Mental Health Policy - The History of Mental Health Policy in the United States

Policy II Mental Health Policy Concepts of Mental Illness and the Social Construction of MI

Mental Health Policy IIThe History of Mental Health Policy in the United States (The Rise of the Community Mental Health Movement)1

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2Mental Health Policy IIThe History of Mental Health Policy in the United States Legislation generally assumes a static universe; a legal mandate supposedly alters individual and group behavior in ways that overcome older policy deficiencies. But reality is far more complex.Faced with laws designed to transform policy, individuals and groups often adjust their behavior in the light of new realities. In so doing they transform legislative intent in unforeseen and unpredictable ways, thus giving rise to unanticipated consequences.

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Mental Health Policy IIThe History of Mental Health Policy in the United States Moral treatment (1790s to 1900s)

Provide humane care for the mentally ill; replaced sanitariums.

Moral treatment ala Phillipe Pinel; conceived of humane care through environmental intervention. Forerunner of milieu therapy.

Resulted in the erection of state mental hospitals in the United States (Dorothea Dix).

Never lived up to original intentions (small clinics became large asylums).

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4Mental Health Policy IIThe History of Mental Health Policy in the United States

Phillipe Pinel (1745-1826)

Regarded by many as the father of modern psychiatry. Did away with bleeding, purging, and blistering in favor of a therapy that involved close contact with and careful observation of patients. Observed a strict nonviolent, nonmedical management of mental patients that came to be called moral treatment though psychological might be a more accurate translation of the French moral.

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5Mental Health Policy IIThe History of Mental Health Policy in the United States Benjamin Rush (1745 1813) Considered the "Father of American Psychiatry", publishing the first textbook on the subject in the US: Medical Inquiries and Observations upon the Diseases of the Mind (1812). An advocate of insane asylums, believing that with proper treatment mental diseases could be cured. Emblem of the APA bears his portrait. Developed the conception of addiction as a form of medical disease and the idea that abstinence is the only cure for addiction.

Advocated forced psychiatric treatment: a favorite method was to tie a patient to a board and spin it at a rapid speed until all the blood went to the head. Placed his own son in one of his hospitals for 27 years, until his son died. Believed that being black was a hereditary illness which he referred to as 'negroidism but also believed that since it was merely a skin condition slavery and racial discrimination should be abolished.

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Patient in a spinning cheer

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7Mental Health Policy IIThe History of Mental Health Policy in the United States Dorothea Dix (1802 1887)

Suffered a debilitating breakdown in her mid-thirties. In hopes of a cure, in 1836 she traveled to England , where she met men and women who believed that government should play a direct, active role in social welfare.

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8Mental Health Policy IIThe History of Mental Health Policy in the United States The Indigent Insane Bill

Promoted a grant of land for the relief and support of indigent, curable and incurable insane.

Provide asylums that would emphasize moral treatment

Humane treatment based on compassion and care rather than assigning mentally ill people to jails, poorhouses, or life on the streets.

Orderly routine with social contact, exercise and work rather than efforts to rid the body of demonic possession and corporal punishment.

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Mental Health Policy IIThe History of Mental Health Policy in the United States President Franklin Pierce Vetoes the Bill in 1854 "If Congress has the power to make provisions for the indigent insane, the whole field of public beneficence is thrown open to the care and culture of the federal government. I readily acknowledge the duty incumbent on us all to provide for those who, in the mysterious order of providence, are subject to want and to disease of body or mind, but I cannot find any authority in the Constitution that makes the federal government the great almoner of public charity throughout the United States."

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10Mental Health Policy IIThe History of Mental Health Policy in the United States Asylums Supported by States

Dix resumes her campaign, state by state, for the establishment of public asylums supported by state tax dollars.

Her advocacy led to the founding of 32 hospitals in 18 states.

Over time asylums changed from small therapeutic programs into large custodial public hospitals.

Concepts of "curability" were replaced by concepts of custody and chronicity.

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11Era of the Asylum (1850s to 1950)This is the time when many believe psychiatric treatment was at its lowest point.

The importance of the idea of eugenics, that humans who were mentally ill were genetically inferior to others and should not be allowed to pro-create to avoid polluting the gene plasm.

