A chronicle of change: A case study of the Connecticut mental health system

Administration and Policy in Mental Health Vol. 17, No. 3, Spring 1990

A CHRONICLE OF CHANGE: A CASE STUDY OF THE CONNECTICUT MENTAL HEALTH SYSTEM

Jessica Wolf, Ph.D.

ABSTRACT: This article examines major changes in ideology, administrative structure, and leadership in mental health services in Connecticut from 1963-1987. Connecticut is used as a case study to present a historical account of the struggle to establish a more balanced, comprehensive, responsive, and effective public service system for the treatment of serious mental illness. Formal and informal decision-making, power relations, leadership, and the interplay of intra-system and extra-system forces in influencing policy outcomes are also considered.

INTRODUCTION

Deins t i tu t iona l iza t ion in the m en t a l heal th sector has been controvers ia l f rom its outset . P r o p o n e n t s and opponen t s have clashed over clinical choices,

fiscal exigencies, cyclical adherence to d iamet r ica l ly opposed service para-

d igms, perce ived consequences , and d ivergen t t r e a t m e n t models (Bachrach, 1979; Minkoff , 1987; Ta lbo t t , 1986; Gra ln ick , 1986). As knowledge abou t the

biopsychosocia l c o m p o n e n t s of men ta l illness has increased and new models of

care have been successfully tested, the advan tages of comprehens ive c o m m u -

ni ty services and the role of hospi ta l iza t ion in a ba lanced service sys tem have

b e c o m e m o r e fully recognized.

Po l icy-makers , prac t i t ioners , and scholars share an interest in unde r s t and - ing how policy changes such as deins t i tu t ional iza t ion are conceived and

b r o u g h t to frui t ion. T h e d e v e l o p m e n t and i m p l e m e n t a t i o n of new policy m a y

resemble an Odyss i an j o u r n e y - - l e n g t h y , full o f dangers and seductions, and

wi thout a cer ta in ou tcome.

Jessica Wolf, Ph.D., is Regional Director, State of Connecticut, Dept. of Mental Health, Southwest Regional Mental Health Office, Security Bldg., Suite 309, 1115 Main St., Bridgeport, CT, 06604.

151 �9 1990 Human Sciences Press

152 Administration and Policy in Mental Health

This article examines changes in ideology, administrative structure, and leadership in mental health service delivery in Connecticut from 1963-1987. Using this state as a case study, the article presents a historical account of the struggle to establish a more balanced, comprehensive system. The role of formal and informal decision-making and power relations, leadership, and the interplay of intra-system and extra-system forces in influencing policy outcomes are considered.

CRITICAL THEORETICAL CONCEPTS

Understanding the process of change in mental health policy and practice over time requires both a broad perspective on interorganizational behavior as well as examination and analysis of specific change experiences (Hage, 1986). While substantial changes have occurred during the past 25 years in the types

Understanding change in mental health policy and practice requires a perspective on interorganlzational behavior.

and funding of mental health services, understanding about system bound- aries, preferred organizational structures and relationships, and the nature of change over time is still limited (Leaf, 1986). Exchange theories have empha- sized the importance of resource dependence in predicting interorganizational relationships (Morrissey, Tausig, & Lindsay, 1986; Levine & White, 1961; Aldrich, 1979; Galaskiewicz, 1979). These theories also recognize the interplay of internal and external forces. As long as exchange costs are less within the network than outside, exchanges will occur internally. As the larger environment changes, however, external resources assume greater importance. Mor- rissey, Tausig and Lindsay (1986) in their critique of Van de Ven and Ferry's (1980) theory of interorganizational relations, note the value of a developmen- ' tal perspective on interorganizational relations, as well as the critical role of preexisting power relationships, a workable and flexible definition of coordina- tion, and attention to the importance of change agents. These authors also recognize the importance of assessment of system development activities in numerous localities over time.

