Skip to main content
Log in

A Systemic and Value-Based Approach to Strategic Reform of the Mental Health System

  • Published:
Health Care Analysis Aims and scope Submit manuscript

Abstract

Most writers now recognize that mental health policy and the mental health system are extremely resistant to real changes that reflect genuine biopsychosocial paradigms of mental disorder. Writers bemoaning the intransigence of the mental health system tend to focus on a small analytical level, only to find themselves mired in the rationalities of the existing system. Problems are acknowledged to be system-wide, yet few writers have used a method of analysis appropriate for systemic problems. Drawing upon the General System Theory (GST) analytical perspective, this article advances a systematic approach to understand the mental health system and to facilitate the development of reform strategies that recognize the system's complexity and changing nature. The article first discusses the failure of major reform efforts in the mental health system and the limitations of mainstream analysis of mental health politics and policies with respect to the objectives of analysis and reform. This article describes how systems thinking has thus far influenced the study of the mental health policy and politics system, and argues that a systemic perspective is profitable for reconceiving the mental health system, enabling a fresh basis for the development of reform strategies. The mental health system should be seen as a social system influenced by larger political and economic dimensions, not just as a 'delivery system' scientifically constructed by neutral experts. Furthermore, the policy planning process should be viewed as part and parcel of a mental health system modeled as complex and dynamic. The systemic perspective outlined here should help both to clarify the value-based objectives that we hold for the system and, consequently, to plan for the strategic reforms that have so far eluded us.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • Ackoff, R.L. (1974) The Systems Revolution. Long Range Planning 7, 2–20.

    Article  Google Scholar 

  • Appelbaum, P.S. (1997) Almost a Revolution: An International Perspective on the Law of Involuntary Commitment. Journal of the American Academy of Psychiatry and Law 25, 135–147.

    CAS  Google Scholar 

  • Austin, C.D. (1993) Case Management: A Systems Perspective. Families in Society: The Journal of Contemporary Human Services 74, 451–459.

    Google Scholar 

  • Bahg, C.-G. (1990) Major Systems Theories throughout the World. Behavioral Science 35, 79–107.

    Google Scholar 

  • Bassman, R. (1997) The Mental Health System: Experiences from Both Sides of the Locked Doors. Professional Psychology: Research and Practice 28, 238–242.

    Article  Google Scholar 

  • Bateson, G. (1972) Steps to an Ecology of Mind. New York: Ballantine.

    Google Scholar 

  • Becker, F.W. (1993) The Politics of Closing State Mental Hospitals: A Case of Increasing Policy Gridlock. Community Mental Health Journal 29, 103–114.

    Article  PubMed  CAS  Google Scholar 

  • Bernstein, A. and Lennard, H.L. (1973) The American Way of Drugging: Drugs, Doctors and Junkies. Society 10(3), 14–25.

    PubMed  Google Scholar 

  • Bertalanffy, L. von. (1968) General System Theory: Foundations, Development, Applications. New York: Braziller.

    Google Scholar 

  • Bertalanffy, L. von. (1981) A Systems View ofMan. Boulder: Westview.

    Google Scholar 

  • Black, B.L. (1986) Institutional Context and Strategy: A Framework for the Analysis of Mental Health Policy. In W.R. Scott and B.L. Black (Eds.), The Organization of Mental Health Services: Societal and Community Systems (pp. 233–276). Beverly Hills: Sage.

    Google Scholar 

  • Bloche, M.G. and Cournos, F. (1990) Mental Health Policy for the 1990s: Tinkering in the Interstices. Journal of Health Politics, Policy and Law 15, 387–411.

    PubMed  CAS  Google Scholar 

  • Boguslaw, R. (1979) Crisis in Social Science? Postpositivism and the Dilemmas of Social Planning. Society 16(5), 40–44.

    Google Scholar 

  • Bowler, T.D. (1981) General Systems Thinking: Its Scope and Applicability. New York: North Holland.

    Google Scholar 

  • Breggin, P.R. (1997) Brain-Disabling Treatments in Psychiatry: Drugs, Electroshock and the Role of the FDA. New York: Springer.

    Google Scholar 

  • Brown, P. (1984) The Right to Refuse Treatment and theMovement for Mental Health Reform. Journal of Health Politics, Policy and Law 9, 291–313.

    PubMed  CAS  Google Scholar 

  • Buckley, W. (1967) Sociology and Modern Systems Theory. Eaglewood Cliffs, New Jersey: Prentice-Hall.

