Competing Institutional Demands: A Framework for Understanding Mental Health Policy

Abstract

This paper draws from institutional theory to provide a framework for understanding mental health policy. Institutional theory directs attention to the environment surrounding mental health care delivery systems, and argues that systems respond to both technical and normative demands operating within the external environment. Mental health policy is also a reflection of these technical and normative demands. However, these demands are often contradictory and ambiguous. Consequently, mental health policy lacks coherence and consistency, and delivery systems come to reflect the interests of the most powerful institutional actors within a given system. More specifically, mental health services currently seek to incorporate two opposing ideological models of care: the commodity model and the community model. The commodity model is a reflection of technical demands for efficiency, outcome assessment, and cost containment. The community model is a reflection of normative demands for effective services, quality care, and access to care. The organizational and policy conundrum is to balance conflicting institutional demands for efficiency (cost containment) and effectiveness (quality and access). Two states (Wisconsin and North Carolina) are used to illustrate how these conflicting demands have been mitigated.