In describing the "institutional context and strategy framework," Black (1986) points to the importance of both formal decision-making arrangements and informal power relations among groups of organizations Within a sector. Scott and Meyer (1983) conceptualize the formal distribution of decision- making relative to centralization, fragmentation, and collaboration. The informal qualities of the sector, according to Black (1986), are the interest, power, and ideological dynamics of the interorganizational field. Structural interests, classified as "dominant, challenging, and repressed" (Alford, 1975) contend,

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respectively, to maintain the status quo, to change it according to evolving ideology and practice, and to transform its focus toward truly serving those who are purportedly its clients. Resistance, opposition, acceptance, accom- modation, acquiescence, and departure from the organization are all possible reactions to the initiation of change (Carnall, 1986).

An unders tanding of systems change requires attention to the role of leadership, formal and informal decision-making and power, as well as the dynamic tension between internal and external system variables. Particularly in turbu- lent environments, leaders who can see beyond immediate circumstances must be available to bring a system from status quo to a more adaptive and proactive stance towards change (Bennis, 1984; Tichy and Ulrich, 1984; Wolf, 1981, 1985). Moreover, a management structure must be put into place so that a "critical mass" of adherents can articulate and support the leadership position and help to implement it.

In the description and analysis which follow, particular attention will be paid to the interplay between and among dominant , challenging and repressed interests in shaping a new structure and delivery system in Connecticut as well as the crucial role of leadership in fostering successful outcomes.

CONNECTICUT: A CASE STUDY

Background

The first State mental hospital in Connecticut was opened in 1868 during a period of national ideology promot ing care in asylums in country settings (Carini, Douglas, Heck, & Pearson, 1974; Ro thman , 1971). Connecticut 's state mental hospitals became powerful, autonomous fiefdoms with little outside oversight or control. As independent organizations, they were responsible only to their boards of trustees. Despite numerous reports recommending the creation of a separate department , the Depar tment of Mental Health was not created until 1953 (Carini et al., 1974). The first commissioner resigned after protracted conflicts with the superintendent of Fairfield State Hospital, "who was verbal in his opposition to the Depar tment of Mental Health and overtly resistant to the changes proposed" by the commissioner (Carini et al., 1974). Ironically, two days after the commissioner's resignation, new legislation was passed, giving the commissioner explicit authority subject only to the approval of the Board of Mental Health, and limiting the state hospital boards to an advisory role.

Over the years, in Connecticut, as elsewhere, state hospitals drew increasing criticism for their clinical and social limitations. The establishment of the Bureau of Mental Hygiene represented an initial commitment to community- based services as an alternative approach. However, the hegemony of the


hospitals remained essentially undisturbed until the challenge inherent in the community-based initiatives of the 1960s arose.

The increased use of psychotropic medications in the mid-1950s occurred concomitantly with significant state hospital depopulation. The groundbreak- ing 1961 Report of the Joint Commission on Mental Health called for the development of community-based services. As a consequence of President Kennedy's "bold new approach," the federal government offered planning funds to states to encourage them to develop community mental health centers. The process of transformation of Connecticut's mental illness treatment sector began in earnest with the stimulation of this federal initiative.

1963-1970: The Rhetoric of Community Services

In 1963, on a wave of national and state enthusiasm, Connecticut, involving hundreds of citizens, instituted a state mental health planning process, using newly available federal funds. The first State Mental Health Plan was pub- lished in 1965. Legislation was adopted providing for citizen-based mental health planning councils in 14 regions throughout the state, as well as funding for new community-based mental health services. Following the federal lead, Connecticut envisioned the creation of comprehensive community mental health centers in all catchment areas. The 1965 Plan also recommended that

Leaders must bring a system f rom status quo to an adaptive and proactive stance toward change.

"The Regional Mental Health Planning Councils should move towards increasing their coordinative and authoritative roles, and becoming regional authorities for mental health programs" (State of Connecticut Dept. of Mental Health, 1965).

