Still Pursuing the Promise of Reform Fifty Years Later

lossy-page1-478px-Portrait_Photograph,_President_John_F._Kennedy._White_House,_07-11-1963_-_NARA_-_194255Today marks the 50th anniversary of the Community Mental Health Act of 1963, a major landmark in America’s history of mental health rights. Signed into law by President John F. Kennedy on October 31, 1963, the Act was the first of several federal policy changes that helped spark a major transformation of the public mental health system by shifting resources away from large institutions towards community-based mental health treatment programs. Although this beginning of the larger deinstitutionalization movement lead to great advances in the rights of and treatment options for children, youth, and adults living with mental illness, the full promise of community-based care has yet to be fully realized.

Described as “a bold new approach” by President Kennedy, the Community Mental Health Act was the first federal law to encourage community-based mental health care. The Act provided grants to states for the construction of community mental health centers (CMHC), facilities specially designed for the delivery of mental health prevention, diagnosis, and treatment services to individuals residing in the community. Each center was required, at a minimum, to provide five essential services: consultation and education on mental health, inpatient services, outpatient services, emergency response, and partial hospitalization. The grant program was intended to provide 1,500 new community mental health centers nationwide.

Community-based Care Proposed

The Community Mental Health Act represented a major shift in federal policy. Prior to its passage, most resources were channeled towards institutional-based care. Rates of institutionalization had exploded over the prior half-century: by the mid-1950s, over half a million children and adults were institutionalized for mental illness. This number represented a thirteen-fold increase overall and a growth rate nearly five times that of the general population since the late 1800s.

In the decade leading up to the passage of the Community Mental Health Act, public sentiment regarding the practice of institutionalization began to change. Experts began to question the efficacy of institutional care as new evidence-based treatment options became available, including development of psychiatric medication. Some criticized institutionalization as lacking the ability to treat the individual more holistically while others concluded that the practice actually worsened patients’ mental conditions.

Additionally, growing awareness of the inhumane conditions in many psychiatric hospitals lead to public pressure to create treatment alternatives. Some of the larger state institutions housed tens of thousands of patients, greatly outnumbering the often ill-trained staff members. Media coverage in major newspapers and national magazines such as Readers Digest and Life Magazine detailed the rampant abuse and neglect that was all too common in these institutions. Most patients were warehoused in these institutions for long periods of time without treatment or care­—by 1963, the average length of stay for a patient diagnosed with schizophrenia was 11 years. 

Facing growing public pressure to transform the public mental health system, President Kennedy proposed the Community Mental Health Act, the first of several federal initiatives to create a community-based system of care. In his message to Congress proposing the legislation, President Kennedy emphasized the need for a new national mental health policy:

Kennedy-Quote

Dramatic Decline in Institutionalization

Few anticipated how quickly President Kennedy’s aspiration of reducing the institutional population by half would be realized. By 1980, the inpatient population at public psychiatric hospitals had declined by 75%. In 2000, approximately 55,000 remained in these institutions, representing less than 10% of those institutionalized just fifty years prior. The shift was especially pronounced among children and youth: by 2009, the institutionalized population had declined by 98%.

This rapid shift in population, commonly known as “deinstitutionalization,” was encouraged by federal legislation, policy changes, and litigation that incentivized and eventually mandated public mental health systems to shift the locus of care to the community. In 1965, Congress passed the Medicaid Act, which offered higher reimbursement rates for community-based care and excluded payments to mental health institutions. A few years later, the Supplemental Security Income (SSI) disability benefits program provided direct financial support for eligible individuals with mental illness living in the community. Over the next few decades, mental health advocates secured critical recognition by the judicial system of their client’s civil liberties, including requiring due process protections in involuntary commitment proceedings and mandating treatment in the least restrictive environment appropriate for meeting individuals’ needs.

Insufficient Alternatives to Institutionalization

Despite this progress, however, public mental health systems largely failed to develop sufficient resources and staffing adequate to treat and support individuals in home and community-based settings. The service array in many communities was, and often continues to be, insufficiently comprehensive and intensive to meet the needs of young people and adults returning from or at risk of institutional care. Many public mental health systems were, and remain, critically underfunded and understaffed.

Without adequate services and supports available in the community, many individuals living with mental illness struggle to remain safely in their own homes and communities. Some of the symptoms of our inadequate public mental health system include increased risks of homelessness, substance abuse disorders, suicide, and incarceration among mentally ill children, youth, and adults. The nation’s three largest public mental health providers are correction systems: Los Angeles County, Rikers Island in New York, and Cook County in Illinois. Juvenile justice experts estimate that as many as 70% of detained youth have a diagnosable mental disorder and 20% have a serious mental illness. Tens of thousands of families relinquish custody of their children to child welfare and juvenile justice systems each year in order to access mental health services that are otherwise unavailable in the community.

Fifty years on, the promise of the Community Mental Health Act is yet to be fully realized.  Shuttering institutions without expanding community-based funding and services has imposed severe hardships on many children, families and communities.  But the fundamental principles of community care espoused in the Act provided the vision and foundation for substantial progress.  In the five decades since President Kennedy challenged wholesale institutionalization, the Nation’s laws and institutions have broadly rejected “methods of treatment which imposed upon the mentally ill a social quarantine, a prolonged or permanent confinement…”

Significant work remains to be done, however, to realize the full promise of the Community Mental Health Act and community-based care.  Young Minds is working towards the goal of providing treatment to young people and their families in their own homes and communities, in part through litigation, such as T.R. v. Dreyfus. By ensuring that needed community-based services and supports are offered and funded as a matter of right, this lawsuit, and others like it, is helping to secure the promise made by President Kennedy and the Congress 50 years ago.

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Photo Credit: John F. Kennedy 1963 (Wikimedia Commons)