III. The 20th Century
IV. Mental Health Policy and Services Today
V. Who Are the Mentally Ill?
A. Consumer Choice and Involuntary Treatment
B. Mental Illness and Criminal Justice
Mental health has been and still is a problematic policy area. People with mental illness have faced many problems from society throughout the ages. In the past, people with mental illness were often believed to be possessed by demons or the devil and were left in the care of their families or left to wander. They were sometimes mistreated. Eventually, society chose to hospitalize people with mental illness, but their status was reflected in Pennsylvania, where the first mental hospital was placed in the basement of the general hospital. Mental health has continued to be the poor stepchild of the wider health care arena.
Institutional care began in a few Arab countries; asylums were established as early as the eighth and ninth centuries to care for people with mental illness. Somewhat later in Europe, during the Middle Ages, the community began to seek confinement of people who were different. Some monasteries housed the mentally ill, usually treating them well. As societies became more urban and families became less able to care for persons with mental illness, eventually society chose to hospitalize people with mental illness.
In 1828, Horace Mann, an educational reformer, put forward a philosophy of public welfare that called for making the “insane” wards of the state. This philosophy was widely put into effect, and each state assumed responsibility for those with mental illness in that state. States often built their psychiatric hospitals in rural areas. Moral treatment and compassionate care were the main approach at this time, but with rapid urbanization and increased immigration, the state mental health systems began to be overwhelmed. Many elderly people who in rural areas would have been cared for at home could no longer be cared for when their families moved into the cities. Women, as well as men, frequently worked away from home, and there was no one to care for the elderly or see to their safety. Many people with brain-based dementias, probably caused by Alzheimer’s or small strokes, became patients in mental institutions for the remainder of their lives. The institutions also had many cases of people in the last stages of syphilis. Many of those suffering from mental retardation, epilepsy, and alcohol abuse were also committed to the institutions; in hard economic times, the number of people admitted to the institutions increased.
By 1861, there were several state mental hospitals, and one federal hospital in Washington, DC. In the second half of the 19th century, attitudes changed and group and treatment practices deteriorated. Massive immigration to the United States led to a growing proportion of foreign-born and poor in the state hospitals. Most psychiatrists, community leaders, and public officials were native-born and generally well off and thus apt to be prejudiced against those who were neither (Rochefort 1993).
As more and more people were admitted to the institutions, the focus changed from treatment to custodial care. Commitment laws sent the dangerous and unmanageable to the state hospitals. More patients were alcoholic, chronically disabled, criminally insane, and senile. Treatment practices deteriorated. The institutions became overcrowded, and, by the late 19th century, the state hospitals were places of last resort, with mostly long-term chronic patients. Better treatment was found in small private psychiatric hospitals for those who could afford the care.
The 20th Century
As the 19th century drew to a close, a new idea, promoted by what is known as the eugenics movement, took hold. This movement held that insanity could be inherited. Professional conferences, humanitarian groups, and state legislatures increasingly identified insanity as a special problem of the poor. Insane persons were increasingly seen as possibly violent and incurable and as a threat to the community (Caplan 1969). These beliefs led to numerous state laws restricting the lives of people with mental disabilities, including involuntary sterilization laws and restrictive marriage laws. As a result, 18,552 mentally ill persons in state hospitals were surgically sterilized between 1907 and 1940. More than half of these sterilizations were performed in California (Grob 1983, 24).
Mental hospitals turned to the use of mechanical restraints, drugs, and surgery. Psychiatrists spent time diagnosing large numbers of patients rather than delivering individualized care. State legislatures did not increase budgets to meet the needs of the growing hospitals. Physical plants became overcrowded and deteriorated. Salaries were not adequate to attract good personnel. Superintendents no longer saw patients but spent their time on administrative tasks, and their influence declined as they became subordinate to new state boards of charity, which were focused on efficiency (McGovern 1985).
The first half of the 20th century saw some promising new treatment developments and attempts to establish community-based systems of services. In 1909, Cliff ord Beers founded the National Committee for Mental Hygiene to encourage citizen involvement, prevention of hospitalization, and aftercare for those who left the hospitals. The custodial institutions remained the main site of care, but some institutions developed cottage systems that placed more able patients in small, more homelike structures on the hospital grounds, and family care programs were created to board outpatients. All these approaches, however, served only a small part of the population.
