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Mental health policy inquiry, its importance, and its rewards
Mental health policy inquiry, its importance, and its rewards


by David Rochefort



The relationship between mental health and public affairs has fascinated scholars of government from as far back as Harold Lasswell's publication of Psychopathology and Politics (1930) and Power and Personality (1948). That interest continues to thrive today in the many college offerings on political psychology, in the pages of the academic journal Political Psychology, and in the ongoing stream of writings on the psychological dimensions of leadership, public opinion, and mass political behavior.


Curiously, however, little comparable attention has been paid to the broader question of the public's mental health and government's role in the provision and financing of mental health care. In short, study of the "psychology of politics" has failed to spawn interest in the "politics of psychology." One would have to be persistent indeed to find an article on the latter subject in a mainstream public policy or political science journal. Even in the pages of specialized health care periodicals, mental health policy analyses are surprisingly few and far between. For example, in the journals Health Affairs and Journal of Health, Politics, Policy and Law, fewer than 10 articles out of a total 100 published in 1993 dealt directly with mental health care issues.


A sophisticated sociology-of-knowledge exploration would be necessary to assess the many possible factors involved in the currently low standing of mental health policy research topics: training opportunities, available project funding, perceived size of the audience, the social stigma of mental illness, and others. Such an examination is not within the compass of this article. However, one can assume that most policy research arises from a sense of the importance of the topic. There are two primary dimensions for gauging such importance. The first is the prominence or impact of a policy area in "real-life" terms, with respect to allocation of resources, political conflict, or social well-being. This may be called its pragmatic significance. The second dimension has to do with the anticipated insights of an area for the public policymaking process in general. This may be called its theoretical significance.


This Policy Studies Journal symposium offers an unusual opportunity to communicate to a broad community of policy researchers the salience of mental health questions. Taking advantage of this opportunity, I intend to argue the case for the importance of mental health policy inquiry on these grounds of both pragmatic and theoretical significance. However, first I will set the stage with brief background on the problem of mental illness and the historical development of mental health policy in the United States.


The Ambiguity of Mental Illness


There are extreme states of emotional and psychological malfunctioning that virtually all observers would identify as pathological. Short of these extremes, however, much ambiguity exists concerning the line between mental normalcy and abnormality. One possible way of identifying mental illness might be to focus on those persons who seek medical attention for a psychological problem. Yet, it is not necessarily the most disordered who choose to enter the treatment system, and a host of social and economic variables complicate the behavior involved in seeking help even when the need for that help has been assessed correctly by the person. In practice, a variety of criteria have been suggested for determining the condition of mental illness, including the performance of social roles, aberrant behavior, and symptomatology (Mechanic, 1989).


One of the most notable efforts to date to develop a comprehensive classification system for mental disorders is the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (Goldman & Grebb, 1988). The first version of the DSM was published in 1952. Since that time four updates and revisions have appeared, including the release of DSM-IV in 1994, with each successive version incorporating new research findings and theoretical perspectives relevant to psychiatric diagnosis (Goleman, 1994). For example, one controversial change made in 1973 was the elimination of homosexuality as a mental disease (Bayer, 1987). The manual follows a descriptive, or "phenomenologic," approach, categorizing some 300 mental disorders by means of specific inclusion and exclusion criteria based primarily on clinical signs and symptoms. The public policymaking significance of the DSM tool is seen in recent health care proposals, such as the Clinton administration's Health Security Act that would require a specific psychiatric diagnosis before a mental problem could be covered.


The DSM generally makes no assumptions about the causality of mental disorder (aside from a handful of instances where etiologic considerations enter as part of the diagnostic picture, as, for example, with post-traumatic stress syndrome). Throughout its history, the field of psychiatry has been riven by contending schools of thought, based on environmental, biological, genetic, and personality factors (Gottesman, 1991). As these varying perspectives have won or lost the support of public policymakers in different periods, the field has veered from one direction to another, sometimes reviving once-abandoned service modalities and ideologies (Rochefort, 1993).


