The role of the state hospital: a new mandate for a new era

We are fast approaching a centennial of New York State's institutional system, the anniversary of the State Care Act of 1980. This can be evaluated against another important anniversary; the quarter century mark of the current convulsion/revolution of the mental hygiene care system of the entire United States, commonly referred to as deinstitutionalization. The state institutions, which for the past century were built up and maintained as the major locus of care for the chronically mentally ill, no longer occupy that central place in many localities. Yet these hospitals must continue to struggle with overwhelming burdens. Their inpatient populations, although now much smaller, still include many seriously mentally ill patients as well as the essentially non-dischargeable elderly. In addition, they must provide for young adults with a new profile of difficult behavior and challenging demands. This article is an attempt to redefine the role of the state institution in what has become the new era of community care, and to suggest fruitful new directions for the future which incorporate a contemporary shift in focus: from the concept of illness to that of disability, and from a reliance on a facility or specific program to the development of a comprehensive and integrated system of treatment and support services.