This article on the history of mental health reform in NC was published in a special North Carolina Insight report in March 2009.
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.
A review of the evolution of mental health policy in the state 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? 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 parameters 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.
America’s Post-Revolutionary Period: The Asylum Movement
During America’s post-Revolutionary period, the Founding Fathers focused on creating a new governmental framework that limited the functions of the federal government and retained a large reservoir of power for state governments. Under this framework, responsibility for the health and social welfare of American citizens, including individuals who suffered from mental illness, was relegated solely to state and local, rather than the federal, government. The mere assignment of such responsibility, however, did not automatically translate into the development by the states or local communities of coherent policies for the mentally ill. Rather, early approaches in caring for them tended to focus on families as caregivers and ad hoc charitable and community-based efforts. Although North Carolina authorized county courts to appoint guardians for the mentally ill in order to protect their property, the state refused to assume any further responsibility on their behalf until the mid-1800s.
The central role played by local communities in the care of the mentally ill shifted significantly in the early 1800s with the emergence of the asylum movement, which promoted the view that the older, ad hoc community ways, which had often resulted in cruel and inhumane treatment, should be replaced by a system of public mental hospitals to care for and treat citizens with severe and persistent mental disorders. In the first 50 years of the 19th century, 20 such institutions in 19 states were established whose focus was not only on the support and maintenance of the mentally ill, but also the development of methods for curing these patients. As a result of the asylum movement, the mental hospital became a public policy priority until after World War II.
Despite the efforts of several North Carolina governors in the 1820s and 1830s to make care of the mentally ill a legislative priority, North Carolina was next-to last among the original 13 colonies to enact legislation for the establishment of a state asylum, primarily because the cost of constructing an asylum was considered too high. Dorothea Dix, a crusader for the humane treatment of the mentally ill and ardent advocate of the asylum system, appealed to the hearts, minds, and pocketbooks of the state legislature, noting that the costs of treating, and in many instances curing, the mentally ill in state hospitals was 32 times less expensive to the state or local coffers than leaving them untreated in either poor houses, jails, or other unsuitable environments.
Construction of the North Carolina Insane Asylum in Raleigh was completed in 1856. Before the turn of the 20th century, two additional psychiatric facili- ties had been approved and built in North Carolina. Broughton Hospital in Morganton, which serves the 27 westernmost counties, admitted its first patient in 1883. Goldsboro’s Cherry Hospital was named the “Asylum for the Colored Insane” when it opened in August 1880. Until the implementation of the Civil Rights Act 85 years later, this hospital served the entire black population of the State of North Carolina. It now serves 33 eastern North Carolina counties.
After the Civil War: A State Responsibility
The post-Civil War years saw a dramatic increase in the number of mentally ill and demand for placement in the state asylum. In response, in 1868, for the first time the state constitution provided for the maintenance of penal and charitable institutions as follows:
Such charitable, benevolent, penal, and correctional institutions and agencies as the needs of humanity and the public good may require shall be established and operated by the State under such organiza- tion and in such manner as the General Assembly may prescribe.
For the first half of the 20th century, the emphasis on the use of asylums to address mental health issues and dual responsibility between the state and counties was the norm in North Carolina. Up until the 1940s, public hospitals cared for nearly 98 percent of all institutionalized mental patients, two-thirds of the members of the American Psychiatric Association practiced in public institutions, and there was little impetus to question the role of state mental hospitals in the treatment of the mentally ill, even if policymak- ers did not always agree on policy details or the quality of some institutions was sub-par.
Post-World War II: A Shift to Community-Based Care
During and after World War II, however, the paradigm started to shift when activists began to promote a new mental health policy that moved away from the care and treatment of the severely ill in state institutional settings and towards community-based alternative settings. Numerous factors pro- pelled this change during the last half of the 20th century including: (1) the changing composition of the asylum population; (2) the changing nature of the psychiatric model; (3) the creation of effective psychotropic drugs;
(4) the emergence of legal advocates for the mentally ill and a more active judiciary; (5) the decline in quality and image of state institutions; and, most significantly, (6) the federal government’s foray into mental health policy- making and funding directly through mental health legislation and indirectly through Social Security entitlement programs.
Although the goal of the community-based movement was eventual elimi- nation of state hospitals, during the 1950s most states supported both with attempts to improve state hospital conditions as well as expand community services. According to Gerald Grob, a professor at Rutgers University, in an article on the development of mental health policy in America, community- based initiatives that began to develop during the 1950s included “general hospital psychiatric units, outpatient clinics, halfway houses, day hospitals, social clubs for ‘ex-patients,’ family care, anti-stigma interventions, preventive services, and the use of visiting professional teams to go into patients’ homes, private doctors’ offices, or remote rural areas.” Problems remained, however, albeit in a different venue.
