The Transfer of Care: U.S. Mental Health Policy since World War II

Recent criticism of mental health policy has raised many questions about the so-called “mental health revolution.” Following World War II, the federal government and the growing mental health lobby planned the first nationally oriented system of psychiatric treatment, rehabilitation, and prevention. The rapidly expanding National Institute of Mental Health coordinated that policy, particularly through its Community Mental Health Centers program. Custodial state hospitals were depopulated and their patients “dumped” in nursing and boarding homes, which now constitute the largest arena for and most expensive form of psychiatric care. While there has been some progress in decreasing the hospital population and in improving conditions, as well as in providing services to certain people who otherwise would never receive them, failures have been more dominant. Admission and readmission rates have climbed precipitously. Unplanned hospital discharge has led to hundreds of thousands of ex-patients living in dangerous, nontherapeutic nursing homes where the main concern is profit. They, and many others, are maintained on psychiatric drugs, another source of profit as well as a dangerous technology. Community mental health programs have maintained psychiatry's traditional class, race, and sex biases, and have incurred widespread intrusion into communities. This article shows that such problems are part of an interconnected system in which the driving forces are fiscal crisis, ideological justifications for dumping patients, attempts to pass responsibility from state governments to federal and local bodies, restrictions on government and insurance reimbursements, the free enterprise economics of the nursing home and drug industries, and the professionalist practices of the mental health field.