Person in the Center: Mental Health Care Transformation from Asylums to the ACA

March 23, 2010, Barack Obama signed the Patient Protection and Affordable Care Act (PPACA, commonly referred to as "The Affordable Care Act," or ACA).

Five years prior, in anticipation of it, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) held the National Summit on Recovery and outlined, among other things, 12 guiding principles of recovery and 17 elements of recovery-oriented systems of care. The first of the 17 identified elements of a recovery-oriented system of care is that such a system would be "person-centered."

In 2009, A. Katherine Power (see photo above), then director of the Center for Mental Health Services (CMHS) within SAMHSA, published an article in the May 2009 issue of Psychiatric Services titled "A Public Health Model of Mental Health for the 21st Century," in which she described public health as "a population-based approach that supports the development of whole-health, person-centered health care."

That March, Power had given a presentation at a public SAMHSA event offering a"A Vision for a Mentally Healthy America," in which "mental health is regarded as essential for overall health" and in which the focus shifts "from illness to health." In a transformed system, Powers imagined, mental health would be integrated with general health care and chemical dependency treatment, resilience and recovery would be ongoing priorities, and society would move closer to the vision of "a life in the community for everyone." Many in the field believed we were nearing a paradigm shift.

At this time, many were wrestling with visions of health care integration, and a consensus was forming that one of the first priorities would be to achieve meaningful integration between what have been largely disparate fields of mental health and substance use treatment into a more effective behavioral health system. A further possibility envisioned ways to better integrate primary care's role in interfacing with and participating in the treatment activities of a behavioral health ecosystem.

Power offered "core components of a public mental health approach for children and families," the first of which was that public health be "holistic and person-centered." In a white paper entitled "Guiding Principles and Elements of Recovery-Oriented Systems of Care" put out by SAMHSA in August 2009, the following statement appeared—

"Person-centered services offer choice, honor each person's potential for growth, focus on a person's strengths, and attend to the overall health and wellness of a person with a mental illness and/or addiction."

Such a statement would not seem particularly innovative or novel to most of us in 2016. The term "person-centered" itself has become ubiquitous—search the term, and you'll find "person-centered psychotherapy," but also"person-centered dementia care," "person-centered disability care," "person-centered recovery," "person-centered expressive arts," "person-centered consulting," "person-centered outcomes," "person-centered medicine," and even "person-centered career planning." Ad infinitum.

Yet just a bit of historical perspective reminds us of how far we have come and how important our increasingly person-centered values are and continue to be as we work together to shape the future of health care delivery for generations to come.

Lunatic Asylums

By the mid-1800's, the widely available mental health treatment option across Western societies for what we now refer to as "the severely and persistently mentally ill" was large institutions called "lunatic asylums," also known as "insane asylums." Persons experiencing psychosis as well as a variety of other problems affecting their mental health—even, in many cases, those experiencing what was considered "neurosis"—found hope in the belief that asylum treatments would help. In 1842, the Georgia Lunatic Asylum became the largest asylum in the world, boasting by World War II over 200 buildings on 2,000 acres with up to 13,000 patients, under by then the new name, Central State Hospital but widely known by the name of its nearby town, Milledgeville.

In 2015, Doug Monroe wrote in Atlanta Magazine of Milledgeville,

"By the 1950's, the staff-to-patient ratio was a miserable one to 100. Doctors wielded the psychiatric tools of the times—lobotomies, insulin shock, and early electroshock therapy—along with far less sophisticated techniques: Children were confined to metal cages; adults were forced to take steam baths and cold showers, confined in straitjackets, and treated with douches or 'nauseants.'"

In the mental health system of yesteryear, folks who complained of any mental ailment ran a risk of finding their way into large institutions that, first, were not prepared to provide any meaningful, never mind person-centered, treatment for their condition and, second, were at most experimental laboratories and, in many cases, essentially elaborate money making schemes. Exhausted parents sometimes enrolled their children in such institutions. Spouses were sometimes committed as a way to escape marriage. Witch hunts of many kinds have been said to have occurred. Many of us take for granted modern behavioral health services and are unaware of the horrors that came before.

Well, the story goes that between the mid-1960's and the mid-1970's, a couple of governors of Georgia—Carl Sanders and then later Jimmy Carter—worked to deinstitutionalize Central State Hospital, overseeing the distribution of remaining patients to—I'll say more modern—hospitals, clinics, and other smaller treatment facilities, aided significantly by the advent of a new age in psychiatric pharmaceuticals.

