Mental illness is one of the most serious public health problems in the United States. Approximately 19 percent of the population suffers from some form of mental disorder ranging from phobias, to personality problems and stress-related conditions, to major illnesses like schizophrenia and manic depressive disease.
Although diagnostic classifications, causal theories, and treatment methods have changed over the centuries, mental illness seems to have been a constant feature of humankind's presence on earth. Society no longer considers psychotic people to be possessed by demons or able to endure torture without feeling pain; nor does it condone lifelong incarceration of people with mental illness in human warehouses. Nevertheless, it would be a mistake to conclude as the final decade of the twentieth century opens that society has discovered the most effective way of caring for its mentally ill citizens or that the stigma attached to mental illness has been eliminated. The confusion and controversy that surround mental illness treatment (whose accepted euphemism is "mental health services"), together with society's failure to agree on the role that government should play in caring for mentally ill people, are among the leading contributors to the impossibility of the task of the state mental health commissioner. The commissioner has to achieve the unachievable and meet demands that cannot be met. The impossibility of the job arises not only from the nature of mental illness and limits in treatment technology but also from the unique political context in which the commissioner operates.
It would be difficult enough for a mental health commissioner to deal with the usual politics surrounding the allocation of roles and resources among state agencies and disputes about policies. The politics of mental illness, however, are charged with emotion. Parents of a young adult with recurring and seemingly intractable antisocial behavior are understandably frustrated and exasperated because the mental health agency has been unable to find a permanent solution to their problem. Local elected officials, concerned about safety, call state legislators to complain about a plan to move state hospital patients into a halfway house in a residential neighborhood. With equal vehemence, advocacy lawyers criticize the commissioner for denying other state hospital patients their freedom by not releasing them into the community. Dedicated proponents of a particular treatment ideology are moved to publicly demand the commissioner's resignation for a perceived lack of enthusiasm for their preferred approach. A newspaper armed with few facts launches a crusade to reform an allegedly archaic mental health system, blaming the commissioner for conditions the commissioner neither created nor condoned.
The emotions that activate the politics of mental illness are to some extent a product of the fear that everyone has of losing their mind or of encountering disabled mental functioning in a family member or close friend. The political world of the state mental health commissioner reveals that many people-even those well educated, including mental health professional themselves-are profoundly ambivalent in their attitudes toward the mentally ill. We are frightened by them and we seek distance and protection from them, yet we also feel compassion toward them and we urge sympathetic care and protection of them.
On Being Investigated
One of the least pleasant aspects of being commissioner is the almost constant scrutiny of the mental health agency by some type of oversight or investigating committee. The committees are usually created by governors or legislatures in response to a controversy that has reached the media. A committee's purpose ranges from learning more details about a problem in the agency, to eliciting information upon which to base changes in state law, to just satisfying the constituency of an elected official that something is being done about an issue. Even personnel matters can result in investigations. In Texas, for example, a legislative investigating committee was appointed in 1982 because legislators were unhappy about the dismissal of an institutional superintendent.
Commissioners know that it is impossible to run a large system of institutions and community programs without problems. There is always the possibility of physical or sexual abuse of patients by hospital personnel, improper psychiatric treatment of a patient, or misuse of state funds by an employee. Patients sometimes do commit suicide or injure other patients, even when all of the professionally accepted precautions have been taken. State mental health agencies employ a multiplicity of internal controls and other devices to reduce the likelihood of such occurrences. Among them are patient-rights and abuse committees, quality assurance and professional peer-review programs, internal audits of facilities, screening of new employees for criminal records, uniform training and orientation of all employees, written rules and regulations, toll-free hotlines for patient complaints, and so forth. Inevitably, however, in every state mental health system an incident occurs that leads to the appointment of an investigating committee. Although these committees and the public hearings through which they conduct their business are integral to a system of open government, they nevertheless have a vast potential for creating adverse publicity, damaging the credibility of the system, and possibly shortening the tenure of the commissioner in charge.
Even in the absence of controversy, mental health agencies are studied and reviewed by a variety of groups. Standing committees of the state house and senate typically oversee operations of the mental health agency. Sunset committees, a special challenge for the commissioner, are ostensibly concerned with determining whether a mental health agency should continue or be abolished, but they are usually more interested in restructuring the agency. At their invitation, professional organizations, consumer and advisory groups, and members of the general public testify about their views of how the state law that established the mental health agency should be changed. A commissioner who lives through the time-consuming and stressful ordeal of a sunset review may wind up with a very different agency and possibly a different kind of job.
Evaluating the Commissioner's Performance
How do we know if the commissioner has done a good job? In the private sector and even in some public agencies, it is relatively easy to measure the performance of the chief executive officer. For example, increases in revenues or profits or the introduction of successful new products are objective indicators that permit stockholders or the board of directors of a corporation to assess the achievements of its leader. On the other hand, in state mental health agencies there are few objective measures to evaluate the performance of the commissioner. In fact, there is not even agreement as to what constitutes success. A major new program is seen as a significant advance by some of the commissioner's constituents and as a dangerous or regressive step by others. Achievement of accreditation by all state hospitals, one of the few objective standards available, is useless in a state like Texas where this goal has already been reached.
Because of the lack of objective criteria to gauge a commissioner's performance, the commissioner tends to be judged not on accomplishments but on how he or she is viewed by other people. In the private sector an executive may not be especially well liked by company directors, peers, or employees, but if the executive is making a lot of money for the corporation, it is inclined to forgive the executive's unpopularity. In the case of the mental health agency, the commissioner's survival is almost entirely dependent on how the commissioner is regarded by key politicians and leaders of various constituency organizations.
There are numerous examples of commissioners who have significantly improved services to the mentally disabled (in our opinion) and yet were forced to leave for purely political reasons unrelated to job performance. Virtually any move in any direction by a commissioner elicits some degree of dissatisfaction from at least one constituency-for example, advocacy groups, parent organizations, labor unions, federal courts, legislators, the governor, and so forth. Therefore, a commissioner must be exceptionally skilled in negotiating, compromising, placating, and horse-trading just to stay in the job long enough to make a difference.