Although the Division of Mental Hygiene was created in 1930 in the U.S. Public Health Service, it did not address institutional or community mental health care in general but only narcotics addiction. During the Great Depression of the 1930s and World War II, few resources were available to psychiatric institutions, but they continued to grow anyway. Some hospitals had as many as 10,000 to 15,000 patients. From 1930 to 1940, the number of people in state mental hospitals increased five times faster than the general population to a total of 445,000 (Rothman 1980, 374).
Four new therapies arose in the 1930s: insulin coma therapy, metrazol-shock treatment, electroshock therapy, and lobotomy. These treatments were given to thousands of patients, in many cases with devastating results; nevertheless, they were widely used until the appearance of antipsychotic medications in the 1950s.
The National Mental Health Act of 1946 brought the federal government into mental health policy in a significant way. The act created new federal grants in the areas of diagnosis and care, research into the etiology of mental illness, professional training, and development of community clinics as pilots and demonstrations. The act mandated the establishment of a new National Institute of Mental Heath (NIMH) within the Public Health Service to encourage research on mental health.
The states moved toward reform when, in 1949, the Governors’ Conference released a report detailing the many problems in public psychiatric hospitals, including obsolete commitment procedures; shortages of staff and poorly trained staff ; large elderly populations; inadequate equipment, space, and therapeutic programs; lack of effective state agency responsibility for supervision and coordination; irrational division of responsibility between state and local jurisdictions; fiscal arrangements damaging to residents; and lack of resources for research. In 1954, a special Governors’ Conference on Mental Health adopted a program calling for expansion of community services, treatment, rehabilitation, and aftercare.
During the 1950s, the states pursued both institutional care and expansion of community services. In the mid-1950s, major deinstitutionalization of hospitals began. The introduction of psychotropic medicines to reduce and control psychiatric symptoms created optimism that some mental illnesses could be cured and others could be modified enough to allow persons with mental illness to function in the community. Because of the apparent success of the drugs, more emphasis was placed on a biochemical view of mental illness. The discovery and use of psychotropic drugs in the 1950s had a profound impact on the treatment of the mentally ill. Tranquilizing drugs were widely used in the state institutions and played a major role in deinstitutionalization. Early discharge programs became common, and the inpatient census of public psychiatric hospitals continued to steadily decline.
In 1955, the Mental Health Study Act was passed, leading to the establishment of the Joint Commission on Mental Illness and Health, which prepared a survey and made recommendations for a national program to improve methods and facilities for the diagnosis, treatment, and care of the mentally ill and to promote mental health. The commission recommended the establishment of community mental health centers and smaller mental hospitals. It laid the groundwork for the Community Mental Health Centers Act of 1963. During the 1960s, the civil rights movement and public interest law strengthened mental health policy and encouraged community mental health treatment and the decline of the role of psychiatric hospitals. The belief that the community would be involved in care for the mentally ill became more widely accepted, and the passage in 1965 of Medicaid and Medicare stimulated the growth of skilled nursing homes and intermediate-care facilities. In 1971, Title XIX of the Social Security Act (Medicaid) was amended to require institutional reform and the meeting of accreditation standards by facilities in order to receive federal funding. But the fiscal erosion of the 1970s and the 1980s took a heavy toll on state and local mental health programs.
In 1990, only one in five of those with mental illness received treatment (Castro 1993, 59). The National Institute of Mental Health estimated the cost of treating mental illness at $148 billion, which included $67 billion for direct treatment (10 percent of all U.S. health spending) and $81 billion for indirect costs such as social welfare and disability payments, costs of family caregivers, and morbidity and mortality connected to mental disorders (Castro 1993, 60).
In the U.S. Department of Health and Human Services, from which federal funding still largely comes, mental health programs were organized in 1992 into the Substance Abuse and Mental Health Services Administration, consisting of the Center for Mental Health Services, the Center for Substance Abuse Prevention, and the Center for Treatment Improvement. The institutes on mental health, drug abuse, and alcohol and alcohol abuse were shifted to the National Institutes of Health and began to focus only on promotion of research in mental health and substance abuse. The Department of Veterans Affairs and the Bureau of Indian Affairs in the Department of the Interior provided community mental health services directly in a number of locations.
