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Improving the American Mental Health System Requires Accurate History

Today's system is undoubtedly inadequate in many ways -- but it is better than it was when the transition to community mental health policy took place. It's important to recognize this because inaccurate history is not a good guide for making the current system better.
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This post is co-authored by Sherry A. Glied and Michael B. Friedman.

Allen Frances (The Huffington Post August 7, 2014) claims that the American mental health system is worse now than ever before. He and other critics who share this view are wrong. Today's system is undoubtedly inadequate in many ways -- but it is better than it was when the transition to community mental health policy took place. It's important to recognize this because inaccurate history is not a good guide for making the current system better.

Over the past five decades, changes in mental health policy have enabled millions of people to lead far better lives. If this is not apparent it is because the failures of community mental health policy -- the terrible plight of the homeless and incarcerated -- are heartbreaking and visible, but the successes -- people living ordinary lives in the community -- are, by their nature, invisible and hidden.

Contrary to the mythology from which Dr. Frances and others draw their views, most people with severe, long-term mental disorders never did live in state hospitals. In 1955, the peak year of institutionalization in state hospitals, less than one-third of this very vulnerable population were in these facilities.*

For most of the two-thirds living outside of hospitals, life was very difficult. Welfare benefits and health coverage were nearly nonexistent, and at best half of those living in the community received any treatment at all. Those who were not sheltered by their families often lived in deep poverty and in squalid housing. The inadequacy of outpatient treatment not only left people without any help in coping with devastating illnesses, it also meant that there was little ability to identify those who were a risk to themselves or others.

Despite the challenges of survival in the community, studies at the time (and since) showed that most people with mental illness preferred life outside to institutionalization in the hospital. Besides denying people liberty, state hospitals/asylums were mostly horrible. Patients usually lived barracks-style, on wards of 50 or more people, and the staff-to-patient ratios were unimaginably low. Treatment was sporadic, rarely effective, and often inhumane. Neglect and abuse -- emotional, physical, and sexual -- were commonplace. The shift to community-based care was precipitated by recognition of these terrible conditions.

In addition, the shift from institution-based to community-based policy was not a one-time expulsion of mentally ill people from institutions. Rather, it has been an ongoing process of policy adjustment, emphasizing the expansion of "Community Support Programs," including housing; psychiatric rehabilitation; inpatient treatment in local, general hospitals; expanded outpatient treatment; and case management. For example, NYS, which offered no specialized housing for people with serious and persistent mental illness in 1978, today has about 35,000 units run by the mental health system and thousands more units in various other supportive housing programs. State hospitals -- now much smaller -- are far better places than they used to be.

The biggest change has been in the community. The quality of, and access to, treatment in the community have advanced tremendously. With greater knowledge about the benefits and risks of psychotropic medication, it is possible for people with serious mental illness to get safer and more effective medication treatment. And evidence-based non-pharmacological treatments, such as "assertive community treatment," are now available, contributing to better clinical outcomes. Most importantly, the introduction and expansion of Medicaid and Medicare, Social Security Disability Income, Supplemental Security Income, food stamps, and housing supports have helped most people with serious and persistent mental illness to have tolerable lives the community.

That doesn't mean the problems Dr. Frances has pointed to aren't real. Today, an unacceptably high share of people with serious and persistent mental illness (SPMI) -- about 7 percent -- live in totally disgraceful conditions in jails and prisons or homeless on the streets or in shelters. In addition, roughly 5 percent of people with SPMI, who might have been in mental hospitals/asylums have simply been transferred to nursing homes or similar facilities, many of which provide inadequate care. Many of these people could live in the community if adequate housing were available. And too many people with serious illness in the community receive very little or inadequate treatment.

More is definitely needed, but the system has not been sitting on its hands all these years.

Over the past few decades, many, if not most, people with serious and persistent mental illness have benefited from greater liberty and respect for their rights, from better social welfare policies, from improvements in treatment, and from the shift to the model of community support.

Our nation clearly needs to address the enduring problems of our mental health system. How? We know there is need for more stable housing. We know there is a need for more "assertive" community services, to reach out to people who do not benefit from the current system where they are rather than waiting for them -- or forcing them -- to come to the mental health system on their own. We know there is a need for higher quality care and treatment. We know that there is a need for more mental health services with better access. Some critics of the current system claim that there is a need for more hospital beds and for more involuntary inpatient and outpatient treatment. It's an emotionally appealing idea, but complex, highly controversial, and not clearly beneficial.

Shaping the system of the future will be difficult because of ideological disputes, because the creation of effective systems of care is inherently complicated, and because it will cost a lot more money. Succeeding will take intellectual rigor and historical accuracy. Nostalgic mythology about a better mental health system in the past is an unfortunate impediment to the progress we need.

*All the data in this article are drawn from Better But Not Well: Mental Health Policy in the United States since 1950 by Richard G. Frank and Sherry A. Glied. Johns Hopkins University Press, 2006.

Sherry A. Glied is the Dean of the Wagner School of Public Service at NYU. Previously she served as Assistant Secretary for Evaluation and Planning at HHS. She is the co-author of Better But Not Well, an assessment of the past 50 years of mental health policy. Michael B. Friedman is the retired Founder of The Center of Policy and Advocacy of the Mental Health Association of NYC and Adjunct Associate Professor at Columbia University School of Social Work.