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Michael B. Friedman, CSW
Mental Health News Fall 2002

President Bush recently announced the formation of a Commission on Mental Health to develop recommendations for changes in mental health policy in the United States-a remarkable event if only because major Federal Commissions on Mental Health are so rare. In the second half of the 20th century, there were only two of them. The first was created by The Mental Health Study Act of 1955. That Commission issued a report in 1960 which became the basis of The Community Mental Health Act of 1963. It triggered massive deinstitutionalization of State mental hospitals and contributed to the development of mental health services in the community. The second Commission was established by President Carter in 1977 and produced recommendations that led to the passage of the Mental Health Systems Act at the very end of his administration. Although the Reagan administration never implemented the Systems Act, its central idea-that the mental health system is a fragmented non-system that must be reorganized-has been a driving force in mental health policy for the past twenty-five years.

There are a number of lessons the current Commission should learn from the prior two experiences.

First, the Commissions have been convened a quarter century apart. This Commission, therefore, needs to project mental health policy for the next twenty-five years.

Second, however thorough and complex their reports are, Presidential Commissions end up being known for, and driving, a very few simple ideas. The first Commission drove the transformation of the public mental health system from an institutional system to a community system. The second President's Commission contributed to the expansion of the community support program and lent credence to the belief that reorganization could solve our problems.

Third, there is a very sharp divide between idea and implementation. The initial phases of deinstitutionalization were tragic for a great many people with serious mental illnesses and their families. Nearly forty years have passed since the Community Mental Health Centers Act was passed. Many people are faring better now, but we still do not have a fully adequate community mental health system. Unlike deinstitutionalization, the ideas behind the Mental Health Systems Act have not had tragic consequences. In fact some of the efforts that have emerged-such as case management-have been helpful to people with mental illnesses and their families; and the management of mental health has improved. But many of the most brilliant ideas about systems change have either foundered on the rocks of reality, led to remarkable but unduplicable model programs, or been turned into humdrum bureaucracy.

History, then, suggests that The President's Commission on Mental Health needs to think about the needs of the next quarter century and seek a few clear, central ideas that can be the basis of changes in practice that take into account the pitfalls of implementing great ideas.

Here is one suggestion. The Commission should focus first on the mental health needs of people rather than on the needs of the "system." Who will need mental health services over the next twenty-five years? What kinds of services will they need? What research should be sponsored to determine service need and effectiveness? Who will provide services? Only after answering these questions should the Commission ask how to organize and finance mental health?

Who are the people who need mental health services in the foreseeable future?

Post-Deinstitutionalization Populations: Clearly there are a number of populations who still are not adequately served after years of deinstitutionalization. One critical population consists of people with severe and recurrent mental illnesses who live on the edge in the community and tend to reject traditional mental health services. The other critical population consists of people who have been "transinstitutionalized." Of primary concern are people in adult homes and those in jails and prisons. Just over the historical horizon are those who have been transferred to nursing homes with inadequate mental health services.

Children and Adolescents: Promises to address the mental health needs of children and adolescents go back at least a quarter of a century. There have been some accomplishments, but nothing that approaches fulfilling the promise to develop an adequate community-based mental health system for kids. It is time to keep that promise while keeping in mind the fundamental lesson of the deinstitutionalization of adults. Don't take down the institutional elements of care without developing adequate alternatives first.

It is also critical to be clear that the goal is to help kids with serious emotional disturbances wherever they are, not just those who turn up in formal mental health settings. There are more kids with mental health needs in child welfare, education, and juvenile justice than are served by formal mental health providers. Public mental health authorities have done far too little to help these children.

Changes in Demography: Over the next twenty-five years there will be vast demographic shifts in the United States. There will be tremendous growth of older adults (who will be more likely to seek mental health services than the current generation of older adults), and there will be tremendous growth of minority populations (who together may constitute a majority of the American population.) Mental health services for aging Americans living in diverse settings will be a critical challenge during the next quarter century. And the development of cultural competence must go beyond politically correct lip-service if this nation is to be able to meet the mental health needs of a majority of its citizens in the future.

It may well be that if the President's Commission devotes its attention to all the populations I have noted, its work will become too complex and diffuse. Perhaps it should set sharper priorities. But it is surely critical that the Commission anticipate the needs of diverse populations over the next twenty-five years, and those findings-rather than findings about organization and finance-should drive its deliberations.

(Michael B. Friedman is the Public Policy Consultant for The Mental Health Associations of New York City and of Westchester County. The opinions expressed here are his own and are not necessarily shared by the Associations.)

This "Mental Health E-News" posting is a service of the New York Ass'n of Psychiatric Rehabilitation Services, a statewide coalition of people who use and/or provide community mental health services dedicated to improving services and social conditions for people with psychiatric disabilities by promoting their recovery, rehabilitation and rights.
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Last Updated on 04/08/04



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