In November 1999 the Virginia Commission on Community Services and Inpatient Care proposed a plan to restructure the state's mental health system, which included recommendations to close Eastern State Hospital (ESH), the oldest state psychiatric institution in the nation, and divert some of the patients currently living there to community-based care. However, an uncertainty remains as to whether the patients released from ESH will be discharged into local communities that can adequately care for them.

This study focuses on the effects that de-institutionalization could have upon the mentally ill at Eastern State Hospital through an analyses of literature from academic journals, interviews with mental health experts, patients currently residing at ESH, and survey responses from the residents of the Greater Williamsburg area. The study concludes that (1) Eastern State Hospital is the best provider of mental health care for the long term mentally ill, (2) the short term mentally ill could be adequately treated in community facilities, and (3) education of the public about ESH's services must be improved.

Introduction

Background on Eastern State Hospital

Eastern State Hospital was founded in 1773 and originally included 3,000 acres. Throughout its 228-year history, the Commonwealth of Virginia has slowly downsized ESH. As James City County grew, a portion of Eastern State was sold to developers to build Ford's Colony, a residential community. The state used some land to build the Dillard Complex of the College of William and Mary, and another portion was sold to James City County for the James City County Recreational Center and a water tank.

Currently, the hospital sits on 573 acres, parts of which border the College of William and Mary. The Hospital grounds include 29 buildings, 9 of which are occupied. Eight of these buildings are used for patient treatment and one building is used for administration (see Map 1). There are two buildings currently scheduled for demolition, five buildings declared surplus, and four buildings scheduled for demolition pending the availability of capital outlay (Kellogg 1999).

Eastern State Hospital is one of 15 Department of Mental Health Mental Retardation and Substance Abuse Services (DMHMRSAS) operated facilities. Concurrent with the nationwide trend of de-institutionalization, admissions at Virginia's state mental health facilities have decreased. In the past 15 years, there has been a 62.7% reduction in state psychiatric admissions across Virginia (see Table 1) from 9,880 in 1984 to 3,685 in 2000 (Kellogg 1999). Eastern State, for example, experienced a drop in admissions between calendar year 1999 and 2000 of 38% (Kline 2000).

Table 1: Admissions to Virginia 's State Psychiatric Facilities, 1984-2000
SOURCE: Kellogg, Richard. Commissioner, Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services. "Development of a Commonwealth Trust Fund and the Restructuring of ESH. " Presentation to the Governor's Commission on Community Services and Inpatient Care, 6-9, November 30, 1999.

The Implementation of De-Institutionalization

The model of de-institutionalization -- the moving of patients from large mental health facilities into the community for services -- is based upon two premises- (1) treatment in the community enhances the quality of life of the individual- and (2) the shift of care from state institutions to the community conserves limited public funds and resources (Geller 2000). The de-institutionalization of America's state mental hospitals began in the 1960s due to a confluence of factors: the belief that treatment closer to relatives and community jobs was better than isolated, segregated treatment; the overwhelming number of resource poor state hospitals at the end of World War II; the first psychopharmacological revolution with chlorpromazine as the first drug to combat schizophrenia; and, above all, the ability of the states to shift costs to the federal government through Medicare, Medicaid, federal grants, and Supplemental Security Income (Geller 2000). In the 1960s, outpatient services expanded rapidly into the community as federal legislation authorized grants to fund community mental health centers. Thus, between 1954 and 1996, de-institutionalization resulted in decreasing the national state mental hospital census by an astonishing 89% (Geller 2000). Nationally, this decline in state hospital admissions has coincided with the rising cost of maintaining a state facility. In 1984, for example, the cost to run a state psychiatric facility with an average daily census of 3576 was $108,647,490 compared to the cost of $257,679,445 to run a state psychiatric facility in 2000 with an average daily census of 1819 (Kellogg 1999).  

Methodology

This study focuses on the effects that de-institutionalization could have upon the long- and short- term mentally ill at Eastern State Hospital (ESH), the oldest state mental hospital in the nation. The background information about mental health and de-institutionalization was derived from a literature review in the fields of psychiatry, psychology, and community health. In addition to news articles, articles were obtained from academic journals, consultants' reports, and documents from the Commonwealth of Virginia. Two primary sources were used to evaluate the impact of the downsizing of ESH on the patient population- a public opinion survey and interviews.

Public Opinion Survey

To determine the needs and preferences of the residents of the City of Williamsburg and James City County, this study used two specific questions on a public opinion mail survey, developed by Marrin, Hayford, and Sollenberger (2000) and sent to 2,200 randomly chosen residents of the Greater Williamsburg area. Question number four asks the respondents to rate their level of familiarity with the services at ESH, with 1 indicating no familiarity and 5 representing great familiarity. Question number five asks the citizens whether or not they support the closure of all or parts of Eastern State Hospital. The response rate for the survey was 33.8%.