Efforts to translate community services rhetoric into actual program outcomes were only marginally successful. Minimal seed monies were appropriated through the state legislature to establish community "aftercare" programs, such as halfway houses and increased community psychiatric clinic services. Community mental health center development continued very slowly. While several communities applied for, and received federal construction and staffing grants, at the State level, there was not a strong leadership thrust to blanket the State with mental health centers. During this era the State hospitals did reorganize into geographic units in an effort to be more responsive to community needs.

However, considerable resistance to the idea of a decentralized system Continued. The "Central Office" Department of Mental Health administrators depended upon support and positive relationships with the powerful state hospitals and seemed to demonstrate little interest or impetus to shift resources and power to the community level.

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Thus, the state hospitals continued to receive the overwhelming prepon- derance of state funds, and their hegemony was essentially unchanged. In- creasingly vocal community advocates challenged these dominant interests, calling for closing of the state hospitals and serving all in the community. Advocates, motivated by optimism resulting from the promise of psychotropic medications, an ideology of prevention and cure, and the activist influence of the civil rights movement, were convinced that state hospitals were no longer needed.

The emerging battle between the state institution Goliaths and the community services Davids was thus joined. Communi ty services proponents sought to wrest control, power and dollars from the dominant hospital interests, seeking local services with a greater balance between lay "consumer" and professional authority. These ideological, structural and power conflicts were fought out in the ensuing years within the Department of Mental Health, in state mental health plan development, and in the legislative process.

1971-1975: The Battle for Regionalizalion

Having failed to change the allocation of resources, power, and the prevail- ing, ideology, community advocates representing "challenging" and "repressed" interests now sought to change the structure of the Department as the means to attaining their desired ends. They were not initially in agreement, however, and several different, and frequently contradictory models were proposed.

Following a study of mental health issues by the Institute of Public Adminis- tration for the Mental Health Association in 1970-1971, legislation strengthening the commissioner's position and relegating the State Board to an advisory role was passed in 1971. The Association had also proposed regional mental health authorities responsible only for community mental health services. This proposal, however, failed.

The Advisory Council to the State Board of Mental Health soon began a "Master Strategy" process, designed to develop and complete a comprehensive plan for mental health services in the State. The December 1972 Advisory Council Steering Committee Final Report proposed a regionalized service delivery system, with not more than seven regions. In each region, a Regional Mental Health Services Director accountable to the commissioner would have been advised by a Regional Mental Health Advisory Board. The regional director was to be delegated all appropriate powers of the commissioner in the region and to be responsible for all state facilities as well as community grants programs. In the proposed system, budgetary allocations were to be made to regions rather than facilities. The Report stated:

"It is clear to the Steering Committee that institutional-based care will not disappear immediately or even inevitably. Rather the utilization of facility-based mental health services will, over time, come to be those that are most appropriate not only in terms of


service needs but also relative to economies of operation" (Steering Committee of the Advisory Council, 1972).

The report was not submitted to the State Board of Mental Health until October 1973. Regionalization advocates were able to cite this report as the mandate for the future, although Department leadership were hardly enthusiastic.

Arguments continued regarding whether the Mental Health P lann ing Councils should be transformed into regional authorities with full responsibility for all mental health services in their regions, or whether regional authorities should be responsible for community mental health services only, with the state facilities continuing to report separately to the commissioner and clinical deputy. Some opposed any decrease in the number of regions from the 14 that existed; others argued for the status quo.

State hospitals were criticized for their clinical and social limitations.

During this period, Connecticut was also swept up into much discussion and debate about human services as well as state and regional health planning. Advocates for substance abuse services and children's services were also vocal in promoting their interests. These forces impacted significantly on the development of mental health legislation, as debates continued regarding the creation of a human services department and a process was undertaken to determine health service areas. Ultimately, regionalization legislation for mental health was permitted to move forward concurrent with the development of a limited human services structure and designation of five health services areas. Eventually, children's mental health services were transferred to a separate department. Substance abuse services remained in the Department of Mental Health during this period. The depopulation of state hospitals continued, with essentially no infusion of new resources into community-based services.

