The broadest approach for the treatment of schizophrenia and other severe mental disorders is the community approach. In 1963, partly in response to the terrible conditions in public mental institutions and partly because of the emergence of antipsychotic drugs, the U.S. government ordered that patients be released and treated in the community. Congress passed the Community Mental Health Act, which stipulated that patients with psychological disorders were to receive a range of mental health services—outpatient therapy, inpatient treatment, emergency care, preventive care, and aftercare—in their communities rather than being transported to institutions far from home. The act was aimed at a variety of psychological disorders, but patients diagnosed with schizophrenia and other severe disorders, especially those who had been institutionalized for years, were affected most. Other countries around the world put similar sociocultural treatment programs into action shortly thereafter (Wiley-Exley, 2007).

510

Thus began several decades of deinstitutionalization, an exodus of hundreds of thousands of patients with schizophrenia and other long-term mental disorders from state institutions into the community. On a given day in 1955, close to 600,000 patients were living in state institutions; today fewer than 40,000 patients live in such facilities (Althouse, 2010). Clinicians have learned that patients recovering from schizophrenia and other severe disorders can profit greatly from community programs. As you will see, however, the actual quality of community care for these people has often been inadequate throughout the United States. The result is a “revolving door” pattern for many patients. They are released to the community, readmitted to an institution within months, released a second time, admitted yet again, and so on, over and over (Burns & Drake, 2011; Torrey, 2001).

People recovering from schizophrenia and other severe disorders need medication, psychotherapy, help in handling daily pressures and responsibilities, guidance in making decisions, social skills training, residential supervision, and vocational counseling—a combination of services sometimes called assertive community treatment (Keller et al., 2014). Those whose communities help them meet these needs make more progress than those living in other communities (Malm, Ivarsson, & Allebeck, 2014; Swartz et al., 2012). Some of the key features of effective community care programs are (1) coordination of patient services, (2) short-term hospitalization, (3) partial hospitalization, (4) supervised residencies, and (5) occupational training.

Coordinated ServicesWhen the Community Mental Health Act was first passed, it was expected that community care would be provided by community mental health centers, treatment facilities that would supply medication, psychotherapy, and inpatient emergency care to people with severe disturbances, as well as coordinate the services offered by other community agencies. When community mental health centers are available and do provide these services, patients with schizophrenia and other severe disorders often make significant progress (Burns & Drake, 2011; Rapp & Goscha, 2008). Coordination of services is particularly important for so-called mentally ill chemical abusers (MICAs), patients with psychotic disorders as well as substance use disorders (De Witte et al., 2014).

Short-Term HospitalizationWhen people develop severe psychotic symptoms, today’s clinicians first try to treat them on an outpatient basis, usually with a combination of antipsychotic medication and psychotherapy (Addington & Addington, 2008). If this approach fails, they may try short-term hospitalization—in a mental hospital or a general hospital’s psychiatric unit—that lasts a few weeks (rather than months or years) (Craig & Power, 2010). Soon after the patients improve, they are released for aftercare, a general term for follow-up care and treatment in the community. Because short-term hospitalization usually leads to more improvement and a lower rehospitalization rate than extended institutionalization (Soliman et al., 2008), countries throughout the world now favor it over long-term institutionalization.

511

Partial HospitalizationPeople’s needs may fall between full hospitalization and outpatient therapy, and so some communities offer day centers, or day hospitals, all-day programs in which patients return to their homes for the night. Such programs actually originated in Moscow in 1933, when a shortage of hospital beds necessitated the premature release of many patients. Today’s day centers provide patients with daily supervised activities, therapy, and programs to improve social skills. People recovering from severe disorders in day centers often do better than those who spend extended periods in a hospital or in traditional outpatient therapy (Bales et al., 2014; Mayahara & Ito, 2002).

Another kind of institution that has become a popular setting for the treatment of people with schizophrenia and other severe disorders is the semihospital, or residential crisis center. Semihospitals are houses or other structures in the community that provide 24-hour nursing care for people with severe mental disorders (Soliman et al., 2008). Many individuals who would otherwise be cared for in state hospitals are now being transferred to these semihospitals.

