Community Mental Health Care: An Alternative to Neglect or Institutionalization

BEFORE 1955, a person who needed psychiatric care, but could now afford private therapy, had only two options. He either suffered without help or entered a state mental hospital through voluntary or involuntary commitment. State mental hospitals are oppressive institutions. In each, generally one thousand to two thousand patients live in understaffed, locked wards without their personal possessions. The challenge of simply coping with life in a mental institution destroys a patient's self-respect and saps his desire to work out his problems and return to life in his community. Many patients deteriorate. Many never leave. It is a disgraceful sham to call these institutions hospitals. They are human garbage dumps for communities which choose to hide their undesirable and disturbed members from view rather than to help them.

Large state mental institutions are still around. Several ring the Boston metropolitan area: Boston State Hospital, Westboro State Hospital, Metropolitan State Hospital and Bridgewater State Hospital. After 125 years of development, they still fail miserably to meet the needs of their patients. Westboro, for example, has only four doctors for approximately one thousand patients. Since 1955, though, a desperately needed alternative to despair without help or stagnation in a mental institution has developed for people who cannot pay for private therapy: networks of community mental health programs.

Community mental health programs help people cope with their emotional and mental problems with as little disruption of their lives as possible. They avoid hospitalizing people except in emergencies, such as threatened suicides and extremely severe psychoses. Instead, they make therapy and counseling available to the large numbers of people who can continue to function in their families and communities while they receive psychiatric help.

Such community programs have only developed in Massachusetts in the past fifteen years. At first there were only isolated, small-scale programs, such as family counseling centers, halfway houses for former alcoholics and for ex-mental patients, and schools for emotionally distrubed kids. These programs served only a tiny fraction of the people who needed help.

IN 1966, the Massachusetts Mental Health and Retardation Act officially reoriented state mental health care away from merely custodial, institutional care toward extensive, community-based systems. The Act divided the state into thirty-nine mental health and retardation districts, called catchment areas, each one run by an Area Board composed of concerned citizens and professional mental health workers. This official reorganization of state mental health services has spurred a great acceleration in the development of community programs in the past six years. Two catchment areas in the Boston region have been at the forefront of the community mental health movement in Massachusetts: the Cambridge-Somerville Area and the Harbor Area, which comprises Beacon Hill, the West End, the North End, East Boston, Charlestown, Revere, Chelsea and Winthrop. These areas exemplify the progress, shortcomings, problems and promise of community mental health in Massachusetts.

The Cambridge-Somerville Area had a small loosely-knit collection of public and private mental health programs when the state established the Cambridge-Somerville Mental Health and Retardation Center on Sacramento Street in 1969. The Mental Health and Retardation Center has since given a needed boost to already existing community efforts by contributing money and staff, has started whole new programs, and has begun to coordinate services throughout the area. The Center now serves as the administrative focus for the whole Cambridge-Somerville Area, coordinating a comprehensive array of services for emotionally disturbed and mentally retarded people in eighteen locations.

Its programs include: the Cambridge and Somerville Guidance Centers, the Cambridge Infirmary, and the Cambridge Hospital Department of Psychiatry. These projects together provide in-patient care, therapy on an out-patient basis, and recreational and therapeutic day care for emotionally disturbed adults and children. Mental health care in the area includes more than just psychiatric help. Other services in this comprehensive system are a ten-bed detoxification program for alcoholics in the Cambridge Hospital, a halfway house for former alcoholics, a program for retarded people at the Walnut Street Clinic, and a nursery school for emotionally disturbed and mentally retarded kids under seven years of age. These programs represent cooperative ventures between the state Mental Health and Retardation Center, the cities of Cambridge and Somerville, and private organizations such as the Cambridge Mental Health Association and the Board of Casper.

IN ADDITION to these public mental health centers and cooperative, public-private efforts, there are still many small-scale, private mental health projects in the Cambridge-Somerville Area. These include Harvard's Clinical Psychology Program (CPP), the Cambridge-port Problem Center, Wellmet Halfway House for ex-mental patients, the Mental Patients' Liberation Front's informal after-care group, and the Neighborhood House after-care program for ex-mental patients.

The Harbor Area offers another example of good, but limited, efforts recently supported, expanded and coordinated by state help. Before November 1970, there were several fine, local mental health programs in the Harbor Area. As early as 1955, a team of Revere school social workers led by Dr. Joseph DeLena extended its work beyond the schools to serve the needs of Revere Students. The group's efforts culminated two years ago in the opening of CHEC--the Comprehensive Health Education Center. Maintaining its base of operations in the Revere schools, CHEC has expanded to meet a remarkable number of Revere's mental health needs. CHEC provides emergency psychiatric care; group, individual and family therapy and counseling; and a homemaker service for families with physically or emotionally disabled members. It also offers drug counseling, operates a hotline for people in crisis situations, and teaches high school courses to help teen-agers deal with sex, alcohol and drug issues. CHEC is a model of cooperation between the community and professionals to meet the mental health needs of the community.

Other local mental health programs in the Harbor Area include a halfway house in East Boston and the North Suffolk Mental Health Center. The North Suffolk Center opened in 1962 in East Boston as a child guidance center run by the cities of Revere, Chelsea, Winthrop and East Boston in cooperation with the North Suffolk Mental Health Association. This program expanded into a comprehensive mental health care system which serves the four communities.

