From Poorhouses to Homelessness: Policy Analysis and Mental Health Care, 2nd Ed.


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Rochefort, David A. From Poorhouses to Homelessness: Policy Analysis and Mental Health Care, 2nd Ed. Westport, CT: Auburn House, 1997. xvii + 321 pp. $24.95 Paperback."Policy" is a ubiquitous word that can apply to general statements such as "The United States is committed to provide adequate mental health services for all its citizens." It can refer to specific legislation such as "The Community Mental Health Centers (CMHC) Act of 1963." It can refer to the specific regulations such as "The policy of this center is that bills are paid before service is given."In the analysis of mental health policy under review here, all these meanings are present. This text aims to provide knowledge of mental health policy, understanding of policy making, and comprehension of how government deals with mental health questions. The presentation is in five parts containing 12 chapters. After the introduction there is a historical analysis of health policy, and examination of theoretical and political perspectives, a presentation of contemporary policy trends and issues, and a conclusion, which presents the system as in flux. This is a second edition. All the chapter titles are the same as in the first edition, and the conclusion is new.Rochefort wanted to avoid the extremes of the progressive view that sees a small band of idealists working to improve conditions for the mentally ill and the radical view that sees current mental health policies as an oppressive and punishing control of the mentally ill. His approach is to examine selected policy initiatives with a view toward illuminating cultural themes that bear on mental health. Each analysis is hung around a different set of eclectic factors that he deems to fit the issue being presented.This results in a choppy presentation that parallels the conclusion he develops about mental health policy. Among the major topics covered is a brief but competent historical review of mental health care, community mental health, the varieties of funding options and the way these and other political considerations make coordination difficult. There are also case studies related to deinstitutionalization and whether other structural options make a difference.The conclusion is developed in a variety of ways. Mental health continues to be low on the scale of supported health needs. The move toward block grants and other forms of defederalization has resulted in fewer funds being available. Political infighting connected with the struggle over categorical programs and block grants prevented analysis of whether the block grant approach could give the same service more efficiently. Case management was supposed to bring efficiency but it turned out to be the most duplicated service. What all of this boils down to is that saying what the overall mental health policy is in this country is hard. Services chase the dollars so patients and clinics adopt the presentation of self to qualify for what is available. The result is an underfunded, inadequately coordinated, and constantly changing picture of services and policies.This work is adequate as a textbook for undergraduate courses related to mental health policy. There are only hints of the type of analysis that would make it suitable for advanced courses or a contribution to clarifying or advancing mental health policy in the United States. For example, the analysis of the mental health system in Nova Scotia, Canada, shows that it is organized in exactly the way liberals in this country say the American system should be organized and funded. Despite this, the Nova Scotia mental health system is just as disorganized and uncoordinated as that in the United States.

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