TOWARD A PUBLIC POLICY ON THE CHRONIC MENTALLY ILL PATIENT

Amer. 1. Orthopsychiut. 50(I}, lanuuty 1980

DELIVERY OF SERVICES

TOWARD A PUBLIC POLICY ON THE CHRONIC MENTALLY ILL PATIENT

John A. Talbott, M.D.

Professor of Psychiatry, Cornell University Medical College, New York

This paper outlines the problems posed by the chronic mentally ill, which have become a national disgrace. T h e historical background of deinstitutionalization is reviewed, issues critical to an understanding of the problems of the chronic mental patient are examined, solutions are suggested, and a public policy on the chronic mental patient is proposed.

tate mental hospitals in the United S States reached their maximum cen- sus of 550,000 in 1955. Thereafter their population steadily and dramatically declined to its current low of 180,000. Reasons for this decline include: I ) development of the philosophy that it is better to treat mental patients in the community than in institutions; 2 ) tech- nological advances, especially the intro- duction of new psychopharmacological agents; 3 ) increasing emphasis on patient rights by legal, legislative, and judicial forces; and 4 ) the shift in a substantial part of the economic responsibility for the several million chronic mentally ill patients from the states to the federal government

(through SSI, Medicaid, and Medicare funding) as patients were discharged from state hospitals to nursing and board and care homes. The resultant change in the locus of treatment and care of society’s most severely and chronically mentally ill from hospital t9 community settings, an unplanned but intentional movement, has euphe- mistically been labeled deinstitutionalization. T h e definition of deinstitutionalization includes both the discharge of patients from hospitals into community settings and the reduction in admis- sions to governmental hospitals of cer- tain patient populations, especially the elderly and those in need of purely “custodial” care.‘

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Presented at the 1979 annual meeting of the Americun Orthopsychiatric Association, in Wmh- ington, D.C.

000Z-9432/80/010043-11$00.75 0 1 9 8 0 American Orthopsychiatric Association, Inc. 43

44 THE CHRONIC PATIENT

By 1975, it had become clear in many American communities that deinstitutionalization was not an unqualified suc- cess. T h e media called attention to the wretched conditions many discharged patients lived in; 21 governmental in- vestigations into the lack of services for these patients followed; 4 an outcry came from communities into which hun- dreds of patients had been “dumped;”27 and psychiatrists began openly to con- demn the movement as a “national disgrace.’’ 10 The overutilization of crisis services by chronic paiients became so serious that the Emergency Services Committee of the New York County District Branch of the American Psy- chiatric Association, composed of the directors of psychiatric emergency services in America’s largest regional psychiatric association, urgently re- quested the national APA to study the problem and propose solutions.

Since 1975, several publications have documented the impact of cleinstitu- tionalization 20 and have provided some guidelines for treatment of the chronically mentally ill.3#0,9- 17.24 This paper draws upon these contributions, as well as the three years’ work of the APA Ad Hoc Committee on the Chronic Mental Patient,” and provides a summary of the problems, solutions, and recommendations for a public policy regarding the chronic mentally ill patient.20

CRITICAL ISSUES

W h o and Where are the Chronic Mentally Il l Patients? 13.28

I n order to construct a map of chronic mentally ill patients, it is necessary ini-

tially to establish some operational defi- nitions. Chronicity usually is used for an illness lasting “a long time,” inter- preted by some as hospitalization for one or two years o r the presence of a major psychosis (e.g., schizophrenia) for the same time period. Chronic disability, on the other hand, is defined as eligibility for SSI (Supplemental Secu- rity Income). While Bachrach’s definition of the chronic mental patient is descriptively ideal, no statistics are available on “those individuals who are, have been or might have been, but for the deinstitutionalization movement, on the rolls of long term mental institutions, especially state hospitals.” 1 So a reconstruction is necessary.

How many chronic patients are there in the United States? There are 1,100,- 000 schizophrenics, 180,000 of whom are in hospitals and almost a million in the community. Of the total number of elderly in the United States, one million are in institutions, mainly state hospitals and nursing homes: of these, 750,000 have psychiatric diagnoses. There are also one million psychotic elderly persons living in the community. In addition, of all the severely mentally disabled (e.g., receiving SSI benefits), 1.1 million are housed in institutions and 3.1 million are not. Thus there are between one and four million chronic mentally ill patients in this country.

