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Mental patients' rights: An empirical study of variation across the United States
International Journal of Law and Psychiatry, Punted I” the U S A All nghts reserved
Vol
1 I, 157-I
65. 1968 CopyrIght
Mental Patients’ Rights: An Empirical Variation Across the United States
0160.2527/66 $3.00 + 00 c: 1968 Pergaman Press plc
Study of
Phil Brown* and Christopher J. Smith**
Introduction Numerous theoretical accounts have emerged in recent years to explain the changes that have occurred in the provision of services in the area of welfare and human services. In discussions of the deinstitutionalization of mental patients, for example (Brown, 1985); and the “decriminalization of public drunkenness” (Fagan & Mauss, 1978), rival accounts differ sharply: some see the changes coming about as the result of humanitarian concerns, while others believe that the changes result from institutional concerns with reducing the costs of providing welfare services. This divergence of opinion is also evident in different accounts of the development of mental patients’ rights. Many professionals and administrators in the mental health system, as well as a number of social science, psychiatric, and legal researchers, have interpreted the concern for patients’ rights as a humanitarian concern (Ennis & Emery, 1978). On the other hand, political and economic analysts tend to interpret patients’ rights either as a response to the “fiscal crisis” of the state (Scull, 1977), or to a combination of social, political, institutional, and economic forces (Brown, 1981; C. Smith, 1983). It is plausible, for example, that the provision of patients’ rights is simply a part of the overall logic and process of deinstitutionalization (Smith & Hanham, 1981). An alternative explanation is that provisions made for patients’ rights are related to the prevalence of social problems and each state’s commitment to social reform and the provision of welfare services. The existing research in this area can only provide the most general clues about why variations in patients’ rights might occur. Much of the research has been in the form of general theoretical statements, with some policy studies conducted in either individual states (Bardach, 1972; Warren, 1984) or one specific hospital (Zeigenfuss, 1983). Nationwide data on mental patients’ rights is available (Beis, 1983; Lyon, Levine, & Zusman, 1982) but beyond the simple enumeration of each state’s progress in moving toward patients’ rights, no *Associate Professor of Sociology, Brown University, Providence, RI 02912, U.S.A. **Associate Professor of Geography and Regional Planning, State University of New York at Albany, Albany, NY 12222, U.S.A. This research was supported in part by Biomedical Research Support Grant PHS 2 SO7 RR 07085-18 from the National Institutes of Health. The authors are grateful to Elizabeth Cooksey and Mary Taggart for research assistance and to Paul P. Freddolino for discussions concerning some of the measures. Joseph P. Morrisey and Henry J. Steadman read a draft of the paper and contributed valuable comments. 157
158
attempts progress.
PHIL BROWN and CHRISTOPHER
have been made to identify
the factors
J. SMITH
that might help or hinder that
Research Question As an initial exploration in that direction, this paper describes a search for the significant correlates of mental patients’ rights. Four theoretically possible categories of predictors can be suggested: political liberalism, economic indicators, social problems indicators, and mental health epidemiological and service delivery indicators. If concern for patients’ rights is a result of general humanitarian interest, then progress toward patients’ rights in a particular state should be related to general political liberalism. If patients’ rights are, alternatively, part of the overall logic and process of deinstitutionalization, then rights should be related to mental health epidemiological and service delivery variables. If economic concerns determine the provision of patients’ rights, then economic variables should be significant. Lastly, if mental patients’ rights are an aspect of general social service policies, the social problems indicators should be significant. This model of four different groups of variables makes an assumption that there are four separate phenomena. This may be an untenable assumption, given the complex interweaving of social forces. For example, political and economic factors are often inseparable, as are social problems and mental health policy directions. If the four phenomena are not separable, either intuitively or through our knowledge of social forces in general, we cannot really decompose our variables as we do. But given the exploratory nature of this research, it is an acceptable assumption to test. This research is exploratory in that it tries to quantify relationships which heretofore have been largely a matter of opinion and policy discussion. The exploratory nature is evident in two components. First, the operationalization of variables is exploratory. The variables chosen may not be the most suitable ones. But in the absence of research of this type, there is no guide to appropriate measurements. Subsequent work may well provide us with different measurements for such a research question as we propose. Second, the analysis is exploratory. This stems from the potential measurement error in the operationalization, as noted above. It also stems from the fact that the four phenomena we address may be inseparable. Finally, the analysis may not take into account other unspecified factors which may play a role in the provision of mental patients’ rights. Methods Measures As a measure of patients’ rights we have used each state’s compliance with the rights suggested in the Mental Health Systems Act of 1980 (Lyon, Levine, & Zusman, 1982). The Act, which was a result of President Carter’s President’s Commission on Mental Health, was repealed by the Reagan administration. It represented a significant departure from traditional mental health policy, and included a strong patients’ rights component (Foley & Sharfstein, 1983; Levine,