    Google Scholar 

  • Campbell, J. (1982) Grammatical Man: Information, Entropy, Language, and Life. NewYork: Simon & Schuster.

    Google Scholar 

  • Capra, F. (1990) Life as a Mental Process. Quest: A Quarterly Journal of Philosophy, Science, Religion & the Arts (Summer), 7–10.

  • Casey, P., Keilitz, I. and Hafemeister, T.L. (1992) Toward an Agenda for Reform of Justice and Mental Health Systems Interactions. Law and Human Behavior 16, 107–128.

    Article  Google Scholar 

  • Charles, C. and DeMaio, S. (1993) Lay Participation in Health Care Decision Making: A Conceptual Framework. Journal of Health Politics, Policy and Law 18, 881–904.

    PubMed  CAS  Google Scholar 

  • Charlton, M. (1991) Controversial Decision Making - The Public Inquiry and Systems Thinking. In S.C. Holmberg and K. Samuelson (Eds.), Systems Science in the 21st Century: Integrating the New Sciences of Complexity in Service of Humans and Their Environment. Volume II: Advances in General Systems Theory and Philosophy (pp. 27–33). Östersund, Sweden: Östersund University.

    Google Scholar 

  • Cohen, C.I. (1997) The Political and Moral Economy of Mental Health. Psychiatric Services 48, 768–774.

    PubMed  CAS  Google Scholar 

  • Cohen, D. (1988) Social Work and Psychotropic Drug Treatments. Social Service Review 62, 576–599.

    Article  Google Scholar 

  • Cohen, D. (1994) Quelles sont les conséquences sociales et psychologiques en terme de qualité de vie des neuroleptiques et de leurs effets secondaires? In Conférence de consensus: Stratégies thérapeutiques à long terme dans les psychoses schizophréniques. Textes des experts (pp. 149–184). Paris: Frison-Roche.

    Google Scholar 

  • Cohen, D. (1997) A Critique of the Use of Neuroleptic Drugs in Psychiatry. In S. Fisher and R.P. Greenberg (Eds.), From Placebo to Panacea: Putting Psychiatric Drugs to the Test. New York: Wiley.

    Google Scholar 

  • Cohen, D. and McCubbin, M. (1990) The Political Economy of Tardive Dyskinesia: Asymmetries in Power and Responsibility. Journal of Mind and Behavior 11, 465–488.

    Google Scholar 

  • Crozier, M., and Friedberg, E. (1977) L'acteur et le système. Paris: Seuil.

    Google Scholar 

  • Davidson, L., Hoge, M.A., Godleski, L., Rakfeldt, J. and Griffith, E.E.H. (1996) Hospital or Community Living? Examining Consumer Perspectives on Deinstitutionalization. Psychiatric Rehabilitation Journal 19(3), 49–58.

    Google Scholar 

  • DeLeon, P. (1994) Democracy and the Policy Sciences: Aspirations and Operations. Policy Studies Journal 22, 200–212.

    Article  Google Scholar 

  • Dobuzinskis, L. (1992) Modernist and Postmodernist Metaphors of the Policy Process: Control and Stability vs. Chaos and Reflexive Understanding. Policy Sciences 25, 355–380.

    Google Scholar 

  • Dorvil, H. (1997) Reform and Reshaping Mental Health Services in the Montreal Area. International Journal of Social Psychiatry 43, 164–174.

    PubMed  CAS  Google Scholar 

  • Emanuel, E.J. and Emanuel, L.L. (1997) Preserving Community in Health Care. Journal of Health Politics, Policy and Law 22, 147–184.

    PubMed  CAS  Google Scholar 

  • Evans, R.G. and Stoddart, G.L. (1990) Producing Health, Consuming Health Care. Social Science & Medicine 31, 1347–1363.

    Article  CAS  Google Scholar 

  • Fineman, N. (1991) The Social Construction of Noncompliance: A Study of Health Care and Social Service Providers in Everyday Practice. Sociology of Health & Illness 13, 354–374.

    Article  Google Scholar 

  • Fisette, J. (1986) Les fondements pragmatiques de la planification. Revue internationale d'action communautaire 15, 55–64.

    Google Scholar 

  • Flaskas, C. (1994) Postmodernism, Constructionism and the Idea of Reality: A Contribution to the 'ism' Discussions. Australia and New Zealand Journal of Family Therapy 16, 143–146.

