The Half-Delivered Promise of the Community Mental Health Act

Fifty-one years ago, President John F. Kennedy enacted the Community Mental Health Act of 1963 (CMHA). The law aimed to shift the focus of mental health treatment from large institutions to home and community-based services to better serve the needs of those diagnosed with mental illness.

Envisioned as a “bold new approach” to mental health treatment by President Kennedy, the CMHA paved the way for the construction of mental health centers to serve individuals within their own communities. This was a major change for mental health policy, which until then had been focused on large-scale institutions, eventually housing over half a million children and adults for mental health treatment by the mid-1950s.

However, advances in treatment options and the growing awareness of the often-hostile conditions in these institutions helped shift public opinion away from the established system. Faced with these changes, President Kennedy proposed a “wholly new emphasis and approach to care for the mentally ill,” focused on a community-based system of care.

The CMHA and other policy changes sparked a huge change in institutionalization rates, which declined by about 90 percent between 1950 and 2000. However, while mental health institutions around the country were closed, the community-based treatment options to replace them were never sufficiently implemented.

In fact, only about half of the proposed health centers were ever built, and even those were not given the funding and staffing resources needed to treat and support individuals in home and community settings. Inadequate funding and few alternatives left those in need of treatment with nowhere to turn, leading to chronic homelessness, substance abuse, and often incarceration. This paradox has led to an ironic development: in a post-institutional system, the three largest mental health providers in the state today are jails.

Unfortunately this trend is also true for young people with mental health needs, especially those involved in the child welfare system. Too often the traditional approach to meeting the mental health needs of children with serious behavioral and emotional disorders has been to institutionalize youth in group homes or psychiatric facilities, or detain young people in juvenile halls and jails because more appropriate alternatives are unavailable. A lack of community-based alternatives can be especially damaging for young people, whose development can be deeply affected by the absence of close ties to their family members, a caregiver, or their community.

Advocates, providers, parents, young people, and others are seeking to fix this broken system by developing intensive home and community-based mental health services to improve the effectiveness of treatment and achieve better outcomes for families and children. Towards this goal, some advocates have sought to enforce the rights of Medicaid-eligible children and youth to appropriate care through lawsuits such as Katie A. v. Bonta.

Settled in 2011, Katie A. recognizes the rights of California’s foster youth to receive needed services and supports in their own homes and communities, consistent with the CMHA’s aims. Nearly three years later, advocates and stakeholders are seeking to fully implement the Katie A. Settlement Agreement and thereby ensure that all eligible children in California (estimated to include more than 35,000 youth) are afforded intensive home and community-based services, rather than less effective or more restrictive treatment.

While the Community Mental Health Act’s shift away from institutional care reshaped mental health treatment for the better, without greater fiscal and political support for community-based mental services, the lofty goals of President Kennedy will continue to go unmet. In California, children and youth continue to face significant barriers to accessing intensive services in their own homes and communities.

In order to realize the promise of reform offered by legislation like CMHA or lawsuits such as Katie A., stakeholders must continue to advocate that needed community-based services and supports are offered and funded as a matter of right.

Emily Bisnett is a staff attorney for Young Minds Advocacy Project.

Note: This post was originally posted on Young Minds Advocacy Project‘s blog, “Hear Me Out,” on Oct. 31.

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Young Minds Advocacy is a nonprofit organization based in San Francisco, California that uses strategic advocacy and communications to help youths and their families to access mental health services and supports, and improve mental health system performance and accountability.

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