From Hospital to Community Care: The Change in the Mental Health Treatment System in California Uri Aviram, D.S.W.* Steven Segal, A.C.S.W., Ph.D.

ABSTRACT: In 1968 California enacted a law transforming its state hospitalcentered mental health services to a single system of patient care based on local community responsibility. The 1968 law was not the cause of radical change in California, but rather the culmination of a process that began three decades earlier. The 1963 federal regulation enabling former mental patients to become eligible for categorical aid through public assistance programs and the development of psychoactive drugs were two necessary catalysts that provided the opportunity to maintain many formerly hospitalized mental patients in the community and to avoid lengthy hospitalization of others.

Comparison of the mental health care system existing in California today with that of 20 years ago reveals a complete transformation from a state hospital-centered system to one of community mental health care. Prior to 1957 the state hospital was the primary public mental health service available; today mental health services are locally operated in all of California's counties. The community mental health programs now control state hospital utilization (California State Governor's Budget, 1974). The state's appropriations for local mental health care have far exceeded its appropriations for state hospitals, increasing 10-fold in the decade from 19621963 to 1972-1973 (California State H u m a n Relations Agency, 1972). The number of residents in state institutions has declined from over 37,000 in 1955 to less than 7,000 in 1973. Three state hospitals have been closed in recent years, with other closures indicated in the future barring any change in the legal admissions framework. The dramatic drop in resident patients has been accompanied by an increase in admissions, which have risen from 28,000 during the 1961-1962 fiscal year to 44,000 ten years later. Apparently, the incidence of diagnosed mental illness has been rising, although the length of inpatient care has been declining (Aviram & Segal, 1973). There are now many more people, defined at one time or another as mentally ill, residing in California communities. This is reflected in the increased activities of the local mental health programs (California State H u m a n Relations Agency, 1972) and in the tremendous increase in the use of protective *Dr. Aviram is Lecturer and heads the Concentration in Community Mental Health, School of Social Work, Tel-Aviv University, Tel-Aviv, Israel. Dr. Segal is Assistant Professor and Co-Chairman of the Community Mental Health Program, School of Social Welfare, University of California, Berkeley, California 94720. The authors wish to thank Arthur Blum who made helpful comments on an earlier draft of this paper. Part of the support for this research was provided by NIMH Grant No. MH 25417-02. 158

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living environments. Twenty years ago there were fewer than 1,000 former mental patients of all ages residing in community facilities. In 1973, in the 18to 65-year age group alone there were 12,400 (Segal & Aviram, 1977). Although part of a general trend in the United States, California, excelling in many areas, has pioneered in providing local care for the mentally ill. Many attribute these changes to the California Community Mental Health Services Act of 1968, which represents a major legal overhaul of California's mental health system. Without detracting from the importance of this law, we contend that it only represented the conclusion of a process begun many years earlier. Major change in the mental health system cannot be attributed to a single act. It is a result of a convergence of a series of events and actions. In California a variety of factors contributed to the dramatic change in its mental health system, including policy decisions, administrative programs, new treatment techniques, economic incentives, and an organizational context conducive to change. This historical review will describe these factors and attempt to analyze their significance. IDEOLOGY Community care for the mentally ill, the ideology of the community mental health movement (Roberts, Halleck, & Loeb, 1966) has given a sense of mission to its proponents and provided a rationale for new programs and approaches. The idea of community care, based essentially on medical and financial considerations, originated in California in the late 1930s and early 1940s. A new era in California's mental health system began in 1939 with the appointment of Dr. Aaron Rosanoff as Director of the Department of Institutions (part of which later became the Department of Mental Hygiene). His attack on the legality of retaining many patients in state hospitals and his belief in community care programs served as a base for the strong ideological commitment of those who followed him (Aviram, 1972). His ideas and some of his programsj for example, the Total Push program and the Supervisor for Extramural Care, laid the foundation for legislation and programs such as the Short-Doyle Act and the depopulation policy and the Bureau of Social Work, which went into effect 10 to 20 years later. The impact on Dr. Portia Bell H u m e of Rosanoff's ideas was, perhaps, most important in directing California's patient care system away from a state hospital focus. Dr. Hume, thought of by many as the Founder of the Community Mental Health movement in California, was appointed in 1951 to the Department of Mental Hygiene as Deputy Director of Community Programs. Dr. Hume's most important contribution, was in implementing the notion of local responsibility. In a recent interview she indicated that it was her firm belief, perhaps one prevalent in the country in the early 1950s, that local communities would become more interested in their mentally ill if they were responsible for them (Earl Warren and State Department of Health, 1973). Although the state could do a more efficient job, she viewed the importance of local interest as the primary factor. Toward this end Dr. H u m e sponsored the

