Prior to the nineteenth century, mental illnesses were often regarded as moral, spiritual, or supernatural problems. The accepted treatment involved, at best, isolation in mental asylums. Dramatic changes took place internationally in public attitudes about the mentally ill in the nineteenth and twentieth centuries. Several prominent mental health professionals developed and applied fresh ideas about public health, bringing about the evolution of an improved, state-controlled psychiatric hospital system. The concepts of disease prevention and cure were considered in psychiatry for the first time, and several powerful mental health advocacy groups were born. In the United States, an influx of experienced doctors returning home after treating combat-related mental disorders in World War II, combined with the discovery of effective psychiatric medicines like chlorpromazine, spurred the belief that severe mental illnesses could be cured.
The modern community mental health movement emerged in the 1960s in an effort to improve the psychiatric treatment of a particular group of patients, known as the severely and persistently mentally ill (SPMI). By the early 1960s, state hospitals had become a financially burdensome system of warehouses for the SPMI. In 1963, President John F. Kennedy invited "a bold new approach" to the treatment of the SPMI. Congress developed a plan for deinstitutionalization, or depopulation of the state psychiatric institutions, in favor of a federally funded system of community-based mental health centers (CCMHC).
According to the plan, government funding would be reduced over eight years. As the eight-year deadline approached, it became clear that the clinics could not function without federal funds, and the deadline was extended. In the 1980s, the Reagan administration passed a law to fund the clinics with federal block grants that would ultimately expire, leaving the CMHCs without federal funding. In contrast to the optimistic projections endorsed by the Reagan administration, it seems clear that the cost of caring for the SPMI will always be, to some extent, the responsibility of the government. What remains unclear is to what degree public funds will be used in this endeavor.
CMHC treatment applies several basic concepts.
- Fixed responsibility. The CMHC remains active in the long-term care of its assigned patients, regardless of whether the patient is hospitalized, in crisis, temporarily lost to follow-up, or stable.
- Community collaboration. The success of the CMHC depends on the ability of staff members to collaborate with local law enforcement officials, social service providers, government agencies, hospitals and clinics, and community leaders.
- Outreach. CMHCs employ diverse methods to introduce services to the homeless and other difficult-to-reach groups.
- Integration of services. The multiple needs of the SPMI require an active, organized, multiagency treatment system, with the CMHC serving as a central manager for this system of services.
- Continuity of care. Consistent, effective treatment relationships can be established by pairing patients with treatment teams on a long-term basis in which the same staff members directly provide outreach, evaluation, and follow-up care.
- Respect for patients' civil rights. Decisions regarding patients' medications and overall psychiatric care are made with the patient's input and consent whenever possible, including the concept of least restrictive alternatives, which recognizes patients' rights to receive treatment in a setting that balances individual freedom with the safety of the individual and the community.
Several functional elements comprise the CMHC, each addressing particular needs of the SPMI in specific ways. Crisis and emergency services are necessary to evaluate patients when they are acutely ill or suffering from overwhelming symptoms and to direct them to crisis treatment resources. Some CMHCs have mobile teams that can be dispatched to assess patients at home or on the streets. Brief hospital treatment is reserved for patients who are suddenly unable to deal with their symptoms in the community environment despite CMHC support. The main goal of acute hospitalization is to rapidly stabilize patients until they can safely return to the community. Rarely, usually after multiple brief hospitalizations in a limited time period, long-term hospital treatment may be recommended for some patients.
Long-term treatment in the CMHC system is provided in an outpatient clinic setting. Several professions are involved in providing treatment, but the main specialties represented are psychiatry, social work, and nursing. These disciplines provide medications, emotional support, personal advocacy, and organization of social networks. Although CMHCs are effective for many populations, the homeless SPMI remain a particularly complex group to treat. The size of this group is difficult to compute accurately, but estimates suggest that at least one-third of homeless people suffer from mental illnesses. Providing services remains a difficult challenge for society.
(SEE ALSO: Substance Abuse, Definition of)
Bibliography
Kaplan, H. I., and Sadock, B. J., eds. (1995). Comprehensive Textbook of Psychiatry, 6th edition. Baltimore, MD: Williams and Wilkins.
Naierman, N. et al. (1978). Community Mental Health Centers: A Decade Later. Cambridge, MA: ABT Books.
— TODD MITCHELL; STUART J. EISENDRATH