MENTAL PATIENTS’
159
RIGHTS
1981). The choice of compliance with the 1980 Act (MHSA) as the dependent variable was made after considering a number of alternatives. As we see in Table 1, overall compliance with the Act is highly correlated with most of the individual components, so it is reasonable to use the composite measure rather than some or all of the individual components. This dependent variable actually measures the degree to which state laws as of 1980 comply with the MHSA. As a result of missing data on several independent variables, Alaska and Hawaii are not included in the analysis. Independent variables for this study were collected in four categories, each of which was based on the above-mentioned hypotheses about the provision of patients’ rights. The categories were: political liberalism, economic indicators, social indicators, and mental health epidemiological and service delivery indicators. Political Liberalism: If a concern for patients’ rights is a result of general humanitarian interest, then the extent of compliance with the 1980 Act should be related to general measures of “liberalism,” which would include belief in liberal issues and the “liberalness” of the State Legislature. Three measures of political liberalism were selected: the proportion of the electorate voting for the Democratic candidate for President in 1980; the Democratic composition of the state legislature; and an index of political liberalism constructed from the 1980 National Election Survey (Inter-University Consortium for Political and Social Research, 1980). An index was computed from six items on the Election Survey which dealt with the role of government in providing jobs, abortion rights, relations with the Soviet Union, aid to minorities, affirmative action, and governmental regulations on pollution. Cronbach’s alpha is 0.49. The 3,587 respondents of the Election Survey were grouped into census regions, because the sample size in
Correlation
TABLE 1 Matrix of Total MHSA Compliance 1
rights and communi-
3. MHSA-consent cations 4. MHSA-consent and communications rights excluding right to refuse treatment 5. MHSA-information and records rights 6. MHSA-grievance and access rights 7. MHSA-all other rights
lp< .05 **p<.o1 ‘*‘p<.ool
3
4
5
6
7
-
1. MHSA (all items) 2. MHSA-treatment
2
with Components
.70***
-
.75***
.40**
-
.73***
.41**
.95***
-
.76*‘*
.28
.61***
.55***
-
.49*” .70***
.36’ .58***
.16 .41**
.22 .41**
.09 .46***
.42*’
-
160
PHIL BROWN and CHRISTOPHER
J. SMITH
some states was small. Each state was assigned the mean value for its census region, a technique employed by Strauss (Strauss, 1973).
Economic Indicators: To evaluate the “fiscal crisis” perspective on patients’ rights, a number of economic indicators were selected as independent variables. These were as follows: median family income (1979); percentage of the population receiving AFDC benefits (1980); growth or decline in manufacturing employment from 1966-1977 (Norton & Rees, 1979); a measure of income inequality (D. Smith, 1977); and a measure of income redistribution (Booms & Halsdorson, 1973). Social Indicators: These included crime rates per 100,000 of the population (1980); prisoners per 100,000 (1980); the rate of juvenile offender deinstitutionalization (Sigelman, Roeder, & Sigelman, 1981); an index of general social wellbeing that is a composite measure constructed by D. M. Smith (1977); and an index of “stress” at the state level constructed by Strauss (1973). Mental Health Epidemiology and Service Delivery Indicators: To measure state-to-state variations in mental health indicators, both discharge and resident patient rates per 100,000 of the population for 1980 were used (Redick & Witkin, 1983); and also the rate of deinstitutionalization among the mentally retarded (Sigelman, Roeder, & Sigelman, 1981). To act as measures of trends or changes over time in the pattern of mental health indicators, data from Smith and Hanham’s (1981) time path analysis of admissions to, releases from, and resident populations in mental health hospitals from 195551975 were used. To assess the variations in commitment to mental health care in each state, we also used per capita mental health expenditures (Redick & Witkin, 1983) and per capita federal funding of community mental health centers from 1965- 1980 (C. Smith, 1984); a state’s greater spending along these lines might also lead a state to be more favorable to patients’ rights. Results Table 2 shows correlations of all independent variables with the dependent variable, as well as beta coefficients for the independent variables. Simple correlations for four variables were significantly related to patients’ rights liberalism. The 1955-1975 time path for patient population was significant at the .Ol level; and median family income, income redistribution, and social wellbeing were significant at the .05 level. These latter three correlations indicate a relationship between patients’ rights and higher income, greater income redistribution, and more commitment to social welfare spending. But in, a stepwise multiple regression analysis only one variable was significant-the ‘time path’ of resident populations in mental hospitals between 1955-1975 (Beta=.388; p. =Ol). This one variable explains 15 % of the variance. The time path scores used in this analysis represent the extent to which the temporal trend in each state’s resident population in mental hospitals was consistent with the mean trend throughout the country. As Smith and Hanham (1981) have shown, this trend was for a gradual decline in resident populations in the late 1950s and
MENTAL PATIENTS’
Pearson Correlation
