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Adult Homes: A Crisis of ConscienceAn Opinion by Michael B. Friedman, CSW
The recent New York Times coverage of the dreadful conditions in some adult homes in New York State did not surprise me. For those of us who have been active in mental health over the past 30 years or so, it's an old story that makes new headlines every few years. But this time the revelations provoked a crisis of conscience in me. I realize that I have paid too little attention to adult homes as an advocate and that I did too little about them when I was Director of the Hudson River Region of the New York State Office of Mental Health at the end of the Cuomo administration. During those years I took pride in moving people to the community from the state hospitals for which I was responsible. We considered adult homes part of the community, even though it was obvious then, as it had been obvious for many years, that the large adult homes are institutions, albeit institutions that are different from state psychiatric institutions. Of course we took steps that were meant to be protective. Staff from my office visited the adult homes to which we sent residents. We stopped referrals to those which were poor and did not improve care quickly. We encouraged, and funded, working relationships between adult homes and local mental health providers to be sure that people with mental illnesses got the mental health care they needed. Policy of "Transinstitutionalization" Instead of Professed Policy of DeinstitutionalizationMany people got quite decent care. But the fact remains that by our actions we supported a mental health policy that is fundamentally wrong. Many years ago John Talbott called it a policy of "transinstitutionalization" in contrast to the professed policy of deinstitutionalization. Community mental health is about integrating people with mental illnesses into the community. Transinstitutionalization is about meeting arbitrary goals in one institutional system by transferring people to another institutional system. In the beginning it was a policy of desperation, a policy adopted because there was no decent housing in the community for people with mental illnesses who needed some degree of supervision or support. Once New York State developed a policy of providing housing for people with mental illnesses in the community, the use of adult homes became a policy of convenience, making it possible to reduce the perception of the need for more community-based housing. When I say that housing people with serious mental illnesses in adult homes is the wrong policy, I mean that putting people in large, congregate living facilities--even if they are well-supervised--violates the most fundamental insights and goals of the community mental health movement. The goal of community mental health is to help people lead decent lives as full-fledged members of the general community. Well-supervised adult homes do not, and cannot, fulfill that goal; and, therefore, reforming adult homes by making sure that they are safer and that they provide more services is not enough. It's an obvious truth, so obvious that I wonder how I have missed it until the most recent set of revelations about scandalous conditions. Fragmentation of Decision-Making Results in Lack of Overall PolicyCoincidentally, I have just read Jonathan Glover's book Humanity: A Moral History of the Twentieth Century. In it he reviews many of the atrocities committed over the course of the past century and explores what made it psychologically possible for apparently decent people to participate in atrocities. Two of his observations are very important for understanding why good people agree to carry out bad--even shameful--social policy. First, he notes that fragmentation of decision-making results in no one being, or feeling, responsible for the overall policy. We each do our piece, making the best of a situation which is beyond our control. I took pride, for example, in the extent to which my Regional Office instituted some protections. I had done the best I could. Drift to Moral ComplacencyGlover also notes a process of what he calls "moral drift". The making of a decision to pursue the lesser of evils makes it easier to make other decisions between the lesser of greater evils until ultimately one has agreed to something truly awful. I don't think that the adult home situation rises to the level of evil of the atrocities that Glover is exploring, and the current state of adult homes does not reflect exactly the same kind of moral drift. In this case it's more a drift to moral complacency. Each revelation leads to a minor reform and a period of pride in minimal achievement. This contributes to our growing reconciliation with a policy which is fundamentally wrong. Can understanding why we continue to face the same basic issues about adult homes that first surfaced 30 or so years ago help us make it better? I think it can. We need to be clear that what we need is not the kind of patching of a flawed system that is now being proposed in response to the Times expose.
The goal should be for all people with serious mental illnesses who need supervised or supported housing in the community to get housing in small, homelike settings or in independent living settings with supports. These settings should have a rehabilitative structure designed to promote recovery, independence, and full integration into the community. Five Actions to Move in Direction Towards IdealObviously it will take years to achieve these goals. But some actions can be taken immediately which will move in the right direction.
Major Change in Policy Required to Make Real DifferenceEach time terrible conditions in adult homes have been revealed in the past, we have tinkered with the system. I realize now that I had become inured to it and cynical about it. This time I hope we will all face the truth, that a major change in policy is the only reform that will make a long term difference. (Michael B. Friedman is the Public Policy Consultant for the Mental Health Associations of Westchester County and New York City. The opinions expressed in this essay are his own and not necessarily shared by the Mental Health Associations.) Return to the top of the page.
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