Cross Currents; Panel on Mental Health with Joan Smith and Frank McNeil, Part 3 of 3

Cross currents is made possible by a grant from the Vermont Council on the humanities and public issues. Today's crosscurrents programme is the last in a four part series sponsored by the Church Street Center for community education in Burlington and by the Vermont Association for Mental Health in titled why I'm different. You're maladjusted and he's crazy definition authority and responsibility issues in mental health. The series was recorded in Burlington in May presenting an historical viewpoint on the definition of mental illness and its treatment is Joan Smith a sociologist with the State University of New York who resides in Hartland Vermont. Here now is Joan Smith. I'm going to speak from a historical point of view. I'm going to speak from a historical point of view for two reasons. The first reason is that I think that we have sometimes models in our mind about about how things occur from normal everyday social processes that in fact are not correct and that those models that we have in our head about how things work when they're not correct

when we then start making changes or trying to make changes what we tend to do is reinforce precisely the thing we're trying to change. It's almost as though we have a machine in front of us and we have a blueprint and we keep on trying to fix the machine with the blueprint except the blueprint doesn't correspond to the machine. So rather than fixing the machine all we're doing is messing it up even more. So they think that if you use a historical point of view you can kind of see how causal models are ones that we operate with every day but quite often they're inaccurate they miss the point. They're off center a little bit. That's the first thing. The second thing is that I think that any phenomena in the world whatever it is even boring things like a chair or my shoes have a history in the nature of the nature of the thing is imbedded in the history itself. In other words if you really if you really want to understand my shoes socially you have to understand their history. Now obviously you're not going to study the history of my shoes but I bet you'd be

interesting. They add in that because their main issue is 50 because their products they come out of social relationships that have a history that people struggle over etc.. So they had you could look at my shoes in one way it kind of flattened out way. This is going some wonderful on the radio. Jones misuse. You could look at me flattened out way in terms of what they're made out of how much I spent for them so forth and so on. Or you could really ask yourself the question how they get themselves into the world issues. It's a really interesting question. So that when we're considering any kind of social phenomena understanding its history is also to understand its nature. It's not just an idle exercise. Now when you turn to disease like you mind boggles how can appendicitis have a history. Obviously it doesn't have a history or so we think. In other words people probably had appendicitis in the year 2000 B.C. they simply didn't

know it was appendicitis. Andy now anthropologists go around and they do get cavemen and show that they had appendicitis. The latest finding is cavemen had arthritis. And if you thought the history of my shoes was an interesting I mean does anybody want to know about arthritis among cavemen. Now what I want to say however is that disease just like my issues just like. Any phenomena in the world can be seen historically. It comes into the world as a social phenomena for historical reasons starting in about in pinning down where you are in the world starting in about the 14th century something very dramatic was taking place in the world and what was taking place is all the reservoirs that held together social Labor held it together in the sense of glued together in its social form manners household's the aristocracy Gil. All of the varieties of institutions

that took Labor and shaped it in certain ways started breaking apart. Now for reasons that are not the real interesting but they they don't they don't make a difference in this particular story. And those reservoirs of labor were breaking apart so that the labor would be could be deployed in a very different way. Questions arose about what to do about certain kinds of activities. And there are basically two kinds of activities that were centered on one much more than the other. One was medicine and the other was law. With with the legal profession we can leave it aside for a while. It's not very interesting and it doesn't become interesting until the 19th century but very early on extremely early on certainly by the 16th century. There was real trouble in the land and the real trouble was the following. If all Labor was to be available on a market. In other

words if your labor now is not constrained by either your household relationships the relationship your household stood to the manner or the relationship your household stood to a guild if you could deploy your labor any way you want it given the market situation. What was to keep you from deciding that you would take out tonsils or that you would. Cure with Herb's or that you would be a deliverer of babies. In fact nothing gills were being broken up and being broken down. And as they had occurred there was an emergence of quote unquote healers that were laid outside of the normal gills and normal gills were basically the barbers. The Royal College of Surgeons in England they had different names depending on where you were in the one in the other guild the name which I can never say. A