The Entrance of the Federal Government
The states remained solely responsible for mental health policy and, in most instances, continued mainly to pursue traditional institutional solutions while dabbling in community alternatives. The ultimate factor that tipped the bal- ance from an institutionally-based to a community-oriented mental health policy was the decision of the federal government to take responsibility for promoting the mental health of all Americans. A series of post-World War II legislative enactments helped promote community mental health and dein- stitutionalization practices. The federal government’s role as the key agent of reform and innovation in public mental health policy continued for approxi- mately 35 years until the early part of President Reagan’s administration.
In reality, however, the state hospitals proved resistant to change due to several factors including (1) continuing support from community residents and hospital employees; and (2) the existence of a group of mentally ill individuals who were so disabled that institutional care appeared to be the only option. Thus, despite dehospitalization, state hospitals remained the largest provider of total inpatient days of psychiatric care and, in their common role as the system of last resort, their patients disproportionately came from the ranks of the uninsured, treatment resistant, the most dif- ficult, troubled, and violence-prone, and those most difficult to relocate to alternative settings.
The Americans with Disabilities Act and the Olmstead Decision
The community-based movement gained further strength in the 1990s due to significant legislation at the beginning of the decade and a decision by the U.S. Supreme Court at the end. In 1990, Congress enacted the Americans
with Disabilities Act (ADA) to eliminate discrimination against those with dis- abilities. The ADA applies to all public entities and the use of public funds; therefore, it has implications for publicly-funded Medicaid services to people with mental and other disabilities.
Nine years after the enactment of the ADA, the U.S. Supreme Court held in Olmstead v. L.C. that the ADA requires states to provide placement in com- munities for individuals with disabilities if the state’s treatment professionals have determined that such community-based placement is appropriate, if the individuals affected do not oppose such placement, and if such placement can reasonably be provided considering the state’s resources and the need of others with disabilities. The decision challenged all levels of government to create “additional opportunities for individuals with disabilities through more accessible systems of cost-effective community-based services.”
During the last decade of the 20th century, North Carolina’s public mental health system consisted of: (1) state-operated services under the supervi- sion of the N.C. Division of Mental Health, Developmental Disabilities, and Substance Abuse Services including the four psychiatric hospitals (built between the 1850s and the 1940s), developmental disability centers, and alcohol and drug rehabilitation centers; (2) 39 multiple or single-county semi-autonomous governmental area programs created in the 1970s that provided direct services; and (3) private, non-profit and for-profit provid- ers who offered services through purchase of service contracts with area programs. This system’s dysfunction, especially in light of the U.S. Supreme Court’s Olmstead decision, became painfully evident in the 1990s.
North Carolina’s 2001 Reform Legislation
A central outcome of North Carolina’s 2001 reform legislation was (1) the transfer, over a multi-year period, of management and oversight functions of mental health, developmental disability, and substance abuse programs from the existing quasi-independent local area authorities to fully governmentally accountable local management entities; and (2) privatization of mental health services by divesting clinical services from public area authorities to private nonprofit and for-profit provider groups. As a result, North Carolina will ef- fectively be operating dual systems—both state institutions and community centers—for anywhere from seven to 10 years, if not longer.
Like the asylum movement and federal community-based initiative, North Carolina’s 2001 mental health reform has resulted in both successes and
failures and continues to be a work in progress with the threads of both prior movements still playing significant roles. The legislation’s vision is to provide: (1) community-based rather than institutional services and support;
(2) a system that is participant-driven, prevention-focused, outcome-oriented, reflective of best practices, cost-effective, community-integrated, with re- source equity and fairness throughout the state; (3) screening, triage, and referral to everyone in need; and (4) other services and support to those most in need, including the most seriously mentally ill or disabled, racial/ethnic minorities, and individuals with more than one disorder. However, from the beginning, individuals involved in the reform effort have expressed concerns about how the vision would be implemented. According to Drs. Marvin Swartz and Joseph Morrissey, “The reform plan clearly proposed targeting care to those most in need; but defining the population most in need, esti- mating their clinical needs and proposing a financing plan to address these needs are a daunting set of challenges.”
The current state of mental health reform in North Carolina cannot be viewed in a vacuum. Rather, the ghosts of past reforms continue to play a significant role from the continuing existence of state psychiatric hospitals to the cre- ation of additional community options to the current funding patterns with interwoven threads of federal, state, and local dollars. An understanding of past policy decisions that have dramatically impacted the care and treatment of the mentally ill today should serve to guide future reform efforts which, as with past efforts, continue to focus on these central issues:
What is the responsibility of each level of government for the welfare of the mentally ill?
Which individuals and disabilities should be included in government- provided mental health care and what services should be paid for by the government?
Is there an adequate supply of trained workers who can care for the mentally ill and provide treatment?
How will the necessary services be paid for?
Going forward, reform has to be a state priority and not just on the front burner when there is a newspaper exposé or a leader committed to raising the profile of the issue. A system 200 years in the making cannot be reformed overnight. The success of reform efforts going forward will depend on leader- ship, funding, time and support for development, and a qualified work force.