Independent 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
161
RIGHTS
TABLE 2 Coefficients and Beta Coefficients
Variables
Democratic vote 1980 Democratic composition of legislature Liberalism index Median family income Percent on AFDC Manufacturing employment Income inequality Income redistribution Crime rate per 100,000 Prisoners per 100,000 Juvenile offender deinst. Social well-being index Social stress index Psychiatric discharge per 100,000 Psychiatric residents per 100,000 Mental retardation deinst. rate Time path-psych. admissions Time path-psych. releases Time path-psych. census Per capita mental health expend Per capita CMHC funding
Correlation MHSA - ,055 - ,222 - ,051 .287* ,079 -.177 - ,246 .336* ,232 -.123 .068 ,330’ - ,073 ,011 - ,020 ,314 ,128 ,173 .388* * ,191 - ,080
Beta Coefficients (stepwise multiple regression) - ,071 - ,201 -.152 ,144 ,049 - ,001 -.112 .163 ,176 ,031 ,028 ,175 - ,028 ,098 - ,066 .253 ,086 ,109 .388* * ,037 - ,026
‘p < .05
**p< .Ol
early 196Os, with the rate accelerating after about 1962, and then tapering off again in the 1970s. This time path describes the general pattern of deinstitutionalization in the United States. The implication of the findings here is that in the states where the deinstitutionalization process closely followed the general trend, compliance with the 1980 Act’s recommendations on the provision of patients’ rights was most likely. Discussion The failure of the political liberalism measures to predict the provision of mental patients’ rights indicates that no macro-level attitudes toward the care of the mentally ill could be identified. On the other hand, it is possible that liberal attitudes among mental health planners and administrators played an indirect role by helping to shape the overall pattern of deinstitutionalization within a given state. To the extent that this can be measured with our data, however, no such evidence was found when a path analysis was used to examine such a causal sequence. The measures used here are probably not sensitive enough, and future work should find ways to study this causal chain. The failure of the
162
PHIL BROWN and CHRISTOPHER
J. SMITH
social indicator variables to predict patients’ rights also suggests that the actions taken by individual states do not appear to be related to their overall approach to social problems. Neither the general economic measures nor any of the mental health cost variables are significantly related to patients’ rights, which suggests that there is no simple economic base for patients’ rights (in the sense that, for example, having safeguards on involuntary commitments would help to reduce the costs of hospitalization). Given an earlier caveat about the separability of the four sets of variables, we must be cautious in making inferences about how the data do or do not support the four models. We can, however, be clear that only one variable-not even a group of variables-was a significant predictor of patients’ rights. The results of this study imply that groups of states approached the area of mental health reform in similar ways. Among the most important of these reforms are deinstitutionalization and patients’ rights, and the data we have collected suggest that in those states where deinstitutionalization followed the standard format between the years 1955 and 1975, patients’ rights were more likely to emerge by the end of the 1970s. In their analysis of mental hospital populations, Smith and Hanham (1981) identified six different patterns of deinstitutionalization, based on the extent to which each state’s trends (or time path) varied from the dominant trend for the whole country. Examples of each of the six groups are shown in Figure 1, and it is group 4 that most closely resembles the national trend. As the illustration shows for Rhode Island, for example, the process began with a high rate of institutionalization (in Rhode Island this was 420 per 100,000 of the population, and in other states with similar patterns, we also find such -high rates, for example, 490 in New Hampshire; 460 in Massachusetts, 400 in Connecticut; 410 in New Jersey). After a relatively slow start, the size of the hospital populations dropped off rapidly in the 1960s; then slowed again in the 1970s. In Rhode Island, the resident population levelled-off at just under 200 per 100,000 of the population. The other group of states with high scores on the dominant time path is illustrated by New York in Figure 1. This group consisted only of New York and Washington, D.C. and both experienced rapid deinstitutionalization rates during the two decades in question, starting from extremely high rates in 1955 (relative to the national norm). The findings reported here imply that, at least at this macro-level of analysis, the more rapidly a state deinstitutionalized its mental patients, the more likely it was to make provisions for patients’ rights. It is possible to use this conclusion as evidence of reverse causality, in other words, to suggest that patients’ rights contributed to the rate of deinstitutionalization. The compliance with the 1980 Act does not mean that states revised their statutes after 1980; it merely means that as of 1980, the statutes were at different levels of compliance with the model national program. In fact, this study does not take into account when states changed statutes. Thus, we are looking at a final product rather than a process which may or may not be continued. Perhaps the general movement for patients’ rights precipitated deinstitutionalization, largely due to fear of litigation and the resultant implementation costs. It is possible that this process began in one or two key states, then spread or diffused to other states that were
600 550 500-i a Lu a
450
Group
400
CALIFORNIA
450 !
1
Group 3
’
400
350
350
300 -
300
250
250
NEW
MEXICO
I
200-
:::k 55
60
65
70
75
600 -
60
55
65
70
75
600 1
550 500 450-
Group
400 -
OHlO
500 550 1 450.
