Introduction to Mental Health Reform in North Carolina

Mental Health Reform began in North Carolina partially out of economic necessity. Other states had had to do so in the Midwest during the decade of the 1990’s for similar reasons, the decline of manufacturing in the so-called “Rust Belt,” but one example used mental health reform undeniably as a nearly vindictive budget slashing measure, singling out more than any other major expenditure category of a state budget for drastic cuts.

North Carolina’s impetus was truly largely driven by a perfect storm [no pun intended but it is one unfortunately nonetheless as the reader will quickly see below] confluence of unexpected and massive budgetary hits to the NC state coffers. In 1999-2000 along with a number of other segments of the economy, the “Dot Com” bubble burst nationally. This affected NC severely as North Carolina had long been building an information economic powerhouse through especially the Triangle area’s [Durham, Chapel Hill and Raleigh which are all within 8 or 15 miles of each depending on which leg of the triangle connecting the three cities you measure] universities, Duke, UNC-Chapel Hill, and North Carolina State University, respectively. NC State at the time and still is the most technically driven of the three and is now beginning to rival Rensselaer, MIT, Georgia Tech and Cal Poly in terms of research, award winning faculty, technical centers and spin off high tech companies. In fact, NC State had already established a new technical campus, the Centennial Campus adjacent to NC State’s campus and on the way to Research Triangle Park toward Durham. That campus has continued to massively grow in the years since the dot com recovery, for instance now housing the headquarters of Red Hat, the world’s leading commercial Linux distribution. This illustrates how much of an economic vortex the RTP {Research Triangle Park) is, generating hundreds of millions of dollars into the state economy. When the Dot Com bubble burst in those days when idiotic Internet companies were starting up, having no real product but promising getting groceries delivered to your house (now perhaps closer to reality), being overvalued in the stock market by unimaginably inflated multiples, the RTP of North Carolina suffered greatly, more so than Silicon Valley which was older, more established, larger and deeper. Jobs by the thousands were lost which were very high paying. High tech personnel left the state, state income tax revenues took a substantial hit. All this was a preview on a mini-scale of what was to come in the 2008 mortgage housing and financial derivatives scandal and bubble/Great Recession, partially still with us.

Continue reading “Introduction to Mental Health Reform in North Carolina”


Mental Health Reform–The Beginnings of It All

A State Hospital Dome
A Typical State Hospital Skyline








Since this is the very first entry into this site devoted to the contemporary history of one of the states’ efforts at “mental health reform’ since the late 1990’s, I should preview what will the be the ongoing thrust and intent of this effort.