In 1973-1974, community mental health advocates succeeded in coming together and obtaining passage of regionalization legislation. The coalition consisted of the Statewide Coordinating Committee of Mental Health Plan- ning Councils, the director of planning in the Department of Mental Health, the Mental Health Association executive director and key officers, and sympa- thetic legislators who were receptive to the argument that more community services could only be developed when there was an administrative structure which could bring inpatient and community services together.

Adherents were surprised at how easily the legislation passed. Much of the mental health constituency evidently was not fully aware at the time of the impact of this legislation. Potential and actual opponents, primarily based in the institutions and broader psychiatric community, were afraid that resources would be diverted to community services without attention to the hospitals; that state-employed regional administrators would wield undue power via ~ vis

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both state inpatient facilities and grant funded community services; and that centralized Department of Mental Health authority would be eroded.

As passed, the Regionalization law (P.L. 74-224) contained serious structural problems. The representation it required would have resulted in com- pletely unwieldy Advisory Boards with, in some cases, hundreds of members. Three positions were articulated in response to this dilemma: repeal the legislation, amend it, or implement it on July 1, 1975 as originally passed.

Representatives of the Department of Mental Health, the Advisory Council, the State Board, the Mental Health Association, and the Statewide Coordinat- ing Committee of Mental Health Planning Councils met during the fall and winter of 1975 to choose a strategy. The group developed a set of proposed amendments, which were passed by the legislature and became P.L. 75-563, the Connecticut Mental Health Services Act. During this process, the concepts and potential impact of regionalization were more fully communicated to various consulting groups, and opposition diminished.

The amended law provided for regional mental health directors, appointed with the approval of the Regional Mental Health Boards, to report to the Commissioner. The regional mental health directors were to be responsible for supervising and directing all divisions and facilities of the department in their regions. The Regional Mental Health Boards were given strong advisory powers in the areas of funding allocations, planning, and evaluation, and were permitted to hire their own staff. The building blocks of the regional boards were to be catchment area councils, comprised of town-appointed consumer (non-provider) representatives, and members at large, who could be con- sumers or providers, as long as there was a consumer majority. The catchment area councils were to elect members to sit on the regional mental health boards. Other key provisions of the legislation included "formula funding" for the regions and the concept of "regional budgeting."

The independence of regional board staff was one of the most fiercely fought issues and remained a theme in ensuing years. It went to the heart of the lack of trust between the Department of Mental Health and the community mental health advocates, who feared that departmental staffing of the advisory boards would kill their independence. The community advocates won this point. The Department of Mental Health then agreed to adopt the five regions which had been recommended through the health services area designation process.

Following the passage of P.L. 75-563, the Department and Mental Health Councils undertook a transition process to implement the new legislation. The current commissioner retired, and in 1976, a new commissioner took charge. The community advocates had successfully challenged the dominant forces of the status quo. Now, as they looked forward to the restructuring of the system, the state hospital supporters and some Department Central Office bureaucrats were inevitably in a defensive posture. They had not sought this new system. Would it irrevocably alter their positions and authority?


1976-1981: Regionalization Manqu6

The commissioner's leadership was now acknowledged as the critical vari- able in proceeding with the legislatively mandated systems change. The new commissioner adopted a cautious approach to implementation, and, indeed, questioned whether regional directors' authority was in fact properly mandated in P.L. 75-563. Initially, acting regional directors were appointed without pay, pending State Personnel approval of the positions. When regional directors were subsequently hired, their salaries were far below those of the hospital superintendents, they reported to the director of planning rather than directly to the commissioner, and they were given no authority over the state-run facilities. Superintendents continued to report directly to the deputy commissioner for clinical services, thus continuing the dual lines of authority which regionalization was to have corrected.

