Part II: Lessons From History – How the Crisis in Mental Health Care Came to Be
By John F. Baggett Ph.D
In Part I of this three part series I described the current sad state of affairs in Mental Health Care. In this post, I will discuss how the current crisis came to be. It is my conviction that history helps us not only understand how to avoid the mistakes of the past, but also offers important clues for developing an advocacy plan for future quality treatment and care.
In the late 1830s, the mental health reformer, Dorothea Dix, toured many prisons, jails, almshouses and homes. She called attention to the deplorable conditions in which mentally ill persons were then forced to exist. In the 1840s she addressed several state legislatures where she described mentally ill persons as “confined ….in cages, closets, cellars, stalls, pens! Chained, beaten with rods, lashed into obedience.” Legislatures and medical societies soon responded with mental health reforms characterized by more humane ways to care for persons with mental illnesses.
Unfortunately, in recent years, many of the conditions Dorothea Dix set out to correct have again become commonplace. As pointed out in Part I of this series, ten times more mentally ill people are now in jails and prisons than in state psychiatric hospitals, and approximately 250,000 mentally ill persons are currently homeless.
So, how did it come about that we as a nation abandoned the ideals of humane treatment advocated by Dorothea Dix in the 19th century? Why are there so many mentally ill persons in prisons and so many homeless today? I believe the answer can be found in two major policy shifts implemented across the nation since the 1960s. The first was deinstitutionalization, a movement to cut inpatient care in the hope of shifting resources to effective community services. The second was privatization, the abandonment of the vision of public care for persons with mental illnesses, and, in its place, a model of private market place treatment.
The original vision of deinstitutionalization was well intentioned. According to the ideology of many patient advocates, the financial resources used for hospital care could be better used in a system of community care – including crisis intervention, housing, case management, outpatient treatment, and vocational rehabilitation. There was nothing wrong with the vision. Sound research had already demonstrated such a system of care was not only more humane than long-term psychiatric hospital confinement, but also more effective in alleviating symptoms, and in improving quality of life for persons with mental illnesses.
Unfortunately, the vision of quality community care for persons with mental illnesses has yet to be realized. Psychiatric hospitals have always been expensive to operate and have historically represented huge line items in state budgets. As the ideology of deinstitutionalization took hold across the nation an “unholy deinstitutionalization alliance” formed between patient advocates and politicians anxious to cut government spending. Within a few years the psychiatric hospital censuses were down, budgets were slashed, hospitals closed, but the promised community based services received only a small fraction of the funding promised. As a rule, care for persons with mental illnesses was not a priority for politicians. In many states, legislatures quickly moved the savings from deinstitutionalization to other more popular purposes.
The results of this policy shift were profoundly tragic. Due to the shortage of beds, hospital care was stringently rationed. Community based services were inadequately developed. The nation soon descended to pre-Dorothea Dix practices. Mentally ill persons were inhumanely confined in prisons and jails, and housed in nursing and residential homes ill prepared to care for psychiatric patients. In order to survive, persons with mental illnesses were forced to sleep in doorways, in the woods, under bridges, and to make the rounds to homeless shelters and soup kitchens.
The second major culprit in the current mental health crisis was, once again, a well-intentioned but misguided ideology. Privatization sounds good, especially to those who ideologically believe government is inherently bad, or, at the least, inefficient. According to privatization advocates, services for people with psychiatric conditions are no different than those provided in other service industries. Just as entrepreneurs provide hair styles and lawn services better, and more cost efficiently, than a government agency would likely do, so, the argument goes, the marketplace should produce better treatment programs for persons with mental illness. It is a fundamentally flawed argument that has led to disastrous results.
The major fallacy in the privatization movement is the notion that expensive state-run mental health services, with very low overhead, can be replaced with for-profit agencies, save money, and still provide quality care. The numbers simply do not add up. Under the privatization model, privately run programs operate within contracted fixed budgets. The companies must cover administrative costs, provide care to clients, and also realize profits for investors. Consequently, this model skews incentives away from quality care because profits depend on rationing care – in getting clients in and out of treatment as quickly as possible without regard to long term outcomes. Clients blessed with excellent private mental health insurance are the exception. In those cases the monetary incentives may encourage longer term treatment than is necessary.
Unfortunately, the history of mental health care in this nation has been a tragic one. This is not because mental health professionals do not know how to provide quality effective care that honors the dignity of those who have mental illnesses. Professionals have the expertise, backed by sound research, to provide much needed care, but we, as a nation, have not yet demonstrated the political will to do so.
I will attempt to address the possibility of creating political motivation for improving care in Part III of this series: How to Advocate for Improvements in Mental Health Care – A Call to Action.