³Ô¹ÏÍøÕ¾ to more than 2,000 patients with severe psychiatric illness in 1950, Pennsylvania’s Allentown State Hospital was shuttered in 2010 and razed in 2020, an end common to former mental asylums in the U.S.
As that hospital was being demolished, another in the French village of Billiers was expanding its services, adding: in-home care; vocational training and short-term housing to complement individualized attention from large teams of professionals; an arts center; and employment workshops.
What accounted for the facilities’ different fates? And why, from similar origins, did France’s publicly funded services for mental health challenges – including schizophrenia, chronic depression and severe bipolar disorder – eventually triple that offered in the U.S.?
In a new, open-access book, “The Welfare Workforce: Why Mental Health Care Varies Across Affluent Democracies,” Isabel M. Perera, assistant professor in the Department of Government in the College of Arts and Sciences, investigates this widely varying provision of services to one of society’s most vulnerable and disenfranchised populations – even in countries with otherwise similar health systems and social policies, such as Norway and Sweden.
“In some countries, such as the United States, policymakers closed hospitals but failed to replace them with adequate social and medical supports,” Perera writes. “Other countries, though, developed much more expansive public mental health care systems.”
The comparative analysis, Perera writes, offers a window into how government employees are shaping social policy. She discussed the book – based on her award-winning dissertation – with the Chronicle.
Q: Every affluent democracy deinstitutionalized, a process that peaked in the 1970s and 80s. Was that the right thing to do?
A: Psychiatric deinstitutionalization certainly had a humanitarian justification. By the 1970s and 1980s, a combination of poor hospital conditions and post-1960s social reform ideas had convinced many observers that people with mental illnesses were better off living “in the community” than inside the walls of “the asylum.” Novels and movies like “One Flew Over the Cuckoo’s Nest” helped to spread that message.
But deinstitutionalization soon became a fiscal measure. The 1970s and 1980s were also a period of significant economic crisis. As a result, many governments decided to close mental hospitals, claiming humanitarian concerns but largely motivated by budgetary pressures. Those governments were also reluctant to fund the community-based services (outpatient medical care, supportive housing, employment workshops) required to successfully transition patients out of hospitals. The United States was particularly unsuccessful at this task. The lack of appropriate community-based services has left many Americans with severe and chronic mental illnesses living on the streets, or in prisons.
Not all countries approached deinstitutionalization in the same way as the United States. Some governments, in fact, managed to expand, not contract, the public mental health services during that period. In other words, there is another, more humane way to deinstitutionalize. The book explores the politics that produces that outcome.
Q. What is the “welfare workforce,” and why did it become central to your analysis?
A: Welfare workers are the people who work for the welfare state – and, by extension, have a vested political and economic interest in maintaining or expanding it. Think of teachers, nurses, social workers. Their jobs depend on the structure and financing of a society’s education, health and care policies. That gives them a powerful incentive to advocate for service expansions.
Welfare workers are also important because they tend to be well-organized. Across virtually all affluent democracies, unionization rates are higher in the public than private sector. This is a significant historical change, both empirically and theoretically. While private sector (usually industrial) workers were the center of the trade union movement and the central advocates of redistributive policy through the mid-20th century, public sector (usually service) workers have since taken on both those roles. The two groups also differ in the kinds of welfare programs for which they most advocate. While the former might focus more on redistributive transfers (pensions, unemployment insurance), the latter tends to be more concerned with redistributive services (health, education). I propose that this shift in political power could be shifting the overall architecture and priorities of the welfare state.
Q: Considering Billiers and Allentown, what explains why one institution is thriving while the other was shut down?
A: Behind the contrasting examples of Billiers and Allentown is the political response of hospital employees to the threat of cutbacks. While Allentown State Hospital once employed more than three times the staff of the hospital in Billiers, the unions representing them were less successful at protesting retrenchment than were their French counterparts.
I find that these differences, in turn, result from longer-term and macro-level trends in mental health worker organizing in the two countries. Since the 1960s, welfare workers in the French mental health sector had been gaining significant political momentum, both benefitting from and contributing to the expansion of services in this area. The opposite had occurred in the United States, where public mental health workers – once amounting to up to a quarter of the membership of major public employee unions – had gained far less political influence over public policy.
Q: What has been key to sustaining or increasing public funding for expensive mental health services in some nations?
A: Many factors, but what is instrumental, I find, is whether and how welfare workers organize. In particular, I show that an alliance between public employees and their managers is key. When this coalition forms, then, it can be a powerful method to draw revenues to public services.
Q: What are your findings’ implications for mental health care in the U.S.?
A: The policy implications are complex and multi-faceted, though some lessons are especially potent. First, American mental health policy has long assumed that community services will only increase if hospitals first close. But the international data shows that these services can be complements, not substitutes (as I also argued in a Psychiatric Services article). None of the countries I studied closed hospitals before expanding community services – in fact, they required the former to help finance and administer the latter.
Related, and second, mental health services require substantial public investment (as I also argued in The Lancet). People with chronic and severe conditions rarely have the private means to afford their own care, which is often complex and highly labor-intensive. That means that mental health services cannot survive on private financing alone. Public funding is common and necessary.
Third, that market structure and those financing needs mean that workforce development is key. Mental health occupations are very demanding; they are also often underpaid. Public support for increasing the quality and pay of those jobs will not just help to grow the workforce but also the political will to maintain these services over time.
