In some respects, the course of mental health treatment and policy in New York State and in the United States from the late nineteenth to the late twentieth century has been circular. Psychiatrists and advocacy groups representing families of the mentally ill now concur that serious mental illnesses are biologically rooted. In the future, the mountain of studies into the neurochemical dimensions of mental illness may alter the very manner in which it is conceptualized: the New York City chapter of the NAMI asserts that "mental illness" is a misnomer and that "neurobiological disorder" is a more appropriate and precise way of classifying disorders such as schizophrenia, and the term seems to be gaining favor. Although the OMH continues to assert that its actions should be guided by "the expectation that each person can recover from mental illness," advocacy groups such as the NAMI and most members of the psychiatric profession have become markedly pessimistic about curing serious mental disorders. The federal government's retreat from extensive involvement in the shaping of mental health policy and the increasing latitude given the state also calls to mind the decades before the Second World War.
However, these apparent similarities obscure as much as they reveal about the trajectory of mental health policy. The federal government has since the mid-1980's resumed some responsibility for mental health policy and compels states seeking federal funds to adhere to certain requirements concerning care of the seriously mentally ill and development of community-based programs. The OMH and its counterparts in many other states preside over a decentralized system of care and treatment that consists of both local and state agencies and which is supported by a combination of state, local and federal monies. The office also strives to meet the needs of a much broader client population: the expansion of mental health treatment to cover those suffering less serious forms of mental illness or having difficulty coping with difficult life circumstances that began during the Progressive era and blossomed from the 1960's onward has compelled it to develop its programs accordingly. In devising these programs, the OMH continues to rely upon psychiatrists, the traditional providers of care and treatment of the mentally ill, but it also works with psychologists, social workers, and other mental health professionals who no longer defer to psychiatric expertise. State inpatient institutions, which once housed most of the mentally ill, have become but one of several kinds of facilities providing care and treatment, and it is highly unlikely that they will once again predominate: even if the state had the money needed to reconstruct the extensive network of hospitals that once existed, the numerous court cases that established patients' right to refuse treatment would militate against the recreation of the old mental health system.
Changing attitudes toward treatment also work against the reestablishment of the old state hospital-centered system. The hope of finding easy and permanent cures for serious mental illness has been discarded, but few mental health professionals and advocacy groups believe that simple custodial care such as that formerly furnished on the back wards of state hospitals is desirable. Recognizing that serious mental illness is chronic and that those who suffer from it are likely to suffer relapses from time to time, they have instead focused upon trying to ensure that mentally ill people can function to their fullest potential and to reduce the dislocations that the illness produces. Of course, these hopes do not always coincide with reality: in many instances, the quality of life in PPHA's and other institutions that developed as state hospital systems were being dismantled is little better than that found in the back wards of the old state facilities, and community-based programs in many areas remain fragmented and ill-equipped to prevent those with serious mental illness from falling through the gaps in the safety net.
The mental health system of New York State resembles the integrated network envisioned by the drafters of the 1954 Community Mental Health Services Act much more closely than it does the centralized hospital system created by the 1890 State Care Act. However, it continues to exhibit many of the problems highlighted by its critics from the mid-1950's onward: lack of cooperation between state and local providers, gaps in provision stemming from the state's efforts to tailor policy to maximize reimbursements from the federal government, and an unfortunate tendency to lose track of the most acutely ill. Recent policy initiatives spearheaded by the OMH, state lawmakers, and federal authorities have sought, with varying degrees of success, to address these problems, and it seems that this relatively modest goal will in the immediate future continue to animate state and federal policy reforms: given the immense difficulty of radically restructuring such a complex system and the seeming absence of the political will needed to do so, it seems likely that most efforts at changing the mental health system will focus upon correcting its more readily identifiable and (apparently) remediable flaws.