Interviews

The individuals interviewed included Community Service Board (CSB) employees, ESH staff, College of William and Mary Department of Psychology faculty, other professionals in the field of mental health, elected officials, members of the Williamsburg Crossroads Steering Committee, and patients at ESH. In order to interview the current patients at ESH, it was necessary to complete a Research Proposal Application for the ESH Agency Research Committee which required a description of the interview process, paperwork for the Virginia Department of Mental Health Mental Retardation and Substance Abuse Services (DMHMRSAS), a consent form, a literature review, as well as a list of questions for the patients. After the families gave their written consent, the study's author and Dr. Sarah W. Bisconer, ESH's Chairperson of the Agency Research Committee at ESH, met with six patients on July 14, 2000.

De-Institutionalization at Eastern State Hospital

Proposal to Restructure

In November 1999, the Governor's Commission on Community Services and Inpatient Care announced its intentions to restructure ESH in order to more efficiently distribute mental health services across the Commonwealth. The Commission offered this suggestion not only as a result of the nationwide trend of de-institutionalization, but also because ESH was utilizing only the eastern and northeastern portions of the property, leaving the vast majority of valuable land undeveloped (see Map 1). The Commission felt that the restructuring of ESH would be based "on best practice, quality, and protected services, and decentralized delivery" (Kellogg 1999). The Commission set goals for the future of mental health in the Commonwealth as expanding the necessary community service options,, assuring better outcomes and quality of life for the consumers, and focusing on the facility provision of long-term, extended services, and specialized care (Kellogg 2000). To achieve that end, the Commission recommended a shift in the locus of care from ESH to the community facilities, affecting the 90 beds in acute care, the 231 long-term beds, and the 260 beds in the Hancock Geriatric Treatment Center. Table 2 describes the Commission's recommendations concerning the three distinct populations currently residing at ESH. The most drastic change would be involved in the transferal of the acute care beds from ESH to the community based facilities, whereas the Commission recommended the maintenance of around 200 long term beds at the state level. Finally, the Commission offered to maintain the Hancock Geriatric Treatment Center and transform it into a locus of specialized mental health services for the elderly.

Table 2: Services Currently Provided at Eastern State Hospital and Recommendations for The Future
SOURCE: Kellogg, Richard. Commissioner, Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services. "Development of a Commonwealth Trust Fund and the Restructuring of ESH. " Presentation to the Governor 's Commission on Community Services and Inpatient Care, 6-9, November 30, 1999.

Through interviews with the patients currently residing at ESH, it appears that patients would find de-institutionalization and their relocation into community facilities traumatic. According to Dr. Sarah W. Bisconer, Senior Psychologist at ESH, a key component of mental health therapy for the long-term mentally ill is repetition of activities and schedules, and an interruption, such as this relocation, would stall or, perhaps even prevent progress (Bisconer 2000). One of the patients emphasized, "I need the schedule. Breaking a schedule messes up my entire day." Many patients who had already experienced treatment in community facilities described feeling like "specimens" and one patient added, "It is disorienting to go from one place to another."

The lack of structure in the community is not the only reason why the de-institutionalization of ESH is not beneficial to the long-term mentally ill patients currently residing there. The 573-acre campus itself provides therapy, which would be lost if the facility were to close. One patient offered, "I am a big believer in the use of nature... peace and quiet is therapeutic. A high rise facility would not work. ESH gives patients the freedom they need in a therapeutic, natural environment." De-institutionalization would deprive these patients the peace that has contributed to their treatment.

In addition, many patients feared treatment in the community because of the stigma they felt in that environment. Those who had already received services in the community felt that their overall quality of life was lowered in the community as a result of the frustration with the mental health services provided, the dissatisfaction with social supports, and the feeling of alienation.

De-institutionalization of ESH patients would also have serious effects upon the Greater Williamsburg community. As they currently exist, community facilities do not have sufficient staff or funding to adequately treat the relocated patients. Patty Gilbertson, Director of the Hampton CSB stated that, "Community programs are more complex to manage than the programs at ESH and the money [from the state] does not often move into the community" (Gilbertson 2000). The cost in terms of people and dollars to maintain the long-term mentally ill in the community is much greater than the combined cost of a hospital staff in an institution (Martin 1995).

Finally, the public opinion survey of the Greater Williamsburg area shows that the plurality of residents surveyed do no support the closing of ESH (see Table 3). Of the 400 respondents, 39% oppose closing all or parts of ESH. Citizens also recognize ESH's importance as a major employer in the region as well as a crucial provider of mental health service. Given the 1,120 individuals employed at ESH, any shift in care from the state hospital will pose serious concerns for the distribution of employment in the Tidewater region.

Table 3: Results of Public Opinion Survey: Closure of ESH
SOURCE: Public opinion survey of the residents of the Greater Williamsburg area conducted by Tamara Hayford, Barbara Marrin, and Kimberli Sollenberger July 2000.

Question 4 from the survey asked respondents to rank on a scale of 1 to 5 with 1 being not at all familiar and 5 being very familiar, how familiar they are with the services provided at ESH. As seen in Table 4, the plurality of the citizens of Williamsburg and James City County are not that familiar with the services provided at ESH; about 80% of the respondents indicated a low to moderate level of familiarity with the services provided whereas only 20% of the respondents indicated a rating of 4-5, a high level of familiarity with the services.

