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Trends in community mental health nursing

During the past three years much has been written and said about community mental health programs. Their development has been traced, their elements defined, and their goals articulated. I shall assume that the readers of this magazine are both interested in and well informed about community mental health programs. This assumption will permit me to direct my discussion, provocatively I hope, to new trends in programing, new patterns of organization, new concepts of treatment, and the new problems that are emerging. The most important of the new trends is the national effort to plan community programs for the mentally ill and retarded. This planning is a cooperative enterprise between professional mental health workers and a vast number of other citizens. Conjoint planning has produced master plans in every state for the mentally ill and for the mentally retarded. The success of this venture may be expected to extend planning efforts to include a national program of services for children, special programs in the correctional field, and services for chronic alcoholic patients. It has been demonstrated that good planning has led to successful social and political action and has brought closer together the citizens and the professionals interested in the field. The problems they are encountering and the choices they are making among alternative solutions are leading to more meaningful communication among these groups. Another trend of great significance is the delivery of services by the federal government, which heretofore has been concerned largely with promoting research, developing manpower resources, and supporting training. Under new legislation the federal government already is distributing services for the mentally ill and retarded. Its present role in the programs for heart, cancer, and stroke is to plan training and research programs, but the next phase could be to offer service. When the federal government defines and provides services, it also sets standards. Moreover, when federal money is involved, there must also be federal control, lest government money be wasted or improperly used. We must also face the reality that service follows the dollar. With medicare support, for instance, many people will be diagnosed and evaluated in a general hospital and then moved to a nursing home, for whose services they are also eligible. Thus we may expect that an increasing number of patients over 65 will be sent, after a short stay in an intensive treatment facility, to nursing homes or to other types of extended-care facilities that will undoubtedly develop. However, nursing homes lack the resources to offer psychiatric treatment, and many elderly psychiatric patients may be better served in a mental hospital that can offer intensive treatment for three to six months, longer than is feasible in a general hospital psychiatric unit and more intensive than is possible in a nursing home. The decline in the census of mental hospitals, recognized at Boston State Hospital as early as 1950, may be expected to continue. During the decade that ended in 1954, public mental hospitals in this country showed a 21 per cent increase in the number of patients in residence. In the decade that ended in 1965, there was a decrease of 15 per cent . This decline occurred during a period when the country's population was expanding rapidly, and when admissions to the hospitals were increasing.

Some mental hospitals have dramatically exceeded the 15 per cent census reduction. The Medfield and Worcester state hospitals in Massachusetts and the mental hospitals in Iowa, among others, have already exceeded the 50 per cent decline in census predicted by President Kennedy. Early case-finding and early treatment, better rehabilitation, and the intensive development of alternatives to inpatient care have contributed to this amazing decline. LaFave reports a 60 per cent reduction in the census at the provincial mental hospital in Weyburn, Saskatchewan . It was achieved by: Preadmission screening by a senior psychiatrist who was on 24-hour call to discuss the need for hospital admission or a desirable alternative; A tenfold increase in the number of patients seen in outpatient departments. We know that aftercare reduces the need for readmission, because unsupervised patients frequently fail to take prescribed medicines or to follow instructions and also because family physicians sometimes prescribe inadequate amounts of drugs; A larger number of patients successfully treated in general hospitals, so that they were never admitted to a mental hospital. Even at the point of admission, an alternative to inpatient care can often be found. As the hospital census declines, a larger number of patients can be admitted who stay for shorter periods. Treatment programs to achieve shorter stay have to be more intensive and call for a larger number of skilled personnel than do custodial programs. Many former patients and many who never had inpatient care are living in the community and receiving treatment through day care wards, day hospitals, or outpatient departments. Most mental hospitals have an intensive rehabilitation program for discharged patients. Carrying out these activities makes greater demands on the staff than concentrating services upon inpatients. If the hospitals are also to reduce their readmission rate, they will have to step up their rehabilitation activities. Public mental hospitals are operating more effectively than ever before and need continued and increased support to fulfill their enlarged mission. We can no longer use the number of patientoccupied beds as a base for financing. The treatment of inpatients has become but a small part of the hospital's total responsibility for the continuing management of ambulatory patients. As patient-stay in the public mental hospitals becomes shorter, an increasing number of people are willing to come in either on a voluntary commitment or to seek informal admission. As a consequence the trend is to open doors and to give patients as much responsibility for their own management as possible. With this trend has come increasing respect for the dignity of each patient. A recent survey has shown that between 465 and 500 of the 5400 community general hospitals in this country have established psychiatric units of at least ten beds and that more than 1000 general hospitals admit patients with psychiatric disorders to their general wards. In the four years from 1954 to 1958, the number of psychiatric admissions to general hospitals increased by