Let's rewind and consider the shifting and shaping of the mental health profession during that stretch. By the late 1800's, we were still broadly categorizing the mentally ill as "psychotics" and "neurotics." A person now considered to have a "severe and persistent mental illness" was then referred to as "psychotic" and considered "insane" or "mad." "Psychosis" refers to a conditions that affects one's grasp on reality. "Neurosis," on the other hand, is considered to be a mental illness resulting in a comparatively less severe disturbance, such as depression, anxiety, or the like. Neuroses were thought to involve nervous system functioning and had been studied since the 1700's, yet no mainstream treatment for neuroses was available until the turn of the 19th century.

The First Force in Modern Psychology

During the 1890's, young postgraduate Sigmund Freud wrestled to carve his place outside of the academy. In 1900, he published The Interpretation of Dreams, followed shortly thereafter in 1901 by The Psychopathology of Everyday Life, in which he originated a theory of the unconscious. Freud's treatment approach, psychoanalysis a.k.a. "the talking cure," resulted in psychoanalytic clinics popping up around Austria, Europe, the United States, and throughout the Western world.

While the asylum offered the only treatment available to "psychotics," "neurotics" had nearly no treatment option at all. Freud's psychoanalytic movement resulted in a new option for so-called neurotics. Thousands of psychiatrists left the asylums to pursue a new, exciting, and alternative career option: what we now call psychotherapy. Many did not. It would take more than a half-century more, as I alluded to above, for biological psychiatry to exit the Dark Ages.

Freud's psychoanalysis was primarily past-oriented, pathology-focused, unstructured yet directive in approach, and theory-driven, with the therapist as expert. Freud's theory was largely deterministic and reductionistic in nature: "deterministic" in that he believed that our futures, and meaningful changes in their course, are largely outside the bounds of our control, and "reductionistic" in that he attributed seemingly complex cognitive, emotional, and behavioral processes to a few universal urges, especially sexual.

Freud's influence in the field constituted what has become known as "the first force" in the field of modern psychology. There is plenty of earned criticism heaped onto the early days of Freudian psychoanalysis. In historical context, Freud's outpatient mental health treatment was in many respects, however, quite impressive, and the reality is that the field of psychotherapy owes a great deal to Freud's innovation.

The Second Force in Modern Psychology

The next methodological innovation to capture the imagination of the field was B.F. Skinner, whose behaviorist viewpoint constituted a "second force" in the field.

B.F. Skinner studied psychology at Harvard and worked to develop objective ways to study behavior. He dismissed the sort of interpretation and conjecture that psychoanalytic and other psychotherapies at that time employed, believing science would forge the field of psychology into a new and more credible era.

Skinner strove to be more scientific in his approach than the psychoanalysts. In order to move the field away from flagrantly subjective psychoanalytic theories, he studied only the observable, which meant a clear shift from the study of the mind to behavior.

Skinner's theory was, like Freud's, largely deterministic and reductionistic in nature: "deterministic in that he believed future behavior inevitably results from past learning, and "reductionistic" in that he attributed complex processes to simple formulas involving a stimulus and a response.

"Ockham's razor," also called the law of parsimony, is a problem-solving principle credited to William of Ockham, an English Franciscan Friar who lived in the 14th century. Ockham's razor is generally stated as follows—

"No more things should be presumed to exist than are absolutely necessary; that is, the fewer assumptions an explanation of a phenomenon depends on, the better the explanation."

The law of parsimony was a guiding principle for the behaviorists. Skinner's behaviorism was impressive yet earned its own share of criticism and, ultimately, did not prove to affect a greater impact on health care than the psychoanalysts.

While these two overlaying forces worked hard to capture the imagination, the narratives, and the funds of the field for the first half of the twentieth century, a third force—humble, yet bold; diplomatic, yet revolutionary—turned the tide of history.

The Third Force in Modern Psychology

Young Carl Rogers found himself new to the field in the 1920's as a psychotherapist working with children and families at the Rochester Society for Prevention of Cruelty to Children in Rochester, New York. At that time, generally, such clinics gave advice to families upon interpreting the dynamics in the family affecting the child. Rogers found these practices ineffective and wished, in his own work, to eliminate interpretation and advice and achieve a therapy approach that honored the autonomy and individuality of each child and family and that would be rooted in warmth, acceptance, and empathy.