2
400 -2
350
350 -
300 -~
300 -
250 -.
250 -
200
200-
150
150 -
100.
100 50
50-1 I/l/,/l/l,/’ 55
Group 4 RHODE ISLAND
‘/ 60
65
70
55-5
75
600550500450400
4504oo _
Group 5 NEW YORK
350
Group 6 MISSISSIPPI
350300 250
-
j---y
““L 55
60
50 1 65
70
75
-‘IT
55
FIGURE 1. Residents 1955-1975.
163
75
164
PHIL BROWN
and CHRISTOPHER
J SMITH
either nearby or that faced similar mental health service problems during the same period. What makes this alternative hypothesis less tenable is that no variables entered the model as significant predictors of patients’ rights, with the exception of the time path measure, which is an indicator of only very general trends of deinstitutionalization. It may be useful to point out that the time path measure does not necessarily imply a continual trend over the two decade period. It is possible that deinstitutionalization occurred in phases, as a response to different sets of factors. Conclusion
Despite potential measurement error, our evidence suggests that the only significant predictor of variations in provisions for patient rights, is the extent to which each state followed the typical time path of deinstitutionalization during the two-decade period from 19551975. It appears from our results that there is little evidence to suggest that these rights were the direct outcome of humanitarian or liberal beliefs about the way mental patients ought to be treated. The changes in patients’ rights were an integral component of the overall process of change in the mental health care system over a two-decade period.
Implications for Future Research We hope that this examination of state-level data will stimulate further statelevel research, not only on patients’ rights but on many other mental health concerns. Such research requires far stronger data bases than currently exists. The present study has some weak measures which could only be strengthened if data bases were developed to provide the necessary information. Much of what is needed can at present be obtained only through tedious searching through each state’s data, and that data is often quite unstandardized. This type of investigation can provide valuable information on state differences, including the way that certain states might cluster with reference to similar factors. That in turn might explain successes and failures of certain programs and strategies, while pointing to different alternatives and innovations. References Bardach, E. (1972). The skill factor in politics: Repealing [he mentol commitmenl laI(‘.y in Cali&orniu. Berkeley: University of California Press. Beis, E. (1983). State involuntary commitment statutes. Men/a/ flisabilitv Law Reporrer, 7, 358-369. Booms, B. H., & Halsdorron, J. R. (1973). The politics of redistribution: A reformation. American Politicul Science RedeM: 67, 924-933. Brown, P. (1981). The mental patients’ rights movement and mental health institutional change. Inrernarional Journal of Health Services, II, 523-540. Brown, P. (1985). The transfer of care: Ps_vchiatric cleinstituiionaliza(ion and i/s aftermurh. Boston: Routledge and Kegan Paul. Ennis, B. J., & Emery, R. D. (1978). The righl5 oj’mentalparienrs. New York: Avon. Fagan, R. bc’., & Mauss, A. L. (1978). Padding the revolving door: An initial assessment of the uniform alcoholism and intoxication treatment act in practice. Social Problems, 26, 232-247.
MENTAL PATIENTS’
RIGHTS
165
Foley, H. A., & Sharfstein, S. S. (1983). Madness and government: Who cares for the mentally ill? Washington, D.C.: American Psychiatric Press. Inter-University Consortium for Political and Social Research. (1980). American national election study, 1980. Ann Arbor, MI: Author. Levine, M. (1981). The history and polifics of community mental health. New York: Oxford University Press. Lyon, M. A., Levine, M. L., Zusman, J. (1982). Patients’ bills of rights: A survey of state statutes. Mental Disability Law Repotter, 6, 178-201. Norton, R. D., & Rees, J. (1979). The product cycle and the spatial decentralization of American manufacturing. Regional Studies, 13, 141-151. Redick, R. W., & Witkin, M. J. (1983). State and county mental hospitals, United States, 1979-80 and 198081. Mental Health Statistical Note, 165. Rockville, MD: National Institute of Mental Health. Scull, A. T. (1977). Decarceration-community treatment and the deviani: A radical view. Englewood Cliffs, NJ: Prentice-Hall. Sigelman, L., Roeder, P. W., Sigelman, C. K. (1981). Social service innovation in the American states: Deinstitutionalization of the mentally retarded. Social Science Quarter/y, 62, 5033515. Smith, C. J. (1983). Innovation in mental health policy: Community mental health in the United States of America, 196551980. Environment and Planning-D: Society and Space, I, 447-468. Smith, C. J. (1984). Geographic patterns of funding for community mental health centers. Hospital and Community Psychiatry, 35, 1133-l 140. Smith, C. J., & Hanham, R. Q. (1981). Deinstitutionalization of the mentally ill: A time path analysis of the American states, 1955-1975. Social Science & Medicine, 150, 361-378. Smith, D. M. (1977). Human geography: A welfare approach. New York: Edward Arnold. Strauss, M. A. (1983, June). Social stress in American states and regions: An example of research using the state and regional indicators archive. Paper presented at the International Conference on Data Bases in the Humanities and Social Sciences, Rutgers University. Warren, C. A. B. (1984). The courf of last resort: Mental illness and the law. Chicago: University of Chicago Press. Zeigenfuss, J. T. (1983). Patients’ rights and organizafional mode/s. Washington, DC: University Press of America.
