Editor's note: The case history offered here illustrates the shift one organization experienced and the subsequent order that emerged after a prolonged period of chaos. The author was a principal participant in most of the proceedings covered here. We offer this case study in contrast to the struggle individuals experience as they search for order and meaning in their lives. The study further illustrates the scaling concept which asserts that the dynamics of self-organization and the order that lie beneath the chaos occurs on all levels of experience. Toward the end of its career as a model for mental health services, practices at the institution were organized around a series of strong leaders. There was a period of effective internal leadership of one individual who brought his experiences as a Navy Captain, who proved as effective as his predecessors. When he left, a period of disorder emerged as the leadership structure was replaced by legislative and court action. This series of actions further complicated the self-organizing process and added complexity. Training in particular experienced a bifurcation and was taken over by another organization creating yet another system. The chaotic situation that ensued with the departure of an effective administrator and the external influences brought on by changes in the delivery of mental health services eventually reorganized into a very complex system made up of several sub-systems taking shape as regional service providers, a revised residential institution, and a separate training model within a local university. The single-system hospital-based model evolved into a consumer-driven model, characterized by several smaller, community based systems and one statewide, university-based training system. The case history illustrates the impact efforts to regulate self-organization has on systems, and the difficulty decision makers face when competing needs and interests vie for control. Regardless of the chaos, an order will emerge, even if it includes the settlement of a class action suit as is the case in this study. The dynamics observed in this case study are reflected among individual, organizations, and political systems on all levels.
Beginning in the 1840s, Maine's public mental hospital was considered a model for humane and excellent treatment for persons with mental illness. In fact, Maine built and funded one of the first public mental hospitals in the United States. According to Maine records, the hospital was built in 1 840 directly across the Kennebec River from the State Capital building to enable the legislature to never lose sight of the fact that a mental hospital was within its view. This hospital continued to offer excellent respite care and services for patients throughout the 1 800s and 1900s and was well funded by the state. When the Joint Commission on Accreditation of Hospitals and Organizations (JCAHO) commenced its work, Maine's public mental hospital was one of the first hospitals in the country to receive accreditation. It was the only public mental health facility in the country to receive continuous accreditation until the late 1980s. In 1984, the American Psychiatric Association presented the hospital with its distinguished award as the best public mental hospital in the country.
In 1958, the state hospital inpatient population reached a maximum of 3,400 clients. At that time, patients generally spent long years within the confines of the hospital, but they could garden, perform tasks that seemed to satisfy their desire for work and no serious complaints were registered by them. The hospital did not begin the deinstitutionalization movement until 1970 when the community mental health centers were established. By 1976, the hospital population reached its lowest point of 275 patients (Augusta Mental Health Institute and Bangor Mental Health Institute,1989). Hospital wards were organized by geographic county units, in hopes that when patients were discharged from the hospital, they would return to the county where they formerly resided. Instead, however, many patients chose to remain near the state hospital where they seemingly felt more secure. Revolving door syndrome became the norm when mental health clients would be admitted to the hospital for short stays and then be discharged to the community to live in somewhat substandard housing and then again return to the hospital for another stay. Community support services were introduced under the Medicaid plan as an option for those who were eligible in 1980.
The patient-to-staff ratio during the 1970s and 1980s was three staff members to one patient. The hospital mental health workers, at the time of their hire, did not possess any particular credentials or formal training and education (Career Mobility Project, 1980). Instead, they were given a month long training program during the probationary period where they were expected to successfully complete a series of short courses in CPR, CNA, medication management and non-abusive physical and psycho- logical intervention techniques. Upon completion of this training they commenced working on the wards, where they were expected to assist people with severe and persistent mental illnesses such as schizophrenia, bi-polar disorder, major depression and certain forms of dementia. In addition to the geographic units, there was a unit for disturbed adolescents and another for the elderly, who had one or more psychiatric diagnoses.
