Recently I worried about the pending closure of Mayview Hospital, home to more than 200 people with severe mental illness. My concern is for their future: Where will they go? What will they do? What if they don't have family or community resources? Will they end up homeless?

My nervousness for their future provoked a few reponses, particularly after I suggested that deinstitutionalization has failed many people, and I cited Philadelphia in particular. But that's oversimplifying things -- something that's all too easy to do on a blog.

Mental health care advocate extraordinaire Fran Hazam sent out a very interesting report, "Learning From History: Deinstitutionalization of People with Mental Illness As Precursor to Long-Term Care Reform," by the Kaiser Foundation -- coincidentally published just a few days ago. It does a good job of examining the key mistakes made in the past, one of which was an overreliance on families as a source of support. (When you ask families to take on the role of professional caregivers, maybe you end up with TAC. Just a thought. And an overly simplistic one, at that!)

The Kaiser report identified the following as some of the mistakes in past deinsitutionalization policy:
Inappropriate living situations, insufficiently provided essential services; insufficient connection between state policy for institutions and federal policy for community care; insufficient resources; multiple funding streams were uncoordinated; and discrimination in housing.

Thankfully, we can learn from those mistakes. And in the case of Philadelphia, we did and we have, as Susan Rogers, of the Mental Health Association of Southeastern Pennsylvania, points out. She writes:

You write, “Though it’s generally cause for celebration when people get out of the hospital, we've seen, especially in cities like Philly, how deinstitutionalization failed many former patients, who ended up homeless and hungry.” Liz, it is not state hospital closings that render people homeless; it is the lack of decent, affordable housing.

I’d like to call your attention to an article from the Philadelphia Inquirer (“Mentally Ill’s Safety Net Found Strong,” 5/13/96), about a Pew study of what happened to people after Philadelphia State Hospital was closed. The third and fourth paragraphs read:

The city [of Philadelphia] can care for its mentally ill population without a state institution as a safety net, according to a new study funded by The Pew Charitable Trusts. ``The dire predictions of lack of access to care, of homelessness, of people sitting on grates throughout the city don't appear to be borne out by the data,'' said Carolyn Asbury, Pew's director for health and human services.

In fact, the closing of Philadelphia State Hospital sparked a revolution in the city’s public mental health system. You say “deinstitutionalization failed many former patients.” This is true of the deinstitutionalization movement of the early 1960s, when people were released from institutions with no provisions made to serve them in the community. It is very different from the closing of Philadelphia State Hospital, when the Coalition for the Responsible Closing of Philadelphia State Hospital made sure that the dollars supporting the hospital followed the patients into the community to set up a system of services and supports, so that they wouldn’t fall through the cracks. This system was also designed to serve what is known as the “diversion” population – people who would have been served by the state hospital if it had remained open.

Clearly, people must have stable housing in the community, along with the services and supports they need in order to live successfully there. According to the article you posted from the Pittsburgh Post-Gazette, state officials are working on making sure that these things are in place. And I do believe that, any time people who have been locked up in an institution are released to live their lives in freedom, it is a cause for celebration.

I agree with that, of course. I want people to be free and well. I'm just a worrier, I guess. And maybe I'm only worrying about a small number of people, as the Kaiser report suggests:

Clearly, deinstitutionalization policy has been a success for most people who might in other times be in a public psychiatric hospital. But for many it has fallen short of providing the services necessary to move toward recovery and have a desirable quality of life. For a small minority (about 1% of those with serious mental illness, or 136,000 people in 2000) now incarcerated in jail and prison, the situation is particularly bad.

My understanding is that that number is quite a bit higher now. I also worry about quality of life. I know it's better to be out of an institution. I just wish we could find a way for people to be more successful when they come out, particularly when they're older. Again, from the Kaiser report:

Still unaddressed are problems of poverty. SSI condemns recipients to live with incomes at about 75 percent of the federal poverty level. As a result, in 2004, they would have needed 110 percent of their entire monthly income to rent a modest one-bedroom unit. Many individuals now in nursing homes have depleted their resources and will be left with SSI or similarly low incomes. Many elderly individuals living in the community will be in similar situations. Addressing the problems of abject poverty will take a comprehensive effort.

Luckily, in 2007, we are better prepared than ever before to deal with a hospital closing like this one. I feel confident that Susan is correct, and I will try my best not to worry so much.

[Photo by atomicpuppy68]