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Reforming Mental Health Reform the History of Mental Health Reform in North Carolina

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Reforming Mental Health Reform the History of Mental Health Reform in North Carolina North Carolina MARCH 2009 SPECIAL REPORT Reforming Mental Health Reform The History of Mental Health Reform in North Carolina by Alison Gray North Carolina Center for Public Policy Research Funding for the Center’s study of reforming mental health reform in North Carolina was provided in part by grants from the Kate B. Reynolds Charitable Trust of Winston-Salem, N.C., the Moses Cone ~ Wesley Long Community Health Foundation of Greensboro, N.C., the Annie Penn Community Trust of Reidsville, N.C., and the Rex Endowment of Raleigh, N.C. The N.C. Center for Public Policy Research extends its sincere thanks to these organizations for their generous support of this project. ______________________________________________________________________________ N.C. Center for Public Policy Research ______________________________________________________________________________ Board of Directors The North Carolina Center for Public Policy Research is an independent, Chair nonprofit organization dedicated to the goals of a better-informed public Betsy Justus and a more effective, accountable, and responsive government. The Center identifies public policy issues facing North Carolina and enriches Vice Chair the dialogue among citizens, the media, and policymakers. Based on its Leslie Anderson research, the Center makes recommendations for improving the way Secretary government serves the people of this state. In all its efforts, the Center Wanda Bryant values reliable and objective research as a basis for analyzing public policy, independence from partisan ideology, the richness of the state’s Treasurer diverse population, and a belief in the importance of citizen involvement John Willardson in public life. Treasurer-Elect Robert Burgin The Center was formed in 1977 by a diverse group of private citizens for the purpose of gathering, analyzing, and disseminating information Melinda Baran concerning North Carolina’s institutions of government. It is a Astrid Chirinos nonpartisan organization guided by a self-elected Board of Directors and Betty Craven has individual and corporate members across the state. Natalie English Ken Eudy Center projects include the issuance of special reports on major policy Lynn Holmes questions; the publication of a journal called North Carolina Insight; a James Jones newsletter called “From the Center Out;” joint productions of public Connie Majure-Rhett affairs programs with WPTF-AM, the N.C. Radio News Network, and Danny McComas Time Warner Cable; and the regular participation of members of the staff Karen McNeil-Miller and the Board in public affairs programs around the state. An attempt is Bill Parmelee made in the various projects undertaken by the Center to synthesize the Fred Stang thoroughness of scholarly research with the readability of good Jack Stanley journalism. Each Center publication represents an effort to amplify Gwynn Swinson conflicting ideas on the subject under study and to reach conclusions Gregg Thompson based on sound rationalization of these competing ideas. “B” Townes __________________________________________________________ Jolanta Zwirek Published by the North Carolina Center for Public Policy Research, Inc. Executive Director (a nonprofit, tax-exempt organization), P.O. Box 430, 5 West Hargett Ran Coble Street, Suite 701, Raleigh, NC, 27602. Telephone (919) 832-2839. Staff Annual membership rates: Individual, $36; Organizational, $50; Tammy Bromley Supporting, $100; Full-Service, $250; Supporting Corporate, $500; Mebane Rash Patron, $1,000; Benefactor, $5,000. The Center is supported in part by Nancy Rose grants from the Z. Smith Reynolds Foundation, as well as 9 other Jeff Sossamon foundations, 137 corporate contributors, and almost 500 individual Sam Watts members across the state. Visit the Center website at www.nccppr.org. Reforming Mental Health Reform The History of Mental Health Reform in North Carolina Table of Contents EXECUTIVE SUMMARY iii INTRODUCTION 1 MENTAL HEALTH POLICY AND REFORM: POST-REVOLUTIONARY PERIOD THROUGH WORLD WAR II 4 Ad Hoc Local Community Care of the Insane During the Post-Revolutionary Period 4 State Intervention: The Asylum Movement During the 1800s 6 North Carolina’s Role in the Asylum Movement 8 The Effect of the Asylum Movement on the Relationship between State and Local Governments 11 The Status of NC’s Asylums and State and County Relations from the Turn of the Century Through World War II 18 State and County Roles 18 The Ever-Present Problem of Demand Exceeding Supply and the Various Mentally Ill Populations Vying for Treatment 20 Other Considerations 22 POST-WORLD WAR II MENTAL HEALTH POLICY: THE COMMUNITY-BASED