When Neal Brown began his federal career as an intern with the National Institute of Mental Health nearly 40 years ago, life was very different for Americans with mental illness. Beyond carrying a significant social stigma, they often were removed from their communities and placed in institutions, with no say in their treatment and sometimes living under abusive conditions.
In those intervening years, Brown has become a leading federal advocate for shifting care and government resources from the large psychiatric institutions toward a less expensive community-based rehabilitative model. In the process, he has helped bring mental health consumers into policy development, program design and services implementation at the federal, state and local government levels.
“These individuals questioned the quality of treatment they received in the mental health system, voiced vehement objections to what they saw as an abrogation of their civil rights, and made the strong argument for including consumers in the self-determination of their own course of treatment and their own lives,” said Anna Marsh, the deputy director of the Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration (SAMHSA).
“Today, mental health consumers have won the battle to be heard. More than any other single individual, Neal Brown has been instrumental in fostering this evolution,” said Marsh.
Brown, the longtime chief of the Community Support Programs Branch at SAMHSA, led the development of a now widely followed conceptual model for the delivery of comprehensive mental health community services. This concept recognizes that traditional mental health care is not enough, and that services such as housing, employment, medical care and rehabilitation also are essential.
He helped organize a network of community groups, consumers and their families to promote change; created and implemented a grant program to support change agents in the states; and helped develop an initiative to demonstrate and replicate effective programs. The idea was to demonstrate and pilot effective strategies and program models so that the states could change the way their mental health systems operated. His efforts have helped shift national policies, and led to a transformation in the way states have organized and funded mental health activities.
“We started this community support approach to infiltrate the system, change the thinking of state mental health leaders, and help people get housing, get jobs and have a full life,” said Brown. “We were not in the mainstream at the time. We were on the edge of an organization mainly focused on research. We were taking chances trying to represent the people who had the illness.”
Brown said even with deinstitutionalization, many individuals who left psychiatric hospitals were not receiving adequate treatment or rehabilitation in the community, and some were not able to leave the hospitals because there was either no housing or services, or both. Others were moved out of hospitals and ended up in bad situations or on the streets. A major reason for starting the federal grant program in the late 1970s was to provide federal leadership to address these issues.
“We looked at how communities viewed the stigma of having people with mental illness living in the community,” said Brown. “It started as an integrated idea at the federal level, taking a role in the deinstitutionalization of people with mental illness—people who could do much better in the community, and people who had already shifted into the community without support structures,” said Brown
In the early 1980s, Brown said only about 33 percent of state resources funded community-based mental health services, but it reached 72 percent by 2008.
“The struggles go on, but the concepts are still in play: to have a rehabilitation model instead of an institution model; to have a strengths-based system instead of an illness-based system; and to help people recognize that people with mental illness can and do recover,” said Brown.
For Brown and the citizens for whom he advocates, the road has been a tough one, especially with changing administrations and fluctuating funding levels.
“There’s a cyclical nature of the work, a waxing and waning of interests in transforming health care,” said Kathryn Power, director of CMHS. “You need to constantly take advantage of changing opportunities. Neal is always able to keep his eye on the prize and keep focused on the overarching goal.”
Brown said a key to making progress has been establishing relationships with the grantees, the people doing the work in the communities, and finding ways to work cooperatively with the states that have different system and funding sources.
Jacqueline Parrish, Brown’s former deputy, said Brown has been committed to the mission for decades, and is intent on making a positive impact.
“This is what public service is about,” said Parrish. “It’s not working for money. It’s working for the public good.”