Figure 14.2 The percentage of adults who received mental health treatment in 2004–2008 is shown. Adults seeking treatment increased slightly from 2004 to 2008.

Before we explore the various approaches to therapy used today, let's begin our study of therapy by looking at how many people experience mental illness and how many receive treatment. According to the U.S. Department of Health and Human Services (2013), 19% of U.S. adults experienced mental illness in 2012. For teens (ages 13–18), the rate is similar to that of adults, and for children ages 8–15, current estimates suggest that 13% experience mental illness in a given year.

With many different treatment options available, approximately how many people receive mental health treatment per year? According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2008, 13.4% of adults received treatment for a mental health issue. These percentages, shown in Figure 14.2, reflect the number of adults who received care in inpatient and outpatient settings and/or used prescription medication for psychological disorders.

Children and adolescents also receive mental health services. The Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey (NHANES) found that approximately half (50.6%) of children with mental disorders had received treatment for their disorder within the past year. However, there were some differences between treatment rates by category of disorder (Figure 14.3). For example, children with anxiety disorders were least likely to have received treatment in the past year, while children with ADHD or a conduct disorder were more likely to receive treatment. Can you think of some possible reasons for these differences in receiving treatment?

Considering the many forms of treatment for mental health disorders available today, how did these forms of treatment emerge? Let's take a look at the history of mental health treatment from the past (with some questionable approaches in light of modern understanding of mental illness) to where we are today.

Figure 14.3 About one-third to one-half of U.S. adolescents (ages 8–15) with mental disorders receive treatment, with behavior-related disorders more likely to be treated.

Treatment in the Past

For much of history, the mentally ill have been treated very poorly. It was believed that mental illness was caused by demonic possession, witchcraft, or an angry god because early beliefs incorrectly attributed all unexplainable phenomena to deities deemed either good or evil. For example, in medieval times, abnormal behaviors were viewed as a sign that a person was possessed by demons. If someone was considered to be possessed, there were several forms of treatment to release spirits from the individual. The most common treatment was exorcism, often conducted by priests or other religious figures: Incantations and prayers were said over the person's body, and she may have been given some medicinal drinks. Another form of treatment for extreme cases of mental illness was trephining: A small hole was made in the afflicted individual's skull to release spirits from the body. Most people treated in this manner died. In addition to exorcism and trephining, other practices involved execution or imprisonment of people with psychological disorders. Still others were left to be homeless beggars. Generally speaking, most people who exhibited strange behaviors were greatly misunderstood and treated cruelly.

Figure 14.4 This painting by Francisco Goya, called The Madhouse, depicts a mental asylum and its inhabitants in the early 1800s. It portrays those with psychological disorders as victims.

Figure 14.5 This painting by Tony Robert-Fleury depicts Dr. Philippe Pinel ordering the removal of chains from patients at the Salpêtrière asylum in Paris.

From the late 1400s to the late 1600s, a common belief perpetuated by some religious organizations was that some people made pacts with the devil and committed horrible acts, such as eating babies. These people were considered to be witches and were tried and condemned by courts—they were often burned at the stake. Worldwide, it is estimated that tens of thousands of mentally ill people were killed after being accused of being witches or under the influence of witchcraft.

By the 18th century, people who were considered odd and unusual were placed in asylums (Figure 14.4) Asylums were the first institutions created for the specific purpose of housing people with psychological disorders, but the focus was ostracizing them from society rather than treating their disorders. Often these people were kept in windowless dungeons, beaten, chained to their beds, and had little to no contact with caregivers.

In the late 1700s, a French physician, Philippe Pinel, argued for more humane treatment of the mentally ill. He suggested that they be unchained and talked to, and that's just what he did for patients at La Salpêtrière in Paris in 1795 (Figure 14.5). Patients benefited from this more humane treatment, and many were able to leave the hospital.

Figure 14.6 Dorothea Dix was a social reformer who became an advocate for the indigent insane and was instrumental in creating the first American mental asylum. She did this by relentlessly lobbying state legislatures and Congress to set up and fund such institutions.

In the 19th century, Dorothea Dix led reform efforts for mental health care in the United States (Figure 14.6). She investigated how those who are mentally ill and poor were cared for, and she discovered an underfunded and unregulated system that perpetuated abuse of this population. Horrified by her findings, Dix began lobbying various state legislatures and the U.S. Congress for change. Her efforts led to the creation of the first mental asylums in the United States.

Despite reformers' efforts, however, a typical asylum was filthy, offered very little treatment, and often kept people for decades. At Willard Psychiatric Center in upstate New York, for example, one treatment was to submerge patients in cold baths for long periods of time. Electroshock treatment was also used, and the way the treatment was administered often broke patients' backs; in 1943, doctors at Willard administered 1,443 shock treatments. (Electroshock is now called electroconvulsive treatment, and the therapy is still used, but with safeguards and under anesthesia. A brief application of electric stimulus is used to produce a generalized seizure. Controversy continues over its effectiveness versus the side effects.) Many of the wards and rooms were so cold that a glass of water would be frozen by morning. Willard's doors were not closed until 1995. Conditions like these remained commonplace until well into the 20th century.