Once states became responsible for the distribution of the federal grant funds for mental health, many funds were shifted from the community mental health centers to community mental health services more responsive to the needs of the seriously mentally ill (Hudson 1983). The complex intergovernmental array of organizations involved made coordination difficult.
Mental health care continued to be both inpatient and community based, but the site of inpatient care shifted from state institutions to general acute care hospitals in the community, with many people seen in psychiatric units in general acute care hospitals or in short-term public or private community inpatient facilities. Children began to be able to receive services in special community or residential treatment centers for children. The cost of inpatient care rose at all sites, but most sharply in general hospitals. Total costs were held in check because the length of stay decreased. Most of the decrease occurred in state mental hospitals and Veterans Administration facilities, even though those facilities had the longest stays (Kiesler and Sibulkin 1987). Community inpatient services were complemented by community outpatient services, such as the private practices of mental health professionals, family services agencies, community mental health centers, social clubs, day hospitals, halfway houses, group homes, assisted housing, and foster care.
Mental Health Policy and Services Today
In the 21st century, the history of modern mental health care continues to be complex and cyclical. There is a tug and pull between many of the viewpoints about mental illness. Should people with mental illness be free to manage their lives as they see fit, or should there be social control by the government? Is mental illness physical, environmental, or both? Is mental illness a part of physical illness, a brain disease or disorder?
As was the case in the 20th century, the United States continues to have no national mental health system. Each state has its own distinctive system. This approach allows for adjusting programs to the unique characteristics of different states and communities but has the disadvantage of creating disparities and differences in levels of community services. The private, nonprofit, and public sectors all play major roles in the delivery of services to people with mental illness. The system remains two-tiered, with lower-income people relying on the public sector and higher-income people on the private sector. People with insurance or sufficient income can access private mental health providers, from private psychotherapists, to general hospital psychiatric units in private and nonprofit hospitals, to private psychiatric facilities. The public mental health system remains the provider of last resort for people needing mental health services. However, there is a trend for more of these services being contracted out to the private sector rather than being provided by public agencies. The missions of most state mental health agencies focus resources on people with the most severe and persistent mental illnesses, such as bipolar disorder and schizophrenia.
The states remain the critical players in the development and maintenance of the public mental health system. “In fact, mental health more than any other public health or medical discipline, is singled out for exclusion and discrimination in many federal programs because it is considered to be the principal domain of the states” (Urff 2004, 84). In most states, the mental health system is administered by a state mental health agency. This agency may be an independent department but is most often an agency within a larger department, usually health or social services. As states downsize and close public psychiatric hospitals, services provided by private and nonprofit organizations take on increasing importance.
Who Are the Mentally Ill?
Mental disorders occur across the lifespan, affecting all people regardless of race, ethnicity, gender, education, or socioeconomic status. The World Health Organization has estimated that approximately 450 million people worldwide have mental and behavioral disorders, and mental disorders account for 25 percent of all disability in major industrialized countries (World Health Organization 2001, 7). The most severe forms of mental disorders have been estimated to affect between 2.6 and 2.8 percent of adults aged 18 years and older during any one year (Kessler, Berglund, Zhao, et al. 1996; National Advisory Mental Health Council 1993). About 15 percent of adults receive help from mental health specialists, while others receive help from general physicians. The majority of people with mental disorders do not receive treatment, and 40 percent of people with a severe mental illness do not look for treatment (Regier, Narrow, Rae, et al. 1993). Ronald C. Kessler, principal investigator of the National Comorbidity Survey Replication study, and colleagues (1996) determined that about half of Americans will meet the criteria for a DSM-IV (the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders) diagnosis of a mental disorder over the course of their lifetime, with first onset usually in childhood or adolescence. Based on their analysis, lifetime prevalence for the different classes of disorders were anxiety disorders, 28.8 percent; substance use disorders, 14.6 percent; and any disorder 46.4 percent. Median age of onset is much earlier for anxiety and impulse control disorders (11 years for both) than for substance abuse (20 years) and mood disorders (30 years) (Romano 2005).
The disease model of mental illness remains important. For the seriously mentally ill, it places a focus on finding and treating the causes of the emotional, behavioral, and/or organic dysfunction, with an approach based on diagnosis, treatment, and cure or recovery. The treatment focus is on short-term inpatient care, with the emphasis on medications and the ability to function in the community. Various services are provided to assist maintenance in the community, including housing, employment, and social services.