  • This author will endeavor to focus primarily on my state’s mental health reform efforts since the late 1990’s
  • I will also in these early posts draw upon my knowledge of some of the first efforts in the United States to begin to grapple with the long dormant tasks, needs and dilemmas of the public mental health services sectors, long neglected and unchanged since the 1963 ‘Comprehensive Mental Health Center Act’
  • I will trace the many steps and changes that the effort in North Carolina has undergone, from incremental changes, improvements and commendable efforts at correction, the fits and starts, the usual “unintended consequences,” tough lessons learned since 1999-2001 when this started
  • I intend to also give credit where credit is due to the state of North Carolina, its leaders, political structure and veteran Department of Health and Human Services, to reach recently now consolidating improvements, and recent commendable achievements wrought under difficult circumstances when many were harsh and vocal critics of this uncertain reform effort, myself included in past years
  • And finally, I will try to observe a personal tenet of mine, to give credit and ‘compliments, as the positive fruits begin to take unmistakable and firm footing, that were long doubted by many especially the sector of mental health professionals [again including this humble observer; I believe that in our currently polarized and argumentative public climate, we have just about lost the sense of fairness in complimenting each other, looking past philosophical differences and vilify or deny the worth of others’ ideas; and a fitting compliment goes a long way to forging partnerships needed for fashioning corrective steps and improvements, when taking on such complex and overwhelming social problems that this blog attempts to describe, educate and promote a better grasp of where we have been and where we are hopefully headed in our efforts of promoting the common weal and good for all our citizens in need.
  • Along the way I hope to show how North Carolina, in my view is one of the nation’s leaders in devoting impressively large and comprehensive resources in addressing the effort of mental health reform even in these times of a lasting and lingering economic slowdown, where the temptation could be understable to stint on budgeting sufficient resources, and end up repeating the decades or even centuries old practice of giving short shrift to the mentally ill and cutting their budgets since they by and large, do not have powerful lobbying groups on a level with labor unions, huge corporations, nationally based special interest groups, with a few exceptions that serve special groups among the mentally ill populations.
  • Finally I pledge to the readers of this commentary observational effort, to present as even handed a presentation and historical accounting as this practitioner can, given I am not a trained historian, reporter or writer; similarly I must make “full disclosure” particular to this effort and my position: I am a psychiatrist and subject to the views and educational, clinical ethos or bias that goes along with and arises out of my four decades of practice and experiences, that I have practiced in many settings from private, academic, public state hospital and local mental health centers, HMO clinics, Native American populations, correctional facilities for adults and adolescents, outpatient and inpatient settings of all stripes from acute to residential. Mostly, I must respect the ethical expectations of my current employer, a state hospital of the state of North Carolina, and will not abuse this position and knowledge I have of this institution, its staff, leadership and especially its clients, all of whom I owe a debt of gratitude for permitting to practice and do what I love best, treat and help patients, and teach trainees and participate in a care organization that puts its efforts where its mission statements vows, to be an aid to all, operate with respect and be honestly transparent, and to constantly self-monitor and improve. I am in the twilight of my career in some ways, and realized when I came to work here, that I had come full circle, from my first years out of residency at Duke when I took a state hospital staff psychiatrist position at the then but no longer existing John Umstead Hospital north of Durham, to help start an acute inpatient adolescent unit and a comprehensive multidisciplinary family therapy training program. I was green, inexperienced, eager and did not know my own limits but always itching to contribute. Now I work with, in many ways, the most challenging clients of my career, and think in a karma kind of way, that venue I have worked in heretofore, no matter how different, has prepared me for what I do now, and I am ever grateful to be here, at a time of great change and challenge. I hope the reader will enjoy the story I will attempt to tell.

Respectfully yours,


Frank Black Miller MD DFAPA


We Need the “Asylums” Again Believe It Or Not

On January 16, 2015 the American Medical Association issued a press release giving notice of an article that asserted the current model fo treating the mentally ill as “ethically unacceptable and financially costly.” It was walking about the decades old failure of “de-institutionalization” that in in its second or third cycle of failure, being re-enacted in states all over the country once again, with similar and predictably disastrous results. I have the feeling that its title and byline in the press release was a little bit intentionally inflammatory to call attention to the importance of this issue.

This article was startlingly timely in that this author had just this week launched this blog on the broad topic of “mental health reform” and the state by state and national debacle it has become since the 19990’s in Michigan and since 1999-2000 since the same dishonest cruel blueprint was foisted upon the naive and desperate legislators in those states to save monies. Michigan by the 1990’s was in accelerating economic swandive mode because of the near bankruptcy of the Big Three American auto makers at the end of the second George W. Bush Presidency, forcing the surprisingly opposition to the bail out first of the two USA life saving bailouts that were left to the the new Obama administration. One would think that the Republicans would remember the satirical but emblematic motto of the character of “General Bullmoose,” in the old “Lil’ Abner” cartoon series by the great satirist Al Capp, “What’s Good for General Bullmoose is Good for the USA!” General Bullmoose was a character who represented the auto (GM–get it?) and military interests that dominated the country in those decades from the 1950’s onward. Business was supreme and has always been the organizing ideological center of the Republican Party. Michigan was one of the Rust Belt States losing population by the thousands yearly as families fled the loss of jobs in the auto and allied industries foretelling a trend that continues to this day.

Meanwhile North Carolina in the late 19990’s suffered enormously from the precipitous “Dot .com” bust of overvalued darling companies of stock hucksters on Wall Street that were innovative but made no money and somehow a free Internet based serviced equalled or guaranteed riches in the future. Conservative economists and stock experts who warned in ever darker tones in those years about that folly were lampooned unwisely by the upstarts of the New Economy that no one could define as old fuddy duddies with their economic heads in the sands of progress. North Carolina was perhaps the third most important “Dot .com” economic engine in the country after Silicon Valley and the Boston Corridor because of North Carolina State University’s technical powers and the graduation of the RTP (Research Triangle Park”) into the tech Big Leagues with dozens of start up tech companies who went bust as funding vaporized when results never appeared and tight money clamped down. Then North Carolina got hit with Hurricane Floyd which devastated an Eastern part of the state and cost the state in short order between one and two Billion dollars to helps its citizens rebuild. Then North Carolina lost a very important legal economic case in the early 1990’s that went all the way to the Supreme Court and cost the state over $900B in one year. North Carolina lost its contention that it could, as it had been for 9 or 10 year years, taxing the federal retirement pensions and benefits of retired federal workers living in the state. The loss meant the state had to refund almost a billion dollars swiftly as NC is a state that requires by its own Constitution that its annual state budget always be balanced, no matter what, no funky borrowing or issuing junk bonds as a way out. So the General Assembly was desperately looking for a way to save approximately two billion dollars quickly and fell sucker to the pitchmen from Michigan and before that Massachusetts in the 1980’s who had saved those states huge amounts of monies but slashing the budgets and costs of the mental health systems with a new plan that was called euphemistically “Mental Health Reform.”