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Abshire Act, a noncomprehensive, "trial balloon" passed in 1953, which provided a state subsidy for locally operated outpatient program services in mental health. Its warm reception ultimately laid the groundwork for the passage of the comprehensive Short-Doyle Bill. Although Hume, Rosanoff, and his Bureau of Social Work Director, Nathan Sloat, emphasized the concepts of community care as late as the middle 1950s, the actual size and number of community programs was very small. That individuals operated from the notion of a strong hospital system was illustrated in the appointment of Frank Ford Tallman as Director of Mental Hygiene in 1949, after a nationwide search. Tallman's primary emphasis was on better hospital care. The most important contribution of these individuals was their conceptual emphasis on community care, shared in the early 1950s with the group of state senators who would ultimately wage the legislative battles to implement them. This coincided with advances in the drug and welfare fields in the 1950s. POPULATION TRENDS IN MENTAL HOSPITALS Any historical analysis should not only list the events preceding a problem of interest, but should also try to identify the most significant among them. Although the introduction of psychoactive drugs is generally acknowledged (Brill & Patton, 1961) as contributing to the decline of the resident population of U.S. mental institutions after 1955 (Kramer, Pollack, & Redick, 1961), some question the relative importance of this contribution (Epstein, Morgan, & Reynolds, 1962). Mosher and Feinsilver (1971) attributed the major significance to policy decisions and administrative mechanisms in this decline. Wide discrepancies among states, in spite of the general availability of theories and treatment techniques, does, in our opinion, indicate that differences in policies and administrative mechanisms are, indeed, of major importance. A recent comparative epidemiological study using a time-trend analysis of changes in hospital population showed marked variations in the curve of hospital population. The study demonstrated that these variations were related to policy decisions and administrative programs undertaken in California during the 1950s and 1960s, which contributed heavily to the direction and magnitude of the changes in the mental health service system (Syme & Aviram, 1974). The analysis leads us to focus attention on the period starting in 1963. The resident population in mental institutions reached a plateau in 1955, showed a small decline in 1959, but only in 1963 did it start to drop sharply. The decline rate in the inmate population increased during 1963-1964 by 6 times the rate of decline in any of the previous years. In 1965-1966 the decline rate rose sharply to more than 12% above the preceding year, and in the peak year of 1966-1967 it rose by another 17%. Although the proportion of aged population in mental institutions grew in other states in the period from 1955 to 1969, the California figures show a

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decline that was even more dramatic than that for younger age groups. This pattern also began in 1963, and between 1966 and 1969 the proportion of aged declined by a fourth over 1964-1965 (Syme & Aviram, 1974). The general trend of decline continued after 1969. The number of units of inpatient services dropped by 21.8% between 1969 and 1971. During the same period outpatient services were almost doubled (California State H u m a n Relations Agency, 1972). The number of former mental patients in a protective living environment in the community increased only slightly before 1961. It rose somewhat faster between 1961 and 1965, and then very rapidly after 1965. Figures of a statewide placement program indicate an almost 50% rise in the year 1965-1966 (Aviram, 1972). Directing our attention to those years that show drastic changes in the mental hospital population and to corresponding community care figures, we can specify events directly connected with the changes, as well as events that precipitated or laid the groundwork for change. CHEMICAL CONTROL, INCOME MAINTENANCE, AND ECONOMIC INCENTIVES In addition to a treatment center, the state hospital was an agent of social control that provided financial support for its residents. Many patients were kept in the hospital mainly because they lacked any other means of support. Two events that took place in the United States between 1955 and 1965 provided an unusual opportunity to change the patterns of care for the mentally ill. California took full advantage of that opportunity. Psychoactive drugs introduced in the 1950s provided a chemical means of control. It thus became possible to maintain in the community many of the people who in the past would have had to remain hospitalized. Many attribute the reversal since the mid 1950s of the mental hospitalization trend in the United States to the introduction of psychoactive drugs. As part of the general trend toward a welfare state, the Federal Government assumed responsibility for groups not previously included in the public assistance programs. In 1962 the U.S. Department of Health, Education, and Welfare revised its policy pertaining to mental patients (HEW, Section No. 3533, 1962). As a result, persons on conditional release from a mental hospital were no longer barred from eligibility for state public assistance programs by lack of matching federal funds. It was found that the community tenure of many of the released patients depended upon the availability of sufficient funds to support them (Miller, 1965). The HEW reinterpretation made available categorical aid funds through Aid to the Totally Disabled (ATD), thus increasing the chances that former mental patients would remain in the community. Seizing the opportunity, California instituted public assistance for this group. In addition to medical and humanitarian considerations, there were obvious economic and political advantages. It was both more convenient and more economical to transfer responsibility to local communities. Furthermore, the policy change made the forgotten patients in the back wards a "transac-

