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Grantwatch

ESSAY

Are Foundations Overlooking Mental Health?

Abstract

 
Over the past decade philanthropic giving for health has increased dramatically, but giving for mental health has not kept pace. Historically, foundations have been key partners in efforts to improve care for people with mental disorders, and foundation funding has influenced the evolution of U.S. mental health services and systems. Although mental health giving grew in the 1990s, the rate of growth was far below that for total foundation giving or giving for health. The authors suggest possible reasons why mental health funding lost ground and describe promising funding approaches and models for increasing both the amount and the impact of philanthropic giving for mental health.

Under the auspices of Grantmakers In Health (GIH)—a nonprofit educational organization serving foundations and corporate-giving programs that make grants in health—several foundations that fund in mental health have recently begun to share information and strategies. Their goals are to better understand foundations’ impact on mental health issues individually and as a combined force, as well as to increase foundation dollars’ effect on improving mental health services and policies. The authors researched foundations’ role in mental health funding, and this essay shares some of their findings.

First, it is necessary to clarify how mental health is defined here. It was clear from the beginning of these GIH discussions that foundations include a broad spectrum of programs under the rubric of "mental health"—from those that promote mental health among the general population to those that focus on specific aspects of mental illness. The Hogg Foundation for Mental Health, in Texas, for example, uses a broad definition and funds a variety of programs and approaches to achieve impact, while others target their funding more narrowly. In his groundbreaking report on mental health, former Surgeon General David Satcher defined mental health as "the successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity." At the other end of the continuum, he defined mental illness as "health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning."¹ This essay adopts these definitions and includes the full range of conditions, from positive mental health through serious mental illness.

Historical Perspective

Top Historical Perspective Recent Trends In Funding Challenges To Foundations’... Editor's Notes NOTES

 
The role of organized philanthropy in mental health can be traced to the early 1900s. The Rockefeller Foundation and the Milbank Memorial Fund were key funders in the establishment of the National Committee for Mental Hygiene in 1909. This organization, which later merged with two other groups to become the National Mental Health Association, brought together psychiatrists and citizens to focus on improving conditions and services for people with mental illnesses. Since its inception, it has been pivotal in shaping mental health policies and practices.

Foundations demonstrated their unique capacity to bring divergent disciplines to bear on social issues or problems. This occurred in mental health, for example, when Rockefeller supported a series of scientific and professional conferences and papers in the 1930s and 1940s that are credited by medical historian Gerald Grob with moving "psychiatry in an interdisciplinary direction by merging a biologically oriented medicine with psychoanalysis."²

Leveraging government resources was yet another activity of foundations during this period. A notable instance of this resulted from the formation of the Albert and Mary Lasker Foundation in 1942. The Laskers and their foundation colleague Florence Mahoney used extensive connections in Congress and the support of the National Committee for Mental Hygiene to play a pivotal role in inspiring the legislation that authorized establishment of the National Institute of Mental Health (NIMH). With the NIMH in place, the responsibility for support of mental health research moved from the private to the public sector. Foundations continue to play an important role in supporting mental health research, but public funds are now the primary source of mental health research dollars.³

Foundation funds also supported health services research and system change in mental health. In the mid-1950s, for example, the Russell Sage Foundation supported an innovative experiment at the Boston Psychopathic Hospital, where Milton Greenblatt and colleagues collaborated with other hospitals to test the controversial concept that patient-staff interactions in psychiatric hospitals could have important effects on patient outcomes. This project demonstrated that methods of control, such as restraints and seclusion, were not needed in an environment in which staff and patients alike had stronger, more collaborative roles in the therapeutic process.⁴

The growth of federal funding for mental health notwithstanding, there remains a critical need for the approaches that foundations do best. The history outlined above demonstrates the key role of foundation support of advocacy groups, interdisciplinary discussion, policy analysis, and innovation in health services. But what about the future? Have the changes in the role of government funding led to fundamental shifts in foundations’ interest in supporting work in mental health? Although data are lacking to examine trends in foundation giving during 1950–1980—a period of intense growth for the National Institutes of Health (NIH)—the Foundation Center (FC) began tracking foundation giving in 1980. Thus, it is now possible to examine quantitative trends in specific areas of giving.

Recent Trends In Funding

Top Historical Perspective Recent Trends In Funding Challenges To Foundations’... Editor's Notes NOTES

 
The Foundation Center collects data on foundation grants of more than $10,000 from a sample of approximately 1,000 of the country’s largest foundations; the data can be used to examine trends from 1990 to the present.⁵ Grant-makers In Health also collects information on health grant making that can be used for illustrative purposes.

