Electronic Journal of Sociology (1998)
ISSN: 1198 3655
Ronald Reagan and the Commitment of the Mentally Ill:
Capital, Interest Groups, and the Eclipse of Social Policy
Alexandar R Thomas
Department of Sociology and Anthropology
Northeastern University
alex@telenet.net
Abstract
Conventional wisdom suggests that the reduction of funding for social welfare policies during the 1980s is the result of a conservative backlash against the welfare state. With such a backlash, it should be expected that changes in the policies toward involuntary commitment of the mentally ill reflect a generally conservative approach to social policy more generally. In this case, however, the complex of social forces that lead to less restrictive guidelines for involuntary commitment are not the result of conservative politics per se, but rather a coalition of fiscal conservatives, law and order Republicans, relatives of mentally ill patients, and the practitioners working with those patients. Combined with a sharp rise in homelessness during the 1980s, Ronald Reagan pursued a policy toward the treatment of mental illness that satisfied special interest groups and the demands of the business community, but failed to address the issue: the treatment of mental illness
Introduction
Almost ten years after Ronald Reagan left office as president, the legacy of his administration continues to be studied. What is almost indisputable is that the changes in public policy that were implemented during the 1980s were sweeping and marked a turning point in American domestic policy. Faced with increasing competition from overseas, American business found it necessary to alter the social contract. This would require a realignment of the political economy so as to weaken labor unions and the social safety net. In Reagan, the Right found a spokesman capable of aligning conservatives, centrists, and working class whites. With this coalition, Reagan was able to bring about a number of reactionary changes in public policy (Alford, 1988).
This paper provides an illustration of this co-optation by examining the policies regarding involuntary commitment of the mentally ill. The shifts in such policies were not the result of overt attempts at change, but rather part of an overall effort to realign the political economy to be more profitable for business. The overall result was that political discourse shifted from a focus on social policy to a focus on fiscal policy. As such, social programs that necessitated financial outlays on the part of the federal government were overlooked in favour of policies that seemed less costly.
Still, the administration did not, and perhaps could not, act in isolation and without public support. But they didn't have to. By the middle of the 1970s, there was a consensus among interested groups that reform of the Mental Health Care System was n ecessary. Lobbying on the part of special interest groups and a commitment on the part of President Jimmy Carter led to passage of the Mental Health Systems Act.
With the planned transfer of responsibility for the mentally ill to the states, reformers needed to build coalitions of fiscal conservatives concerned with the cost of social programs; "law and order" Republicans concerned with crime; and those who dea lt with the mentally ill who, in the absence of more comprehensive reform, sought more limited alternatives (Becker, 1993). Within this context, statutes and procedures dealing with involuntary commitment of the mentally ill were attractive. Easing standards cost relatively little, allowed the Administration to claim action simultaneously on mental health care policy, crime, and homelessness, and appeased health care providers and families of the mentally ill.
The Economy
In the aftermath of World War II, the United States experienced a period of dramatic economic growth. The industrial economies of Western Europe and Japan were by and large devastated by the war. As a result, American firms found little competition abr oad in an expanding world market. The implementation of the Marshall Plan under President Truman provided American goods and services on credit to the war ravaged economies. During this period of economic hegemony, American companies were able to make con cessions to labor in regard to wages and fringe benefits. Thus, the postwar political economy of the United States was characterized by relative peace between management and labor. With record corporate profits and rising standards of living, the United States government passed a series of liberal reforms throug hout the period. Among these reforms was the passage of the Civil Rights Act, various social welfare programs, the construction of the interstate highway system, and the deinstitutionalization of the mentally ill.
During the late 1960s and early 1970s, the rebuilt economies of Europe and Japan began to give American companies stiff competition in the world marketplace. The growth experienced by American firms during the previous two decades began to slow, and profit margins were deemed to be too low (Barlett and Steele, 1996; Gruchy, 1985). In order to increase profits, many American firms attempted to become more comp etitive by trimming labor costs through layoffs and the relocation of factories (Bluestone, 1990; Bluestone and Harrison, 1982; Gruchy, 1985; Harrison and Bluestone, 1988; Moriarty, 1991; Perrucci et al, 1988; Sassen, 1991; Wallerstein, 1979). In addition , the reduction of corporate taxes was pursued with a renewed vigor (Barlett and Steele, 1994).