tri apothecary. I did it. I can then say there were three apothecaries. The Barbers the surgeons and then here in their different kinds of physicians but they weren't really physicians in our sense of the word at all. So that people other people were getting in on the act. Other people were literally setting up themselves as healers. And now when I say other people don't get a vision in your mind at all about some lunatics running around deciding all of a sudden that they could cure people. Remember that healing in the period I'm talking about was a pretty mystical process. I mean it wasn't extremely scientific. In fact in laboratory sciences weren't discovered until several centuries after the time I'm talking about. So they had to if you went to Cambridge or Oxford for example. And then wanted to decide you were going to study medicine what you did was you

read old texts and in Latin you never once touched a body saw a sick person did anything in a laboratory. You just study these old texts so that when we lay in the eye you have to use the word very very loosely lay people started to get in on the act. Don't imagine for a second that this was an extraordinarily dangerous thing that had to be stopped otherwise people would die because no one had a particular expertise as we now have a sense of expertise in healing. And in fact quite the opposite quite often Leahy was turned out to be much better because they didn't hear there no Stuckey in dusty books that they were studying herbs they were studying different kinds of healing that you couldn't do if you were at Oxford or Cambridge. The story's a little bit different if you turn to Italy and especially paddle up but let's just hold England. So the World College of Surgeons are having a bit of a heart attack to say the very least. And when they're having a bit of heart attack to say the very least they start making petitions to the king to protect their guild like

reservoir of labor. Keep us together as a guild and of course they're still fighting with the apothecary's and they're fighting with the barbers and there's all kinds of alliances made between these three different guilds in England. And the reason that they're making alliances is because there's all those other guys out there in the countryside getting in on the act and that's not good for business. And so in fact they were all College of Surgeons makes an alliance with the with the barbers and they both go to the cane and they demand they petition the king for a new licensing but not licensing in our sense of the permission to practice. This goes on for several centuries. Now here's the problem. At the same time this is going on for several centuries. There's what we call a small revolution in England it happens in the 17th century in that revolution what that revolution was all about was the right to be able to go and sell your labor to the highest bidder. At that point there was real trouble and

you can see it in a very very nice short passage in a fairly famous book called The Wealth of Nations by intimate 1776. He writes the marketplace the invisible hand shall guide everything and then he goes on to say even the practice of medicine. Because if you're a good healer the market will see to it that more people come to your door and you will be able to heal well. And if you get bad here very soon people find out you're no good the market will do its duty and people will not come to your door you have to go into being a bricklayer or whatever. They were all college of physicians right Stan Smith and there's a debate and now I want you to hear the terms of the debate. They say Oh yes everything you say is true. Why are they saying this. Well this is interesting they're giving it up. The reason they're saying it of course is because they're still looking for a license from the government but the government now is dedicated to these laissez faire principles of not having the

government in on the act so they have to say yes of course you're right. There should be no special licensure for bricklayers and for candle makers and for tinsmith but for us we're different. And here's the arguments a wonderful argument. The reason it's different for us is because when people are sick. They're incapable of acting rationally. You're nodding your head. But you know you figure it's coming from there. They make the argument that the market system is quite correct for everything. It's marvelous for everything. However for us it's not so hot. And the reason it's not perhaps so hot so hot for us is because sick people are not rational people. OK so immediately long before there was the modern notion of disease remember this is the mid 18th century before there's a modern notion of disease. We've already gotten through to the world. One thing we know about really sick people.

They're rational now. So already we know that if you're really sick you stand in a dependent relationship to someone who has a grip on rationality. That's the first thing we know that I could keep on going on and on about that and we would have to move to the United States and what happens to licensure is in the United States the end of the 18th century into the fall of the 19th century. And there's loads of little kind of stories like this that are really nice but which each one of them shows. And I think shows very graphically is that when practitioners make a claim in the middle of a kind of society that allow some kinds of social relationships and not others they must make their claims in terms of the kinds of social relationships that that society admit is legitimate and proper so that when the Royal College of Physicians in the end of the the mid 1776 makes the argument I think

