VOL. 5, NO. 1, 1979
Letters to the Editor
Community Support Systems To the Editor:
Several staff members from the New York State Office of Mental Health were participants in the NIMH working conferences that helped to develop the Community Support System Program. With this valuable information from the conferences we were able to develop our Five-Year Program Statement entitled, "Appropriate Community Placement and Support" in August of 1977. This document has been the cornerstone of New York State's Community Support Systems approach. The program statement and the accompanying budget proposal developed from its content have resulted in a dramatic commitment on the part of the Executive and Legislative branches of New York State Government to the development of Community Support Systems throughout the State. Furthermore,
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I was delighted to see the recent issue of Schizophrenia Bulletin (Vol. 4, No. 3,1978) devoted to the topic of Community Support Systems. This is a vital area of interest to mental health practitioners. I was especially interested in Ms. Turner and Mr. TenHoor's article entitled, "The NIMH Community Support Program: Pilot Approach to a Needed Social Reform" (4:319-348, 1978). However, I was distressed by the implication in their article that the Community Support Systems program is considered a pilot. Although NIMH may view their Community Support Program (CSP) as a pilot, many of us throughout the country see this not as a pilot but as the direction of present reform.
this commitment has been given the financial support of the New York State Legislature with an appropriation for this current fiscal year of $15.1 million. Similar success in the appropriation or redeployment of funds to community-based programs has been experienced by my colleagues in Massachusetts, Ohio, and Colorado. Other states such as Florida are in the process of budget preparation for statewide program development. This type of administrative and financial backing to the development of Community Support Systems demonstrates that it is no longer a pilot project. Rather, it is being implemented in an operational mode. Within the first year of implementation of Community Support Systems within New York State, significant results have already been achieved. Community-based service programs have been developed through a partnership among relevant service providers, State, local, and voluntary, which are adapting their services to meet the needs of the chronically mentally ill, which have historically been the sole responsibility of State mental health agencies. Through a Request for Plan process and Community Support System implementation steps, communication among these agencies has been enhanced and their focus on a common mission—that of optimizing the community experience for the chronically mentally ill —has led to an increased sense of cooperation and mutual participation. Mechanisms, including a performance contract and a sophisticated monitoring system, which permit the flexibility to adapt the service system to local need but which also assure accountability, have been devised. Furthermore,
16
James A. Prevost, M.D. Commissioner New York State Office of Mental Health 44 Holland Ave. Albany, N.Y. 12229
To the Editor: I would like to respond to the recent article by Turner and TenHoor
(Schizophrenia Bulletin, 4:319-348, 1978). First, our programs for chronic patients continue to be treatment-oriented. We are ready to spend large sums for treatments administered by a variety of professionals, despite scant evidence for their usefulness. The chronically disabled schizophrenic does not need these treatments. Chronic psychiatric patients have lost their natural social support system. Healthy adults contribute sufficiently to their extended social support system to sustain it. The chronic psychiatric patient cannot do this, so the system atrophies, and the patient ends up in isolation. Professional therapists should not be used as replacements for a caring support system because, as professionals, their "caring" involvement with their clients is strictly limited. How, then, to supply the missing caring? This cannot be a lifetime profession. We must find ways of introducing a steady stream of individuals who can care, who participate in the system for 6 months to 2 years. They can afford to care because their role is timelimited. I see a national, voluntary service system in the future, with young people serving 2 years in chronic patient care, the military, environmental programs, enrichment programs for children, etc. As long as we try to meet chronic patients' needs through the use of professionals, we will continue to fail. Such patients need treatment as indicated, especially medication, physical care (housing, food, clothing), and a reasonable level of social activity—but not through activity therapy and "caring." Enthusiastic
professionals are able to contribute this last item only for short periods. Sooner or later, caring disappears. Occasionally, it is dependent on the leadership of one individual and disappears when that individual moves on. Community programs need professional staff for monitoring administration and stability, and short-term participants to supply the caring and personal involvement— involvement that is not dominated by 8-hour days. There is another type of patient for whom our programs fail. This is the patient who can work successfully as long as someone else maintains an adequate social support system for him. Presently, as soon as the patient works successfully, we withdraw the resources for this support system. The patient cannot pay for the support system out of his own earnings. This dilemma is built into the concept of the halfway house, which implicitly believes in "cure." Many people need permanent halfway house living, mostly without active treatment. Our need is for old-fashioned boarding homes. Private rooms, shared breakfast and dinner, a common living room— these would provide an ever-ready social group for interaction and prevent isolation. But such boarding homes could only function if subsidized. Hans R. Huessy, M.D. University Associates in Psychiatry, Inc. Central Vermont Division R.D. No. 4 Montpelier, Vt. 05602
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ by guest on August 29, 2015
attention has been focused on geographic areas throughout the State that have previously been affected by deinstitutionalization. On the State level we are equally "committed to examining concepts and strategies on a continuing basis and to modifying either or both in light of new knowledge and experience" (Turner and TenHoor, p. 341). Again, New York State has taken a proactive approach to the evaluation of both our three demonstration sites and to the Statesupported Community Support Systems development. We are committed to modification of policy and program components based on the results of these evaluations. However, the problems that have plagued the mental health delivery systems over the last decade will not be eradicated by small pilot projects. Rather, they will be addressed only by deliberate and concerted effort to change the system and to create a coalition of dedicated service providers who are willing to learn from the mistakes of the past and who are committed to bold steps for the development of a system of opportunities for this neglected population.