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tionable commodity," that is, a source of income to people in communities. Former mental patients were placed where the economic incentives to take them were greatest (Aviram, 1972). Lack of medical services could be a serious obstacle to the return of patients to the community requiring those on leave to go back to the state hospital for treatment. Since the early 1950s California has had a program of Medical Assistance to the Aged (MAA) for aged public assistance recipients. However, for the nonaged former mental patient, publicly supported medical services were not available until 1965, when the Social Security Amendment instituted Medicaid and Medicare which enabled recipients of public support to acquire the services of local physicians. It is our opinion that the availability of income maintenance through public assistance programs was the major factor responsible for the mass emigration out of the state hospitals beginning in 1962. The availability of medical services in the community since 1965 and tranquilizing drugs helped to maintain many of the former mental patients in the community and to avoid the lengthy hospitalization of others, thus contributing to the change in California's mental health services. Discrepancies between states in the reduction of state mental hospital population and differences in community care services are best explained by differences in state policies since the extent to which the n e w chemical technology and federal money were used depended on local conditions. California has excelled compared to other states in taking full advantage of the opportunities provided in the United States, and with creating radical change in the mental health service system. POLICIES AND PROGRAMS Policies are set, basically, on two levels: (a) the formal level, in legislation; (b) the administrative level, in administrative plans and programs. The ultimate test of policies is their ability to effect the desired change.

Alternatives to Hospitalization As early as 1939, California started to look for alternatives to hospitalization, concentrating on (a) tightening admissions policies, (b) releasing patients who did not need hospital treatment, and (c) developing community placement and treatment facilities.

Placement Programs Unless the state could create a placement program for former patients and potential patients w h o could not live alone, admissions and release policies could not successfully be tightened. In 1939 an "extramural care" unit started a community-based program placing mental patients in family care homes. In 1946 this unit became the Bureau of Social Work, a major vehicle in the state's placement program.

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Also, in 1939 the state legislature in the Family Care Program authorized funds to support former mental patients in the community in protective living environments. Twenty years later there were over 4,000 former mental patients in family care homes, 20% of the total patient population on conditional leave in the community (Aviram, 1972). Thus when federal money became available, California already had a wellestablished administrative mechanism and a network of community placement facilities. We believe that these were instrumental to California's successful exploitation of the federal policy change. Those involved in the community placement program daimed that it was a preferable alternative to hospitalization for three reasons: It was more humane; it was good politics; it was economical. Removing people from the overcrowded wards was considered humane, especially after expos6s of state hospitals were published in the 1940s and 1950s. Politically it was an astute policy, not only in saving regular operating costs of the state hospitals, but also in decreasing the capital outlay for new hospitals and in reducing the number of hospital employees.

The Long-Range Plan In March 1962 the California Department of Mental Hygiene released its blueprint for future mental health programs in California, a Long-Range Plan (California State Senate, 1963). This document is of major interest in the mental health field. Among its many goals, it stipulated that all psychiatric services should be located as close as possible to the people served and that hospitalization should be used only as long as intensive treatment was necessary. It was implicit that the goal of the state hospital system was not necessarily total cure, but rather to return the patient to his former level of functioning, or to a level that would allow his stable maintenance in the community. We believe that the previous presumption of many state hospitals to a total cure was one of the factors responsible for the large backward populations in state hospitals.

