Some state mental health agencies are independent while others are combined with social services, public assistance, public health, and rehabilitation agencies to form a comprehensive organization, often referred to as an umbrella agency. The mental health agency, whether independent or a division of an umbrella agency, may be concerned solely with services to the mentally ill. Alternatively, it may be charged also with responsibility for serving people with substance abuse disorders (alcohol and drugs); mental retardation; or mental retardation and other conditions (including autism, epilepsy, and cerebral palsy) collectively referred to as developmental disabilities. Of the fifty state mental health agencies, twenty-seven have additional responsibility for the state's mental retardation or developmental disabilities program and twenty for the state's substance abuse program. State mental hospitals are typically under the direct supervision of the state mental health commissioner, while CMHCs are usually operated by private not-for-profit organizations or local governmental units that negotiate contracts with or receive grants from the state mental health agency.
Some mental health commissioners are appointed by and report to the state's governor; others answer to a board of lay persons. The commissioner of a state mental health agency that is a part of an umbrella agency usually reports to the commissioner or secretary of the umbrella agency. In umbrella agencies that separate program services from line management, the mental health commissioner may lack real authority over mental health programs, instead serving mainly as an advisor or consultant to other executives in the agency who actually supervise the programs.
Although as recently as the late 1960s, every state mental health commissioner held a medical degree (and usually specialized in psychiatry), today's commissioners have diverse educational backgrounds. Academic credentials range from medical degrees with psychiatric specialization, to doctorates in psychology and a variety of other fields, to master's degrees in social work, health care, business, or public administration, to bachelor's degrees.
During the 1950s and 1960s the role of state mental health commissioner was relatively uncomplicated. Except for an occasional media expose, a commissioner could run the agency almost as if it were a private company, with little interference from outside forces. Few members of the general public were aware of what actually transpired in state mental hospitals. Although knowledgeable legislators knew of the dilapidated condition of some of these institutions and the generally inadequate staffing and funding, commissioners were seldom blamed for these conditions, required to explain their actions, or asked to justify publicly their budgetary and programmatic decisions. Few advocacy or consumer organizations had sufficient visibility and clout to pressure the commissioner to demand additional funds from the legislature or to modify some policy or practice in the mental health system. The era of class-action litigation against state mental health agencies did not begin until 1972, when the Wyatt v. Stickney decision in Alabama resulted in massive changes in state institutions pursuant to a judicially determined "right to treatment."
Budgets were usually organized by line items with specific dollar amounts appropriated for each state hospital and the agency central office. Almost all of the money came from state appropriations; federal funding was limited to relatively small formula grants under the Comprehensive Health Planning Act, hospital improvement project grants (of up to $100,000 per hospital), and, beginning in 1963, CMHC grants provided directly to the community centers. Although the federal Medicare (Title 13) and Medicaid (Title 19) programs were initiated in 1965, use of Medicaid for adults ages twenty-one through sixty-five in state mental hospitals was prohibited by federal law. The Medicaid intermediate care facility-mental retardation program (ICF-MR), which contributed significantly to the financing of state institutions for the mentally retarded, did not begin until 1974.
In this period, it was still neither required nor expected by the public, governors, or legislatures that state mental health agencies have the sophisticated fiscal management capability now considered essential. Peer review, quality assurance, and patient-rights protection systems were not yet obligatory in state mental hospitals or state mental health agencies. Since mental health agencies were less complex and demanding, commissioners without management experience were frequently hired. Psychiatrists from the world of private practice or academia were expected to quickly transfer their skill in managing the therapy of individual patients to managing systems providing care to thousands. Presumably, the necessary expertise would be acquired via on-the-job training.
During the 1980s the role of state mental health commissioner changed dramatically. The commissioner is now supposed to possess a range of skills and knowledge that is rarely, if ever, found in a single person: management abilities suited for running a multimillion- (sometimes multibillion-) dollar organization; knowledge of the clinical and technical aspects of mental health service delivery; an ability to conceptualize, develop, and administer multifaceted systems of care; familiarity with hospital administration; comprehensive financial knowledge that covers such complex federal programs as Medicare and Medicaid; skill as a public speaker including the ability to testify before legislative committees; skill in communicating with the news media; a working knowledge of mental health law, litigation, and legal strategy; skill as a negotiator in dealing with unions and employee and professional organizations and with citizen, parent, and advocacy groups; an ability to convey such elusive attributes as "leadership," "charisma," and "creativity"; and, finally, mastery of the political process and of the political intrigue that almost always surrounds the office of state mental health commissioner.
Why the Job Is Impossible
The impossibility of the commissioner's task is only partly the result of the complexity of the job and the diverse range of abilities required. If success were merely a matter of hard work and skill in the several areas listed above, a knowledgeable, intelligent, and reasonably competent person willing to put in about sixty hours a week could be expected to master the job of commissioner over time and to receive at least passing grades from the many people who stand ready to evaluate the commissioner's performance. Unfortunately, this is not the case. The commissioner must deal with powerful people and constituencies who place demands on the mental health agency that are both unreachable and contradictory. Because any commissioner, even an exceptionally skilled one, cannot satisfy all such demands, the commissioner is invariably seen by at least some observers as failing to carry out the responsibilities of the position.
We should qualify our remarks by pointing out that the number and intensity of the demands on a mental health commissioner vary from state to state and are sporadic within a single state. The commissioner's ability to improve the mental health system or survive in the job for a reasonable period of time may depend on such variables as the political and economic climate in the state, the political debts incurred by the governor or the umbrella-agency head to whom the commissioner reports, the personalities of the leaders of citizen and employee organizations, the ownership and editorial stance of the newspapers, and the personal relationship of the commissioner with key elected officials in the state.
Even under the best of circumstances, the impossibility of the job eventually takes its toll. The average tenure for the state mental health commissioner is 2.61 years. The above discussion demonstrates the unreasonable and contradictory demands that make the commissioner's job impossible.