when they were all college of physicians make the argument that sick people are rational it's not because you know what it what the disease is. No one has made any argument about what it is to this disease. What in fact they're centering on is the appropriate social relationships which will allow them the kind of practice they need. Now if you move to the 19th century very quickly you'll see this the most graphic of course is with regard to women. And now what I want to say about that is this is not an argument. Specifically about feminism but it's an argument that if it goes on with women in the terms of that relationship must be for everybody. Let me go very slowly here. By the 19th century the medical profession has the capacity for defining people's

social existence and the way we can see there is by taking a very good look at the medical textbooks of the 19th century. You don't have to go to what's going on in the state legislatures in order for physicians to get licensing and see to it that someone else doesn't have licensing in this particular case midwives. If one takes just a very good look at the textbooks of the period what is actually going on is the medical profession having the capacity to define illness as a kind of social existence. Now is this because medicine practitioners in medicine are bad people. Not at all. It goes on with teachers. It goes on with lawyers. It goes on with any organized group of people who want to maintain control over the terms and conditions of their own labor. Now having said all of that having said that the social relationships of the period dictate our understanding of

illness. Now we want to ask why a particular kind of understanding in one another and this will take me straight to mental illness. Let me stop for a minute before I get into that. Let me just be very clear. Just because social relationships in the long run dictate what a cold is doesn't mean you don't have a cold anymore. You still have the cold. You still have the runny nose. You see most often people quite started thinking that if it was social relationships that dictate the phenomena I'm looking at the phenomena is less real so that I can see my shoes come out of social relationships. It doesn't mean my shoes are less real they're still shoes. Same thing with the cold just because our experience of the cold is socially organized and defined doesn't mean that you know it's sick. So that with their background I want to now say that just because I'm now going to argue that mental illness is socially range socially colored

socially controlled does not mean for a moment that someone suffering from schizophrenia is not truly suffering. Mental illness we now have to go back again to the seventeenth and eighteenth century during the 17th and 18th century of print. One principle became more important than any other principle. If religion was the principle of an earlier period rationality was the principle of this period. It was extraordinarily important for the philosophers for the thinkers of the period to be able to define what it was to be rational. We hash anality become problematic. Why did it become problematic for a very straightforward reason. The old institutions of the society were being destroyed in any period when all the institutions are going to be destroyed. Some new phenomena must enter into the social landscape in order to define for people

of the period what that new world ought to look like. Well if you're standing there saying the aristocracy should go the guild should go all principles of organizing social life should go what gets super imposed on social life during this period is a normal rationality. What it is to be a rational person. Well if you look at it very very closely what it is to be a rational person is a person who can dispose of their labor in their property in which in terms of calculated cost calculated benefit. It's a possessive individual ism it's an individual ism that decides what one should do with their prefer their or their possessions and decided based on a calculation of good calculation of individual good. I'm stressing that point and perhaps a little too much there was some debate about that at that period but basically back floats through all the thinking of the seventeenth and eighteenth century. However there were severe limits to

rationality obviously. And you can see this in a million different accounts you can see it reading Locke you can see it reading all of the liberal philosophers when it comes to women in the family. Very liberal philosophers. If you're female one doesn't have to worry about rationality because the interest of the husband in the wife are so much alike says lack for example they're so much alike that the woman does not have to be rational because her husband's rationality can act for both of them. Is John Stuart Mill writes many many pages about rationality. And you're just loving it you think Yeah well that's just right that's right and you turn the page and it's the next page this is all this of course can that go for the people of the darker continents of Africa. Why in the world does he say they have. Obviously he stand in the middle of an empire that's moving into the darker continents of Africa so that there has to be all kinds of ways of exempting people from norms of

rationality. Who how can we tell who's rational and who isn't rational. Well one of the ways you can tell who is rational and who isn't rational IS WHO sick and who isn't sick. Sickness becomes the lack of rationality. Mental illness becomes a way of organizing treatment and controlling people who will not act rational in terms of stablished by the 17th and 18th century liberal philosophers. The idea rationality then becomes the idea the absence of which allows the community to interfere. Why in the world that the community have to get this new standard for one reason and one reason alone. Up until that time the ability of the community to interfere with people's lives was precisely the thing that everybody was fighting against. It was a revolutionary period. So that the community had to have new standards for organizing people social life. But those standards could no longer be the traditional standards of

