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history of mental health in the United States has not always been a pleasant one. Prior to the mid-20th century those unfortunate numbers of Americans who were considered mentally ill were either ignored or placed in asylums (Philo, 1997). The asylum approach was considered to be a logical one. It protected the community for potentially dangerous or unwanted individuals; it provided families relief from the burden of having to care for a mentally ill family member; and, at least theoretically, they offered humane custodial care. The asylum system operated without question for many years in the United States. Society, as a whole, paid little attention to the concerns of the mentally ill and there was a general attitude that the mentally ill were largely undesirable.
Subsequent to the Second World War societal attitudes began to transform as the warehousing of the mentally ill in asylum was beginning to be considered as inhumane and the health care community began to advocate for treatment and prevention of mental illness. Gradually through the fifties and sixties, the traditional asylum system began to disappear and new alternative methods of housing and treatment of the mentally ill began to appear.
The changes that occurred following the Second World War were the result of an evolution in public policy. These changes occurred as a result of some major adjustments in American society.
One of the factors that contributed to a change in public policy was in how the care of the mentally ill was funded. Prior to the Second World War the financial responsibility for providing care for the mentally ill was vested with the local community (Shorter, 1997). Families that could afford to contribute to the care were expected to do so but the majority of those receiving treatment were listed as paupers. Not unexpectedly, this financial expectation placed considerable pressure on the budgets of local communities and the state governments were expected to step in and assist local communities in bearing the costs. What transpired was a constant battle between the states and local communities relative to what each jurisdiction would financially bear and caught in the middle were those needing treatment and care. What developed was a system that provided minimal care and early discharge as a cost-saving maneuver.
The states of New York and Massachusetts began the move toward a unified system where the authority for providing for the mentally ill was no longer divided between local communities and the state. Both states enacted legislation that resulted in a centralized system of mental health services that relieved local communities of any role in the care of the mentally ill. The theory was that a centralized system would result in a higher quality of care, unfortunately, unscrupulous local officials saw the opportunity to also relieve themselves of the responsibility of taking care of the elderly, as well, under the guise of their being senile and, in the initial stages, the change over from local to state management of the mentally ill was overburdened. The state system eventually adjusted but how the local communities took advantage of the changeover indicates the lack of respect afforded mental health care.
The influx of large numbers of elderly patients due to local communities rushing to rid themselves of their care caused a major changeover in the demographics of those housed in state mental health institutions. The number of patients classified as chronic and long termed increased and the states were forced to absorb the costs of providing housing and care for these individuals.
These changes in funding and patient populations caused a corresponding change in the overall character of most state funded mental hospitals. By the end of the Second World War, most state hospitals had become overburdened by the numbers of aged persons and chronically ill that they had become warehouses for housing individuals who had no hope of ever leaving the facility.
The social activism that followed the Second World War had its impact on the delivery of mental health care. First, the psychiatric, psychological, and social work professionals began to adopt a proactive approach in regard to their treatment regimes. Professionals in these fields began to emphasize the importance of life experiences and socio-environmental factors in the diagnosis and treatment of the mentally ill and, as a result, hospitalization began to be viewed as a less attractive option. Instead, a new attitude was developing that viewed early intervention and community involvement as being a successful means of preventing the need for subsequent hospitalization of the mentally ill. Increased faith was also developing in the ability of mental health professionals to provide the treatment necessary to lessen the effects of certain forms of mental illness and a corresponding introduction of new drugs and treatments created new optimism that the mentally ill could be treated without society having to absorb the cost of long-term hospitalization. Finally, for the first time the federal government began to involve itself in the treatment and care of the mentally ill which served to ease the burden on the state governments that had burdened solely with its costs since assuming the responsibility from the local communities in the last wave of reform.
The move toward community oriented mental health treatment received a major boost by the passage of the National Mental Health Act of 1946 (Mental Health Act 1946). This Act provided grants to the states that allowed the funding of existing outpatient facilities and the establishment of new ones. The impact of the Act was considerable. Before 1948 more than half of the states had no clinics; by the end of 1949 all but five of the states had established one or more. Collaterally, the mental health professional community intensified their efforts in promoting community-oriented treatment and intensified their efforts to encourage early identification of mental health related problems. The decade following the enactment of the National Mental Health Act witnessed a flurry of legislative activity increasing the availability of funding for mental health treatment and programs intended to promote early intervention and identification. The decade marked a remarkable expansion in not only the availability of mental health services but also the quality of services.
This movement toward community based out-patient treatment, however, brought new problems. Although the new system eased the burden on in-patient facilities and resulted in fewer such admissions the number of individuals using out-patient services sky rocketed and far exceeded the expectations. The result was that the system began to treat individuals who previously had not sought treatment and those who were most in need of treatment were neglected.
Although mental health care improved substantially in the decades following the Second World War, the stigma attached to such treatment and the lack of available health care insurance to provide high quality treatment was severely limited. The community out-patient programs were an improvement over what had been historically available but only the wealthiest Americans could afford access to private mental health treatment. Others were forced to utilize the services of community agencies where the waiting lists for treatments were long and where staffing was limited.
The coordination of the out-patient treatment programs that began in the fifties and sixties were finally coordinated under the auspices of the National Institute of Mental Health in the early 1970's. This was followed by a period of approximately twenty years in which the U.S. government continued to provide funding for mental health programs but in the mid-1980's managed care became a part of the delivery of mental health care (Iglehart, 1996). Under managed care the responsibility for delegating the payment of mental health benefits was assigned to private health companies with the result that several states saw their mental health programs collapse while other states were only able to provide services to the most severely ill. The overall result was that the delivery of mental health services throughout the country was on the verge of collapse. In 2003 a Commission, identified as the President's New Freedom Commission, was authorized to investigate the state of mental health treatment (New Freedom Commission on Mental Health, 2003). The Commission determined that there were major problems in the country that needed to be addressed. Some of the problems noted by the Commission included the continued stigma attached to mental illness, the limitations placed on mental health care by the private insurance industry, and the fragmented nature of the limited care that was available. The Commission recommended that the mental health system needed to re-organize to provide more efficient and more reliable treatment. In addition, the Commission made the following recommendations:
The preparation of the a national campaign to reduce the stigma of a mental illness and to create a program that treated mental illness with the same urgency as physical health
Address the disparity as to the availability of competent mental health services in rural and remote areas
Enactment of legislation requiring individual care plans that include mental health coverage and protection
Establishment of early intervention programs that detect mental health problems, substance…[continue]
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