Origins Of The Community Mental Health Movement In Twentiethcentury America

Widespread implementation of conceptions of community mental health did not begin in America until the early 1960s, even though these ideas and practices had numerous roots that originated both in previous centuries and in other nations. In fact, several scholars date the origins of interest in prevention as an alternative to treatment back to the twelfth-century Spanish philosopher Maimonides who spoke of "preventing poverty.''

Returning to more recent history, in 1961, in response to a Congressional mandate the final report of the Joint Commission on Mental Illness and Health entitled Action for Mental Health was released. Among other things, it called for improved and expanded mental health services including: (a) improved care in small psychiatric hospitals of chronically mentally ill patients; (b) improved and expanded aftercare services, both partial hospitalization and rehabilitation in the community; (c) intensive care for acutely disturbed mental patients in mental health clinics in the community, general hospital psychiatric units, or in small intensive psychiatric centers; and (d) increased efforts at public education about both psychological disorders and the citizenry's inclination to reject the mentally ill.

President John F. Kennedy was extremely receptive to the Action for Mental Health report. In a message delivered in 1963, he stated:

we must seek out the causes of mental illness . . . and eradicate them . . . For prevention is far more desirable . . . more economical and it is far more likely to be successful. Prevention will require both specific programs directed especially at known causes, and the general strengthening of our fundamental community, social welfare, and educational programs which can do much to eliminate or correct the harsh environmental conditions which are often associated with mental retardation and illness (p. 2).

Comprehensive care available to all people in their local communities was central to his clarion call for a "bold new approach.'' These concepts were enacted into legislation as part of the Community Mental Health Centers Act of 1963.

As a result of this legislation, some 1500 catchment areas (currently referred to as mental health service areas) with populations ranging from 75,000 to 200,000 people were created in the United States; each catchment area was eligible for federal construction and staffing funds for a community mental health center. These centers were mandated initially to offer inpatient care, outpatient care, emergency services, partial hospitalization, and consultation and education, and ultimately to include diagnostic services, rehabilitation services, precare and aftercare services, training, and research and evaluation.

Both implicitly and explicitly, the goals of the Joint Commission on Mental Illness and Health, the Kennedy Administration, and the Community Mental Health Centers Act were to provide more humane and effective rehabilitation to those who were severely mentally ill. Patients needed to be integrated into their local communities and smaller treatment settings in contrast to huge, anonymous state hospitals in remote physical locations. Most importantly, they needed continuity of care, as indicated by the array of services to be offered by the local community mental health center.

Several other factors converged with this more humane and progressive approach to the treatment of the chronically mentally ill that were critical to the implementation of this movement toward deinstitution-alization. The use of phenothiazines made it more feasible to return patients to their communities as they were less likely to engage in the extremes of deviant behavior. At the same time, deinstitutionaliza-tion was seen as a dramatic cost-saving device by fiscally conservative legislators. As we describe below, ultimately, these fiscal motives undermined the con

Community Mental Health tinuity of care and services in the community envisioned by its originators.

Other salient factors that drove the community mental health movement included well-publicized, analytic reports that indicated that the mental health needs of the population far outstripped the resources of trained personnel. Moreover, those that needed services the most, for example, urban and rural poor, children, adolescents, and the elderly, received them least often and, generally paid more for these services when they did receive them. If prevention was to fulfill its promise, hard-to-reach, unserved, and underserved populations needed to be reached.

The principles of comprehensive community-based treatment, prevention and the promotion of well-being inherent to the ideology of the community mental health movement have continued to hold sway among practitioners and scholars to the present time. However, presidential support, implementation mechanisms, and financial resources at the national level were seriously undermined during the Nixon and Reagan Administrations.

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