the household it could no longer be the traditional standards of the aristocracy it could no longer be the traditional standards of religion a new standard rationality. If you were not rational then the community could interfere in your social existence and your social being. But now the lack of rationality was not something that existed with you in your kin group. You in your lineage you in your community you carried with you as part of your personal makeup your failure at being a rational human being. Treatment became individualized. So that if nothing else mental illness became something that occurred to you because of something that was interior to you not something that was about your social existence but something that was carried by you much as you would carry a disease like measles. Furthermore

the treatment accorded you was best accorded you by whipping you out of your social circumstance and putting you someplace else now for hundreds and hundreds of years there had been asylums but there wasn't an asylum in the sense of our asylum until the 18th century. It was only in the 18th century that the asylums ceased to be something that was convenient. In other words in the 18th up until the 18th century if you went to an asylum you would find all kinds of people that the community didn't want to round but they were it was a holding action. You didn't know what else to do with them. The 18th century the asylum becomes part of the community's reaction to the mentally ill not as get them away from us not as what else are we going to do with these people. But this is how we're going to treat them. We are going to rip them out of their social circumstances and see them as abstracted individuals people abstracted outside of society and outside of history.

I'm trying to think what else I should say about it. OK lastly let's move to the 20th century very quickly now that schizophrenia has probably been around as one in human beings as have colds migraine headaches arthritis rheumatism. But it's not until the 20th century that the complete individualization of that phenomena really takes place to the point there. I mean things are changing obviously right now to the point that giving birth and dying those ultimate of human activities takes place in the deepest recesses of the darkest hallway you can find in the largest hospital as far away from home as you can possibly get. Now that's obviously changing. I think the women's movement has been extraordinarily successful in criticizing that ripping out of your social circumstances socio social phenomena that have biological roots

mental illness obviously for the last 30 years now there has been in a a an effort to bring the mentally ill back to the community. But just as with dangers in the women's movement I think there's real dangers in this. That and then we refer back to the women's movement in what is done in terms of childbirth to see if I can draw an analogy. Quite often what happens is the alienated experience of giving birth is then return to the community in other words birth is defined as an alienating frightful traumatic event. One stands in that relationship to that event and then via political organizing except that alienating event is returned back to the community as but remains an alienated event and quite often you can see this the same thing with mental illness I think that or

any kind of illness the hospice movement suffers from this problem. I think that mental illness as a vent that is outside of history and outside of society and outside of the community has been created over several centuries. That then a sick individual is replaced in the place back into the community again. But with already bad definition attached to the person that took several centuries to develop. It is I think a danger because what happens is is that it ends up. As the state's ability to escape fiscal responsibility it can no longer absorb. I think with mental illness you see this absolutely with the deinstitutionalization movement. Take the patient that has been in the hospital the longest get them out of the hospital get them back into the community. It goes back in the community is this alienated person with the

alienated disease attached to their person. And what the state has of course is the relief from supporting the a person in a mental hospital. One then studies that person directs treatment towards their person organizes that person's life as though their person is still walking around with their disease that alienated the historicity of the socialized disease. But now that person somehow has to make it in a community that they have been ripped out of daily in it in their treatment. And I think that what I've argued and what I think is hard to put into practice is that it with deinstitutionalization there is still the view that the individual is the the center of focus and in the individual has problems quite independent of the social circumstances within which those problems arise. So that it would be unthinkable for example in other social circumstances to

develop psychotropic drugs which is I mean that that would be you would not find the development of those drugs in another's in another kind of social setting. That is not because other social settings aren't smart enough to figure out how to manufacture these drugs. It's simply that the illness itself as it presents itself is not something seen as controllable by doing something to the individual. The idea of returning the individual the can to the community. I think it's a facade in certain respects to say that now the community will take responsibility for the person. It's still the person walking around with the disease that still gets the treatment. Rather than asking ourselves the more central question how is it a society in its population 9 wind only distributed problems of

rationality. In other words it's when someone starts talking about disease and then talks about disease in terms of socio economic class you really have to ask yourself some very serious questions about how you think about disease. In other words if disease is something that actually exists inside a biological entity then how is it that those biological entities are not distributed equally across the society but in fact seem to occupy very specific socio political status. Now you could argue that crazy people are more likely to be poor because they can't hold a job except I think it's quite the other way around. I think poor people are much more likely to be crazy because they're poor. I know that I shouldn't use the word crazy. That's that's a no no and then he threw her. So there for example women much more likely to be in individual therapy than men. I had a student the other day an older woman who came up to me and said.

