The political and economic context of mental health care in the United States

Since the mid-1970s, the mental health treatment system in the U.S. has faced budgetary famine. This is in stark contrast to the growing cornucopia of fiscal resources enjoyed by the overall health care system. This paper explores the complex reasons for this disproportionate allocation in health spending. On the one hand, mental health may suffer from the perception that its diagnoses are largely "subjective" and its treatments do not fit the traditional "medical model" that can be defined precisely and paid for by third-party insurers. But more importantly, the death of mental health resources can be attributed to the peculiar nature and characteristics inherent in American politics. This paper describes the American political environment, from both a historical and a contemporary perspective, to give some insight into the development of policies affecting the mental health system in the U.S. Given the current climate of fiscal conservatism in this country toward any increases in social spending, it is likely that the profound mismatch in need and spending for mental health programs will continue indefinitely.     

Mental Health Court Outcomes: A Comparison of Re-Arrest and Re-Arrest Severity Between Mental Health Court and Traditional Court Participants

Mental health courts have been proliferating across the country since their establishment in the late 1990's. Although numerous advocates have proclaimed their merit, only few empirical studies have evaluated their outcomes. This paper evaluates the effect of one mental health court on criminal justice outcomes by examining arrests and offense severity from one year before to one year after entry into the court, and by comparing mental health court participants to comparable traditional criminal court defendants on these measures. Multivariate models support the prediction that mental health courts reduce the number of new arrests and the severity of such re-arrests among mentally ill offenders. Similar analysis of mental health court completers and non-completers supports the prediction that a "full dose" of mental health treatment and court monitoring produce even fewer re-arrests.     

Policymaking cycles in mental health: critical examination of a conceptual model

Analysts have frequently used the concept of a cycle to describe the historical development of mental health policy in the United States. According to the "cyclical" perspective, the mental health system alternates between crests of high policy and program activity and troughs of stagnation and decline. Analysts also observe that past policy themes are periodically rediscovered, only to eventually lose favor and recede into the background once again. This article critically examines the cyclical model of mental health policymaking, placing it within a context of broader theoretical work on the dynamics of public policy formation. The purpose is to organize in a conceptually coherent way what has emerged as the leading theoretical approach to understanding the evolution of the mental health system; to identify major issues and ambiguities in the application of the cyclical framework to mental health policy analysis; and to derive some general insights about problems and possibilities in modeling policy change.     

Mental health and human rights: the role of the law in developing a right to enjoy the highest attainable standard of mental health in Australia

Article 12(1) of the International Covenant on Economic, Social and Cultural Rights requires governments to recognise "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health". However, the traditional focus of mental health laws on the treatment and detention of those with low-prevalence serious mental illnesses may have skewed resources such that the development of a right to mental health for all individuals with mental illnesses has been stymied. In Australia, a number of inquiries and reports have found that while legislation has been changed to comply with human rights principles, access to mental health care and follow-up post-hospitalisation need critical attention. This article outlines a five-year project aimed at exploring how mental health laws can help develop and support a right to enjoy the highest attainable standard of mental health.     

Models of mental health service delivery to correctional institutions

The mentally disordered offender falls into the "no man's land" between prison and mental health systems. A number of reasons are given to explain why mental health service to this special group is in crisis again, and to lay the base for understanding the advantages and disadvantages of five different models of service delivery. The authors conclude by favoring small psychiatric units attached to major prisons.     

Origins of the "Third psychiatric revolution": the Community Mental Health Centers Act of 1963

In recent decades the community mental health movement has achieved a dramatic reduction in the census of state and county mental hospitals in the United States, and hundreds of federally-funded community mental health centers have been established nationwide. At the same time, national controversy has arisen in response to what in places has seemed the haphazard process of implementing "deinstitutionalization" and the fate of many chronically mentally ill persons who are without needed social services and psychological care. Despite the widespread attention that this contemporary program has received, theoretical analysis of the complex social, scientific, intellectual, and political origins of America's community mental health policy remains deficient. This article examines the background and development of the Community Mental Health Centers Act of 1963, tracing how an important shift in national policy toward the mentally ill grew out of changing perceptions--among policymakers, professional groups, and the general citizenry in the post-World War II era--of the nature of the problem of mental illness.     

Criteria for designation of mental health professional shortage areas--PHS. Final rule

This final rule amends the existing regulations governing the criteria for designation of health manpower shortage areas, or HMSAs (now health professional shortage areas, or HPSAs; name changed by Public Law 101-597, the National Health Service Corps Revitalization Amendments of 1990) under section 332 of the Public Health Service Act. Specifically, this amendment revises the existing criteria for designation of HMSAs having shortages of psychiatric manpower, transforming them into criteria for designation of HPSAs having shortages of mental health professionals, to take into account not only psychiatrists but also mental health service providers other than psychiatrists. The intended effect of this amendment is to more accurately assess the supply of mental health service providers when making shortage area determinations. This notice also summarizes the comments received by the Department on the Notice of Proposed Rulemaking published on August 8, 1989, which set forth the proposed methodology for making this and other changes to the HMSA criteria. It also formally changes "HMSA" to "HPSA" throughout the regulation, to conform with Public Law 101-597.     