Pseudo-science predominated with virtually no control over what kind of treatments patients received:Insulin-shockHydrotherapyLobotomy

Mental Health Policy IIThe History of Mental Health Policy in the United States

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Hydrotherapy

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Insulin shock

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14Era of the Asylum (1850s to 1950)100 years of state-based approaches.Long term institutional careLarge hospitalsCustody rather than treatment

By the mid-1950s about 560,000 Americans resided in state supported institutions.

The average length of stay was measured in years. Many patients spent their entire lifetime in Asylums.


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15Deinstitutionalization Late 1950sMany factors led to deinstitutionalization: Journalistic exposs.

Introduction of chlorpromazine (thorazine) which initiated the psychopharmacologic revolution.

President Eisenhower's major study of the care of the mentally ill population:


Mental institutions were often viewed as inhuman snake pits factories for the manufacture of madness.

Evidence of social and functional deterioration following long-term care reinforced the notion that institutions caused chronic disorder.

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16Mental Health Policy IIThe History of Mental Health Policy in the United States Life Magazine Expose Bedlam 1946Pennsylvanias ByberryOhios Cleveland State

"All of a sudden America sees these photos that look like concentration camp photos. You see people huddled naked along walls, strapped to benches benches and it really is this descent into this shameful moment." - Robert Whitaker, author of Mad In America

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Life Magazine Expose

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18Mental Health Policy IIThe History of Mental Health Policy in the United States Life Magazine Expose

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19World War II

Several new ideas emerged with military psychiatry:

Proximity - treatment should occur as close as possible to where symptoms were exhibited. Immediacy - early identification and treatment lead to better outcomes.

Simplicity - the major part of intervention should consist of rest, nourishment, and social support

Expectancy - return to former functioning was possible. Mental Health Policy IIThe History of Mental Health Policy in the United States

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20The First CMHCs

The first CMHCs were principally devoted to consultation and education for community agencies.

Offered treatment to new groups of previously untreated, acutely ill, and emotionally troubled patients.

Few persons with severe and chronic illnesses were treated Mental Health Policy IIThe History of Mental Health Policy in the United States

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21Mental Health Study Act - 1955

In 1955 Congress passed the Mental Health Study Act to study the problems of mental illness.

The final report (1961 Action for Mental Health issued by The Joint Commission on Mental Health and Illness):

Immediate care be made available to mentally ill patients in community settings.

Fully staffed, full full-people US time mental health clinics be accessible to all people living in the US.

Community based aftercare and rehabilitation. Mental Health Policy IIThe History of Mental Health Policy in the United States

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22The Kennedys

In 1961 John F Kennedy became president. He had family experience with mental disability.

When she was 23, Kennedys father was told by doctors that his sister Rosemary Kennedys mood swings could be calmed through a cutting edge procedure. This is the doctors description of the surgery:

We went through the top of the head, I think she was awake. She had a mild tranquilizer. I made a surgical incision in the brain through the skull. It was near the front. It was on both sides. We just made a small incision, no more than an inch." The instrument Dr. Watts used looked like a butter knife. He swung it up and down to cut brain tissue. "We put an instrument inside," he said. As Dr. Watts cut, Dr. Freeman put questions to Rosemary. For example, he asked her to recite the Lord's Prayer or sing "God Bless America" or count backwards. ... "We made an estimate on how far to cut based on how she responded." ... When she began to become incoherent, they stopped. - James W. WattsMental Health Policy IIThe History of Mental Health Policy in the United States

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23The Kennedys

The lobotomy reduced her to an infantile mentality that left her incontinent and staring blankly at walls for hours and her verbal skills were reduced to unintelligible babble.

She lived out her life in a Wisconsin institution and died at the age of 86.

See: Torrey, E. F. (2013). American psychosis: How the federal government destroyed the mental illness treatment system. New York, NY: Oxford University Press.


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24Community Mental Health Movement (1960s through 1990s)Mental Health Policy IIThe History of Mental Health Policy in the United States In 1963, JFK addressed Congress on A Bold New Approach

A national mental health program to assist in the inauguration of a wholly new emphasis and approach to care for the mentally ill

Focus on comprehensive community care.

We need a new type of health care facility; one which will return mental health care to the mainstream of American medicine, and at the same time upgrade mental health services.

I recommend, therefore, that the Congress: Authorize grants to the states for the construction of comprehensive community mental health centers.

Authorize short term project grants for the initial staffing costs.