It was quite horrible. We ere we was a lecturer I forget what it was quite appropriate. Later she came to my office and she said I don't want to say anything in class but something happened to me that sprang into my head and was relevant to what we were talking about in class and she said My husband had an affair and I went to a psychiatrist and his staff for a minute he thought wait a minute it was he he did something and you went to a psychiatrist Yes and I had 37 electric shock treatments. They had I mean it was appalling I mean I was I gassed and I thought how do you see that how can you possibly describe that. Your husband did something that the community perhaps does not respect whatever I think that is there's a bit of a double standard there. But you know turning yourself into a psychiatrist in your psychiatry see something enough wrong with you that you go get 37 shock treatments. Now I think that that's not unusual. I think it is quite common for groups of

people who stand in subordinate positions to have defined for them their problems they're having with subordination has problems of mental distress mental illness etc.. That is not to say that people who are in subordinate positions aren't experiencing a great deal of stress and need a lot of support. It's simply to say they had a drug is not it's not the support they need what they need to do is be able to locate where their distress is coming from it's not coming from inside their head. You've been listening to John Smith a sociologist at the State University of New York responding to the views presented by Dr. Smith is Frank McNeil director of Franklin County Grand Isle mental health services. Frank McNeil This is the information that was sent to me. But I just must say it was rather sparse and. It didn't interest me statement in which appeared to me at least

to state that the usual causal model by which medicine is practiced is that when illness goes to knowledge treatment to be ultimately leads to the organization of medicine. But her basic model would reverse that. And I think she ultimately concludes that illness. What we know about it and how we treat it is a product of how medicine is organized or administered. And that brought to mind a statement I heard one time that Malcolm Muggeridge ex-editor a punch and I thought it fit in rather nicely. That kind of model. So I looked it up and it read like this. He said and I quote I've always been deeply interested in the administrative side of love. Which he said I find more absorbing than is truly erotic aspects. What Lady Chatterley in her gamekeeper did in the woods is to me of only passing interest

compared to how they got there. What arrangements were made for a shelter in case of inclement weather. What was arranged for refreshments. How they accounted for their absence. Whether either party could recover incidental expenses and if so how. This attitude he continues is after all not so unreasonable as many great generals that amid the planning campaigns and winning victories to be further easier than the arranging of transport and supplies and arming Napoleon said marches on its stomach. So if the administrative arrangements are faulty the campaign which follows can be but laborious and the victor brings little satisfaction. Now while I must confess myself that I have greater interest in Mr. Muggeridge and what the good lady in the gamekeeper did in the woods I think his point is well taken

and the stress you now have you somewhere. I'd like to encourage among mental health professionals at least a greater intimacy with the economic factors that govern what they do and how they do it. And while I can't promise that their love affair will be as it rather the sightings of Lady Chatterley's you know it should be just as rewarding we think. So to jump off on the the topic I kind of focused in on Mental Health Administration and the role generally of economics in the treatment of mental illness as it has impacted on the scene in the past 25 years. Now the system under which we administer mental health.

You know we define. What people are mentally ill what their care is and how the treatment is prescribed. And this basically drives a strength and its weakness from the values of the society in which it's practiced. What we define as mentally ill depends on the norms of society. What it is prepared to tolerate and what it finds intolerable and the modes of care and treatment evolve out of complex interactions between rival philosophies. Now often the planning and the expenditures that go into this may take for granted or obscure the basic philosophical questions Who are the mentally ill. What are their special needs and how do we handle their problems the way we do. Now if you've ever read anything on the history of mental mental illness and how it evolves and how it's been treated over the years

you'll find probably that there's nothing new under the sun that cycles come and go. And if you look back far enough you'll see a repetition of just about every kind of direction in the cycle of caring for the mentally ill over the centuries. The traditional model developed in the 19th century involved in the United States and Great Britain a great investment in bricks and mortar. And the treatment involved basically institutionalizing individuals. This was the way society dealt with that phenomenon that Dr Smith has just related. Got them out of the way put them someplace. And of course this was an incredible waste of human lives. And the reaction to this

