TALKING WITH CARL THISTEL
Passage of the Community Health Act during the Kennedy Administration in 1963 contributed to an accelerating de-institutionalization of patients from psychiatric hospitals.
“Preliminary to the Walter P. Carter Center, the Inner City Community Health was the virgin experience, if you will, for the state of Maryland in the City of Baltimore in community mental health. It was predicated on the then new Community Health Centers Act of 1963 that the Kennedy administration had passed. It was beginning the process of the second deinstitutionalization as it affected the state hospitals around MD. There were huge warehouse populations of people in hospitals surrounding every urban area in the US. I forget what the population was at that time, but it was enormous numbers of people.
But the first wave of deinstitutionalization occurred in the first decade after World War Two when Thorazine and other neuroleptics were invented. After the war the millions of veterans in hospitals needed medication and the Veterans Administration began the exiting of patients. Veterans were sent home with a shopping bag full of Thorazine or whatever. There was absolutely no social work involved, and no planning. I think that was the most crude deinstitutionalization movement in the country ever.
With the Community Mental Health Services Act there was an attempt to do it right…The community mental health movement really had some startling features to it. This whole notion that there were disease producing and health producing things at the macro level of the community was very innovative. At the same time we were ready to receive these casualties in the hospital, we were really into prevention. It was the most innovative and radical thing that we have ever done in the history of this country in terms of mental health. It was to some extent a failed revolution because it really didn’t take hold.”
Part of the revolution was learning more about how people actually got help.
“One of the concepts of mental health, which is community mental health, was that intervention with people, especially in the underclasses in South Baltimore, required a major change in how you delivered services. I found that as a community health planner, when the whites had problems they went to primarily three or four sources of help, what I called ‘first echelon helpers.’ They went to fortunetellers and bartenders. In the case of the blacks they went to storefront ministers. They were very influential then and still are in southwest Baltimore. Down in the Locust Point area they went to union bosses. In other words when they were hurting for whatever reason or had a problem, they went to the bartender; to the local places.”
The Wyatt v. Stickney court decision had a large and significant effect on the target population and the delivery of mental health services.
“When I first came to Sheppard Pratt in 1972 the medium length of stay was nine months, which was regarded as horrendously short. When I left it was nine days. You had a different staffing pattern, too. The staffing was a lot thinner before Wyatt v. Stickney…When I was first there the average daily rate was something like $25 a day. When I left it was $725 a day. Insurance companies were getting involved for the first time, because Sheppard could no longer survive solely on the basis of super wealthy people. They had to start taking middle class people, and the middle class people had insurance policies. Most of those in those days were indemnity insurance policies, which paid big, but had limits. There were no care managers in those days, but they were beginning to make rumbles and saying, ‘You know we have a problem. Ms. Smith has a 2 million-dollar limit on her policy expense and she has used about three-quarters of it. After that we’re not paying anymore.’ If you are in a psychiatric based institution the tendency, the culture there tends to think of case managers and insurance companies as the enemy.
I don’t think it was deliberately exploitative economically, but the fact is we spend hundreds of millions or billions of dollars keeping people in institutions, much longer than they ever should have stayed for their own benefit. There is that backdrop by which you have to judge whatever miscalculations and shortfalls have occurred to deinstitutionalization since then. Yes, the pendulum has swung the other way and yes it is bad, but never forget where the pendulum came from. Because where it came from was worse in my view, than where it is now.
The insurance carriers, the state and then the new Hospital Services Cost Review Commission were beginning to question us for the first time. We had been left alone for the last 50 years, now they wanted to know what we were doing. So I remember in the 1970’s we did a massive study. The research department was given unlimited funds from within the hospital and the hospital system to do this massive study. For five years we were comparing lengths of stay, and treatment outcomes. Six prestigious journals were waiting for this study. And guess what? It never got published. Why did it not get published? We did not like the results! It did not show what we wanted it to show. Now it is to our credit that we didn’t fudge the data. It’s not to our credit, I think, that we deep-sixed it. To this day, I don’t know what ever happened to that study.
The data showed not only no positive correlation between treatment outcome and length of stay but we never saw the data in detail. We had it described to us by the researchers. What they were telling was bad news. I’m inclined to think that if you looked at the data you would find a negative correlation. As indeed I think you would because anybody that spends ten years in an institution anywhere can be in jeopardy.”
What about the role of Wyatt v. Stickney in the problem of homelessness among the mentally ill?
“I don’t think the blame can be laid on those doorsteps of Wyatt-Stickney or the Community Mental Health services. It is society that frequently wants to blame in both ways, that is unwilling to put its funding where its mouth is. Most people, most legislators still don’t know much about mental illness. They do not want to spend the money to find out. And it is not just legislators. Most people don’t want to do it until they either work in the field or have a relative in the field or they are a patient themselves. The study that I talked about and dozens like them over years should have helped us self correct so that this deinstitutionalization wave would not have been necessary. We would have been doing it without the external mandates or requirements to do it. And we would have been doing it very planfully, but that’s not the way things happened.”
Wyatt v. Stickney affected private as well as public mental hospitals.
“…with the self-pay, obviously it didn’t [affect the private hospital]. When this case came down there was still a significant, maybe 30-40% self-pay, it didn’t make a difference. For the vastly increasing percentage of people who were middle class who were beginning to come into Sheppard with insurance and with others who were answerable to external funding sources, yes, it affected Sheppard very, very strongly. I would say that while the immediate impact may have been greater in the state hospitals, ultimately it almost eliminated freestanding psychiatric institutions.”
Wyatt v. Stickney’s effect on the future of mental health service delivery, is it good or bad?
“ I don’t see the downs. I think court cases no matter how raw the implications always boil down to one case. There may be inferences made beyond that case, but you cannot nail the court decision because they did not deal with the reciprocal and unanticipated effects of its decision. The court is not responsible for what people do with these findings. I think you would have to go beyond the scope of that case to deal with the future in terms of what one hopes that we would finally get an outcome approach toward treatment of mental illness. And in order to do that we are going to have to find out more about mental illness. And we are going to have to separate the chaff from the wheat when it comes to what kinds of illnesses are reflective of chemical imbalances. And what kind can yield to genetic intervention and chemical intervention.
We think we know something now about medication, but what we know is very crude. We will get into individually designed medications, whatever the disorder, thanks to genetic intervention and genetic breakthroughs that are really just around the corner I think. Medication will be tailored to each individual’s use. What is happening with the genome thing is going to reshape everything we do, particularly in the area of mental illness. It’s going to reshape it rather drastically. So a lot of what we are doing now is going to seem so crude, I do believe, after all the chemical and neurological and genetic intervention are made.”
And what is the future of the profession of social work and mental health?
“I see social work’s future as extraordinarily bright. After all the dust settles and at the end of the day, people who have returned to their communities are going to need support. They are going to need support well before they return to the communities. It is about aftercare planning. I would not begin to have a psychiatric service that was not heavily loaded with social workers, because you need to start planning for discharge the day you’re admitted.”
Mr. Thistle was interviewed by Ms. Sally Crown