Inadequacies of the Current Mental Health System
Despite the improvements that have emerged because of the Community Support Program, there
are a number of notable inadequacies with the current mental health system.
Adults with Serious Mental Illnesses
- A substantial number of people with recurrent, serious mental illnesses reject, or cannot use,
traditional mental health services.
Some people who avoid treatment manage quite well without it, but many end up in crisis
and then experience long hospitalizations. An increasing number of them are now in jails
and prisons, generally for minor offenses. A very few commit acts of violence which make
the headlines that dominate public debate about mental health policy. Many of these
episodes of inappropriate treatment and human tragedy could be averted if relevant and
responsive community services were available.
- A substantial number of people with serious mental illnesses have been "transinstitionalized" to
large congregate care facilities for poor people, who are believed to be unable to live
independently in the community. (In New York State they are called "Adult Homes.")
These facilities generally provide poor care, sometimes scandalously poor. In addition they
become dead-ends for people who may be able to live more independently in the
community if appropriate housing, services, and supports were available.
- There is not enough appropriate housing for people with serious mental illnesses, who often
need help finding and paying for decent places to live and who often also need a variety of
supports to be able to live in the community.
Lack of housing results in homelessness, in living in squalor and danger, in excessive
reliance on inappropriate institutions of various kinds and in family burden.
- Despite decades of talk about providing integrated treatment services for people who are
mentally ill and abuse substances and other co-occurring disorders, such services are not widely
available.
- Mental health services for adults with serious mental illnesses and their families are often not
based on practice models for which there is research support because many mental health
professionals are inadequately trained in state-of-the-art models and because regulatory and
financing structures are frequently based on outmoded treatment models.
- Even when they get decent care and treatment, most people with serious psychiatric disabilities
are not employed despite their desire to work and despite the existence of a rehabilitative
technology that could help them to get and keep jobs. Unfortunately rehabilitative
opportunities are not widely enough available.
- Services provided by people with mental illnesses for their peers, while growing, remain
limited and tenuous despite successful experiences throughout the country.
- There has never been adequate support for families of adults with serious mental illnesses even
though they provide a large amount of care for their family members.
As the current generation of parents providing care for their family members with
psychiatric disabilities becomes too old to provide care and eventually dies, a resource on
which our society depends informally will be lost.
- Many adults with mental illnesses, whether mild or severe, cannot get access to mental health
services in the private sector because of inadequate insurance coverage and because mental
health professionals, in both the public and the private sector, are simply not available in
some parts of the country.
Children and Adolescents with Serious Emotional Disturbances
Children and adolescents with serious emotional disturbances frequently do not get mental health
services or do not get the mental health services that would best meet there needs.
- There are not enough mental health services for children and adolescents in the public mental
health system.
- Many children and adolescents with emotional disturbances cannot get access to mental health
services in the private sector because of inadequate insurance coverage and because there is a
shortage of mental health professionals for children and adolescents.
- Mental health services for children and adolescents are often not based on practice models for
which there is research support because many mental health professionals are inadequately
trained in state-of-the-art models and because regulatory and financing structures are frequently
based on outmoded treatment models.
- Outpatient services generally are not flexible enough with regard to time, place and nature of
services provided. In addition they generally are not responsive enough to crises in the lives of
emotionally disturbed children and their families.
- Inpatient services and residential treatment, which are critical elements of a comprehensive
mental health system for children and adolescents, are over-utilized because of the absence of a
comprehensive system of community-based services which provides a full continuum of
services.
- Involvement of families in the treatment of their children and support for these families or
caretakers is not nearly as widespread as it should be.
- Children with serious emotional disturbances often are served in several child-serving systems.
Little progress has been made in the effort to integrate child-serving systems.
Quality of Care and Treatment
Despite remarkable improvements in the effectiveness of treatment over the past twenty years and a
dramatic shift in attitude among the best practitioners towards recipients of services and their
families, serious problems with the quality of care remain.
- A human resources crisis has emerged due to low salaries for mental health workers.
Recruitment and retention of well-qualified staff has become exceedingly difficult resulting in
serious problems maintaining minimally adequate staffing levels and in providing continuity of
care.