T h e location of these patients has changed as deinstitutionalization has progresced. At the start, over 65% of discharged patients returned to their fiimilies, and only 20%--25a/, lived alone or were referred to nursing or boarding

John A. Talbott, chair; James T. Barter, Donald Harnmersley, Maurice Laufer, \V. Walter Menninger, Arthur T. Meyerson, Mildred Mitchell-Bateman, Samuel Muszinski, Lucy Ozarin, John Spiegel and Harold Visotsky, members.

JOHN A. TALBOTT 45

homes. However, as the deinstitutionalization movement proceeded, and the easier to place and less severely and chronically ill had been discharged, the proportion of patients who were discharged to live by themselves or in nursing or board and care homes increased until currently only 23% return to their own homes.

The level of functioning of discharged patients is measured by sevcral indices, which include: readmission rate, presence of symptoms, employment record, social isolation, and participation in after-care. Whereas before deinstitutionalization only 25% of hospital admis- sions were readmissions, that proportion had increased to 64% by 1972. Regarding symptoms, only one-third of all deinstitutionalized patients are asymptomatic, another third are mildly symptomatic, and a third are severely symptomatic. Although 30%-50% of discharged patients return to work, 70% of them return to a less skilled job; after a year, only 20%-30% of discharged patients are still employed. In addition, 25% of discharged patients live in total isolation, 50% in moderate isolation, and only 25% in a family setting. Furthermore, no more than 50%- 70% of discharged patients receive any after-care, only 50% continue their medication as prescribed, and no more than 25% are followed in regular after- care programs for more than one to two years.

What are the Needs oj Chronic Menlal Patients? 18.28

T h e needs of chronic mentally ill patients far exceed those of acutely ill patients. In addition to the generally available psychiatric services, they have greater need for %-hour, sevenday-a-

week crisis services; they are more likely to require programs emphasizing the skills of everyday living; and they need vigilant medical attention since they 2re more prone to medical illness and are less likely to seek medical attention. Housing is a more critical issue for this population; a spectrum of graded living alternatives is required, irom quarter-way houses to independent living arrangements. This spectrum is seldom available, and its ab- sence has resulted in inappropriate placement of many patients, particu- larly the elderly, in nursing homes. Chronically ill patients are more likely to lack financial support, and need employment opportunities (especially part- time jobs), vocational rehabilitation, and welfare. Those who cannot work full-time need help in developing meaningful daytime and evening activities. Social contacts and socialization are other critical needs, as are the kinds of counseling and caring that a case management or monitoring system can provide. In addition, there is an important need for counseling and supportive services to help family and friends cope with problems of chronic disability.

To be successful in providing programs for chronic patients in the community, all the above needs must be considered. There are serious current deficiencies in all of these areas: for example, in 1974, there were only 232 halfway houses in the entire United States, with provisions for only 9000 ex-patients, or one percent of schizophrenics residing in the community.

What Programs Work Best? 2 .7

Successful programs for chronic mental patients include hospital programs that prepare patients for discharge and


communtiy programs that provide supportive services. A prototype of the preparatory programs has been described by Paul and Lentz.17 It empha- sizes a social-learning approach that uses behavioral modification, training in the skills of everyday living, and social and vocational rehabilitation. Results of the intensive 4M-year program dem- onstrate that about ten percent of patients receiving this preparatory program were rehospitalized, compared to 30% of the control group receiving milieu therapy, and 50% of patients receiving traditional state hospital treatment.

A good example of a community program is that run by Fountain House in New York City. Fountain House combines several elements necessary to insure chronic patients’ survival in the community, including: inexpensive apartments, job training, job placement in low-stress employment situations, psychiatric coverage, and many social and recreational activities. The rate of rehospitalization of ex-patients in Foun- tain House’s programs is significantly lower than that of controls: 17% after six months (vs. 37% of controls), 38% after two years (vs. SO%), and 53% after five years (vs. 70%). Fountain House members also stay in the community twice as long as their matched controls.

A model program a; Mendota State Hospital spans both hospital prepara- tion and community supports.24 This program combines psphopharmacol- ogy, a high stafflpatient ratio, a wide variety of services, and training in everyday living. Outcome studies dem- onstrate that the patients treated in the experimental program spend less time in hospital and earn more money while in the community than the control pop

ulation, that the quality of life of the experimental program patients is no worse outside the hospital than in, and that the self-esteem of the two groups and the burden to their families is similar.

