Understanding the current facts and principles of mental health system planning.

The state mental health services planning encouraged by Pub.L. 99-660, TitleV, will be a very different process from the services planning of previous decades. The services planning stimulated by this new legislation will be influenced by a philosophy and set of values that contrast markedly with past services planning. In this article, service planning principles are articulated that can guide the planning of a comprehensive community-based service system. Yet, no matter how well crafted the plan; its worth is based on what it does for the people being served. New technology exits to change the program structures and staff competencies in ways that will lead to better client outcomes. The challenge of successfully implementing these new service plans will only be met when mental health authorities directly support the use of the new technologies. It appears that mental health system planning in the 1990s will be influenced by a vision and a philosophy that is very different from previous mental health planning efforts. Stimulated by a developing consensus about the underlying philosophy of community support and rehabilitation (Anthony, 1992; Parrish, 1989; Turner & TenHoor, 1978), mental health planning is riding a wave of optimism about what could be, realistically tempered by a trough of pessimism about what currently exits and how much needs to be done. The articles in this section describe this future vision and present reality (Chamberlin & Rogers, 1990; Kennedy, 1990; Romeo, Mauch, & Morrison, 1990; Weisburd, 1990). The Model Plan for a Comprehensive, Community-Based System (National Institute of Mental Health (NIMH), 1987), a technical assistance document to help state implement Pub.L. 99-660 (State Comprehensive Mental Health Plan Act, 1986), is imbued with the community support and rehabilitation philosophy that undergrads this new vision. This philosophy specifically includes (a) understand the person with mental illness as a person first, with basic needs and goals similar to other members of the community; (b) involving consumers and family members in system planning and implementation activities; (c) recognizing the family as a resource to the helping effort; and (d) developing services that are consumer-centered and empowering. This philosophy is the foundation for service system planning. It must also be reflected in the overall mission of the state plan. The NIMH (1987) has provided the following example of a mission statement as one that is consistent with this new philosophical base: To implement programs and services that assist adults with severe, disabling mental illness to control the symptoms of the illness; to develop the skills and acquire the supports and resources they need to succeed where they choose to live, learn, and work; and to maintain responsibility, to the greatest extent possible, for setting their own goals, directing their own lives, and acting responsibly as members of the community. (p. 12) To develop new plans that incorporate this philosophy, planners must not only think differently about the possibilities for consumers in their future service system, they must also think smarter. They must do away with their outdated assumptions and be guided by current knowledge and principles. Old Planning Myths and New Planning Principles Planners of a comprehensive community-based system must be armed with new knowledge; they must be disarmed of old planning assumptions. A description of 10 facts and principles about which planners must be knowledgeable in order to plan follows. 1. Consumers of mental health services can identify realistic goals for themselves that can then be factored into planning a system’s services. Previous system wide planning efforts seemed to mistakenly assume that persons with severe psychiatric disabilities will not be able to come up with goals or that the goals they come up with will be destructive (e.g., will harm someone) or unrealistic (e.g., wants to be an astronaut). The fact is that, if given the opportunity and support, most clients can identify realistic goals that planners can use as the basis for their service system design. When consumers are asked about their goals in a supportive manner, the goals they mention are the same goals that other persons would mention-satisfying jobs, decent places to live, a chance to return to school, and a reduction of psychological distress. System planners must ensure that their planning proceeds from a good understanding of the goals of the persons whom the system is designed to serve. 2. The mission of the state department of mental health is to help people function better so that they can become more successful and satisfied in their various living, learning, working, and/or social environments, with the least amount of ongoing assistance from agents of the mental health system. This mission is a variation of the mission suggested in the model plan (NIMH, 1987). The key difference between this suggested mission and prior descriptions of the mission of state mental health departments is that the focus of the preferred mission is on outcomes for the clients rather than on process objectives for the mental health authorities. Historically, the state level mission has been to provide “comprehensive services” or “continuity of care” are quality control objectives that may or may not achieve client outcomes. When clients are asked what their ultimate mission or goals are, none of them indicate “comprehensive services” –neither should mental health service systems. 3. The role of the state hospital in the system plan should be consistent with the state department’s overall mission. Historically, system-level mission statements have incorrectly written that the elimination of state hospital beds was a major element of the mission of the state department of mental health. However, the ultimate focus of the plan should be on the hospital’s role, not the size. The hospital is apart of the community, and a community-based system of services, the hospital is designed, like other services, to help people live successfully in the community, not simply to keep them out the community or keep them in. The emphasis in the plan is on creating services consistent with the mission of the system, and not simply on eliminating beds. Bed reduction is a byproduct of a successfully achieved mission, not a mission in and of itself. 4. Improving client functioning, and not simply maintaining people in the community, must be a part of the system’s mission. A maintenance-only mission is yesterday’s mission. A variety of programs have demonstrated their capacity to maintain people in the community (e.g. Cannady, 1982; Stein & Test, 1980). Although such programs have not yet been routinely implemented nationwide, a system mission of community maintenance reflects yesterday’s accomplishments and values. Consumers “maintained” in the community are now asking, where can I go in it? What can I do in it? Helping persons with psychiatric disability to grow in the community, rather than just to survive in the community, must be the focus of the system’s mission. 5. Psychiatrically disabled persons’ skills and supports relate to community outcomes more strongly than do their symptoms. System planners must ensure that their services provide for skill development and support development, and not just symptom relief. Both new and old service dollars need to be directed at programs that focus on skill and support development outcomes. System planners must realize that persons with psychiatric disabilities are limited not only by their major psychiatric symptoms but primarily by their persistent social vocational deficits and exaggerated emotional response to stressful life events. The substance of a system’s service delivery programs must reflect this fact. 6. Persons who are psychiatrically disabled need different services, at different times, and at different levels of intensity. Persons with psychiatric disabilities do not need the same kinds of services. Thus, the service system must develop a large range of service alternatives, packaged differently for different clients. These unique services for each client are tied together by a common mission. The individual service package flows from the person’s goals and an assessment of the skills and supports needed to achieve these goals. For example, the type of housing in which one resides need not dictate the kind and intensity of services one receives, or vice versa. The fact is that persons should receive the kinds of services they need and want, no matter what their housing situation. System planners must tie their services to the person and not to the house. A client shouldn’t have to live in a group home in order to receive the kind of services he or she needs, or attend day treatment to live in the type of home he or she wants. A wide range of services must be provided over the wide range of housing options, which increasing and decreasing levels of intensity and support as needed by the client. One shouldn’t have to continually change residences in order to get more, less, or different services. 7. Many persons with psychiatric disabilities don’t want the services the system provides because they often find these services unappealing, inappropriate, or demeaning. The high attrition rates of mental health programs are not a function of client deficits, but rather service deficits. Thus, system planners must constantly check to see if the services created are consistent with the philosophy and values of a community-based services system (NIMH, 1987). Explicit statements of values in the plan provide one yardstick against which implementation can be judged. The values specified in the plan can do more than help make the planners feel good; they help the implementers of the plan do good. Some persons with psychiatric disabilities who want and need services won’t seek them out. Systems of the