nor support services.” suicide prevention was a national priority.” Many examples of successful programs were high- lighted. As detailed in Chap. 41, the commission References recommended six general goals: 1. It must be understood that mental health is Angell, M. (2011). 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Unfortunately, no monies were attached to the Bhuga, D. (1992). Psychiatry in ancient Indian texts: report or its recommendations, so the report’s A review. History of Psychiatry, 3 , 167–186. Brothwell, D. R. (1981). Digging up bones: The excava- capacity to provide tangible infl uence to support tion, treatment and study of human skeletal remains . evidence-based practice was limited. To its credit, Ithaca, NY: Cornell University Press. the federal Center for Medicaid and Medicare Cohen, C. I., Feiner, J. S., Huf fi ne, C., Mof fi c, H. S., & Services embraced and promulgated a mantra of Thompson, K. S. (2003). The future of community psychiatry. Community Mental Health Journal, 39 , moving science into service, and has focused 459–471. funding on that research which could do so. Crossley, N. (2006). Contextualizing contention. 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