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General hospital psychiatry and deinstitutionalization: A systems view
Commentary and Perspective From time to time, the Journal receives manuscripts which can be thought of as opinion pieces, essays, or editorial comment on matters of topical interest. Such submissions will be refereed in the usual fashion and if suitable, published in this section. The Editorial Board invites Letters to the Editor or rebutting commentary with the understanding that all submissions are subject to editing.
General Hospital Psychiatry and Deinstitutionalization: A Systems View Leona L. Bachrach, Ph.D. Research Professor of Psychiatry,
Maryland
Psychiatric
Abstract: The shift in responsibility for the care of chronic mental patients has generated a variety of problems for general hospital psychiatry. In response to fhese new demands, general hospital psychiatry has evolved a variety of effective strategies. Nevertheless, widespread concern over the appropriateness of serving chronic patients in an acute care setting persists. The level and direction of general hospital psychiaf y’s involvement with chronic mental patients will vary according to the specific characteristics ofa community’s patient population, itsgoalsfor those patients, and the resources at its disposal for realizing those goals. General hospital psychiatry must make a serious effort to minimize its being forced into a reactive position by deinstitutionalization policies generated by distant authorities. It must assume, instead, its rightful position as an autonomous, but fully cooperative, element within the psychiatric service system. Only then can its responsibility to the chronically mentally ill, to other patients, and to its own integrity be assured.
There has been a decided change in focus in the general hospital psychiatry literature in recent years. Early writings tended to concentrate on the specialty’s ruison d’etre-on what Schulberg and Burns [l] in this issue describe as general hospital psychiatry’s need to justify its presence. Today’s literature, by contrast, is more likely to be concerned with such substantive issues as identifying target populations and delineating appropriate service approaches [2]. From this perspective, there is little question that general hospital psychiatry has “come of age” [3]. It has successfully legitimated its claim as a medical specialty within the general hospital setting at the same time that it has established its position as a bona fide segment of the greater psychiatric service system [3-51. Yet, even as general hospital psychiatry exhibits signs of maturation, it continues to encounter a General Hospital Psychiatry 7, 23%248, 1985 0 Elsevier Science Publishing Co., Inc. 1985 52 Vanderbilt Avenue, New York, NY 10017
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variety of problems that affect service delivery and patient care. Many issues stem directly from the policies, practices, and initiatives associated with deinstitutionalization [6], the major policy to determine the direction of psychiatric services in the latter half of the twentieth century. This article analyzes the effects of deinstitutionalization from a systems perspective and offers some conclusions about the current role of general hospital psychiatry in the care of chronic mental patients.
Policy Levels A systems framework suitable for viewing today’s psychiatric service system is provided in the work of Johnson [7]. According to his conceptualization, directions in any portion of that system are simultaneously determined in four environments that exist at varying distances from the service site. In the case of the general hospital psychiatric unit, the environment most proximate to actual service provision, the core-levelenvironment consists of the psychiatric service itself as it operates within the context of its unique character and mandates. Closely related, the specific environment consists of those agencies associations, and individuals that collaborate with, extend, and to some extent modify the general hospital core-level services. This includes other specialty units within the hospital, as well as other psychiatric and social service agencies that work in close collaboration with the general hospital psychiatric unit. At further distance from the core service unit is the supportive environment, which is composed of agencies, institutions, and professional associa239 ISSN 0163~8343/65/$3.30
L. L. Bachrach tions that provide the general hospital psychiatric unit with staffing, funding, and legitimation. Finally, at greatest distance from the service delivery site is the general environment, the broad context or sociologic framework of psychiatric service delivery, which consists of such critical elements as economic and political conditions, legal mandates and constraints, and societal attitudes that influence the character of general hospital psychiatric services. Decisions and initiatives affecting general hospital psychiatry are made, and difficulties are generated or exacerbated, within all of these environments. However, since they vary in their proximity to day-to-day unit operations, the initatives promulgated within them may be at considerable variance with the realities of direct patient care. It is ironic that, as general hospital psychiatry is beginning to deal effectively with its boundary problems in the core-level and specific environments, it is increasingly having to respond to the demands of the more distant supportive and general environments. Thus, the presence of a psychiatric unit within the general hospital, and the acceptance of the general hospital as a bona fide site for psychiatric service delivery, are rarely questioned today [3]. In many instances, however, the actual structure and functions of the unit are controlled by external agents and associations, often with little participation from the unit itself. This kind of “top-down” decision making is evident in a variety of specific policies handed down to the general hospital psychiatric unit that exert a profound influence on the character of patient care. For example, the general hospital psychiatric service must generally conform to accreditation standards that originate far from the service delivery site and that are in some respects better suited to other kinds of service facilities [8-91. Similarly, the imposition of catchment area boundaries by planning bodies external to the general hospital unit may serve to control patients’ access to care [lo]. Finally, the advent of DRGs promises an increase in externally imposed initiatives that run the risk of harming patients by denying the realities of their illnesses [ll-131. In addition to these concrete examples of policy determination from afar, there are other less tangible effects resulting from general directives. Frequently, these are broad and coercive (if sometimes vague) policies that originate in the supportive and general environments and profoundly influence the character of service delivery at the local level. A 240
prime example is deinstitutionalization, which has had a marked impact on psychiatric services in the general hospital setting [1,2,6,14].
Understanding Deinstitutionalization Actually, deinstitutionalization is an extremely complex phenomenon that may be understood as having three distinct facets. It is a fact, a process, and a philosophy [15]. As a fact, deinstitutionalization encompasses a series of objective events that are manifested in a massive shift in the locus of care for chronic mental patients. For the past three decades, psychiatric services in all organized care settings except the state hospital have shown an increase. However, the increase has been proportionately greater in outpatient settings, so that inpatient care has vastly decreased as a proportion of all care for this patient population [16]. It is this overall change in patient care settings that provides substance for the fact of deinstitutionalization; and deinstitutionalization as a fact is precisely where many understandings of that movement begin-and end. Deinstitutionalization is, however, more than a fact; it is also a process. Specifically, it is a process of social change, of movement away from one treatment orientation to another that is radically different. This process of change has, all by itself, affected the lives of people who are chronically mentally ill, and the course of service delivery in all segments of the psychiatric service system. Deinstitutionalization as a process is reflected in a continuing and ongoing series of accommodations and boundary shifts within the psychiatric service system [17], and few patients or service providers have been immune to its effects. The entire division of responsibility within the system has undergone a major upheaval. Thus, it continues to change, as public and private facilities compete for funds, state hospitals become acutecare facilities [ 151, and general hospitals become the “core service to succeed the state hospital” [18]. Nevertheless, a full understanding of deinstitutionalization’s influence derives from viewing that movement as something even more than a fact and a process. It is also a philosophy with roots in postWorld War II America, when a variety of civil rights protests were gaining widespread support. Like other civil rights initiatives in that post-war era, deinstitutionalization emphasized the inalienable rights of disfranchised individuals and their legitimate claims on society. In this sense, the deinstitu-
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tionalization movement undertook no less impressive a task than that of “humanizing” the care of the mentally ill-of reversing the dehumanizing influences that were widely considered to be the inevitable accompaniments of institutional residence [19]. It is important to add, however, that deinstitutionalization’s affinity to the civil rights movement was not its sole source of ideological commitment. In addition to the belief that community-based care is more humane than institutional care, there was a second belief: that community-based care is also less costly [20,21]. Such a coalition of two ordinarily antagonistic constituencies, social reformers and fiscal reformers, gave the deinstitutionalization movement unprecedented impetus [22]. It may be noted parenthetically that these two beliefs were never really tested-that in the 1960s they were primarily matters of faith, not science. Indeed, even today our outcome studies remain largely inadequate to the task of providing empirical support for these assumptions [23-2.51. Yet they continue, with their humanistic and fiscal appeal, to serve as powerful forces in determining the course of the psychiatric service system. So powerful are the twin assumptions of more humane treatment and less expensive services that they actually serve as a conceptual framework for psychiatric service planning. They presuppose an ability and a willingness on the part of communities to provide ready alternatives for the full range of services and functions typically associated with institutional care [26]. In short, the philosophy of deinstitutionalization holds that communities can, and will, provide total care for the chronically mentally ill [26-281 and that they will accommodate patients’ residential [29,30], treatment [31], support [32], and asylum [33-3.51 needs.
