We’ve been listening back to a 1989 report on the state of mental health care in New Hampshire. Last week, reporter Kathy McLaughlin explored the living conditions in the old New Hampshire Hospital buildings, which could be crowded and grim.
Today, we share part two of that report. NHPR’s Martin Murray spoke with Paul Gorman, superintendent of New Hampshire Hospital, who explained how the hospital’s new, community-oriented facility sought to treat patients.
While 1989 was a high point for New Hampshire’s mental health care, the story has taken a few twists and turns since then. I spoke with NHPR’s current Health & Science reporter, Jack Rodolico, to find out what’s changed.
Keep reading after the story for the transcript of my conversation with Jack Rodolico.
First, from the archives this week, part two of NHPR's 1989 report on New Hampshire's mental health services.
A visitor may be forgiven if upon visiting the state’s Acute Psychiatric Services Center, built in 1989, he or she is confused. It doesn't appear as one might imagine a hospital for the severely mentally ill to be. Some patients are in the lobby, visiting the beauty salon, passing the time of day with friends, or standing in line waiting to make a transaction at the center’s bank.
Such features are prominent throughout the center – a greenhouse, fitness center, library – an attempt to combine treatment facilities with an atmosphere of community. The $28 million center, located on the grounds of the state hospital in Concord, is the pride of New Hampshire’s mental health system, but it’s the last stop, not the first. It’s reserved for those who suffer the most severe symptoms of mental illness.
“We have continuing care units in the hospital for these people,” said hospital superintendent Paul Gorman. “Some of them may stay here for a year, two years, some as far as five years -- until we’re able to work with them in such a way that they get some control over the symptoms of their mental illness such that they’re able to go back to the community. Our goal is always to try and help people so that they can live and work and function in the least restrictive environment.”
The center is a culmination of sorts in the never-ending search for the best therapy, for the most efficient treatment. But a more critical crossroads was reached years earlier. De-institutionalization, the emptying of the “warehouses,” as some of the country’s hospitals were called, as patients re-entered the community – sharing apartments and homes, being treated at private non-profit centers spread around the state.
“Over a period of time, as the process of downsizing of the state hospital continued, the resources were shifted away from the hospital and into the community,” Gorman said. “There are now approximately 650 beds in group homes and supervised apartments and independent living situations that are managed by the community mental health centers throughout the state that give our severely mentally ill people a place to live that is dignified and proper in the community.”
A More Humane Environment
In 1989, the vast majority of New Hampshire’s mentally ill were treated not at the state hospital, but at the ten community mental health centers. Gorman said that careful planning provided assurance that that treatment was adequate. Homelessness among the mentally ill, he said, was not a serious problem in the state in 1989.
Was the 1989 treatment process working? Gorman said it was. Advances in medication in the 1940s were a key to controlling symptoms, but the institutions continued to dull minds. The brick walls simply contained. Staff simply provided necessary care. Gorman came to his superintendent position from one of the community centers. He said the new programs and living arrangements contributed to a more humane environment.
“The ability of these particular patients to hold down jobs, to have a life like we all take so much for granted – have friends, have supports, have recreation, have specific times in their lives for functions – that kind of thing gets very controlled in an institutional setting,” he said. “Just the freedom of choices that people have in a community setting is dramatically different.”
A Focus On Active Treatment
A difference is evident too inside the new hospital. Two-thirds of those admitted spent less than three weeks there. The emphasis was not on care-giving, but on treatment. Gorman said that made a world of difference.
“I think that that makes the staff person themselves, whether it’s a mental health worker or a nurse, feel more valued,” he said. “Because the contribution that they’re making to the patient is structured within an organized treatment plan that’s individualized for every patient in the hospital. What their contribution, that is the staff person’s contribution to that is clear. And it’s that active treatment modality that we’re involved in now that is different from the more passive caretaking role that staff had several years ago.”
There were other changes as well in the state’s approach to the treatment of the mentally ill. In 1984 there was a proposal to get out of the business altogether and contract the care out to private hospitals. That didn’t happen, but the state did enter into an agreement with Dartmouth Medical School to provide psychiatric services. This public/private partnership was pointed to as a keystone to the future of New Hampshire’s mental health services, assuring care that the state alone could not, and placing increased emphasis on education and research.
- Q & A with NHPR's Jack Rodolico:
Eric Larrabee: It’s been over 25 years since these stories were produced. What about them caught your attention?
Jack Rodolico: Well it’s interesting because the late eighties is now sort of considered the golden age in mental health treatment in New Hampshire, in that we had this sort of enlightened period where we realized people had a right to be treated in a way that was more humane. They didn’t have to be in institutions; they had a right to live in communities. And I hear people that work in the mental health field talk about that time period all the time. Almost every time I do an interview that comes up.
And the sort of counterpart to that now that really stood out to me, there was a quote in there that said that homelessness among individuals with mental illness was not a problem back then. And that was supposed to be seen as evidence of we had a system that was functioning well. We have the polar opposite problem now, because things have been defunded over the years. Something like 40 percent of the people in NH who are homeless self-report having a severe mental illness. Something like 30 percent are alcoholics or drug addicts, which is truly also considered a mental illness. So, we’ve come a long way since the late ‘80s.
EL: So like you said, at the time in 1989, NH was viewed as one of the top states in the country in terms of mental health services. So what do you think has been the biggest change since then? Is it the inconsistent funding?
JR: The drop in funding has been pretty dramatic over that time period. And again, if homeless people are sort of the canary in the coal mine, they’re a pretty clear indication that we don’t have enough places for people with mental illness to live out their lives in a way that is healthy for them.
EL: With the questions of funding issues, now last year there’s been a settlement of a class-action lawsuit against the state, and the state settled for $30 million to improve mental health services. So where is that $30 million coming from? And can you tell us just a little about that settlement and the other mental health reports you’re working on?
JR: Sure. So essentially, to close the loop on these stories, we had defunding, defunding by the state legislature over the course of a couple decades, to the point where a group called The Disability Rights Center sued the state, and said, “You’re violating the civil rights of people with mental illness, because by not providing community services, you’re essentially forcing them into institutions.”
And the federal Department of Justice jumped on that lawsuit, and the state decided to settle. The legislature is now appropriating money to beef up community services. The goal being that hopefully people just don’t wind up in hospitals unless they absolutely need to. Whereas now hospitals are sort of the front line. If you don’t have enough therapists and emergency services right in town, whether it’s in Concord or in Laconia or any other part of the state, those people will wind up in an emergency room and then in the state hospital.
So, the goal is for the legislature to fund that $30 million over the course of four years. And so, it’s an interesting time. I guess what I’m going to be looking at is how good a job the state does in implementing this settlement. The people that sued the state seem to think we’re doing an O.K. job so far, there’s a lot of honest efforts, but it is a gargantuan undertaking, as it is essentially an entire revamp of the state’s mental health system. So I think I’m going to be watching that pretty closely over the next year or two.