Rogers work with families was effective, and he found that opportunities to teach his approach were growing each year. By 1940, his methods were well established—known initially as "non-directive therapy" and later "person-centered" and "client-centered"—and he moved on to Ohio State University where he had opportunity in an academic realm to develop in grand specificity the core elements of a "client-centered therapy."

Rogers' approach, in contrast to psychoanalysis or behaviorism, was more experiential and emotion-focused in nature, with treatment not focusing on the past or on causes. It was unstructured like psychoanalysis but also non-directive, driven by empathy rather than by methodology, with the therapist as facilitator rather than expert, and the efficacy of the therapeutic relationship the crux of research rather than that of interpretation, advice, or targeted behavior modification through external conditioning.

Rogers hadn't stayed at Ohio State long before moving onto the University of Chicago where he founded a counseling center where groundbreaking research was conducted that focused on the processes of change in therapy. Here Rogers was the first in the field, by twenty years, to analyze every sentence of hundreds of transcripts of sessions with clients using objective outcome metrics, research which is now common.

It was in Chicago that Rogers, in 1957, published his famous formulation of six conditions he considered necessary and sufficient to bring about client change. Rogers' goal was for psychotherapy to move clients from being more out of touch with their emotions and more rigidly organized to being increasingly open and adaptable (Elliott, 2010). Some in the field developed models explicitly derived from Rogers theory, and others developed theories beyond the bounds of a strictly empathy-oriented framework, yet the entire field has been indelibly marked by Rogers' revolution.

Rogers was the first to introduce the term "client" as an alternative to the term otherwise universally used in the field, "patient." Rogers intention was to shift psychotherapists away from language that implied a person in therapy was a subject with an illness to be cured rather than a person with the agency to engage in self-change. In an era of "client" as consumer, the person in therapy gained in both respect and responsibility.

In Chicago, he required clients' permission to record sessions and devised procedural policies for releases and disclosures related to client records and privacy. His ethic is now accepted as the norm, but at the time it was new. Professional ethics then mostly meant a doctor’s duty to protect other doctors.

Rogers was proactive in ensuring that the under-served—blacks, women, gays, and others found help at his counseling center and worked innovatively to teach and coach his therapists to develop competence and understanding in their practices as they worked with those who came from different cultures, beliefs, and lifestyles.

Rogers was lauded among his students in Chicago for "[publishing] transcripts of a case of his own that was a failure. In the intern group he would play tapes of model interviews, but sometimes he would bring a bad one, saying, 'I don't know what's going wrong here.' The students could hear a great deal going wrong, and it made them feel free to present their own bad interviews" (Gendlin, 2002).

To be clear, Carl Rogers was actively shaping new standards of psychotherapy practice, supervision, and research, many which have stood the test of time.

Person-Centered Mental Health Care for the 21st Century

Abraham Maslow called the humanistic psychology movement that he and Rogers led "the third force" of modern psychology, a title well-earned and broadly accepted and celebrated to this day. The reality, beyond that, is that the entire field of psychotherapy was radically reshaped under the tutelage of Carl Rogers, who provided a vision for a reformation, challenged conventions, engaged in qualitative research never before tried in the field, and inspired multiple generations who are now leading the front.

Twenty-nine Practice Transformation Networks across the U.S. are right now actively and collaboratively innovating new advanced value-based payment models with pay structures that will incentivize smarter use of health care dollars, rewarding positive outcomes on key indicators and penalizing negligence of client/patient care on one extreme and waste on the other, providing opportunities for both shared savings and shared risk. These health care transformation initiatives are leveraging public-private partnerships to innovate cross-system contract and payment redesigns that will provide for clever upstream systemic integrations between primary and specialty medical care and psychiatric, psychotherapeutic, and substance use treatment services.

Downstream, innovative system redesigns such as client/patient-centered community health care data hubs, patient-centered health care medical home models, and vastly improved cross-silo provider-to-provider referral pathways are just a few examples of systemic transformations aimed at putting client/patient dollars more efficiently at work and placing them in the center of their local and regional health care communities rather than forcing our clients and patients to accommodate to largely fragmented and difficult-to-navigate systems where no one is in the center of anything.