Emerging Issues Today, 30 years past the peak of residential enrollment in state mental hospitals [16], we may stand back and evaluate the consequences of deinstitutionalization as a fact, a process, and a philosophy for services in the core-level environment. It appears that deinstitutionalization has actually had mixed outcomes. On the positive side, it has generated a series of planning principles and programs based on these principles that truly enhance the lives of many individuals who are chronically mentally ill [27]. It has also served to alter the ways in which we think about the needs of chronic patients
and encouraged us to regard them as individuals with highly specific and idiosyncratic program needs [36]. Deinstitutionalization has only partially realized its goals, however, and there have been major and serious disjunctions among the fact, the process, and the philosophy of the movement. Regardless of the existence of some exemplary programs devoted to the care of chronic mental patients and the evolution of relevant and practicable planning principles, the problems that are associated with deinstitutionalization are numerous. Most notably, institutional settings have in many cases been emasculated or totally destroyed before a sufficient array of community-based services has been assured [26], so that, on a nationwide basis, the problems that are associated with deinstitutionalization appear to outweigh the benefits at the present time. Bradley [37] provides a context for understanding these effects in a systems framework by distinguishing between program termination and program development objectives in deinstitutionalization. Although the movement’s philosophy originally embodied both kinds of objectives, the former have been pursued more vigorously than the latter in most parts of the country. Thus, the fact and the process of deinstitutionalization have focused primarily on the reduction or elimination of institution-based service sites and have been out of synchrony with the philosophy of deinstitutionalization that stresses alternative loci of care. Indeed, so ingrained in our thinking are the program termination objectives of deinstitutionalization, that is common for us to measure its progress statistically through data that reflect the diminished role of the state hospital, e.g., patient terminations or facility closings [38]. Yet the emergence of a generation of chronic mental patients who are unserved by the service system [39] is every bit as valid an indicator of deinstitutionalization’s multiple effects as is a drop in state hospital censuses. The net result for patients of our failure to pair program termination and program development objectives in a systematic manner in deinstitutionalization programming has led to a circumstance known popularly as “falling through the cracks.” Many chronic mental patients have simply been ignored or inappropriately served in the newly emerging psychiatric service settings.
Problems in Service Delivery In a very real sense, then, deinstitutionalization has been only partially implemented in most of the 241
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United States. An exchange of treatment settings has certainly occurred, but new program initiatives have generally lagged or been incomplete or nonexistent. To understand the implications of these events for people who are chronically mentally il1 it is necessary to know something about the character of community-based psychiatric services in the United States. Generally speaking, these services may be described as lacking in continuity and comprehensiveness and as inadequate for the complex service needs of people who are chronically mentally ill. More specifically, although some communitybased programs successfully target and serve chronic mental patients, many are either unable or unwilling to do so. A major problem affecting service delivery in deinstitutionalized service systems revolves around the complexities of implementing continuity in the care of chronic mental patients [36,40-411. Since the service needs of these individuals tend to endure over time, efforts must be made to reduce the possibility that hiatuses in service delivery will occur. This, in turn, requires the design of proactive and carefully detailed program plans, as well as the presence of “continuity agents” [42] to, anticipate and mitigate barriers to care. In contrast to this requirement, however, deinstitutionalized program initiatives tend to be designed for the “single-episode user of services,” and thus, in the words of Hansel1 [43], to exhibit “a deficiency of interest in people with lifelong disorders.” In addition, there have been widespread serious practical difficulties attending the provision of comprehensive services to chronic mental patients in deinstitutionalized service systems. As noted above, comprehensive care for these patients is often tantamount to total care [22]. Yet the various separate functions that constitute total care have often been blurred in the planning process, so that one of them may become a major planning focus, whereas the others are virtually ignored. We see this, for example, in calls for improved shelter for homeless mentally ill individuals without simultaneous acknowledgment of these individuals’ needs for medical and psychiatric care [44-461. Similarly, the concept of the least restrictive alternative has traditionally encouraged planning for patients’ residential placements without at the same time acknowledging their needs for treatment and asyIum 133,471, Perhaps, however, the single most far-reaching outcome of deinstitutionalization programing is 242
that it has generated a dramatic change in the character of the chronically mentally ill patient population. These individuals, who only a few decades ago constituted a primarily long-stay institutional population with relatively stable utilization patterns, today fall into a variety of subgroups [15]. There are, first, old long-stay patients [48] who have had many years, sometimes decades, of state hospital residence. Some of them have been discharged to the community, but others have remained institutionalized. In addition, there are other patients newly admitted to the state hospital. Some will become nezulong-stay patients, and others short-stay patients with only brief hospital tenures. Finally, there are increasing numbers of never-institutionalized chronically mentally ill people whose treatment histories have been determined by so-called admission diversion policies at many state hospitals [49-521. Many of the short-stay and never-institutionalized patients fall into the grouping now called new long-ferm patients by Wing and Morris [48] in Britain, in order to differentiate them from longstay chronic mental patients. In the United States, attention has focused on the age of this population because of an overrepresentation of baby-boom generation individuals among them, and they have been called yoloungadz& chronic p&e&-even though the validity of this term has recently been called into serious question [54,55]. Although the course of illness for new long-term patients is chronic, they have had an essentially noninstitutional history and do not exhibit the constellation of symptoms and passive behaviors frequently identified with institutional tenure, with what Goffman [19] called “institutionalism.” To the contrary, many are demanding, volatile, and disruptive individuals. The literature typically describes them as “difficult” patients or “problem” patients” [39]. Many are without social supports, and increasing percentages of them are episodically or permanently homeless [56]. These patients are reported to be regular and repeated users of services in all psychiatric settings. However, they appear in many places to affect the general hospital setting disproportionately [57-621, and they pose particular problems for emergency psychiatric services. Indeed, as the result of deinstitutionalization, the general hospital psychiatric emergency service has in many places become a substitute facility for the state hospital. Sometimes this has led to dreadful consequences, as this statement in a New York Times news story illustrates:
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“Yesterday the [general] hospital was attempting to relieve its overcrowding by discharging those judged to be least sick- a form of psychiatric triage that was being performed in the emergency room, where only patients who appear to be a danger to themselves or others are admitted” [62].
General Hospital Issues General hospital psychiatry, partly because its growth and development have coincided temporarily with deinstitutionalization and partly because it has often provided the only available medical environment for chronic mental patients, has frequently been charged with the responsibility of correcting the disjunctions among the fact, the process, and the philosophy of deinstitutionalization. In the absence of clearly formulated program development objectives, general hospital psychiatric units, including emergency services, have often become the major, and sometimes the only, loci of care for many chronic mental patients, either by arrangement or default [63]. This shift in responsibility for the care of the chronically mentally ill has generated a variety of problems for general hospital psychiatry [1,2,6]. A major area of difficulty concerns the hospital’s need to absorb large numbers of chronically ill patients in an acute-care setting [13], a population that, 30 years ago, probably would have been institutionalized. Not surprisingly, this has at times generated a competition for resources that local general hospital units are ill prepared to handle. Nor is it merely the matter of increased numbers of patients that is often troublesome to general hospital psychiatry. There is also some question about the proper limits of general hospital psychiatry’s concern with the chronically mentally ill. That the general hospital psychiatric unit has inherited the treatment function from the state hospital psychiatric unit is not surprising. However, the general hospital has often been the “only show in town” available to serve chronic mental patients. Moreover, in a service climate where the separate functions subsumed under total care are often blurred, the general hospital psychiatric unit has also sometimes been faced with having to fulfill other, less traditional, functions. Specifically, general hospital psychiatry has frequently been charged with the total care of the chronically mentally ill and has been expected to provide for their residential, social support, and asylum needs, in addition to their treatment needs [58].
It must be noted, however, that in spite of these concerns, the inclusion of chronically ill psychiatric patients in general hospital programs is not uniformly viewed as inherently problematic. Many psychiatrists see this trend as a challenge and a source of revitalization in their programs [64-671. Others are less sanguine, however [13]. Whatever one’s view, it is becoming clear that what Talbott [68] calls the “chronicizing of general hospital psychiatry” is rapidly occurring. These circumstances have prompted some to call for a renaissance of state hospital services [69], but such an event is unlikely to occur on any large scale. For one thing, the clear benefits that accrue to many, though certainly not all, chronic patients from community-based care are sufficiently evident [70,71], that planners and policy makers are not likely to tolerate a total backlash. In addition, even if a concentrated effort to revive the central role of the state hospital could be mounted, yesterday’s service patterns could probably not be duplicated today. The old-time institution is rapidly slipping away, as today’s state hospitals serve more and more as acute-care settings instead of long-term custodial facilities [72,73]. These changes are supported and reinforced by a host of legal decisions and staffing constraints that have altered the character of the state hospital materially [13,74-761.