Growth in foundations. The last decade of the twentieth century witnessed an explosion in the growth of foundations, fueled in part by the longest-running bull market in U.S. history and by the early stages of an inter-generational transfer of wealth from those who made fortunes in the post–World War II era. According to FC data, in 1991 there were 33,000 foundations with combined assets of about $163 billion. By 2000 there were more than 56,000 foundations, and assets had more than tripled to reach $486 billion.

During this same decade the number of foundations dedicated to health also increased greatly. Since the early 1980s health has been a major focus of foundation giving, ranking second only to education in almost all years. In the 1990s this giving increased largely because of the conversion of many nonprofit hospitals and health plans to for-profit status. As these conversions started occurring in large numbers, states began requiring converting organizations to preserve for public benefit at least a portion of the assets that they had accumulated under their nonprofit status. In many cases, this resulted in funds being placed in a new foundation dedicated to improving health.

In a 2003 study, GIH identified 105 new health foundations established during the 1990s from conversions.⁶ These new foundations together held $12 billion in assets at the time GIH’s study was prepared. Including new health foundations formed from conversions before 1990 and those created in 2000–2002, GIH reported that foundations created from conversions together held more than $16.4 billion in assets. Because private foundations are required by law to give away 5 percent of their asset base per year, $820 million in potential annual grant making was made available to improve health in local communities.

As a result of the establishment of new health foundations and increased allocations to health from existing foundations, health giving by funders in the FC’s grants sample increased from $817 million in 1991 to more than $3 billion in 2000. Health giving increased from 17 percent of all foundation funding in 1991 to a high of 20.5 percent in 2000.

Mental health funding. Foundation giving for mental health also increased during the 1990s, but not at the same high rate as foundation giving generally or giving for health.⁷ The FC’s annual data include grants for mental health and substance abuse (hereafter referred to as behavioral health). This category of giving increased from $108 million in 1991 to $218 million in 2000. Although the amount of grant funds going to behavioral health increased, this category became a smaller proportion of all foundation giving (dropping from 2.2 percent in 1991 to 1.5 percent in 2000) as well as a smaller proportion of foundation health giving (dropping from 13 percent in 1991 to 7 percent in 2000). For the decade 1991–2000, funding for behavioral health averaged just under 2 percent of all foundation giving and 11.5 percent of health giving.

To determine whether this relative decline was due to a relative decrease in funding for either mental health or substance abuse alone, the authors obtained FC data for 1991–2000 that disaggregated funding for these two components.⁸ Over this ten-year period disaggregated mental health funding averaged 50.25 percent of the behavioral health category and was just under 1 percent of overall giving and 5.8 percent of all giving in health. The following analyses report on giving in just the mental health portion of the behavioral health category.

Leading funders and recipients. Foundation Center data show a dramatic growth curve for overall foundation giving between 1991 and 2000, an upturn in health giving, and a relatively flat line for giving in mental health. The John D. and Catherine T. MacArthur Foundation, a national funder, tops the list of mental health funders with $41.3 million in mental health grants aggregated across 1996–2000. Other national funders in this group include the Robert Wood Johnson Foundation (RWJF), Annie E. Casey Foundation, Theodore and Vada Stanley Foundation, and Robert R. McCormick Tribune Foundation. The remaining five of the top ten foundations (William K. Warren, van Ameringen, Brown, and Moody Foundations and California Endowment) primarily fund within specific states or communities.

Some foundations that are major funders in mental health concentrate their grants in specific institutions, some of which are among the major recipients of mental health grants. For example, the William K. Warren Foundation in Tulsa, Oklahoma, established the Laureate Psychiatric Clinic and Hospital and the Warren Clinic in 1988; largely because of its grant making, Laureate Mental Health Corporation tops the list of recipients. Similarly, the Transitional Learning Community at Galveston (Texas), a rehabilitation center that offers psychological and other services for survivors of brain injury, was founded in 1982 by Robert K. Moody following an automobile accident in which his son sustained a traumatic brain injury. It is the second-largest recipient of mental health grant funds, largely accounted for by gifts from the Moody Foundation. Other leading recipients include research and teaching institutions such as Baylor College of Medicine (Houston, Texas); University of California, Los Angeles; Kennedy Krieger Institute (affiliated with the Johns Hopkins University in Baltimore, Maryland); and University of Pittsburgh. Also represented on this list are organizations that both fund research and advocate for increased research funding for different types of brain disorders and mental illnesses (such as the National Alliance for Research on Schizophrenia and Depression, the Alzheimer’s Disease and Related Disorders Association, and the National Alliance for the Mentally Ill Research Institute). Overall, FC data indicate that most mental health grant funds during 1996–2000 were targeted for program support (41 percent), nearly a quarter were for capital support and general support, and 16 percent supported research.