27 per cent and the number of general hospitals accepting mental patients rose by 41 per cent (4). Soon all truly general hospitals will admit psychiatric patients. Smith and McKerracher say that all psychiatric disorders can be handled in a general hospital. However, at a conservative estimate, between 5 and 20 per cent of psychiatric patients admitted to general hospitals are transferred to mental hospitals. The number transferred may become larger when the intake policies of general hospitals no longer exclude some varieties of mental illness. Even today the trend in psychiatric units in general hospitals is to treat a larger number of major mental disorders, whereas formerly nearly all the psychiatric admissions were for depressions, psychoneuroses, or character disorders. A recent study by Mannucci and Kaufman showed that 39 per cent of admissions to a general hospital psychiatric unit were for psychoneuroses, 11 per cent for character neuroses, 7 per cent for personality disorders, and one per cent for alcoholism. Among the more severe disorders, schizophrenia accounted for 15 per cent of admissions and organic brain syndromes for 3 per cent . Both the number of patients being admitted and the variety of illnesses being treated are increasing. In the general hospital there is also a trend toward a shorter period of inpatient treatment. The average psychiatric patient spends 20 days in a general hospital, with a median of 17 days. At Metropolitan Hospital in New York City, a six- to ten-day stay is followed by posthospital management supervised by a public health nurse. The development of the day hospital and the day ward for resident patients is of great significance. As experience with this modality increases, we are finding that a large number and variety of patients can be managed by partial hospitalization. The principal contraindications to day care are suicidal tendencies and paranoid ideation. We note also the increasing nationwide trend toward treating psychiatric disorders in the private offices of psychiatrists and other physicians. The number of visits to outpatient services and to aftercare clinics has also markedly increased. The number of clinics increased 11 per cent in the two years from 1961 to 1963, and the number of man-hours of therapist time available in these clinics increased by 22 per cent during the same period . The availability of insurance benefits to pay for outpatient services may be expected to encourage the trend toward greater use of ambulatory psychiatric treatment. The few studies now available on use of insurance benefits indicate that a considerable number of patients require only four or five interviews and that the median number of hours of outpatient treatment is between eight and ten . Becker, Murphy, and Greenblatt have highlighted the importance of an emergency service; they describe the home treatment service established at Boston State Hospital in 1957, in which it was found that alternative care was possible for one half of the patients deemed in need of hospitalization by the referring agent . In 1964 the establishment of a screening service at the hospital revealed that 75 per cent of the patients could be handled without resorting to inpatient care.

The federal regulations governing Title II (Community Mental Health Centers Act) of Public Law 88164, which became law in May 1964, provided that one of the five essential components of a community mental health center must be 24-hour emergency service. This requirement will accelerate the trend to establish such services. Recently the Joint Information Service of the American Psychiatric Association and the National Association for Mental Health made a study of emergency services in various parts of the country and described them in the book The Psychiatric Emergency, published this year. Some 154 facilities were identified as providing such services, in emergency rooms of general hospitals, walk-in clinics, suicide prevention centers, and psychiatric hospitals and clinics. No longer, therefore, is there exclusive reliance on inpatient services for psychiatric treatment. The rapid development of alternative programs is leading to a decline in the estimated number of inpatient beds required for psychiatric illness, once stated to be 3 beds per 1000 general population. Studies made in Great Britain indicate that 1.8 beds per 1000 might be sufficient. A study done at University Hospital, Saskatoon, Saskatchewan, showed that an even lower bed ratio might suffice (5). Mental hospitals in many areas are developing programs that provide intensive inpatient care, outpatient services, emergency services, halfway houses, aftercare clinics, and rehabilitation programs. Many of these programs have been financed by a Hospital Improvement Project grant from the National Institute of Mental Health. General hospitals with psychiatric units are likewise developing outpatient clinics, day hospitals, and other community services. From such programs may well evolve comprehensive mental health centers. In Illinois, for example, the department of mental health has divided the state into regions, each served by a zone community mental health center that offers a comprehensive range of services. The public health department of San Mateo County, California, has created a network of public agencies that provides a continuum of services through which the patient may move. The planning was based on the needs of the county's population. Private psychiatrists, too, are moving toward a more varied practice. Many have patients in a general hospital, use their offices for outpatient services, see patients when an emergency develops, supply consultation to other community physicians whose patients suffer from emotional problems, and make contractual arrangements with community agencies to offer consultation, service, or both to psychiatric patients. These many new patterns of organization may go a stage further by federating all community agencies into one network, and fill gaps in the existing services by creating new resources. In such a federation it would be possible to admit a patient to any one unit within the network and thereafter allow him to move freely within the system according to his needs. Today the word community has a new meaning. It is more than a geographical area. It offers its residents many kinds of services and fills a variety of needs. The cultural traditions and the customs of the various ethnic groups in the population are important. Both behavior and interpretation of psychopathology are influenced by sociocultural factors. Mental health workers are beginning to develop sensitivity to the community they serve, to learn its complexities and its