A Range of Solutions By design or default, then, general hospital psychiatry is today critically involved in delivering services to chronic mental patients. Has it been successful in this endeavor? A review of the current literature [2] suggests that, although there are certainly problems, there is also evidence that the general hospital unit has often responded with innovative and relevant initiatives 177,781. This is particularly true for those units located in public facilities [2]. Some general hospital psychiatric services have approached the care of chronic mental patients by absorbing them into existing programs with minimal changes in the structure of the unit. Others have found that dividing the unit into locked and unlocked portions has effectively met their needs. Still others have constructed physically separated service structures at some distance from the main portion of the hospital. It thus appears that a variety of approaches may potentially be used in serving chronic mental patients. Furthermore, it is clear from the literature that local variations in the com243
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position of the target population, specific program goals, and available resources interact to determine the precise direction of service planning for this patient population in any one general hospital setting [79]. Nevertheless, regardless of these varied alternative approaches, widespread concern over the appropriateness of serving chronic patients in the general hospital setting persists. Questions have been raised as to whether such a use of general hospital resources is in fact always in the best interests of chronic patients, of other patients, and of the psychiatric unit itself. The prevalent view in the literature appears to be, in the words of Sederer and his colleagues [13], that the general hospital “cannot become the repository for all patients without compromising what it aims to provide, namely acute care, proximal to general medical resources, for relatively brief illness periods.” These authors go on to suggest that “chronic cases and severely behaviorally unmanageable patients (particularly the more violent) must be treated in other facilities for the general hospital to continue to meet its mandate.” Another view, however, is put forth in this issue by two Canadian authors, Richman and Harris [80], who write in support of a general hospital psychiatric unit that assumes a pivotal role in the service system and takes on responsibility for the care of all mental patients. Their ideal general hospital psychiatric unit is the core planning and service agency in a system of unified psychiatric care. Such a broad role stands in direct contrast to general hospital psychiatry’s traditionally held adjunctive role, in which, according to Richman and Harris, that service provides “brief treatment to highly selected types of patients,” particularly those who are “compliant, unobtrusive, and rapidly responsive.” Should Richman and Harris’ suggestion of a pivotal general hospital psychiatric unit be pursued in American psychiatry? Cotton and his associates [65] demonstrate that, at least in some communities, it is indeed possible and practicable for the general hospital psychiatric unit to assume such a role in the service system. However, necessary preconditions must be met before this end can be achieved. Specifically, the unit must have the freedom to adopt appropriate treatment procedures, to pursue intensive staff training, and to serve as a leader in establishing essential interagency collaborative ties. The fact that general hospital psychiatric units have the ability to assume a pivotal role in some 244
communities does not necessarily mean, however, that they can, or that they would be well advised to take on such a responsibility in all communities. It is perhaps a jaded observation, but it is nonetheless accurate, that there can be no uniform format for the delivery of psychiatric services that is equally appropriate for all communities in the United States. The history of federally funded community mental health centers amply illustrates the truth of this statement [81]. In short, there is no single “right” way to respond to Richman and Harris’ suggestion in this country. In some places, the general hospital may indeed be able to assume pivotal responsibility and may be able to do so at once. In other communities, such a role will have to be adopted slowly and cautiously. Moreover, in still other communities, the general hospital psychiatric unit may not foresee a pivotal role in its future at all and will elect to depend on other service agencies to take the lead responsibility in caring for the chronically mentally ill. My own observations and reading of the literature lead me to the conclusion that, generally speaking, the contribution of general hospital psychiatry to the philosophy of deinstitutionalization is enhanced when the general hospital can work in close cooperation with another facility such as the state hospital that provides backup for the longterm care needs of those chronic patients who are most refractory. That both the general hospital psychiatric unit and the long-term care facility are adequately staffed and funded and are concerned with providing the best possible care for chronic mental patients are, of course, essential preconditions. When general hospital psychiatry is thus relieved of the pressure to be all things to all patients, the threat of preemption is diminished, service decisions become more appropriate and humane, and chronic patients are better served [81]. The major problem to be solved in such cooperative enterprises is to work out the complentarity of facilities’ roles and to assign unambiguous responsibility in gatekeeping [83] and patient screening and referral [361-a task that is both negotiable and practicable and that depends on local goals and available resources [84].
Conclusions The various observations made here lead logically to several conclusions regarding the relationship
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between deinstitutionalization and general hospital psychiatry. First, there is a need for openness in the general hospital setting. Deinstitutionalization may potentially have a challenging and salubrious effect on service delivery in general hospital psychiatric units by broadening the scope of their programs and revitalizing their service role. Moreover, any potentially negative effects of deinstitutionalization can probably best be neutralized by the adoption of a positive attitude toward change on the part of those in the psychiatric unit. In the succinct words of a British planning team, “Building a satisfactory service for the mentally ill . . . has to challenge past assumptions” [85]. Visotsky and Plaut’s [86] blueprint for the future of general hospital psychiatry reinforces this conclusion. Second, a conceptual distinction must be made between what general hospital psychiatry is able to do under optimal circumstances and what it should do in any one particular community. General hospital psychiatry has shown itself to be potentially capable of delivering care to all kinds of mental patients, including those who are chronically ill. In some settings this is obviously a desirable course to pursue. It does not, however, follow that such a global charge is necessarily an appropriate one under all circumstances. The level of general hospital psychiatry’s involvement with chronic mental patients must be determined by the character of a particular community’s patient population, its goals for those patients, and the resources it has at its disposal for realizing those goals. Its specific obligation will be tempered by the availability of other facilities, such as state hospitals and community mental health centers that welcome the chronically mentally ill, to share in the care of that population. Third, where general hospital psychiatry does assume responsibility as the core-level agency in serving chronic mental patients, it must be aware that some among those individuals will probably require total care. General hospital psychiatry must accordingly be prepared to work in concert with other agencies to serve this population, and it must be ready to negotiate its core-service role and cede some territory. Fourth, possibilities for compromise not only exist but are also essential to pursue. The general hospital psychiatric unit need not necessarily adopt an all-or-nothing approach to the care of chronic mental patients [87], In addition, the general hospital unit may serve chronic patients well by becom-
ing an active member of an interagency consortium designing individually-tailored program placements for chronic mental patients [4,88,89]. In fact, the general hospital psychiatric unit may be uniquely equipped to serve as a centralized screening and referral agency, because of its location in the community and its connection with medical services. Finally, although general hospital psychiatry must be willing and able to work together with other service agencies, it must not relinquish its autonomy. It is critical that the general hospital psychiatric unit be a full partner in determining the direction and limits of its own patient care responsibilities. In the absence of self-determination, confusion, resentment, and deterioration of serviceswith predictably dire consequences for chronic patients-are likely to occur. General hospital psychiatry must thus make a serious effort to minimize its being forced into a reactive position by deinstitutionalization policies generated in the distant supportive and general environments. It must, instead, assume its rightful position as an autonomous, but fully cooperative, element within the psychiatric service system. Only then can its responsibility to the chronically mentally ill, to other patients, and to its own integrity be assured.
References 1. Schulberg HC, Burns BJ: The nature and effectiveness of general hospital psychiatric services. Gen Hosp Psychiatry 7:249-257, 1985 2. Bachrach LL: General hospital psychiatry: Overview from a sociological perspective. Am J Psychiatry 138:879-887, 1981 3. Lebensohn ZM: General hospital psychiatry U.S.A.: Retrospect and prospect. Compr Psychiatry 21:500519, 1980 4. Keill SL: The general hospital as the core of the mental health services system. Hosp Community Psychiatry 32:776-778, 1981 5. Pardes HE: Mental health-general health interaction: Opportunities and responsibilities. Hosp Community Psychiatry 32779-782, 1981 6. Bachrach LL: The effects of deinstitutionalization on general hospital psychiatry. Hosp Community Psychiatry 32:787-790, 1981 7. Johnson PJ: Community support systems for deinstitutionalized patients. New Directions for Mental Health Services no. 17: Deinstitutionalization: 81-92, 1983 8. Flamm GH: Summary of progress. Newsletter of the American Association of General Hospital Psychiatrists 3-5, Winter 1980 24s
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9. Langsley DG: Viewpoint. Psychiatric News, pp 3,28, August 1, 1980 10. Marcos LR, Gil RM: Psychiatric catchment areas in an urban center: A policy in disarray. Am J Psychiatry 141:875-878, 1984 11. Widem I’, Pincus HA, Goldman HH, Jencks S: Prospective payment for psychiatric hospitalization: Context and background. Hosp Community Psychiatry 35447-451, 1984 12. Goldman HH, Pincus HA, Taube CA, Regier DA: Prospective payment for psychiaric hospitalization: Questions and issues. Hosp Community Psychiatry 35:460-464, 1984 13. Sederer LI, Katz B, Manschreck TC: Inpatient psychiatry: Perspectives from the general, the private, and the state hospital. Gen Hosp Psychiatry 6:180-190, 1984 14. Mooney DA, Zirker ME: General Hospital Psychiatry in Massachusetts. Burlington MA, MHA-DMH Mental Health Project, December 1981 15. Bachrach LL: A conceptual approach to deinstitutionalization. Hosp Community Psychiatry 29:573578, 1978 16. Goldman HH, Adams, NH, Taube CA: Deinstitutionalization: The data demythologized. Hosp Community Psychiatry 34:129-134, 1983 17. Dinitz S, Beran N: Community mental health as a boundaryless and boundary-busting system. J Health Sot Behav 12:99-108, 1971 18. Greenhill MH: Psychiatric units in general hospitals: 1979. Hosp Community Psychiatry 30:169-182,1979 19. Goffman E: Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Garden City, NY, Anchor Books, 1961 20. Cramer PK: Report on the current state of deinstitutionalization: Period of retrenchment. Commentaries on Human Services Issues, (Philadelphia, Health & Welfare Council, Inc.), May 1978 21. Lyons RD: How release of mental patients began. New York Times, pp Cl, C4, October 30, 1984 22. Okin RL: The future of state mental health programs for the chronic psychiatric patient in the community. Am J Psychiatry 135:1355-1358, 1978 23. Bachrach LL: Assessment of outcomes in community support systems: Results, problems, and limitations. Schizophr Bull 8:39-61, 1982 24. Braun I’, Kochansky G, Shapiro R, Greenberg S, Gudeman JE, Johnson S, Shore MF: Overview: Deinstitutionalization of psychiatric patients. Am J Psychiatry 138:736-749, 1981 25. Love RE: The Community Support Program: Strategy for reform. In Talbott JA (ed), The Chronic Mental Patient: Five Years Later. Orlando, FL, Grune and Stratton, 1984, pp 195-214 26. Bachrach LL: Deinstitutionalization: An Analytical Review and Sociological Perspective. Rockville MD, National Institute of Mental Health, 1976 27. Bachrach LL: Principles of planning for chronic psychiatric patients: A synthesis. In Talbott JA (ed), The Chronic Mental Patient: Five Years Later. Orlando, EL, Grune and Stratton, 1984, pp 165-182 28. Talbott JA: Deinstitutionalization: Avoiding the di-
246
29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.