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25CMHC Construction Act of 1963Mental Health Policy IIThe History of Mental Health Policy in the United States The Mental Retardation Facilities and CMHC Construction Act signed on October 31, 1963.

Ended 109 years of federal noninvolvement in state services for the mentally ill.

Congress refused to authorize funds to hire staff for CMHCs.

Less than a month later President Kennedy was assassinated.

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26CMHC Construction Act of 1963

President Johnson signs amendments in 1965 that provide staffing grants (Accomplished out of sentiment for JFK)

In 1965 mental health catchment areas of 75,000 to 200,000 people all over the country began applying for federal grants.

Program based on federal seed money grants:

Local communities applied for federal funds that declined over several years.

Alternative funds like third-party payments were expected to replace declining federal grants. Mental Health Policy IIThe History of Mental Health Policy in the United States

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Provide five essential services: Inpatient Outpatient Day treatment Emergency care Consultation and education

Ensure continuity of care between the services.

Be accessible to the general population.

Serve people regardless of their ability to pay: a reasonable volume of services to the indigent


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Aside from the staff funding issue, there were several fundamental flaws in the 1963 act that first funded CMHCs which led to later problems:

Relationships with existing psychiatric hospitals were not spelled out or considered in any detail. This led to fragmentation of services (among other reasons) and no continuity of care.

Created a system that largely bypassed state authority (feds worked directly with local communities) because states were seen as inept and invested in psychiatric hospitals.

Population to be served was not well defined. This opened the door to the CMHCs providing care to the worried well and not to those with severe and persistent mental illnesses.


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29New Requirements, No New Funding

In the early 1970s Richard Nixon tried to discontinue the program but was rebuffed by the Democratic Congress.

In 1974 Gerald Ford vetoed the extension of the Community Mental Health Act.

Existing centers were supported by congressional continuing resolutions until a new bill could be developed.


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30New Requirements, No New Funding

In 1975 another extension was also vetoed by Ford on the grounds that it was too expensive but Congress overrode the veto by a wide margin.

Congress passed amendments that added more requirements for the mental health centers but did not appropriate the funds necessary to pay for the newly required services or to cover even half of the country in the time frame initially envisioned.

Services for children, the elderly, and chemically dependent persons as well as rehabilitation, housing, and preventive services. Mental Health Policy IIThe History of Mental Health Policy in the United States

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31After 1975 no new construction was attempted due largely to prohibitive costs. Actual federal dollars were reduced while inflation more than doubled the cost of construction and staffing costs.

Most CMHCs were focused on primary and secondary prevention programs: Crisis clinics and hot lines to prevent mental illness. Staff more interested in insight oriented psychotherapy than in case management and rehabilitation.

Severely mentally ill persons leaving state hospitals did not receive follow-up services necessary to live in the community. Failure to Meet GoalsMental Health Policy IIThe History of Mental Health Policy in the United States

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32Between 1955 and 1980 the population of state mental hospitals dropped from 558,000 to 140,000.

Were these people better off out of state hospitals?

CMHCs and DeinstitutionalizationMental Health Policy IIThe History of Mental Health Policy in the United States

Funds from the states that were supposed to follow patients from the hospital into the community did not provide sheltered housing and treatment.

Poverty, homelessness, and criminalization resulted.

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33Medicaid and Medicare had much more to do with the population decline in psychiatric hospitals than either the CMHCs or psychotropic drugs such as thorazine.

The locus of care for people with SPMI became nursing homes because of generous federal payments (Medicaid). In effect the states were cost-shifting the burden of care for people with SPMI to the federal government. (Illinois was/is a major offender.)

The shift from psych hospitals to nursing homes had nothing to do with improved quality of care. Some have attested that it had a lot to do (especially in Illinois) with the powerful and well moneyed nursing home lobby.CMHCs and DeinstitutionalizationMental Health Policy IIThe History of Mental Health Policy in the United States

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34State hospitals too started to shorten the length of stays (probably also for cost-saving and due to civil commitment laws).

Pressure on hospitals and psychiatry also from people such as Thomas Szasz who argued that mental illness was a myth and that individuals behaving in unconventional ways were being controlled.

Other Factors Leading to DeinstitutionalizationMental Health Policy IIThe History of Mental Health Policy in the United States

Tom Szasz & Tom CruiseThe thinking of Thomas Scheff was also important: Labeling Theory which posited that psychiatric diagnoses were convenient labels attached to individuals who violated conventional behavioral norms and led to stigmatizing them.

