Innovative Approaches to Mental Health Evaluation

Gerald J. Stahler, William R. Tash, Gerald J. Stahler, William R. Tash

• Éditeur: Academic Press
• Année: 2013
• ISBN:
  9781483276502
• Sujet: Politique et relations internationales
• Sous-sujet: Politique sociale

Innovative Approaches to Mental Health Evaluation is a collection of papers that provides a broad range of ideas, methods, and techniques in program administration and evaluation in the field of mental health. The book is organized into 2 sections. Part I, consisting of 8 chapters, presents the necessary evaluation strategies and approaches that effectively address the important mental health issues for the 1980s such as prevention programs; the linking of health and mental health delivery systems; accountability in assuring quality of services; deinstitutionalizing the chronically mentally ill; and providing for greater local participation in mental health program management. Part II, surveys the promising evaluation methods, approaches, and relevant issues that are emerging in the new organizational and political environment of the mental health system. The book will be of good use to mental health administrators, researchers, managers, students, and evaluators.

I

MAJOR MENTAL HEALTH ISSUES: THE EVALUATIVE RESPONSE

1

THE DESIGN AND EVALUATION OF FUTURE MENTAL HEALTH SYSTEMS

JOHN C. WOLFE and HERBERT C. SCHULBERG

Publisher Summary

The energy problems, world events, economy, and many other contemporary factors will shape the future of the mental health system and developments within the field itself. The ebb and flow of external and internal events reflect the Hegelian philosophy and insure a mental health system that constantly experiences change. This chapter provides a snapshot view of future systems and subsystems that relate to the mental health field. The greatest challenge of the present decade resides in the ability and energy of mental health system to bring healing to its member components, and to develop and maintain a vision of the future that rises above the morass of each day’s events. The accountability system has a significant role in determining whether or not programmatic priorities are being met with regard to the patient populations needing care, and in terms of the ability of the service delivery system to improve the functioning of its several target populations.

EDITOR’S INTRODUCTION

Wolfe and Schulberg set the stage for the following chapters by describing what they believe to be the mental health system of the coming decade. They see the emerging system as one increasingly oriented toward closer collaboration between general health and mental health. The mental health field’s multiple interest groups will be forced to work together to survive in an era of fiscal conservatism. The chronically mentally ill, the elderly, children, and minority groups will be highlighted for attention and resources. There will also be a broadening of the traditional domain of mental health concern to include such areas as weight control and life management consultation. Primary prevention will become a more visible part of the mental health system, and pressures from the major mental health disciplines for reimbursement of their individual services will continue to be intense.

The authors then discuss the role that evaluation will play in the future. They anticipate decreased participation of citizens and consumers in the evaluative process, with a larger focus on accountability studies.¹ Wolfe and Schulberg see evaluative attention being focused on such issues as providing clarification as to which populations are most appropriately served by community mental health centers (CMHCs), developing more detailed indices of performance measures for CMHCs, and ascertaining which benefits are received by which client groups. The authors still see major difficulties confronting the use and design of outcome studies. They suggest that research into the effectiveness of primary prevention, as well as cost–benefit analyses, however, will become a significant venture during the next several years. Overall, they view the accountability system as having a particularly significant role in determining programmatic priorities.

The mental health system of the future will be no more singular than that of today. In fact, the overall “system” will probably contain even more component “subsystems” than exist at present. This chapter attempts to provide a snapshot view of future systems and subsystems that relate to the mental health field; most are already familiar, but their functions and significance are expected to change. The reader could organize and identify these components by different groupings; however, the following are evident to us in the often chaotic world of mental health service delivery:

The Political System

The Patient System

The Delivery System

The Reimbursement System

The Manpower System

The Accountability System

Each system will be described in terms of its major present and future characteristics and the implications for change of the delivery of mental health services during the 1980s.

THE POLITICAL SYSTEM

History operates, according to Hegel, in a dialectical process that starts with a thesis, develops an antithesis, and later a synthesis. The synthesis becomes the thesis of the future and the entire process begins anew.

At the risk of oversimplifying past events, the political system in the United States for the past 20 years reflects this Hegelian dialectic as it relates to mental health. The Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 was signed by President John Kennedy. Alongside other liberal legislation of the 1960s, the Community Mental Health Centers Act offered monies and new resources for the care of the mentally ill. During the 1970s, the federal administration attempted to eliminate this effort; funds were impounded, and threats were made to terminate all federal support of the program. In the late 1970s and in 1980, the mental health field experienced new hope with the creation of the President’s Commission on Mental Health (PCMH), which seated Mrs. Rosalynn Carter, the first lady, as its honorary chairperson. The 1978 report of the PCMH resulted in the administration’s proposal of the Mental Health Systems Act (MHSA), which was enacted in 1980. The MHSA represents the synthesis of the liberal policies of the 1960s (the thesis) and the reactionary policies of the 1970s (the antithesis). It purports to offer new directions with limited resources.