In order to reduce corporate taxes, it was necessary to reduce the size of the welfare state. This objective was carried out by the Reagan administration (Abramovitz, 1992). After taking office in 1981, the administration set out on a course to alter t he (relatively) labor sensitive political economy to be more business friendly. Reagan appointed anti-union officials to the National Labor Relations Board, "implicitly [granting] employers permission to revive long shunned anti-union practices: decertify ing unions, outsourcing production, and hiring permanent replacements for striking workers" (102). Reagan himself pursued such a policy when he fired eleven thousand striking air traffic controllers in 1981. Regulations designed to protect the environment , worker safety, and consumer rights were summarily decried as unnecessary government meddling in the marketplace (Abramovitz, 1992; Barlett and Steele, 1996). Programs designed to help the poor were also characterized as "big government," and the people who utilized such programs were often stigmatized as lazy or even criminal. With the help of both political parties, the administration drastically cut social welfare spending and the budgets of many regulatory agencies.
The new emphasis was on "supply side" economics, which essentially "blamed the nation's ills on 'big government' and called for lower taxes, reduced federal spending (military exempted), fewer government regulations, and more private sector initiatives " (Abramovitz, 1992, 101). Thus, to effect a change in the political economy, Reagan was able to win major concessions regarding social policy that continue today. By taking away the safety net, the working class was effectively neutralized: workers no lo nger had the freedom to strike against their employers or depend upon the social welfare system as a means of living until finding employment. Business was thus free to lower wages, benefits, and the length of contracts. The overall result was that the av erage income for the average American dropped even as the average number of hours at work increased (Barlett and Steele, 1996; Schor, 1992).
It should be understood that a realignment of the political economy did not require the complete dismantling of the welfare state -- although ideally this would be the case. Rather, the welfare state had to be rearranged in a way favorable to business. The concept of the new federalism would perform this function. The new federalism was an outgrowth of the debate over the appropriate role of the federal government relative to that of the states. While liberal Democrats argued that social welfare progra ms and governmental regulation fell within the purview of the federal government, many conservatives argued that such powers should be reserved for the individual states. Since the new environment supported conservative ideologues, the federal government was seen to have improperly assumed powers it had not been granted in the Constitution. The new federalism required that individual states create their own social policies tailored to their own particular needs. Thus, each state would have its own regulat ory and social welfare system. As each state tried to pay for such programs, this would mean fifty different state taxation policies. This effectively pitted states against each other in competition for the most favorable business climate.
Among the policies in need of reform to suit the corporate agenda were those that affected the mentally ill. The funding cuts that altered these policies were part of the overall attempt to alter the political economy in a way that would be more profit able for business rather than a direct assault on the policies themselves. Within the scope of the cutbacks, interest groups operated both in opposition and in support of the changes, both within and outside the government.
Growing Discontent
The fight over involuntary commitment during the 1980s was in some ways separate from the Reagan agenda. But it was fortuitous since it coincided with the administration's desire to dismantle the liberal era reforms. However to understand why groups made committment an issue in the 1980s, we have to take a step back and look at reforms that occurred during the 1960s.
During the early 1960s a series of initiatives designed to reform the mental health system were passed. At issue was the system of state run hospitals for the mentally ill, which were increasingly perceived as inhumane and, with the help of new medicat ions, rather unnecessary for large portions of the patient population. In 1961, the Joint Commission on Mental Illness released Action for Mental Health, calling for the integration of the mentally ill into the general public with the aid of Commun ity Mental Health Centers. In 1963, the Mental Retardation Facilities and Community Mental Health Centers instituted the centers, but due to the financial drain of the Vietnam War during the 1960s and the financial crisis of the 1970s, the program was not fully funded.1 The result was the release of patients into an environment lacking the Community Mental Health Centers to adequately treat them (Becker and Schulberg, 1976; DeLeonardis and Mauri, 1992; Hollingsworth, 1994; Rachlin, 1974; Rachlin et al, 1975; Saathoff et al, 1992; Shwed, 1978, 1980; Talbott, 1992; Worley and Lowery, 1988;).
