Rapprochement and Reform: Overcoming Factionalism in Policy Making for Serious Mental Illness

Abstract

This paper traces the history of factionalism in SMI policy making and advocacy from deinstitutionalization to the present day. It draws on deliberative democratic theory to illustrate how factionalist advocacy causes advocates and policy-makers to fail in their duties to represent those with SMI and how this factionalism has bred distrust and undermined efforts to address the needs of people with SMI. It proposes a Public Mental Health Policy Commission, guided by principles of deliberative democracy, to overcome factionalism and improve SMI policy.

Political factionalism presents a significant challenge in public health and healthcare policy development. It has been especially problematic for developing policies to help the 5% of Americans who live with serious mental illness (SMI), such as psychotic disorders; bipolar disorder, type 1; or treatment-resistant depression (1). These individuals face numerous inequities and are generally recognized as among the most disadvantaged members of society. They die 10–20 years earlier than the general population: a mortality gap that has widened over time (2–4). They are at greatly increased risk of suicide (5) and greatly increase cardiovascular risk (6), and they are more likely to receive inadequate general medical care that worsens this risk (7). Individuals with SMI also experience numerous adverse social determinants of health, including frequent housing instability, high rates of incarceration, and, for individuals with schizophrenia, 80%–90% unemployment (4). Roughly 20% of incarcerated individuals have a SMI, and thus carceral settings have been inappropriately transformed into de facto mental health care facilities (8).

Ongoing efforts to address these inequities have been hampered by ideological and scientific differences. The political context of deinstitutionalization and the long-standing conflicts between competing factions in SMI policy making are well-documented (9–15). The fact that these conflicts have created obstacles to funding for and implementation of evidence-based services for those with SMI may be less well understood. So too may be the fact that there are potential solutions that have been developed in other domains of public policy that could be applied to SMI policy.

Problems of factionalism are not unique to SMI policy. Political theorists have developed accounts of democratic deliberation to address factionalism and applied them to other policy domains. According to these theories, in a democratic society, citizens and their representatives must carefully deliberate together about the laws and policies that they will live under (16, 17). In the context of health policy, representatives most obviously include government officials, but others as well, such as health care professionals, lobbyists, and disease advocates. Clinicians—by dint of their professional obligations—must represent their patients and advocate for improved policies for their patients (18). Similarly, mental health advocates and advocacy organizations, who aim to influence policy on behalf of particular patient populations, assume special obligations as representatives through their political activity. Each of these groups should adhere to mutually respectful rules for deliberating about policy, and those rules should promote evidence-based policy development. When stakeholders do not follow shared rules of deliberation or when deliberative processes are not carefully designed, ideological entrenchment is reinforced, resulting in suboptimal policies. This has been the case in SMI policy development for many decades.

Focusing chiefly on the federal level of policy making, we first describe how factionalism has short-circuited ethically sound SMI policy development. We then recommend that the Biden administration establish a Public Mental Health Policy Commission (PMHPC) focused squarely on the development of evidence-based policies for individuals with SMI. Finally, we propose a set of shared rules and procedures, based in deliberative democratic theory, to ensure the outputs of this commission are evidence based, equitable, and broadly accepted.

Factionalism From Deinstitutionalization to Early Patient Self-Advocacy

Factionalism is pronounced in psychiatry generally as evidenced by regular, heated debates about nosology, pronounced divisions between ‘brain-based’ and ‘mind-based’ approaches, and turf wars between different professional organizations (9, 14, 19–23). But it is particularly prominent in SMI policy where it appears rooted in the promises and failures of deinstitutionalization in the United States.

Deinstitutionalization began with a coalition of former patients, mental health professionals, activists, journalists, and politicians that catalyzed the sweeping closure of state psychiatric hospitals beginning around 1955 (15). The coalition was motivated to end the abuses exposed in state hospitals and—with the advent of the first antipsychotic medications—to provide superior treatment in the community. Meanwhile conservative-minded policymakers saw hospital closure as way to defray significant costs away from state coffers (24).