Supervised ResidencesMany people do not require hospitalization but are unable to live alone or with their families. Halfway houses, also known as crisis houses or group homes, often serve individuals well (Lindenmayer & Khan, 2012; Levy et al., 2005). Such residences may shelter between one and two dozen people. The live-in staff usually are paraprofessionals—lay people who receive training and ongoing supervision from outside mental health professionals. The houses are usually run with a milieu therapy philosophy that emphasizes mutual support, resident responsibility, and self-government. Research indicates that halfway houses help many people recovering from schizophrenia and other severe disorders adjust to community life and avoid rehospitalization (Hansson et al., 2002; McGuire, 2000). Here is how one woman described living in a halfway house after 10 hospitalizations in 12 years:

512

Occupational Training and SupportPaid employment provides income, independence, self-respect, and the stimulation of working with others. It also brings companionship and order to one’s daily life. For these reasons, occupational training and placement are important services for people with schizophrenia and other severe mental disorders (Johnsonn et al., 2014; Bell, Choi, & Lysaker, 2011; Davis et al., 2010).

Many people recovering from such disorders receive occupational training in a sheltered workshop—a supervised workplace for employees who are not ready for competitive or complicated jobs. The workshop replicates a typical work environment: products such as toys or simple appliances are manufactured and sold, workers are paid according to performance and are expected to be at work regularly and on time. For some, the sheltered workshop becomes a permanent workplace. For others, it is an important step toward better-paying and more demanding employment or a return to a previous job (Becker, 2008; Chalamat et al., 2005). In the United States, however, occupational training is not consistently available to people with severe mental disorders.

An alternative work opportunity for people with severe psychological disorders is supported employment, in which vocational agencies and counselors help clients find competitive jobs in the community and provide psychological support while the clients are employed (Solar, 2014: Bell et al., 2011). Like sheltered workshops, supported employment opportunities are often in short supply.

There is no doubt that effective community programs can help people with schizophrenia and other severe mental disorders recover. However, fewer than half of all the people who need them receive appropriate community mental health services (Burns & Drake, 2011; Lehman et al., 2004; McGuire, 2000). In fact, in any given year, 40 to 60 percent of all people with schizophrenia and other severe mental disorders receive no treatment at all (Wang et al., 2002; Torrey, 2001). Two factors are primarily responsible: poor coordination of services and a shortage of services.

Poor Coordination of ServicesThe various mental health agencies in a community often fail to communicate with one another. There may be an opening at a nearby halfway house, for example, and the therapist at the community mental health center may not know about it. In addition, even within a community agency a patient may not have continuing contacts with the same staff members and may fail to receive consistent services. Still another problem is poor communication between state hospitals and community mental health centers, particularly at times of discharge (Torrey, 2001).

To help deal with such problems in communication and coordination, a growing number of community therapists have become case managers for people with schizophrenia and other severe mental disorders (Mas-Expósito et al., 2014; Burns, 2010). They try to coordinate available community services, guide clients through the community system, and help protect clients’ legal rights. Like the social therapists described earlier, they also offer therapy and advice, teach problem-solving and social skills, ensure that clients are taking their medications properly, and keep an eye on possible health care needs. Many professionals now believe that effective case management is the key to success for a community program.

513

Shortage of ServicesThe number of community programs—community mental health centers, halfway houses, sheltered workshops—available to people with severe mental disorders falls woefully short (Zipursky, 2014; Burns & Drake, 2011). In addition, the community mental health centers that do exist generally fail to provide adequate services for people with severe disorders. They tend to devote their efforts and money to people with less disabling problems, such as anxiety disorders or problems in social adjustment. Only a fraction of the patients treated by community mental health centers suffer from schizophrenia or other disorders marked by psychosis (Torrey, 2001).

