(Caution: This post is a draft of what I hope will be an article or book chapter – perhaps in the book on mental health planning I am trying to write. Please be warned that it is a work in progress that may be changed to correct errors or for stylistic reasons. Also, please do not use material from this post without proper attribution to the post or the references cited.)
CYCLES OF REFORM AND FAILURE AND THE NEED FOR BETTER PLANNING
“They were morning glories — looked lovely in the mornin’ and withered up in a short time, while the regular machines went on flourishin’ forever, like fine old oaks. Say, that’s the first poetry I ever worked off. Ain’t it great?”
George Washington Plunkitt, New York Tammany Hall Leader, on Reforms, (Gunnison 1966)
Public Domain Photo
The history of the public mental health system for adults with serious mental illness has been marked by cycles of planned reform followed by failures to reach desired goals and subsequent public disillusionment. (Bachrach 1979; Goldman and Morrissey 1985; Sharfstein 2000; Grob and Goldman 2006; Pirkis, Harris et al. 2007) . Each cycle is a response to policies and interventions of the previous cycle, emerging technologies and contemporaneous societal trends. (Note: This analysis focuses on the adult mental health system. Although a similar analysis might be useful for the child mental health system, it is beyond the scope of this paper.)
In 1985 Goldman and Morrissey counted four mental health cycles of reform (Goldman and Morrissey 1985): The first in the early 19th century introduced moral treatment and focused on the asylum; the second in the early 20thcentury was associated with the mental hygiene movement and emphasized the psychopathic hospital; the third in the mid 20th century developed out of the community mental health movement and supported community mental health centers, and the fourth, in the 1980s came to be known as the Community Support Program and focused on a broad network of community-based mental health and social welfare services, which were coordinated with or absorbed into the mental health services (Goldman and Morrissey1985). I would argue that after the Community Support Program we experienced a fifth cycle of reform – the consumer movement focusing on consumer involvement in all aspects of mental health care, the era of the new federalism, focusing on state mental health systems, and a sixthcycle, the era of evidence-based practices, the focus of which is the individual service.
Table 1, based on work by Goldman and Morrissey (1985), Palmer (Palmer No Date) and the Minnesota Psychiatric Society (2004) shows a more detailed and extended history of major national reform efforts from 1840 to the present and our formulation of the cycles of reform with which they are associated. We have re-named Goldman and Morrissey’s (1985) third cycle of reform beginning in 1955 “Deinstitutionalization and Community Mental Health.” Deinstitutionalization preceded community mental health, but the two eventually became linked in planning and service system development (Koyanagi 2007). We also have added three additional cycles of reform, the consumer movement, focusing on consumer directed care and consumer operated services (Fisher, Chamberlin et al. 2005), the New Federalism, focusing on state mental health systems (Osborne 1990) and the most recent, Evidence-based Practices emphasizing discrete services (Drake, Goldman et al. 2001).
Table 1 Brief History of National Mental Health Reform Efforts
First Cycle of Reform: Moral Treatment
1840: There were only eight “asylums for the insane” in the United States. Dorothea Dix
crusaded for the establishment or enlargement of 32 mentalhospitals, and transfer of those with
mental illness from almshouses and jails. First attempt to measure the extent of mental illness
and mental retardation in the United States occurred with the U.S. Census of 1840, which
included the category “insane and idiotic.”
Second Cycle of Reform: Mental Hygiene
1900: The “mental hygiene” movement began; Clifford Beers, a mental health consumer, who
shocked readers with a graphic account of hospital conditions in his famous book, The Mind that
Found Itself
1946:: On July 3, President Truman signed the National Mental Health Act, creating for the first time in US history a significant amount of funding for psychiatric education and research and leading to the creation in 1949 of the National Institute of Mental Health (NIMH).
Third Cycle of Reform: Deinstitutionalization and Community Mental Health
1955:: Congress authorized the Mental Health Study Act of 1955 and called for “an objective,
thorough, nationwide analysis and reevaluation of the human and economic problems of mental health.” The act results in the historic study conducted by the Joint Commission on Mental Illness and Health, Action for Mental Health.
1961: Action for Mental Health transmitted to Congress. It assessed mental health conditions and resources throughout the United States “to arrive at a national program that would approach adequacy in meeting the individual needs of the mentally ill people of America.”