probably did not occur until the latter pert of the 40s and 50s when we started to get somewhat widely publicized articles about the conditions for the purple conditions in our mental hospitals and more and more information. Came out in various forms either from authors who wrote novels about it like kisi or Goffman who did a very thorough analysis on the silence and the conditions that exist now in the past 20 years 25 years. The flight from a closed monolithic mental

hospital system has been general. However two facts clearly stand out. That despite its relatively poor public image the mental hospital system is remarkably tough and seems to survive all onslaught on all arms lots. Even though admission rates of fluctuated there are still of there still very much a medical perk of almost all mental health systems the United States and Canada. And to that despite some 25 years of experiments and community based psychiatry we are still much clearer about what we are running away from than about where we are running to right now. If we just look at the try to look at the impact of the economic system on the mentally ill we don't have to look any further than the history of

deinstitutionalization following what Dr. Smith has stated that if you understand the history of something you can probably understand a lot more about mental illness. Now we're just trying to relate quickly to the history of mental illness at the turn of the century. Again the institution was the prime place for treatment. Very little or very few other resources existed. There was some work by individual therapists some attempt at treatment individually but it was very scattered. Basically. And from nineteen hundred to nine hundred fifty five state hospitals were the key.

They were built large monoliths attics and kept up at extremely expensive cost both in terms of human lives and in financing it. It was only during World War Two that it appeared that we started to get some understanding of the deplorable state of the mentally ill in our country when we had something like 2 million draftees rejected on the basis of problems around their intellectual emotional state. There was also a great number of individual individuals who were conscientious objectors who were also very vocal who worked in mental hospitals and discovered the deplorable conditions that existed there.

Now in 1946 you know MH was founded by congressional a legislative act and this was the first federal involvement in mental health policy. Prior to that the states of the Union were responsible soley for the care of the mentally ill in the early 50s you had the advent of the psychotropic drugs and the possibilities of managing the patient more easily. From 1955 to 972 we had an enormous crew increase in admissions and with that you had a recognition that the institution was the sole way to deal with something you had to find another way to deal with the mentally ill. Now last proponents of our political economic theses

and that say that the institutionalization was nothing but that will say that the rising costs of running a hospital of new construction that was needed for the increase in admissions are most moved people to find another system to deal with the mentally ill and the commission that was established to study mental illness which culminated in action for mental health. The Bono approach. By which legislation for construction and staffing of a new model a community center model with federal monies and with specified services. Was initiated.

I'm not going to go into the details of that but there were also some interesting legislation that followed in the mid 60s with the Social Security amendments establishing Medicaid and Medicare which allowed for the elderly clients in the mental hospitals to be placed in nursing homes. It also allowed for the expenditure of the or the cost of certain individuals in state hospitals to be covered under federal monies which allowed the states to move that money into other areas. The whole method by which. Mental health a mellowness was looked at and its treatment was governed more and more by federal intervention and by programs that not only dictated who would be served but how they would be served and by home. The whole

organization changed. There was an increase in terms of requirements documentation record keeping. The whole process of obtaining this money and the criteria for eligibility and specific conditions under which you could obtain treatment or the monies for treatment. It opened up the mental health field to a very different and I think interesting approach. Same time in 1972 for example there were there was the legislation that developed a social security income that allowed individuals who were moved out of institutions to be able to collect monies to live in the community.