By the start of the Carter administration in 1977, involuntary commitment had been restricted to those who were deemed as potentially dangerous to themselves or, perhaps more significantly, those around them.2 Typically, the commitment had to be sponsored by a family member and/or ordered by the court. A result of this policy was that the mentally ill patient who refused treatment typically did not receive any at all. If the patient had lost contact with family members, she or he would not be committed unless found to be a threat by the court. Often, those arrested ended up in jail rather than in treatment if they had not been found to be a threat but had committed a crime (Abramson, 1972; Conrad and Schneider, 1980). On e result was a high degree of stress and frustration experienced by the relatives of the patient. Throughout the 1970s, family members organized with the purpose of correcting a policy that they perceived was wrong.
Professional organizations also joined the backlash against the liberal era reforms of commitment regulations. One obvious reason for this is self-interest. When some mentally ill patients do not receive treatment, mental health professionals have lost (or never gained) a potential client. These professionals as a group have much to gain in terms of patients and income if the laws governing involuntary commitment are expanded to include those patients who refuse help but do not pose a serious threat to themselves or the people around them.
Perhaps more important than self-interest is the burden that deinstitutionalization put on mental health practitioners. Time spent in court took away time spent with patients. Moreover, the medical profession saw themselves as being second-guessed by o thers outside the medical community: lawyers, judges, policy makers, etc. The treatments that psychiatrists and psychologists viewed as necessary for the well being of the patient often could not be applied because of the legal rights of the patient. Invo luntary commitment would force those who needed care into the hospitals and force patients to keep appointments and take medication. Without commitment, these things were more difficult for the practitioners (La Fond and Durham, 1992, 112-13).
Critics of Community Mental Health charged that in the rush to shrink the state hospital population, many patients were released prematurely (Robitscher, 1976; Yarvis et al, 1978). Some patients went off their medications after being released into the community. The criteria of "dangerousness" for civil commitment also meant that some patients who needed treatment but were not a danger could not be committed. As a result, patients whose behavior was considered odd by the community in which they lived were increasingly arrested for bothersome and minor infractions such as vagrancy. These individuals were thus detained in the criminal justice system rather than the mental health system (Abramson, 1972; Conrad and Schneider, 1980).
Groups representing mentally ill patients also organized, but generally did not have the success that groups representing their families and practitioners had. Organizations representing patients, such as the Mental Patients Liberation Front and the Na tional Alliance for the Mentally Ill, lacked the political clout of larger organizations and tended not to be as well funded as the other organizations. Phillip Armour (1989) summarized the situation in this way:
In sum, congressmen do not confront well-funded lobbyists for the mentally disordered in the halls of the Capitol, they typically do not receive large contributions from the residents of state and county mental hospitals or the clients of com munity service centers, and they do not have to calculate the electoral risks of offending a multimillion member association of former mental patients. (187-8)
Although many groups were interested in seeing reform, there was a general lack of coordination between them. In addition, the interests of each groups shaded in and out of congruence. No two groups saw the situation the same way. This essentially left the political arena open to corporate interests and other well funded organis ations interested in mental health and capable of lobbying the government (e.g., the American Psychiatric Association, the American Psychological Association, the American Federation of State, County, and Municipal Employees, etc.). Still, the discontent of the practitioners, families, and patients dealing with the mental health system led to new hearings on mental health care policy.
Shortly after taking office in 1977, President Carter appointed the President's Commission on Mental Health. This commission was charged with assessing the particulars of mental health services, and then making specific suggestions on how things should be changed. The commission collected data by holding regional hearings in order to hear testimony from professionals, relatives of the mentally ill, and other politicians. This technique has been utilized as a politically conspicuous means of proving tha t action is being taken, but often has little merit in terms of scientific methodology.3 The final reports from the commission and its task forces were characterized in this way by Levine (1981: 179):
The quality of the Task Panel reports vary widely; apparently its members understood their instructions very differently. The reports range from very brief ones, which look as if they had been written by someone on the plane on the way to the meeting, to well-thought out analytic reviews. Some consist of little more than a list of recommendations. No more than a third of the Task Panel reports would pass muster as scholarly documents. The preparation of the reports was sloppy. Many are poorly written. Citations made in the body of the report do not appear in the bibliographies. Citations for key points are often to unpublished sources. To be fair, it should be stated that some of the Task Panels did not expect their reports to be published.