The mental health approach to people with less serious emotional disorders is focused on outpatient treatment, often through prescription of medication by a general practitioner. Primary care physicians provide at least 40 percent of mental health care. Employee assistance programs help employees in the workplace with assessment of mental health issues and referral to appropriate treatment sources. Those who are less seriously mentally ill are sometimes referred to in a derogatory way as the “worried well.” When resources are short, conflict can arise as those who speak on behalf of the seriously and chronically mentally ill do not wish to see resources expended on the less seriously ill. However, many people at one time need assistance with a mental health problem in their lives, and failure to address their problems can lead to significant costs to society, including suicide.
Studies suggest that the prevalence of mental illness is about equal in urban and rural areas, but access to services is much more difficult in rural areas. Ninety-five percent of the nation’s rural counties do not have access to a psychiatrist, 68 percent do not have access to a psychologist, and 78 percent lack access to social workers (California Healthline 2000).
Consumer Choice and Involuntary Treatment
What is now known as the consumer, or survivor, movement is generally recognized as having begun in the early 1970s, when several small groups of people who had been involved in the mental health system began to meet in several cities to talk about their experiences. They began to develop agendas for change.
Involuntary treatment is an issue that engages the attention of not only mental health consumers but family groups, providers, citizen advocacy groups, and law enforcement. On one side of the issue are those who would outlaw the use of force and coercion completely to protect individuals from dangerous interventions and abuse. They believe forced treatment violates basic civil and constitutional rights and erodes self-determination. They also believe forced treatment can lead to distrust and an avoidance of voluntary treatment. Those favoring involuntary treatment are found along a continuum, ranging from those who believe such treatment is justified only under extreme situations, when people are demonstrably dangerous to themselves or others, to those who believe involuntary treatment is acceptable based on a broad set of criteria.
Mental Illness and Criminal Justice
Along with homelessness and other negative outcomes of deinstitutionalization, the number of mentally ill in the correctional system has increased sharply. Crime, criminal justice costs, and property loss associated with mental illness cost $6 billion per year in the late 1990s, and people with mental illnesses are overrepresented in jail populations (U.S. Department of Health and Human Services 1999). Many of these inmates do not receive treatment for mental illness. A recent report by the Pacific Research Institute for Public Policy on criminal justice and the mentally ill noted that the total costs for state and local governments for arrest, processing in court, and jail maintenance of people with mental illnesses exceeds the total state and local government expenditures on mental health care. According to a 1999 Department of Justice report, more than 16 percent of adults in jails and prisons nationwide have a mental illness, and more than 20 percent of those in the juvenile justice system have serious mental health problems (Pyle 2002). There are more mentally ill people in U.S. prisons and jails (283,000 in 1998) than in mental hospitals (61,772 in 1996) (Parker 2001).
Recovery is now a major element in health reform. William Anthony’s (1993) “Recovery from Mental Illness: The Guiding Vision of the Mental Service System in the 1990s” used the phenomenon of recovery identified by Patricia Deegan and others to formulate a plan to become a guiding vision for the provision of mental health services. He used consumers’ narratives of their recovery experiences to describe processes, attitudes, values, goals, skills, feelings, and roles that lead to a satisfying and contributing life even with limitations of illness. He stated that the process of recovery can occur without professional aid, but it can be helped by the support of trusted others, and it might be correlated with a reduction in the duration and frequency of intrusive symptoms. He held that individuals needed to recover from the consequences of illness, including disability, disadvantage, and dysfunction, as much as, or more than, from the illness itself. He argued that much of the disability, disadvantage, and dysfunction that people with mental illness experience are caused by the systematic and societal treatment of individuals who have psychiatric diagnoses. He believed that two models of service provision promote recovery: the psychiatric-rehabilitation model and the community-support-system model.
Mental health policy and services have traveled a long way from the days of the overcrowded state mental hospital. The civil rights movement brought many protections to people with mental illness. Yet the very deinstitutionalization of mental patients and the lack of funding for community care have led to new problems of homelessness and growing numbers of persons with mental illness in the criminal justice system. Although the stigma against people with mental illness is declining, many people with mental illness still have no access to treatment.
Donna R. Kemp
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