From the outset, regional directors were in a no-win position. Cut off from a direct relationship with the commissioner, they had no choice but to try to build support with the grantee agencies which they were supposed to oversee, and the regional mental health boards. While the latter were to advise the regional directors, they often were in a stronger position because of their relative independence from the Department and the fact that they were in place before the regional directors were appointed. While limited to oversight of community services allocations by the commissioner's interpretation of the law, regional boards assumed a strong role in making funding recommendations.

The commissioner worked to obtain additional community services funds for the Department, as discharges from the hospitals continued. In 1978, $1.2 million in new community funds was appropriated. Much energy was also spent in developing a formula for "formula funding." However, the formula was only applied to community mental health services dollars, which remained a very small part of the Department's overall budget. In fact, in August 1979, the Legislative Program Review and Investigations Committee noted, "The major f i n d i n g . . , is that the Department has had only limited success in translating its goals and policies into programs which adequately respond to Connecticut's mental health needs" (Connecticut General Assembly, 1979). This report highlighted the continued dominance of state hospital inpatient programs, insufficient community-based services, "perpetuation of two separate service delivery sys tems- the state hospitals and community focused programs." It recommended that the commissioner clarify his intentions concerning regional budgeting, formula funding, and citizen participation. The debates grew about regionalization, authority, whether the Department was truly committed to decentralization and community services. At one point, the Commissioner proposed that there be regional superintendents, to whom the regional directors would report (Connecticut General Assembly, 1979). This unleashed a storm of objections, and led to the creation of a Task Force of the

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Board of Mental Health. The Subcommittee on Regionalization recommended that regional budgeting be implemented, that the Regional Director be responsible for all publicly-funded mental health services in the region (including state run facilities and community grants programs), that the position be upgraded; that state facilities be included in the Regional Boards' purview, and that lines of control within the Department of Mental Health be clearly stated. The committee indicated that no new legislation was needed.

At the first conference on regionalization, in Bethel, Connecticut in Novem- ber 1979, representatives of all affected groups discussed the committee's report. The general consensus was to move ahead to full implementation of regionalization, although the Commissioner continued to indicate that he thought new legislation might be needed. Subsequently, in June 1980, a five person committee (including one hospital superintendent, one regional director, the commissioner, the chairman of the state board of mental health, and a regional mental health board president) recommended that regional administrators should report directly to the commissioner; that the staffing functions of the regional boards should be assumed by the regional administrator's office; that formula funding be continued for community grants account funds and as a planning tool for the whole system; and that the changes be phased in during 1980-1981.

After massive protest by the regional boards, the report was revised as of July 24, 1980 to recommend that regional board staff would be provided through the regional administrator's office or, where appropriate, the regional administrator could contract with Health Systems Agencies for Mental Health planning and evaluation services.

A final report entitled the Connecticut State Board of Mental Health Re- gionalization Implementation Report (Connecticut State Board of Mental Health, 1980) was circulated and then adopted at the second regionalization conference on October 4, 1980. The key change was the provision that the regional mental health boards would either retain their independent staff or, if they so chose, they could receive staff support from the regional administrator's office.

Resistance to decentralization continued with little interest in shifting resources and power to community services.

In early 1981, the commissioner resigned, the upgraded regional administrator positions were rejected by the Office of Policy and Management, and the legislature's "Sunset" committee recommended abolition of the State Board of Mental Health as too dosed and restrictive a group. At the eleventh hour, however, the much larger and more cumbersome (though more representative) advisory council to the State Board was abolished, and the membership of the State Board expanded to add regional mental health board chairs (and, subse-


quently, a second designee from each board) to the governor's appointees. The State Board became a larger, and more representative group.

The commissioner had supported the status quo forces in delaying the legislatively mandated requirement of a single administrative structure for community-based and inpatient services. He had succeeded in obtaining very modest increases in community services funding, but not enough either to prime the pump of a more balanced service system or to deter the challengers to whom full regionalization continued to represent the means to attain a more equitable and appropriate delivery system. During the selection of a successor, leadership capacity to assure full implementation of regionalization was considered a very critical criterion.