This too became an argument for not putting people in psychiatric hospitals.

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35The decline in state psychiatric hospitals also saw a rise in general hospitals adding specialty psychiatric wings. But these provided shorter-term, acute care.

A large increase in clinically trained mental health personnel including social workers together with the expansion of diagnostic categories in the DSM (DSM-IIIR and DSM-IV) led to a new and expanded group of people receiving psychiatric care of one type or another. CMHCs and DeinstitutionalizationMental Health Policy IIThe History of Mental Health Policy in the United States

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36One author (Grob) puts forth the hypothesis that there was a shift in the nature of people with psychiatric disorders in the 1970s that coincided with deinstitutionalization. The significance of this shift is that people who would have formerly been hospitalized were now in the community and even more difficult to treat in that context:

Baby boom children (large numbers).Treated in the community and not in hospitals.High rates of alcoholism and drug addiction (heroin and then cocaine).High rates of homelessness (veterans).Used psychiatric facilities but in an unsystematic way (also used ERs, jails, and prisons).Non-compliant with medications or treatment generally.CMHCs and DeinstitutionalizationMental Health Policy IIThe History of Mental Health Policy in the United States

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37Ironically, at the very time that unified, coordinated, and integrated medical and social services were needed to deal with a new patient population, the policy of deinstitutionalization had created a decentralized system that often lacked any clear focus and diffused responsibility and authority.

Their point is that as bad as the state psych hospitals were, they provided structure and consistency that was lacking in the CMHCs. CMHCs and DeinstitutionalizationMental Health Policy IIThe History of Mental Health Policy in the United States

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38The CMHC movement played out along several dimensions that repeat often (and swing back and forth in US policy in various areas). These are all good policy questions for consideration:

The role of the states versus the federal government?

Provide services to many people or focus on the few with the most severe disorders?

To what extent should prevention be a focus (Carter commission)?CMHCs and DeinstitutionalizationMental Health Policy IIThe History of Mental Health Policy in the United States

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Community Support ProgramsMental Health Policy IIThe History of Mental Health Policy in the United States CSPs were the NIMHs response to the unmet needs of the CMI (Chronically Mentally Ill).

By 1982 most of the states had received some sort of community support planning help for CMHCs.

Case managementPsychosocial rehabilitationSupported livingSupported workingCrisis care

New evidence-based practices (EBP).Assertive Community Treatment

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401977 Presidential Commission on Mental Health chaired by First Lady Rosalyn Carter.

Persons with chronic mental illness who had been deinstitutionalized lacked the basic necessities of life including adequate housing, clothing, and food.

Half of the people released from large mental hospitals were being readmitted within a year of discharge Reassessment of the CMHC ProgramMental Health Policy IIThe History of Mental Health Policy in the United States

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41National Mental Health Systems Act of 1980Mental Health Policy IIThe History of Mental Health Policy in the United States An effort to reinvigorate the CMHC program and redirect it to those with chronic mental illness.

Restructure federal, state, and local relationships allowing the states more control of the management and distribution of federal funds coming to local programs.

Give priority to vulnerable groups such as the chronically mentally ill, children, adolescents, and the elderly. Supported strengthening of personal and community supports (emphasis on support systems rather than treatment per se).Provide the most appropriate care in the least restrictive environment.

Signed one month before Carter lost the election to Reagan.

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42Withdrawal of Federal Government New Federalism Mental Health Policy IIThe History of Mental Health Policy in the United States

Reagan promises to reduce government waste and regulation and to return responsibility for many social programs to the states

The Omnibus Budget Reconciliation Act of 1981Repealed the Mental Health Systems Act of 1980Eliminated all of the federal initiatives of the previous 18 yearsEliminated all of the 10 federal regional offices of NIMHLack of capacity to supervise and provide technical assistance to surviving federal CMHCs

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43Withdrawal of Federal Government Mental Health Policy IIThe History of Mental Health Policy in the United States

OBRA 1981: Withdrew direct federal grant support from CMHCs and replaced it with block grants to the states Returned primary authority to states to decide how and to whom mental health services should be provided. Ceased to make official use of the term community mental health center to describe a unique entity. Only 754 of a possible 1,500 eligible catchment areas nationwide had applied for and received funding for CMHCs.CMHCs increased fees and reduced staffing and services Waiting lists developed Service quality decreased

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44MedicaidMental Health Policy IIThe History of Mental Health Policy in the United States Created in 1965 to provide health insurance for low-income parents, children, seniors, and people with disabilities.