Vol
1 I, 157-I
65. 1968 CopyrIght
Mental Patients’ Rights: An Empirical Variation Across the United States
0160.2527/66 $3.00 + 00 c: 1968 Pergaman Press plc
Study of
Phil Brown* and Christopher J. Smith**
Introduction Numerous theoretical accounts have emerged in recent years to explain the changes that have occurred in the provision of services in the area of welfare and human services. In discussions of the deinstitutionalization of mental patients, for example (Brown, 1985); and the “decriminalization of public drunkenness” (Fagan & Mauss, 1978), rival accounts differ sharply: some see the changes coming about as the result of humanitarian concerns, while others believe that the changes result from institutional concerns with reducing the costs of providing welfare services. This divergence of opinion is also evident in different accounts of the development of mental patients’ rights. Many professionals and administrators in the mental health system, as well as a number of social science, psychiatric, and legal researchers, have interpreted the concern for patients’ rights as a humanitarian concern (Ennis & Emery, 1978). On the other hand, political and economic analysts tend to interpret patients’ rights either as a response to the “fiscal crisis” of the state (Scull, 1977), or to a combination of social, political, institutional, and economic forces (Brown, 1981; C. Smith, 1983). It is plausible, for example, that the provision of patients’ rights is simply a part of the overall logic and process of deinstitutionalization (Smith & Hanham, 1981). An alternative explanation is that provisions made for patients’ rights are related to the prevalence of social problems and each state’s commitment to social reform and the provision of welfare services. The existing research in this area can only provide the most general clues about why variations in patients’ rights might occur. Much of the research has been in the form of general theoretical statements, with some policy studies conducted in either individual states (Bardach, 1972; Warren, 1984) or one specific hospital (Zeigenfuss, 1983). Nationwide data on mental patients’ rights is available (Beis, 1983; Lyon, Levine, & Zusman, 1982) but beyond the simple enumeration of each state’s progress in moving toward patients’ rights, no *Associate Professor of Sociology, Brown University, Providence, RI 02912, U.S.A. **Associate Professor of Geography and Regional Planning, State University of New York at Albany, Albany, NY 12222, U.S.A. This research was supported in part by Biomedical Research Support Grant PHS 2 SO7 RR 07085-18 from the National Institutes of Health. The authors are grateful to Elizabeth Cooksey and Mary Taggart for research assistance and to Paul P. Freddolino for discussions concerning some of the measures. Joseph P. Morrisey and Henry J. Steadman read a draft of the paper and contributed valuable comments. 157
158
attempts progress.
PHIL BROWN and CHRISTOPHER
have been made to identify
the factors
J. SMITH
that might help or hinder that
Research Question As an initial exploration in that direction, this paper describes a search for the significant correlates of mental patients’ rights. Four theoretically possible categories of predictors can be suggested: political liberalism, economic indicators, social problems indicators, and mental health epidemiological and service delivery indicators. If concern for patients’ rights is a result of general humanitarian interest, then progress toward patients’ rights in a particular state should be related to general political liberalism. If patients’ rights are, alternatively, part of the overall logic and process of deinstitutionalization, then rights should be related to mental health epidemiological and service delivery variables. If economic concerns determine the provision of patients’ rights, then economic variables should be significant. Lastly, if mental patients’ rights are an aspect of general social service policies, the social problems indicators should be significant. This model of four different groups of variables makes an assumption that there are four separate phenomena. This may be an untenable assumption, given the complex interweaving of social forces. For example, political and economic factors are often inseparable, as are social problems and mental health policy directions. If the four phenomena are not separable, either intuitively or through our knowledge of social forces in general, we cannot really decompose our variables as we do. But given the exploratory nature of this research, it is an acceptable assumption to test. This research is exploratory in that it tries to quantify relationships which heretofore have been largely a matter of opinion and policy discussion. The exploratory nature is evident in two components. First, the operationalization of variables is exploratory. The variables chosen may not be the most suitable ones. But in the absence of research of this type, there is no guide to appropriate measurements. Subsequent work may well provide us with different measurements for such a research question as we propose. Second, the analysis is exploratory. This stems from the potential measurement error in the operationalization, as noted above. It also stems from the fact that the four phenomena we address may be inseparable. Finally, the analysis may not take into account other unspecified factors which may play a role in the provision of mental patients’ rights. Methods Measures As a measure of patients’ rights we have used each state’s compliance with the rights suggested in the Mental Health Systems Act of 1980 (Lyon, Levine, & Zusman, 1982). The Act, which was a result of President Carter’s President’s Commission on Mental Health, was repealed by the Reagan administration. It represented a significant departure from traditional mental health policy, and included a strong patients’ rights component (Foley & Sharfstein, 1983; Levine,