Such changes optimize opportunities to best serve primary care consumers by, for instance, collaborative hub-based networks which better track and ensure evidence-based milestones that include increased well-child visits, immunizations, asthma management, and decreased unnecessary emergency room visits, while optimizing opportunities for communities to better serve those consumers who are severely and persistently mentally ill through strategic partnerships with better collaboration, shared data, and conjoint efforts which eliminate barriers to care and unnecessary complexity.

Clever and innovative redesigns will embed systemic incentives to closing gaps in rural service delivery, facilitate community alliances who anticipate local and regional needs, and increase community accountability while reducing unnecessary regulatory hurdles. New models acknowledge "whole person health" through health care innovations never before tried on a large scale. In the end, both clients/patients as well as health care providers will have opportunities to achieve significant and meaningful gains.

As SAMHSA has worked to guide legislators and practitioners over this past decade toward a recovery oriented system of care, one that supports the development of whole health and person-centered health care, I don't know to what extent those involved have been aware of early trailblazers that made such possibilities possible, but as I participate in health care transformation efforts here in Washington state, as a psychotherapist, it is clear to me that we are standing on the shoulders of giants like Carl Rogers.

We can look back over the 20th century and see that an obvious and radical transformation took place in the field of mental health. Clearly, the field of medicine has also undergone incredible leaps of innovation as well. What changes will the 21st century bring? Reforms prevailing, the health care system will look very different than it did only a few years ago by the time the Affordable Care Act is fully implemented. As we all now are well aware, full implementation has yet to be seen, and a new presidential administration may orchestrate another massive overhaul. Regardless, Nathan Johnson, Chief Policy Officer for Washington state's Health Care Authority, has made it clear that my state is committed to robust integrative health care transformation.

Whatever lies ahead, this is an exciting time for psychotherapists and other behavioral health professionals and, indeed, the entire field of health care. What is your vision for the future evolution of mental health care? Integrated health care? What barriers and problems do you anticipate for those who continue to forge large scale transformation? If the ACA is repealed, what ways might health care take steps backward in its "person-centered" trajectory? What positive opportunities might a repeal offer?

As health care transformation efforts forge ahead, I am encouraged by the resolve and ingenuity of those committed to see it through. Although in the midst of the grind the work can feel tedious and slow-going, a historical perspective reminds us that the change that occurs over time often surpasses expectation. Therefore, let us not entertain fear or cynicism but be bold, ask difficult questions, work together, and remember that whatever form it takes, a transformed system must be fundamentally person-centered.

Blake Griffin Edwards is a Behavioral Health Champion for the American Academy of Pediatrics' Transforming Clinical Practices Initiative in Washington state, a licensed marriage and family therapist, clinical fellow in the American Association for Marriage and Family Therapy, and clinical supervisor. His writing has been featured at GoodTherapy.org and PsychCentral.com as well as in Family Therapy Magazine, Context, and Voices Journal.

References

Center for Substance Abuse Treatment. 2005. National Summit on Recovery: Conference report (2005). DHHS Publication No. (SMA) 07-4276. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Elliott, R. [The Counselling Channel]. (2010, March 4). Understanding approaches: Person centred and process experiential emotion focused therapy (1 of 2) [Video File]. Retrieved from https://www.youtube.com/watch?v=eginkO443G8.

Gendlin, E.T. (2002). Foreword. Carl Rogers: The quiet revolutionary, an oral history. Roseville, CA: Penmarin Books.

Johnson, N. (2017, January). Healthier Washington: How the pieces fit together. Opening session at the North Central Accountable Community of Health Whole Person Care Workshop, Chelan, Washington.

Monroe, D. (2015, February). Asylum: Inside Central State Hospital, once the world's largest mental institution. Atlanta Magazine.

Power, K. (2009). A public health model of mental health for the 21st century. Psychiatric Services (60) 5, 580-584.

Power, K. (2009). A vision for a mentally healthy America. Washington, DC: SAMHSA Public Dissemination Event for Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities.

Rogers, C.R. (1957, April). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), pp. 95-103.

Sheedy, C.K., & Whitter, M. (2009). Guiding principles and elements of recovery-oriented systems of care: What do we know from the research? HHS Publication No. (SMA) 09-4439. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.