Supplemental Security Income established in 1972 provided welfare to those disabled due to mental illness.

By the 80's all CMHCs switched to Medicaid and away from block grant money.

From 1981 through 1983, the Reagan administration attempted to purge SSI/SSDI roles through use of continuing disability investigations/reviews; eventually this was reversed and reforms in how SSI/SSDI mental health disabilities were determined was revised and made clearer.

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45CMHCs of TodayMental Health Policy IIThe History of Mental Health Policy in the United States CMHCs have survived but service priorities and the locus of cont have changed.

CMHCs remain the only option for mental health treatment for low-income uninsured people.

CMHCs have had to use revenues from a patchwork of funders to cover the costs of caring for uninsured and underinsured:

Paying patientsFederal governmentsState governmentsLocal governmentsFund raising

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46CMHCs of TodayMental Health Policy IIThe History of Mental Health Policy in the United States Availability of services have steadily decreased in the last twenty years.

Individuals often sit on waiting lists for extended periods or are turned away.

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47Mental Health Policy IIThe History of Mental Health Policy in the United States Reagan Administration

CMHC programs and deinstitutionalization were implemented without evidence of effectiveness of treatments and without a social welfare system for the disabled mentally ill.

Communities lacked availability of: Supported housing Community treatment approaches Vocational opportunities Income supports

Many became homeless Many became incarcerated

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48CMHCs could not handle the huge numbers of patients who had been released after spending months or years in the large institutions:

Nowhere in our society is the debacle of deinstitutionalization felt more than in our criminal justice system. Americas jails and prisons are now surrogate psychiatric hospitals for thousands of individuals with the severest brain diseases.Treatment Advocacy Center Briefing Paper. Criminalization of individuals with severe psychiatric disorders. 4/2007

10- 16% of US inmates have serious psychiatric illnesses like schizophrenia, bipolar disorder and disabling depression. Mental Health Policy IIThe History of Mental Health Policy in the United States Out of the Asylum Into the Cell

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49Mental Health Policy IIThe History of Mental Health Policy in the United States Hindsight

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50Mental Health Policy IIThe History of Mental Health Policy in the United States HindsightMany of those patients who left the state hospitals never should have done so. We psychiatrists saw too much of the old snake pit, saw too many people who shouldn't have been there and we overreacted. The result is not what we intended, and perhaps we didn't ask the questions that should have been asked when developing a new concept, but psychiatrists are human, too, and we tried our damnedest.

Dr. Robert H. Felix, past director of the NIMH and a major figure in the shift to CMHCs

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51Mental Health Policy IIThe History of Mental Health Policy in the United States HindsightThe psychiatrists involved in the policy making at that time certainly oversold community treatment... the policies were based partly on wishful thinking, partly on the enormousness of the problem and the lack of a silver bullet to resolve it, then as now.

Dr. John A. Talbott, past president of the American Psychiatric Association

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52Health Security Act of 1993 (would have):Provided universal health care coverage for all Americans including coverage for mental health careIntended to eliminate two-tier system of careDefeated by intense lobbying underwritten by the AMA and insurance companies quality of health care would decreaseunnecessary big government successful Harry and Louise commercialsLed to 3-tier structurePublic (Medicaid and Medicare)Private not-for-profitPrivate for-profitMental Health Policy IIThe History of Mental Health Policy in the United States A Failed Attempt at Universal Healthcare

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53Compare the original Harry and Louise ad, circa 1994:https://www.youtube.com/watch?v=Dt31nhleeCg

With this ad designed to dissuade people from supporting the Affordable Care Act circa 2013:https://www.youtube.com/watch?v=rMnojpcSqwg

The message is the same: government interference in health care is bad.

Mental Health Policy IIThe History of Mental Health Policy in the United States A Failed Attempt at Universal Healthcare

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54Definition: Any kind of health care services which are paid for, all or in part, by a third party (including any government entity) and for which the focus of any part of clinical decision-making is other than between practitioner and the client or patient.