There are various reasons for this shortage of services. Perhaps the primary one is economic (Feldman et al., 2014; Covell et al., 2011). On the one hand, more public funds are available for people with psychological disorders now than in the past. In 1963 a total of $1 billion was spent in this area, whereas today approximately $171 billion in public funding is devoted each year to people with mental disorders (Rampell, 2013; Gill, 2010; Redick et al., 1992). This represents a significant increase even when inflation and so-called real dollars are factored in. On the other hand, rather little of the additional money is going to community treatment programs for people with severe disorders (Feldman et al., 2014; Covell et al., 2011). Much of it goes instead to prescription drugs, monthly income payments such as social security disability income, services for people with mental disorders in nursing homes and general hospitals, and community services for people who are less disturbed. Today, the financial burden of providing community treatment for people with long-term severe disorders often falls on local governments and nonprofit organizations rather than the federal or state government (Rampell, 2013), and local resources cannot always meet this challenge.

What Are the Consequences of Inadequate Community Treatment?What happens to people with schizophrenia and other severe disorders whose communities do not provide the services they need and whose families cannot afford private treatment (see Figure 15-2)? As you have read, a large number receive no treatment at all; many others spend a short time in a state hospital or semihospital and are then discharged prematurely, often without adequate follow-up treatment (Burns & Drake, 2011; Gill, 2010).

Many of the people with schizophrenia and other severe disorders return to their families and receive medication and perhaps emotional and financial support, but little else in the way of treatment (Barrowclough & Lobban, 2008). Around 8 percent enter an alternative institution such as a nursing home or rest home, where they receive only custodial care and medication (Torrey, 2001). As many as 18 percent are placed in privately run residences where supervision often is provided by untrained staff—foster homes (small or large), boardinghouses, care homes, and similar facilities (Lindenmayer & Khan, 2012). These residences vary greatly in quality. Some of them are legitimate “bed and care” facilities, providing three meals a day, medication reminders, and at least a small degree of staff supervision. However, many do not offer even these minimal services.

Another 34 percent of people with schizophrenia and other severe disorders live in totally unsupervised settings. Some are equal to the challenge of living alone, supporting themselves effectively, and maintaining nicely furnished apartments. But many cannot really function independently and wind up in rundown single-room occupancy hotels (SROs) or rooming houses, often located in inner-city neighborhoods (Torrey, 2001). They may live in conditions that are substandard and unsafe, which may exacerbate their disorder (Bhavsar et al., 2014). Many survive on government disability payments, and a number spend their days wandering through neighborhood streets.

514

Finally, a great number of people with schizophrenia and other severe disorders have become homeless (Ogden, 2014; Kooyman & Walsh, 2011). There are between 400,000 and 800,000 homeless people in the United States, and approximately one-third have a severe mental disorder, commonly schizophrenia. Many have been released from hospitals. Others are young adults who were never hospitalized in the first place. Another 135,000 or more people with severe mental disorders end up in prisons because their disorders have led them to break the law (Morrissey & Cuddeback, 2008; Peters et al., 2008) (see MediaSpeak below). Certainly deinstitutionalization and the community mental health movement have failed these individuals, and many report actually feeling relieved if they are able to return to hospital life.

Despite these very serious problems, proper community care has shown great potential for assisting people in recovering from schizophrenia and other severe disorders, and clinicians and many government officials continue to press to make it more available. In addition, a number of national interest groups have formed in countries around the world that push for better community treatment (Frese, 2008). In the United States, for example, the National Alliance on Mental Illness (NAMI) began in 1979 with 300 members and has expanded to 200,000 members in more than 1,000 chapters (NAMI, 2014). Made up largely of families and people affected by severe mental disorders (particularly schizophrenia, bipolar disorders, and major depressive disorder), NAMI has become not only a source of information, support, and guidance for its members but also a powerful lobbying force in state and national legislatures; and it has pressured community mental health centers to treat more people with schizophrenia and other severe disorders.

515

516

Today, community care is a major feature of treatment for people recovering from severe mental disorders in countries around the world. Both in the United States and abroad, well-coordinated community treatment is seen as an important part of the solution to the problem of severe mental dysfunctioning (Wise, 2014; Burns & Drake, 2011).