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Community Mental Health

Community mental health services refer to a system of care in which the patient’s community, not a specific facility such as a hospital, is the primary provider of care for people with a mental illness. The goal of community mental health services often includes much more than simply providing outpatient psychiatric treatment. Services may also provide the patient with general case management services such as help finding housing, employment, and appropriate recreational activities.

History

Origins

Community mental health services began as an effort to contain those who were “mad” or considered “lunatics.” Understanding the History of mental disorders is crucial in understanding the development of community mental health services. As psychology developed as a science and shifted toward the treatment of the mentally ill, psychiatric institutions began to develop around the world, and laid the groundwork for modern day community mental health services.

Pre-Deinstitutionalization

On July 3rd, 1946 President Harry Truman signed the National Mental Health Act which, for the first time in the history of the United States, generated a large amount of federal funding for both psychiatric education and research. The passing of this Act eventually led to the founding of the National Institute of Mental Health (NIMH) in 1949. At the end of the 1940’s and moving into the beginning of the 1950’s, the governor of Minnesota Luther Youngdahl initiated the development of numerous community-based mental health services. He also advocated for the humane treatment of people in state institutions.

Deinstitutionalization

Philippe Pinel played a large role in the ethical and humane treatment of patients and greatly influenced Dorothea Dix. Dix advocated the expansion of state psychiatric hospitals for patients who were at the time being housed in jails and poor houses. Despite her good intentions, rapid urbanization and increased immigration led to a gross overwhelming of the state’s mental health systems and because of this, as the 19th century ended and the 20th century began, a shift in focus from treatment to custodial care was seen. As quality of care declined and psychotropic drugs were introduced, those with mental illnesses were reintroduced to the community, where community mental health services were designated as primary care providers.

Mental Health Movements

Reform Movement	Era	Setting	Focus of Reform
Moral Treatment	1800-1850	Asylum	Humane, restorative treatment
Mental Hygiene	1890-1920	Mental hospital or clinic	Prevention, scientific orientation
Community Mental Health	1955-1970	Community mental health center	Deinstitutionalization, social integration
Community Support	1975-present	Communities	Mental illness as a social welfare problem (e.g. treatment housing, employment)

Post-Deinstitutionalization

Following deinstitutionalization, many of the mentally ill ended up in jails, nursing homes, and on the streets as homeless individuals. It was at this point in history that modern community mental health services started to grow and become influential. In 1955, following a major period of deinstitutionalization, the Mental Health Study Act was passed. With the passing of this Act, the U.S. Congress called for “an objective, thorough, nationwide analysis and reevaluation of the human and economic problems of mental health.” Following Congress’ mandate, the Joint Commission on Mental Illness conducted numerous studies. For the next four years this Commission made recommendations to establish community mental health centers across the country. In 1963 the Community Mental Health Centers Act was passed, essentially kick-starting the community mental health revolution. This Act contributed further to deinstitutionalization by moving mental patients into their “least restrictive” environments. The Community Mental Health Centers Act funded three main initiatives:

1. Professional training for those working in community mental health centers
2. Improvement of research in the methodology utilized by community mental health centers
3. Improving the quality of care of existing programs until newer community mental health centers could be developed.

That same year the Mental Retardation Facilities and Community Mental Health Centers Construction Act was passed. President John F. Kennedy ran part of his campaign on a platform strongly supporting community mental health in the United States. Kennedy’s ultimate goal was to reduce custodial care of mental health patients by 50% in ten to twenty years. In 1965, the Community Mental Health Act was amended to ensure a long list of provisions. First, construction and staffing grants were extended to include centers that served patients with substance abuse disorders. Secondly, grants were provided to bolster the initiation and progression of community mental health services in low-SES areas. Lastly, new grants were established to support mental health services aimed at helping children. As the 20th century progressed, even more political influence was exerted on community mental health. In 1965, with the passing of Medicare and Medicaid, there was an intense growth of skilled nursing homes and intermediate-care facilities that alleviated the burden felt by the large-scale public psychiatric hospitals.

The 20th Century

From 1965 to 1969, $260 million was authorized for community mental health centers. Compared to other government organizations and programs, this number is strikingly low. Unfortunately, the funding drops even further under Richard Nixon from 1970 – 1973 with a total of $50.3 million authorized. Even though the funding for community mental health centers was on a steady decline, deinstitutionalization continued into the 1960’s and 1970’s. The number of state and county mental hospital resident patients in 1950 was 512,501 and by 1989 had decreased to 101,402. This continuing process of deinstitutionalization without adequate alternative resources led the mentally ill into homelessness, jails, and self-medication through the use of drugs or alcohol. In 1975 Congress passed an Act requiring community mental health centers to provide aftercare services to all patients in the hopes of improving recovery rates. In 1980, just five years later, Congress passed the Mental Health Systems Act, which provided federal funding for ongoing support and development of community mental health programs. This Act strengthened the connection between federal, state, and local governments with regards to funding for community mental health services. It was the final result of a long series of recommendations by Jimmy Carter’s Mental Health Commission. Despite this apparent progress, just a year after the Mental Health Systems Act was passed, the Omnibus Budget Reconciliation Act of 1981 was passed. The Omnibus Act was passed by the efforts of the Reagan administration as an effort to reduce domestic spending. The Act rescinded a large amount of the legislation just passed, and the legislation that was not rescinded was almost entirely revamped. It effectively ended federal funding of community treatment for the mentally ill, shifting the burden entirely to individual state governments. Federal funding was now replaced by granting smaller amounts of money to the individual states. In 1977, the National Institute of Mental Health (NIMH) initiated its Community Support Program (C.S.P.). The C.S.P.’s goal was to shift the focus from psychiatric institutions and the services they offer to networks of support for individual clients. . The C.S.P. established the ten elements of a community support system listed below:

1. Responsible team
2. Residential care
3. Emergency care
4. Medicare care
5. Halfway house
6. Supervised (supported) apartments
7. Outpatient therapy
8. Vocational training and opportunities
9. Social and recreational opportunities
10. Family and network attention

(Turner & Tenhoor, 1978)

This conceptualization of what makes a good community program has come to serve as a theoretical guideline for community mental health service development throughout the modern-day United States psychological community. In 1986 Congress passed the Mental Health Planning Act of 1986, which was a Federal law requiring that at the state government level, all states must have plans for establishing case management under Medicaid, improving mental health coverage of community mental health services, adding rehabilitative services, and expanding clinical services to the homeless population. More specifically, community mental health providers could now receive reimbursement for services from Medicare and Medicaid, which allowed for many of the centers to expand their range of treatment options and services. As the 1990’s began, many positive changes occurred for people with mental illnesses through the development of larger networks of community-based providers and added innovations with regards to payment options from Medicare and Medicaid. Despite these advancements, there were many issues associated with the increasing cost of health care. Community mental health services moved toward a system more similar to managed care as the 1990’s progressed. Managed care as a system focuses on limiting costs by one of two means: either keeping the total number of patients using services low or reducing the cost of the service itself. Despite the drive for community mental health, many physicians, mental health specialists, and even patients have come to question its effectiveness as a treatment. The underlying assumptions of community mental health require that patients who are treated within a community have a place to live, a caring family, or supportive social circle that does not inhibit their rehabilitation. These assumptions are in fact often wrong. Many people with mental illnesses, upon discharge, have no family to return to and end up homeless. While there is much to be said for the benefits that community mental health offers, many communities as a whole often harbor negative attitudes toward those with mental illnesses. Historically, people with mental illnesses have been portrayed as violent or criminal and because of this, “many American jails have become housing for persons with severe mental illnesses arrested for various crimes.” In 1999 the Supreme Court ruled on the case Olmstead v. L.C. The Court ruled that it was a violation of the Americans with Disabilities Act of 1990 to keep an individual in a more restrictive inpatient setting, such as a hospital, when a more appropriate and less restrictive community service was available to the individual.

21st Century & Modern Day Trends

In 2002 President George W. Bush increased funding for community health centers. The funding aided in the construction of additional centers and increased the number of services offered at these centers, which included healthcare benefits. In 2003, the New Freedom Commission on Mental Health, established by President Bush, issued a report. The report was in place to "conduct a comprehensive study of the United States mental health delivery system..." Its objectives included assessing the efficiency and quality of both public and private mental health providers and identifying possible new technologies that could aid in treatment. As the 20th century came to a close and the 21st century began, the number of patients diagnosed with a mental health or substance abuse disorder receiving services at community mental health centers grew from 210,000 to approximately 800,000. This nearly four-fold increase shows just how important community mental health centers are becoming to the general population’s wellbeing. Unfortunately, this drastic rise in the number of patients was not mirrored by a concomitant rise in the number of clinicians serving this population. The staggering new numbers of patients then are being forced to seek specialized treatment from their primary care providers or hospital emergency rooms. The unfortunate result of this trend is that when a patient is working with his or her primary care provider, he or she is more likely for a number of reasons to receive less care than with a specialized clinician. Politics and funding have always been and continue to be a topic of contention when it comes to funding of community health centers. Political views aside, it is clear that these community mental health centers exist largely to aid areas painfully under resourced with psychiatric care. In 2008, over 17 million people utilized community mental health centers with 35% being insured through Medicaid, and 38% being uninsured. As the 2000’s continued, the rate of increase of patients receiving mental health treatment in community mental health centers stayed steady.

The Future

On one hand, despite the field’s movement toward community mental health services, currently “insufficient empirical research exists regarding the effectiveness of community treatment programs, and the evidence that does exist does not generalize to all types of community treatment.” In addition to the fact that community mental health’s overall success must be further evaluated, in the times when it has proved effective, very little research exists to help in understanding what exact aspects make it effective. Effective and insightful research will be crucial in not only evaluating, but also improving the techniques community mental health utilizes. On the other hand, the demand for and necessity of community mental health is driving it into the future. With this seemingly unrelenting increase in the number of people experiencing mental health illnesses and the number of people reporting these problems, the question becomes what role will community mental health services play? In 2007, almost 5% of adults in the United States reported at least one unmet need for mental health care. Funding has historically been and continues to be an issue for both the organizations attempting to provide mental health services to a community and the citizens of the community who are so desperately in need of treatment. The community mental health system’s goal is an extremely difficult one and it continues to struggle against changing social priorities, funding deficits, and increasing need. Community mental health services would ideally provide quality care at a low cost to those who need it most. In the case of deinstitutionalization, as the number of patients treated increased, the quality and availability of care went down. With the case of small, private treatment homes, as the quality of the care went up their ability to handle large numbers of patients decreased. This unending battle for the middle ground is a difficult one but there seems to be hope. For example, the 2009 Federal Stimulus Package and Health Reform Act have increased the funding for community health centers substantially. Undoubtedly as community mental health moves forward, there will continue to be a juggling act between clinical needs and standards, political agendas, and funding.

References

• Grob, G. N. (1991). From Asylum to Community: Mental Health Policy in America. Princeton, NJ: Princeton University Press.

• Donaldson, L. (2005). "Collaboration Strategies for Reforming Systems of Care: A Toolkit for Community-Based Action". International Journal of Mental Health. 34: 90–102.