MENTAL PATIENTS’
159
RIGHTS
1981). The choice of compliance with the 1980 Act (MHSA) as the dependent variable was made after considering a number of alternatives. As we see in Table 1, overall compliance with the Act is highly correlated with most of the individual components, so it is reasonable to use the composite measure rather than some or all of the individual components. This dependent variable actually measures the degree to which state laws as of 1980 comply with the MHSA. As a result of missing data on several independent variables, Alaska and Hawaii are not included in the analysis. Independent variables for this study were collected in four categories, each of which was based on the above-mentioned hypotheses about the provision of patients’ rights. The categories were: political liberalism, economic indicators, social indicators, and mental health epidemiological and service delivery indicators. Political Liberalism: If a concern for patients’ rights is a result of general humanitarian interest, then the extent of compliance with the 1980 Act should be related to general measures of “liberalism,” which would include belief in liberal issues and the “liberalness” of the State Legislature. Three measures of political liberalism were selected: the proportion of the electorate voting for the Democratic candidate for President in 1980; the Democratic composition of the state legislature; and an index of political liberalism constructed from the 1980 National Election Survey (Inter-University Consortium for Political and Social Research, 1980). An index was computed from six items on the Election Survey which dealt with the role of government in providing jobs, abortion rights, relations with the Soviet Union, aid to minorities, affirmative action, and governmental regulations on pollution. Cronbach’s alpha is 0.49. The 3,587 respondents of the Election Survey were grouped into census regions, because the sample size in
Correlation
TABLE 1 Matrix of Total MHSA Compliance 1
rights and communi-
3. MHSA-consent cations 4. MHSA-consent and communications rights excluding right to refuse treatment 5. MHSA-information and records rights 6. MHSA-grievance and access rights 7. MHSA-all other rights
lp< .05 **p<.o1 ‘*‘p<.ool
3
4
5
6
7
-
1. MHSA (all items) 2. MHSA-treatment
2
with Components
.70***
-
.75***
.40**
-
.73***
.41**
.95***
-
.76*‘*
.28
.61***
.55***
-
.49*” .70***
.36’ .58***
.16 .41**
.22 .41**
.09 .46***
.42*’
-
160
PHIL BROWN and CHRISTOPHER
J. SMITH
some states was small. Each state was assigned the mean value for its census region, a technique employed by Strauss (Strauss, 1973).
Economic Indicators: To evaluate the “fiscal crisis” perspective on patients’ rights, a number of economic indicators were selected as independent variables. These were as follows: median family income (1979); percentage of the population receiving AFDC benefits (1980); growth or decline in manufacturing employment from 1966-1977 (Norton & Rees, 1979); a measure of income inequality (D. Smith, 1977); and a measure of income redistribution (Booms & Halsdorson, 1973). Social Indicators: These included crime rates per 100,000 of the population (1980); prisoners per 100,000 (1980); the rate of juvenile offender deinstitutionalization (Sigelman, Roeder, & Sigelman, 1981); an index of general social wellbeing that is a composite measure constructed by D. M. Smith (1977); and an index of “stress” at the state level constructed by Strauss (1973). Mental Health Epidemiology and Service Delivery Indicators: To measure state-to-state variations in mental health indicators, both discharge and resident patient rates per 100,000 of the population for 1980 were used (Redick & Witkin, 1983); and also the rate of deinstitutionalization among the mentally retarded (Sigelman, Roeder, & Sigelman, 1981). To act as measures of trends or changes over time in the pattern of mental health indicators, data from Smith and Hanham’s (1981) time path analysis of admissions to, releases from, and resident populations in mental health hospitals from 195551975 were used. To assess the variations in commitment to mental health care in each state, we also used per capita mental health expenditures (Redick & Witkin, 1983) and per capita federal funding of community mental health centers from 1965- 1980 (C. Smith, 1984); a state’s greater spending along these lines might also lead a state to be more favorable to patients’ rights. Results Table 2 shows correlations of all independent variables with the dependent variable, as well as beta coefficients for the independent variables. Simple correlations for four variables were significantly related to patients’ rights liberalism. The 1955-1975 time path for patient population was significant at the .Ol level; and median family income, income redistribution, and social wellbeing were significant at the .05 level. These latter three correlations indicate a relationship between patients’ rights and higher income, greater income redistribution, and more commitment to social welfare spending. But in, a stepwise multiple regression analysis only one variable was significant-the ‘time path’ of resident populations in mental hospitals between 1955-1975 (Beta=.388; p. =Ol). This one variable explains 15 % of the variance. The time path scores used in this analysis represent the extent to which the temporal trend in each state’s resident population in mental hospitals was consistent with the mean trend throughout the country. As Smith and Hanham (1981) have shown, this trend was for a gradual decline in resident populations in the late 1950s and
MENTAL PATIENTS’
Pearson Correlation
Independent 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
161
RIGHTS
TABLE 2 Coefficients and Beta Coefficients
Variables