It was in 1987, that the chaos commenced. The hospital superintendent of long standing resigned after being offered a better position in another state. During his administration the hospital ran smoothly with little or no major disruptions in care. His administration was a difficult act to follow, and his replacements never were able to solve the hospital's shortcomings nor plan for appropriate remedies. During the summer of 1987, several patients died of preventable illnesses. Three died from heat prostration and three others died from undiagnosed medically related conditions that should have required surgery and intensive care at the local general hospital. These kinds of deaths within the state hospital were not noted in this mental health institute's history. As a result of the deaths of patients, the hospital lost Medicare and non-geriatric Medicaid monies. Many legislative hearings were conducted during the spring of 1988, and a great deal of legislative time was devoted to seeking solutions to the problems of the mental health institute. An Overcrowding Commission report was filed, and the Maine Commission on Mental Health was established by state legislative action. There was a turnover in the superintendents when two resigned in a short time after several patients died by suicide. According to a National Conference of State Legislatures, "A mental health system must provide assistance in a brief crisis, periodically or over a life time depending on the individual consumer's need." (Mental Health Financing and Programming, 1990).
By 1989, a Legislative subcommittee was created to monitor the state hospital and to investigate mental health related issues. At this point, the hospital in-patient population rose to 650-670, which certainly contributed to overcrowding in a hospital that was trying to downsize its number of patients. A Systems Assessment Commission, composed of community members, was created to sort out the problems within the larger mental health system. It was concluded that Maine's community mental health system was not prepared to meet the many demands of people who had been hospitalized for relatively long periods and who needed intensive community based services in order to end the cycle of the revolving door syndrome from hospital to community and back to the hospital again. Also, people working within the hospital needed more intensive training and education to help patients transition to the community. Additionally, the community based system was short staffed and ill equipped to deal with the myriad of difficulties that clients encountered when they were expected to be integrated into the community. Transitional services from hospital to community were in short supply. Many people lost their jobs at the hospital as it became apparent that with shortened patient stays not as many workers were needed. Two State Mental Health Commissioners resigned during this short period, and the adolescent and geriatric units at the state hospital were closed, resulting in further job loss.
Since the advent of the Community Mental Health Centers Act of 1963, it was deemed necessary to have a better prepared and educated work force to implement community mental health services. Hiring standards for the community mental health centers required that people working at the centers would have a minimum of an Associate degree, with preference given to people with Bachelor's degrees. These hiring standards, however, were hard to meet at that time, since no university or college was offering courses or degrees that prepared mental health workers for employment in agencies that served people with severe and persistent mental illness. Often people who lost their positions at the state hospital were not qualified by credentials to work in community mental health settings resulting in unemployment and increasing chaos.
Due to the findings of the Maine Commission on Mental Health, the Overcrowding Commission, the Systems Assessment Commission and the seemingly preventable patient deaths at the state hospital, an Augusta Mental Health Institute (AMHI) Consent Decree and settlement agreement was signed in 1990. A new Commissioner was appointed, and he became the defendant in this class action suit, which became known as Bates vs. Glover. All patients, who were in the hospital at the time of the patient deaths and all those who were admitted after 1988 became class action members. It was this class action suit that eventually brought change to Maine's mental health system, resulting in better service practices, a better educated work force, and finally brought order to the troubled mental health system of the time.
In October of 1 992, a Task Force on Mental Health Licensure was formed by act of the legislature for the Planning and Delivery of Mental Health Services. This Task Force was created to ensure that people working in the mental health field were both qualified and credentialed to work within Maine's Mental Health System. As a result of the Task Force findings, the Human Resource Development Project was founded to improve training and education in mental health and psychosocial rehabilitation (Mental Health Financing and Programming, 1980). It was recognized at this time that the University of Maine at Augusta offered more courses related to the mental health field than did its sister institu- tions of higher education. It was deemed that courses in Community Mental Health Care, Crisis Intervention, Interviewing and Counseling, Case Management, Group Process, Sexual Abuse and Trauma, Substance Abuse Counseling for Special Populations, Mental Health and Aging, Cultural Competency and Psychosocial Rehabilitation would provide the skills and knowledge that workers needed to better serve people with mental illness. These courses instill a strengths-based model to enable clients to reach their goals and to nullify the stigma of mental illness. The University of Maine at Augusta held the primary responsibility for delivering these courses to people working within the mental health system or aspiring to work within the mental health system. Since 1993, these courses have been offered at over 100 locations in Maine through distance education technologies, including interactive television, compressed video and more recently web-based instruction, in which time and place are no longer a problem for persons working on shifts or unable to travel to classes.
