Why is the community mental health Act of 1963 still relevant today

The Community Mental Health Act of 1963, was the first federal law that inspired community-based mental health care, and it ignited the transformation of the public mental health system (Young Minds Advocacy, 2016). Other names of the Act are Mental Retardation and Community Mental Health Centers Construction Act of 1963. It was the beginning of the Deinstitutionalized movement in mental health treatment options for children, youth, and adults (National Council for Behavioral Health (NCBH), 2015). States received money from grants, from the Community Mental Health Act for the construction of these mental health centers. Initially, the intention of the grant program was to provide 1500 mental health centers nationally (Young Minds…show more content…
Institutional care was condemned, as in many cases patients’ mental conditions deteriorated, and institutions were not able to treat the individual in a holistic manner. In many state institutions, patients numerously outnumbered the poorly trained staff. Many patients were boarded in these facilities for extensive periods of time without receiving any services. By 1963, the average stay for an individual with a diagnosis of schizophrenia was eleven years. As the media and newspapers publicized the inhumane conditions that existed in many psychiatric hospitals, awareness grew and there was much public pressure to create improved treatment options (Young Minds Advocacy, 2016). .
In an effort to transform the public mental health system, in 1963, President Kennedy proposed the Community Mental Health Act. It was the first among several federal initiatives to create a community mental health care system. Once the act was ratified, there was an intense deterioration in institutionalization, otherwise known as “deinstitutionalization”, and by 1980 there was a 75% declined of the inpatient population at many public psychiatric hospitals. In 2000, there was less than 10% of the public institutionalized just fifty years earlier. In 2009, there was even a more dramatic shift among children and adolescence whereby there was a 98% decline in

President John F. Kennedy signs the Community Mental Health Act into law on October 31, 1963. (PHOTO: BILL ALLEN/AP)

Fifty years ago, President John F. Kennedy signed the Community Mental Health Act. The law signaled a shift in thinking about how we care for the mentally ill: instead of confining them into institutions, the act was supposed to create community mental health centers to provide support.

But studies on the prevalence of mental illness among inmates and the homeless (PDF) show many patients are ending up on the street or in jail, instead of served by the treatment centers envisioned in the law. The homes that do exist are often subject to loose laws and regulations, leaving already fragile patients vulnerable to further abuse and neglect.

How far have we come? Here are some important reads on the state of mental health care today.

• Milwaukee County Mental Health System Traps Patients in Cycle of Emergency Care, Milwaukee Journal Sentinel, June 2013
In Wisconsin, psychiatric patients are often put through a revolving door of treatment: Experience a breakdown. Get arrested and brought to the emergency ward. Be released just a few days later. Repeat. Overall, "one of every three persons treated at the [psychiatric] emergency room returns within 90 days."

• Schizophrenic. Killer. My Cousin., Mother Jones, May 2013
When a parent is faced with an ill, potentially violent child, where can they turn? Journalist Mac McClelland details how community outreach in the 1970s and 1980s allowed her aunt to stay "independent until the very end." Thirty-four years and billions of dollars in mental health cutbacks later, her cousin's battle with schizophrenia came to a much more tragic conclusion.

• Nevada Buses Hundreds of Mentally Ill Patients to Cities Around Country, Sacramento Bee, April 2013
Psychiatric patient James Flavy Coy Brown got off a bus in Sacramento with no money, no medication, and no idea why he was there. He'd been sent to the California capital from a hospital in Las Vegas, who had regularly been discharging patients and busing them across the country. Patients are only supposed to be sent to other states when there's a clear plan for their care. But stories like Brown's show how many patients fall through the cracks.

• ‘Boarding' Mentally Ill Becoming Epidemic in Washington State, Seattle Times, October 2013
The number of available psychiatric beds in Washington state is shrinking. When those few spots are full, the state is increasingly turning to its emergency rooms and hospitals to "warehouse" the mentally ill. Patients are forced to wait an average of three days, but sometimes up to several months, without any psychological treatment.

• Breakdown: In Rural Minnesota, Mental Health Safety Net Is in Limbo, Minneapolis Star Tribune, October 2013
Minnesota ranked last in 2010 for psychiatric beds per capita. "The safety net is pretty much gone," said one mental health worker. And a Star investigation found that the few community mental health centers that are available are often ill-equipped to cope with severe disorders.

