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Keeping The Promise of Community Mental Health

An Opinion by Michael B. Friedman, CSW
First Published in The Journal News, August 8, 2003

On July 22, 2003, The President's Freedom Commission on Mental Health released its final report, "Achieving the Promise: Transforming Mental Health Care in America" [which can be found at http://www.mentalhealthcommission.gov/reports/reports.htm]. If pursued, its recommendations could lead to great progress. Unfortunately the Commission maintains that additional funding will not be necessary--that giving the states more flexibility in how they use federal funds is enough. I disagree. Social progress requires investment, not just restructuring.

Nation Failed to Keep Promises to People with Serious Mental Illnesses

Nevertheless, the report is a powerful reminder that-despite significant improvements in the care and treatment of people with mental illnesses over the past half century-our nation has fundamentally failed to keep its promises to people with serious mental illnesses.

In the mid-1950's the first President's Commission on mental health called for a shift from an institution-based public mental health system to a community-based system. This report led to the Community Mental Health Centers Act of 1963 and to deinstitutionalization. In essence this nation made a promise to people with serious mental illnesses that they would no longer be treated as the dregs of humanity and banished to institutions to live in squalor and in danger without access to decent psychiatric treatment. Instead, the nation promised, they could live freely as full citizens of their society.

Deinstitutionalization did not Fulfill Its Promise

Deinstitutionalization did not fulfill this promise. People were abandoned without adequate services in the community or were transinstitutionalized to adult homes, which were often as squalid and dangerous as the institutions they left. Most returned to their families, who became the unofficial core of the nation's mental health system.

In 1978 the second President's Commission on mental health recognized that, despite the grand vision from which it arose, deinstitutionalization had failed to fulfill its promise. It recommended that the nation provide a broad array of systematically organized treatment and support services in the community. Its report led to the Mental Health Systems Act and to the development of the Community Support Program.

The Community Support Program made life better for a great many people with serious mental illnesses by providing housing and expanding outpatient and community support services. But, as the current Commission documents, it left very significant inadequacies. The original promise remains unfulfilled.

Must Transform Current Mental Health System to Fulfill Original Vision

According to the Commission, we now have enough knowledge to fulfill the original vision, but this requires nothing less than a "transformation" of the current mental health system.

Here are a few of the Commission's recommendations:

We need to be more optimistic about people with serious mental illnesses. Many can recover, and the system should be reoriented to focus on recovery rather than on what the Commission calls "symptom management."
Facilitating recovery requires the use of state-of-the-art practices. Remarkable advances in treatment and rehabilitation technology over the past two decades have been slow to reach the field. It is critical to spread knowledge rapidly.
Recovery requires individualization. Mental health programs are often structured as if everyone can benefit from a short menu of services. Instead a unique array of services and supports should be wrapped around each individual. This requires flexibility in service delivery and funding.
The mental health system needs to reach out to people with mental illnesses and engage them. Many people reject help from the mental health system because of myths and stigma about mental illness or because the services that are available are not responsive to their needs. This calls for education of the general population and a more flexible and responsive mental health system.
Transforming the system requires the active participation of people with mental illnesses and their families. Only by understanding and incorporating the experiences and perspectives of the people who use the system can the system become responsive to their needs.
Transformation requires long-term planning to bring about progressive change.

Requires Financial Commitment

These, and many of the Commission's recommendations, can be creatively translated into action. But doing this will require more than rhetorical promises. It will also require financial commitment.

For example, the Commission report points out that full participation in the community "will require a few essentials" such as "access to health care" and "adequate and affordable housing." Just giving the states more flexibility in the use of federal funding cannot provide these and other "essentials".

Also federal funding for mental health services is primarily Medicaid and Medicare. For Medicaid, "flexibility" has become a codeword for limiting future federal financial contributions to the states.

The Commission is right that the mental health system needs transformation. But keeping the promise of community mental health requires a long-term commitment to provide additional resources as well as to implement contemporary ideas.

(Michael B. Friedman is the Public Policy Consultant for the Mental Health Associations of New York City and Westchester County. The opinions expressed in this column are his own and not necessarily the positions of the Mental Health Associations.)

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