Democratic vote 1980 Democratic composition of legislature Liberalism index Median family income Percent on AFDC Manufacturing employment Income inequality Income redistribution Crime rate per 100,000 Prisoners per 100,000 Juvenile offender deinst. Social well-being index Social stress index Psychiatric discharge per 100,000 Psychiatric residents per 100,000 Mental retardation deinst. rate Time path-psych. admissions Time path-psych. releases Time path-psych. census Per capita mental health expend Per capita CMHC funding
Correlation MHSA - ,055 - ,222 - ,051 .287* ,079 -.177 - ,246 .336* ,232 -.123 .068 ,330’ - ,073 ,011 - ,020 ,314 ,128 ,173 .388* * ,191 - ,080
Beta Coefficients (stepwise multiple regression) - ,071 - ,201 -.152 ,144 ,049 - ,001 -.112 .163 ,176 ,031 ,028 ,175 - ,028 ,098 - ,066 .253 ,086 ,109 .388* * ,037 - ,026
‘p < .05
**p< .Ol
early 196Os, with the rate accelerating after about 1962, and then tapering off again in the 1970s. This time path describes the general pattern of deinstitutionalization in the United States. The implication of the findings here is that in the states where the deinstitutionalization process closely followed the general trend, compliance with the 1980 Act’s recommendations on the provision of patients’ rights was most likely. Discussion The failure of the political liberalism measures to predict the provision of mental patients’ rights indicates that no macro-level attitudes toward the care of the mentally ill could be identified. On the other hand, it is possible that liberal attitudes among mental health planners and administrators played an indirect role by helping to shape the overall pattern of deinstitutionalization within a given state. To the extent that this can be measured with our data, however, no such evidence was found when a path analysis was used to examine such a causal sequence. The measures used here are probably not sensitive enough, and future work should find ways to study this causal chain. The failure of the
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social indicator variables to predict patients’ rights also suggests that the actions taken by individual states do not appear to be related to their overall approach to social problems. Neither the general economic measures nor any of the mental health cost variables are significantly related to patients’ rights, which suggests that there is no simple economic base for patients’ rights (in the sense that, for example, having safeguards on involuntary commitments would help to reduce the costs of hospitalization). Given an earlier caveat about the separability of the four sets of variables, we must be cautious in making inferences about how the data do or do not support the four models. We can, however, be clear that only one variable-not even a group of variables-was a significant predictor of patients’ rights. The results of this study imply that groups of states approached the area of mental health reform in similar ways. Among the most important of these reforms are deinstitutionalization and patients’ rights, and the data we have collected suggest that in those states where deinstitutionalization followed the standard format between the years 1955 and 1975, patients’ rights were more likely to emerge by the end of the 1970s. In their analysis of mental hospital populations, Smith and Hanham (1981) identified six different patterns of deinstitutionalization, based on the extent to which each state’s trends (or time path) varied from the dominant trend for the whole country. Examples of each of the six groups are shown in Figure 1, and it is group 4 that most closely resembles the national trend. As the illustration shows for Rhode Island, for example, the process began with a high rate of institutionalization (in Rhode Island this was 420 per 100,000 of the population, and in other states with similar patterns, we also find such -high rates, for example, 490 in New Hampshire; 460 in Massachusetts, 400 in Connecticut; 410 in New Jersey). After a relatively slow start, the size of the hospital populations dropped off rapidly in the 1960s; then slowed again in the 1970s. In Rhode Island, the resident population levelled-off at just under 200 per 100,000 of the population. The other group of states with high scores on the dominant time path is illustrated by New York in Figure 1. This group consisted only of New York and Washington, D.C. and both experienced rapid deinstitutionalization rates during the two decades in question, starting from extremely high rates in 1955 (relative to the national norm). The findings reported here imply that, at least at this macro-level of analysis, the more rapidly a state deinstitutionalized its mental patients, the more likely it was to make provisions for patients’ rights. It is possible to use this conclusion as evidence of reverse causality, in other words, to suggest that patients’ rights contributed to the rate of deinstitutionalization. The compliance with the 1980 Act does not mean that states revised their statutes after 1980; it merely means that as of 1980, the statutes were at different levels of compliance with the model national program. In fact, this study does not take into account when states changed statutes. Thus, we are looking at a final product rather than a process which may or may not be continued. Perhaps the general movement for patients’ rights precipitated deinstitutionalization, largely due to fear of litigation and the resultant implementation costs. It is possible that this process began in one or two key states, then spread or diffused to other states that were
600 550 500-i a Lu a
450
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’
400
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Group 5 NEW YORK
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Group 6 MISSISSIPPI
350300 250
-
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FIGURE 1. Residents 1955-1975.