1981-1987: Regionalization Realized

Arriving on a wave of commitment to regionalization in July 1981, the next commissioner quickly moved ahead. She successfully convinced the Office of Policy and management to reconsider the regional administrator upgradings, and four new administrators, along with one former regional director, began work in February 1982. The Commissioner made clear that the superintendents were to report to the regional directors. She also insisted that the regional boards were to advise the regional directors, who were her representatives in the regions. As the regional directors' authority was reinforced, the regional boards were impelled to retreat from their previous more dominant position vis

vis the regional directors. Not surprisingly, this occasioned some discomfort. The governor appointed a Blue Ribbon Task Force on Mental Health

Policy, whose April 1983 report became the common ground on which proposals to develop a more comprehensive system were based. The department developed and promulgated a mission statement, and clearly articulated its commitment to persons with long-term mental illness, thereby informing grantee agencies and regional boards alike of the Department's primary responsibility to define and shape policy. A new deputy commissioner for Plan- ning and Policy Analysis provided balance and leadership and was able to capture critical federal community support services and human resource development grants. As part of the state's move towards program budgeting, the Department created a taxonomy and program budget categories, including inpatient, community psychiatric, and community support services. This taxonomy greatly helped the Department in formulating its needed community support services expansions (Wolf, 1985).

With the support of the State Board of Mental Health, the regional mental health boards, the Mental Health Association, and the Connecticut Alliance for the Mentally Ill, the commissioner obtained legislative and gubernatorial support for significantly increased funding to develop new residential, psycho- social rehabilitation, vocational, and case management services. In addition, as part of its initiatives, and also in response to lawsuit and legislative proposals

Jessica Wolf 161

initiated by the Connecticut Hospital Association, the Department received funding to initiate crisis intervention centers to provide effective emergency care and divert patients from hospitalization when possible. The lawsuit had been initiated because general hospitals were experiencing serious difficulties in assuring admissions to state hospitals from emergency rooms. The hospital association argued that more inpatient beds were needed. The Department asserted that crisis intervention and community support services were essential components in a system of care which could avoid inappropriate hospitalization and assure access to acute care.

The fiscal year 1981 Department of Mental Health budget was approximately $96 million. Expenditures in 1987-1988 were $200,472,477, with approximately 32% earmarked for community-based services and 58% for inpatient services, compared to pre-regionalization proportions of approximately 10% and 90% respectively. Community-based residential capacity increased from 274 to 1,013. Case management clients increased from 100 to more than 3,000; over 7,000 clients were served in crisis intervention programs, 2,600 in Fountain House Model programs, and 415 in work services programs. Median inpatient length of stay decreased; state hospitals' census declined; and acute inpatient admissions decreased as a proportion of all crisis program dispositions.

The Department articulated three major goals: to reduce clinically inappropriate over-reliance on hospitals for long-term care of patients who do not need continued hospitalization; to improve the accessibility of appropriate acute care; and to develop a managed and high quality service system. It also stressed the importance of balance and integration between psychiatric and rehabilitative approaches. The creation of a strong management team, the focus on mission and goals, and the infusion of new resources were all undertaken to expand community services, provide a continuum of care, and create a balanced service system and integrate inpatient care into it.

The commissioner resigned in the fall of 1986. The deputy commissioner for Planning and Policy Analysis served as acting commissioner until the appoint- ment of the new commissioner in May 1987. Formerly deputy commissioner for Administrative Services, the new commissioner stressed his commitment to continuing and strengthening the Department's existing policy direction. The Department's resulting budget proposals demonstrated ongoing efforts to integrate residential, case management, and outpatient services through creation of mobile community treatment teams; to broaden and increase the flexibility of residential services by offering a range of residential supports; to increase the employment opportunities available to individuals with mental illness; to maintain and enhance the quality of inpatient care; and to foster the development of consumer advocacy groups.