    Google Scholar 

  • Foley, H.A. and Sharfstein, S.S. (1983) Madness and Government: Who Cares for the Mentally Ill?. Washington: American Psychiatric Press.

    Google Scholar 

  • Fontaine D. (1997) Repères pour une modélisation systémique des programmes de santé: Approach for a Systemic Modelling of Health Programmes. Social Science & Medicine 44, 503–517.

    Article  CAS  Google Scholar 

  • Forester, J. (1995) Toward a Critical Sociology of Policy Analysis. Policy Sciences 28, 385–396.

    Article  Google Scholar 

  • Gilbert, P. (1995) Biopsychosocial Approaches and Evolutionary Theory as Aids to Integration in Clinical Psychology and Psychotherapy. Clinical Psychology and Psychotherapy 2, 135–156.

    Article  Google Scholar 

  • Gleick, J. (1988) Chaos: Making a New Science. New York: Penguin.

    Google Scholar 

  • Hagan, T. and Smail, D. (1997) Power-Mapping - I. Background and Basic Methodology. Journal of Community & Applied Social Psychology 7, 257–267.

    Article  Google Scholar 

  • Hegarty, J., Baldessarini, R.J., Tohen, M., Waternaux, C. and Oepen, G. (1994) One Hundred Years of Schizophrenia: A Meta-Analysis of the Outcome Literature. American Journal of Psychiatry 151, 1409–1416.

    PubMed  CAS  Google Scholar 

  • Hollingsworth, E.J. (1992) Falling Through the Cracks: Care of the Chronically Mentally Ill in the United States, Germany, and the United Kingdom. Journal of Health Politics, Policy and Law 17, 899–928.

    PubMed  CAS  Google Scholar 

  • Hollingsworth, E.J. (1996) Mental Health Services in England: The 1990s. International Journal of Law and Psychiatry 19, 309–325.

    Article  PubMed  CAS  Google Scholar 

  • Holstein, J.A. (1993) Court Ordered Insanity: Interpretive Practice and Involuntary Commitment. New York: de Gruyter.

    Google Scholar 

  • Ingleby, D. (1985) Mental Health and Social Order. In S. Cohen and A. Scull (Eds.), Social Control and the State (pp. 141–188). Oxford: Blackwell.

    Google Scholar 

  • Isaac, R.J. and Armat, V.C. (1991) Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill. New York: Free Press.

    Google Scholar 

  • Jennings, A. (1994) On Being Invisible in theMental Health System. Journal of Mental Health Administration 21, 374–387.

    PubMed  CAS  Google Scholar 

  • Juba, D.W. (1997) A Systems Perspective on the Introduction of Narrative Practice in Human Services Organizations in the Era of Managed Care. Contemporary Family Therapy 19, 177–193.

    Article  Google Scholar 

  • Keen, E. (1997) Psychiatric Power and Levels of Concealment. Journal of Constructivist Psychology 10, 125–137.

    Google Scholar 

  • Kiesler, C.A. (1992) U.S. Mental Health Policy: Doomed to Fail. American Psychologist 47, 1077–1082.

    Article  PubMed  CAS  Google Scholar 

  • Lane, D.C. and Jackson, M.C. (1995) Only Connect! An Annotated Bibliography Reflecting the Breadth and Diversity of Systems Thinking. Systems Research 12, 217–228.

    Google Scholar 

  • Larner, G. (1995) The Real as Illusion: Deconstructing Power in Family Therapy. Journal of Family Therapy 17, 191–217.

    Article  Google Scholar 

  • Mack, J.E. (1994) Power, Powerlessness, and Empowerment in Psychotherapy. Psychiatry 57, 178–198.

    PubMed  CAS  Google Scholar 

  • McCubbin, M. (1994a) Deinstitutionalization: The Illusion of Disillusion. Journal of Mind and Behavior 15, 35–53.

    Google Scholar 

  • McCubbin, M. (1994b) A Systems Theory Perspective of Mental Health Services and Policy Formation. Groupe de recherche sur les aspects sociaux de la santé et de la prévention, Université de Montréal, unpublished monograph.

  • McCubbin, M. (1997a) Population Health: A Call for Breadth (Mental Health) and Depth (Psychosocial Theory). Groupe de recherche sur les aspects sociaux de la santé et de la prévention, Université de Montréal, GRASP Working Papers, 3. Presented to X International Congress of the International Association of Health Policy, Perugia, Italy, Sept. 1998.