43. 44. 45.
46. 47. 48.
49. 50.
sasters of the past. Hosp Community Psychiatry 30:621-624, 1979 Budson RD: Sheltered housing for the mentally ill: An overview. McLean Hosp J 4:140-157, 1979 Lamb HR (ed): The Homeless Mentally Ill. Washington, American Psychiatric Association, 1984 Talbott JA (ed): The Chronic Mentally Ill: Treatment, Programs, Systems. New York, Human Sciences Press, 1981 Cutler D: Networks. In Talbott JA (ed), The Chronic Mental Patient: Five Years Later. Orlando, FL, Grune and Stratton, 1984, pp 253-266 Bachrach LL: Asylum and chronically ill psychiatric patients. Am J Psychiatry 141:975-978, 1984 Lamb HR, Peele R: The need for continuing asylum and sanctuary. Hosp Community Psychiatry 35:798802, 1984 Talbott JA: The need for asylym, not asylums. Hosp Community Psychiatry 35:209, 1984 Bachrach LL: Planning services for chronically mentally ill patients. Bull Menninger Clinic 47163-188, 1983 Bradley VJ: Policy termination in mental health: The hidden agenda. Policy Sci 7215-224, 1976 Manderscheid RW, Witkin MJ, Rosenstein MJ, Bass RD: A review of trends in mental health services. Hosp Community Psychiatry 35:673-674, 1984 Bachrach LL: Young adult chronic patients: An analytical review of the literature. Hosp Community Psychiatry 33: 189-197 Bachrach LL: Continuity of care for chronic mental patients: A conceptual analysis. Am J Psychiatry 138:1449-1456, 1981 Wasylenki D, Goering P: A framework for continuity of care. Perspectives in Psychiatry (University of Toronto Department of Psychiatry) 3:1-5, April 1984 Granet RB, Talbott JA: The continuity agent: Creating a new role to bridge the gaps in the mental health system. Hosp Community Psychiatry 29:132-133, 1978 Hansell N: Services for schizophrenics: A lifelong approach to treatment. Hosp Community Psychiatry 29:105-109, 1978 Comer R: Playing the dumping game with the homeless. Philadelphia Inquirer, p. 25A, December 7,1984 Drake RE, Adler DA: Shelter is not enough: Clinical work with the homeless mentally ill. In Lamb HR (ed), The Homeless Mentally Ill. Washington, American Psychiatric Association, pp. 141-151 A street is not a home. New York Times, p A24, August 24, 1984 Bachrach LL: Is the least restrictive environment always the best? Sociological and semantic implications. Hosp Community Psychiatry 31:97-102, 1980 Wing JK, Morris B: Clinical basis of rehabilitation. In Wing JK, Morris B (eds), Handbook of Psychiatric Rehabilitation Practice. Oxford, Oxford University Press, 1981 Dionne EJ: Mental patient cutbacks planned. New York Times, p B3, December 8, 1978 Morrissey JP, McGreevy MM: The fates of applicants denied admission to state mental hospitals: Some
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51. 52. 53. 54.
55.
56.
unexamined consequences of deinstitutionalization in the USA. Presented at the meeting of the Intemational Sociological Association, Mexico City, August 1981 Pepper B, Ryglewicz H: Testimony for the neglected: The mentally ill in the post-deinstitutionalized age. Am J Orthopsychiatry 52:388-392, 1982 Shapiro JG: Patients refused admission to a psychiatric hospital. Hosp Community Psychiatry 34:733736, 1983 Pepper B, Kirshner MC, Ryglewicz H: The young adult chronic patient: Overview of a population. Hosp Community Psychiatry 32:463-469, 1981 Bachrach LL: The concept of young adult chronic psychiatric patients: Questions from a research perspective. Hosp Community Psychiatry 35:573-580, 1984 Schwartz SR, Goldfinger SM, Ratener M, Cutler DL: The young adult chronic patient and the care system: Fragmentation prototypes. New Directions for Mental Health Services no. 19: Effective Aftercare for the 198Os:23-34, 1983 Bachrach LL: The homeless mentally ill and mental health services: An analytical review of the literature. In Lamb HR (ed), The Homeless Mentally Ill. WashEgto;, American Psychiatric Association, 1984, pp.
57. Bassuk E, Gerson S: Chronic crisis patients: A discrete clinical group. Am J Psychiatry 137~1513-1517, 1980 58. Diamond RJ, Davidson SL: Patients perceived as having psychosocial problems in a general hospital emergency room: A study of registered and unregistered patients. Psychosocial Rehabilitation J 748-58, 1984 59. Goldfinger SM, Hopkin JT, Surber RW: Treatment resisters or system resisters? Toward a better service system for acute care recidivists. New Directions for Mental Health Services no. 21: Advances in Treating the Young Adult Chronic Patient:17-27, 1984 60. Robbins E, Stern M, Robbins L, et al: Unwelcome patients: Where can they find asylum? Hosp Community Psychiatry 2944-46, 1978 61. Schwartz SR, Goldfinger SM: The new chronic patient: Clinical characteristics of an emerging subgroup. Hosp Community Psychiatry 32:470-474, 1981 62. Sullivan R: Hospital forced to oust patients with psychoses. New York Times, p B3, November 8, 1979 63. Bachrach LL: General hospitals taking greater role in providing services for chronic patients. Hosp Community Psychiatry 30:488, 1979 64. Becker A: Inadequacy of institutional psychiatric care (letter to editor). N Engl J Med 294:1068, 1976 65. Cotton PG, Bene-Kociemba A, Cole R: The effect of deinstitutionalization on a general hospital’s inpatient psychiatric service. Hosp Community Psychiatry 30609-612, 1979 66. Egri G: A general hospital model. In Talbott JA (ed), The Chronic Mentally Ill: Treatment, Programs, Systems. New York, Human Sciences Press, 1981, pp. 175-186 67. Meyerson AT: What are the barriers or obstacles to
68. 69. 70. 71. 72. 73. 74. 75. 76.
77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88.
treatment and care of the chronically disabled mentally ill? In Talbott JA (ed), The Chronic Mental Patient. Washington, American Psychiatric Association, pp. 129-134 Talbott JA: The Death of the Asylum: A Critical Study of State Hospital Management, Services, and Care. New York, Grune and Stratton, 1978 Sigel GS: In defense of state hospitals. Hosp Community Psychiatry 35:1234-1236, 1984 Freeman SJ: The chronic patient rediscovered: Ten propositions. Canada’s Mental Health: 15-16, 24, December 1983 Glick ID, Klar HM, Braff DL: Guidelines for hospitalization of chronic psychiatric patients. Hosp Community Psychiatry 35:934-936, 1984 DeRisi W, Vega WA: The impact of deinstitutionalization on California’s state hospital population. Hosp Community Psychiatry 34:140-145, 1983 Goldman HH, Taube CA, Regier DA, Witkin M: The multiple functions of the state mental hospital. Am J Psychiatry 140:296-300, 1983 Gaver KD: Considerations in providing psychiatric services in general hospitals. Hosp Community Psychiatry 24:252-253, 1973 Okin RL: State hospitals in the 1980s. Hosp Community Psychiatry 33:717-721, 1982 Diamond RJ: The role of the hospital in treating the chronically disabled. New Directions for Mental Health Services no. 2: Community Support Systems for the Long-Term Patient: 45-56, 1979 Crowder JE, Klatte EW: Involuntary admissions to general hospitals: Legal status not the issue. Hosp Community Psychiatry 31:325-327, 1980 Franciscan Mental Health Center: 1984 Annual Report. Rock Island IL, 1984 Okin RL, Kinzer DM, Mooney DA: Major obstacles to the development of psychiatric units in general hospitals. Hosp Community Psychiatry 34:966-967,1983 Richman A, Harris I’: General Hospital psychiatry: Are its roles and functions adjunctive or pivotal: Gen Hosp Psychiatry 7:258-266, 1985 Group for the Advancement of Psychiatry: Community Psychiatry: A Reappraisal. New York, Mental Health Materials Center, 1983 Talbott JA: The patient: First or last? Hosp Community Psychiatry 3534-344, 1984 Central Toronto Youth Services Foundation: Reaching Out: Outreach Treatment Programming. (Part I) Toronto, 1982 Bachrach LL: Developing objectives in community mental health planning. Am J Public Health 64:11621163, 1974 Towel1 D (ed): Managing psychiatric services in transition. Health Sot Serv J (London) l-8, October 25, 1984 Visotsky HM, Plaut EA: Psychiatry in the general hospital: Visualizing the changes. Hosp Community Psychiatry 33:739-741 Leeman CP: The “least restrictive environment”: From rhetoric to practice. Gen Hosp Psychiatry 3:229-232, 1980 Dressler DM, Fitzgibbons DJ: The general hospital as
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a center for mental health services. Conn Med 40:407-409, 1976 89. Spiro HR: Reforming the state hospital in a unified care system. Hosp Community Psychiatry 33:722728, 1982
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Direct reprint requests to: Leona L. Bachrach, Ph.D 11001 Wickshire Way Rockville, MD 20852
General Hospital Psychiatry and Deinstitutionalization: A Systems View Leona L. Bachrach, Ph.D. Research Professor of Psychiatry,
Maryland
Psychiatric
Abstract: The shift in responsibility for the care of chronic mental patients has generated a variety of problems for general hospital psychiatry. In response to fhese new demands, general hospital psychiatry has evolved a variety of effective strategies. Nevertheless, widespread concern over the appropriateness of serving chronic patients in an acute care setting persists. The level and direction of general hospital psychiaf y’s involvement with chronic mental patients will vary according to the specific characteristics ofa community’s patient population, itsgoalsfor those patients, and the resources at its disposal for realizing those goals. General hospital psychiatry must make a serious effort to minimize its being forced into a reactive position by deinstitutionalization policies generated by distant authorities. It must assume, instead, its rightful position as an autonomous, but fully cooperative, element within the psychiatric service system. Only then can its responsibility to the chronically mentally ill, to other patients, and to its own integrity be assured.