The Evolution of United States Mental Health Policy


Historically, mental illness and poverty have been intertwined closely as social problems (Rochefort, 1993). In the colonial era, prior to the emergence of any kind of formalized mental health system in this country, public authorities dealt with the mentally ill under the same laws and practices that were devised to deal with indigence. Local overseers dispensed various kinds of "indoor" (that is, institutional) and "outdoor" (community) relief to the mentally ill, sometimes boarding them with neighbors at public expense. In cases of violent patients, the insane often were confined in jails. By the early 1800s localities across the states increasingly were relying on poorhouses to cope with the growing numbers of people requesting public support. Accordingly, a steady accumulation of the mentally ill collected in these congregate facilities, along with the blind, the disabled, those who were physically ill, and other dependent citizens.


Establishment of mental hospitals in the 1800s marked the initiation of a specialized mental health system in the United States. This development was a response both to the ghastly conditions in overstrained poorhouses and new theories regarding the treatment of mental illness within carefully controlled and humane institutional settings. Once begun, the asylum movement spread quickly, resulting in the establishment of 27 state mental institutions by the eve of the Civil War. Private mental hospitals grew in size and number, in tandem with the public system, during these years and often survived on a combination of private and public dollars. The renowned reformer, Dorthea Dix, herself was involved in more than 30 mental hospital projects in the United States and other countries during her reforming years.


Initial optimism about the services of public mental hospitals was strong. Some advocates promised cure rates close to 100%. However, such institutions did not prove equal in the ensuing decades to the challenge of providing effective, high-quality menial health care. In part, the problem lay with the intransigence and diversity of the conditions confronting the population in need, for whom only limited drug and psychological treatments were known at the time. More important, however, was the fact that state legislatures generally failed to provide necessary levels of funding for the upkeep and expansion of facilities, so that in time many hospitals evolved into wretched and overcrowded human warehouses in which patients received little individual attention. Alternative community services, such as they were, remained sharply limited in scope and often functioned as an adjunct to state hospital facilities. As pessimism deepened regarding public psychiatry, hospital administrators increasingly embraced radical somatic interventions, including shock treatment and lobotomy, without adequate protections for patients.


Following World War II, a number of forces combined to produce a dramatic shift in United States mental health policy. Frequent exposes in newspapers and magazines brought to widespread attention the conditions of patient care in state hospitals. The plight of many returning American servicemen with psychiatric problems also sensitized policymakers and the public to the problem of mental illness. Just as important was the discovery of powerful tranquilizing drugs that helped control mental patients' most bizarre and disruptive symptoms while opening new avenues of therapy. Within the mental health professions, dynamic growth in the numbers and variety of practitioners in different disciplines stimulated spirited debates that brought new treatment ideas to the fore. Reflecting all of these currents, in 1963 the United States Congress passed the Kennedy administration's community mental health centers (CMHC) program, which provided federal funding and operational guidelines for a nationwide network of local mental health agencies offering a range of outpatient, short-term inpatient, and preventive services.


President Kennedy's national program called for an eventual reduction of 50% in the number of patients in state mental hospitals. "Deinstitutionalization" has surpassed even this ambitious target. By 1975, the number of patients in state and county mental hospitals was down by 65% from its peak of 559,000 in 1955. It has continued to drop since that time, reaching 110,000 by the mid-1980s. However, it is debatable whether Kennedy's CMHCs played much of a role in causing this decline, because other developments that would prove to be even more momentous were sweeping through the mental health system at that time. For example, psychiatric benefits under private health insurance became widely available during the 1960s and 1970s. Also, in 1965, the Medicaid and Medicare public insurance programs were passed, thereby expanding insurance coverage for mental disorders within the general population. These new sources of payment made it possible to cover a greater spectrum of services in an expanded range of treatment settings.


