Changing trends in mental health legislation: anatomy of reforming a civil commitment law.

In this article, we discuss changing trends of mental health legislation in the United States using a case study of the process of reforming the civil commitment law in New Jersey. That state's new commitment law, commonly called the "screening law," was enacted after a thirteen-year legislative process. Changes in the orientation of the proposed legislation and the dynamics of the process of reforming the commitment law in the state exemplify changing national trends in civil commitment legislation. We consider how the proposed legislation shifted in emphasis from a strong civil libertarian orientation to a social service approach. We assess the role of various interest groups, their negotiations, and the compromises that emerged. Our analysis of the process shows that changes in the social and political environment were the decisive factors that stimulated the process of reforming the civil commitment laws. Many of these changes occurred outside the mental health system and could be neither anticipated nor controlled by the various parties. Our examination of the process and the final outcome of this legislation reveals how organizations and interest groups, in their efforts to adapt to changing conditions, shaped the legislative outcome according to their interests.

Discharge-ready patients who remain hospitalized: a re-emerging problem for mental health services.

There is evidence that mentally ill patients nationwide are retained in state hospitals in spite of the fact that they are discharge-ready. New Jersey provided a unique opportunity to study this phenomenon, since it has been using specific procedures to identify discharge-ready patients in state hospitals. An analysis of New Jersey state hospital data found that about 45% of the state hospital patients were designated by either the legal or the clinical system, or both, as discharge-ready. Although a substantial number of these patients were disabled, they were assessed as being able to manage in the community with appropriate support. Characteristics and service needs of these patients are described, and the differences between those designated as discharge-ready and those who were not are examined. Recommendations are made for future research addressing the legal, clinical and social processes that affect discharge readiness.

Screening services in civil commitment of the mentally ill: an attempt to balance individual liberties with needs for treatment.

Screening services are a central feature of New Jersey's new civil commitment law. This law, more commonly referred to as the screening law, exemplifies a nationwide trend in civil commitment legislation, attempting to balance liberty interests and the need to treat the mentally ill. Screening services, designated as the preferred process of entry into involuntary hospitalization, were expected to prevent unnecessary commitment and to provide community mental health services. When deemed necessary, commitment in local general hospitals rather than in state mental hospitals was to occur. This paper reports results of a study of screening centers that were already in operation in New Jersey prior to the implementation of the new law. It assesses the function of screening services and their potential impact on the commitment process in light of the objectives of the law. Data were obtained from in-depth interviews with key informants from the screening centers as well as from their environment, and from statistical reports on hospitalizations in state hospitals, admissions to screening centers, and admissions to psychiatric inpatient units of general hospitals. Analysis suggests that without more resources for alternative community facilities, screening services cannot achieve their objectives and the new reform may not live up to expectations. Shortage of alternatives to hospitalization and lack of incentives to develop and use them appeared to be counterproductive to achieving the objectives of the law. The availability of screening service and psychiatric units in general hospitals for involuntary hospitalization, on one hand, and the lack of alternatives in the community, on the other, may actually lead to inappropriate commitments and an increase in the number of civil commitments. Furthermore, findings indicated that screeners encouraged hospitalization readily even if other, less restrictive environments could have been pursued. Screening centers may become "gate openers" instead of playing their expected role as "gate keepers."

Community care of the seriously mentally ill: continuing problems and current issues.

The crisis in community care for the seriously mentally ill (SMI) stems from organizational and financial difficulties as well as from deeply embedded structural factors. The analysis shows a preference for medicalizing and individualizing the problems of SMI rather than viewing them as structural social welfare issues. The author discusses problems of deinstitutionalization, homelessness, service provisions, financing, accounting and reporting, employment, bureaucratic skimming and burden to families and points out the ambivalent ideology and the inherent contradictions within the mental health service system. Finally, the centrality of social control and the maintenance of orderly social life in public policy and program development is illuminated.

Community care of the severely mentally ill: is social control a "necessary evil" in policy-making considerations?

Analysis of the crisis in community care for the severely mentally ill (SMI) reveals that it stems not only from organizational and financial problems, but also from the social structure and ideological perspectives embedded in American society. The desire of society for social control and the maintenance of orderly social life is illuminated as a central factor in public policies regarding the SMI. Policy planning, aimed at improving services for the SMI, must take social structural consideration into account and accept the social control component, perhaps as a necessary evil, nevertheless a necessity, in policies regarding the severely mentally ill.