Challenges To Foundations’ Impact On Mental Health

Top Historical Perspective Recent Trends In Funding Challenges To Foundations’... Editor's Notes NOTES

 
These findings pose two questions: Why has mental health funding lost ground as a percentage of total foundation grant dollars and dollars allocated for health? And is it possible to promote a more strategic use of foundation dollars for mental health?

Possible reasons for the decrease. Data, recent trends, and discussions in GIH meeting sessions on mental health over the past two years suggest several possible explanations for the relative decrease in mental health funding.

First, mental health is not a major focus of either the largest foundations or the largest health foundations. There is considerable overlap between the largest foundations in the United States and the major givers in health. There is little overlap, however, between either of these types of foundations and foundations with major commitments to mental health (Exhibit 1). Only the California Endowment and the RWJF are among the lead givers in overall funding, in health funding, and in mental health funding, and the RWJF has no defined giving program in mental health. Simply put, the largest foundations and the largest health foundations for the most part do not list mental health as a funding priority.

Third, the move to managed care contributed to marginalizing mental health. Starting in the 1980s and accelerating in the 1990s, state Medicaid programs and private health insurers alike began using managed care approaches to control use and costs. Many health grant-makers responded by supporting efforts to educate consumers and assess the impact of managed care on vulnerable populations. In many managed care programs, however, behavioral health services were "carved out" from the rest of the system, and therefore mental health services and consumers tended to be less well served by health grantmakers.

Fourth, some foundations may avoid grant making in mental health because of a perception that their available resources are insufficient to address the current financing deficiencies for mental health services. In addition, the mental health system is sometimes perceived as being more fragmented and uncoordinated than the physical health system. As a result, foundations may believe that it is difficult to develop an effective strategy for promoting measurable change or to identify gaps that can be addressed through grant-making programs. Few foundations have staff with expertise in mental health.

Fifth, new health foundations are slow to move into mental health funding. There is evidence that new health foundations do not devote many resources to mental health during their early years of operation. The FC reported in 2001 that foundations resulting from health care conversions contributed 3 percent of their health dollars to mental health, compared with 7 percent contributed by other health foundations.⁹ This finding, however, may not hold over time because as new health foundations begin to mature, they appear to increase funding commitments to mental health.

Two foundations in California are examples of this. In 1999, 70.3 percent of the mental health dollars from new health foundations were provided by the California Endowment and the California Wellness Foundation (TCWF), which initiated grant making in 1997 and 1992, respectively. Both foundations have since made mental health a funding priority. At TCWF, for example, mental health is now one of eight priority areas, and the foundation receives more requests for funding in mental health than in any other area. The endowment allocated approximately $54 million to mental health for 2000–2002, with an emphasis on improving systems of mental health care for California’s underserved multicultural communities. Several other new health foundations, including the Colorado Trust, the MetroWest Community Health Care Foundation, and the Health Foundation of Greater Cincinnati, have followed this pattern as well, initiating mental health programs after gaining knowledge of community needs through early grant making. If these foundations are bellwethers for other new health foundations, funding for mental health could increase as new foundations mature.

Promoting more strategic use of mental health dollars. The absolute number of dollars dedicated to mental health is one gauge of foundations’ impact in this area. Because giving for mental health has not kept up with overall giving in health or with the increased demand for mental health services, many aspects of mental health are underfunded. Of course, foundations cannot meet all of the needs. But the challenge for them is not just to fund more, but also to fund more strategically.

The lists of top mental health funders and top grant recipients illustrate an important barrier to foundation impact. Rather than displaying a picture of a systematic approach to improving mental health services and policies, these lists demonstrate a patchwork quilt of funding, with each foundation having a different emphasis and geographic focus. Although foundations as a whole address a wide range of mental health issues and use a broad array of approaches, they infrequently communicate with each other, even when addressing the same issues. National foundations seldom work directly with state and local grantmakers to shape a collaborative foundation approach to a particular issue. Nor do most state, regional, or local foundations look to national foundations for leadership, because they respond primarily to needs in their target geographic areas. The tendency of most foundations to act as solo practitioners prevents a more collaborative or coordinated approach.

