The End of Mental Health: Do Mental Health Patients Get Their Own Treatment? Dr. Sharfstein, a Los Almshouse, and the Beginning of Community Mental Health

Eventually, he and his fellow residents banded together and refused to go. The patients were supposed to be moved back to central Boston and treated at the community mental health center. Their small protest was part of a growing movement to close state psychiatric hospitals across the nation and replace them with community-based care.

Those hospitals had also arisen from a movement: In the mid-1800s, after visiting hundreds of almshouses, jails and hospitals and seeing the horrid conditions that most people with mental illnesses lived in, the reformer Dorothea Dix begged health officials to create asylums where those patients could be treated more humanely. The first such facilities were small, designed for short-term, therapeutic care, and functioned more or less as Dix had hoped they would. Local officials started foisting more of their indigent populations onto the states, and as a result they became human warehouses. Most of the patients Dr. Sharfstein held were for many years at a time.

The vast majority of mental health patients should be treated with care and respect in their own communities, according to the advocates of a community-based approach.

The Congress tried to revive Community Mental Health in 1980 with a bill that was more than double Kennedy’s original plan. President Carter signed that bill into law, but President Reagan repealed it the following year. He replaced it with a block grant program that gave state leaders more freedom in how they spend federal mental health dollars. “It was more or less the death knell for a national community mental health system,” Dr. Appelbaum says. We already knew that some of the things they spent the money on were not working.

The law didn’t provide long-term funding for new clinics, just grants for planning and construction. The hope was that states would step in with their own money once the grants expired. But this thinking proved overly optimistic. Most states spent the money saved from asylum closed on other priorities, such as cutting taxes orshoring up pensions.

The mayor of New York told the world that they would begin to hospitalize severely mentally ill homeless people even if they posed no risk of harm to others. My sister was living in an apartment in Queens but she is not homeless. But she has a serious mental illness and in November a neighbor called 911 after seeing her on the street carrying a chef’s knife.

Families like mine are a key constituency that has been largely sidelined during the national crisis about caring for the mentally ill. That may be starting to change. The directive is a step in the right direction. In California, where I live, the Legislature recently passed the Community Assistance, Recovery and Empowerment Act, known as CARE, a law that allows families, domestic partners, even roommates to petition courts for county intervention, including outpatient care for seriously mentally ill people. The new law, and the gradual rollout, which staggers deadlines by county, is seen as a potential model for state mental health care.