Table 4: Results of Public Opinion Survey: Familiarity with ESH
SOURCE: Public opinion survey of the Greater Williamsburg areaconducted by Tamara Hayford, Barbara Marrin, and Kimberli Sollenberger July 2000.

Thus, any policy recommendation related to the closure of Eastern State Hospital must address (1) the need for a strong infrastructure for the patients relocated to the community; (2) the maintenance of ESH as a provider of mental health care for the long-term mentally ill, and (3) lost jobs.

Best Practices

The most significant problem with the current policy of de-institutionalizing Eastern State patients is the lack of structure for the relocated patients in the community. Several models of de-institutionalization have successfully provided community services to rehabilitate and resettle patients, and certain aspects of these programs can be applied to ESH.

Baker Act

In the United States, the Baker Act in Florida shifted short-term psychiatric care into the community while promoting the need for state institutions for the long-term mentally ill (Archer 2000). Under this Act, voluntary and involuntary admissions to local hospitals were transferred to a state facility after 7-10 days, allowing the community hospitals to more effectively treat the short-term patients (Archer 2000). Similarly, Health Planning Region V (HPR V) in Richmond, Virginia, experimented with diverting its short-term patient population entirely into the community while maintaining the state hospital for the long-term mentally ill (Hubbard 2000).

HPR V

On a one-year grant from the Commonwealth of Virginia, HPR V launched this experimental program with the goal of improving the level of care at both the community and institutional level. The program was a success as it transferred the beds from the state institutions designated for short-term care directly into the community facilities and the dollars previously allocated to the institution followed the beds into the community (Hubbard 2000). This program gave the community facilities the resources to care for the short-term mentally ill while at the same time maintaining the state institution for the long-term mentally ill. Due to the success of the one-year program, HPR V intends to continue this policy permanently and completely phase out its short-term care at the institutional level (Hubbard 2000).

Recommendations

Based on the successes of these programs, a literature review, and interviews with professionals in the field of mental health as well as mental health patients, the following policy changes should be implemented during any restructuring of ESH :

1. Transfer short-term care into the community: Following the successful models of HPR V, short-term mentally ill patients should be treated immediately at the community level. Beds in ESH, which had been previously designated for short-term care should be relocated into community facilities and the dollars should follow the beds into the community. If after 7-10 days a patient's condition has not improved, then the patient should be transferred directly to ESH, similar to the situation in Florida (the Baker Act).

2. Maintenance of ESH for the long-term mentally ill: For those individuals who suffer from a long-term mental illness, there is no substitute for the care and treatment provided at ESH. The long-term mentally ill need the structure and the care that a state institution provides and any relocation into community facilities could be detrimental to their social and mental health.

3. Education of the public: As the public opinion survey of the Greater Williamsburg area illustrated, the plurality of the citizenry is unclear about the types of services that ESH provides. In order to promote awareness not only concerning ESH treatments but also mental health in general, ESH can develop and distribute educational materials in the community and perhaps organize educational programs for the citizens of the Greater Williamsburg area.

Conclusion

The goal of this study was to determine what, if any, impact there would be on the patient population if ESH were to close. This determination is based upon literature from academic journals, interviews with experts in the field of mental health, random sample survey responses from residents in the Greater Williamsburg community, and interviews with the patients themselves. This research indicates that community life for mentally ill individuals is only beneficial if it provides the same level of care and structure that the patients would receive in an institution. Unfortunately, most communities do not have this infrastructure already in place.

Institutional living provides mentally ill individuals with a sense of dignity and belonging, whereas communities are often hostile to mentally ill individuals. In a state institution, the patients and their individual needs are the highest priority. Community-based care tends to homogenize the patients' problems and needs simply as a result of the overwhelming case load of consumers. The long-term mentally ill residing at ESH need the structure and the treatment that ESH provides and a shift to the community would possibly impair their mental and social health, while short-term patients could be effectively relocated to the community if the beds and funds are provided by the state. Finally,, the complete closure of ESH is not in the best interest of the patients, and the plurality of the Greater Williamsburg community opposes it.

Acknowledgements

The author wishes to express her gratitude to the National Conference on Undergraduate Research and the Lancy Foundation for the scholarship opportunity to conduct this research. In addition, Dr. David Finifter (Director, Center for Public Policy Research, and Professor of Economics, College of William and Mary) and Ms. Kelly Metcalf-Meese (Associate Director, Center for Public Policy Research, College of William and Mary) provided invaluable support in the development of the research questions, the implementation of the project, and the editorial corrections. Furthermore, Dr. Sarah Bisconer (Senior Psychologist, Eastern State Hospital) dedicated her time to the consolidation of my research proposal and questions to the ESH patients. Finally, my student colleagues - Tamara Hayford, Barbara Marrin, Ryan Schuchardt, and Kimberli Sollenberger - provided an endless source of enthusiasm and encouragement throughout the study.