The commission made special references to political interest groups throughout both the task panel reports as well as the final recommendations. After the reports were completed and the Congress attempted to codify these recommendations into law, the l obbying organizations continued to be a presence throughout the process. Some groups were by nature opposed to each other: the National Council of Community Mental Health Centers (NCCMHC) and the National Association of State Mental Health Program Directo rs (NASMHPD), for instance. The former of these groups represents the interests of community mental health centers that would benefit by expanding these services. The latter group represents the directors of state mental hospitals. They would benefit by i ncreases in the funding of such hospitals and reinstitutionalization (Armour, 1989, 185). On this point, the commission searched for a compromise.
The final report of the commission to President Carter contained the recommendations upon which the Mental Health Systems Act of 1980 was based. Despite the methodological flaws of the earlier report, the act was considered a landmark in mental health care policy. The key to the proposals included an increase in funding for Community Mental Health Centers and continued federal government support for such programs. But this ran counter to the financial goals of the Reagan administration, these were of c ourse to reduce federal spending, reduce social programs, and transfer responsibility of many if not most government functions to the individual states. So, the law signed by President Carter was rescinded by Ronald Reagan on August 13, 1981. In accordance with the New Federalism and the demands of capital, mental health policy was now in the hands of individual states.
Settling for Smaller Reforms
In the aftermath of the non-implementation of the Mental Health Systems Act of 1980, the power of the various interest groups had been further weakened. Clearly, the groups that represented the patients themselves were the weakest. Such groups, represe nting the targets of involuntary commitment, tended to be opposed to the easing of commitment requirements. But facing interest groups representing mental health professionals and patients' families, the patient's rights groups found themselves underfunde d and understaffed.
The interests of others fared somewhat better. Pressure from organizations (some of which represented the families of the mentally ill) lead to new legislation in several states that made it easier to commit a mentally ill patient involuntarily. As noted earlier, much of this pressure emerged because the current underfunded system was not providing adequate supports for patients or family. Families of the mentally ill were genuinely concerned about loved ones who they felt were not receiving adequate care. Also, families who were responsible for providing care for their mentally ill members could not support the burden which came from care provision without adequate institutional supports. From the position of the family member, deinstitutionalization appeared more like an attempt by the government to download responsibility. In this context a loosening of commitment standards would, it was thought, force patients to receive care and (hopefully) reduce the burden on the family.
Mental health professionals were also concerned that patients were not receiving adequate care. Estimates of the homeless population ranged from 250 to 500 thousand people (Dear and Wolch, 1987; Jencks, 1994; Rossi, 1989; Wright, 1989). Of these, appro ximately a third were mentally ill (Rossi, 1989). In many cases, such mentally ill patients were arrested for vagrancy and other minor infractions and were processed by the criminal justice system. Concerned that this population was receiving no treatment at all, mental health workers advocated involuntary commitment as a means of getting the mentally ill homeless into treatment.
With such activism, a coalition between the neoconservatives who opposed liberal reforms in general and the interest groups mentioned above was possible. In the absence of the comprehensive reforms planned in the Mental Health Systems Act, the interest groups who opposed specific outcomes of liberal era reforms, although not necessarily all the reforms, turned to the neoconservatives for narrowly focused reforms. The activism of the interest groups supplied the Reagan Campaign with a supportive constituency which could be used as a foil for reactionary reforms. However there was a deep irony here. The 1980 Reagan Campaign received support from a population which might have otherwise supported the liberal objectives of the previous era (had they been adequately funded, for example). The fact that these interest groups had become disillusioned with the implementation of liberal reforms (specifically deinstitutionalization which was largely viewed as a failure), meant that this population would support a change in policy even if it meant policy reforms that would otherwise be unpalatable.
The composition of this coalition was of course antithetical to the interests of the mentally ill themselves. But groups representing the patients themselves were relatively weak. Despite the fact that groups representing the patients stressed the need for better treatment, debate most often revolved around issues defined by other stakeholders in the system like the growing homelessness problem and the burden on the families. And of course, better treatement automatically translated, in an underfunded system, to more more funding - this argument ran counter to the neoconservative need to cut back the welfare state. So often patients concerns were simply ignored.