1963: President Kennedy proposed and signed Community Mental Health Act that started community mental health center movement to substitute comprehensive community care for custodial institutional care.
1965: The CMHC (Community Mental Health Center) Act Amendments of 1965, (P.L. 91-211), were enacted and included the following major provisions: Construction and staffing grants to centers were extended and facilities that served those with alcohol and substance abuse disorders were made eligible to receive these grants. Grants were provided to support the initiation and development of mental health services in poverty-stricken areas. A new program of grants was established to support further development of children’s services.
1975: The CMCH Act Amendments of 1975 (P.L. 94-63) mandated a more detailed community mental health center definition emphasizing comprehensiveness and accessibility to all persons regardless of ability to pay, through the creation of a community governing board and quality assurance. Required core services expanded from the 1963 levels from 5 to 12, which included the following: Children Services Elderly Services Screening Services Follow-up Care Transitional Services Alcohol abuse Services Drug abuse Services.
1978: Medical Assistance (MA) added for community MH services (outpatient and day treatment).
Fourth Cycle of Reform: Community Support Program
1980: The Mental HealthSystems Act, (P.L. 96-398), restructured the federal community mental healthcenter program by strengthening the linkages between the federal, state, and local governments. The Act was the final result of a series of recommendations made by President Jimmy Carter’s Mental HealthCommission. Per the Mental Health Systems Act, a number of grant programs mandated for the CMHCs to assist in expanding services to meet an array of priority populations. They included the following:
* An expansion grant for a wide range of services for the severely mentally ill (SMI) population;
* Grants for the severely emotionally disturbed (SED) population;
* Non-revenue producing services were also funded via a grant aimed at expanding education and consulting needs;
* Additionally, the commission sought to include consumer input and involvement in service and treatment.
Fifth Cycle of Reform: Consumer Movement
1970: Founding Mental Health Insane Liberation Front in Portland OR.
1978: Judi Chamberlin publishes On Our Own :patient-controlled alternatives to the mental health system.
1995: First Substance Abuse and Mental Health Services Administration Center for Mental Health Services Consumer Affairs Specialist hired.
1996: Passage of the first parity law. The law prohibited insurers or plans serving 50
or more employees from setting lower annual or lifetime dollar caps on mental health benefits
than for other health benefits.
1999: : The Supreme Court issues its opinion on Olmsteadv. L.C which held that it is a violation of the Americans with Disabilities Act to keep individuals in restrictive inpatient settings when more appropriate community services are available.
Sixth Cycle of Reform: New Federalism
1981-2: Alcohol, Drug Abuse and Mental Health Block Grant, replaces Federal Mental Health Systems Act which is repealed. ADMHS block grant decreased by 30% resulting in dramatic service reductions. Despite passage of block grants, the federal share of funding decreased to 11% of the total while state and local funding share increased.
1986: Mental Health Planning Act of 1986 (Federal law requiring state plans) passed; Case management established as a distinct benefit under Medicaid; Medicaid amendments improve MH coverage of community MH services, add rehabilitative services, and expand clinical services to homeless.
1988: Behavioral health managed care introduced. Massachusetts was the first state that utilized a managed care platform regarding service of its behavioral healthcare needs.
The Clinton White House held a conference on mental health issues in June 1999 that focused on dispelling the myths about mental illness and decrying prejudices against behavioral health consumers, one of which was insurance coverage that excludes behavioral health services. The conference also brought together the mental health community in anticipation of the Surgeon General’s Report. Mental Health: A Report of the Surgeon General published in late 1999 seeks to eradicate the stigma surrounding mental health and simultaneously encourage the use of innovative pharmaceutical and psychotherapy treatments
2002: President Bush forms the New Freedom Commission on Mental Health, which will seek “to conduct a comprehensive study of the United States mental health service delivery system, including both private and public sector providers.” The Commission is charged with a set of objectives that includes reviewing the current quality and effectiveness of private and public providers, identifying innovative services, treatments, technologies, and issuing a report on its subsequent recommendations.
2003: New Freedom Commission final report issued.
