States of Mind: A Comparative and Historical Study on the Political Economy of Mental Health

Why do levels of public service provision vary across governments? This dissertation examines this question in the context of services for vulnerable populations, and in particular, through the lens of psychiatric deinstitutionalization. Governments around the world have transformed mental health policy over the past century by rejecting the insane asylum as an appropriate site of care. Yet some governments opted for the wholesale closure of these hospitals, while others opted to diversify and expand public psychiatric services. ^ The conceptualization and measurement of differences in public psychiatric care, both over time (1935-present) and across countries (15 high-income democracies), demonstrate this variation in government choices, and facilitates the selection of two countries for a comparative study: the United States and France. The comparison draws on primary and secondary historical sources, such as archival documents, out-of-print journals, and national statistical yearbooks. ^ This study proposes that, absent a powerful client interest group, the maintenance and expansion of public services depends on public workers. The ability of public workers to organize together with their managers constitutes a unique source of influence. Where a labor-management coalition formed, governments maintained and expanded mental hospitals and facilities. But not all public employees gained the support of their managers – particularly in countries where managers’ political representatives included private practitioners. There, government reduced services. ? ^ The two case studies trace ensuing positive and negative feedback cycles. In France, public psychiatrists placated the demands of their employees through the strategic use of student protests in 1968, discretionary funds in the post-crises 1970s, and cost containment initiatives in the turn-to-austerity of the 1980s. Each of these efforts attracted more state funds to mental health, and at every step, empowered the public workforce further. Their counterparts in America, however, were unable to do the same. The inclinations of the American Psychiatric Association’s public membership notwithstanding, its otherwise private membership diverted its attention from the public mental health financing initiatives of the Great Society programs, restrained its support for the employees of deinstitutionalizing hospitals in the 1970s, and enabled the retrenchment of services in the 1980s, with contrasting consequences for the American public mental health system and its workforce.