Two recent major developments of United States mental health policy are shaping the outlines of the postdeinstitutionalization era in mental health care, although in disjointed fashion. One is the strengthened control of the community mental health system by state government. As part of his plan for government decentralization, President Reagan succeeded in grouping together a number of federal grants into new or revised block grants that were given over to the states for administration. Community mental health centers were one of the programs affected. As a result of this changed funding mechanism, as well as accompanying budget cuts, local centers have had to undergo a difficult reorientation to widen their base of financial support and to satisfy state policy priorities, including targeting services to the chronically mentally ill. The consequences of this transformation still are being measured.


The second development, still very much unresolved, is the struggle for national health care reform. During 1994, all eyes in the mental health policy field were trained on Washington, DC, to see how mental health benefits would be handled within a national health reform package. Who gets covered, for what, where, by whom, and under what contingencies are critical issues that have far-reaching impacts on future patterns of care and the structure of mental health systems (Aarons, Frank, Goldman, McGuire, & Stephens, 1994). Some proposals, like President Clinton's, recommended covering a specific set of mental health services, while others either omitted such benefits or left them for future determination administratively. The collapse of health care reform during the fall of 1994, followed by the election of a more conservative Congress, makes the prospects for national mental health insurance reform more uncertain than ever. It may be that the expansion of mental health benefits is likely to occur first through state-level policy experiments.


Whatever may be the ultimate vehicle - but especially under a scenario of state-sponsored change - one of the major continuing issues in national mental health policy will be the great variability in state resources and programmatic direction around the country that is a legacy of the historical evolution of the United States mental health system.


The Pragmatic Significance of Mental Health Policy Inquiry


Mental illness has tremendous pragmatic significance as a public policy problem, as may be judged by numerous indicators, including the number of people affected, economic costs, and its contribution to other social maladies.


In 1978, President Carter's Commission on Mental Health and Illness called for a national study to determine the extent of psychiatric illnesses within the population. Fifteen years later, the first such investigation based on a structured psychiatric interview was completed as part of the National Comorbidity Survey (Kessler, McGonagle, Zhao, Nelson, Hughes, Eshleman, Wittchen, & Kendler, 1994). Making use of a diagnostic instrument administered by trained interviewers, the study examined both lifetime and 12-month prevalence rates for 14 major disorders among those 15 to 54 years old using DSM-III-R criteria. The study's findings revealed higher rates of mental illness than had been suspected previously by researchers. In brief, approximately one-half of the respondents indicated that they had suffered from at least one disorder over their lifetime. The most common disorders were major depression, alcohol dependence, and social and simple phobias. Nearly 30% had experienced a mental disorder during the past year. Most respondents had never received professional treatment for their illnesses. About one-sixth of the respondents reported that they had experienced three or more disorders during their lifetime.


A special interest in mental health policymaking is the population that suffers the most serious and long-term disorders. Private insurance and support services, to the extent these are available, typically feature time and expense limitations that force such individuals to rely heavily on public resources. In 1989, the National Institute of Mental Health carried out a nationwide survey to estimate the number of "seriously mentally ill" persons in the household population of the United States (Barker, Manderscheid, Hendershot, Jack, Schoenborn, & Goldstrom, 1992). The resulting approximation was that 3.3 million adults, 18 years and older, could be characterized as suffering serious mental illness. For roughly 1.4 million adults under age 70, mental illness either rendered them unable to work or limited their workforce participation. Based on the survey, about 700,000 adults are estimated to receive government disability payments due to their mental disorder.


A recent sophisticated analysis of the economic impact of mental illnesses placed the total costs, excluding alcohol and drug abuse and related mental problems, at $103.7 billion in 1985 (Rice, Kelman, & Miller, 1992). This figure can be broken down into direct treatment and support ($42.5 billion), reduced or lost economic productivity due to morbidity and premature death ($56.7 billion), and family caregiving and other costs ($4.5 billion). Of total direct treatment costs, 55% was public money, divided nearly equally between federal and state/local sources.