  • McCubbin, M. (1997b) Free Will, Rationality, and Teleological Explanation. Groupe de recherche sur les aspects sociaux de la santé et de la prévention, Université de Montréal, GRASP Working Papers, 12.

  • McCubbin, M. (1998a) General System Theory as a Postmodern Epistemology for the Social Sciences. Groupe de recherche sur les aspects sociaux de la santé et de la prévention, Université de Montréal, GRASP Working Papers, 21.

  • McCubbin, M. (1998b) Global Anarchy: Market Failure, the Prisoners' Dilemma, and Sovereignty over Health and Social Policy. Presented to X International Conference of the International Association of Health Policy, Perugia, Italy, Sept.

  • McCubbin, M. and Cohen, D. (1996) Extremely Unbalanced: Interest Divergence and Power Disparities between Clients and Psychiatry. International Journal of Law and Psychiatry 19, 1–25.

    Article  PubMed  CAS  Google Scholar 

  • McCubbin, M. and Cohen, D. (1998) Les droits des usagers de services en santé mentale: Le noeud étroit du pouvoir, de la loi et de l'éthique, Santé mentale au Québec 23, 212–224.

    PubMed  CAS  Google Scholar 

  • McCubbin, M. and Weisstub, D.N. (1998) ”Meeting the Needs of the Mentally Ill”: A Case Study of the “Right to Treatment” as Legal Rights Discourse in the U.S.A. Groupe de recherche sur les aspects sociaux de la santé et de la prévention, Université de Montréal, GRASP Working Papers, 20. Presented to XXIInd International Congress on Law and Mental Health. Paris, July.

  • McLean, A. (1995) Empowerment and the Psychiatric Consumer/Ex-Patient Movement in the United States: Contradictions, Crisis and Change. Social Science & Medicine 40, 1053–1071.

    Article  CAS  Google Scholar 

  • Mechanic, D. (1996) Technologies for the Delivery of Mental Health Care. International Journal of Technology Assessment in Health Care 12, 673–687.

    Article  PubMed  CAS  Google Scholar 

  • Meyer, J.W. (1985) Institutional and Organizational Rationalization in the Mental Health System. American Behavioral Scientist 28, 587–600.

    Google Scholar 

  • Miedema, B. (1994) Control or Treatment? Experiences of People who have been Psychiatrically Hospitalized in New Brunswick. Canadian Journal of Community Mental Health 13, 111–122.

    PubMed  CAS  Google Scholar 

  • Milewa, T., Valentine, J. and Calnan, M. (1998) Managerialism and Active Citizenship in Britain's Reformed Health Service: Power and Community in an Era of Decentralisation. Social Science and Medicine 47, 507–517.

    Article  PubMed  CAS  Google Scholar 

  • Morin, E. (1990) Introduction à la pensée complexe. Paris: ESF Éditeur.

    Google Scholar 

  • Mossman, D. (1997) Deinstitutionalization, Homelessness, and the Myth of Psychiatric Abandonment: A Structural Anthropology Perspective. Social Science & Medicine 44, 71–83.

    Article  Google Scholar 

  • Motloch, J.L. and Woodfin, T. (1993) General Systems Theory, Cultural Change, and a Human Science Foundation for Planning and Design. Systems Research 10, 3–25.

    Google Scholar 

  • Popay, J. and Williams, G. (1998) Partnership in Health: Beyond the Rhetoric. Journal of Epidemiology and Community Health 52, 410–411.

    Article  PubMed  CAS  Google Scholar 

  • Prilleltensky, I. (1997) Values, Assumptions, and Practices: Assessing the Moral Implications of Psychological Discourse and Action. American Psychologist 52, 517–535.

    Article  PubMed  Google Scholar 

  • Prilleltensky, I. and Gonick, L. (1996) Polities Change, Oppression Remains: On the Psychology and Politics of Oppression. Political Psychology 17, 127–148.

    Google Scholar 

  • Reed, S.C. and Lewis, D.A. (1990) The Negotiation of Voluntary Admission in Chicago's State Mental Hospitals. Journal of Psychiatry & Law 18(1), 137–163.

    Google Scholar 

  • Rochefort, D.A. (1984) Origins of the 'Third Psychiatric Revolution': The Community Mental Health Centers Act of 1963. Journal of Health Politics, Policy and Law 9, 1–30.

