Exploratory discussions with stakeholders in the mental health system will, sooner or later, focus on their capacity to make mental health services available to those who need them most. Before an agent of change reaches out to representatives of the mental health system, it is essential that he or she appreciate how the mental health system works.

As mentioned earlier, the advent of new treatments and service system models is, in many ways, revolutionizing the mental health system. No less dramatic has been the change in orientation from grim acceptance of the supposed irreversibility of the decline associated with mental illness that characterized all thinking about the condition just a few decades ago to the burgeoning belief in recovery today expressed by researchers, clinicians, advocates, families, and - most of all - consumers. Recognition that people with mental illness can and do get better has given hope to many individuals. It is also changing the way people think and talk about mental illness and thus altered the course of policy.

With a foundation of hope and recovery, the system sees reintegration into the community as perhaps its highest priority. Clinical decisions, funding structures, and other incentives are aligned in many places to direct people with mental illness toward community integration. Administrators, advocates, consumers, and experts see hospitalization as a costly alternative residing at the far end of a continuum that should include a rich offering of community-based interventions. Agreement in the field dissolves, however, when stakeholders discuss where to turn when mental health treatment systems have failed to successfully engage an individual in treatment. Conflicting views on involuntary commitment illustrate this tension. Some see involuntary inpatient or outpatient treatment as the ultimate intrusion, a dehumanizing deprivation of rights to be avoided at all costs. Others hail involuntary treatments as necessary and lifesaving tools that must be employed when an individual's judgment is impaired. Most in the field feel torn and seek a balance that respects both realities.

The trend away from hospitalization and the embrace of recovery have led to a new view of the place of control in mental health treatment. Just as laws and policies in effect in most states steer mental health clients toward treatment in the "least restrictive setting," so do treatment professionals speak of ensuring patients the greatest possible degree of control over their own treatment choices. In recent years, mental health advocates and professionals have reexamined the use of coercive measures in mental health treatment settings. Many practitioners have worked hard, for example, to reduce the use of restraints and punitive seclusion in clinical settings, recognizing that they have no therapeutic value and can only be justified when physical safety is at issue, and laws and regulations have been rewritten to reflect this new understanding. Appreciating the mental health system's views regarding coercion may be particularly difficult for someone working in the criminal justice system, where coercion is inherent at every juncture to ensure people obey laws and follow rules. Yet, the use - and perceived use - of coercion has become the subject of much concern and debate within the mental health community. Most of the recommendations offered in this report address issues that arise when people with mental illness are in contact with - or are under control of - the criminal justice system, and they reflect the powers at that system's disposal. By the same token, the report takes into account the mental health system's values and largely steers away from making recommendations that would apply coercive measures to people with mental illness on whom the criminal justice system has no hold.

In addition to understanding key values of the mental health system, an agent of change should become familiar with its complex organizational structure. Understanding how a system is organized largely depends on learning how it is funded. When it comes to the mental health system, this can be a true challenge. No rational organization chart can possibly be drawn that accurately depicts the administration and delivery of mental health services in this country. In contrast to the criminal justice system, which has a fairly straightforward structure, the mental health system draws revenue from a dizzying variety of sources: Medicaid, Medicare, state general revenue funds, local matches, federal Mental Health Block Grants (grants administered by three or more federal agencies), and patient fees, just to name those most common. In some states, funds are funneled through managed-care frameworks. In others, counties present an additional level of administration. "System," indeed, may be a misnomer for what is often a patchwork of programs, services, and complex funding structures.

Solutions to many of the problems encountered by the criminal justice system might logically be found in the mental health system. Sadly, the mental health system in too many places has been too beset by internal challenges and lack of support to address some of the most visible signs of its failure. For the public mental health system to assist the criminal justice system in addressing the needs of people with mental illness, policymakers and community change agents will need to ensure that it has sufficient resources and public support.