Finally, mental health problems also play a role in various forms of community disorder, although precise measurement of the specific relationships involved can be extraordinarily difficult. For example, most empirical studies place the prevalence of psychiatric impairments among the homeless population at between 30% and 40%, with a few estimates ranging much higher (Rochefort & Cobb, 1992). Mental illness among those who commit criminal acts is a reality, as is criminal behavior among the mentally ill; but analytic complications arise when trying to determine causality and controlling for changes in incarceration practices that affect the definition of the phenomenon under study (Johnson, 1990). Still, it is hard to imagine how such social problems could be mitigated effectively without policy strategies that also address the interrelated mental health care issues.


The Theoretical Significance of Mental Health Policy Inquiry


To say that mental health issues qualify as important according to standard social indicators is not to say that they always have been viewed as such within the political system. As William James (1890, p. 28) observed, anticipating a later generation of work on the politics of agenda-setting and the social construction of reality, "a thing is important if anyone thinks it important." In fact, concern with mental illness as a public problem has risen and fallen over the decades among policymakers and the general citizenry in a manner that poses fundamental questions about agenda entrance and cyclicality (Rochefort, 1993). Identifying the forces that underlie such a pattern, and comparing them with the mainsprings of action in other areas, offers an avenue of insight into the politics of "reform" that goes beyond the specifics of mental health.


The latest macrosystemic shift in mental health policy - toward a deinstitutionalized system - is one of the most far-reaching policy revolutions experienced by any public sector activity in the twentieth century, judged in terms of program philosophy, service structures, or financial flows. Its repercussions for patient treatments, administrative control, organizational complexity, and legal advocacy already have been enormous and still are being played out. By any standard, this episode must be termed an "innovation," to apply a well-known theoretical construct from the policy sciences (Polsby, 1984). The roots of this transformation - in a changing "problem definition" of mental illness (Rochefort, 1993; Weiss, 1990) and in an "iron triangle" of executive/congressional/interest group policymaking at the national level (Foley, 1975) - are well understood, although more advanced theoretical frameworks make new analysis possible and can, in turn, be refined by this application. For example, Baumgartner and Jones' (1993) model of "punctuated equilibria" provides one suggestive tool for linking the establishment and eventual decay of policy monopolies to new problem "images." At the same time, developments in interest group theory on "issue networks" have relevance for understanding the evolving content and form of group demands consequent to major policy redirection for mental health (Peterson, 1993).


Students of political economy already have found mental health to be a fertile field for exploring the intricate connection between market and government forces (Brown, 1985; Kenig, 1992; Scull, 1984). With the development of community mental health centers and the rapid expansion of mental health treatment following World War II, a system that once had been dominated by state governments came under pluralistic controls and became more responsive to the intended and unintended incentives operating within the health care economy. For example, it is impossible to understand the patterns of deinstitutionalization - geographic, temporal, and organizational - without reference to the impact of public and private insurance programs, as well as new welfare and disability entitlements. In this and other ways, the mental health experience demonstrates, as Kenig (1992, p. 1) maintains, that "the applications of the intellectual products of social scientists [and other reformers] are influenced by the political economic context in which those products are applied."


Privatization may be characterized as an explicit, deliberate effort to shift the public-private balance within the political economy. Often simplified as a conservative attack on big government, it is really a much more profound development in the history of public policy formation, reflecting the problems of structural deficits, bureaucratic rigidity, and the collapse of western collectivism (Donahue, 1989). Yet the meaning of privatization across policy sectors is not constant; every instance requires its own assessment of how far, through what mechanisms, and with what public safeguards the process might be undertaken wisely. Mental health care deserves serious attention on this spectrum of analysis. As Dorwart and Schlesinger (1988) summarize the situation, the privatization of mental health care is a "megatrend" that presents a unique combination of issues having to do with tiering services, the connection between the form of ownership and organizational performance, community input, the appropriateness of service, and coordinated planning and delivery.