MOVEMENT AND THE ENTRANCE OF THE FEDERAL GOVERNMENT INTO THE MENTAL HEALTH ARENA 23 Factors Contributing to the Decline of the Social and Medical Legitimacy of State Institutions and the Rise of Community-Based Treatment 25 The Changing Composition of the Asylum Population 25 The Changing Nature of the Psychiatry Model 27 The Emergence of Psychotropic Drugs 28 The Emergence of Mental Health Legal Advocates and a More Active Judiciary 30 The Decline in the Quality and Image of State Institutions 30 The Entrance of the Federal Government: National Mental Health Legislative Enactments 32 The National Mental Health Act of 1946 33 The Mental Health Study Act of 1955 35 Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 36 The Entrance of the Federal Government: National Social Welfare Legislation Indirectly Impacting Mental Health Policy 37 The Amendments to the Social Security Act of 1965: Medicare and Medicaid 37 SHIFTING POLITICAL WINDS: THE 1970s AND 1980s 39 Federal Actions 39 North Carolina’s Actions During the 1970s and 1980s 40 The History of Mental Health Reform in North Carolina i OVERVIEW OF THE CONSEQUENCES OF THE COMMUNITY-BASED MOVEMENT OVER THE LAST HALF OF THE 20th CENTURY 43 Inherent Problems in the Community-Based Approach 44 The Diminution of State Involvement in Mental Health Policies and Its Impact on the Severely Mentally Ill 45 The Effect of the Community-Based Movement on State Mental Institutions: “Dehospitalization” 46 The Progressive Depopulation of State and County Mental Institutions 46 The Increase in Other Institutional Settings 47 The Rise of a New Generation of Mentally Ill Different From Institutionalized Patients 48 Homelessness and Incarceration 48 THE 1990s: LEGISLATIVE AND JUDICIAL DECISIONS AND THE EMERGENCE OF INITIATIVES DESIGNED TO ADDRESS THE FRAGMENTATION OF RESPONSIBILITY AND FINANCING IN THE MENTAL HEALTH SYSTEM 51 The Americans with Disabilities Act of 1990 and the Olmstead Decision 51 Outpatient Commitment 52 Evolving Approaches to Financing and Organizational Issues in the Mental Health System 52 CONSEQUENCES OF THE COMMUNITY-BASED MOVEMENT ON NORTH CAROLINA’S MENTAL HEALTH SYSTEM DURING THE DECADES BRIDGING THE NEW MILLENNIUM 54 Overview of Flaws in North Carolina’s Mental Health System Prior to Reform 54 Steps Toward Reform 56 MENTAL HEALTH POLICY IN THE NEW MILLENNIUM 61 North Carolina’s Reform Legislation: Key Provisions 61 AN OVERVIEW OF THE CURRENT STATE OF NORTH CAROLINA’S REFORM EFFORTS . 64 The Impact of Reform on Consumers 64 The Impact of Reform on the Availability of a Qualified Work Force 66 The Impact of Reform on System Governance 69 Legislative Commitment to Funding Reform 71 The Quest for Integrated Funding 72 The Impact of Reform on State Hospitals 74 Privatization of Services 76 North Carolina’s Olmstead Plan 78 CONCLUSION 81 SIDEBARS What’s PC These Days? A Look at the Language of Mental Health 3 When Regret Is Not Enough: Newspapers Report on Deaths of Mentally Ill Patients in the State’s Care 7 The Key Role of Leadership in Mental Health Policy 14 Mental Health in the Movies 29 The Four Sectors of the Mental Health System 42 The News and Observer Sheds Light on North Carolina’s Mental Health System 67 Mental Health Legislation in the 2007-08 N C General Assembly 81 Glossary of Mental Health Terms 82 Glossary of Mental Health Treatment Options 83 ii North Carolina Center for Public Policy Research Reforming Mental Health Reform The History of Mental Health Reform in North Carolina Executive Summary Recent exposés about the severe problems in the implementation of North Carolina’s 2001 mental health reform legislation inevitably lead to the broader question of how North Carolina got where it is today — which in some, but certainly not all, respects is a malfunctioning mental health care system. A review of the evolution of mental health policy in the state illustrates that re- gardless of the nature of the reform, there are complex and not easily resolved core issues that remain to be addressed, involving (1) governance — which government entity has responsibility for the welfare of the mentally ill; (2) coverage — which individuals should be included in government-provided mental health care; (3) funding — how will the necessary services be paid for; and (4) work force — by whom will the treatment be provided? The history of reform shows that improving the treatment and care of the mentally ill is a complex process that evolves incrementally — sometimes with major leaps forward followed by substantial retreats. Finding solutions is not simple, but history can help illuminate the policy and funding parameters that in many ways help shape future reform, as well as stand as a testament to the fact that progress can be achieved as long as the public will and legislative commitment to reform are strong. America’s Post-Revolutionary Period:
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