Saleem A. Shah

This article introduces a special section ofLaw and Human Behavior entitled Commenorative Articles in Memory of Saleem Shah. The six articles that it introduces describe Shah's lifetime contributions to the development of concepts and research in law and mental health, as well as his substantial influence on the quality of forensic mental health services nationally and internationally.     

Examining the Impact of Proximate Culpability Mitigation in Capital Punishment Sentencing Recommendations: The Influence of Mental Health Mitigators

In spite of the ruling in Atkins v. Virginia (2002), concerns remain that individuals with mental illness and reduced capacity are eligible for the death penalty. When mental illness or reduced capacity is not enough to preclude death-eligibility, these factors are often discussed at the sentencing phase as mitigators. Mitigation remains an under-researched avenue in the sentencing literature, particularly when it comes to the influence of specific types of mitigation. The present study contributes to knowledge on mental health mitigation by examining five mitigators relevant to the mental health and capacity of defendants. Using data from 834 capital sentences in North Carolina, the influence of these proximate culpability mitigators on jury sentence recommendations is examined. Results indicate that acceptance of certain mental health mitigators reduces the probability of death, but acceptance of others is not significantly related to death recommendations. These findings and their implications are discussed.     

Mental health policy in the liberal state: the example of the United States

Mental health policy arises out of the interaction of many different variables. These include (but are not limited to) the composition of the population of persons with severe mental illnesses; the means of dealing with disease and dependency; concepts of the etiology and nature of mental disorders; the organization and ideology of psychiatry; funding mechanisms; and existing popular, political, cultural, and professional values. But an often neglected but crucial factor in shaping policy is the very structure of the American political system, which played a crucial role in shaping mental health policy. Rather than emphasizing the neo-liberal theory and its accompanying hostility toward "unsuccessful" people and disdain of welfare, this article suggests that an understanding of mental health policy in the latter half of the twentieth century is better served by an examination of what actually happened. Theory, however attractive, rarely can encompass the messy data of reality.     

Private regulation in mental health

General hospitals are increasingly important sources of care for chronic and acute mental patients. Joint Commission on Accreditation of Hospitals (JCAH) standards for staffing in general hospitals require the same degree of physician supervision and control for all services, including mental health. This paper considers the economic impact of JCAH standards on the practice of psychologists in hospitals. The “voluntariness” of the standards is assessed and the evidence that these standards foster economic protectionism is considered. We conclude that in light of the demonstrated capability of nonphysician professionals, methods of quality control appropriate for physician health care in general hospitals should be reconsidered as these instutions diversify into mental health services.     

Psychiatric aspects of arsonists.

Arson is a major source of property damage, injury and death in the United States. Many people who commit arson have extensive psychiatric histories and symptoms at the time of their fire-setting. However, traditionally the law enforcement community and the mental health community have not shared information about the characteristics of people who set fires. This study examined mental health records and/or prison files from 283 arsonists. 90% of arsonists had recorded mental health histories, and of those 36% had the major mental illness of schizophrenia or bipolar disorder. 64% were abusing alcohol or drugs at the time of their firesetting. Pyromania was only diagnosed in three of the 283 cases. Different motives for setting fires are discussed; many patients were both angry and delusional. A survey instrument, which captures both psychiatric and legal data, is included. Suggestions are made for gathering future "profiling" information. A matrix approach to coding diagnosis and behavior is presented.     

Nonsexual boundary violations: sauce for the gander

Numerous articles in the mental health literature concern sexual contact between therapists and patients, which is explicitly prohibited by all four mental health professions' ethical codes. There is relatively little about nonsexual boundary violations, which are often covert and much more difficult to recognize (particularly in their early stages) than sexual violations; what little there is assumes that the clinician has the power in the relationship and uses that power for personal advantage. In this article the authors discuss the situation, rare in civil mental health facilities but common in correctional and forensic mental health facilities, in which personality-disordered patients manipulate and coerce clinicians to cross appropriate professional nonsexual boundaries for the patients' benefit; this reversal of the usual power dynamics between treaters and patients requires recognition of the role reversals present and requires different strategies for preventing such violations (hence "sauce for the gander").     

Risk,response, and mental health policy: learning from the experience of the United Kingdom

Policy makers in the United States and the United Kingdom recognize that mentally disordered offenders present special challenges to law enforcement, mental health, and social service systems, as well as the community. Although various policy initiatives have advanced over the past twenty years to improve the management of mentally disordered offenders, mental health policy has chronically failed in both countries. Because safety concerns have emerged as the mental health system has been "deinstitutionalized," debate is growing about whether the community-care approach works-for the community. This study argues that mental health policy fails because policy makers focus on the wrong risks and design policies that manage these risks in ways that increase the possibility of adverse clinical and economic outcomes. The argument made here uses the case of persons with severe mental illness in the United Kingdom as an example of the complex relationship between risk and policy making in democratic governance. Emphasis is on the nature of risk in mental health policy and how government responds to policy and political risks. Mental health policy in Britain is then analyzed in terms of its response to and management of risks. Mental health policy has historically mismanaged the risk issue in the United Kingdom and as such has set in motion the growing community-care backlash. The path to a better outcome lies in the responsible management of the right risks. Lessons from the United Kingdom experience can be usefully applied to mental health issues in many industrial democracies.     