needs in all kinds of health programs. They are also learning the importance of the power structure of the individual community, and how this structure supports and balances the kaleidoscopic patterns of responsibility for the administration and funding of various social programs, including the medical ones. We are also beginning to understand more about the populations from which we draw our patients, and to identify those populations in which mental disorders are likely to be most prevalent. If a family belongs to a nonwhite race and has a woman as the chief wage earner, the likelihood of poverty rises from 40 per cent to 81 per cent. If the same family is in a rural area, the likelihood of poverty becomes 89 per cent. The very poor have high divorce and separation rates: harsh and inconsistent punishment in childhood is often a corollary, and teen-age marriages may result, thus perpetuating the poverty cycle, because neither the boy nor the girl is mature enough for marriage and responsibility. Single factors involve relatively little risk to mental health. A broken home by itself may not increase mental illness; poor physical health of parents may possibly be more significant. When several stress factors impinge on the individual at once, the likelihood of his developing mental disorder may be increased. We are just beginning to appreciate the implications of studies in depth of populations at risk. Within each community the goals must be the same: individual treatment and rehabilitation for all patients of all ages and with all types of illness. This assistance must be continued from the moment the need is recognized until the problem is acceptably resolved. Anybody eligible for any service must be eligible for every service he needs. Ideally the therapist who is responsible for giving care during one phase of the treatment will continue to work with the patient in all other phases of his illness. The longer psychiatrists and other mental health workers spend in the community, the less they are inclined to see the patient out of context. Instead of treating him in isolation from his family, we are increasingly turning to family and group therapy, realizing that individual therapy, besides being costly in professional time, may be an inappropriate tool with which to attack some types of mental disorders. Another development to be expected is the extension of the consultant role of the psychiatrist to physicians, to mental health professionals, and to social agencies, as consultation services are required in all federally supported community mental health programs. The literature on the consultant role is scanty. Although the pattern may be expected to follow that used by other medical specialists, problems are inevitable. There are discrepancies between the expectations of other professionals and the services given by the psychiatric consultant; these discrepancies are based largely on the differences in orientation toward psychiatry. Interest in preventing mental illness has revived. We are making strides in secondary prevention by reducing complications and by shortening the duration of illness, thus lessening its handicapping chronicity. Evidence that we can achieve primary preventionreducing the incidence of illnessalso exists, but in a more limited context, as I have discussed elsewhere .

We are eager to explore the relevance of social theories that hold that to reduce stress on individuals will also reduce the prevalence of mental disorders. We would like to see dependency prevented, poverty eliminated, the aged cared for, and delinquency controlled. The trick is how to do these things. If they were done, would mental disorder disappear? Duhl, Fried, Watts, Freedman, and many others have studied urban communities, and from their studies much has been learned about certain stresses upon the individual and the family . If these stresses can be decreased and a more healthy environment created, this may reduce the incidence of mental disorder. In general, the public expects us to use most of our scarce psychiatric resources for the seriously mentally ill, who cause the community distress and who may endanger themselves or others. The public is concerned, too, about those who, because of mental illness, cannot work. Lower in its priorities is help for people who are troubled personally but who can still function. Lowest of all comes the public desire for preventive treatment for those who, under stress, may be susceptible to mental and emotional illness. If, however, the weight of evidence offered by the behavioral and medical sciences can demonstrate that manipulation of social systems will reduce the incidence of mental illness, then more of our resources will be shifted to this type of prevention. Meanwhile, basic and applied research will continue to seek new and more specific treatments for mental illnesses and to explore other, more effective ways to prevent them. With the increase in population, acceleration of social change, and expanding horizons in science has come an increased need for communication. Resources for the exchange of information have increased enormously. The volume of printed words increases, as well as the number of conferences and meetings and other insistent demands upon our attention. It is said that there are now 9000 medical journalsmore than the most eager practitioner could hope to read and digest if he devoted his total working life to the task. Under a grant from the National Institute of Mental Health, the APA has launched a four-year study of the processing of information, how it should be stored, and how it can be retrieved. The study will attempt to determine the wants and needs of psychiatrists for information and will attempt to devise new and more effective ways to package information to facilitate its use. As the rate of scientific advances accelerates, so does the need to reduce the time it now takes to apply new knowledge. For instance, a new drug may be introduced into psychiatric treatment, but after a period of use it may produce a severe toxic reaction. We must reduce the time lag between this discovery and its publication in the scientific literature, and we must also secure the attention of physicians, so that in prescribing the drug they may apply the appropriate safeguards. We must also continue to seek new ways to effectively continue the education of all mental health professionals to enable them to keep abreast of burgeoning information. With the development of these new trends have come new problems. They are similar to those encountered by our medical colleagues, who, once they understood and conquered infectious and toxic disorders, turned their attention to improving the management of chronic medical