Starting in 1954 and gaining popularity in the 1960s, antipsychotic medications were introduced. These proved a tremendous help in controlling the symptoms of certain psychological disorders, such as psychosis. Psychosis was a common diagnosis of individuals in mental hospitals, and it was often evidenced by symptoms like hallucinations and delusions, indicating a loss of contact with reality. Then in 1963, Congress passed and John F. Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Act, which provided federal support and funding for community mental health centers. This legislation changed how mental health services were delivered in the United States. It started the process of deinstitutionalization, the closing of large asylums, by providing for people to stay in their communities and be treated locally. In 1955, there were 558,239 severely mentally ill patients institutionalized at public hospitals. By 1994, by percentage of the population, there were 92% fewer hospitalized individuals.

Dig Deeper

A Timeline of Mental Health Institutions in the U.S.

1773 - First Psychiatric Hospitals Open

The nation's first two psychiatric hospitals opened in the late-1700s. Eastern State Hospital in Williamsburg, Va., opened Oct. 12, 1773 and Spring Grove Hospital opened in Baltimore in 1798.

1825-1847 - Dix and the Growth of Institutions

After observing the conditions in which the mentally ill were forced to live in jails and poorhouses, Dorothea Dix contributed to the moral treatment movement by beginning a vigorous program of lobbying state and federal governments for legislation and funds to reform the mental health system. Her work created the first generation of mental hospitals and asylums in the U.S.

1954 - New Drugs Introduced

Before the development of psychiatric drug therapy, the most commonly used treatments for mental illness were electroconvulsive therapy, insulin coma therapy and lobotomies. These treatments often left patients severely damaged. In the 1950s, the development of psychoactive drugs and their approval by the FDA initiated a new form of treatment for mental illness. When the anti-psychotic Thorazine was introduced in 1954 as a way to calm patients with disorders such as schizophrenia and manic-depression, millions of people were prescribed the drug as a way to help hospital staff keep order in crowded facilities.

1955 - Half a Million in Institutions

In 1955 state mental institutions in the U.S. housed nearly 560,000 patients.

1963 - The Community Mental Health Centers Act

President John F. Kennedy signed the Community Mental Health Centers Act. The Act provided $150 million for new mental health center programs and triggered deinstitutionalization in the U.S. by mandating the construction of community facilities instead of regional mental hospitals. As a result of Kennedy's legislation, the number of patients in state mental hospitals declined by 62 percent by 1975. Support for the program ended in 1981.

1977 - Mental Institution Population Drops

By 1977, U.S. mental institutions had reduced the size of their collective population to about 160,000 patients.

1980 - The Mental Health Systems Act

President Jimmy Carter helped establish the Mental Health Systems Act of 1980, which restructured federal community health center programs by increasing and strengthening links between local, state and federal governments. The act mandated the Community Mental Health Centers to increase a number of grant programs for the mentally ill, such as services for the severely mentally ill, the severely emotionally disturbed and increasing education and consulting needs.

1982-1985 - Budget Cuts Change Care

The 1980s marked a period in which sweeping budget cuts led to a decline in services for the mentally ill. President Ronald Reagan supervised cuts to social programs throughout the decade that hampered support for the poor and mentally ill, among other groups. Reagan repealed the Mental Health Systems Act of 1980 soon after taking office in 1981, because the federal support of Community Mental Health Centers ran counter to his goals to reduce spending and social programs. In its stead, Reagan enacted the Alcohol, Drug Abuse and Mental Health Block Grant, which decreased funding by 30 percent in 1982, leading to major service reductions. Under this system, the federal government simply redistributed money to the states, but in smaller amounts, which increased the burden placed upon local and state governments.

1999 - Olmstead Case Decided by Supreme Court

The U.S. Supreme Court's 1999 Olmstead ruling gave institutionalized mental health patients more ammunition in seeking community-based care. The ruling of the case affirmed that under the Americans with Disabilities Act, unjustifiable institutionalization of a person with a disability is discrimination when the treating provider believes that community-based care would be better; when the affected person does not oppose the community-based option and when the placement can be reasonably accommodated. The court ruled that institutionalization limits a person's ability to interact with other people, to work and to make a life for him or herself, according to the case document. The Olmstead case has brought progress for many individuals, successfully transitioning them from institutions to community settings. But waiting lists for community services have grown, and many who would like to receive community services aren't able to obtain them.

2008-2012 - Justice Deptartment Cracks Down

When President Obama took office in 2008, he reinvigorated the Justice Department's efforts to crack down on states violating or failing to comply with the Supreme Court's Olmstead decision. The department's Civil Rights Division has been aggressively investigating the mental health care systems of states nationwide. Officials have looked into at least 20 states and have negotiated settlements with many of them. The agreements typically involve closing or significantly downsizing most or all of the state-run institutions in the jurisdiction in question and implementing a timeline by which to launch specific numbers and types of community programs and services. Additionally, the Office of Civil Rights conducted 581 investigations into Olmstead compliance, and 61 percent of those resulted in corrective measures being put in place.