    PubMed  CAS  Google Scholar 

  • Rochefort, D.A. (1988) Policymaking Cycles in Mental Health: Critical Examination of a Conceptual Model. Journal of Health Politics, Policy and Law 13, 129–152.

    PubMed  CAS  Google Scholar 

  • Scott, W.R. (1985) Systems within Systems: The Mental Health Sector. American Behavioral Scientist 28, 601–618.

    Google Scholar 

  • Scott, W.R. (1987) The Adolescence of Institutional Theory. Administrative Science Quarterly 32, 493–511.

    Article  Google Scholar 

  • Scott, W.R. and Black, B.L. (Eds.) (1986) The Organization of Mental Health Services: Societal and Community Systems. Beverly Hills: Sage.

    Google Scholar 

  • Shakun, M.F. (1981a) Formalizing Conflict Resolution in Policy Making. International Journal of General Systems 7, 207–215.

    Google Scholar 

  • Shakun, M.F. (1981b) Policy Making and Meaning as Design of Purposeful Systems. International Journal of General Systems 7, 235–251.

    Google Scholar 

  • Skyttner, L. (1996) General Systems Theory: Origin and Hallmarks. Kybernetes 25, 16–22.

    Google Scholar 

  • Smith, R.W. (1973) A Theoretical Basis for Participatory Planning. Policy Sciences 4, 275–295.

    Article  Google Scholar 

  • Strijbos, S. (1994) The Individual and the Collective in Health Care: A Problem of Systems Ethics. Systems Research 11, 67–75.

    PubMed  CAS  Google Scholar 

  • Sutherland, J.W. (1973) A General Systems Philosophy for the Social and Behavioral Sciences. New York: Braziller.

    Google Scholar 

  • Swift, C. and Levin, G. (1987) Empowerment: An Emerging Mental Health Technology. Journal of Primary Prevention 8, 71–94.

    Article  Google Scholar 

  • Thompson, D.J.C. (1977) The Systems Model of Policy-Making and the National Health Service. Political Studies 25, 397–403.

    Google Scholar 

  • Thompson, J.W. (1994) Trends in the Development of Psychiatric Services, 1844- 1994. Hospital and Community Psychiatry 45, 987–992.

    PubMed  CAS  Google Scholar 

  • Torrey, E.F. (1997) Out of the Shadows: Confronting America's Mental Illness Crisis. New York: Wiley.

    Google Scholar 

  • Twaddle, A.C. (1996) Health System Reforms - Toward a Framework for International Comparisons. Social Science and Medicine 43, 637–654 (errata 43[10], III- IV)

    Article  PubMed  CAS  Google Scholar 

  • Tyhurst, J.S., Chalke, F.C.R., Lawson, F.S., McNeel, B.H., Roberts, C.A., Taylor, G.C., Weil, R.J. and Griffin, J.D. (1963) More for the Mind: A Study of Psychiatric Services in Canada. Toronto: Canadian Mental Health Association.

    Google Scholar 

  • Upshur, C.C., Benson, P.R., Clemens, E., Fisher, W.H., Leff, H.S. and Schutt, R. (1997) Closing State Mental Hospitals in Massachusetts: Policy, Process, and Impact. International Journal of Law and Psychiatry 20, 199–217.

    Article  PubMed  CAS  Google Scholar 

  • Wainwright, D. (1996) The Political Transformation of the Health Inequalities Debate. Critical Social Policy 49, 67–82.

    Google Scholar 

  • Wald, P.M. and Friedman, P.R. (1978) The Politics of Mental Health Advocacy in the United States. International Journal of Law and Psychiatry 1, 137–152.

    Article  PubMed  CAS  Google Scholar 

  • Wells, J.S.G. (1997) Priorities, 'street Level Bureaucracy' and the Community Mental Health Team. Health and Social Care in the Community 5, 333–342.

    Article  Google Scholar 

  • Winick, B.J. (1994) The Right to Refuse Mental Health Treatment: A Therapeutic Jurisprudence Analysis. International Journal of Law and Psychiatry 17, 99–117.

    Article  PubMed  CAS  Google Scholar 

  • Ziegenfuss Jr, J.T. (1983) Patients' Rights and Organizational Models: Sociotechnical Systems Research on Mental Health Programs. Washington: University Press of America.

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

McCubbin, M., Cohen, D. A Systemic and Value-Based Approach to Strategic Reform of the Mental Health System. Health Care Analysis 7, 57–77 (1999). https://doi.org/10.1023/A:1009443902415

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1023/A:1009443902415

Navigation