Cuts in funding for mental health services continued throughout the 1980s, with the emphasis being on the provision of services via the private sector. Overall, the number of beds available to the mentally ill in public and private hospitals dropped ov er forty percent between 1970 and 1984 (Reamer, 1989). Most of this decline was due to cuts in public hospitals. During the 1980s, the number of beds provided by general hospitals in psychiatric wards and in private hospitals for the mentally ill increase d. In 1970, there were 150 private psychiatric centers; in 1980, there were 184; by 1988, there were 450 in the United States. General hospitals offering psychiatric services increased from 1,259 in 1984 to over two thousand in 1988 (Reamer, 1989, 25; LaF ond and Durham, 1992, 115-16). With such growth in the private sector, there were substantial profits to be made in mental illness, assuming that the patient had adequate health insurance. Those without medical insurance frequently did not receive adequat e care.
A Supportive Public Climate
The intersection of interests noted above was an important factor in creating an environment within which reactionary reforms could take place. However other environmental factors also played an important role in creating conditions whereby the desires for progressive reform could be co-opted. For example, the goals of the Reagan Administration were well received in some quarters of the National Institute of Mental Health (NIMH). In the 1980s, the NIMH started to come under the leadership of a different cohort of individuals. While the NIMH had originally been led by individuals who had come of age during the Great Depression, the leaders of the 1980s had come of age later. The result was that while the former cohort had been committed to innovations in government al social policy, the latter generation tended to be less interested in actual social policy and more supportive of measures to reduce the cost to the federal government (Armour, 1989, 187).
The Administrations goals of fiscal restraint also received support from the general public due to the perception of a federal government too prone to waste revenues and not address other basic concerns, such as crime prevention. Certain forms of social welfare spending, such as programs for the mentally ill, were perceiv ed as wasteful and thus easy targets for budget cuts (Gans, 1995; Katz, 1989). In contrast, other social programs, such as Social Security, were perceived as being "earned" by the recipients, and thus equitable. Despite the fact that the average Social Se curity recipient receives more in return than they pay into the system, programs such as this are perceived as being a pension for which the recipient has already paid. As such, they are less susceptible to cuts than categorical spending programs, such as community mental health treatment centers. Indeed, Social Security funding per beneficiary increased under the Reagan Administration (Levitan, 1990, 30). Mental health policy lacks the widespread public support that benefits Social Security (Armour, 1989 , 186). In light of this, it is not surprising that the Reagan Administration was able to cut these programs relatively easily (186-7).
The concerns of the general public were also mobilized in the context of fear over the possibility of a patient committing a violent or otherwise anti-social act. Media attention paid to the problems of the mental health system tended to concentrate in two areas: the growing homelessness problem of the early 1980s and the possibility of criminal acts committed by deinsitutionalized patients. Throughout the 1970s and 1980s, hundreds of thousands of mentally ill people concentrated in the inner cities. With the rise of gentrification during the 1980s, many of them became displaced from their relatively affordable housing and were unable to fin d new accommodations. Many of these patients had lost contact with family members and were unable to work, and many did not have health insurance. Thus, they were unable to receive mental health services in the private sector. Media coverage of the growin g homeless problem helped to pressure legislators in many states to rewrite commitment laws to extend the net and make the streets "safer."
This media attention played into, and supported, the growing perception of violent crime as a problem in the United States. The Reagan Administration answered this general alarm by calling for quick and severe punishment of offenders. For those offenders who were not mentally ill, prison was normally seen as the solution (Gans, 1995). For the mentally ill however, involuntary committment seemed the best answer. Either way, quick removal of individuals threatening the social order fit well with the administration's "law and order" stance (LaFond and Durham, 1992, 114).
The new laws, however, were not intended to make it easier to commit the dangerous mentally ill. Rather, the new laws had more general application and made it easier to commit those only considered a threat (Lafond & Durham, 1992, 118). In addition to this, many of the existing liberal justices began to rule on a "right of treatment" clause rather than a straight civil libertarian viewpoint. The result was that at both the state and federal level, the court became increasingly reluctant to strike down legislation that broadened the definition of who was eligible for involuntary commitment (119). Again, this more stringent approach meshed well with the "law and order" stance taken by the administration.
