Policy makers who have become interested in how to reshape America's mental health policy generally need to know more about its history and complexity than they realize. A great starting point would be the new (the sixth) edition of Mental Health and Social Policy by David Mechanic, Donna McAlpine, and David Rochefort.
For many years the prior editions, written by Prof. Mechanic alone, have been the standard text for students of mental health policy. This edition promises to continue to be the standard text because it provides so much information and insight so clearly and briefly.
In addition, the new edition focuses attention on several of the major controversies regarding mental health policy, including, among others:
• The presumed, but actually very weak, link between mental illness and violence.
• The use of managed care to improve access and quality and to contain costs.
• Disputes about the new system of diagnosis that will be introduced in May.
• Discussion of the pros and cons of expanded reliance on psychiatric medications.
Mechanic and his colleagues have a great appreciation of the fact that nothing is simple when it comes to mental health policy, not even defining mental illness and mental health. If we accept the idea that mental illness involves dysfunctions of thinking, feeling, and/or behavior, we still need to face the question of at what point ordinary human struggles become illnesses. Some people do not think as clearly as others. When is failure to grasp reality accurately a disease? Everyone is unhappy at one time or another. When are they clinically depressed? Most people (especially children and adolescents) exhibit undesirable behavior at least occasionally. When is this a reflection of an underlying mental illness? Criminal behavior is almost always deviant. Does that make it pathological? And is mental health simply the absence of mental illness, or is it a positive state of human well-being that can be promoted through various social policies and social actions?
Mental Health and Social Policy walks us through these and other very basic questions, which -- of course -- have a tremendous impact on thinking about what public (and private) mental health policy should be. Is it the job of government to provide and/or pay for interventions to treat all mental illnesses or only the most severe? Should government cover everyone or only those people who cannot afford care and do not have mental health coverage through work? To what extent should government promote human well-being, above and beyond overcoming and avoiding mental illness?
Mechanic and his colleagues provide a very good, brief overview of the history of public mental health policy in America. They trace the transformation from a system that focused almost exclusively on people with the most severe and disabling mental illnesses and provided care almost exclusively in institutions to a community-based public mental health system in which government also supports services for people with less severe mental disorders especially those who cannot afford to pay themselves. Community mental health policy combined with Medicaid and Medicare vastly expanded the realm of public mental health policy and programs.
These changes have led to better and more accessible, although far from fully adequate, mental health services. In addition, they have generated a number of critical controversies. Should there be more or less inpatient care? Should there be more or fewer coercive interventions? Should there be more or less spending on mental health services? Do we rely too much on psychiatric medications? Should mental health services be merged into physical health care organizations? Should eligibility for social welfare benefits (such as Social Security Disability, SSI, and supported housing) be tightened or expanded? Should people with mental illness who commit crimes get special treatment in the criminal justice system? And more.
Central to the future of America's mental health system is how health care reform will affect the delivery and financing of mental health services. At the moment, there is great confidence that "managed care" and the development of large, integrated service systems such as "medical homes," "health homes," and "accountable care organizations" will create a more accessible, higher quality, and more affordable mental health system. Mechanic and his colleagues raise questions about this, particularly about whether the integration of physical and mental health care into basic medical organizations will work for people with the most severe and disabling forms of mental illness.
But, and this is very important, this book does not argue for any particular mental health policies. Its purpose is to expose readers to the fundamentals of American mental health policy, to highlight the controversies, and to provide an overview about what available research seems to reveal. Ultimately, readers must make their own judgments about how to change American mental health policy. Hopefully policy makers will be among those readers.
For more by Michael Friedman, L.M.S.W., click here.
For more on mental health, click here.