The Erich Lindemann Mental Health Center opened in Government Center in November, 1970, as a combined project of the out-patient wing of the Massachusetts General Hospital's Department of Psychiatry and the Massachusetts Department of Mental Health. This facility has begun to give local Harbor Areas programs the same kind of help that the Cambridge-Somerville Mental Health and Retardation Center gives to its area. Besides pumping in money and staff to existing Harbor Area projects, the Lindemann Center has established new programs and provides valuable coordination. The Lindemann Center has 25 bed ward for Hardor Area residents, soon to increase to 100 beds. It also offers adult psychiatric day care and out patient therapy. When the North Suffolk Mental Health Center split into the East Boston-Winthrop and Revere-Chelsea psychiatric clinics, the Lindemann Center took charge of the Revere-Chelsea team. The East Boston-Winthrop group continues to operate out of the North Suffolk Mental Health Center, while Lindemann's Revere-Chelsea team works in the Chelsea Memorial Hospital and CHEC.

RATHER than reinstitutionalize psychiatric care into one central building, the Lindemann Center tries to coordinate an extensive network of community-based programs. Accordingly, it oversees and consults on out-patient psychiatric care at the North Suffolk Mental Health Center, the new Bunker Hill Health Center in Charlestown, and the Acute Psychiatric Service at the Massachusetts General Hospital.

In addition, the Lindemann Center coordinates several small, but growing, programs for emotionally disturbed and mentally retarded children, and children with learning disabilities. These include day care, transitional classes for retarded children about to enter public schools, and learning disabilities classes at the Lindemann Center. Within individual Harbor Area communities, the Center sponsors day activity programs, clinical nursery schools and treatment clinics for retarded and emotionally disturbed kids. In helping children, the Lindemann Center tries to catalyze and support local programs rather than centralize all care in one large institution.

These new community mental health programs have begun to offer a necessary alternative to neglect or hospitalization for people who cannot afford expensive, private therapy. At this time, however, the scale and quality of the efforts in the Cambridge-Somerville and Harbor Areas still do not adequately meet the needs of these communities. These delivery systems still fall short of the goal of providing effective, comprehensive care for all the residects of their communities. They have made great progress; they simply have a long way to go.

In the Cambridge-Somerville Area, for example, there are long waiting lists for extended, out-patient psychotherapy (including after-care) for people just released from inpatient wards and for day care for retarded people. The 22-bed psychiatric ward at the Cambridge Hospital cannot accommodate everyone who needs in-patient help; many Cambridge-Somerville residents are sent instead to understaffed Westboro State Hospital--forty miles from Cambridge--for in-patient care. Furthermore, although new, effective techniques of group, milieu, and drug therapies have decreased the average length of hospitalization in the psychiatric ward of the Cambridge Hospital to only six weeks, many former patients soon deteriorate and sometimes even return to in-patient wards in the Cambridge Hospital or Westboro because of inadequate after-care programs.

THE MENTAL HEALTH organizations of the Cambridge-Somerville Area are working to improve and expand the delivery of care in the district. For example, since out-patient after-care for ex-mental patients is very expensive and since the staff at the Cambridge Hospital is small, the Community Service of the Hospital's Department of Psychiatry is working with organizations such as the Welfare Department and Neighborhood House to set up group after-care programs. Such efforts to increase the scope and quality of mental health services in Cambridge and Somerville must continue and accelerate if community mental health is to offer a real alternative to institutional care for the residents of this area.

The Harbor Area faces similar problems in the scale and quality of community care. Only Revere offers comprehensive help. The Bunker Hill Health Center in Charlestown, the Revere-Chelsea Clinic, and the North Suffolk Mental Health Center in East Boston provide effective, but more limited, mental health services. The North End, the West End and Beacon Hill still lack their own programs. The new Lindemann Center and the Acute Psychiatric Service of the Massachusetts General Hospital are moving to meet these needs, but their efforts have either just begun or are still in the planning stages. As in the Cambridge-Somerville Area, much remains to be done in creating a comprehensive mental health system in the Harbor Area.

The major obstacle to expansion and improvement of community mental health care is lack of money. For example, the Community Service of the Cambridge Hospital and the inpatient and out-patient programs of the Lindemann Center could really improve with an increase of funds and staff. An entire floor of the Lindemann Center designed for biochemical research remains totally unused because of a money shortage. Furthermore, community mental health workers have found that the more they extend their efforts into the community, the more people they find in need of help. For example, the new alcohol detoxification program at the Cambridge Hospital is already flooded with more applicants than it can handle. Meeting the mental health needs of the Cambridge-Somerville and Harbor Areas will require far more money than is currently available to expand existing programs, establish new ones, do research to develop more effective techniques of therapy, and train and hire mental health workers.

DESPITE the shortcomings and obstacles in the development of community mental health programs, the systems in Cambridge and Somerville and in the Harbor Area have come a long way and show great promise for the future. In 1965, none of the budget of the state Department of Mental Health went to community programs. Today 25 per cent of the budget is earmarked for such projects. This year the Department of Mental Health will try to convert money and transfer staff from the recently phased-down state hospitals to community programs. This trend in funding is likely to continue and accelerate in coming years.

Another resource for help in the development of community mental health programs, especially in the Boston area, is cooperation between these programs and universities. Harvard Medical School currently plays a key role in mental health projects at the Lindemann Center and the Cambridge Hospital; Harvard's Clinical Psychology Program and the mental health committee of Phillips Brooks House also participate in local programs. MIT gave a building to the Neighborhood Family Care Center. Students in graduate clinical psychology programs of Boston University, Boston College and the Simmons School of Social Work take part in local mental health services. These kinds of cooperative efforts should develop even further.

Since 1955, the number of patients in Massachusetts state mental hospitals has dropped 50 per cent. Mental institutions are being phased down throughout the state; one--Grafton State Hospital near Worcester--is even closing down. This progress has only been achieved because communities in the state, such as the Cambridge-Somerville and Harbor Areas, have begun to offer alternatives to neglect or institutionalization for people who need psychiatric help