Several conclusions can be drawn irom an examination of successful programs for chronic patients. They offer a variety and continuum of services that maximize individualized care and provide for easy access, entry, and reentry to services as well as crisis responsive- ness. Succesful programs for chronic patients are led by knowledgeable people who are dedicated to chronic mental patients, and who can appreciate small progress in their patients. These programs usually employ aggressive outreach, and effective patient-monitoring and patient-advocacy systems. Adminis- tration is well-structured, both vertically to governmental agencies and hor- izontally to other agencies, and they have stable financial and community support. In addition, they have good systems for accountability and responsibility. Finally, and significantly, they manage to keep in view all those elements necessary for the treatment and care of chronic mental patients, including: symptomatic behavior, family and community involvement, social and in- terpersonal skills, and meaningful vocational rehabilitation.

Obstacles to Successful Treatment 125 16 One oE the most critical obstacles to

applying the lessons learned above in providing successful programs for the chronically mentally ill is attitudinal. Patients, families, community leaders, elected representatives, community members, and health professionals all have negative attitudes toward this pop-

JOHN A. TALBOTT 47

ulation. Chronic patients are seen as difficult to treat, uninteresting, frighten- ing, and bizarre; the poor past records of both institutional and community programs in coping with chronic patients intensify these attitudes.

There are also legal and ethical obstacles to the successful treatment of chronic patients. Recent legal trends supporting informed consent, compe- tency, and the right to refuse treatment, and the increasing assault on involuntary commitment, simultaneously protect the rights of the individual while erecting barriers to that individual’s rehabilitation. In somewhat the same way, the plethora of regulatory agencies, each with its own accreditation, monitoring, and paperwork, tends to foster ineffective treatment.

The administrative structure of mental health services also poses a serious obstacle to rehabilitation of the chronic patient. Responsibility for chronic patients is diffuse and divided among state, county or city, and voluntary agencies, as well as among agencies primarily concerned with medical care, social services, and supportive services (housing, income, etc.). Each agency has its own standards and qualifications for service, further compounding the problem of providing patients with what they need most. Administrative red tape prolifer- ates, especially with regard to evaluation for services, and partisan, jurisdic- tional, and professional politics hamper efforts to provide good treatment and care.

Funding poses monumental problems for the care of chronic patients. In addition to fragmentation of funding, and different eligibility rules in different governmental agencies, both governmental and private insurers have long

discriminated against the chronically mentally ill. Thus, Medicaid does not reimburse state or private mental hospitals, and private insurers set limits on both inpatient and outpatient care that preclude long-term care.

The lack of integrated community support and care programs represents another serious obstacle. We have multiple systems, with multiple funding sources, multiple levels of oversight and planning, as well as multiple levels of accountability. In addition, all levels of government contract for services by local entities and operate their own com- peting services. The net result of this conflict of interest is a predictable cut of services in community programs in periods of economic scarcity.

Yet another obstacle to successful programs is the lack of personnel trained in the rehabilitation-resocialization model. Although psychiatric and medical care are important to this population, attention to skills in everyday Iiving and vocational and social treatment needs of this population is equally important, and woefully lacking in the mental health system.

Economic Issues 11.23

Health accounts for nine percent of America’s gross national product (GNP), and 15% of that is allocated to mental health services. The direct costs of mental illness, that going to institutions and practitioners, were 14 billion dollars in 1974, or one percent of the GNP. Most (71%) of this sum went to such institutions as nursing homes @Ox), state and county hospitals (23%), and general hospitals (1 1 %), and only eight percent to private psychiatrists and five percent to free-standing outpatient clinics. Indirect costs of mental


illness, such as labor and production loss and public assistance to the mentally ill, account for an additional 20 billion dollars. The total for mental health, using 1974 figures, comes to at least 34 billion dollars, of which 87% can be attributed to the treatment and care of chronic patients.

It is not easy to determine whether it is less expensive to treat chronically ill patients in the hospital or in communities. Sharfstein,22 who followed a single patient for 15 years, found that for the first three years, the costs were equiva- lent, but subsequently community care was less costly. Weisbord, Test and Stein 29 demonstrated that community care was ten percent more expensive. T o state departments of mental hy- giene, however, costs appear to be lower in the community because inpatient costs include nonpsychiatric li fe-su p- port (food, shelter, and clothing) and general medical costs that are provided to outpatients by federally-funded Med- icaid and SSI as well as extended families or private organizations. It should be noted that, while direct treatment costs are greater in the community, every other cost (e.g., indirect treatment, law enforcement, maintenance, and family burden) is lower. In addition, patients in community-based programs have earnings double those of a control group, so the final tally demon- strates that community care costs $400 less than the benefits derived by patients in such settings.