Seventh Cycle of Reform: Evidence-based Practices
2007: National Registry of Evidence-based Programs and Practices (NREPP) for mental healthservices, substance abuse treatment and substance abuse prevention launched by Substance Abuse and Mental Health Services Administration. Efforts generally influenced by work of Cochrane(Cochrane 1972); in public mental health by Drake and colleagues (Drake, Goldman et al. 2001).
End of Table
None of these reforms have lived up to expectations (Bloche and Cournos 1990; Bell and Shern 2002), although some recent analyses assert that incremental gains can ensue from these reforms (Koyanagi and Goldman 1991). As Goldman and Morrissey wrote of the first three:
“Each [of the first three reforms]… failed to eliminate chronicity or to fundamentally alter the care of the severely mentally ill. In each cycle, the optimism of reform gave way to pessimism and therapeutic nihilism toward the increasing numbers of incurable chronic mental patients. In the face of an expanding population of needy patients, public support turned to neglect (Goldman and Morrissey 1985, p. 726).
The Community Support Program and the New Federalism also have generated disillusionment (Bloche and Cournos 1990). This disillusionment stems from phenomena such as “transinstitutionalization,” or the “migration” of persons with mental illness to nursing homes, jails, prisons, or homeless shelters, fragmentation of services, decreasing real dollars in entitlement streams and “formidable obstacles to eligibility’ (Bloche and Cournos 1990): These problems resulted in commissions, reports and program initiatives (Bell and Shern 2002; New Freedom Commission 2003) we have discussed in previous posts and will discuss in future ones.
It can be argued that cycles of reform five and seven are still in process, but they are already encountering problems. The consumer movement continues to seek a unified voice and evidence for its positions ((Fisher, Chamberlin et al. 2005)); and states, counties, and localities are having difficulties implementing evidence-based practices with fidelity and taking them to scale (Frank, McGuire et al. 1999; Drake and Bond 2008). As Drake and Bond (2008)note:
“…it is clear that most states lack the infrastructure for [implementing EBPs] (NAMI 2006). Instead, salaries and training continue to decrease, states spend their limited training dollars on conferences and brief trainings that do not change clinicians’ behavior (Hoge et al. 2003), and services continue to erode (New Freedom Commission on Mental Health2003). Implementing effective services always takes a back seat to financial issues, as agency administrators cautiously weigh financial risks and benefits (Panzano and Roth2006). Beyond implementation, states do not have the capacity for on-going fidelity monitoring, providing technicalassistance, and aligning financing with evidence-based practices—all of which would be needed to sustain and amplify success (p.225).
This history of repeated and disappointing reform raises the question of why we do not do better. We can point to many factors that limit the effectiveness of our reforms like resource constraints and the lack of “magic bullet” technologies to cure mental illnesses or fix important problems in access and quality. However, my analysis, explained in detail in forthcoming posts, is that a primary reason why mental health system reforms have not been more successful and satisfying is that they have been inadequately planned leading to less than optimal resource deployment and unrealistic expectations (Pirkis, Harris et al. 2007).
Given this analysis, my recent work has been focusing on how to improve mental health system planning. The federal government, states, counties, localities and providers repeatedly make mental health systems plans. Some of these plans, such as the National Plan for the Chronically Mentally Ill (United States. Dept. of Health and Human Services. Steering Committee on the Chronically Mentally Ill. 1980) are developed by Presidential and other commissions. Other plans such as Olmstead Plans (National Council on Disability 2003) are required by the judiciary. Additional plans, such as Block Grant Plans (SAMHSA’s National Mental Health Information Center: Center for Mental Health Services 2010) and Comprehensive Mental Health Plans (Substance Abuse and Mental Health Services Administration, 2010) are necessary to receive funding. Still others, such as 10 year plans to end homelessness (National Alliance to End Homelessness 2000) are recommended to guide policy and service development. Also, plans such as state budget plans and transformation or reform plans (e.g., North Carolina Department of Health and Human Services 2007) are intended to satisfy legislative requirements and so on.
Better planning for mental health systems will always be in the critical path of deploying new technologies and resources, can result in safer and more effective mental health systems and can prepare stakeholders for the risks and limitations of reform as well as its opportunities. Nevertheless, to our knowledge there has been no efforts at the federal, state, county or provider level to identify or promulgate mental health planning best practices for planners to follow and planning tools for planners to use. We will discuss such best practices and tools in subsequent posts.
References
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