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PHIL BROWN
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J SMITH
either nearby or that faced similar mental health service problems during the same period. What makes this alternative hypothesis less tenable is that no variables entered the model as significant predictors of patients’ rights, with the exception of the time path measure, which is an indicator of only very general trends of deinstitutionalization. It may be useful to point out that the time path measure does not necessarily imply a continual trend over the two decade period. It is possible that deinstitutionalization occurred in phases, as a response to different sets of factors. Conclusion
Despite potential measurement error, our evidence suggests that the only significant predictor of variations in provisions for patient rights, is the extent to which each state followed the typical time path of deinstitutionalization during the two-decade period from 19551975. It appears from our results that there is little evidence to suggest that these rights were the direct outcome of humanitarian or liberal beliefs about the way mental patients ought to be treated. The changes in patients’ rights were an integral component of the overall process of change in the mental health care system over a two-decade period.
Implications for Future Research We hope that this examination of state-level data will stimulate further statelevel research, not only on patients’ rights but on many other mental health concerns. Such research requires far stronger data bases than currently exists. The present study has some weak measures which could only be strengthened if data bases were developed to provide the necessary information. Much of what is needed can at present be obtained only through tedious searching through each state’s data, and that data is often quite unstandardized. This type of investigation can provide valuable information on state differences, including the way that certain states might cluster with reference to similar factors. That in turn might explain successes and failures of certain programs and strategies, while pointing to different alternatives and innovations. References Bardach, E. (1972). The skill factor in politics: Repealing [he mentol commitmenl laI(‘.y in Cali&orniu. Berkeley: University of California Press. Beis, E. (1983). State involuntary commitment statutes. Men/a/ flisabilitv Law Reporrer, 7, 358-369. Booms, B. H., & Halsdorron, J. R. (1973). The politics of redistribution: A reformation. American Politicul Science RedeM: 67, 924-933. Brown, P. (1981). The mental patients’ rights movement and mental health institutional change. Inrernarional Journal of Health Services, II, 523-540. Brown, P. (1985). The transfer of care: Ps_vchiatric cleinstituiionaliza(ion and i/s aftermurh. Boston: Routledge and Kegan Paul. Ennis, B. J., & Emery, R. D. (1978). The righl5 oj’mentalparienrs. New York: Avon. Fagan, R. bc’., & Mauss, A. L. (1978). Padding the revolving door: An initial assessment of the uniform alcoholism and intoxication treatment act in practice. Social Problems, 26, 232-247.
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Foley, H. A., & Sharfstein, S. S. (1983). Madness and government: Who cares for the mentally ill? Washington, D.C.: American Psychiatric Press. Inter-University Consortium for Political and Social Research. (1980). American national election study, 1980. Ann Arbor, MI: Author. Levine, M. (1981). The history and polifics of community mental health. New York: Oxford University Press. Lyon, M. A., Levine, M. L., Zusman, J. (1982). Patients’ bills of rights: A survey of state statutes. Mental Disability Law Repotter, 6, 178-201. Norton, R. D., & Rees, J. (1979). The product cycle and the spatial decentralization of American manufacturing. Regional Studies, 13, 141-151. Redick, R. W., & Witkin, M. J. (1983). State and county mental hospitals, United States, 1979-80 and 198081. Mental Health Statistical Note, 165. Rockville, MD: National Institute of Mental Health. Scull, A. T. (1977). Decarceration-community treatment and the deviani: A radical view. Englewood Cliffs, NJ: Prentice-Hall. Sigelman, L., Roeder, P. W., Sigelman, C. K. (1981). Social service innovation in the American states: Deinstitutionalization of the mentally retarded. Social Science Quarter/y, 62, 5033515. Smith, C. J. (1983). Innovation in mental health policy: Community mental health in the United States of America, 196551980. Environment and Planning-D: Society and Space, I, 447-468. Smith, C. J. (1984). Geographic patterns of funding for community mental health centers. Hospital and Community Psychiatry, 35, 1133-l 140. Smith, C. J., & Hanham, R. Q. (1981). Deinstitutionalization of the mentally ill: A time path analysis of the American states, 1955-1975. Social Science & Medicine, 150, 361-378. Smith, D. M. (1977). Human geography: A welfare approach. New York: Edward Arnold. Strauss, M. A. (1983, June). Social stress in American states and regions: An example of research using the state and regional indicators archive. Paper presented at the International Conference on Data Bases in the Humanities and Social Sciences, Rutgers University. Warren, C. A. B. (1984). The courf of last resort: Mental illness and the law. Chicago: University of Chicago Press. Zeigenfuss, J. T. (1983). Patients’ rights and organizafional mode/s. Washington, DC: University Press of America.