Financing, organization and control: the problem of implementing comprehensive community mental health services.

Abstract

IT has been said that we have now come full circle on the issue of providing care for mentally ill persons. The argument here runs that, prior to the nineteenth century, the care of mentally ill persons was the responsibility of the community. In the early nineteenth century, the work of liberal reformers in this area, such as Dorothea L. Dix, resulted in a shifting of responsibility from the community to the state and the advent of that venerable institutionthe state mental hospital. In fact, we have every reason to believe that the early state hospitals, proceeding in enlightened climate to do what has been referred to as therapy, were quite effective. Over a relatively brief period, the community got out of the business of caring for its mentally ill and, probably with some relief, referred these persons to the state hospital. There they received, at least during the first part of the nineteenth century, what appeared to be adequate care. The state hospital, however, rapidly declined as an effective treatment modality, and by the end of the nineteenth century was essentially a custodial warehouse for all kinds of undesirable, impoverished individuals. The reasons for its decline are complex, but certainly some of the factors had to do with the size of these institutions. They continued to grow as they absorbed the ever-increasing number of patients who flowed into them from the community and with the change in climate in professional thought. A more scientific attitude eventually displaced the earlier commitment to moral therapy.' The poor conditions in our state hospitals have been very well documented, and this topic received perhaps its most comprehensive exposition in the Joint Commission Report published in 1961.2 Thus, by the mid-twentieth century, we found ourselves in the rather interesting position of having the federal government spearhead a movement to return the locus of care and the central responsibility for mentally ill persons to the community. Not only did we come full circle; one could embellish the story further by indicating that state mental hospitals in many respects are currently returning to a philosophy of moral treatment. The full circle parable, however, is quite deceptive. One can never really