Clearly, the barriers to more strategic partnerships are not unique to mental health giving, and, fortunately, there now appears to be more collaboration among foundations. Many within foundations have observed a marked increase in network building and collaborative funding. A series of lectures and reports on trends within foundations points to the increasingly dense networks and affiliations that grantmakers are creating through affinity groups, funding collaboratives, and other mechanisms.¹⁰ These networks both reflect and accelerate a growing collective identity among foundations that chips away at the individualistic culture that has long been their hallmark.

Foundations have an important role to play in building knowledge about the need for mental health services and the capacity of mental health service systems at the local, state, and national levels. If foundations are to use their resources effectively, they must first understand what services people need, how they gain access to them, and the barriers they encounter. For example, eight foundations in Colorado have come together to commission a study of the status of mental health in Colorado, with the explicit aim of identifying how grantmakers can help address problem areas. The sponsoring foundations—a diverse group—believe that the study will lead to action, collectively or individually, to improve the mental health system in Colorado.

Foundations can also integrate mental health into initiatives focused on other issues or special populations. Funders working on complex issues such as domestic or community violence, welfare reform, or child welfare often find that their initiatives must include a mental health component if they are to succeed. Similarly, foundations working with vulnerable populations such as immigrants and refugees or youth at risk of involvement in the juvenile justice system might find that mental health issues must be addressed before sustained progress can be made in other areas.

Another trend that could bolster the effectiveness of foundations is their increased focus on supporting groups that work to inform public policies and programs. While maintaining a safe distance from the legally proscribed activity of lobbying, foundations are exploring how to make their grant making more policy relevant. Indicators of this shift include an FC special report in 1998 documenting the increased focus on policy grants among health funders in the period 1990 to 1995 and higher attendance at meetings and training sessions with a policy focus that have been sponsored by GIH, regional associations of grantmakers, and others.¹¹

The mental health funding of the Mac-Arthur Foundation, the largest mental health funder, exemplifies the policy focus increasingly popular among foundations. MacArthur has supported key mental health law and policy projects for many years and has filled the gap in public funding for mental health research. This support has been critical to projects and organizations such as the Network on Mental Health and the Law (which links a number of academic researchers, legal practitioners, and activists around the country) and the Judge David L. Bazelon Center for Mental Health Law, in Washington, D.C. A third Mac-Arthur-supported project, the Mental Health Policy Research Network, supports a multi-disciplinary group of researchers examining issues ranging from how mental health care compares with care for other health conditions in terms of quality and other variables to a detailed mapping of movement of people among the mental health, welfare, substance abuse, criminal justice, and other systems in King County, which includes Seattle. These projects share the potential for key policy impact and tend to be high-risk projects that might not attract federal funds.

Effective Mental Health Funding Enters The Twenty-First Century This essay began with examples of effective mental health funding and concludes with selective examples of funding approaches that appear effective nearly a century later. Most of the early-twentieth-century examples told the story of single foundations or, at most, two or three foundations coming together to fund projects that influenced the development of mental health services. Although some foundations addressed social policy, the dominant strategy for effecting change was to demonstrate a particular approach or technique. The assumption of foundations was that good work would then speak for itself, naturally find its way into service systems, and graft itself onto ongoing funding streams.

Although many examples point to the effectiveness of the "demonstrate-disseminate" model, there are many other instances when it was not effective. To address the many ills facing the U.S. mental health system, there needs to be an increase in effective funding strategies that involve multiple foundations and have an explicit policy focus. Several selective examples point to models of foundation funding that appear to be effective in today’s philanthropic landscape.

The accomplishments of the Corporation for Supportive Housing (CSH) serve as an example of the power of collaborative funding when it is coupled with a well-executed strategy for influencing public policies. The CSH was incorporated in 1991 to develop housing for people with mental disabilities. The CSH supports the capital costs of bricks and mortar—as well as case management and other supportive services—to help clients retain their housing despite the ups and downs of their illnesses.

National funders made major long-term commitments of core support. The RWJF, Pew Charitable Trusts, and Rockefeller and Ford Foundations provided a total of $45 million over ten years for this purpose, even though none has a program for funding in mental health. The funders were willing to offer support because of the CSH’s ability to identify the glaring problem of homelessness among the mentally ill and propose a reasonable strategy for addressing it. Starting with one site in New York City, the CSH now has sites in eight states and has obtained an additional $65 million from more than 160 foundations.

