Once it became apparent that the efforts implemented in 2001 to “reform” the mental health system in North Carolina had failed, editorials and opinion pieces started appearing in North Carolina newspapers.
At first, they tended to be speculative in an effort, I believe, to examine the causes that would eventually lead to solutions. They held various pieces of the system responsible: the General Assembly for passing the original legislation, the state-level mental health office for the law’s implementation and private providers for misspending Medicaid dollars.
Recently, speculation has focused on the closing of Dorothea Dix Psychiatric Hospital in Raleigh as the reason mental health reform failed. The argument has been taken one step further: The reason for North Carolina’s poor record in taking care of its psychiatrically disabled residents can be attributed to a lack of hospital beds. It would then seem logical that the first step toward getting back on the right track would be to build more hospitals or provide more beds.
However, that would fly in the face of the massive amount of scientific and anecdotal evidence amassed in the last 60 years. Building more residential beds to house psychiatric patients would be a giant step backward and a disservice to the families and individuals who are struggling daily to cope with life.
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Partway through my 40-year career, the term “best practices” started receiving attention. Federal, state and national accrediting and licensing agencies applied this term extensively to the standards pertaining to mental health. Simply put, it means treating the patient with the best available methods. These methods are research based – not anecdotal. Of course, there is no such thing as a recipe book for mental health treatment. We cannot apply a set of treatment procedures for every diagnosis. As the profession progresses, however, more of these tested treatment methods are being developed.
“Best practices” dictate treating the mentally disabled in the community. In fact, one of the criteria for judging the quality of services is the elimination, over time, of psychiatric beds – especially a reduction of the number of patient days spent in large public psychiatric hospitals.
Unfortunately, newspaper articles can be misleading. An Aug. 17 Focus article chronicled a creative community program in Vance County. This program has a simple objective: To make sure mentally ill individuals take their medications properly. This program keeps people out of psychiatric hospitals and in their homes where they are closer to existing and familiar resources.
However, the article said the Mobile Medications program was created, in part, as a response to a lack of psychiatric beds. This is misleading because “best practices” dictate that patients are better served in the community rather than in a hospital setting.
When talking about mental health care in North Carolina, it is the lack of community-based programs that should be emphasized rather than building more large, expensive hospitals to house the psychiatrically disabled. “Best practice” dictates that a hospital is only one of the options on a continuum of treatment and care for a patient – not the preferred option, as is sometimes implied.
During the initial few months of my first job in mental health in 1967, I began to learn about deinstitutionalization. I was working in an institution. I saw the problems it faced in providing a high level of care to our residents. The answer was to provide community-based treatment. It still is. I was told the money would follow the patient, that as we closed beds the funding would be transferred to community services. Regrettably, this never happened.
Obviously, this tiny bit of North Carolina history cannot do justice to the decades of work by so many mental health professionals and advocates who’ve worked tirelessly to develop services in our state. In the smallest of nutshells, our work needs to be concentrated on growing community services, coupled with the use of institutionalization as a last resort.
William A. Harrington, DrPH, lives in Durham.