The Past and Future of Mental Health Services: An Interview With Leona Bachrach

Editor's Note: Few people have followed the deinstitutionalization movement and subsequent changes in the delivery of mental health services more closely than sociologist Leona L. Bachrach, Ph.D., who has had a long and close association with Psychiatric Services as a consultant and a contributing editor. Dr. Bachrach was a sociologist with the Division of Biometry and Epidemiology at the National Institute of Mental Health and later staff sociologist with the President's Commission on Mental Health before joining the faculty of the Maryland Psychiatric Research Center of the University of Maryland School of Medicine. During her 20 years there, she became an internationally known consultant on service delivery issues. Dr. Bachrach shares her perspectives on the past and future of mental health services in this interview with John A. Talbott, M.D., editor of the journal.

Dr. Talbott: What do you think have been the biggest changes in psychiatric services in the past 50 years?

Dr. Bachrach: Obviously a major development has been the deinstitutionalization movement—the closing and reduction of state hospitals and long-term-care facilities in general. The concurrent growth—or, often, lack of growth—of community-based care to replace the functions that the hospital served is another. More recently the biggest change has been the introduction of managed care and the provision by private enterprise of services that used to be provided by public agencies.

You've done a lot of consulting in this country and around the world and have seen both good and bad examples of the universal move from asylum care to community care. Could you make some generalizations about why some areas have been more successful than others in making this transition?

That's a very, very complicated question. When I first started consulting, almost all of it was done here in this country. I was invited to evaluate facilities where people cared deeply about transferring care from hospitals to the community and giving improved services. But as issues of funding began to supersede issues of service delivery, most of my consulting was done in other countries, where interest in providing good care has continued. Toward the end of my active career, almost all of my consulting was done in Europe and Australia, where there is a cultural attitude that supports giving help to those who have difficulty helping themselves. I think we lack that attitude here, in large part.

Please amplify, if you can, on what the cultural support comes from and how it expresses itself.

Sometimes it puzzles me greatly because our country, like Canada and Australia, is a frontier society. Frontier societies in other parts of the world still have an attitude that we need to care for other folks. In this country it has become more of a survival thing—if you can't survive by yourself, then perhaps you don't deserve to be cared for.

How would you explain the current tolerance of things that 25 years ago would have been seen as shameful or horrible—homeless mentally ill persons, people eating out of garbage cans, the fact that the prison system is the largest mental health system that we have. What has happened to a society that used to value self-respect and have a sense of shame?

Twenty-five or 30 years ago this country still had a sort of backup system to take care of people, and that was the state hospital. As state hospitals have diminished in size and number, it has become apparent that either mental health workers in the community take care of these people or nobody will. And too often nobody does.

But hasn't society also changed?

I think we go through cycles of caring and not caring. I think in the 1960s and toward the end of the 1970s we were at high points in the cycle of caring. But in general we have been in a downward slope in this cycle. I think we're now at a place where we don't care very much.

The positive side of what you've just said is that the cycle may recur. What do you think could cause it to recur?

I don't know what might cause it to happen. But one sees evidence of it sometimes now in the anger that people feel toward managed care. Even legislators are getting angry and are trying to intervene in the process that has made getting care more difficult. So I think in some ways we're beginning an upward trend, but the political climate isn't entirely ready for it yet.

What's going on now that excites you, that gives you some sense not necessarily of hope but that the challenges are going to be met differently?

There are two major things that excite me. One is the continued growth of the American Association of Community Psychiatrists and what it stands for—a lot of young professionals coming into the field with an idealism that I haven't seen for a few decades. As long as we have young people coming in who care about providing good services, I think that's a hopeful sign.

The other thing I find exciting is that more people appear to be rejecting a search for instant answers. Although some people are promoting a few so-called models of service delivery, others I talk to are focused on finding local solutions to their problems rather than importing what has worked someplace else. I think that's very encouraging.

Getting back to the young professionals coming into the field, what routes do you think they're going to follow to bring about change? In the past people have come up through the state systems and advocacy systems. Do you think these young people will use such traditional routes to bring about change?

I think we're going to need a political climate that more aggressively will support what they want to do. I don't believe such a climate currently exists. But it's going to come back sometime. I pin my hopes on the fact that we have these enthusiastic young people and also have so much more technology now than we did in earlier decades.

I realize the future is impossible to predict, but what do you feel most optimistic and most pessimistic about in terms of the future direction of psychiatric services in this country? What things do you worry about, and what directions would please you?

What looks good to me? The things that I mentioned before—the true caring that I see among some of the young professionals, their activism, and their wish to be heard within the field of psychiatry. I think it's very exciting.

What I worry about most of all is access to care. Instead of improving access to care for some people who have severe mental illnesses, we are saying in effect that they don't deserve it. We are ignoring them, closing facilities, and making it difficult for them to get into programs. It worries me also that we have a geriatric population that has been either sporadically or inadequately served, and I don't know where we're going to go with them; we can't even take care of the people whom we know about as well as we might.

Another thing that worries me is that we have never defined the words that are the basic tools of our field. I think poor use of language and undefined terms have been a major barrier to what we do. We say, "We're going to give community care," whatever it means. We have unstated definitions of rehabilitation, community care, continuity—what in the world is continuity? Each of these terms means different things to different people.

One interesting thing I've noted recently is that more users of mental health services are willing to be called patients now. Whether it's because you get some entitlements by being a patient or for other reasons, I'm not sure. But it comes as a surprise to me.

You certainly have written and thought a lot about the unclarity of definitions, and also about the patient-client-survivor issue. But are there other areas of change in the language that have interested you? Is the field using new terms that strike you as interesting or funny or bizarre?

I think the only one that is really bizarre is SPMI, which stands for severe and persistent mental illness. In discussions I have heard people with illnesses referred to as "speemies," which bothers me immensely. I still don't think there's anything wrong with being a patient or with the word chronicity. The fact that those words have been invested with a certain kind of negativism is not the fault of the words; it's the projections of the people who have these feelings about them. The replacements, like SPMI, have only made things worse. I think it's dreadful that we can't face the reality that people who have an illness can be patients, and that you can get help by being a patient.

Let's go back to your optimism about younger professionals entering the field. Again, you've had a lot of experience with governments, both in this country and abroad. In this country, do you see a vacuum of leadership or a need for new or revitalized leadership? In other eras, the leaders might have been wrong and overzealous, but they were out there. I sense that now we're searching for consolidation around some ideas and leaders.

I think there is a vacuum in leadership, despite the efforts of Mrs. Gore. Somehow her efforts have not reached people as Mrs. Carter's and the Kennedy efforts did. But I don't know that it's so much a lack of leadership as it is a lack of milieu in which leadership can occur. It's hard to say in this time what's going on. We can look back much more easily.

But I have hope. One cannot be in the business of caring for people with mental illness and face the future with equanimity unless one is optimistic. Progress may be slow and uneven, but I believe that it is inevitable, given our history and technology.