Discussion
The net result of federal abdication of responsibility, the push to state orientated programs (often underfunded), the dis-organization of groups, and the confluence of public interests (in crime prevention and fiscal restraint) with state goals, were reforms that only marginally addressed the real concerns of stakeholders and that ultimately benefitted capital by reducing the cost of social safety net. To be sure, the shift in policies dealing with involuntary commitment emerged from larger social issues. By the middle of the 1970s, groups representing the mentally ill, their families, and those who cared for them had reached a consensus on the need for reform. This culminated in the passage of the Mental Health Systems Act. This implementation, though not without its problems, was seen as a progressive step forward. However the costs of these reforms were unacceptable in the new neoconservative climate and ran counter to the interests of capital. Reagan, who never presumed to support social policy, promised to cut federal spending and ensure a "favorable business climate." So under Reagan the new law was rescinded. This signaled that for Reagan's administration, social policy was of lower priority than fiscal policy. After this act, the interest groups would need to settle for piecemeal reforms within the limitations of the administration's desire for low cost reform measures.
The "New Federalism" served as justification for relaxed federal "interference" in state issues, including mental health policy. The business community was facing a crisis of accumulation, and a shift in the political economy was perceived as necessary to guarantee adequate profit. With the abdication of the federal government, mental health policy was almost entirely in the province of the individual states.
A survey of initiatives shows that they came primarily from individual state legislatures, and thus varied according to state (Peters et al, 1987; LaFond and Durham, 1992). The procedures for commitment of the mentally ill accordingly vary by state. Ma ny states have adopted outpatient commitment as an alternative to inpatient care, and this policy has met with mixed results. 4 Many state hospitals have been closed, and many others are facing the possibility. Debate around mental health policy is still, to a large degree, concentrated around issues of deinstitutionalization and reinstitutionaliza tion and the relative merits of each.5 Sadly, professional groups with opposing interests have stalled the implementation of a comprehensive mental health policy in most states (Becker, 1993; Wilson, 1993).
Under the Reagan Administration, groups and individuals who had hoped for a change found that the federal government did very little to effect a change. The appointment of conservative justices for the federal court system was a part of the "law and or der" platform advocated by the administration and thus was never intended to have a direct effect on procedures regarding involuntary commitment or any other aspect of mental health policy.
Perhaps what is most interesting about the change in policies of involuntary commitment is the coalition that helped bring it about: a combination of "law and order" conservatives, economic conservatives, and liberal groups that sought reform in the pr ovision of mental health services. But the policy shift had hardly anything at all to do with the mentally ill or the practitioners who treated them. It was designed to lower taxes and shift responsibility away from the federal government. Ironically then , the need for reform perceived by those involved and concerned with the mentally ill (practitioners and families) was co-opted by the interests of capital.
Reagan's social policy is best seen as an abdication. Reagan's economic policy was to adjust government regulation so that it favored business once again, and social policy was merely an outgrowth of this larger issue. While family groups and professi onal groups and patient groups did clamor for respect, the real struggle was between the state and the business community. Reagan worked to lessen the tax load for the rich, and the social policies were meant to match this goal. Business needed a more fav orable corporate climate, and Reagan worked to that end. The coalitions that were necessary for election were either gratified (the elderly) or abandoned (the poor). As for the mentally ill, certain changes that their families and practitioners wanted wer e gained, and the administration pointed this out. Even though these changes came about primarily through state governments and the courts, the Administration would take credit. All in all, business interests were served. Families and doctors were appease d. Patients were forgotten.
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Endnotes
1. For a more detailed account of the development of policies regarding deinstitutionalization, see Mechanic (1989) and Wagenfeld and Robin (1976).
2. For practical purposes, "dangerousness" has been a vague consideration in the United States as the definition changes from state to state. See Brooks (1974), LaFond and Durham (1992), and Teplin (1984) for greater discussion.
3. For a further discussion of this practice, consult Grant and Murray (1985) and Midgley (1992).
4. Consult Mulvey et al (1987), Korr (1988), Wilk (1988), and Scheid-Cook (1990) for further discussion.
5. Examples include Shwed (1980), Tancredi (1980), Luckey and Berman (1981), Durham et al (1984), Hoge (1989), Lidz (1989), Segal (1989), and LaFond and Durham (1992).
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