It’s rarely a happy marriage when political ideology mixes with mental health policy. To use the most egregious example in psychology’s relatively brief history, the eugenics movement of the early- to mid-twentieth century saw misguided—and devastating—principles of psychological measurement based on then-mainstream theories of racial purity enshrined into law. That leaders of our profession championed such law and policy brings enduring shame and serves to remind us that the passage of time doesn’t minimize these wrongs. It also illustrates that science and society always exist in tandem and can never be divorced. Those that believe there is a purity of scientific reasoning that transcends social mores are wrong, often dangerously so, because their thinking is characterized by a sense of absolutism and irrevocable truth that almost never withstands the scrutiny of history. And it’s not just social sciences. Whether you’re discussing astrophysics or intellectual assessment, science reflects society and its manifold foibles.
A recent New York Times editorial carried the over-optimistic headline of “The Solution to America’s Mental Health Crisis Already Exists.” The editorial reminds us of the history of the community mental health movement that sprang from the abuses of asylums and the deinstitutionalization movement that began in the 1950s. John F. Kennedy’s last signed legislation, the Maternal and Child Health and Mental Retardation Planning bill, funded the development of community mental health centers, which Kennedy explicitly envisioned as operating in the community in concert with universities, private and public health care, and community leaders. Their expense was acknowledged at the time but it was successfully argued that overall costs would be lower and individual outcomes far superior than in the institutional system that preceded them. Thus, a network of community resources for those with mental disorders was established, providing a safety net and resources, albeit limited and incomplete.
Community mental health centers grew in the decade or so that followed. They never were a panacea, and ongoing funding was a perpetual issue. Long-term investments in mental health and other population health have always been a difficult political issue because of their expense, and this problem is magnified in a system where health care is driven by the profit motive. Most politicians have little stomach to champion agendas that don’t promise tax cuts or immediate tangible returns. But the potential of community mental health centers was recognized and where they existed they more or less served their intended purposes. As the Times editorial pointed out, Jimmy Carter in 1980 signed similar legislation to expand them.
But then ideology intervened, in the form of Ronald Reagan’s Director of the Office of Management and Budget, David Stockman. Famously depicted in editorial cartoons of the day as an executioner wielding a bloody axe, Mr. Stockman saw his mission as slashing federal spending and giving states broad leeway in how funds were spent. Federal funding for mental health clinics was accordingly dispensed to states in the form of block grants to spend more or less as they wished. The results were predictable. Mr Stockman was able to claim that the heavy hand of federal regulation had been lifted from the backs of oppressed states, states spent the money in haphazard and unrelated ways, and the population of untreated patients, often homeless, swelled. Ideology had been preserved, but at tremendous long-term cost. (Those with a keenly developed sense of schadenfreude will recall that Mr. Stockman was later accused of defrauding private equity investors and escaped criminal prosecution after agreeing to a multi-million dollar settlement with the Securities and Exchange Commission.)
While we all should be circumspect about the establishment of new federal programs, what was true in the 1960s remains true today: National problems require national solutions. To attempt to solve national problems with 50 different solutions squanders national resources and often results in healthcare inequities that compound individual misery. Our patchwork quilt approach to managing federal dollars via state Medicaid program results in tremendous variability in access to services and individual well-being.
As the Times editorial points out, there are now renewed federal efforts to establish community mental health networks, and initial efforts have seen some success. I also note that our integrated care colleagues have established excellent programs in Federally Qualified Health Centers, which are mandated to provide mental health care and which often serve the neediest groups of patients with excellent physical and mental health care. But here too manifold threats exist—many budgetary (these will never be inexpensive solutions), and some grounded yet again in ideology. Richard Nixon’s ‘war on drugs’ echoes even today in thwarted attempts to expand the use of a proven intervention— buprenorphine—to treat those with opioid addiction.
Let’s not be Pollyanna. It’s impossible to completely separate ideology from policy, just as science and society are ineluctably intertwined. But when ideology intrudes in effective mental health treatment, it’s up to us to call it out. Let’s start doing that now.
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