In planning for a possible national health insurance scheme, i t will be necessary to differentiate between the direct services i t will reimburse (such as diagnostic and treatment services, home health, day care and outreach services, and the costs of medication, etc.) and

the supportive services (such as vocational, educational, housing, transpor- tation, homemaking, meals, chore services, protective services, and maintenance). Currently, in order to obtain supportive services, mental health professionals and chronic patients partici- pate in what may best be described as a “scrounging system,” wliich is margin- ally effective at best. Planning for any luture national health insurance must consider the special problems of reim- bursing both direct and supportive services for chronically ill patients.

Case Management 10, 1 5

As opposed to countries like the USSR, where there is a single service system, the United States has spawned a multitude of services, requiring coor- dinators to assist patients who are un- able to negotiate the various systems by themselves. Case management is one method by which patients can be helped to find their way among the multitude of services. The concept of some type of general practitioner has existed for years in medical practice. Only recently has it been recognized as a useful device in the general human services field. When families are available, they usually carry out the case management function, but even competent families are often limited in their capacity to deal with complex systcms. When competent families are not available, social workers have traditionally replaced them. Recently, the development of a new profession or paraprofession of case management has been advocated, which may, however, be redundant con- sidering the rich array of professionals and paraprofessionals now working in the field of mental health. Others have experimented with the me of the thera-

JOHN A. TALBOTT 49

peutic team, rather than any individual, as a case management system. In any case, i t seems obvious that for severely disabled, chronic patients, some form of case management is necessary, predicated on clear goals, an up-to-date treatment plan, and active participation of the patient.

Levels of Governmental Responsibility 8 , 1 4

In Colonial America, the chronic mentally ill simply wandered about. Later, by the mid-eighteenth century, they began to be kept in almshouses and poorhouses. Subsequently, around the middle of the nineteenth century, Doro- thea Dix’s efforts led to their care in mental hospitals administered by state governments. The federal government has also administered some services to some chronic patients, either through direct provision of care as in VA and Armed Forces hospitals and community mental health renters or through funding (Medicare, Medicaid, and SSI). Through the years, responsibility for the chronically ill has remained divided and poorly defined with respect to co- ordination, continuity, implementation, monitoring, and evaluation of care. There is no system of care; instead there is a nonsystem that cries out for the tletignation of a single point of responsibility and authority for the chronic mental patient. Administrative structure must be reorgani~ed and clarified, both vertically with respect to federal, state, and local agencies, and hori~on- tally with respect to interagency referral, rase management, and budgetary considerations. Intergovernmental con- flirt of interest, in both directly providing and coordinating or contracting service$, must end. Finally, social services

must become part of the formal structure of local mental health administrative agencies,

Patients Rights 6

Chronic mental patients are discriminated against considerably more than other disadvantaged groups, such as the mentally retarded, welfare recipients, or prisoners. Even acutely ill mental patients are subject to less bias by Medic- aid and other funding sources, in housing, etc. T h e same insurance reimburse- ment, housing opportunities, health rare, and right to treatment should ap- ply to chronic patients in the community as it does to acute patients or to chronic patients in mental institutions. Commitment to hospitals must involve due process and legal ombudspersons. While the individual patient’s confidentiality should be respected, the patient’s right to assume that adequate information will be exchanged to ensure continuity of care is also vital. Institutional peonage as well as discrimination against chronic mental patienis in employment should cease.

A PUBLIC POLICY ON THE CHRONIC MENTAL PATIENT

To fulfill the needs of the chronic mental patient, this nation must adopt a public policy that specifically and ade- quately cares for these patients. This policy must include: I j public sensitiv- ity and financial commitment to a system of graded and comprehensive o p portunities and services; 2 ) designation of clear responsibility for providing services at appropriate levels of government; 3) full civil rights for the mentally ill; 4 ) a reform of funding mechanisms; and 5 ) adaptation in the delivery of services to meet the cultural values

THE CHRONIC PATIENT

and perceptions or needs of various eth- nic, minority, and subcultural groups. Specific recommendations can be made in several broad areas to accomplish these critically important goals.