conditions. Chronic diseases, medical or psychiatric, call for new public health measures if the total health of the community is to be protected. Ethical as well as public health problems arise. For centuries the physician's code of ethics has governed medical behavior. Today the patient is often the concern of several agencies, and with the free movement of patients within a treatment system, the need to share information increases. Some agents who must have information are nonmedical associates. Insurance carriers need it; personnel departments in industry need it; patients and clients themselves have the right to certain information about their illness. We must develop new standards of confidentiality that will enable us to share the information that is essential to fulfill an assigned mission and at the same time not violate the patient's right to have certain aspects of his illness kept confidential. Payment of fees and other methods for financing the treatment of mental illness are also coming under scrutiny. It has been traditional for the private physician to charge those who can pay for his services. Today he may collect consultant fees from state, federal, municipal, or county governments in return for giving consultation to a community mental health program. Part of his income may be a monthly fee from a health agency; other payments may come from insurance carriers and from medicare funds. As the private physician receives more of his income from multiple sources, we must develop ethical guidelines to ensure adherence to the principle of "usual and customary" fees. We must be alert, too, to evaluate the results of the newly developing community mental health programs. Without evaluating these new systems of management, we cannot accumulate evidence to demonstrate the value of the changes or to point the way to needed corrective action. Defects will become apparent as our experience continues. The increased demands of the expanding mental health programs make manpower development crucial. The APA Commission on Manpower is striving to discover and test new ways of developing essential manpower. We must continue to support essential training activities and to seek new ways of attracting young people into the mental health professions. It has been demonstrated that student and volunteer programs and career days for students do attract recruits, or at least provide the stimulus for young people to seek more information about psychiatric careers. We must attract more women into medicine and into psychiatry. Only 7 per cent of all physicians in this country are women, but the fact that 12 per cent of all psychiatrists are women illustrates the gain that is possible. The number of Negro physicians being trained is not proportionate to their increasing racial population, and there are few Negroes in psychiatry. Long-standing prejudices, unfavorable attitudes within the family and in society, and financial barriers still prevent these two important groupswomen and Negroesfrom coming into medicine and psychiatry. We must work to create a more favorable social climate for them. One of the quickest ways to increase the number of new physicians is to reduce the number of medical school dropouts. The selection process usually ensures only a student's intellectual potential, not his emotional fitness. There is some evidence that medical schools that offer their

students highly developed health services, including counseling for emotional problems, have lower dropout rates than schools that do not offer these resources. Innovation may well characterize some of the solutions proposed to offset manpower deficits. Reiff and Riessman have pointed out the need for an expediter in the community who would help a patient find an appropriate service. The White House Conference on Health called attention to the potential value of a health visitor and also suggested the use of subprofessionals as aides to professional personnel. It is easy to conceptualize many other new problems that we expect to develop concurrently with the development of new services, but it is more difficult to design corrective actions. Although the goals and regulations of the new services are determined at the federal level, the implementation of programs on paper requires local cooperation. We must remember that social change depends in part on the development of new methods. It would be self-defeating for social institutions to rush to get new money and apply it in traditional ways under new labels. It is essential to coordinate the many fragments of the new programs, but it is difficult to do so. Although specialization is essential to the scientific pursuit of new knowledge and to its application in professional practice, the disorders of individuals do not, unfortunately, divide themselves into neat compartments. Community mental health programs will fail if each agency and each profession seeks to use public funds to create new empires. But if, sacrificing our vested professional and administrative interests, we work together toward developing better ways of meeting the needs of all mentally ill people, we may succeed in establishing successful community mental health programs.