There has been a decided change in focus in the general hospital psychiatry literature in recent years. Early writings tended to concentrate on the specialty’s ruison d’etre-on what Schulberg and Burns [l] in this issue describe as general hospital psychiatry’s need to justify its presence. Today’s literature, by contrast, is more likely to be concerned with such substantive issues as identifying target populations and delineating appropriate service approaches [2]. From this perspective, there is little question that general hospital psychiatry has “come of age” [3]. It has successfully legitimated its claim as a medical specialty within the general hospital setting at the same time that it has established its position as a bona fide segment of the greater psychiatric service system [3-51. Yet, even as general hospital psychiatry exhibits signs of maturation, it continues to encounter a General Hospital Psychiatry 7, 23%248, 1985 0 Elsevier Science Publishing Co., Inc. 1985 52 Vanderbilt Avenue, New York, NY 10017
Research Center
variety of problems that affect service delivery and patient care. Many issues stem directly from the policies, practices, and initiatives associated with deinstitutionalization [6], the major policy to determine the direction of psychiatric services in the latter half of the twentieth century. This article analyzes the effects of deinstitutionalization from a systems perspective and offers some conclusions about the current role of general hospital psychiatry in the care of chronic mental patients.
Policy Levels A systems framework suitable for viewing today’s psychiatric service system is provided in the work of Johnson [7]. According to his conceptualization, directions in any portion of that system are simultaneously determined in four environments that exist at varying distances from the service site. In the case of the general hospital psychiatric unit, the environment most proximate to actual service provision, the core-levelenvironment consists of the psychiatric service itself as it operates within the context of its unique character and mandates. Closely related, the specific environment consists of those agencies associations, and individuals that collaborate with, extend, and to some extent modify the general hospital core-level services. This includes other specialty units within the hospital, as well as other psychiatric and social service agencies that work in close collaboration with the general hospital psychiatric unit. At further distance from the core service unit is the supportive environment, which is composed of agencies, institutions, and professional associa239 ISSN 0163~8343/65/$3.30
L. L. Bachrach tions that provide the general hospital psychiatric unit with staffing, funding, and legitimation. Finally, at greatest distance from the service delivery site is the general environment, the broad context or sociologic framework of psychiatric service delivery, which consists of such critical elements as economic and political conditions, legal mandates and constraints, and societal attitudes that influence the character of general hospital psychiatric services. Decisions and initiatives affecting general hospital psychiatry are made, and difficulties are generated or exacerbated, within all of these environments. However, since they vary in their proximity to day-to-day unit operations, the initatives promulgated within them may be at considerable variance with the realities of direct patient care. It is ironic that, as general hospital psychiatry is beginning to deal effectively with its boundary problems in the core-level and specific environments, it is increasingly having to respond to the demands of the more distant supportive and general environments. Thus, the presence of a psychiatric unit within the general hospital, and the acceptance of the general hospital as a bona fide site for psychiatric service delivery, are rarely questioned today [3]. In many instances, however, the actual structure and functions of the unit are controlled by external agents and associations, often with little participation from the unit itself. This kind of “top-down” decision making is evident in a variety of specific policies handed down to the general hospital psychiatric unit that exert a profound influence on the character of patient care. For example, the general hospital psychiatric service must generally conform to accreditation standards that originate far from the service delivery site and that are in some respects better suited to other kinds of service facilities [8-91. Similarly, the imposition of catchment area boundaries by planning bodies external to the general hospital unit may serve to control patients’ access to care [lo]. Finally, the advent of DRGs promises an increase in externally imposed initiatives that run the risk of harming patients by denying the realities of their illnesses [ll-131. In addition to these concrete examples of policy determination from afar, there are other less tangible effects resulting from general directives. Frequently, these are broad and coercive (if sometimes vague) policies that originate in the supportive and general environments and profoundly influence the character of service delivery at the local level. A 240
prime example is deinstitutionalization, which has had a marked impact on psychiatric services in the general hospital setting [1,2,6,14].
Understanding Deinstitutionalization Actually, deinstitutionalization is an extremely complex phenomenon that may be understood as having three distinct facets. It is a fact, a process, and a philosophy [15]. As a fact, deinstitutionalization encompasses a series of objective events that are manifested in a massive shift in the locus of care for chronic mental patients. For the past three decades, psychiatric services in all organized care settings except the state hospital have shown an increase. However, the increase has been proportionately greater in outpatient settings, so that inpatient care has vastly decreased as a proportion of all care for this patient population [16]. It is this overall change in patient care settings that provides substance for the fact of deinstitutionalization; and deinstitutionalization as a fact is precisely where many understandings of that movement begin-and end. Deinstitutionalization is, however, more than a fact; it is also a process. Specifically, it is a process of social change, of movement away from one treatment orientation to another that is radically different. This process of change has, all by itself, affected the lives of people who are chronically mentally ill, and the course of service delivery in all segments of the psychiatric service system. Deinstitutionalization as a process is reflected in a continuing and ongoing series of accommodations and boundary shifts within the psychiatric service system [17], and few patients or service providers have been immune to its effects. The entire division of responsibility within the system has undergone a major upheaval. Thus, it continues to change, as public and private facilities compete for funds, state hospitals become acutecare facilities [ 151, and general hospitals become the “core service to succeed the state hospital” [18]. Nevertheless, a full understanding of deinstitutionalization’s influence derives from viewing that movement as something even more than a fact and a process. It is also a philosophy with roots in postWorld War II America, when a variety of civil rights protests were gaining widespread support. Like other civil rights initiatives in that post-war era, deinstitutionalization emphasized the inalienable rights of disfranchised individuals and their legitimate claims on society. In this sense, the deinstitu-
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tionalization movement undertook no less impressive a task than that of “humanizing” the care of the mentally ill-of reversing the dehumanizing influences that were widely considered to be the inevitable accompaniments of institutional residence [19]. It is important to add, however, that deinstitutionalization’s affinity to the civil rights movement was not its sole source of ideological commitment. In addition to the belief that community-based care is more humane than institutional care, there was a second belief: that community-based care is also less costly [20,21]. Such a coalition of two ordinarily antagonistic constituencies, social reformers and fiscal reformers, gave the deinstitutionalization movement unprecedented impetus [22]. It may be noted parenthetically that these two beliefs were never really tested-that in the 1960s they were primarily matters of faith, not science. Indeed, even today our outcome studies remain largely inadequate to the task of providing empirical support for these assumptions [23-2.51. Yet they continue, with their humanistic and fiscal appeal, to serve as powerful forces in determining the course of the psychiatric service system. So powerful are the twin assumptions of more humane treatment and less expensive services that they actually serve as a conceptual framework for psychiatric service planning. They presuppose an ability and a willingness on the part of communities to provide ready alternatives for the full range of services and functions typically associated with institutional care [26]. In short, the philosophy of deinstitutionalization holds that communities can, and will, provide total care for the chronically mentally ill [26-281 and that they will accommodate patients’ residential [29,30], treatment [31], support [32], and asylum [33-3.51 needs.
Emerging Issues Today, 30 years past the peak of residential enrollment in state mental hospitals [16], we may stand back and evaluate the consequences of deinstitutionalization as a fact, a process, and a philosophy for services in the core-level environment. It appears that deinstitutionalization has actually had mixed outcomes. On the positive side, it has generated a series of planning principles and programs based on these principles that truly enhance the lives of many individuals who are chronically mentally ill [27]. It has also served to alter the ways in which we think about the needs of chronic patients
and encouraged us to regard them as individuals with highly specific and idiosyncratic program needs [36]. Deinstitutionalization has only partially realized its goals, however, and there have been major and serious disjunctions among the fact, the process, and the philosophy of the movement. Regardless of the existence of some exemplary programs devoted to the care of chronic mental patients and the evolution of relevant and practicable planning principles, the problems that are associated with deinstitutionalization are numerous. Most notably, institutional settings have in many cases been emasculated or totally destroyed before a sufficient array of community-based services has been assured [26], so that, on a nationwide basis, the problems that are associated with deinstitutionalization appear to outweigh the benefits at the present time. Bradley [37] provides a context for understanding these effects in a systems framework by distinguishing between program termination and program development objectives in deinstitutionalization. Although the movement’s philosophy originally embodied both kinds of objectives, the former have been pursued more vigorously than the latter in most parts of the country. Thus, the fact and the process of deinstitutionalization have focused primarily on the reduction or elimination of institution-based service sites and have been out of synchrony with the philosophy of deinstitutionalization that stresses alternative loci of care. Indeed, so ingrained in our thinking are the program termination objectives of deinstitutionalization, that is common for us to measure its progress statistically through data that reflect the diminished role of the state hospital, e.g., patient terminations or facility closings [38]. Yet the emergence of a generation of chronic mental patients who are unserved by the service system [39] is every bit as valid an indicator of deinstitutionalization’s multiple effects as is a drop in state hospital censuses. The net result for patients of our failure to pair program termination and program development objectives in a systematic manner in deinstitutionalization programming has led to a circumstance known popularly as “falling through the cracks.” Many chronic mental patients have simply been ignored or inappropriately served in the newly emerging psychiatric service settings.
