This article was published in a special North Carolina Insight report on the History of Mental Health Reform in North Carolina in March 2009.
“Whereof what’s past is prologue, what to come In yours and my discharge.” — William Shakespeare, The Tempest
Recent exposés about the severe problems in the implementation of North Carolina’s 2001 mental health reform legislation inevitably lead to the broader question of how North Carolina got where it is today—which in some, but certainly not all, respects is a malfunctioning mental health care system. The answer is inex- tricably linked to the history of mental health reform in our country. This includes earlier reforms such as the asylum movement in the 1800s, which led to the creation of the state psychiatric hospital system. It also includes the federal community- based initiatives beginning after World War II and blossoming in the 1960s, which shifted the mental health paradigm in a completely different direction and ushered in a greatly expanded federal role. The threads of these prior movements are still at play today since state hospitals play, at a minimum, a vitally necessary “safety net” role in the provision of mental health services for the most severely and persistently mentally ill, even though community-based facilities have as a practical and legal matter supplanted the role of institutional care as the more advantageous approach to the care and treatment of the mentally ill.1
A review of the evolution of mental health policy also illustrates that regardless of the nature of the reform, there are four complex and not easily resolved core issues that remain to be addressed.
- Governance—What is the responsibility of each level of government for the welfare of the mentally ill?
- Coverage—Which individuals and disabilities should be included in government-provided mental health care and what services should be paid for by the government?
- Work force—Is there an adequate supply of trained workers who can care for the mentally ill and provide treatment?
- Funding—How will the necessary services be paid for? As demonstrated below, at various times the answers provided were different, but all of these issues remain as central to today’s reforms as they were in 18th century America.
In addition, it is clear that providing an answer to the questions above does not always result in the consequences intended. This too is true of today’s more modern reforms in North Carolina where the most severely and persistently ill were certainly intended to be beneficiaries of the reform efforts but, as in the past, are often the ones who are most left out in the cold.
“Health organization and policy never arise anew. They evolve from prior culture and understandings, health care arrangements, health professional organizations, and political and economic processes.”—David Mechanic, Ph.D.
Finally, the prior reforms demonstrate that any major mental health reform evolves over time—sometimes decades or longer. The “Catch-22” (generally used to reference a no-win situation) of this reality is that the passage of time also inevitably involves other unexpected changes (such as state budgetary crises, changes in government administrations elected with different priorities, or scientific discoveries affecting the type and place of treatment and care) that can impact the success or failure of the reform either short or long-term.
“Historical knowledge can deepen the way in which we think about contemporary issues and problems. It can also sensitize us to the dangers of simplistic solutions.” —Gerald N. Grob, Ph.D.
The history of reform shows that improving the treatment and care of the mentally ill is a complex process that evolves incrementally—sometimes with major leaps forward followed by substantial retreats. Finding solutions is not simple, but history can help illuminate the policy and funding issues that in many ways help shape future reform, as well as stand as a testament to the fact that progress can be achieved as long as the public will and legislative commitment to reform are strong. As stated by mental health policy scholar Dr. David Mechanic, “Effective treatment of mental illness in future decades will depend on advances in knowledge and technology and on the social and political factors that affect social policies in general and mental health policies in particular.”2
An awareness of why the mental health system functions as it does at present and what has and has not worked in the past also can play an invaluable role.
See the full PDF of the report here
- The U.S. Surgeon General’s 1999 report, “Mental Health: A Report of the Surgeon General,” notes that Mental illness is the term that refers collectively to all diagnosable mental disorders. Mental disorders are health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning. Alzheimer’s disease exemplifies a mental disorder largely marked by alterations in thinking (especially forget- ting). Depression exemplifies a mental disorder largely marked by alterations in mood. Attention- defcit/hyperactivity disorder exemplifies a mental disorder largely marked by alterations in behavior (overactivity) and/or thinking (inability to concentrate). Alterations in thinking, mood, or behavior contribute to a host of problems—patient distress, impaired functioning, or heightened risk of death, pain, disability, or loss of freedom (American Psychiatric Association, 1994). On the Internet at http://www.surgeongeneral.gov/library/mentalhealth/chapter1/sec1.html. ↩
- David Mechanic, Chapter 7: “Mental Health Policy at the Millennium: Challenges and Opportunities” in Mental Health, United States, 2000 by the Center for Mental Health Services, Manderscheid, R. W., and Henderson, M. J., eds., DHHS Pub No. (SMA) 01-3537, U.S. Government Printing Office, Washington, DC, 2001. On the Internet at http://mentalhealth.samhsa.gov/publications/allpubs/SMA01-3537/default. asp. ↩