The 1980s offer a most fascinating canvas on which to paint the future relationship of the political and mental health systems. The Congress finds itself reacting to the taxpayer’s demand for relief and a new phrase—the “Proposition 13 mentality”—is used to describe many congressional actions. The legislative branch is now demanding that programs be “accountable” and “cost effective.” Some policymakers speak profoundly of “mainstreaming” mental health into health, while others talk about “multiple funding sources.” The political rhetoric becomes increasingly oriented toward the mental health system as though it is an entity whose parts are discernible and are synchronized. The political system itself is taking more powers away from the presidency; more decisions affecting mental health care are being made in the courts, and the capacity of Congress to deal knowledgeably with the mass of legislation and issues that it confronts is diminishing.

How will these developments affect the political system’s future relationship to mental health? It is safe to assume that, over the next 5 years, there will be an increased fiscal conservatism unlike anything experienced thus far. The juxtaposition of inflation and recession is a paradox even for the economist, and it encourages fiscal controls and conservatism. The Congress will find itself caught between the taxpayer and the “new right” (antiabortion, return to fundamental values of yesteryear, etc.) on the one hand, and those with a vested interest in mental health care on the other. Consequently, federal categorical dollars for mental health will continue to shrink in purchasing power, if not in actual volume, even though Titles XVIII and XIX will expand and provide a little more coverage. The only way to make the political system responsive to this country’s mental health needs is through massive lobbying efforts by all members of the field. This strategy is problematic, however, because of differences between the various disciplines, community care givers, and institutional providers, and the profit and nonprofit sectors.

The complexities of affecting public policy become even greater considering the relationship of federally mandated health planning agencies and the mental health system. The next few years will produce serious power struggles between the various health planning agencies within each state and the state departments of mental health. However, mental health and health planning agencies share enough compatible goals to work cooperatively by 1985.

The last half of this decade portends a brighter future for the mental health system. The antithesis of the early 1980s will occur as a result of economic, political, and international developments. The multiple interest groups in the mental health field will have been forced to work together to survive; coalitions will have developed, and individual agencies and associations will be significant members of a stronger and broader power base.

THE PATIENT SYSTEM

During the past 2 decades, a change of emphasis from institutional care to community care has occurred. Concomitant with this has been a change in the diagnostic categories of patient populations. Information from the National Institute of Mental Health indicates that 15.9% of additions to federally funded CMHCs in 1971 were diagnosed as schizophrenic; in 1977, the proportion had dropped to 14% (NIMH, unpublished data). Although CMHCs have been accused of treating those who are less severely mentally ill, upon further analysis, that may not be the case. It is possible that people are now being identified and treated in the early stages of emotional disturbance (or pathology); consequently, fewer cases are ultimately diagnosed as schizophrenic. Recent NIMH data indicate that the “substantial increase in admissions of patients with other diagnoses has diluted the proportion of admissions of patients with schizophrenia, and the rapid expansion of the number of CMHCs has diluted the average number of admissions of patients with schizophrenia per CMHC [Goldman, Regier, Taube, Redick, & Bass, 1980 p. 86].” In fact, these authors emphasize “that the average absolute number of admissions per year of patients with schizophrenia … has remained relatively stable [Goldman et al., 1980 p. 85].” Nevertheless, some professionals and laymen continue to perceive that community mental health providers are neglecting schizophrenics and other seriously ill persons.

American society seems to have a penchant for emphasizing certain behavioral problems during a particular time period. For example, in the 1960s and 1970s public and political efforts were directed toward resolving both drug and alcohol problems. Substance abuse was, is, and will be troublesome; there had been a long history of neglect in this area that helped to focus resources toward combating its resulting problems. The fact remains, however, that the demand characteristics of some societal segment, other than professionals, created the resources that led to the development of needed treatment, research, and training facilities.

During the early 1980s, several patient populations will receive attention from the public and policymakers as well as from the media. The chronically mentally ill, the elderly, children, and minority groups are consistently presented as receiving short shrift from the mental health establishment. We do not dispute the veracity of such claims but would emphasize that a variety of external events cause particular population groups to be highlighted for attention and resources. Programs subsequently follow the demand.

A broadening of the spectrum perceived to be the domain of mental health concern will occur in the next decade. Behaviors such as smoking and overeating, and life crises such as separation...