My own experience relevant to these enormous challenges involved the almost 15 years during which I served as chief medical
officer for the New York State Office of Mental Health (OMH). When I assumed this role, in 1988, there were almost 25,000
psychiatric state hospital beds operated by OMH, and when I left New York in 2002, there were about 4,500 (and there are even
fewer now). This massive transformation of the public mental health system in New York might be viewed as "planned deinstitutionalization,"
shifting from hospital-based care to community-based care, consistent with a rehabilitation and recovery-oriented treatment
philosophy. The success of this restructuringâand in many ways it was successfulâreflected a wise action by the New York legislature
to override a gubernatorial veto, to pass "reinvestment legislation," so that every dollar saved by closing a state hospital
bed was required, by law, to be reinvested into community-based alternative programs, such as community mental health centers,
ACT teams, supported housing, mobile outreach, and other components of treatment. Even so, New York was not immune to the
rough waters that almost inevitably accompany such extensive change, including transinstitutionalization into nursing homes
and into the correctional system, overloading of emergency rooms, and additions to the ranks of the psychiatrically disabled
homeless. I would often muse about our conceptual framework, the "biopsychosocial" model of care, worrying that a "one-size-fits-all"
attitude could be risky, particularly when it came to the "social" part of the model. For example, some communities in which
to locate care for very needy patients are much better than othersâsome provide strong support, while others may have high
levels of poverty and crime, making them far less safe and supportive than at least the better-run state hospitals of the