The Depopulation Projects The convergence of problems and opportunities resulted in a dramatic project in California in the first half of the 1960s. At the beginning of the decade plans had to be made for two state hospitals with a number of obsolete buildings. Rather than build new wards, it was decided to try to reduce the patient population and thereby vacate the unsuitable quarters. In line with the general policy it was to be achieved without transferring patients to other hospitals and with no additional budget allocation, as new federal regulations provided many of the potential releases with public assistance funds. In July 1963 the Department of Mental Hygiene issued a m e m o r a n d u m on the planned depopulation project for the two state hospitals. In 5 years the

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resident population of these two hospitals was reduced by 3,500, and in 1969 the state closed one of them. Many of those chosen for discharge were either senile aged or chronic schizophrenics. It seemed unlikely that continued hospitalization would result in improvement, and it appeared that they could be maintained in the community without danger to themselves or to others. To effect the policy of depopulation, the state had to overcome the resistance of hospital employees who feared their positions might be jeopardized, and to provide incentives for the project's administrators in addition to relief from overcrowded conditions. The Department of Mental Hygiene dealt with these problems in three ways. (a) The hospital staff was assured that the decline in the hospital's population would not affect their employment; (b) the minimum footage required per patient was increased by 40%; and (c) the major responsibility for finding alternative care was entrusted to an external organization, the Bureau of Social Work. The depopulation project encouraged similar development in other areas of California by demonstrating the technical procedures and by providing experience in obtaining community cooperation and in finding placement facilities for released mental patients. The assurance of income maintenance was essential to the success of the depopulation project and to the recruitment of sheltered care facilities in the community for the released patients who could not live independently. As members of the local communites--professionals, as well as nonprofessional entrepreneurs--became convinced of the advantages of the new system, the depopulation programs acquired the m o m e n t u m that culminated in a major legal overhaul of California's mental health system in 1968.

Controlling Admissions-The Geriatric Screening Project The high admission rate for patients 65 years and over is an important contributing factor to the high proportion of aged in public mental hospitals in the United States (Kramer, Pollack, & Redick, 1961). In spite of the avowed policy of m a n y states to curb unwarranted admissions, the proportion of aged in the mental hospital population has increased since 1955. In California, however, the rate of hospitalized aged patients in 1968 was less than half the corresponding national figure (Syme & Aviram, 1974). A reduction of over 70% in aged population in mental hospitals from 1963 to 1969 is to a great extent attributable to the Geriatric Screening Program which reduced inappropriate commitment of aged persons and promoted the development of community resources for them (Rypins & Clark, 1968). The Bureau of Social Work Policies are not sufficient in themselves for the achievement of change, administrative instruments are needed as well. Many of the observers of the California mental health scene over the past 25 years claim

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that the Bureau of Social Work was the major instrument in carrying out the state's mental health reform policies. An outgrowth of a small extramural unit established by Dr. Rosanoff in 1939, toward the end of the 1960s it became an organization of more than 700 employees, 400 of them professionals, with a caseload of close to 25,000 (Aviram, 1972). Under the administration of the California State Department of Mental Hygiene, it provided supervision for patients on conditional release (leave of absence) and was primarily responsible for finding community placements for these patients. A cohesive organization dedicated to developing and strengthening community care for the mentally ill, it enabled the state to seize the opportunities made available by federal funds and by psychoactive drugs. The bureau established offices throughout California and was often the only professional mental health unit in a particular area. The new community mental health programs, especially in nonurban areas, drew heavily on the professional practices, placement network, and available professional manpower pool of the bureau. This organization and its contribution have been matters of controversy. Never part of the mainstream of the mental health service system, it was first under the state hospital, later the Department of Mental Hygiene, and recently the local community mental health programs. The bureau's special position enabled it to be a catalyst for change, as well as providing the system with a means for its gradual adaptation. It allowed the system to test new ways of delivering mental health services without heavy legal and economic commitments.

Community Mental Health and the Short-Doyle Acts California's efforts at establishing a community mental health service system were formalized in the Short-Doyle Acts of 1957, 1963, and 1968. The Short-Doyle Act of 1957 created a fiscal mechanism whereby counties could receive reimbursement from the state for a certain percentage of the cost of providing mental health services. The state government realized that in order to develop local programs for the care and treatment of the mentally ill, it would have to provide incentives strong enough to counteract the convenience of committing mental patients to state hospitals. Since the mid-1940s California has used federal money provided by the National Mental Health Act of 1946 and the Hill-Burton hospital construction grants to help local communities establish community mental health centers. Although other states, such as N e w York, used some of the funds for improving the state hospital system, California refrained altogether from investing in the state hospital system, and directed its financial efforts toward building community facilities. Critics of the early programs under the Short-Doyle Act pointed out that it

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was insignificant in terms of inpatient services. (The state hospital system continued to be the main provider of these services until the Short-Doyle Amendment of 1968.) However, the original act laid the foundation for community programs for the mentally ill, and in 1969 communities became legally responsible for mental health services.

