When the Village Integrated Services Agency was established by the California Legislature one of the primary flaws of the mental health system they were attempting to address was fragmentation of services, both within the mental health system and between social service systems. We implemented a system of "one stop shopping" where every service from benefits assistance to psychiatric hospitalization would be available. Putting together in one place a psychiatrist, nurse, social worker, substance abuse counselor, job developer, activities coordinator, outreach worker, money manager, etc., while being a huge improvement over going to multiple separate agencies does not insure integrated services. It usually creates a "multidisciplinary team" of people doing separate assessments, pursuing separate goals, using separate languages and techniques, and reporting to separate supervisors, battling over which "part of the elephant" is most important. What's truly needed for integrated services are shared assessments, goals, languages, techniques, and supervisors that encompass the whole person.

Attempts to define the goals of mental health services are deceptively difficult. It is heavily influenced by social context, personal needs and preferences, staff training and inclinations, legal constraints, and funding availability. As a result it changes over time and needs continuous reevaluating. Clear goals, however, are essential to guide system and program design, staff training and actions, and resource allocation.

Historically, in the mid-1800's American psychiatry was described as moral treatment. The goal was to treat people humanely, to shelter them and help them recover their moral balance so that God's work could be done, and they could be healed from their inflictions. This was a socially relevant view with clear treatment implications and strikingly good outcomes.

As society changed, it moved from a supremacy of religious values to Victorian social values, where maintaining social integrity and appearances was more important. The legal change that abolished debtor pressure contributed a population of socially undesirables with no where to go, many of whom were mentally ill. The goal of mental health service was to commit people as inmates to Institutions of Public Mental Hygiene to preserve society. The treatment was primarily custodial and very socially useful.

During this century we became increasing humanistically oriented in everything from child labor laws to social security. Mental health changed it's goals from incarceration, since these people weren't really criminals, to treatment. We applied a variety of psychiatric technologies to both custodial and rehabilitative care in reformed asylums. We took care of unfortunate, incapacitated, ill people in hospitals for their benefit.

The 1960's provided the next great social upheaval with numerous elements including a new civil rights emphasis. Legally, California led the way with LPS law, the most progressive mental health law in the country. CMHC's had been federally established everywhere, and in many of them experiments as to what our new goals should be occurred. Ultimately, however, we reverted to our hospital/medical goals and techniques. We continued hospital style assessments, charts, multidisciplinary teams, problem lists and treatments. The "new" modalities were variants of hospital treatments: partial hospitalization, day hospitals, halfway houses, aftercare, alternatives to hospitalization, follow-up clinics, emergency rooms, etc. The entire change was even named deinstitutionatization. We made an effort to move all the goals and techniques of the hospital to the community, accepting them as valid in a radically changed social and legal context. We never deinstitutionalized our own minds.

What are mental health goals that actually match today's social and legal reality? LPS law is notoriously unsuited for any of the previous goals: Even considering redefinitions like spirituality, or individual self-actualization, or R.D. Laing's promoting journeys of self expression, this law is unsuited to promote moral goals. It doesn't address either "moral degeneracy" or "overly sensitive souls". Police, businessmen, landlords, neighbors, or even fed-up families and friends have found LPS unsuited to getting people off the streets, or taking them away and locking them up. Dangerous to others is hardly a synonym for socially disruptive. Similarly mental health professionals can find no mention of need for treatment, or probable benefit from treatment, or deterioration without it in LPS law. We're also frustrated if we try to force people to get treatment we think they need. So what goal is LPS suitable for? I would assert that it is suited to the peculiarly civil rights goal of community integration.

1% of all people have a serious mental illness. Many are substantially disabled and need assistance. Many are substantially disruptive and destructive, as well. And we have to live with almost all of them ( We also have to live with almost all criminals, drug addicts, immigrants, other races, women, and poor people as well, but those are the subjects of other papers). Even though we don't want to, or think we should have to, we do have to live with them. Community integration is the process of accommodation, assistance, rehabilitation, advocacy, relationship building and ultimately lots of negotiating to be able to live together. Within this context LPS is clear. We must negotiate with people with serious mental illness to try to get along. We can only become coercive, temporarily, if they're dangerous to self or others, or gravely disabled. Otherwise we have to work it out. These LPS criteria are in fact, definitions of failures of community integration. People can be forcibly removed from our community until they can be reintegrated.

Within this context there are four common failures of community integration: jail incarceration, homelessness, suicide, and psychiatric hospitalization. Hospitalization is no longer the comprehensive, but unaffordable treatment to take care of people most intensively that is emulated everywhere. It is a result of a failure of community integration and all of its resources and efforts should be aimed at assessing the reason for that failure and trying to fix them, whether they are clinical reasons or not. The question becomes not how to bring psychiatric treatment to various underserved people and settings, but how psychiatric treatment can assist in the goal of community integration. The community mental health system does not exist as a tool of deinstitutionalization. The hospitals exist as a tool to reconnect failures of community integration.

The primary goal of mental health services should no longer be moral treatment, social hygiene, or even psychiatric treatment. It should be community integration. Our goal should be to help people with serious mental illnesses live as productively, non- disruptively and with as high a quality of life as possible within our community. That is not to say that community integration is the best goal for every society, but it is the best goal within our unique social and legal context, until it changes again. Since everyone at the Village could agree on this goal, new staffing patterns, staff training, treatment techniques, evaluation, languages and funding priorities emerged.

Research has been generated from jailed, homeless, and hospitalized, seriously mental ill that describes what services are most important to avoid these failures of community integration. They are: (1) stable personal funding, (2) stable housing, (3) accessible psychiatric medication, (4) substance abuse services and (5) someone to call in a crisis who knows the person and can help, (" a negotiator"). These can be further strengthened by: (1) Increasing social networks, (2) going to school or getting a job and forming a work identity (3) improving medical care (4) improving communication with the legal system (5) improving or reestablishing family relationships and networks, and (6) improving emotional, social and spiritual awareness and functioning. This list is not a rigid prescription, but rather a menu of services to be individualized depending on the person's need and wants.

This list of services, which we created successfully, is striking different from the list you get if you are pursuing the goal of psychiatric treatment instead of community integration. Regardless of level of funding available, different services emerge. Some services that we consider essential like benefit assistance and SSI payee program rarely exist in CMHC's. Conversely some services like group therapy or an extensive clinical assessment form that are consider essential in CMHC's rarely exist in our program. Many of our services have been adapted from other settings where clinical services failed and innovative alternatives were created ( for example self-help programs, client-run clubhouses, homeless services, substance abuse services, and psychiatric rehabilitation services). Knowledge from all these areas, and also certainly from clinical treatments, can be adapted to, and focused on the goal of community integration. A new challenge is to move beyond successfully adapting and integrating techniques available from elsewhere, to try to discover and develop additional uniquely community integration techniques. When we are focused by the truly pragmatic and comprehensive goal of community integration, integration of services will result.