And there were even federal financial penalties if you didn't depopulate your hospitals at a particular rate. And then 1975 you had another change in the development of community mental health. Centers with an increase in the kinds of services that were required. You know in accountability and evaluation. Ingredients are also thrown in to govern how you would treat the mentally ill or how you would deal with specific kinds of people. Of predicated doing this if you wish to continue to obtain the money necessary to. Follow through with your trip in my down days. There it also involved the

whole thing of licensure. What level of confidence did the individual have this is all dictated again who could serve as a therapist who could deal with the mentally ill. The supervision by a psychiatrist being required in both the federal 19 and 18 programs the tremendous amount of record keeping. That and even the time involved in maintaining documentation generating grant money from the federal government took an enormous chunk of time from the professionals to deal with that level. The whole system of money from the resources making you financially dependent on them if you've got provider status under

Medicaid you have to comply in specific ways. And if you didn't you were no longer able to maintain that level of service for the people you would serve that point. And so while it opened up enormous. Avenues are channels by which more people could obtain mental health services. The other side of the coin was that it also rigid AFAI what you could do with and under what conditions you could do it. The state of Vermont has been very fortunate in one direction by being able to get on the bandwagon of some of these federal programs and

funding practically its total institutionalization program. I would say two thirds of it anyway. By use of Medicaid. But that has a has a serious flaw in it also because there is not been a corresponding contingency plan generated by which if in some time in the future that Medicaid fails too. Have the dollars for deinstitutionalization programs. The state has not generated a plan by which they could make up those dollars that would be lost from the federal S.. I. My main My main point is that

the focus at the moment in terms of the federal monies and which we rely so much on focuses primarily on the chronically mentally ill those who have severe and persistent illness who are now presently in the community in large numbers who must be dealt with. Even though they are has to socialize does Dr Smith I think stated who have very specific problems that we have to deal with multiple problems and time to incorporate them back into the system. The second are the acutely ill who need immediate intervention and crisis resolution and there's less and less money in what we call for what we call the worried well. Or for those kinds of conscience consciousness expanding therapies Clairmont has called the narcissistic indulgences of the upper middle class.

We are beset by policies that say we must treat the least restrictive environment. We there is heavy emphasis on the guarantee of treatment to minorities. We're. Constantly being bombarded with the division of financial responsibility. They can't we can't seem to make up our mind as to who is actually responsible for the welfare of the client. Is it the individual. Is it his family. Is the state is of the local government is it the federal government that continues to be a very pervasive issue and the policy questions that are raised around go beyond just the matter of financial responsibility and address such questions as who should be placed in community care

settings. Just the best candidates for rehabilitation or all institutionalized clients or just those clients of an institutionalized because it was no less restrictive environment available at the time. And again you asked You have to ask yourself on the basis of that. Who decides what constitutes appropriate care. Is the patient. Is it the patient's family. Is it the professional provider. Is it the state. Is the federal government or is it the courts. To seel and pays the pays the piper calls the tune. Well the impact of a protracted no protracted recession be on treatment for the mentally ill. We know that mental illness correlates highly with socioeconomic

status and the poor are more likely to develop severe problems in a recession. We have increased admission rates to hospitals where the community be able to care for them. Where's the money going to come to do that. Well spiraling cost railroad mental health backing of the loss of a distinct identity. And again put on the umbrella of the health department. Will it lose its identity by forcing us to integrate which is the next which is now another key word integrate with other health and social services. And will we follow the same course that that happens. That happened in Great Britain where metal have lost its distinct administrative structure so that their normal

service is in Great Britain at this point. Distinct serves as such so that the economy and the economic impact on treatment I think is a very real one. It governs exactly in most instances how we function with the mentally ill what we can do and how we can do it. And I firmly believe that that social organization the financial administrative organization of the. Illness does determine how we do with it. We know how we live. That was Frank McNeil director of Franklin County Grand Isle mental health services. Earlier in the program you heard Joan Smith a sociologist at the State University of New York presenting

her views on mental illness as part of a series of programs on mental health presented by the Church Street Center for Community Education and the Vermont Association for Mental Health. Today's program produced by Joshua Landis and Marianne Blake is available on cassette by writing to the University of Vermont. I see media library Burlington Vermont 0 5 4 0 1. That's the University of Vermont's IDC media library Burlington Vermont 0 5 4 0 1 Vermont residents. Please enclose a check or money order for a $1 for out-of-state residence. The cost is $4 ask for crosscurrents program mental health part 3 crosscurrents is also heard on W. R. F. B in Stowe Vermont. Today's program will be heard on September 14th Cristo area listeners W. R. F. B is at 1 0 one point seven on the FM dial

crosscurrents is made possible by a grant from the Vermont Council on the humanities and public issues.