• At Homes for the Mentally Ill, a Sweeping Breakdown in Care, Miami Herald, February 2013
Even if Miamians struggling with mental illness avoid arrest, the county's homes for the mentally ill can "still feel like a jail." The Herald's investigation revealed a wide range of abuse and neglect, from staff who were beating and raping residents to ignoring their severe medical needs. And like other assisted living facilities, a patchwork of lax oversight and regulation has allowed even repeat offenders to remain in operation.

• Dallas Psych ER Staff Accused of Violence Were Kept on Duty, Dallas Morning News, November 2011
Instead of emergency care, psych patients admitted to Parkland Memorial Hospital reported receiving beatings at the hands of staff. The Morning News found many staff members were hired despite a history of abuse, and allowed to keep their jobs even after the alleged beatings. "It's supposed to be a safe place," said one patient. "I felt like I was in prison."

• Walter Reed and Beyond: A Soldier's Officer, Washington Post, December 2007
Anne Hull and Dana Priest spotlighted systemic mistreatment and neglect at Walter Reed Army Medical Center, and several other veterans health facilities across the country. Vets seeking psychological care faced dizzying bureaucracy and an under-resourced system buckling under high demand. Though Walter Reed was home to the army's largest psychiatric department, there was no specific PTSD center, and patients rarely received individual attention.

• The New Asylums, Frontline, May 2005
Frontline documents the movement of America's mentally ill away from closing psychiatric hospitals, and into the nation's jails and prisons. The result is a massive strain on the minds of afflicted inmates, and on the strapped prison system tasked with treating them.

• Broken Homes, New York Times, April 2002
Adult homes for the severely mentally ill were meant to be an improvement over New York's long-shuttered psychiatric wards. But a year-long investigation by the Times found a for-profit system neglecting vulnerable residents. The Times investigation found nearly 1,000 deaths at 26 adult homes across the city from 1995 to 2001, including cases of suicide, death at the hands of other residents, death from treatable ailments, and patients left to die after "roasting in their rooms during heat waves."

This post originally appeared onProPublica, a Pacific Standard partner site.

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.

References

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.

Berkowitz, E. D. (1980). The Politics of Mental Retardation During the Kennedy Administration. Social Science Quarterly (University Of Texas Press), 61(1), 139-141.

Community Mental Health Act of 1963, Pub. L. No. 88-164, § 406, 761 Stat. 77 (1963) Retrieved September 23, 2016, from https://history.nih.gov/research/downloads/PL88-164.pdf

Hogan, M. F., (2002, October 29). President’s New Freedom Commission on Mental Health. Retrieved November 03, 2016, from http://govinfo.library.unt.edu/mentalhealthcommission/reports/interim_letter.html

Kemp, D. R. (2007). Mental Health in America. Contemporary World Issues. Santa Barbara, CA: ABC-CLIO.

Kennedy, J. F. (1963, February 5). Special Message to the Congress on Mental Illness and Mental Retardation. Retrieved September 23, 2016, from http://www.presidency.ucsb.edu/ws/?pid=9546.

Kliewer, S. P., McNally, M., & Trippany, R. L. (2009). Deinstitutionalization: Its Impact on Community Mental Health Centers and the Seriously Mentally Ill .The Alabama Counseling Association Journal, Volume 35, Number 1. Retrieved September 23, 2016, from http://files.eric.ed.gov/fulltext/EJ875402.pdf

Kofman, O. L. (2012, April 23). Deinstitutionalization and Its Discontents: American Mental Health Policy Reform (2012). CMC Senior Theses. Paper 342.  25-34. Retrieved September 23, 2016, from http://scholarship.claremont.edu/cgi/viewcontent.cgi?article=1348&context=cmc_theses

Lewis, C. (2013, June 10). Can Community Mental Health Centers be Reinvented? . CRISP. Retrieved December 4, 2016, from http://crispinc.org/2013/06/10/can-community-mental-health-centers-be-reinvented

Rubin, L. B. (2007). Sand Castles & Snake Pits: Homelessness, Public Policy, & the Law of Unintended Consequences,” Dissent Magazine.

Sheth, H. C. (2009). Deinstitutionalization or Disowning Responsibility. International Journal of Psychosocial Rehabilitation. Volume 13, Number 2. 11-20. Retrieved October 31, 2016, from http://www.psychosocial.com/IJPR_13/Deinstitutionalization_Sheth.html

Torrey, E. F. (2013). American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System. Oxford University Press.