Major Trends

The years since 1991, when the first A Shared Vision: The Alaska Mental Health Strategic Plan for the 90s was begun, have been marked by significant changes in the national and state mental health service delivery systems. Nationally, and in Alaska, state hospitals have been reorganized and downsized. In 1991 the bed capacity of the Alaska Psychiatric Institute (API), Alaska's only state mental health hospital, was 160. In 1997, the bed capacity was 79. The theory of downsized hospitals is that savings will be reinvested in community services. In most states, these savings have not gone to support community based care.

Nationally, many states are engaging in planning for or implementing privatization of some aspect of their state operated mental health system. In Alaska private enterprise has begun to take on more components of mental health care services. Though the system is still largely public and non-profit, there has been planning and implementation for greater use of community hospitals for in-patient psychiatric services.

While Alaska labored under the difficulty of resolving the Mental Health Trust Lands Litigation, settled in 1994, half the United States' mental health agencies were involved in class action lawsuits regarding mental health services. In Alaska, the changes brought about by the legal settlement include a reorganization of the planning, budgeting and advocacy board structure and some additional funds into services. For many, there has also been a realization that significant additional funds for mental health services will not be forthcoming, but that there is a possibility of reorganizing service delivery to be more comprehensive and integrated.

Some of the biggest changes in national mental health services go under the heading of "managed care." This heading covers many fundamental system changes, some of which are beginning to be experienced in Alaska. The last decade of the 20th century has seen the commodification of mental health. Mental health services have gone from being a public health concern, largely provided by public mental health agencies, to a commodity that is sold to the lowest bidder through managed care contracts. The emergence of managed care in the public mental health system has raised ethical issues for states, including how to deal with the implicit incentives to underutilize treatment, fiduciary responsibility, and whether to reinvest savings into the mental health system.

The closing years of the decade have seen an increased focus on children's mental health services. National studies have shown the significant underfunding of children's services and the resultant poor quality of care. Alaska has focused attention on the need for greater access to mental health services for children and the need for more effective early intervention. The strategies developed to focus on these needs highlight cross agency collaboration efforts as a means to increase efficiency in service delivery and to treat the children and youth holistically.

The decade of the 90s has seen the welfare reform revolution. This rubric covers broad shifts in public expectations about social and personal responsibility. Many people who have disabilities have found their "entitlement" disappear, while their disabilities which keep them from working have not. Those who continue to receive public benefits receive them in an environment that sometimes appears hostile or lacking in compassion for those whose lives are shattered by psychiatric disabilities.

Criminalization of the mentally ill has become a significant national concern in the last decade. Jails and prisons throughout the states have seen an increase in the number of people with psychiatric disorders who are sentenced to time in correctional facilities. Jails in all states are used too frequently as holding centers when community based mental health care is unavailable or non existent. Alaska, due to the Cleary class action settlement, began to focus attention on this problem earlier than many other states. However, we have been slow to find solutions to this situation and a significant number of mental health consumers find themselves in Alaska's correctional facilities when appropriate community care may have prevented this criminalization.

Among the most welcome changes in mental health services nationally and in Alaska since 1991 has been the growth of the consumer movement. The consumer movement has focused on the need for consumers and their families to be more involved in mental health services from the policy level to the treatment plan level. Alaska has encouraged consumers/families to participate at all levels of policy development, planning and service delivery and we look forward to expansion of this trend in the next decade. Another new focus of the consumer movement has been the "recovery movement"--a shift in our perceptions about psychiatric disorders to emphasize the extent to which people may recover from these illnesses, especially with the support and modeling of others who have had similar experiences. The media has reflected this theme with many new books by people who have recovered from mental illnesses. And public figures can now be heard discussing their own or family members' struggles with psychiatric disorders. This openness is a tribute to the efforts of the consumer movement.

The consumer movement, along with federal imperatives, have required states to develop "outcomes" approaches to measuring the effectiveness of mental health services. This has meant not only "consumer satisfaction" measures, but also the development by many states of "report cards" and other measures of the impact of public mental health services on the conditions and well being of consumers. Alaska has been part of this effort to shift attention away from such measures as the numbers of treatment sessions to measurable changes in quality of life and the functional level of those who experience psychiatric disorders.

Since 1991, the Alaska Mental Health Board (AMHB) has used its mental health services planning process to bring together the various mental health system stakeholders to achieve consensus on the needed direction and priorities for the development of mental health services in Alaska. The first plan, A Shared Vision: The Alaska Mental Health Strategic Plan for the 90s has been used by the Board for determining policy and planning initiatives, as well as budget priorities. System stakeholders have used it for a variety of service planning and funding strategies.

The Alaska Mental Health Board started the development of a plan to replace the first A Shared Vision in 1996. When the Board recognized the need for a new consensus on system direction in 1997, the Board identified the "guiding principles" to be used in the development of the plan and those "system stakeholders" whose efforts and concerns needed to be part of the planning process. This group met in Anchorage in March 1997 to identify issues and goals for Alaska's mental health system over the next few years. Subsequently, the group broke into Action Teams to which other stakeholders were added. The teams were: Children's Services Action Team, Rural Action Team, and Adult Services Action Team which formed two additional sub-groups, Forensic Services Action Team and Senior Services Action Team. The Teams met over the next nine months, producing a first draft in December, 1997. The AMHB arranged many opportunities for public response. The last, an "open telephone" time, was held on June 3, 1998.