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

An important question in social policy analysis is "what kinds of patterns exist in policymaking activity over time?" ( 1 ). It is rare that a publication sufficiently elucidates both the historical forces and policy initiatives impacting the organization and delivery of mental health treatment. Written by historian Gerald Grob and Howard Goldman, a policy researcher and editor of Psychiatric Services, The Dilemma of Federal Mental Health Policy is an important contribution to the field.

The authors focus on policy changes since 1942 that affect adults with severe and persistent mental illness and describe the people, events, and legislation influencing mental health policy. Notable examples include the Joint Commission on Mental Illness and Mental Health, the Community Mental Health Centers Act of 1963, the President's Commission on Mental Health, the Community Support Program, the Omnibus Budget Reconciliation Act of 1981, the 1999 Surgeon General's report on mental health, and the New Freedom Commission on Mental Health. The book also contains a helpful list of acronyms. The major theme of the book is that mental health policy reform efforts have either been incremental or radical and have often ignored individuals with severe and persistent mental illness.

Not surprisingly, the book reads like a historical account of mental health policy. Stories of the people who have played integral roles in developing mental health policy are especially intriguing. A major strength of the book is that it highlights how rhetoric and ideology rather than empirical evidence fueled the establishment of community mental health centers. To emphasize important points, the authors include practical pieces of policy insight based on their first-hand experiences. For example, in comparing the President's Commission on Mental Health (PCMH) to the recent New Freedom Commission on Mental Health, the authors note that "both commissions were expected to recommend far-reaching changes, yet the lesson of the PCMH was that fundamental change was elusive, but small sequential steps guided by a specific set of recommendations were more likely to bear fruit."

One weakness is that the authors did not examine the role that the recent Institute of Medicine report ( 2 ) on the quality of mental health and substance abuse treatment may have in future mental health policy reform. Surprisingly, the book does not include any tables, graphs, or figures to illustrate trends. At a minimum, a chart showing a timeline of significant events would have been helpful.

Readers of Psychiatric Services will find this book relevant and informative. The book will be suitable as a primary text for courses in mental health policy and services research, as well as a supplemental book for general health policy courses. Readers may want to compare this book with Richard Frank's and Sherry Glied's recent book that examines mental health policy changes from an economic perspective ( 3 ) [See the review on page 881]. David Rochefort's text ( 1 ) would also be a useful companion to this book for those interested in understanding conceptual frameworks applied to mental health policy analysis. In fact, Rochefort's thesis that mental health policy represents a cyclical model of change is consistent with Grob and Goldman's narrative. Hopefully future reforms, whether radical, incremental, or cyclical, do not repeat past failures and ignore the needs of individuals with severe and chronic mental illness.