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The 50-Year Evolution of Social Work in Community Mental Health
Peter Beitchman, DSW, Executive Director, The Bridge Inc.
In 1954, one year before the founding of NASW, the community mental health
movement was launched officially in New York State. While the multiple
roles of social workers in community mental health have evolved over time,
the profession has maintained a crucial leadership position in its development
and success.
A number of factors led up to the enactment of community mental health
legislation in New York – legislation which, for the first time,
established a mechanism to combine state and local government funding
and charitable contributions to support community-based mental health
services for the seriously mentally ill.
In the mid 1800’s Dorothea Dix had championed the cause of Moral
Treatment for the mentally ill, adopting the work of France’s Phillipe
Pinel in America. In the early 1800’s Pinel revolutionized thinking
about mental illness by asserting that it could be alleviated “if
the patient was treated in a considerate manner, if he had an opportunity
to discuss his trouble, if his interest was stimulated and if he was kept
actively involved in life.” Pinel’s prescription – considerate
treatment, talk “therapy,” active involvement in life, were
all to be practiced in the therapeutic “asylum” in which the
precepts of moral treatment would be followed. Adopting this idea in the
United States, Dorothea Dix targeted state governments, successfully moving
the locus of care of the mentally ill from the local almshouse to newly
established state “asylum” systems in more than 20 states,
including New York.
Pinel’s and Dix’s vision was never to be realized. The state
asylum systems quickly degenerated into the custodial state hospitals
that burgeoned through the 19th and well into the 20th centuries. In New
York State more than 20 state hospitals were established; at the height
of the system in the early 1950’s there were 93,000 institutionalized
patients.
The shift to the idea of community care and treatment began during World
War II when, for the first time, every military recruit received a mental
health as well as physical health screening. The results were shocking,
with 2 million of 15 million recruits found to have a significant psychiatric
problem. On the national level, this new recognition of the extent of
mental health problems led to the creation of The National Institute of
Mental Health in 1946 to spur basic and applied research in causes and
treatment of mental illness, and ultimately to the Federal community mental
health centers initiative in the early 1960’s.
The Promise of Reform –
Naive at Best
With the costs of the state hospital systems escalating sharply in the
post-war period and with the growing number of “snakepit”
scandals that called governors and state legislators to task for allowing
such inhumane conditions, the public clamor for reform grew. Simultaneously,
mental health professionals were advocating for a new approach to the
treatment of the seriously mentally ill – an approach that gave
primacy to the supportive community. It is not surprising, then, that
with the introduction in 1954 of Thorazine, the first effective anti-psychotic
medication, state legislators and professionals saw the promise of reducing
the state hospital system. The era of deinstitutionalization got underway,
under the new banner of community mental health.
The horrors of deinstitutionalization, with the massive discharge of thousands
of fragile and vulnerable mentally ill men and women without an established
network of support services for them in the community, are well-known.
The belief that those discharged could make a successful transition to
community living by simply taking their medication and showing up to their
next scheduled re-fill appointment, was naïve at best. The development
of a true network of community-based services was painfully slow.
Those community-based agencies, community mental health centers and hospital
outpatient programs that took on the task were overwhelmed in more than
one sense: by the numbers of individuals who needed services, by the sheer
range of services that were needed and by their unavailability. If there
was going to be success, clearly social workers, with their broad understanding
of their clients’ psychosocial needs and pragmatic skills, would
be crucial players.
Social Work Role in Programs
Coming out of a state hospital with no experience in community living
– too often with no place to live, with no experience in self-care,
without medical and income benefits and without daily structure, the challenge
to social workers in helping agencies was truly overwhelming. Clearly
what so many needed was not simply supportive psychotherapy and medication.
Beginning in the late 1950’s, the network of developing social worker-led
and staffed agencies and programs would systematically attack these issues.
Case management services were developed to assist consumers in obtaining
necessary government benefits; helping clients get and maintain adequate
food, clothing and housing became a crucial service. And the transplanting
of hospital day treatment to community-based settings to provide structured
daily activities and a place in which case management and related services
could be offered was an important development. The Continuing Day Treatment
Programs that were created were almost exclusively led by and staffed
with social workers.
An unexpected but necessary role emerged for social workers in the struggle
to provide for the basic needs of the mentally ill in the community: social
workers became real estate developers as the need for quality housing
as an essential stabilizing service became obvious.
Beginning in the 1980’s, social workers and social work agencies
became leaders in establishing residential programs for the mentally ill.
This not only involved taking on the complicated task of bringing together
sufficient funding from a variety of Federal, State and City sources,
it also involved social workers becoming experts in real estate development,
architecture and construction.
The Rise of Special Populations
Beginning in the 1980’s, new challenges confronted social workers
working in the mental health system. With the seriously mentally ill no
longer consigned to a lifetime institutional system, a number of significant
“special populations” emerged: the mentally ill homeless;
individuals dually-diagnosed with mental illness and co-occurring substance
abuse disorders; persons with mental health diagnoses and HIV/AIDS; and,
with many more thousands of mentally ill now in our prisons and jails
than in psychiatric hospitals, the mentally ill who have been in the criminal
justice system.
All of these “special populations” have challenged social
work agencies and social workers to develop new knowledge and skills;
and the profession has responded by embracing and developing many of the
approaches and techniques that have been developed in this work.
As community mental health agencies were able to assist a large number
of the seriously mentally ill individuals in stabilizing and achieving
a positive quality of life by helping them meet their basic needs, many
consumers became “ready” for the next level of rehabilitative
services, especially vocational and educational opportunities and the
development of satisfying social roles.
Achieving Maximum Independence
The shift in community mental health from the largely paternal role of
“taking care of” clients, to assisting them in their active
rehabilitation in order to achieve their individually-defined goals, has
involved social workers in developing new roles and new skills. The values
underlying the current “client-driven recovery and rehabilitation”
model have been embraced by social work as consistent with the profession’s
value of not only “helping” but doing so in such a way that
our clients achieve maximum independence and satisfying lives.
In this work, social workers are learning and participating in such evidence-based
practices as supported employment, illness management and recovery, intensive
and supportive case management, Assertive Community Treatment and family
psychoeducation.
Clearly, social work has played a leading role in the evolution of community
mental health. Our accomplishments in this area have improved the quality
of life of thousands of men and women with serious mental illness. Today,
we remain on the cutting edge of helping to transform community mental
health into a model rehabilitation system.