Psychiatry’s Role Since care of the chronic mentally ill

patient is a public health responsibility, it is incumbent upon psychiatrists and other physicians to join other mental health specialists in actively attending to the needs of this population. Al- though psychosocial problems are more obvious, the medical and psychiatric needs of the chronic patient also require vigilant monitoring. In addition, psychiatrists have an important role in the development of comprehensive services for the chronically mentally ill, and should be involved at all levels in program planning, public education, training, and research related to pre- ventive care and rehabilitation services.

Community Education An intensive effort should be under-

taken to inform the public of the needs of the chronic mental patient and how to meet them. Community education must be oriented toward increasing the visibility and status of programs di- rected to chronic mental patients. A major effort should be undertaken to develop a constituency for the chronically ill mental patient.

Research There must be a greater emphasis on

research in chronic mental illness, including: epidemiology, etiology, thera- peutic methods and outcome, and service delivery. New research should be undertaken in family care, in the com- parison of institutionalized and deinsti-

tutionalized populations, in criteria for deinstitutionalization, in the definiton of the skills, process, and tasks of case management, and in issues relating to confidentiality.

Training An expansion of training programs in

skills appropriate to the needs of chronic mental patients is imperative. These programs should emphasize the community rehabilitation model and interdisciplinary efforts should include strength-assessment and skills of everyday living. Leadership in geriatrics and work in nursing homes should be in- cluded. Funding should also be provided for retraining institutional staffs for communtiy care. Residency training programs in psychiatry should include the care of chronic patients. A program for volunteer case aides should be estab- li s hed .

Provision of Seruices The barriers that currently limit the

access of chronic mental patients to the full range of medical, psychiatric, reha- bilitative, income maintenance, social, employment, and related opportunities in the least restrictive setting should be removed. All systems of care should be continuous between institutions and local programs; well developed systems of inservice program referral should be es- tablished; and a system of case management based on a comprehensive treatment plan should be developed.

Financial Issues As a long-term goal, programmatic

funds should flow froin the federal to the state level and should be earmarked for the chronic mental patient where possible. On the federal, state, and local

JOHN A. TALBOTT 51

levels, structures should be created to provide oversight of legislation and regulations that have an impact on chronic mental patients. HEW should perform a national survey of Medicaid and Med- icare in order to determine current in- equities and help establish national parity. Medicaid, Medicare, and future national health insurance should not discriminate against the chronically mentally ill as a class in any way, and such insurance should include a full range of inpatient, day treatment, and outpatient services encompassing peri- odic medical and psychological evaluation and treatment, resocialization, and rehabilitation. Any such insurance should include cost-effective financial incentives to encourage professionals to care for the chronic mental patient in the least restrictive setting that fosters full rehabilitation. Fiscal incentives to unnecessarily restrictive settings such as nursing homes and mental hospitals should be eliminated. All community mental health centers should provide comprehensive services to this population, and a federal technical assistance program should be developed to help localities develop programs for chronic patients. Funding mechanisms should not penalize states or localities for mov- ing individuals out of the service system, and priority should be given to proposed systems that insure that money follows the chronic mentally ill patient.

Administrative Issues

As a long-term goal, the federal government should establish national policy, should set standards, and should take responsibility for leadership and advocacy of care of the chronically ill mental patient; state governments should carry out leadership and plan-

ning functions, should distribute federal monies, and should designate local authorities to have programmatic responsibility; and local authorities should designate specific local entities to perform program activities and to provide a holistic, integrated program for chronic mental patients. There also should be a federal oversight mecha- nism such as the Select Committee on Aging, to oversee federal legislation and regulations regarding the chronic mental patient. Each state should have an office to plan and support services for chronic patients. The local health planning body should carry out clinical in- tegration independent of any care delivery system of its own that might rep- resent a competitive interest. Account- ability and evaluation of services must be assured. Existing resources should be used, with special concern for patients’ families, instead of building a whole new network of services and programs for chronic patients. States should be discouraged from developing new state- owned and operated facilities for chronic patients and should be encour- aged to phase out unneeded existing facilities. Finally, the federal government should eliminate state or regional op- tions in the use of essential federal funds.

Civil Rights There should be federal legislation

or regulations to: I ) prohibit discrimination against chronic mental patients in employment and housing; 2) endorse the right to adequate treatment for both voluntary and involuntary patients in the least restrictive setting; 3) protect confidentiality while allowing access to relevant information for legiti- mate treatment, planning, and re-

THE CHRONIC PATIENT

search; 4 ) develop and fund an advocacy system independent of service provision to insure implementation of patients’ rights; and 5 ) prohibit zoning discrimination against the mentally ill. A bill of rights for mentally disabled patients living in the community should be enacted.

