The Dilemma of Federal Mental Health Policy: Radical Reform or Incremental Change?

The Dilemma of Federal Mental Health Policy: Radical Reform or Incremental Change?

The Dilemma of Federal Mental Health Policy: Radical Reform or Incremental Change?

The Dilemma of Federal Mental Health Policy: Radical Reform or Incremental Change?


Severe and persistent mental illnesses are among the most pressing health and social problems in contemporary America. Recent estimates suggest that more than three million people in the U.S. have disabling mental disorders. The direct and indirect costs of their care exceed 180 billion dollars nationwide each year. Effective treatments and services exist, but many such individuals do not have access to these services because of limitations in mental health and social policies.

For nearly two centuries Americans have grappled with the question of how to serve individuals with severe disorders. During the second half of the twentieth century, mental health policy advocates reacted against institutional care, claiming that community care and treatment would improve the lives of people with mental disorders. Once the exclusive province of state governments, the federal government moved into this policy arena after World War II. Policies ranged from those focused on mental disorders, to those that focused more broadly on health and social welfare.

In this book, Gerald N. Grob and Howard H. Goldman trace how an ever-changing coalition of mental health experts, patients' rights activists, and politicians envisioned this community-based system of psychiatric services. The authors show how policies shifted emphasis from radical reform to incremental change. Many have benefited from this shift, but many are left without the care they require.


This book is a collaborative work by a historian (Gerald N. Grob) and a psychiatrist (Howard H. Goldman). At first glance our respective disciplines appear to be far apart. Appearances, however, can be deceiving. Both of us have spent much of our careers studying mental health policy, the role of government (local, state, and national), the practice of psychiatry and allied mental health disciplines, and, above all, the fate of individuals with severe and persistent mental illnesses. We have been fascinated by the claims of successive generations that their policies would resolve the pressing needs of individuals whose severe mental illnesses have often created dependency and thus required either public or private assistance. What is equally fascinating is the fact that many “solutions” have embodied an ideological agenda that often lacked any basis in reality and ignored available empirical data.

This book attempts to trace the evolution of federal mental health policy from World War II to the beginning of the twenty-first century. These decades have been marked by a determined effort both to shift the locus of policy away from institutional to community care and to transfer leadership and authority from the states to the federal government. As a result of America’s peculiar federal system, intergovernmental rivalries and efforts to shift costs to different levels of government have played an important if overlooked part in the transfer of power and the reshaping of policy. In recent decades, moreover, policy outcomes have often reflected the actions of federal bureaucrats who are responsible for developing the guidelines to implement legislation. At the same time the growing preoccupation with psychological maladjustment and the creation of myriad diagnostic categories have also brought new groups into the mental health arena. The decline of traditional mental hospital care and the rise of a community care policy, paradoxically, created a fragmented rather than a unified mental health system. Those most in need–persons with severe disorders–have often proved to be the losers.

In tracing the history of mental health policy, we have emphasized intergovernmental relationships and the rise of federal authority. We could have written a separate volume about state mental health policy, since that is where many of the innovations in services and government stewardship of mental health have occurred during the same time period. But we have focused on . . .

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