People who have completed these courses are certified and credentialed by the state as Mental Health Rehabilitation Technicians/Community [MHRT/C] workers. They hold positions such as Case Managers, Crisis Counselors, Independent Living Specialists, Representative Payees, Housing Specialists, Job Coaches and Supported Employment Specialists. Agencies which hire people holding the MHRT/C credential receive Medicaid reimbursement (third party payment). Clients of the Mental Health System are better served by an educated work force, and persons working in the field are better prepared to assist with helping clients make the right choices. State policy requires that state funded agencies must hire MHRT/C qualified individuals in order to receive state funding.
During the mid-1990s, a new Commissioner of Mental Health and Developmental Disabilities was appointed by the Governor. One of her first acts was to fire all the Departmental Program Managers as well as the Superintendent of the Augusta Mental Health Institute. This action took people by surprise and was coined by a newspaper editor as the St. Patrick's Day Massacre. This firing caused additional disruption in an already troubled system. Departments were reorganized and a new system of care was put in place through downsizing the central office and dividing the mental health system into three geographic regions rather than keeping the original six. This Commissioner's overhaul of the Mental Health System in Maine created a number of new challenges that were addressed by numerous forums and a new way of establishing a system of care that was community based and that needed many more well-educated community mental health workers. In addition to the Commissioner's emphasis on a regionally-based community system of care, a client-centered and client-driven philosophy was adopted by the state.
In May 1996, the Task Force on Mental Health was formed to regulate and to institute a better community system of care. The results of this task force eventually led to the closure of the Augusta Mental Health Institute, built in 1840, and its replacement by a new, 90-bed hospital in 2004. The treatment emphasis is on medication management and psychiatric rehabilitation, to prepare patients to return to the community of their choice with a much better chance of not returning to the state hospital in the future.
During the fall of 1996 and spring of 1997, a B.S. degree program in Mental Health and Human Services was specifically designed to prepare students to work in the Mental Health (now called Behavioral Health) field. Courses such as Assessment and Planning, Supervision in Health and Human Services, and several courses related to children and adolescent services, and an internship, were added to the ones listed above. This degree program, which provides state certification for work in the Behavioral Health field, has one of the highest enrollments in the State University System. Career planning and development are major aspects of this popular degree program. AU students in the program must take a 12-credit internship in a mental health and human service agency where they perform tasks under supervision for a full semester. Upon completing this capstone internship, the interns are usually hired by the agencies with permanent employment in professional positions.
The many conditions of the Consent Decree were finally met in 2006, demonstrating that a community based system of care is now in place, and that people working for the benefit of persons with mental illness are both qualified and credentialed. With the conditions of the Consent Decree met, Maine's mental health system has finally reached order. The Maine Department of Behavioral Health merged with the Maine Department of Human Services in 2004 creating the largest department within Maine. The chaos of the late 1980s and 1990s eventually led to positive changes with a new system of care and treatment for persons with serious mental illness.
[Reference]
References
Augusta Mental Health Institute and Bangor Mental Health Institute (1989). Maine Department of Mental Health, State Archives. Admissions and Census Historical Data. Available through the author.
Career Mobility Project (1980). Funded by National Institute of Mental Health. Available through the author.
Mental Health Financing and Programming (1990). National Conference of State Legislatures, 1990. Available through the author.
Mental Health Financing and Programming. (1980). National Institute of Mental Health grant STC (16) 5T23MH19324. Available through the author.
[Author Affiliation]
About the author
Grace M. Leonard is Dean of the College of Natural and Social Sciences, and Professor of Psychology and Mental Health at the University of Maine at Augusta. She authored the Mental Health and Human Services B.S. Degree Program for the University of Maine at Augusta. She also served on the Maine Governor's Mental Health Advisory Council, the Maine Commission on Mental Health, Mental Health Financing and Programming, Task Force for Mental Health Licensure, and the Governor's Mental Health Task Force, in 1996. She wrote the Report to the Legislature Regarding S.P. 505-L.D. 1343-Section 34 of the 1991-115th Legislative Session: An Act Related to Expanding Credentials for Licensed Substance Abuse Counselors, published by the Maine Board of Substance Abuse Counselors in 1993. She earned the B.A. at the University of Kentucky in 1961 and the M.A. at the University of Kentucky in 1963.
Contact her as follows:
Grace M. Leonard, Professor and Dean
College of Natural and Social Sciences
University of Maine at Augusta, Jewett Hall 102
46 University Drive
Augusta, Maine 04330-9410
207-621-3257
e-mail: gleonard@maine.edu
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