By the early 1960s, the movement found support in the recommendations of the Joint Commission on Mental Illness and Health (JCMIH), which advocated for community treatment, significant reduction in institutionalization, and reforms to remaining hospitals. The JCMIH also expressed concerns abouts social needs in the community setting and recommended significant funding at various levels of treatment (25). In so doing, it navigated interprofessional politics and raised concerns that overreaching claims by the commission would undermine the public perception of psychiatry (9), but was not sensitive to concerns from patients and the community that would grow in subsequent years and did not formally include patients and advocates into policymaking.

Members of this coalition were overly optimistic about outpatient treatment for several reasons, including the initial promising evidence about the efficacy of antipsychotics in acute cases (without any evidence that, alone, they could enable independent recovery in the community) and hopes of dynamic therapy (extrapolated from treatment with patients without SMI) (9, 19). The JCMIH’s recommendations for reform of inpatient settings were largely overlooked. The significant financial support necessary for individuals to live in the community, when all housing, social, and nutritional costs had been borne by asylums, were similarly excluded.

Instead, with the promise of federal funding under the 1963 Community Mental Health Care Act, former inpatients, advocates, clinicians, and researchers focused squarely on building a system for community treatment (9, 14). Regrettably, long-term funding for community mental health centers never materialized, leaving instead a fragmented, underfunded community mental health system lacking robust social supports. Soon, as the clinical and economic expectations proved overly optimistic, this coalition dissolved, and, with it, the only contemporary period of general agreement in SMI policy. Politicians would turn to other political matters, and the psychiatric community’s focus would largely return to less severe illness (9).

Around this time, a schism occurred between established medical institutions and advocacy groups descendent from the psychiatric survivors’ and rehabilitation movements. Growing out of the revolutionary ethos of the 1960s, many advocacy groups emphasized a liberatory struggle. They rejected broad involuntary commitment laws and inhumane restraint policies. Some sympathized with the view that mental illness was little more than an oppressive myth (26–28). In contrast, many in “establishment” psychiatry hoped to improve the lives of people with SMI but held paternalistic and stigmatizing beliefs about people with SMI (11–13, 29–31). Opportunities to address the continued fractured and underfunded community mental health system have been overlooked—in part because of infighting reinforced by this ideological gap.

Factionalism and Prior Mental Health Commissions

Despite this schism, a series of commissions attempted to address the problems in the mental healthcare system that became blindingly apparent in the wake of deinstitutionalization. New calls for significant reform began in the 1970s, resulting in the Carter Presidential Commission on Mental Health (PCMH), which called for prioritizing SMI and offered a national plan to address needs of those with SMI (23, 32, 33). Though delayed by changes in Presidential administrations and growing fiscal conservativism, many of the PCMH’s recommendations for improving social services for those with chronic mental illness would eventually be implemented (32).

Nevertheless, the larger system remained underfunded and fragmented. Hence in the 2000s, President George W. Bush’s New Freedom Commission (NFC) readdressed these concerns and crystalized an important shift toward recovery-oriented programs that more fully recognize the importance of patient autonomy and shared decision making (34–36). This recognition elevated the Recovery Movement, helping to integrate aspects of it into psychiatric services, bridging some of the earlier rift between ‘establishment psychiatry’ and the earlier Survivors’ movement.

Notably, each commission built on its predecessors’ recommendations, increasingly calling for systemic reform and financial and social support for individuals with SMI. Nonetheless, twenty years after the NFC, the system remains fragmented and underfunded; and individuals with SMI continue to suffer several inequities. Critically, no prior commission has fully confronted the factionalism within the SMI community, and so factionalism is likely to continue to impede evidence-based policy development and implementation.

For instance, the JCMIH was sparked by an understanding that political and sociological problems contributed to the plight of those with mental illness and cautioned psychiatrists against hubristic statements of authority where they lack expertise, warning that this would undermine public trust (25). But it was driven by and composed of representatives from major professional organizations and, perhaps unsurprisingly, envisioned communication with the public as a public relations campaign rather than a shared deliberation on priorities (9). While the later commissions, improved on this by incorporating some individuals with lived experience (23), representation of those with lived experience remains modest at best.

Likewise, the PCMH featured varying competing interest groups—many with little mental health expertise—that ultimately achieved a unified consensus only when the Commission’s Chair was given authority to compose the final report rather than collate the diverse, potentially conflicting and confusing, preliminary reports (23). Commentators have noted that the PCMH also featured anti-expertise sentiments and non-evidence-based ideological commitments that were enabled to hold sway as non-expert members did not have the ability to identify non-evidence-based claims (14, 23).

The Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) in SAMHSA is the most notable, current, deliberative body in the US government dedicated to SMI. The ISMICC reports to Congress about public psychiatry needs and provides input to the NIMH on funding priorities (37, 38). Yet, as an interdepartmental institution of the executive branch, its roster has large proportions of executive branch appointees with expertise from their home departments, and involvement of representatives with lived experience is proportionally small. While this is reasonable given the ISMICC’s mission, the Committee is not designed to resolve factionalism or for deliberation involving a broad array of stakeholders. Hence, we doubt that ISMICC will solve the deliberative challenges that we raise here.

Factionalism in Contemporary SMI Policy

Given that prior commissions did not adequately address the factionalist problems or realize the deliberative norms required to overcome them, it is unsurprising that factionalist tensions remain. Points of significant disagreement range from the appropriate role of inpatient hospitalization in a comprehensive mental health system to the acceptability of compulsory treatment (8, 39). For instance, some advocates of expanding inpatient treatment have at times declared trauma an “invented illness,” suggested the recovery movement was simply profit-driven pseudoscience, and questioned the epistemic value of lived experience (40, 41). In contrast, opponents of involuntary commitment have created barriers to expanding inpatient capacity (43). Other advocates have overstated the harms of neuroleptics and ECT (44–48) with selective reviews of the literature (49).

Disagreement is to be expected among reasonable people on complex policy matters (16, 54–56). Obviously, the goal of political deliberation should not be to eliminate disagreement entirely (57, 58). Nonetheless, normative guardrails exist to guide how stakeholders should collectively deliberate (16, 54–56, 59). These ethical constraints discourage discourse that then regresses toward ‘“anything goes warfare” (60). Unfortunately, as the aforementioned examples indicate, in the SMI policy arena, respectful deliberation has broken down.

Focus on extreme cases might mislead one to presume that all disrespectful political engagement should be attributed to bad actors who are unwilling to reasonably engage. However, factionalism creates an environment of distrust that discourages collaboration even among well-meaning people. Those with extreme views are not the only ones who fail to deliberate together; so too do more moderate stakeholders who feel that they cannot trust political opponents.

For example, the selective use of incomplete evidence is a commonplace example of a violation of deliberative norms that undermines evidence-based policy making. Advocates for involuntary treatment have implicated links between SMI and mass shootings (50, 51) despite evidence to the contrary (52, 53). Similarly, recent presidential candidates proposed mental health reforms with minimal input from researchers and clinicians. The use of incomplete evidence has resulted in platforms focused exclusively on the expansion of community resources (39), ignoring evidence that the United States has a significant shortage of inpatient hospital resources and has bed capacity below recommended targets, which evidence suggests results in shortened hospital stays, failures of stabilization, and exacerbation of suicide risk after hospital discharge among patients with SMI (8). Instituting norms of democratic deliberation will make possible a collaborative trust that is essential in complex policy making efforts.

A New Deliberative Body for SMI Policy

The JCMIH, PMHC, and NFC had wide-ranging mandates (25, 34, 61), which may account for why their recommendations were often, nonspecific, and difficult to implement. In contrast, the PMHPC should focus on SMI policy reform and should squarely address the political factionalism that persists among SMI policy-makers. A single commission cannot eliminate factionalism that has been entrenched for decades and has impeded SMI policy reform, but it can begin to change the trajectory, encouraging further trust and collaboration by highlighting the problem of factionalism and changing the norms that encourage political gamesmanship. However, by instituting deliberative democratic norms, it can begin to change the trajectory and encourage further trust and collaboration by changing the norms that incentivize political gamesmanship.

Broadly, democratic deliberation requires participants to justify their favored policies in terms acceptable to all reasonable people that are willing to cooperate—whether or not they, agree with the conclusions. By giving reasons for their views and listening to the reasons of others, deliberators extend mutual respect to one another (16, 17, 54–56). Under the right conditions, this respect builds trust in the decision-making process, its outcomes, and the potential for future reform (62–64). In addition to the basic requirement of reason-giving for democratic deliberation, four additional principles should guide the PMHPC in developing SMI policies: include diverse views on mental health and illness, identify areas of consensus, clarify areas of disagreement, and hold participants accountable regarding evidence and transparency.