With respect to the field of intergovernmental relations, the long history and complexity of mental health policy arrangements again provide rich analytic material. Indeed, the record of United States mental health policy development may be sketched in broad strokes as a tableau in which changes in intergovernmental responsibility have provided the major vehicle for altering policy objectives. The first such change was the movement of the indigent insane out of local poorhouses into state-run mental hospitals. It required the intervention of the federal government after World War II, through its mental health policies and other social welfare activities, to spur the community mental health movement. More recently, the devolution of this same federal initiative in community mental health programming down to the states by the Reagan administration has resulted in a reconfiguration of the operation and goals of public care systems, while health care reform once again could reshuffle the federal/state/local roles toward improving access to mental health care and containing costs. The study of these mental health intergovernmental relations - an area of limited scholarship to date - can take us below the parade of abstract policy themes, to consider the changing public order of successive historical periods, each with its own resource transfers, negotiated bureaucratic interactions, and administrative apparatus.


However the topic is approached - through politics, administration, or programmatic initiatives - mental health policy and its issues are a springboard to central questions of process and outcome in social policymaking. Indeed, perhaps there is no better area in which to appreciate the dilemmas of the mature welfare state, whose categorical activities encompass more and more of the population in often overlapping ways, but with little flexibility or true comprehensiveness (Lewis, Shadish, & Lurigio, 1989). Mental health care can be seen as the hub of a policy wheel whose radiating spokes include the areas of housing, health care, disability, homelessness, poverty, children, and the aged. Each of these policy spheres and mental health share a common interest in social predicaments to which the existing social safety net responds poorly. Policy analysts need to examine the significant local experiments for client-based integration of resources that this deficiency has inspired, so that they can contribute to the search for even better solutions that are feasible programmatically, economically, and politically (Goldman, Morrissey, & Ridgely, 1994).


Finally, it is worth emphasizing a number of the current funding priorities in mental health services research, some of which offer special opportunities for merging policy praxis and theory. According to Scallet and Robinson's (1993) review of the Health Services Research Grants Information System, a partial data base of ongoing and recently completed health services research projects, in 1993 nearly 200 grants were focused on mental health issues. Of these, one-third were concerned with services for the most severely mentally ill; the remainder touched on mental health issues related to aging, women, family violence, minorities, substance abuse, general health care, homelessness, and other areas. These analysts predict that the mental health research topics for foundations and federal agencies in the coming years will include the mental health dimensions of national health care reform (e.g., state participation, development of standards and monitoring for managed care, and the fate of Medicaid), the intersection of mental health care with other service sectors and policy trends (e.g., welfare reform, AIDS prevention and treatment, and violence), and the development of integrated mental and health care information systems.




Describing the process of psychotherapy, psychologist Carl Rogers observed that the most particular revelations of individual clients provided insight into the most universal human experiences. A similar irony is found in public policy research. Approached with the right set of questions, an indepth focus on the workings of a single policy area can pay enormous dividends for the general body of policy theory. One need only consult Eugene Bardach's (1977) classic work on the delivery of community mental health services in California during the 1960s and 1970s, which gave rise to a game-playing framework that subsequently shaped the entire field of implementation studies, for a model of how this type of analysis can be done.


Every policy topic has its own conceptual and technical demands that shape us as scholars, too. For mental health policy, the demands are for an approach that is multidisciplinary, sensitive to long-term historical, professional, and ideological forces, wise to the discrepancy between policies and programs, and encompassing in its perspective of the social welfare sector. These are challenging requirements, but ones offering personal intellectual rewards that are self-evident for the policy scientist.




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Bardach, E. (1977). The implementation game: What happens after a bill becomes a law. Cambridge, MA: MIT Press.


Barker, P. R., Manderscheid. R. W., Hendershot, G. E., Jack, S. S., Schoenborn, C. A., & Goldstrom, I. D. (1992). Serious mental illness and disability in the adult household population: United States, 1989. In Center for Mental Health Services and National Institute of Mental Health, Mental health, United States, 1992 (pp. 255-268). DHHS Pub. No. (SMA) 92-1942. Washington, DC: United States Government Printing Office.