Officers' attitudes toward combat stress reaction: responsibility, treatment, return to unit, and personal distance.

This study examines the attitudes of 176 Israel Defense Forces officers toward combat stress reaction (CSR) in four areas: (1) the degree of personal responsibility the officer accepts for the treatment of the CSR casualty; (2) the type of treatment the officer views as most effective for CSR; (3) the officer's willingness to accept the CSR casualty's return to the unit following treatment; and (4) the personal distance the officer experiences between himself and the phenomenon. The impact of the following variables on officers' attitudes was assessed: casualty's rank, casualty's level of combat skill, presence of an additional physical injury, type of symptomatology, and respondent's background variables. Each officer was presented with one of 24 vignettes describing a CSR incident and was requested to fill in an attitudes questionnaire. Findings revealed that officers were more severe and less tolerant in relation to the CSR casualty who was an officer than toward lower ranking casualties. Officers were expected to take more responsibility for their own recovery than simple soldiers, support of commanding officers was seen as less effective in their treatment, and respondents were less willing to accept them back into their units after treatment.

Overutilization of the general hospital emergency room for psychiatric referrals in an Israeli hospital.

Consecutive referrals numbering 177 to the psychiatrist in an Israeli general hospital emergency room (ER) over a two-month period were evaluated. Only one-third met our criteria of justifiability. When the general practitioner (GP) was the referral source, we considered only 29 per cent of cases justified as compared to 70 per cent of the self-referrals. A combination of poor understanding by the GP of when to refer urgently, efforts by the GP to bypass clinic waiting lists, and lack of alternative community facilities may have accounted for this finding.

Facilitating deinstitutionalization: a comparative analysis.

The purpose of the paper is to highlight issues related to deinstitutionalization and community care of the mentally ill by using a comparative approach. Through a comparison of the trends in the U.S.A. and Israel, an attempt is made to account for factors which promoted deinstitutionalization. The paper focuses on specific policies and programs which were crucial in reducing the rate of resident population in mental institutions and facilitating the development of community care for the mentally ill in the U.S. It points out the environmental conditions, social, political, legal and organizational, which may be conducive to legislative and administrative actions in order to facilitate deinstitutionalization.

Reintegrating the mentally ill in the community.

Substantial reductions in the in-patient census of state hospitals throughout the United States have led to the concentration of large numbers of formerly mentally ill individuals in sheltered living arrangements in local communities. These efforts represent a major change in providing care for the long-term chronic patient. How is the life of this individual affected by community placement? A survey was completed of 499 residents in 234 facilities representing all formerly hospitalized non-retarded mental patients between 18 and 65 years old in California's sheltered care facilities. Results indicate that the social functioning of individuals in the external community is enhanced primarily by the characteristics of the community in which they are placed. In contrast, the social functioning of individuals within the immediate environment of their sheltered living arrangements is most affected by the character of the placement itself. The particular characteristics of communities and facilities found to be most important in addition to the characteristics of the residents which impact on social integration are discussed in the study.

Institutions and their changing environments: structures and processes for adaptation (Part 1).

Institutions are an accompanying phenomenon of modern industrial society. Either because they are still a preferred mode of treatment or because society is reluctant to do away with them they are to remain with us. Unless those responsible for them learn to play in the public area they are destined to be buffeted about by external pressures, to the detriment of clientele, staff, and community. The paper attempts to answer the question asked by many executives of institutions: how better to understand environmental forces and how to adapt effectively with minimum strain to the organization. The focus of the paper is on structures and processes which institutions should use in their efforts to adapt to their dynamic environment. Using appropriate structures and strategies should help to avoid regression and stagnation tendencies and will continuously infuse new ideas into the institution. This will revitalize the institution, allow for improved care, raise morale and esteem of staff, and finally, better serve the community.

Institutions and their changing environments: structures and processes for adaptation. Part II.

Institutions are an accompanying phenomenon of modern industrial society. Either because they are still a preferred mode of treatment or because society is reluctant to do away with them, they are to remain with us. This paper attempts to answer the question asked by many executives of institutions: how to better understand the environmental forces and how to adapt effectively with minimum strain to the organization. The focus of the paper is structures and process which institutions should use in their efforts to adapt to their dynamic environment. Using appropriate structures and strategies should help to avoid regression and stagnation tendencies and will continuously infuse new ideas into the institution.