Problems in Service Delivery In a very real sense, then, deinstitutionalization has been only partially implemented in most of the 241
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United States. An exchange of treatment settings has certainly occurred, but new program initiatives have generally lagged or been incomplete or nonexistent. To understand the implications of these events for people who are chronically mentally il1 it is necessary to know something about the character of community-based psychiatric services in the United States. Generally speaking, these services may be described as lacking in continuity and comprehensiveness and as inadequate for the complex service needs of people who are chronically mentally ill. More specifically, although some communitybased programs successfully target and serve chronic mental patients, many are either unable or unwilling to do so. A major problem affecting service delivery in deinstitutionalized service systems revolves around the complexities of implementing continuity in the care of chronic mental patients [36,40-411. Since the service needs of these individuals tend to endure over time, efforts must be made to reduce the possibility that hiatuses in service delivery will occur. This, in turn, requires the design of proactive and carefully detailed program plans, as well as the presence of “continuity agents” [42] to, anticipate and mitigate barriers to care. In contrast to this requirement, however, deinstitutionalized program initiatives tend to be designed for the “single-episode user of services,” and thus, in the words of Hansel1 [43], to exhibit “a deficiency of interest in people with lifelong disorders.” In addition, there have been widespread serious practical difficulties attending the provision of comprehensive services to chronic mental patients in deinstitutionalized service systems. As noted above, comprehensive care for these patients is often tantamount to total care [22]. Yet the various separate functions that constitute total care have often been blurred in the planning process, so that one of them may become a major planning focus, whereas the others are virtually ignored. We see this, for example, in calls for improved shelter for homeless mentally ill individuals without simultaneous acknowledgment of these individuals’ needs for medical and psychiatric care [44-461. Similarly, the concept of the least restrictive alternative has traditionally encouraged planning for patients’ residential placements without at the same time acknowledging their needs for treatment and asyIum 133,471, Perhaps, however, the single most far-reaching outcome of deinstitutionalization programing is 242
that it has generated a dramatic change in the character of the chronically mentally ill patient population. These individuals, who only a few decades ago constituted a primarily long-stay institutional population with relatively stable utilization patterns, today fall into a variety of subgroups [15]. There are, first, old long-stay patients [48] who have had many years, sometimes decades, of state hospital residence. Some of them have been discharged to the community, but others have remained institutionalized. In addition, there are other patients newly admitted to the state hospital. Some will become nezulong-stay patients, and others short-stay patients with only brief hospital tenures. Finally, there are increasing numbers of never-institutionalized chronically mentally ill people whose treatment histories have been determined by so-called admission diversion policies at many state hospitals [49-521. Many of the short-stay and never-institutionalized patients fall into the grouping now called new long-ferm patients by Wing and Morris [48] in Britain, in order to differentiate them from longstay chronic mental patients. In the United States, attention has focused on the age of this population because of an overrepresentation of baby-boom generation individuals among them, and they have been called yoloungadz& chronic p&e&-even though the validity of this term has recently been called into serious question [54,55]. Although the course of illness for new long-term patients is chronic, they have had an essentially noninstitutional history and do not exhibit the constellation of symptoms and passive behaviors frequently identified with institutional tenure, with what Goffman [19] called “institutionalism.” To the contrary, many are demanding, volatile, and disruptive individuals. The literature typically describes them as “difficult” patients or “problem” patients” [39]. Many are without social supports, and increasing percentages of them are episodically or permanently homeless [56]. These patients are reported to be regular and repeated users of services in all psychiatric settings. However, they appear in many places to affect the general hospital setting disproportionately [57-621, and they pose particular problems for emergency psychiatric services. Indeed, as the result of deinstitutionalization, the general hospital psychiatric emergency service has in many places become a substitute facility for the state hospital. Sometimes this has led to dreadful consequences, as this statement in a New York Times news story illustrates:
Deinstitutionalization
“Yesterday the [general] hospital was attempting to relieve its overcrowding by discharging those judged to be least sick- a form of psychiatric triage that was being performed in the emergency room, where only patients who appear to be a danger to themselves or others are admitted” [62].
General Hospital Issues General hospital psychiatry, partly because its growth and development have coincided temporarily with deinstitutionalization and partly because it has often provided the only available medical environment for chronic mental patients, has frequently been charged with the responsibility of correcting the disjunctions among the fact, the process, and the philosophy of deinstitutionalization. In the absence of clearly formulated program development objectives, general hospital psychiatric units, including emergency services, have often become the major, and sometimes the only, loci of care for many chronic mental patients, either by arrangement or default [63]. This shift in responsibility for the care of the chronically mentally ill has generated a variety of problems for general hospital psychiatry [1,2,6]. A major area of difficulty concerns the hospital’s need to absorb large numbers of chronically ill patients in an acute-care setting [13], a population that, 30 years ago, probably would have been institutionalized. Not surprisingly, this has at times generated a competition for resources that local general hospital units are ill prepared to handle. Nor is it merely the matter of increased numbers of patients that is often troublesome to general hospital psychiatry. There is also some question about the proper limits of general hospital psychiatry’s concern with the chronically mentally ill. That the general hospital psychiatric unit has inherited the treatment function from the state hospital psychiatric unit is not surprising. However, the general hospital has often been the “only show in town” available to serve chronic mental patients. Moreover, in a service climate where the separate functions subsumed under total care are often blurred, the general hospital psychiatric unit has also sometimes been faced with having to fulfill other, less traditional, functions. Specifically, general hospital psychiatry has frequently been charged with the total care of the chronically mentally ill and has been expected to provide for their residential, social support, and asylum needs, in addition to their treatment needs [58].
It must be noted, however, that in spite of these concerns, the inclusion of chronically ill psychiatric patients in general hospital programs is not uniformly viewed as inherently problematic. Many psychiatrists see this trend as a challenge and a source of revitalization in their programs [64-671. Others are less sanguine, however [13]. Whatever one’s view, it is becoming clear that what Talbott [68] calls the “chronicizing of general hospital psychiatry” is rapidly occurring. These circumstances have prompted some to call for a renaissance of state hospital services [69], but such an event is unlikely to occur on any large scale. For one thing, the clear benefits that accrue to many, though certainly not all, chronic patients from community-based care are sufficiently evident [70,71], that planners and policy makers are not likely to tolerate a total backlash. In addition, even if a concentrated effort to revive the central role of the state hospital could be mounted, yesterday’s service patterns could probably not be duplicated today. The old-time institution is rapidly slipping away, as today’s state hospitals serve more and more as acute-care settings instead of long-term custodial facilities [72,73]. These changes are supported and reinforced by a host of legal decisions and staffing constraints that have altered the character of the state hospital materially [13,74-761.