1). Include Diverse Views on Mental Health and Illness.

A longstanding principle of deliberative democracy is that including a broad array of stakeholders is critical to a fair outcome. In the context of SMI policy development, inclusion ultimately reduces bias and stigma commonly experienced by individuals with SMI. Individuals with lived experience, advocates for individuals with SMI and mental health professionals must all be included.

Each of these groups adds critical knowledge to the deliberation. Failure to engage clinical and policy experts will undermine fidelity to scientific evidence, and failure to engage politicians and the advocacy community will neglect real-life political trade-offs, stoke partisanship, and make implementation unlikely. In turn, failure to include persons with lived experience and their advocates neglects the knowledge that comes from firsthand experience of living with serious mental illness. Moreover, the full range and heterogeneity of experience with serious mental illness must be included because relying only on representatives with less severe conditions or with greater privilege (in virtue of, e.g., socioeconomic status or powerful roles in advocacy organizations) can reinforce biases (65, 66).

Notably, engagement of those with lived experience in SMI policy must be carefully structured so as to create a productive deliberative environment. Stigma and previous iatrogenic trauma may discourage some individuals from expressing their needs; severe symptoms may inhibit individuals from fully recognizing their needs. The input of individuals with lived experience must be actively sought out and, when necessary, facilitated. A recent proposal to expand the investment of researchers with lived experience (67) would be one means of doing so. But such investment is long term, and addressing the factionalism in SMI policy making should not wait for that investment if it is slow to come; indeed, addressing that factionalism in the context of a new PMHPC might promote such an investment.

2). Identify Areas of Consensus.

Even if consensus is not the only goal of deliberation (57, 58), finding limited points of consensus is a promising means to the general deliberative democratic goal of building a policy making community based on mutual respect and on finding mutually acceptable reasons (16, 56). Such a community fosters further dialogue. For SMI policy making, identifying consensus can reduce polarization within the mental health community, reframe policy making goals, and identify potential allies in policy making. By doing so, consensus can open new avenues of political engagement, counter factionalism and distrust, incentivize cooperation, and discourage unfair portrayal of those with opposing views.

Specifically, we recommend that the PMHPC first identify areas of general agreement. While we cannot prejudge what they will decide, examples of propositions on which there may be potential, broad consensus include the following. (1) SMI is severely underfunded. (2) Decriminalization is an immediate need. (3) Morbidity and mortality are unacceptably high. Finally, (4) policy-relevant research should rapidly be deployed to expand the evidence-base, and (5) implementation science research should determine how to translate policy recommendations into real action.

One virtue of the principle of identifying areas of potential consensus is that consensus-building is often an iterative project that builds on its own successes. In part this is because previous success at establishing some consensus can foster confidence in further success as deliberators’ skepticism about each other decreases. In turn, perhaps less obvious areas of agreement can be identified as deliberation about these five points of agreement unfolds.

3). Clarify Areas of Disagreement.

Though sometimes not appreciated, mutually respectful, disagreement is also productive (57). Such disagreement enables the realization of three goals in particular: (1) prevention of misunderstanding and misinterpretation, (2) promotion of transparency, and (3) highlighting of tradeoffs. Together these clarify targets of further deliberation and areas for evidence development. To set benchmarks and ensure progress, we suggest that within 6 months of its formation, the PMHPC establish a goal to identify the most significant items of disagreement that are empirically testable and, in collaboration with funding agencies, request grant proposals for trials to assess these issues within the first year. But not all disagreement is directly testable. Often, disagreements about trade-offs among policy priorities or moral and political values are not. When empirical studies cannot settle disagreements, deliberation to solve policy problems will be, perhaps, more important.

It is also important to note that overemphasizing consensus while failing to clarify disagreement can mask underlying disagreement and in turn prevent further deliberation that might improve policy. For instance, ethicists, physicians, policy makers, advocates, and families almost universally agree that respect for patient autonomy and shared decision making is critical to the ethical practice of medicine; this agreement masks the fact that there is far less agreement on what these values actually require in a particular case. For example, there is reasonable disagreement among these groups about risk tolerance in support of patient autonomy and what steps providers may take when patients prefer treatment plans that strike providers as unsafe (68). Likewise, many experts argue that different forms of shared decision making are appropriate for different contexts (69), but there seems to be disagreement on which forms apply to what contexts. Hence, the vague general agreement on shared decision making and patient autonomy may leave some stakeholders with the sense that patient autonomy is valued in name, while advocates of moderate parentalism may feel that the sickest patients are being abandoned.