The Community Mental Health Services Act The California Community Mental Health Services Act of 1968 represented a legal overhaul of California's mental health system (Bardach, 1972). In addition to formalizing many existing trends, it innovated new ones. A single system based on local responsibility for the treatment and care of the mentally ill was created, with the community mental health programs controlling state hospital utilization. By state law, funds are allocated to the county according to the requirements of its mental health programs. The Lanterman-Petris-Short Act, which was part of community mental health reform, made involuntary detention in a mental institution for a long period of time extremely difficult and placed legal responsibility for the care of the mentally ill on the county. The use of inpatient care was reduced through financial inducement to the counties to provide alternatives. Thus a largescale system of board and care, operated mainly by private entrepreneurs, has grown in the communities. CONCLUSIONS We have reviewed the process of change in the mental health service system in California. The transformation from a state hospital service system to a community care system cannot be attributed to any single factor. It is the result of a convergence of ideology, state policies, administrative programs, advances in treatment, and economic conditions, both nationwide and within California. Federal funds for public assistance programs to people on conditional leave from mental institutions and the discovery and wide use of tranquilizing drugs were necessary conditions for the change that took place in California. However, the same opportunities in the mental health arena existed throughout the United States. California's uniqueness lay in its taking full advantage of these generally available conditions. We have discussed the ideological foundations of California's policy to develop a community mental health program in the 1930s and 1940s. The supporters of this view were strengthened by its various economic and political advantages and specific programs were aimed at reducing the resident population in mental institutions, controlling admissions, and developing placement resources and treatment facilities in the communities. The state created an organization to exploit successfully the new opportunities presented by federal funding and treatment techniques. In 1968 these developments culminated in the Community Mental Health Services Act. This law formalized some existing trends, intensified others,

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and put new ones in motion. The number of mental patients in the community who are presently in need of treatment or of a protective living environment is much larger than before the mental health reform act. The manner in which the community provides these people with services and the effectivehess of the services are, of course, matters for future analysis. REFERENCES Aviram, U., & Segal, S. Exclusion of the mentally ill: A reflection on an old problem in a new context. Archives of General Psychiatry, 1973, 29, 120-31. Aviram, U. Men tal health reform and the aftercare state service agency: A study of the process of change in the mental health field. Unpublished dissertation, University of California, Berkeley, 1972. Bardach, G. Skill factor In politics. Berkeley: University of California Press, 1972. Brlll, H., & Patton, R. The impact of modern chemotherapy on hospital organization, psychiatric care, and public health policies: Its scope and its limitation. Proceedings of the Third World Conference of Psychiatry (Vol. 3). Toronto: University of Toronto Press, 1961. California State Governor's Budget, 1974-1975. Sacramento: California Governor's Office, 1975. California State Human Relations Agency. California mental health: A study of successful treatment. Sacramento, Calif.: Human Relations Agency, 1972. California State Senate. Final report on the long-range plan of the Department of Mental Hygiene. Sacramento: Author, February 23, 1963. Department of Health, Education and Welfare, Section No. 3533. Person on conditional release from mental institutions. In Federal Handbook of Public Assistance. Washington, D.C.: DHEW 1962. Earl Warren and the State Department of Mental Health. Berkeley, Calif.: Regional Office of Oral History, 1973. Epstein, L. J., Morgan, R. D., & Reynolds, L. An approach to the effect of ataraxic drugs on hospital release rates. American Journal of Psychiatry, 1962, 119, 3647. Krarner, M., Pollack, E. & Redick, R. Studies of the incidence and prevalence of hospitalized mental disorders in the United States: Current status and future goal. In P. Hock & J. Zubin, Comparative epidemiology of mental disorders. New York: Grune & Stratton, 1961. Miller, D. Worlds that faih Restrospective analysis of mental patients' careers. (Monograph #6). Sacramento, Calif. Department of Mental Hygiene Research, 1965. Mosher, L., Feinsilver, D. Special report: Schizophrenia (HEW, USPHS Publication, HSM, 72-9007). Washington, D.C.; National Institute of Mental Health, 1971. Rypins, R., & Clark, M. A screening project for the geriatric mentally ill. California Medicine, 1968, 109, 273--278. Segal, S., & Aviram, U. The mentally ill in community-based sheltered care. New York: WileyInterscience, 1977. Syme, L., & Aviram, U. Reduction of rates of residents in mental institutions; A report to U.S. National Institute of Mental Health (PHS Grant No. 1 RO 3 MH 22388-01. Unpublished memo, Washington, D.C.: 1974.