In the regionalized system the state hospitals have changed considerably. As long-term patients were discharged to community services, wards were closed,


and inpatient staff redeployed to acute care units. State hospitals and community services became increasingly interrelated: off-site programs were initiated; consultation teams of state facility staff were made available in the community. All hospitals have remained accredited. Clarifying the role of inpatient services in a managed service system has become a more salient issue, together with the establishment of a specific locus of accountability in each service area. Recruit- ment and retention of staff, identifying viable provider agencies, and creating and implementing an effective human resource development strategy are all important contemporary Department of Mental Health concerns.

Critically needed leadership ability, vision, a commitment to regionalization, availability of new resources, and strategic management both within the public mental health sector and between it and crucial external environmental forces has finally resulted in transformation in the care of the mentally ill in Connecticut.

Regionalization has resulted in administrative and clinical managers in state and community facilities working closely together.

ANALYSIS AND CONCLUSIONS

In his article, "Institutional Context and Strategy," Black (1986) states:

"Thus the successful implementation of innovative programs depends on the extent to which these programs are empowered by the state to withstand the inevitable domain, ideological, and interest conflicts that a challenge to the existing dominant structural interests will arouse."

The changes in the Connecticut mental health system during the past 25 years have at times seemed tediously slow and ponderously inefficient. Yet, retro- spection reveals that enormous changes have occurred.

The tasks of change included a successful battle to create a viable administrative and advisory structure, the selection of leaders committed to that structure and capable of mediating between and among internal and external forces, the articulation of a shared mission, the capture of significant new resources and their use for new program initiatives, the inclusion of diverse constituency interests, the development of a capable management team, and assurance of orderly transition and succession to new leaders with similar goals.

The Department of Mental Health no longer consists of bifurcated and unrelated structures. The regional directors are clearly responsible for all services in their regions.

Administrative and clinical managers in state facilities and community settings now work more closely together. The regional boards are allies of the Department while continuing to maintain their independence. A long legacy of

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distrust between the Department bureaucrats and the citizen advisory groups has essentially been overcome. The emergence of the Connecticut Alliance for the Mentally Ill, and the growth of viable, active primary consumer groups will further enrich the interorganizational field. All of these developments could only be balanced and managed through effective leadership and a flexible yet firm insistence on the importance of perceived common interest.

Critical challenges continue to confront the Connecticut mental health system. These challenges include improving the quality of care in inpatient settings, assuring that services in the community are fully coordinated, attend- ing to the emergent and problematic interface issues concerning "dually diag- nosed" individuals and the mentally ill homeless, serving forensic clients adequately, and balancing metal health policy commitments within the context of overall state policy initiatives. Regional budgeting has not yet been implemented. Until it is, full authority will not match existing regional responsibility.

Increased resources are no longer available at the level that they were in recent years. The Department may be required to transfer resources internally to continue moving towards a more balanced service system. Resource con- straints may be an "acid test." The impact of fiscal and political problems could potentially undermine the alliances which have been established within the system.

Nevertheless, whatever challenges the future holds, Connecticut represents an intriguing and relatively successful approach to transforming the way services are provided to individuals with prolonged mental illness. Implemen- tation of a unified administrative structure provided the mechanism for policy change over time. The eventual availability of strong leadership in a positive economic climate permitted the capture and infusion of new resources. The willingness of Department leadership to recognize the validity of the concerns raised by Advisory Board advocates guaranteed the Department a vocal and effective lobbying force. While external threats and internal dissension required careful negotiation and strategizing since 1981, in general the Depart- ment and its various constituencies have increasingly shared a common vision of the direction in which policy and service development should go. In the present era, leaders must judiciously ascertain how much to push the system towards continued change and how much to move "with all deliberate speed."

In conclusion, the Connecticut experience offers a rich mine of interorganizational struggles and interesting outcomes, an understanding of which can be instructive to policy makers and practitioners alike.

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Documents

A chronicle of change: A case study of the Connecticut mental health system