HMO Act of 1973 established HMOs and required that they included outpatient mental health services.

Increasingly, states have turned to some form of managed care for Medicaid and Medicare including Illinois.

The County Care program relies on a managed care model of services (rather than fee-for-service) for new Medicaid enrollees (up to 138% of fpl).Managed Care Era (1990s through 2010)Mental Health Policy IIThe History of Mental Health Policy in the United States

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55Many managed care programs have behavioral health carve-outs with a separate company managing mental health and substance abuse services.

Most often, separate company does not cover or include prescription drug benefits (incentive to shift cost back to other company) resulting in disincentive for psychotherapy.

Pharmacy Benefit Managers and Formularies often determine who gets what drugs including psychotropic drugs.Mental Health Policy IIThe History of Mental Health Policy in the United States Managed Care Era (1990s through today)

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56Consumer-driven movement to improve quality of care with emphasis on helping individuals assimilate back into society to the fullest extent possible

Recovery versus decline over the life course.

Consumer and advocate input on treatments and policies.Recovery Era (2000s through today?)Mental Health Policy IIThe History of Mental Health Policy in the United States

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57Created by the Bush Administration to:

study the mental health service delivery system, and to make recommendations that would enable adults with serious mental illnesses and children with serious emotional disturbance to live, work, learn, and participate fully in their communities.

Presidents New Freedom Commission on Mental Health (2003)Mental Health Policy IIThe History of Mental Health Policy in the United States

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58The final report enumerated 6 goals, each with recommendations on how they might be achieved:

Americans understand that Mental Health is essential to overall health.

Mental health care is consumer and family driven.

Disparities in mental health services are eliminated.

Early mental health screening, assessment, and referral to services are common practice.

Excellent mental health care is delivered and research accelerated.

Technology is used to access mental health care and information.

Presidents New Freedom Commission on Mental Health (2003)Mental Health Policy IIThe History of Mental Health Policy in the United States

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59Provides drug benefits under a complicated formula to Medicare recipients and includes psychotropic drugs.

Disincentive to provide medication for those with a severe mental illness under Part D (stand-alone drug plans) and the formularies may be gerrymandered to not include the best medications.

Dually eligible (Medicaid-Medicare) may be hurt the worst. Medicare Prescription Drug Improvement , and Modernization Act (2003)Mental Health Policy IIThe History of Mental Health Policy in the United States

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60Mental Health Parity Act (1996) Close insurance coverage gap between mental health medical insurance coverage.Had many loopholes:Only companies over 50 employees.No requirement to offer mental health benefits. Waiver if too costly to comply.Limits could be set using managed care techniques (10 sessions).

Mental Health ParityMental Health Policy IIThe History of Mental Health Policy in the United States

In 1999, Clinton directs OPM to implement parity in FEHB.

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61Mental Health Parity and Addiction Equity Act (2008):

Continued to apply to employers with >= 50 employees.Closed loopholes for treatment limits, cost-sharing, and network coverages. Applied to substance abuse as well as mental health treatment.

The ACA applied MHPEA to health plans purchased by individuals and on the small business exchange (SHOP).


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62Remaining issues:

Inadequate supply of MH/SA treatment: especially in rural areas and in pediatrics.

Non-equivalence of services: How to provide coverage for care levels and treatment venues that are unique to behavioral health, and aligning these with medical and surgical benefits, is a continuing discussion within health plans and between plans and regulators.

Segregated services: Another obstacle to care that persists despite passage of parity legislation is the fragmentation of the American health care delivery system. Arguably, one reason patients with mental health and substance use disorders experience fragmentation is due to the use of carve-outs for providing mental health/substance use benefits.


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63Main provisions:

Integrate physical and mental health States eligible for 2 million over 5 years. Identify barriers and work to resolve them.

Designate an Assistant Secretary for Mental Health and Substance Use within DHHS.

Establish new grants for early intervention for children as young as 3 and support pediatrician consultation with mental health teams.

Establish interagency SMI Coordinating Committee under Assistant Secretary to promote research and treatment.

Repeal Medicaid exclusion on inpatient care for persons 22 64 if no net increase in spending certified by CMS.

Mental Health Reform Act (Proposed Cassidy-Murphy)Mental Health Policy IIThe History of Mental Health Policy in the United States

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Mental Health Policy - The History of Mental Health Policy in the United States

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