Revictimized Adult Women: Perceptions of Mental Health Functioning and Associated Services

In this study, using a sample of adult women (N = 418) from various environments, mental health outcomes and perceptions about different types of support following childhood and adulthood sexual and physical violence were assessed. The respondents were from three locations: general community, state prison, and sexual assault and domestic violence service providers. A cluster analysis based on victimization experiences was conducted; subsequent analyses showed that women who endured more types of abuse had more self-reported mental health difficulties. Somewhat paradoxically, women who utilized more therapeutic services held more negative perceptions of their mental health functioning, while use of tangible services had no significant association. Those who found therapeutic services helpful had significantly higher self-reported concurrent mental health functioning.     

Attitudes among stakeholders towards compulsory mental health care in Norway

Objectives

The Norwegian Mental Health Care Act allows use of coercion under certain conditions. Even though the current practice has been criticized, little empirical data exist about the attitudes towards compulsory mental health care.

Method

This study used Q-methodology to identify prototypical attitudes and to test possible differences of attitudes between groups of stakeholders towards the use of coercion in mental health care. Sixty-two respondents who represented six groups with different roles in mental health care participated: former patients, relatives of psychiatric patients, members of supervisory commissions, psychiatrists, other physicians, and lawyers.The participants were asked to assess the degree to which they agreed on 30 statements concerning use of coercion for the mentally ill.

Results

Three factors that in a meaningful way express different attitudes towards the question were found. The most widely shared attitude stated that a trusting relationship between patient and therapist is more important than the right to have an attorney. This attitude gives partial support to the present Mental Health Care Act. However, the second most common attitude argues that involuntary hospitalization, if necessary, should be decided in a court and not by the hospital doctor.

Conclusions

Differences in attitude could partly be explained by the respondents' role in mental health care. Both psychiatrists and “somatic” physicians expressed more agreement with the present legislation than the other stakeholders. The findings may have implications for the legal protection of mental health care patients.     

Lay persons' versus psychologists' judgments of psychologically aggressive actions by a husband and wife

Literature assessing knowledge of and attitudes toward social issues has demonstrated that mental health professionals and lay persons often differ greatly. To add to the normative information in the field of psychological abuse and to determine whether the differences previously found between mental health professionals and lay persons extend to this field, a sample from each group rated psychologically aggressive items by a husband toward his wife. For the 102 items, psychologists were more likely to label the behaviors as "psychological abuse," but this tendency was due to psychologists considering the behaviors as either "always" or "possibly" abusive, whereas lay persons demonstrated a bimodal response pattern of rating the behaviors as "always" or "never" psychological abuse. Lay persons were much more likely than psychologists to rate items high in terms of severity level, however. The two groups used different contextual factors for determining that a behavior was psychological abuse when they initially were uncertain that it was abusive.     

Morality and pretextuality, psychiatry and law: of "ordinary common sense," heuristic reasoning, and cognitive dissonance

The thesis of this paper is that we will not make significant progress in understanding the tensions between the legal and mental health systems until we look carefully at a series of dissonances that affect both systems. We must consider the way that the law frequently condones pretextuality as a way of dealing with troubling or cognitively dissonant information, and the way that mental health professionals encourage a self-referential concept of morality as a way of subverting legal doctrines with which they disagree. These dissonances must be considered contextually in connection with the ways that courts generally read social science data and the ways that jurors and legislators employ such cognitive devices as "ordinary common sense" and heuristic reasoning in their judgments of cases involving mental disability questions. To ameliorate the current dilemma, we must redefine institutional and professional roles, reconsider the way we privilege expertise, recalibrate our allocation of "moral jurisdiction" over these matters, and consciously confront the way our simplifying thinking mechanisms distort the underlying social and political issues.     

Outcomes from Referring Batterer Program Participants to Mental Health Treatment

A quasi-experimental study was conducted to investigate the impact of referral to supplemental mental health treatment for batterer program participants who screened positive for mental health problems. The principal outcome measure was re-assault reported during a periodic 12-month follow-up with female partners (n = 308). Batterer program completion and other abuse indicators were also considered. Mandatory court referral to mental health treatment produced no significant improvement in batterer program completion, re-assault and other abuse indicators. These results may be influenced by the low compliance to the referral, since the select number of men who did comply with a mental health evaluation (n = 48 of 148) and those who received treatment (n = 28 of 148) did better than those who did not. Simplified referral procedures or integrated treatment services might prove to be a more effective approach.