Baumgartner, F. R., & Jones, B. D. (1993). Agendas and instability in American politics. Chicago, IL: University of Chicago Press.


Bayer, R. (1987). Homosexuality and American psychiatry: The politics of diagnosis. Princeton, NJ: Princeton University Press.


Brown, P. (1985). The transfer of care: Psychiatric deinstitutionalization and its aftermath. London: Routledge and Kegan Paul.


Donahue, J. D. (1989). The privatization decision: Public ends, private means. New York, NY: Basic Books.


Dorwart, R. A., & Schlesinger, M. (1988). Privatization of psychiatric services. American Journal of Psychiatry, 145 (5), 543-553.


Foley, H. A. (1975). Community mental health legislation: The formative process. Lexington, MA: D. C. Heath.


Goldman, H. H., & Grebb, J. A. (1988). Classifying mental disorders: Diagnostic and statistical manual of mental disorders (DSM-III-R). (3rd ed. rev.). Norwalk, CT: Appleton & Lange.


Goldman, H. H., Morrissey, J. P., & Ridgely, M. S. (1994). Evaluating the Robert Wood Johnson Foundation program on chronic mental illness. The Milbank Quarterly, 72 (1), 37-47.


Goleman, D. (1994, April 19). Revamping psychiatrists' Bible. New York Times, p. C1.


Gottesman, I. I. (1991). Schizophrenia genesis: The origins of madness. New York, NY: W. H. Freeman.


James, W. (1890). The principles of psychology. New York, NY: H. Holt.


Johnson, A. B. (1990). Out of bedlam: The truth about deinstitutionalization. New York, NY: Basic Books.


Kenig, S. (1992). Who plays? Who pays? Who cares? A case study in applied sociology, political economy and the community mental health centers movement. Amityville, NY: Baywood.


Kessler. R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H.-U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the national comorbidity survey. Archives of General Psychiatry, 51 (1), 8-19.


Lasswell, H. D. (1930). Psychopathology and politics. Chicago, IL: University of Chicago Press.


Lasswell, H. D. (1948). Power and personality. New York, NY: Norton.


Lewis, D. A., Shadish, W. R., & Lurigio, A. J. (1989). Policies of inclusion and the mentally ill: Long-term care in a new environment, Journal of Social Issues, 45 (3), 173-186.


Mechanic, D. (1989). Menial health and social policy. (3rd ed.). Englewood Cliffs, NJ: Prentice-Hall.


Peterson, M. A. (1993). Political influence in the 1990s: From iron triangles to policy networks. Journal of Health Politics, Policy and Law, 18, 395-438.


Polsby, N. (1984). Political innovation in America: The politics of policy initiation. New Haven, CT: Yale University Press.


Rice, D. P., Kelman. S., & Miller, L.S. (1992). The economic burden of mental illness. Hospital and Community Psychiatry, 43, 1227-1232.


Rochefort, D. A. (1993). From poorhouses to homelessness: Policy analysis and mental health care. Westport, CT: Auburn House.


Rochefort, D. A., & Cobb, R. W. (1992). Framing and claiming the homelessness problem. New England Journal of Public Policy, 8, 49-65.


Scallet, L. J., & Robinson, G. K. (1993). Opportunities in mental health services research. Health Affairs, 12 (3), 240-250.


Scull, A. (1984). Decarceration: Community treatment and the deviant - a radical view. (2nd ed.), New Brunswick, NJ: Rutgers University Press.


Weiss, J. A. (1990). Ideas and inducements in mental health policy. Journal of Policy Analysis and Management, 9 (2), 178-200.


David A. Rochefort is associate professor of political science at Northeastern University, in Boston. His books include American Social Welfare Policy: Dynamics of Formulation and Change (1986), (editor) Handbook on Mental Health Policy in the United States, and From Poorhouses to Homelessness: Policy Analysis and Mental Health Care (1993). He is a former postdoctoral fellow in the Rutgers-Princeton Program in Mental Health Research, and currently is studying issues in Canadian mental health policy.
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