From the beginning, the CSH has worked to influence public policies on supportive housing. It collaborated with other advocates and legislators to increase federal funding for supportive housing by about $450 million over the past three years alone and has had similar success at the state and local levels. To date, the CSH has helped to develop approximately 10,000 units of housing, with more in the pipeline, by leveraging $750 million in capital and $60 million in annual funding for services and operating costs. Foundations’ investments in individual housing projects and in the CSH’s policy work have resulted in a sevenfold return in public funding for supportive housing.

Another example of effective collaboration is work focused on depression in adults. Since the mid-1990s national and local funders have been working together to develop and test models for improving the recognition and treatment of adult depression by primary care providers. The MacArthur Foundation launched its model development initiative in 1995, and three years later the John A. Hartford Foundation extended the reach of the study in an initiative that focused on depression in the elderly. The RWJF provided funding for evaluation of the model targeting the elderly, and several local funders provided critical support for health care institutions testing the approaches, including the Jewish Healthcare Foundation of Pittsburgh, Hogg Foundation, and California HealthCare Foundation. Research has shown that the approaches developed through these initiatives are effective in identifying and treating depressed patients in primary care settings, and they are being disseminated nationwide.

Although foundations played an important role in funding mental health services and innovations throughout most of the twentieth century, the 1990s showed a relative decrease in foundations’ attention to mental health. This is a cause for concern. But there are also positive signs. For example, it appears that as new health foundations mature, they often develop giving portfolios in mental health. The CSH example shows how a mental health project was able to use a broad base of support from many foundations, including those that have no formalized giving programs in mental health, to leverage government dollars. Through efforts like these and with continued attention to raising the visibility and credibility of mental health initiatives within foundation circles, foundations could continue to play an important role in mental health.

Editor's Notes

Top Historical Perspective Recent Trends In Funding Challenges To Foundations’... Editor's Notes NOTES

 
Ruth Brousseau is director of evaluation and organizational learning at the California Wellness Foundation and is based in San Francisco. Donna Langill is a program associate at Grantmakers In Health, in Washington, D.C. Constance Pechura is a senior program officer at the Robert Wood Johnson Foundation, in Princeton, New Jersey.

The authors acknowledge Katherine Walker at the California Wellness Foundation for coordinating many aspects of this essay and Steven Lawrence at the Foundation Center, who provided much help with the data analyses and thoughtful comments about the paper.

NOTES

Top Historical Perspective Recent Trends In Funding Challenges To Foundations’... Editor's Notes NOTES

 

1. U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General (Rockville, Md.: DHHS, 1999).
2. G.N.Grob, From Asylum to Community: Mental Health Policy in Modern America (Princeton, N.J.: Princeton University Press, 1991).
3. H.A.Pincus and T. Fine, "The ‘Anatomy’ of Research Funding of Mental Illness and Addictive Disorders," Archives of General Psychiatry 49, no. 7 (1992): 573–579.[Abstract]
4. Grob, From Asylum to Community.
5. Some data are publicly available at www.fdncenter.org. This essay includes publicly available data and some commissioned analyses.
6. Grantmakers In Health, A Profile of New Health Foundations: May 2003 (Washington: GIH, 2003).
7. These numbers are based on Foundation Center (FC) annual data on mental health. The definition of mental health used in the FC’s grants taxonomy is as follows: "Programs that promote mental health and treatment of mental illness...; addiction and substance abuse treatment services; crisis intervention services.... Does not include programs that primarily deal with the prevention of crime...; or shelters and other aftercare services to victims of domestic violence." Foundation Center, "Grants Classification: Mental Health, Crisis Intervention," fdncenter.org/research/grants_class/taxf.html (7 July 2003).
8. At the time that this essay was prepared, 2000 was the most recent year for which Foundation Center data were available.
9. S.Lawrence, Health Funding Update (New York: Foundation Center, 2001).
10. E.Skloot, "Slot Machines, Boat-Building, and the Future of Philanthropy" (Inaugural address to the Waldemar A. Nielsen Issues in Philanthropy Seminar, Georgetown University, Washington, D.C., 5 October 2001).
11. L.Renz and S. Lawrence, Health Policy Grant-making: A Report on Foundation Trends (New York: Foundation Center, 1998).

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