A Range of Solutions By design or default, then, general hospital psychiatry is today critically involved in delivering services to chronic mental patients. Has it been successful in this endeavor? A review of the current literature [2] suggests that, although there are certainly problems, there is also evidence that the general hospital unit has often responded with innovative and relevant initiatives 177,781. This is particularly true for those units located in public facilities [2]. Some general hospital psychiatric services have approached the care of chronic mental patients by absorbing them into existing programs with minimal changes in the structure of the unit. Others have found that dividing the unit into locked and unlocked portions has effectively met their needs. Still others have constructed physically separated service structures at some distance from the main portion of the hospital. It thus appears that a variety of approaches may potentially be used in serving chronic mental patients. Furthermore, it is clear from the literature that local variations in the com243
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position of the target population, specific program goals, and available resources interact to determine the precise direction of service planning for this patient population in any one general hospital setting [79]. Nevertheless, regardless of these varied alternative approaches, widespread concern over the appropriateness of serving chronic patients in the general hospital setting persists. Questions have been raised as to whether such a use of general hospital resources is in fact always in the best interests of chronic patients, of other patients, and of the psychiatric unit itself. The prevalent view in the literature appears to be, in the words of Sederer and his colleagues [13], that the general hospital “cannot become the repository for all patients without compromising what it aims to provide, namely acute care, proximal to general medical resources, for relatively brief illness periods.” These authors go on to suggest that “chronic cases and severely behaviorally unmanageable patients (particularly the more violent) must be treated in other facilities for the general hospital to continue to meet its mandate.” Another view, however, is put forth in this issue by two Canadian authors, Richman and Harris [80], who write in support of a general hospital psychiatric unit that assumes a pivotal role in the service system and takes on responsibility for the care of all mental patients. Their ideal general hospital psychiatric unit is the core planning and service agency in a system of unified psychiatric care. Such a broad role stands in direct contrast to general hospital psychiatry’s traditionally held adjunctive role, in which, according to Richman and Harris, that service provides “brief treatment to highly selected types of patients,” particularly those who are “compliant, unobtrusive, and rapidly responsive.” Should Richman and Harris’ suggestion of a pivotal general hospital psychiatric unit be pursued in American psychiatry? Cotton and his associates [65] demonstrate that, at least in some communities, it is indeed possible and practicable for the general hospital psychiatric unit to assume such a role in the service system. However, necessary preconditions must be met before this end can be achieved. Specifically, the unit must have the freedom to adopt appropriate treatment procedures, to pursue intensive staff training, and to serve as a leader in establishing essential interagency collaborative ties. The fact that general hospital psychiatric units have the ability to assume a pivotal role in some 244
communities does not necessarily mean, however, that they can, or that they would be well advised to take on such a responsibility in all communities. It is perhaps a jaded observation, but it is nonetheless accurate, that there can be no uniform format for the delivery of psychiatric services that is equally appropriate for all communities in the United States. The history of federally funded community mental health centers amply illustrates the truth of this statement [81]. In short, there is no single “right” way to respond to Richman and Harris’ suggestion in this country. In some places, the general hospital may indeed be able to assume pivotal responsibility and may be able to do so at once. In other communities, such a role will have to be adopted slowly and cautiously. Moreover, in still other communities, the general hospital psychiatric unit may not foresee a pivotal role in its future at all and will elect to depend on other service agencies to take the lead responsibility in caring for the chronically mentally ill. My own observations and reading of the literature lead me to the conclusion that, generally speaking, the contribution of general hospital psychiatry to the philosophy of deinstitutionalization is enhanced when the general hospital can work in close cooperation with another facility such as the state hospital that provides backup for the longterm care needs of those chronic patients who are most refractory. That both the general hospital psychiatric unit and the long-term care facility are adequately staffed and funded and are concerned with providing the best possible care for chronic mental patients are, of course, essential preconditions. When general hospital psychiatry is thus relieved of the pressure to be all things to all patients, the threat of preemption is diminished, service decisions become more appropriate and humane, and chronic patients are better served [81]. The major problem to be solved in such cooperative enterprises is to work out the complentarity of facilities’ roles and to assign unambiguous responsibility in gatekeeping [83] and patient screening and referral [361-a task that is both negotiable and practicable and that depends on local goals and available resources [84].
Conclusions The various observations made here lead logically to several conclusions regarding the relationship
Deinstitutionalization
between deinstitutionalization and general hospital psychiatry. First, there is a need for openness in the general hospital setting. Deinstitutionalization may potentially have a challenging and salubrious effect on service delivery in general hospital psychiatric units by broadening the scope of their programs and revitalizing their service role. Moreover, any potentially negative effects of deinstitutionalization can probably best be neutralized by the adoption of a positive attitude toward change on the part of those in the psychiatric unit. In the succinct words of a British planning team, “Building a satisfactory service for the mentally ill . . . has to challenge past assumptions” [85]. Visotsky and Plaut’s [86] blueprint for the future of general hospital psychiatry reinforces this conclusion. Second, a conceptual distinction must be made between what general hospital psychiatry is able to do under optimal circumstances and what it should do in any one particular community. General hospital psychiatry has shown itself to be potentially capable of delivering care to all kinds of mental patients, including those who are chronically ill. In some settings this is obviously a desirable course to pursue. It does not, however, follow that such a global charge is necessarily an appropriate one under all circumstances. The level of general hospital psychiatry’s involvement with chronic mental patients must be determined by the character of a particular community’s patient population, its goals for those patients, and the resources it has at its disposal for realizing those goals. Its specific obligation will be tempered by the availability of other facilities, such as state hospitals and community mental health centers that welcome the chronically mentally ill, to share in the care of that population. Third, where general hospital psychiatry does assume responsibility as the core-level agency in serving chronic mental patients, it must be aware that some among those individuals will probably require total care. General hospital psychiatry must accordingly be prepared to work in concert with other agencies to serve this population, and it must be ready to negotiate its core-service role and cede some territory. Fourth, possibilities for compromise not only exist but are also essential to pursue. The general hospital psychiatric unit need not necessarily adopt an all-or-nothing approach to the care of chronic mental patients [87], In addition, the general hospital unit may serve chronic patients well by becom-
ing an active member of an interagency consortium designing individually-tailored program placements for chronic mental patients [4,88,89]. In fact, the general hospital psychiatric unit may be uniquely equipped to serve as a centralized screening and referral agency, because of its location in the community and its connection with medical services. Finally, although general hospital psychiatry must be willing and able to work together with other service agencies, it must not relinquish its autonomy. It is critical that the general hospital psychiatric unit be a full partner in determining the direction and limits of its own patient care responsibilities. In the absence of self-determination, confusion, resentment, and deterioration of serviceswith predictably dire consequences for chronic patients-are likely to occur. General hospital psychiatry must thus make a serious effort to minimize its being forced into a reactive position by deinstitutionalization policies generated in the distant supportive and general environments. It must, instead, assume its rightful position as an autonomous, but fully cooperative, element within the psychiatric service system. Only then can its responsibility to the chronically mentally ill, to other patients, and to its own integrity be assured.
References 1. Schulberg HC, Burns BJ: The nature and effectiveness of general hospital psychiatric services. Gen Hosp Psychiatry 7:249-257, 1985 2. Bachrach LL: General hospital psychiatry: Overview from a sociological perspective. Am J Psychiatry 138:879-887, 1981 3. Lebensohn ZM: General hospital psychiatry U.S.A.: Retrospect and prospect. Compr Psychiatry 21:500519, 1980 4. Keill SL: The general hospital as the core of the mental health services system. Hosp Community Psychiatry 32:776-778, 1981 5. Pardes HE: Mental health-general health interaction: Opportunities and responsibilities. Hosp Community Psychiatry 32779-782, 1981 6. Bachrach LL: The effects of deinstitutionalization on general hospital psychiatry. Hosp Community Psychiatry 32:787-790, 1981 7. Johnson PJ: Community support systems for deinstitutionalized patients. New Directions for Mental Health Services no. 17: Deinstitutionalization: 81-92, 1983 8. Flamm GH: Summary of progress. Newsletter of the American Association of General Hospital Psychiatrists 3-5, Winter 1980 24s
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9. Langsley DG: Viewpoint. Psychiatric News, pp 3,28, August 1, 1980 10. Marcos LR, Gil RM: Psychiatric catchment areas in an urban center: A policy in disarray. Am J Psychiatry 141:875-878, 1984 11. Widem I’, Pincus HA, Goldman HH, Jencks S: Prospective payment for psychiatric hospitalization: Context and background. Hosp Community Psychiatry 35447-451, 1984 12. Goldman HH, Pincus HA, Taube CA, Regier DA: Prospective payment for psychiaric hospitalization: Questions and issues. Hosp Community Psychiatry 35:460-464, 1984 13. Sederer LI, Katz B, Manschreck TC: Inpatient psychiatry: Perspectives from the general, the private, and the state hospital. Gen Hosp Psychiatry 6:180-190, 1984 14. Mooney DA, Zirker ME: General Hospital Psychiatry in Massachusetts. Burlington MA, MHA-DMH Mental Health Project, December 1981 15. Bachrach LL: A conceptual approach to deinstitutionalization. Hosp Community Psychiatry 29:573578, 1978 16. Goldman HH, Adams, NH, Taube CA: Deinstitutionalization: The data demythologized. Hosp Community Psychiatry 34:129-134, 1983 17. Dinitz S, Beran N: Community mental health as a boundaryless and boundary-busting system. J Health Sot Behav 12:99-108, 1971 18. Greenhill MH: Psychiatric units in general hospitals: 1979. Hosp Community Psychiatry 30:169-182,1979 19. Goffman E: Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Garden City, NY, Anchor Books, 1961 20. Cramer PK: Report on the current state of deinstitutionalization: Period of retrenchment. Commentaries on Human Services Issues, (Philadelphia, Health & Welfare Council, Inc.), May 1978 21. Lyons RD: How release of mental patients began. New York Times, pp Cl, C4, October 30, 1984 22. Okin RL: The future of state mental health programs for the chronic psychiatric patient in the community. Am J Psychiatry 135:1355-1358, 1978 23. Bachrach LL: Assessment of outcomes in community support systems: Results, problems, and limitations. Schizophr Bull 8:39-61, 1982 24. Braun I’, Kochansky G, Shapiro R, Greenberg S, Gudeman JE, Johnson S, Shore MF: Overview: Deinstitutionalization of psychiatric patients. Am J Psychiatry 138:736-749, 1981 25. Love RE: The Community Support Program: Strategy for reform. In Talbott JA (ed), The Chronic Mental Patient: Five Years Later. Orlando, FL, Grune and Stratton, 1984, pp 195-214 26. Bachrach LL: Deinstitutionalization: An Analytical Review and Sociological Perspective. Rockville MD, National Institute of Mental Health, 1976 27. Bachrach LL: Principles of planning for chronic psychiatric patients: A synthesis. In Talbott JA (ed), The Chronic Mental Patient: Five Years Later. Orlando, EL, Grune and Stratton, 1984, pp 165-182 28. Talbott JA: Deinstitutionalization: Avoiding the di-
246
29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.