Its basic tenet was to close ‘expensive’ out dated state hospitals and their beds, since everyone knew by that time that being in the state hospital environment was bad for your because of the three decade long promulgation of the modern fallacy of “institutionalization.”

The four state hospitals in Nor Carolina, Dorothea Dix Hospital in Raleigh, Cherry Hospital in Goldsboro, John Umstead Hospital in Butner outside of Durham, and Brougthon Hospital in Morganton in the western third of the state and the largest, had their beds reduced by roughly two-thirds each. The bogus reform plan, a several hundred spreadsheet program utilized in other states notably Michigan, promised the building of comprehensive outpatient services as it dismantled and destrroyed the well functioning local county by county mentalh health services. It was also suppposed to build for a start, sixteen smaller, more regionalized (read local and closer to families) less “isntitutional” smaller “mni” state hospitals. None were built for years by the state except one which was placed in the outskirts of the western town of Sylva without a large enough supportive psychiatric cohort staff of practtioners in an old, converted, rennovated nursing home and one unit housed in a small community hospital in Linville NC.

And the results were predictable, patients lost their long trusted psychiatrists and clinicians by the droves and it took years to replace those. Crises with patient ended up in the ERs of small hospitals all over the state, many with any psychiatrists on their staffs OR any inpatient psychiatric units. Patients also ended up in even greater numbers in the jails, at the country and state levels. Counties suddenly had to find staff, resources and medication budgets to care for at least 10-20 times more mental patients than they had ever had, Jail suicides dramatically increased. And the mental health reform took years to try to catch up.  A prominent then Duke faculty psychiatrist in the mid 2000’s stated publicly for the media in an interview that it would “take 10 years for the state to replace what we had [in state mental health capabilities] ten years ago. A more damning indictment of the the state’s mental health reform effort could not have been verbalized except the description by a Dr. Steve Crane MD a teaching physician for the family practice residency program in Hendersonville and Asheville as “the disaster that just keeps on giving,” which was a satirical take-off on the then current circulating satirical description of Hurricane Katrina and the failure of the Bush Administration to respond to it in a timely fashion which is now a classical study in government and business schools on how NOT to handle a crisis.

To quote the article in the Journal of the American Medical Association published January 20, 2015, “As the United States population has doubled since 1955, the number of inpatient psychiatric beds the United States has been cut by nearly 95 percent to just 45,000, a wholly inadequate equation when considering that there are currently 10 million U.S. resident with serious mental illness.

Continuing, the authors of the article, Dominic Sisti Ph.D., Andreas Segal MS, and Exekiel Emanuel MD Ph.D, wrote “For the past 60 years or more, social political and economic forces coalescent to ove severely mentally patients out of psychiatric hospitals.” They went on to say that the psychological civil rights movement propelled deinstitutionalization and resulted in “transinstitutionalization” which meant the severely mentally ill hit the ERs, jails and homeless shelters and streets around the country in huge numbers.  To further quote, “…most disturbingly, U.S. jails and prisons have become the nation’s largest mental health facilities. Half of all in mates have a mental illness or substance abuse disorder; 15 per cent of state inmates are diagnosed with a psychotic disorder.”

Instead, to quote the press release itself, “the authors suggest that a better option for the severely and chronically mentally ill, and the most ‘financially sensible and morally appropriate way forward includes a return to psychiatric asylum that are safe, modern and humane. They argue the term ‘asylum’ should be understood in its original sense–a place of safety, sanctuary and healing,” and I would add long term care, and long term rehabilitation to permit development of the current mantra ideal goal of “recovery.”