2012 - Prisons See Surge in Mentally Ill

The number of mentally ill Marylanders jailed in state prisons has steadily increased in recent years, as the state has shrunk the number of patients in its psychiatric hospitals, officials say. The increase of the mentally ill in Maryland prisons mirrors a national trend and coincides with a decades-long push to move patients out of mental hospitals and into community-based care. As psychiatric hospitals closed, insufficient funds were provided for community care and residential programs, leaving some mentally ill without proper treatment and with nowhere to go.

Mental Health Treatment Today

Today, there are community mental health centers across the nation. They are located in neighborhoods near the homes of clients, and they provide large numbers of people with mental health services of various kinds and for many kinds of problems. Unfortunately, part of what occurred with deinstitutionalization was that those released from institutions were supposed to go to newly created centers, but the system was not set up effectively. Centers were underfunded, staff was not trained to handle severe illnesses such as schizophrenia, there was high staff burnout, and no provision was made for the other services people needed, such as housing, food, and job training. Without these supports, those people released under deinstitutionalization often ended up homeless. Even today, a large portion of the homeless population is considered to be mentally ill (Figure 14.7). Statistics show that 26% of homeless adults living in shelters experience mental illness.

Figure 14.7 (a) Of the homeless individuals in U.S. shelters, about one-quarter have a severe mental illness (HUD, 2011). (b) Correctional institutions also report a high number of individuals living with mental illness. (credit a: modification of work by C.G.P. Grey; credit b: modification of work by Bart Everson)

Another group of the mentally ill population is involved in the corrections system. According to a 2006 special report by the Bureau of Justice Statistics (BJS), approximately 705,600 mentally ill adults were incarcerated in the state prison system, and another 78,800 were incarcerated in the federal prison system. A further 479,000 were in local jails. According to the study, "people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four times the general population" (Prins & Draper, 2009, p. 23). The Treatment Advocacy Center reported that the growing number of mentally ill inmates has placed a burden on the correctional system.

Today, instead of asylums, there are psychiatric hospitals run by state governments and local community hospitals focused on short-term care. In all types of hospitals, the emphasis is on short-term stays, with the average length of stay being less than two weeks and often only several days. This is partly due to the very high cost of psychiatric hospitalization, which can be about $800 to $1000 per night. Therefore, insurance coverage often limits the length of time a person can be hospitalized for treatment. Usually individuals are hospitalized only if they are an imminent threat to themselves or others.

Most people suffering from mental illnesses are not hospitalized. If someone is feeling very depressed, complains of hearing voices, or feels anxious all the time, he or she might seek psychological treatment. A friend, spouse, or parent might refer someone for treatment. The individual might go see his primary care physician first and then be referred to a mental health practitioner.

Some people seek therapy because the criminal justice system referred them or required them to go. For some individuals, for example, attending weekly counseling sessions might be a condition of parole. If an individual is mandated to attend therapy, she is seeking services involuntarily.

Involuntary treatment refers to therapy that is not the individual's choice. Other individuals might voluntarily seek treatment.
Voluntary treatment means the person chooses to attend therapy to obtain relief from symptoms.

Psychological treatment can occur in a variety of places. An individual might go to a community mental health center or a practitioner in private or community practice. A child might see a school counselor, school psychologist, or school social worker. An incarcerated person might receive group therapy in prison. There are many different types of treatment providers, and licensing requirements vary from state to state. Besides psychologists and psychiatrists, there are clinical social workers, marriage and family therapists, and trained religious personnel who also perform counseling and therapy.

A range of funding sources pay for mental health treatment: health insurance, government, and private pay. In the past, even when people had health insurance, the coverage would not always pay for mental health services. This changed with the Mental Health Parity and Addiction Equity Act of 2008, which requires group health plans and insurers to make sure there is parity of mental health services. This means that co-pays, total number of visits, and deductibles for mental health and substance abuse treatment need to be equal to and cannot be more restrictive or harsher than those for physical illnesses and medical/surgical problems.

Finding treatment sources is also not always easy: there may be limited options, especially in rural areas and low-income urban areas; waiting lists; poor quality of care available for indigent patients; and financial obstacles such as co-pays, deductibles, and time off from work. Availability, accessibility, and acceptability (the stigma attached to mental illness) are all problems in rural areas. Over 85% of the 1,669 federally designated mental health professional shortage areas are rural; often primary care physicians and law enforcement are the first-line mental health providers, although they do not have the specialized training of a mental health professional, who often would be better equipped to provide care. Approximately two-thirds of those with symptoms receive no care at all. At the end of 2013, the U.S. Department of Agriculture announced an investment of $50 million to help improve access and treatment for mental health problems as part of the Obama administration's effort to strengthen rural communities.

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