Before 1963, individuals had no real alternatives other than state mental hospitals to treat their mental illnesses. The problem was, at the time, mentally ill patients were not only treated horribly by said hospitals but they were dealt with at an institutional level. This meant that the mentally ill were isolated from their communities which made it difficult to assimilate with society (Kliewer, 2009). As a reaction to the lack of community-integrative mental health centers, President John F. Kennedy signed Public Law 88-164 or the Community Mental Health Act of 1963 (CMHA).
The CMHA focused on three initiatives. First was to provide states federal funding to build community centers “for comprehensive treatment, training, and care of the mentally retarded”(Kennedy, 1963). Second was to construct inpatient, outpatient and satellite mental retardation treatment clinics to universities and other major medical centers. Third was to have Congress extend the funds available to train teachers of the mentally ill and to initiate funds for special research centers in human development (Berkowitz, 1980). Although there were multiple government agencies that regulated the act, it was mainly ensured by the Secretary of Labor and the Surgeon General (Community, 1963). The act’s overall aim was to decrease the number of mental health patients under custodial care by at least 50 percent in ten to twenty years (Berkowitz, 1980).
One interesting part of the act is Section 406, which states that “nothing in this Act shall be construed as conferring on any Federal officer or employee the right to exercise any supervision of control over the administration, personnel, maintenance, or operation of any facility for the mentally retarded or community mental health center” (Community, 1963). Although the act’s objective was to half the number of patients in state mental institutions, this section revealed that it was also to deinstitutionalize said institutions and deprive state governments of any power over community health care.
Although President Kennedy himself viewed the shape of mental health care as an “antiquated, vastly overcrowded, chain of custodial State institutions,” (Kennedy 1963) there were other motives in developing this act. The shift in policy towards community mental health services was also due to the Kennedy’s administration’s views on state government. During the civil rights movement, the Kennedy administration had a “profound distrust” of state governments and any state resistance in executing federal welfare programs. His administration decided that no federal funds should go to state mental institutions because said institutions would “violate the intent of a Democratic Congress” (Kofman, 2012). Another proponent in developing mental health programs and clinics was to promote community and political support among the poor for the Democratic Party since JFK’s election into office was in part a coalition of poor voters (Kofman, 2012). Some of those who opposed the act were conservatives who believed the act was a further expansion of the welfare state or feared that the federal government would ultimately leave the cost of their operation for the states to bear (Lewis, 2013).
The result of the CHMA were mixed. On the one hand, the CMHA completely changed the system and mental health care and counseling in the United States. The act offered support to construct mental health centers that provided community-based care as an alternative to institutionalization. It not only restructured how services were provided, but it also restructured who performed those services. Therapeutic services to patients with mental illnesses was initially restricted to the medical professionals, but was then also provided by non-medical professionals, such as counselors. Deinstitutionalization legislations that resulted from the CHMA decreased the United States mental asylum populations from 560,000 to just over 130,000 in 1980 (Kofman, 2012). Public opinion shifted into thinking that mental illness is curable (Kliewer, 2009). Many would say that the act was the appropriate response towards shutting down inhuman state mental institutions and developing community-integrative mental healthcare.
On the other hand, the deinstitutionalization movement had its downside. Those with chronic mental illnesses were part of mental asylum populations that decreased in 1980, but the majority of those types of patients had to be re-institutionalized from state hospitals into nursing homes, jails and prisons, or were left homeless. This was mainly because the CMHA failed to properly finance community follow-up care and housing. Initially the states were provided federal subsidies to develop the community mental health centers [CMHC], but the states failed to properly distribute adequate funding, leading to a mental health system deprived of resources. And ultimately in the later years, the act was not able to sustain itself because funding was cut both on a state and federal level (Kofman, 2012). Kennedy’s hopes were unrealized as the public and the community mental health system of the 21st century lies “in shambles” (Hogan, 2002).
Initially, the CMHA’s procedure in developing the needed CMHCs was not an issue. The act would altogether fund 789 centers for the following 13 years with a total of $2.7 billion ($13.3 billion in 2010 dollars) in federal outlays. Aside from construction, the act focused on financing five essential services: inpatient beds, partial hospitalization beds, 24-hour emergency evaluations, outpatient services, and consultation/education. And these five essential services were selected by Drs. Felix, Yolles, and Brown, with input from other NIMH staff. It can be said how the CMHA was enforced was because of Dr. Yolles, the NIMH director and the “key architect of the [community mental health] centers program” (Torrey, 2013).