SCHIZOPHRENIA BULLETIN
Letters to the Editor
Community Support Systems To the Editor:
Several staff members from the New York State Office of Mental Health were participants in the NIMH working conferences that helped to develop the Community Support System Program. With this valuable information from the conferences we were able to develop our Five-Year Program Statement entitled, "Appropriate Community Placement and Support" in August of 1977. This document has been the cornerstone of New York State's Community Support Systems approach. The program statement and the accompanying budget proposal developed from its content have resulted in a dramatic commitment on the part of the Executive and Legislative branches of New York State Government to the development of Community Support Systems throughout the State. Furthermore,
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ by guest on August 29, 2015
I was delighted to see the recent issue of Schizophrenia Bulletin (Vol. 4, No. 3,1978) devoted to the topic of Community Support Systems. This is a vital area of interest to mental health practitioners. I was especially interested in Ms. Turner and Mr. TenHoor's article entitled, "The NIMH Community Support Program: Pilot Approach to a Needed Social Reform" (4:319-348, 1978). However, I was distressed by the implication in their article that the Community Support Systems program is considered a pilot. Although NIMH may view their Community Support Program (CSP) as a pilot, many of us throughout the country see this not as a pilot but as the direction of present reform.
this commitment has been given the financial support of the New York State Legislature with an appropriation for this current fiscal year of $15.1 million. Similar success in the appropriation or redeployment of funds to community-based programs has been experienced by my colleagues in Massachusetts, Ohio, and Colorado. Other states such as Florida are in the process of budget preparation for statewide program development. This type of administrative and financial backing to the development of Community Support Systems demonstrates that it is no longer a pilot project. Rather, it is being implemented in an operational mode. Within the first year of implementation of Community Support Systems within New York State, significant results have already been achieved. Community-based service programs have been developed through a partnership among relevant service providers, State, local, and voluntary, which are adapting their services to meet the needs of the chronically mentally ill, which have historically been the sole responsibility of State mental health agencies. Through a Request for Plan process and Community Support System implementation steps, communication among these agencies has been enhanced and their focus on a common mission—that of optimizing the community experience for the chronically mentally ill —has led to an increased sense of cooperation and mutual participation. Mechanisms, including a performance contract and a sophisticated monitoring system, which permit the flexibility to adapt the service system to local need but which also assure accountability, have been devised. Furthermore,
16
James A. Prevost, M.D. Commissioner New York State Office of Mental Health 44 Holland Ave. Albany, N.Y. 12229
To the Editor: I would like to respond to the recent article by Turner and TenHoor
(Schizophrenia Bulletin, 4:319-348, 1978). First, our programs for chronic patients continue to be treatment-oriented. We are ready to spend large sums for treatments administered by a variety of professionals, despite scant evidence for their usefulness. The chronically disabled schizophrenic does not need these treatments. Chronic psychiatric patients have lost their natural social support system. Healthy adults contribute sufficiently to their extended social support system to sustain it. The chronic psychiatric patient cannot do this, so the system atrophies, and the patient ends up in isolation. Professional therapists should not be used as replacements for a caring support system because, as professionals, their "caring" involvement with their clients is strictly limited. How, then, to supply the missing caring? This cannot be a lifetime profession. We must find ways of introducing a steady stream of individuals who can care, who participate in the system for 6 months to 2 years. They can afford to care because their role is timelimited. I see a national, voluntary service system in the future, with young people serving 2 years in chronic patient care, the military, environmental programs, enrichment programs for children, etc. As long as we try to meet chronic patients' needs through the use of professionals, we will continue to fail. Such patients need treatment as indicated, especially medication, physical care (housing, food, clothing), and a reasonable level of social activity—but not through activity therapy and "caring." Enthusiastic
professionals are able to contribute this last item only for short periods. Sooner or later, caring disappears. Occasionally, it is dependent on the leadership of one individual and disappears when that individual moves on. Community programs need professional staff for monitoring administration and stability, and short-term participants to supply the caring and personal involvement— involvement that is not dominated by 8-hour days. There is another type of patient for whom our programs fail. This is the patient who can work successfully as long as someone else maintains an adequate social support system for him. Presently, as soon as the patient works successfully, we withdraw the resources for this support system. The patient cannot pay for the support system out of his own earnings. This dilemma is built into the concept of the halfway house, which implicitly believes in "cure." Many people need permanent halfway house living, mostly without active treatment. Our need is for old-fashioned boarding homes. Private rooms, shared breakfast and dinner, a common living room— these would provide an ever-ready social group for interaction and prevent isolation. But such boarding homes could only function if subsidized. Hans R. Huessy, M.D. University Associates in Psychiatry, Inc. Central Vermont Division R.D. No. 4 Montpelier, Vt. 05602
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ by guest on August 29, 2015
attention has been focused on geographic areas throughout the State that have previously been affected by deinstitutionalization. On the State level we are equally "committed to examining concepts and strategies on a continuing basis and to modifying either or both in light of new knowledge and experience" (Turner and TenHoor, p. 341). Again, New York State has taken a proactive approach to the evaluation of both our three demonstration sites and to the Statesupported Community Support Systems development. We are committed to modification of policy and program components based on the results of these evaluations. However, the problems that have plagued the mental health delivery systems over the last decade will not be eradicated by small pilot projects. Rather, they will be addressed only by deliberate and concerted effort to change the system and to create a coalition of dedicated service providers who are willing to learn from the mistakes of the past and who are committed to bold steps for the development of a system of opportunities for this neglected population.
SCHIZOPHRENIA BULLETIN