- Many providers are not adequately trained in new treatment methods and/or in the need for
respect and humanity regarding people with serious mental illnesses and their families.
- Research has not yet provided the dramatic breakthroughs in treatment which have been the
central hope for mental health, even though there have been important strides made.
- There have been continuing revelations about inappropriate use of restraint and seclusion,
raising new concerns about patient abuse.
Readiness for Demographic Shifts
The mental health system generally has not been preparing for dramatic demographic shifts which
will take place within the next two decades-especially the growth of older adults (the "baby boom
generation") and the growth of cultural minorities.
- As the number of older adults grows, so will the number of older adults with significant mental
health problems. They will be more likely to seek out and use mental health services than the
current generation of older adults. Nevertheless, meeting the need for more mental health
services for this population is not generally included in plans for new mental health services.
- Minority and immigrant populations are also growing rapidly, and minorities may become the majority of the
American population within the next quarter century. Lack of widespread cultural competence
will become an ever-greater problem as minority populations grow.
MHA's 10-Point Agenda for the 21st Century
In order to promote a meaningful response to the inadequacies noted above, the MHAs of New
York City and Westchester have formulated the following 10-point advocacy agenda.
1. All levels of government should make a multi-year commitment to the progressive development of a comprehensive and integrated array of community-based mental health services including:
- Crisis intervention
- Outpatient services
- Housing
- Rehabilitation
- Case management
- Peer support services
- Family support services
- Inpatient services
An empirically based needs assessment and multi-year planning process should guide this process of development.
2. Priority should be given to the expansion of housing, treatment, support, and rehabilitation services for adults with serious mental illnesses who are not adequately served by the current mental health system, especially:
- People who are homeless
- People in "adult homes"
- People who are mentally ill and involved with the criminal justice system
- People who are mentally ill and abuse drugs or alcohol
- People who avoid or cannot use traditional mental health services
This effort should include expanding initiatives that stress recovery and employment and would enhance access to mainstream society and improve quality of life.
3. Priority should also be given to building a comprehensive, community-based system of care for children and adolescents including:
- Development of a full range of services?crisis, outpatient, community support, case management, family support, residential, and inpatient.
- Expansion and reshaping outpatient and community services with emphasis on services which are flexible, mobile, and responsive to crisis
- Increased use of state-of-the-art treatment models
- Increased attention to children and adolescents who are victims of abuse or neglect, caught up in the juvenile justice system, or are failing in school.
- Improved integration with other child-serving systems
4. There should be a multi-year commitment to prepare for predictable demographic shifts, especially for:
- Older adults with mental health problems
- Cultural minorities, including immigrants, with mental health problems
5. Access to mental health services in the private and public sectors should be improved by:
- Providing parity between health and mental health insurance coverage
- Assuring that care is available to people without insurance coverage, including immigrants and undocumented aliens
- Increasing the availability of mental health professionals in underserved geographic areas
6. There should be a commitment to enhance quality of care by:
- Addressing the human resources crisis
- Supporting mental health biomedical, clinical, services, and policy research which is responsive to contemporary mental health policy goals and which seeks breakthroughs in knowledge and treatment.
- Assuring widespread knowledge of state-of-the-art treatment and rehabilitation
- Eliminating abuse of people with mental illnesses wherever it occurs
7. There should be a commitment to a widespread family support initiative to assist families who are providing housing and other forms of care for their mentally ill
family members, both adults and children. This should include a strong emphasis on psycho-educational approaches that have proved to be effective in
reducing need for hospitalization. In addition, plans should be developed to address the eventual need to replace our society's informal reliance on families.
8. There should be a commitment to overcome stigma and discrimination and to educate the public about the realities of mental illness.
9. Federal, state, and local governments should make a financial commitment commensurate with progressive mental health policy including:
- Maintenance of adequate financial support for core community mental health services with routine adjustments for inflation and assurance of living wages.
- Progressively increasing funding for:
Services for populations who are not adequately served by the current system
Improved education and training of mental health providers
Research
10. Federal, state, and local governments should work together to develop structural, regulatory, and financial models that will support the progressive development of a comprehensive community-based mental health system.
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