In hopes of creating a community-integrative mental health system, Dr. Yolles then later encouraged the newly emerging centers to focus their resources on social problems as a means of preventing mental illness. Because NIMH was the source of their federal funding, the center directors followed his values accordingly. Between 1970 and 1972, a NIMH sponsored survey of 198 CMHCs found that its center directors ranked “the reduction of the incidence of mental disorders (prevention)” as its most important activity (Kofman, 2012). But despite how much Dr. Yolles advocated the importance of prevention, few CMHCs actually did much in this regard. The task Dr. Yolles had assigned were vague and the methods of prevention was a work in progress that did little in reducing incidence of mental disorders in the community. A 1970 NIMH survey reported that CMHCs spent on average between 3% and 4% of staff time in preventive activities, mostly teaching classes on parent and teacher effectiveness. And as mentioned by one CMHC director, the centers were “seldom congruent with those of other public services, voluntary agencies, and the formal and informal political power structure,” which are programs that noticeably impact the community (Kofman, 2012).
Aside from NIMH’s course of action, several acts and historical moments have also affected the implementation of the CMHA. From 1965 to 1969, federal outlay towards CMHCs dropped to $260 million. Then from 1970 to 1973, Richard Nixon drops funding lower to a total of $50.3 million (Kemp, 2007). Congress passed the Mental Health Systems Act of 1980 in efforts to continue funding and support for the remaining CMHCs (Kemp, 2007). A year later the Reagan Administration passed the Omnibus Budget Reconciliation Act of 1981 which effectively ended federal funding of community treatment for the mentally ill and burdened the CMHCs funding to state governments (Accordino, 2001). These and several other acts along with the rising cost of health care resulted in underfunded CMHCs. In addition, historical moments such as the Vietnam War drained the public purse, and the recession of the early 1980s weakened the CMHA (Rubin, 2007). However, there was one historical trends that has most prominently affected the act’s current state, the deinstitutionalization movement.
Deinstitutionalization was meant to be about providing an alternative to long-stay treatments (Sheth, 2009). However, public outrage on the SMIs inhumane conditions shifted the focus towards shutting down said institutions instead of reforming them. Even Dr. Yolles, as described by Dr. Brown in an interview, “hated the state hospitals and wanted to shut down those goddamn warehouses” (Kofman, 2012). The deinstitutionalization movement of the 1960s and 1970s went on to close nearly half the hospitals in the country, dramatically reduced bed capacity in remaining institutions, and left tens of thousands of seriously mentally ill people to fend for themselves.
The CMHCs treatment procedures, which were not fully developed, failed to properly address long-term aid for serious mental illnesses like schizophrenia and bipolar disorder which “are never a one-time problem” (Rubin, 2007). The act itself failed to mitigate these harms since its focus was funding the CMHCs rather than on how to structure the CMHCs to address the needs of those with severe illnesses. And without any backup, the remaining underfunded CMHCs became overwhelmed by demands they couldn’t fulfill. As one veteran recalls “We had no choice but to turn people out into the street…The state hospital, the place of last resort, was gone; there were no halfway homes, no treatment programs, nothing” (Accordino, 2001). In addition, the U.S. Department of Justice found that during the same period when 40 mental health hospitals have closed in the past decade, 400 new prisons have opened up and that 16 percent of those incarcerated have been identified as mentally ill (Kemp, 2007).
There have been efforts in addressing the problem of incarcerating the mentally ill. On November 2000 Congress introduced the America’s Law Enforcement and Mental Health Project (H.R. 2594), which appropriated $4 million in 100 pilot courts that specialize in mental health (PBS). These specialized courts were not only made to relieve pressure on general courts but they also direct nonviolent mentally ill offenders out of jail into long term treatment. Through from establishing special courts the rights of the mentally ill patients would be protected as well as effectively reduce recidivism (Kemp, 2007).
The deinstitutionalization movement reveals that CMHCs have more difficulty providing long-term treatment for the chronically ill than mental institutions do. Rather than building massive, warehouse-like state hospitals that have poor human right records and are difficult to manage, the alternative is to build more psychiatric hospitals on a district and county level with adequate staffing. One suggestion is for the hospitals to establish complexes that focuses on recuperating and rehabilitating patients in society. This will be helpful for those who suffer from severe illnesses, such as schizophrenia or bipolar disorder, and are homeless, which are people who often lack family or communal support. The facilities should also be accessible to family members so that they would be able to visit a patient and the hospitals would be under an indirect vigil of the community. This would reduce incidence of human right violations and would make the atmosphere similar to that of general hospitals (Kemp, 2007). Much like the CMHA itself, these additions and reforms are works in progress, but hopefully there will exist an effective community mental health system that provides quality care at a low cost to those who most need it.
Accordino, M. P., Porter, D. F. & Morse, T. (April 2001). Deinstitutionalization of Persons with Severe Mental Illness: Context and Consequences. Journal of Rehabilitation. 67 (2): 16–21.
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