SUMMARY

There is no more urgent mental health concern than the needs of chronically ill mental patients who suffer from severe persistent or recurrent mental illness with residual social and vocational disabilities. The deinstitutionalization programs of the past decade and the continuing prevalence of high-risk populations that generate chronic mental patients have created problems asso- ciated with the care of these patients which constitute a national crisis.

This paper has outlined the most sig- nificant problems of chronically ill mental patients. It has addressed the questions of: who and where they are; their needs: the types of programs that are successful for them; the obstacles to successful programs; the economic issues affecting chronic patients; the kind of case management needed; the levels of government that should be responsi- ble for specific functions: and the rights of chronic patients.

Based upon the work of the Ameri- can Psychiatric Association’s Ad Hoc Committee on the Chronic Mental Pa- tient, recommendations have been made in regard to the development of a public policy for chronically ill mental patients. These rerommendations have dealt specifically with: psychiatry’s role, community education, research, training, continuity and provision of

services, financial issues, administrative matters, and civil rights. We call on all professional and governmental bodies concerned with issues affecting the chronic mental patient to accord this problem the highest priority and to take definitive action to meet this national crisis.

REFERENCES

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5

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& C A P . 1978. The Chronic hvlental Patient in the Community. Group for the Advance- ment o f Psychiatry, New York. CLASSCOTE, R. 1978. What programs work and what programs don’t work to meet the needs of chronic mental patients. In T h e Chronic hlental Patient: Problems, Solu- tions and Recommendations for a Public Policy, J. Talbott, ed. American Psychiatric Association, \Vashington, D.C. GLENN, T. 1978. Exploring responsibility for chronic mental patients in the community. 1?1 The Chronic Mental Patient: Problems, Solutions and Recommendations for a Pub- lic Policy. J. Talbott, ed. American Psychi- atric Association, Washington, D.C. LAMB, 1 1 . ET AL. 1976. Community Survival for LongTerm Patients. Jossey-Bass, San Francisco. LOIIRIE, N. 1978. Case management. In T h e Chronic Mental Patient: Problems, Solu- tions and Recommendations for a Public

JOHN A. TALBOTT 53

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1 I . h i m N I N c E R , w. 1978. Economic issues in providing effective care for the chronic mental patient. In The Chronic Mental Patient: Problems, Solutions and Recommendations for a Public Policy, J. Talbott, ed. Ameri- can Psychiatric Association, Washington, D.C.

12. MEYERSON, A. 1978. IVhat are the barriers or obstacles to treatment and care of the chronically disabled menially ill. In The Chronic hIental Patient: Problems, Solu- tions and Recornmendations for a Public Policy, J. Talbott, ed. American Psychiatric Association, lvashington, D.C.

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I ~ . O Z A R I N , L. 1978. The pros and cons of case management. I n The Chronic Mental Pa- ticnt: I’rol)lcms, Solutions antl Rccommeii- tlations for a Public Policy, J. Talbott, ed. American Psychiatric Association, Washing ton, D.C.

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1 8 . 1 ’ r T F ~ ~ o N . R. 1978. What are the needs of chronic mental patients? In T h e Chronic Alcntal Paticnt: Prol)lems, Solutions antl Recornmendations for a Public Policy, J.

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~ ~ . S C H U M A C H . hi . 1974. New York Times Jan.- April, 1974.

22. SHARFSTEIN, s. AND NAFZICER, J. 1976. Com- munity care: costs and benefits for a chronic patient. Hosp. Comm. Pqchiat. 27(3).

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STEIN, L. AND TEST, M. 1Y77. Use of special living arrangements: a model for decision- making. Hosp. Comm. Psychiat. 28:608410.

25. TALBOTT, J.. ed. 1978. The Chronic Mental Patient: Problems, Solutions and Recom- mendations for a Public Policy. American Psychiatric Association, Washington, D.C. (Chapter 16)

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29. WEISBORD, B. , TEST, M. AND STEIN, L. 1976. An

For reprints: Dr. John A. Talbott. PWC 163, 525 East 68th St., New York, N.Y. 10021

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TOWARD A PUBLIC POLICY ON THE CHRONIC MENTALLY ILL PATIENT