Similar observations might be made for the importance of recovery, patient-centered care, and other widely endorsed concepts at the center of debates about SMI policy. Indeed, there may be disagreement on what illnesses should count as serious. Serious mental illness is a broadly defined and heterogeneous set of conditions, and any operationalization of it will include and exclude some marginal cases. For instance, some who are not considered to have SMI might object to not receiving priority for benefits that those with SMI should receive. Alternatively, some patients with milder symptoms might object to being deemed to have serious mental illness and reject diagnostic labels they see as applying only to individuals with more serious symptoms. (By way of comparison, a similar problem arose in debates about including individuals who were previously deemed to have Asperger’s Disorder in a general category autism spectrum disorder in the DSM-5 (70)). So, the contours of SMI itself must be an object of deliberation to reach agreement, but to reach such an agreement, we must begin from the rough working notion of the concept of SMI that is broadly shared by the community.

4). Hold Participants Accountable Regarding Evidence and Transparency.

Factionalism encourages stakeholders to overemphasize evidence supporting their own view and to discount evidence that supports their opponents’ views. Hence, holding deliberators accountable to accurately present their evidence and acknowledge contrary evidence will be critical. Emphasizing such accountability both reduces misrepresentation of evidence and encourages fair portrayal of other parties’ rationales.

To promote awareness of evidence and enable responsible discussion of it, public interest subgroups could be formed that would proactively educate the community about the challenges under examination by the PMHPC. Social media, podcasting, and videoconferencing may all be used to connect with and educate the public on the policy ideas and to gather real time, real-world feedback. The PMHPC should thus be framed in the public eye as both a policy incubator and an educational resource.

Examination and deliberation about the quality and state of evidence will also be critical. There is disagreement about how much evidence is needed before implementation and policy making. This sort of disagreement has led to resignations from SAMHSA, intense debates about its leadership, and unilateral, nontransparent changes to what SAMHSA considers adequately evidence-based interventions without open deliberation or stakeholder involvement (71–76). It will be critical to bring disagreements about the state of evidence into transparent deliberation.

Ways Forward

A new presidential commission, the PMHPC, based in the core principles of democratic deliberation, offers a promising means to reform the deliberative environment on SMI policy for two reasons. First, it can institutionalize principles to encourage mutual trust, which are not otherwise likely to be complied with or enforced in public discussion. When they are designed and applied carefully, institutionally enforced principles of fairness prevent deliberators from ignoring various existing power structures, such as limited access, unequal power dynamics, lack of information, and competing power dynamics that otherwise unfairly influence deliberation (58, 77).

On the one hand, mistrust in SMI policy may stem in part from the fact that people with lived experience and advocates for persons with serious mental illness have been unfairly excluded from important policy decisions. Therefore, the PMHPC must prioritize patients’ and advocates’ involvement in policy decision making. On the other hand, researchers and clinicians may also worry that if antiexpertise sentiments prevail, evidence-based policy making might give way to ideology–as some argue has happened in past commissions. Hence, the PMHPC must balance recognition of the expertise of mental health professionals with the firsthand knowledge of those living with SMI.

Second, the PMHPC will call attention to the underappreciated problem of factionalism in SMI policy. The commission may serve as a highly visible forum, increasing awareness of the adverse impact of factionalism in SMI policy and serving as an exemplar of democratic deliberation between patients, advocates, and mental health professionals to develop effective policies. Further steps, such as the use of public interest subgroups and social media suggested above, could augment this publicity.

While entrenched factionalism has complicated SMI policy development and implementation for decades, democratic deliberation suggests a means to overcome this problem. Such deliberation enables well-informed, respectful compromise; in SMI policy, it may create the opportunity for true rapprochement and reform. We believe these goals may be accomplished through a new presidential commission on public psychiatry, the PMHPC, rooted in the ideals of democratic deliberation and evidence-based policy development.