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The Dilemma of Federal Mental Health Policy

The Dilemma of Federal Mental Health Policy: Radical Reform or Incremental Change?

Gerald N. Grob
Howard H. Goldman
Copyright Date: 2006
Published by: Rutgers University Press
Pages: 240
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  • Book Info
    The Dilemma of Federal Mental Health Policy
    Book Description:

    Severe and persistent mental illnesses are among the most pressing health and social problems in contemporary America. Recent estimates suggest that more than three million people in the U.S. have disabling mental disorders. The direct and indirect costs of their care exceed 180 billion dollars nationwide each year. Effective treatments and services exist, but many such individuals do not have access to these services because of limitations in mental health and social policies.For nearly two centuries Americans have grappled with the question of how to serve individuals with severe disorders. During the second half of the twentieth century, mental health policy advocates reacted against institutional care, claiming that community care and treatment would improve the lives of people with mental disorders. Once the exclusive province of state governments, the federal government moved into this policy arena after World War II. Policies ranged from those focused on mental disorders, to those that focused more broadly on health and social welfare.In this book, Gerald N. Grob and Howard H. Goldman trace how an ever-changing coalition of mental health experts, patients' rights activists, and politicians envisioned this community-based system of psychiatric services. The authors show how policies shifted emphasis from radical reform to incremental change. Many have benefited from this shift, but many are left without the care they require.

    eISBN: 978-0-8135-4133-4
    Subjects: Health Sciences, Political Science

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. Preface
    (pp. vii-viii)
    Gerald N. Grob and Howard H. Goldman
  4. List of Abbreviations
    (pp. ix-xii)
  5. Prologue
    (pp. 1-13)

    Lunacy, insanity, mental illnesses—whatever the term or diagnostic category—have seemingly been an omnipresent feature of the human condition. Virtually every society has been forced to confront the presence of persons whose aberrant behavior and condition invariably led to dependency. For families such members created a variety of tragic problems that were often intractable in nature. Community reaction was equally problematic, and ranged from fear, stigmatization, and a desire to exclude, on the one hand, to sympathy, on the other.

    That such persons were generally unable to survive on their own raised grave problems. What was the responsibility of...

  6. Chapter 1 Winds of Change
    (pp. 14-42)

    In 1945 the mental health establishment appeared stable; few observers questioned the presumption that the mental hospital was the proper place to provide care and treatment for persons with severe mental disorders. At that time the average daily resident population in public institutions was about 430,000; approximately 85,000 were first-time admissions. Nearly 88 percent of all patient care episodes occurred in these institutions; the remainder in general hospital psychiatric units.¹ In 1951 total state expenditures for all current operations were $5 billion. Of this sum, 8 percent was for mental hospitals. New York State spent no less than 33 percent...

  7. Chapter 2 Policy Fragmentation
    (pp. 43-67)

    By 1965 psychiatric activists believed that they stood on the threshold of a new era. In their eyes the passage of the CMHC act and the subsequent legislation providing for federal funding for staffing had created the foundation for fundamental changes in the mental health system. They anticipated that the new community-based policy would eventually lead to the disappearance of traditional mental hospitals. Moreover, they had faith that early identification and the deployment of appropriate interventions and caring systems as well as preventive measures would not only reduce the number of individuals at risk but also lead to dramatic improvements...

  8. Chapter 3 A Presidential Initiative
    (pp. 68-90)

    The election of Jimmy Carter in 1976 augured well for those seeking to change a dysfunctional mental health system. One of his first acts after taking office was to create a presidential commission to recommend a more effective national mental health policy. Although several previous commissions had dealt with health-related issues, none had focused on the mental health system. The hope was that a group endowed with a presidential blessing could come up with a plan to strengthen a fragmented system responsible for the care and treatment of large numbers of individuals whose severe disorders had rendered them dependent upon...

  9. Chapter 4 From Advocacy to Legislation
    (pp. 91-118)

    With the task panels’ reports in hand, the commission now faced the herculean task of absorbing their findings and recommendations and preparing a final report to submit to President Carter by April 1978. The writing of the report was complicated by the fact that most of the members did not share the same priorities. The issues were also challenging and difficult. The panel reports were sufficiently complex that the task of translating their recommendations into a coherent policy document was formidable. Moreover, the time to finish the final report was short.

    The members of the PCMH rarely were in direct...

  10. Chapter 5 From Legislative Repeal to Sequential Reform
    (pp. 119-147)

    The 1980s proved to be a decade of surprising success and increasing commitment to individuals with severe and persistent mental illnesses. To be sure, the Reagan administration was committed to policies that were designed to limit if not reduce the social welfare role of the federal government. The means chosen involved sharp reductions in taxation and the transfer of many social welfare responsibilities downward to state and local governments.¹ Although successful to some degree, these policies were mitigated by administrative actions taken by officials within the federal bureaucracy under the pressure of advocates and the Congress. Concerned that preoccupation with...

  11. Chapter 6 Integration, Parity, and Transformation
    (pp. 148-180)

    While federal mental health policy was “inching forward” in the 1980s, the fragmentation of the mental health system intensified. Policy advances followed the recommendations of the National Plan for the Chronically Mentally Ill to make sequential changes in the Social Security Administration disability programs, notably Medicare and in Medicaid. Access to mainstream benefits improved, but that meant that the mental health system of the 1990s had even more diverse sources of revenue and many more regulations to follow than in the 1980s.

    As individuals with severe and persistent mental disorders spent more and more time in their communities, they found...

  12. Epilogue
    (pp. 181-186)

    Much has been accomplished in mental health policy, but much remains to be achieved. Recently two economists, Richard Frank and Sherry Glied have argued that during the past half century the mental health and well-being of Americans have improved. The fate of those who are poorest and most impaired, however, has deteriorated. Frank and Glied conclude that with respect to our mental health we are better, but not well.¹

    Our analysis of the history of federal mental health policy over the same period finds that this mix of progress and disappointment derives from the interplay of the work of policy...

  13. Notes
    (pp. 187-216)
  14. Index
    (pp. 217-226)
  15. Back Matter
    (pp. 227-228)