THINK ABOUT THE NEXT 25 YEARS
ADVICE FOR THE PRESIDENT'S COMMISSION ON MENTAL HEALTH
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
First, the Commissions have been convened a quarter century apart. This
Commission, therefore, needs to project mental health policy for the next
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
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
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