I want to dispense a new term to conceptualise the poison wreaking so much havoc on community mental health. The word: Neo-institutionalisation. Neo-institutionalisation must be stopped at all costs! Neo-institutionalisation is the hazardously complex systematic formula or medical value justifying a patient’s ‘need’ for mental health treatment. As stated under the community mental health model, clinicians explain the need for a person’s treatment every day to enrol them into therapy or mental health service. This formula, or medical value, is inputted into some form for insurance reimbursement or into an application for government services.
Neo-institutionalisation evolved and came into being from the clumsy rollout of deinstitutionalisation policies in the 1970s and 1980s. The very moment deinstitutionalisation stalled is the moment the shadows of neo-institutionalisation passed over the mental health community and it has been looming over our heads ever since. The crisis is only now realised because clinicians are finally asking: Why aren’t some folks recovering? And why do some people keep falling out of the system?
The status of community mental health treatment continues to lose ground. The number of questions is rising around poor patient outcomes. At the root of it, the vision that changemakers had when community mental health came into being is tired, and the frame which is masking the issues within is breaking, if not already broken. The term community mental health evolved from the vacuum left in the wake of deinstitutionalisation. But, like most vacuums, impurities and filth crept into the works, mucking up what could have been a new era for mental health. Instead, these impurities continue to stifle long term progress.
I’ve been a victim of the mental health system’s broken aspects and since I began practicing as a social worker, I have been thinking about reform – how and to what end? When people’s lives and their health are at stake, we need to not only reform but overhaul the system and create a new gold standard in mental health treatment.
However, turning the old system on its head and supplanting it with a functioning replacement seems rather slippery, precarious, and possibly dangerous if something goes wrong. That doesn’t even articulate the issues required to revolutionise the system to replace it, so I can only imagine the enormity of the task ahead.
To make this shift a reality, demystifying neo-institutionalisation to the public needs to be the priority of the day. People already had mixed feelings about discharging or being released from long-term settings and the system, moving to a community mental health model depending on their beliefs about recovery. The new term, community mental health, signalled seemingly more person-centred care in modern mental health treatment, but hidden and covert aspects persisted without pushback.
The local community mental health commission must increase pathways to access services so that consumers can gain access to the many lines of care already provided by the systems of care in New York State, and by all regulatory bodies with a vested interest in mental health treatment. Neo-institutionalisation is complex and insidious, and it must end. The plan I suggest is threefold.
The first phase of operations targets the state psychiatric centres, based on a global assessment of outlying communities and the express needs of the consumers being discharged.
The second phase targets the overhaul of treatment silos and installations in the community, that needs more integrated access for consumers. Without question the resources already exist in the community, and this document proposes how to reconfigure existing structures that provide mental health treatment to serve patients. The success of phase II depends on the elimination of freestanding treatment silos. Treatment programmes that discriminate and choose to serve only subgroups or ‘high functioning’ patients openly will be given a mandate by the Office of Mental Health to broaden their scope of services or be subject to a loss of licensing and funding. An example of a programme that only serves a small niche of ‘qualified’ patients includes outpatient settings that refuse to accept state-sponsored insurance for disabled and reliant patients on Medicaid and other service dollars. Conversely, treatment centres that offer services to all patients or are cited for restructuring and successfully reconfigure their clinics, group practices, and day treatment centres will be awarded funding to commit to on-site projects and community outreach projects to extend community services further.
The third and final phase of this plan is an ongoing community mental health surveillance and hygiene study, which will continue throughout reintegration and the patient discharge to the community. Upon the final release of patients from extended care units, when all existing treatment plans up for review have expired, the final discharge from the locale’s state psychiatric centre will have walked out of the gates of the hospital. Under the assumption that the influx of thousands of newly discharged chronic patients will test the limits of the community’s local emergency rooms and the community hospitals’ abilities to provide services and will primarily increase the census of mental health treatment at health centres, surveillance and hygiene study will bridge the existing gaps in each community during the critical phase of mass-organised discharges from state psychiatric centres.
The study will be monitored and fed into a state-wide planning commission for full community access to and integrate mental health care. Next, a broader approach, including at the global level, can be implemented and used as a model for other state regulatory bodies interested in eliminating the dated care level and the deferred recovery of patients.
I am suggesting that we turn the system on its head without further delay. We first need to re-establish the consumer’s voice in treatment. The system is still very much run by so-called experts and autocratic practitioners, who left behind the noble helping profession for commercial benefit. These ‘clinician-crats’ now dominate the system and make up the ruling or decision-making elite in community mental health and local government. The only exception to this dominating stakeholder is the peer professional and prosumers.
Unfortunately, to do business with these ‘clinician-crats’, the peer profession has been commodified and reduced to dollars and cents on the state budget plan. To truly reform the system, we need to restructure the system to match consumers’ needs with programmes and services genuinely reflective of the community and the values we want to invest in the new mental health structure. I am suggesting that this can only mean full access and integration of mental health care into the community. No gaps, no service delays, or deferral. No disparities and no new adjectives to describe the same treatment used for decades. Integration includes research and clinical trials at the community level to move the discourse further through on-site access to the latest modalities available.
Maxwell Guttman teaches social work at Fordham University. He is also a mental health correspondent for Psychreg where he shares his insights on recovery and healing.