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Mental Health System Not In "Shambles"-YET

An Opinion by Michael B. Friedman, CSW
First Published in Mental Health News, Spring 2003

According to the "Interim Report" of The President's Commission on Mental Health, the mental health system in the United States is "in shambles." I do not agree. "In shambles" is what it was before the Community Mental Health Centers Act of 1963, when hundreds of thousands of people were warehoused in state institutions where the conditions were shameful. "In shambles" is what it was after the inception of deinstitutionalization when tens of thousands of people were discharged from, or denied access to, state institutions with no services or supports in the community.

Mental Health System Improved Since Community Support Program in 1978

But since the Community Support Program was initiated in 1978, the mental health system has improved considerably. Over the past 25 years, there has been significant expansion, even creation, of housing programs, outpatient services, rehabilitation, case management, peer support, inpatient care in local general hospitals, etc. In addition, state psychiatric centers have also improved dramatically. In New York State they now offer a mix of inpatient, residential, rehabilitation, and outpatient services which are often of very high quality.

It is offensive to those of us who have advocated-with considerable success-for community mental health services for the past quarter century to characterize the mental health system in a way that appears to dismiss all that has been achieved.

Still Many Inadequacies

That is not to deny that there are many inadequacies with the current system, some of which are documented in the "Interim Report."

The current mental health system may be as fragmented today as it was in 1978 when the last President's Commission called for the creation of integrated mental health systems.
The current mental health system frequently fails to respond to the needs of people with severe, recurrent mental illnesses who reject traditional treatment.
Large numbers of adults with serious mental illnesses are housed in adult homes, facilities designed for poor people who cannot care for themselves adequately but not for people with marked disabilities.
Far too many people with mental illnesses are in jails and prisons because of inadequate efforts to divert them to appropriate treatment.
Children and adolescents with serious emotional disturbances are often abysmally treated because services are not available, because they are outmoded, and because of failures to integrate the efforts of the mental health system with those of the schools, the child welfare system, and juvenile justice.
Minorities, a rapidly growing part of the American people, are generally not adequately served despite calls for "cultural competence."
And the explosion of the population of older adults is just beginning to be mentioned in policy discussions; plans and services lag way behind.

But Progress Has Been Made

But it would be unfortunate to let the many inadequacies still to be overcome blind us to the progress that has been made over the past quarter century-to the progress we now may have to fight to preserve. I don't think our current mental health system is in shambles now, but it could be in shambles soon.

History of Treatment of People With Mental Illness in America Characterized By Cycles of Improvement and Decline

This thought will come as no surprise to those historians of mental health policy (such as Gerald Grob and David Rochefort) who believe that the history of the treatment of people with mental illness in America is characterized not by progress but by cycles of improvement and decline. Their core observation is that periods of progress in the care and treatment of people with mental illnesses come to a crashing halt during times of economic crisis. Thus the asylums of the early 19th century built on the philosophy known as "traitement morale" (French for "humane treatment") gave way to a philosophy of custodial care during and after the Civil War. Similarly some gains in the humanization of institutions after World War I gave way to the degradation of asylums during the Depression and World War II.

Will the slow and limited gains of the second half of the 20th century similarly give way to a loss of moral concern about people with serious mental illnesses and children with serious emotional disturbances and to a period of rapid decline in both the amount and quality of mental health services?

Signs are Mixed

At the moment the signs are mixed. Despite a growing federal deficit, President Bush has announced his intention to propose $1.75 billion to aid people with disabilities over five years beginning October 2003, though there may also be cuts for some mental health programs and to Medicaid-the major source of federal funding for mental health. In New York Governor Pataki's budget request promises some improvements in future years and appears to preserve most community mental health services. However, preservation of current funding depends on proposals that are far from being done deals, including closing underutilized state psychiatric centers, bed reductions, consolidation of the state's two research centers, and the substitution of federal Medicaid dollars for state dollars. In addition The Governor's budget request would result in funding problems for inpatient and outpatient services at general hospitals.

Despite Inadequacies Current System Must be Defended

Although current funding and policy plans leave the future uncertain, the lesson of history is clear. In bad economic times, people with mental illnesses fall off the political radar screen. Political promises are just as good as the American economy. If the economy does not rebound soon, we will have to fight very hard to preserve the gains of the past 25 years. That will require us all to be clear that a system has been created which, for all its inadequacies, is worth defending.

And that is why it is worthwhile saying again: the current mental health system is not "in shambles"-yet.

(Michael B. Friedman is the Director of The Metropolitan Center for Mental Health Policy and Advocacy, a collaboration of the Mental Health Association of New York City and The Mental Health Association of Westchester County. The opinions expressed in this column are his own and not necessarily the positions of the Mental Health Associations.)

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