43. 44. 45.
46. 47. 48.
49. 50.
sasters of the past. Hosp Community Psychiatry 30:621-624, 1979 Budson RD: Sheltered housing for the mentally ill: An overview. McLean Hosp J 4:140-157, 1979 Lamb HR (ed): The Homeless Mentally Ill. Washington, American Psychiatric Association, 1984 Talbott JA (ed): The Chronic Mentally Ill: Treatment, Programs, Systems. New York, Human Sciences Press, 1981 Cutler D: Networks. In Talbott JA (ed), The Chronic Mental Patient: Five Years Later. Orlando, FL, Grune and Stratton, 1984, pp 253-266 Bachrach LL: Asylum and chronically ill psychiatric patients. Am J Psychiatry 141:975-978, 1984 Lamb HR, Peele R: The need for continuing asylum and sanctuary. Hosp Community Psychiatry 35:798802, 1984 Talbott JA: The need for asylym, not asylums. Hosp Community Psychiatry 35:209, 1984 Bachrach LL: Planning services for chronically mentally ill patients. Bull Menninger Clinic 47163-188, 1983 Bradley VJ: Policy termination in mental health: The hidden agenda. Policy Sci 7215-224, 1976 Manderscheid RW, Witkin MJ, Rosenstein MJ, Bass RD: A review of trends in mental health services. Hosp Community Psychiatry 35:673-674, 1984 Bachrach LL: Young adult chronic patients: An analytical review of the literature. Hosp Community Psychiatry 33: 189-197 Bachrach LL: Continuity of care for chronic mental patients: A conceptual analysis. Am J Psychiatry 138:1449-1456, 1981 Wasylenki D, Goering P: A framework for continuity of care. Perspectives in Psychiatry (University of Toronto Department of Psychiatry) 3:1-5, April 1984 Granet RB, Talbott JA: The continuity agent: Creating a new role to bridge the gaps in the mental health system. Hosp Community Psychiatry 29:132-133, 1978 Hansell N: Services for schizophrenics: A lifelong approach to treatment. Hosp Community Psychiatry 29:105-109, 1978 Comer R: Playing the dumping game with the homeless. Philadelphia Inquirer, p. 25A, December 7,1984 Drake RE, Adler DA: Shelter is not enough: Clinical work with the homeless mentally ill. In Lamb HR (ed), The Homeless Mentally Ill. Washington, American Psychiatric Association, pp. 141-151 A street is not a home. New York Times, p A24, August 24, 1984 Bachrach LL: Is the least restrictive environment always the best? Sociological and semantic implications. Hosp Community Psychiatry 31:97-102, 1980 Wing JK, Morris B: Clinical basis of rehabilitation. In Wing JK, Morris B (eds), Handbook of Psychiatric Rehabilitation Practice. Oxford, Oxford University Press, 1981 Dionne EJ: Mental patient cutbacks planned. New York Times, p B3, December 8, 1978 Morrissey JP, McGreevy MM: The fates of applicants denied admission to state mental hospitals: Some
Deinstitutionalization
51. 52. 53. 54.
55.
56.
unexamined consequences of deinstitutionalization in the USA. Presented at the meeting of the Intemational Sociological Association, Mexico City, August 1981 Pepper B, Ryglewicz H: Testimony for the neglected: The mentally ill in the post-deinstitutionalized age. Am J Orthopsychiatry 52:388-392, 1982 Shapiro JG: Patients refused admission to a psychiatric hospital. Hosp Community Psychiatry 34:733736, 1983 Pepper B, Kirshner MC, Ryglewicz H: The young adult chronic patient: Overview of a population. Hosp Community Psychiatry 32:463-469, 1981 Bachrach LL: The concept of young adult chronic psychiatric patients: Questions from a research perspective. Hosp Community Psychiatry 35:573-580, 1984 Schwartz SR, Goldfinger SM, Ratener M, Cutler DL: The young adult chronic patient and the care system: Fragmentation prototypes. New Directions for Mental Health Services no. 19: Effective Aftercare for the 198Os:23-34, 1983 Bachrach LL: The homeless mentally ill and mental health services: An analytical review of the literature. In Lamb HR (ed), The Homeless Mentally Ill. WashEgto;, American Psychiatric Association, 1984, pp.
57. Bassuk E, Gerson S: Chronic crisis patients: A discrete clinical group. Am J Psychiatry 137~1513-1517, 1980 58. Diamond RJ, Davidson SL: Patients perceived as having psychosocial problems in a general hospital emergency room: A study of registered and unregistered patients. Psychosocial Rehabilitation J 748-58, 1984 59. Goldfinger SM, Hopkin JT, Surber RW: Treatment resisters or system resisters? Toward a better service system for acute care recidivists. New Directions for Mental Health Services no. 21: Advances in Treating the Young Adult Chronic Patient:17-27, 1984 60. Robbins E, Stern M, Robbins L, et al: Unwelcome patients: Where can they find asylum? Hosp Community Psychiatry 2944-46, 1978 61. Schwartz SR, Goldfinger SM: The new chronic patient: Clinical characteristics of an emerging subgroup. Hosp Community Psychiatry 32:470-474, 1981 62. Sullivan R: Hospital forced to oust patients with psychoses. New York Times, p B3, November 8, 1979 63. Bachrach LL: General hospitals taking greater role in providing services for chronic patients. Hosp Community Psychiatry 30:488, 1979 64. Becker A: Inadequacy of institutional psychiatric care (letter to editor). N Engl J Med 294:1068, 1976 65. Cotton PG, Bene-Kociemba A, Cole R: The effect of deinstitutionalization on a general hospital’s inpatient psychiatric service. Hosp Community Psychiatry 30609-612, 1979 66. Egri G: A general hospital model. In Talbott JA (ed), The Chronic Mentally Ill: Treatment, Programs, Systems. New York, Human Sciences Press, 1981, pp. 175-186 67. Meyerson AT: What are the barriers or obstacles to
68. 69. 70. 71. 72. 73. 74. 75. 76.
77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88.
treatment and care of the chronically disabled mentally ill? In Talbott JA (ed), The Chronic Mental Patient. Washington, American Psychiatric Association, pp. 129-134 Talbott JA: The Death of the Asylum: A Critical Study of State Hospital Management, Services, and Care. New York, Grune and Stratton, 1978 Sigel GS: In defense of state hospitals. Hosp Community Psychiatry 35:1234-1236, 1984 Freeman SJ: The chronic patient rediscovered: Ten propositions. Canada’s Mental Health: 15-16, 24, December 1983 Glick ID, Klar HM, Braff DL: Guidelines for hospitalization of chronic psychiatric patients. Hosp Community Psychiatry 35:934-936, 1984 DeRisi W, Vega WA: The impact of deinstitutionalization on California’s state hospital population. Hosp Community Psychiatry 34:140-145, 1983 Goldman HH, Taube CA, Regier DA, Witkin M: The multiple functions of the state mental hospital. Am J Psychiatry 140:296-300, 1983 Gaver KD: Considerations in providing psychiatric services in general hospitals. Hosp Community Psychiatry 24:252-253, 1973 Okin RL: State hospitals in the 1980s. Hosp Community Psychiatry 33:717-721, 1982 Diamond RJ: The role of the hospital in treating the chronically disabled. New Directions for Mental Health Services no. 2: Community Support Systems for the Long-Term Patient: 45-56, 1979 Crowder JE, Klatte EW: Involuntary admissions to general hospitals: Legal status not the issue. Hosp Community Psychiatry 31:325-327, 1980 Franciscan Mental Health Center: 1984 Annual Report. Rock Island IL, 1984 Okin RL, Kinzer DM, Mooney DA: Major obstacles to the development of psychiatric units in general hospitals. Hosp Community Psychiatry 34:966-967,1983 Richman A, Harris I’: General Hospital psychiatry: Are its roles and functions adjunctive or pivotal: Gen Hosp Psychiatry 7:258-266, 1985 Group for the Advancement of Psychiatry: Community Psychiatry: A Reappraisal. New York, Mental Health Materials Center, 1983 Talbott JA: The patient: First or last? Hosp Community Psychiatry 3534-344, 1984 Central Toronto Youth Services Foundation: Reaching Out: Outreach Treatment Programming. (Part I) Toronto, 1982 Bachrach LL: Developing objectives in community mental health planning. Am J Public Health 64:11621163, 1974 Towel1 D (ed): Managing psychiatric services in transition. Health Sot Serv J (London) l-8, October 25, 1984 Visotsky HM, Plaut EA: Psychiatry in the general hospital: Visualizing the changes. Hosp Community Psychiatry 33:739-741 Leeman CP: The “least restrictive environment”: From rhetoric to practice. Gen Hosp Psychiatry 3:229-232, 1980 Dressler DM, Fitzgibbons DJ: The general hospital as
247
L. L. Bachrach
a center for mental health services. Conn Med 40:407-409, 1976 89. Spiro HR: Reforming the state hospital in a unified care system. Hosp Community Psychiatry 33:722728, 1982
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