The Federal Role in Caring for the Severely Mentally Ill
AEI Newsletter
December 01, 2003
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In 1963, President John F. Kennedy signed the Community Mental Health Centers Act (CMHCA), a bill designed to move psychiatric patients from state institutions to smaller community clinics. On the act's fortieth anniversary, panelists judged its effects and the quality of mental health treatment at an October 31 AEI event.
AEI's Sally Satel, M.D., introduced two alarming statistics: one third of all homeless people are mentally ill, and (according to Human Rights Watch) a person experiencing mental illness is three times more likely to be incarcerated rather than treated in a psychiatric facility. She urged policymakers to redefine the role of the federal government in caring for the mentally ill.
Dr. Wayne Fenton of the National Institutes of Health provided an historical perspective on the decline of mental health treatment. Attitudes shifted from colonial days when each community cared for its mentally ill citizens through the family home or the almshouse, to a post-Civil War belief that this was someone else's problem. Overcrowded almshouses gave way to large, factory-like state institutions. The legislation signed by Kennedy sought to end the decline in institutional care, but community health centers have too often dealt with patients in an equally inefficient manner.
Dr. E. Fuller Torrey of the Stanley Research Foundation listed the flawed assumptions underlying patient care as perhaps the most important factor in the decline of mental health treatment since the 1960s. Many recognized the failings of state institutions and believed that simply transferring patients from the confines of the state hospital to the less restrictive community clinic would ease mental disorders. Community centers are not designed to seek out patients whose disorder prevents recognition that they require help. CMHCA allowed the federal government to fund community centers directly but failed to provide proper oversight. States gained an incentive to release patients prematurely as a way to transfer the financial burden onto the federal government. Civil rights advocates began equating liberation from badly run state hospitals with actual freedom. Dr. Torrey concluded: "Ideology won out over rational policymaking, and political correctness won out over scientific correctness."
To address today's problems, Dr. Jeffrey L. Geller of the University of Massachusetts suggested individualizing patient treatment, arguing that the question of adequate restrictions or integration should be determined on a case-by-case basis rather than lumping patients into a single category in need of uniform solutions. Contrary to what many have thought for forty years, institutional freedom is not always the best solution.
Treatment Advocacy Center executive director Mary Zdanowicz contended that some cases require coercive treatment, particularly as many untreated disorders lead to violent behavior and incarceration. She suggested that the federal government can help by fostering coercive treatment when necessary, emphasizing treatment for the severely ill, and prohibiting federal dollars from financing opposition to state laws covering mental health.
Dr. Robert Keisling of Unity Healthcare noted that traditional mental health clinics have bureaucratic structures that often exclude the patients with the greatest needs. He argued that forcing state departments of mental health to compete for funds would greatly improve treatment by providing greater choice in clinical treatment. Torrey concurred, judging that the National Institutes for Mental Health seems unconcerned with the quality of care at community centers, does not invest enough money in research, and fails to recognize that some patients do, in fact, require involuntary treatment.
Stuart Butler of the Heritage Foundation argued that policymakers reviewing legislation often display a great deal of ignorance on mental health questions, and the natural tendency toward gridlock endangers the patient and the community. "The federal government must force clinics to match the dollars they receive with the outcomes they promise," Butler said.
All of the panelists agreed that the federal government has failed the mentally ill and needs to shift tactics to protect both patient and community from dangers posed by early release and untreated illness and to provide quality care that enables the patient, when possible, to rejoin the community through proper rehabilitation.
AEI's Sally Satel, M.D., introduced two alarming statistics: one third of all homeless people are mentally ill, and (according to Human Rights Watch) a person experiencing mental illness is three times more likely to be incarcerated rather than treated in a psychiatric facility. She urged policymakers to redefine the role of the federal government in caring for the mentally ill.
Dr. Wayne Fenton of the National Institutes of Health provided an historical perspective on the decline of mental health treatment. Attitudes shifted from colonial days when each community cared for its mentally ill citizens through the family home or the almshouse, to a post-Civil War belief that this was someone else's problem. Overcrowded almshouses gave way to large, factory-like state institutions. The legislation signed by Kennedy sought to end the decline in institutional care, but community health centers have too often dealt with patients in an equally inefficient manner.
Dr. E. Fuller Torrey of the Stanley Research Foundation listed the flawed assumptions underlying patient care as perhaps the most important factor in the decline of mental health treatment since the 1960s. Many recognized the failings of state institutions and believed that simply transferring patients from the confines of the state hospital to the less restrictive community clinic would ease mental disorders. Community centers are not designed to seek out patients whose disorder prevents recognition that they require help. CMHCA allowed the federal government to fund community centers directly but failed to provide proper oversight. States gained an incentive to release patients prematurely as a way to transfer the financial burden onto the federal government. Civil rights advocates began equating liberation from badly run state hospitals with actual freedom. Dr. Torrey concluded: "Ideology won out over rational policymaking, and political correctness won out over scientific correctness."
To address today's problems, Dr. Jeffrey L. Geller of the University of Massachusetts suggested individualizing patient treatment, arguing that the question of adequate restrictions or integration should be determined on a case-by-case basis rather than lumping patients into a single category in need of uniform solutions. Contrary to what many have thought for forty years, institutional freedom is not always the best solution.
Treatment Advocacy Center executive director Mary Zdanowicz contended that some cases require coercive treatment, particularly as many untreated disorders lead to violent behavior and incarceration. She suggested that the federal government can help by fostering coercive treatment when necessary, emphasizing treatment for the severely ill, and prohibiting federal dollars from financing opposition to state laws covering mental health.
Dr. Robert Keisling of Unity Healthcare noted that traditional mental health clinics have bureaucratic structures that often exclude the patients with the greatest needs. He argued that forcing state departments of mental health to compete for funds would greatly improve treatment by providing greater choice in clinical treatment. Torrey concurred, judging that the National Institutes for Mental Health seems unconcerned with the quality of care at community centers, does not invest enough money in research, and fails to recognize that some patients do, in fact, require involuntary treatment.
Stuart Butler of the Heritage Foundation argued that policymakers reviewing legislation often display a great deal of ignorance on mental health questions, and the natural tendency toward gridlock endangers the patient and the community. "The federal government must force clinics to match the dollars they receive with the outcomes they promise," Butler said.
All of the panelists agreed that the federal government has failed the mentally ill and needs to shift tactics to protect both patient and community from dangers posed by early release and untreated illness and to provide quality care that enables the patient, when possible, to rejoin the community through proper rehabilitation.
