Introduction

The treatment of the severe mental illnesses has seen revolutionary transformations over the past 40 years. At first, care was largely custodial; then, hope was infused by the enthusiastic application of psychoanalytic insights. With the discovery of chlorpromazine, psychiatrists predicted the huge state hospital stone cottages would close forever. Community programs heralded further deinstitution-alization. With time, each area of specialization has developed dramatically. Psychodynamic understandings have evolved substantially. New and more effective chemotherapeutic agents continue to appear. Understanding of brain physiology increases in sophistication. Community-based treatment centers have grown. While there has been much strife and rivalry between specialists in these modalities, as we move toward the millennium, and the areas of overlap between these subspecialties grow, we are recognizing that each group must master the new knowledge gained in the other arenas.

But we are hardly progressing toward an era of improved care for the severely emotionally ill. Clearly, no one has yet discovered a cure for the schizophrenias; medications produce their own problems, such as heightened negative symptoms and neurological difficulties such as tardive dyskinesia and malignant neuroleptic syndrome. The “standards” of psychiatric care increasingly are dictated by insurance companies and other agencies whose fundamental objective is profit. Institutions that attempt to care for the very ill are pressured to aim for rapid removal of symptoms rather than resolution of the underlying difficulties. “Meeting the standards of care in the community” has come to have the darker meaning of capitulating to the standardization imposed on individuals and even individual institutions.

If one judges a society by the care it provides its most vulnerable, ours does not earn high marks. The homeless mentally ill, the severely ill who are admitted to our community and teaching hospitals only