Professor Friedman: We Need "Assertive" Mental Health Services

At the end of last month, Adjunct Associate Professor Michael B. Friedman participated, along with eight other mental health experts, in a virtual roundtable on MedPageToday.com* on the topic of "what went wrong" with the U.S. policy of deinstitutionalization of mental health services.

The premise of the argument was that replacing long-stay psychiatric hospitals with community mental health services has not worked as well as expected. Indeed, today many Americans believe that we have gone too far in the other direction, even to the point where the shortage of "psych beds" threatens public safety.

Professor Friedman’s responses are republished here with the permission of MedPageToday. Go to full article.

Flawed Question?

Michael B. Friedman, LMSW: "Your position regarding serving people with mental illness (please stop using the offensive expression 'the mentally ill') in the community is incorrect for a number of reasons. Most importantly, the shift in policy from institution-based to community-based mental health services has enabled hundreds of thousands of people who would have been held in hospitals unnecessarily to lead far better lives in the community. We need to continue to improve the service system for those who have not fared well in the community."

What Went Wrong?

Friedman: "There is a terrible problem of transinstitutionalization—the movement of people who might in the past have been in mental hospitals/asylums to prisons, nursing homes, and adult homes. There also continues to be a problem of homelessness for some people with serious and persistent mental illness. To address these problems we may (or may not—no one really knows) need more hospital beds. We may or may not need increased use of coercive interventions (forced hospitalization or outpatient treatment); this is highly controversial."

Solution: Better Policy

Friedman: "Your statement totally neglects the policy shifts that have taken place since 'deinstitutionalization.' For example, New York State had no units of specialized housing for people with serious and persistent mental illness in 1978. Today, it has about 35,000 units of housing run by the mental health system, and thousands more in various supportive housing programs. Services in the community have also expanded considerably, and state hospitals—now much smaller—are far better places than they used to be."

What's Working

Friedman: "We need what are called 'assertive' community services, which go to people where they are rather than waiting for them—or forcing them—to come to the mental health system on their own. We definitely need more housing (preferably using a highly effective model known as 'housing first')."

Misplaced Focus

Friedman: "Recent attacks on the mental health system have been stimulated by several awful and highly publicized mass murders, some of which have been committed by people with serious mental illness. (Emphasize 'some.' Most are not). Sadly, the 'fixes' being proposed for the mental health system are highly unlikely to have any significant impact on the rate of mass murders in America."

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* MedPageToday is a news service that seeks to provide a clinical perspective on breaking news of concern to physicians and other healthcare professionals.

Image: A mash-up of the Manhattan Psychiatric Center, by Ralph Hockens (courtesy Flickr), and the brain, by The Health Blog (courtesy Flickr).

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