John F. Kennedy was one of our most visionary presidents. He set a ten-year goal for landing on the moon and, although he didn’t live to see it, the goal was met. He envisioned an agency, separate from the State Department, that would give American citizens the opportunity to live and serve as volunteers in developing countries around the world; and the Peace Corps became a reality. He envisioned, and provided funding for, a national mental health system, made up of local mental health centers, to replace the system where most mental health treatment was provided in large, centralized state institutions.
For most of my career as a psychologist, I was employed at community mental health centers (CMHCs). Little did I know when I started out in 1976, working for a CMHC in rural Alabama, that these were the halcyon days of our national mental health system. Mental health agencies had adequate funding to meet community needs. The plan was to decrease reliance on expensive (and often unnecessary) inpatient treatment in state “mental hospitals,” by providing outpatient mental health services at the local level. Almost all of the initial funding was federal dollars, with the understanding that the federal funds would gradually decrease, and states would allocate a portion of the money saved, to replace the federal funding for community outpatient treatment. The goal of the well-intentioned plan was called “de-instititutionalization.”
All across the country, states made plans to eventually shut down the massive institutions that often “warehoused” patients with chronic. severe mental disorders. This saved the states a lot of money over time, but the state legislatures failed to carry out their part of the plan and replace lost federal funding for community mental health treatment with state dollars. Instead, the money saved went straight into state general funds, and funding for community treatment gradually diminished, year after year. The range of services provided shrank over time. Community outreach and support services programs closed down and CMHCs became understaffed. Clinicians (like me) initially hired to provide individual, family and group therapy found themselves doing less therapy, and more and more bare-bones case management services for their ever-increasing caseloads of underserved clients. A lot of seriously mentally ill people received only occasional fifteen-minute medication management sessions with a psychiatrist.
With the big, centralized institutions shut down or downsized, and with the inability of most CMHCs to adequately meet community needs, across the country more and more people with mental illnesses and substance abuse problems have joined the ranks of the homeless. In many cities, hospital emergency departments stay backed-up because of all of the severely mentally ill people who need treatment and can’t get it elsewhere. Jails and prisons have become primary providers of (often inadequate) mental health services. Often, police officers are the first point of contact with people who are psychotic and out of control, sometimes with tragic results.
Few police officers are adequately trained to do effective interventions with manic and psychotic people. If the states had done their part and adequately funded community-based treatment, and we had the national mental health system that Kennedy envisioned, the first responder in a psychiatric crisis situation would be a social worker or a psychologist, not a cop. Police have enough responsibilities, without having to respond to psychiatric emergencies. Jails and prisons have enough problems to deal with, without having to be de facto mental health centers. Jails and prisons are obviously not environments conducive to stability and recovery.
Mental illness and substance abuse are some of the root causes of the rise in homelessness, and too many Americans are more judgmental than compassionate when they encounter homeless people. There remains in our society a stigma that brands mentally ill people as the Other, not as individuals whose impairments should be recognized and addressed on a societal level. Our national mental health system is a disgrace, partly due to stigma and the consequent marginalization of people with mental illnesses and substance abuse problems. We need to elevate our compassion for these people to the level of our compassion for people suffering from cancer and other physical diseases – maladies that have ad campaigns promoting awareness and compassion We need to treat substance abuse as more a public health issue than as a criminal issue.
Prevention is a vital part of medicine, and gets a lot of attention when it comes to physical illnesses. Kennedy’s plan emphasized prevention, and we need to develop a national model that puts the treatment of mental illness and substance abuse on a par with the treatment of physical injuries and diseases.