CMHC: Dream Deferred But Still Worthwhile

The concept of community mental health centers (CMHCs) once symbolized the hope that a person with mental illness of any income level could live and be treated effectively in communities.

Now, more than 40 years later, those centers often are regarded as “hostile territory” by psychiatrists, according to APA’s immediate past president, Paul Appelbaum, M.D., because many centers underwent a process of “demedicalization” that minimized the importance of psychiatric leadership.

Yet, he and other psychiatrists think that the CMHC model itself offers promise to those searching for ways to address problems of fragmentation and lack of access to mental health services.

Appelbaum told a Senate subcommittee hearing on substance abuse and mental health services, “It was a terrific concept” (Psychiatric News, December 5, 2003).

He joined three other APA members in a conversation with Psychiatric News about what should be retained from the CMHC movement and what mistakes should be avoided.

Michael Engel, D.O., directed two CMHCs and is in private practice. As president of the Michigan Psychiatric Society, he recently testified before the state legislature about the importance of restoring a medical model to CMHCs (Psychiatric News, November 17, 2003).

APA Vice President Steven Sharfstein, M.D., was director of the Division of Mental Health Services Programs at the National Institute of Mental Health (NIMH) when CMHC legislation was being developed, and he co-wrote a book, Madness and Government (APPI, 1983), about that process and some of its outcomes.

Altha Stewart, M.D., was director of the largest CMHC in Michigan, the Detroit-Wayne County Community Mental Health Agency, from 1999 to 2002 and has extensive experience in community psychiatry, managing large public systems in New York City and Philadelphia over the last decade.

Two core ideas about CMHCs “retain their vitality,” said Appelbaum. The first is catchment area, which means that a CMHC is responsible for the mental health of people who live in a defined area.

That clear allocation of responsibility meant that center staff “had every incentive to go out into the community to do early intervention and to encourage prompt use of services instead of waiting for people to come to the clinic or discouraging such use.”

Single point of access is the second idea.

“If people needed help, they knew where to go, even if they didn’t have a private doctor. CMHCs offered a spectrum of services that allowed a single treatment team to retain responsibility for care as a patient’s needs change. Accessing mental health services is incredibly difficult for people today.”

Stewart pointed out that CMHCs also offered “fertile ground for people entering the profession to learn a range of dimensions of psychiatry.”

She and others were able to gain experience with the continuum of care associated with CMHCs and to learn how to work effectively in the community.

“The quality of our workforce is affected when opportunities for those training opportunities diminish,” she said.

Those in training were able to experience an integration of disciplines, said Engel. “In some cases, the centers also became a place for the development of subspecialty expertise in the treatment of serious and persistent mental illness.”

Most CMHCs, however, have not lived up to the hopes of their advocates. (Original article: See article below for brief history.) Money, and the methods by which it was allocated, was a key factor.

Advocates were able to get federal support only for construction costs of CMHCs in the first piece of legislation.

To secure funds for staffing, they compromised and agreed to a seven-year period of decelerating federal support for staff. The hope that state governments and other funding sources, such as unions, would fill the gaps at the end of that period was not fully realized.

“Instead,” Sharfstein said, “centers frequently had to rely on fee-for-service payment in the form of Medicaid and some limited private pay.”

That shift, in turn, led to other negative consequences. Reimbursement was not available for the kinds of services and activities—such as outreach, prevention, and interdisciplinary team development—that could have ensured the long-term success of the model.

In 1971 psychiatrists directed 55 percent of the CMHCs; by 1977, the figure was 26 percent.

Cost was one reason for the shift away from a reliance on psychiatric leadership, said Sharfstein. With declining resources, CMHCs turned to “less expensive” administrative staff and encouraged psychiatrists to spend their time on activities, such as medication management, that provided good reimbursement to the centers.

Larger societal forces also affected the CMHCs.

Stewart said, “The planners never fully appreciated the severity of co-occurring disorders. They thought of people as being mentally ill and didn’t realize the same population also had a high incidence of substance abuse and chronic medical problems. People needed so much more in the way of treatment than was envisioned.”

Even more important, perhaps, was the closing and downsizing of state psychiatric hospitals.

In 1955 a patient admitted to a state hospital stayed six months. By 1977 the average stay was three weeks.

“The bold new CMHC approach had little time and too meager resources to test its mettle before being overwhelmed. . .by the urgent needs of patients with chronic mental illness,” wrote Henry Foley, Ph.D., and Sharfstein in Madness and Government.

The interface with the community turned out to be more complicated than was anticipated.

Engel said, “In some respects, CMHCs were set up like road commissions, rather than entities offering health care. In Michigan, county commissioners select members of CMHC boards, who are not required to have expertise about mental health or management issues.”

The result, often, is trouble for the medical director if there are disputes about clinical issues and a general lack of educated oversight of the CMHC’s operations.

Stewart said, “Psychiatry made assumptions about how services should be rendered and what the community needed. When protests occurred about those assumptions, we were not prepared for the battle and pulled back.”

None of the discussants, however, argued for an abandonment of the CMHC concept.

Both Engel and Sharfstein urged a closer integration of primary and mental health care in a revised model.

Engel said, “We need a new approach in which psychiatrists deliver care in primary care settings.”

He also noted that APA had been extremely helpful by developing model guidelines for psychiatric practice in CMHCs. Those guidelines, which were published in the Manual of Psychiatric Quality Assurance (APPI, 1992), include job descriptions for the CMHC medical director and staff psychiatrist and for evaluation and treatment of patients.

Appelbaum warned, “It would be a big mistake to walk away from everything that is good about the centers. I don’t see another conceptual model out there that addresses the basic problems of service delivery as well as CMHCs.”

Sharfstein agreed, arguing, “CMHCs were a concrete expression of the right of every American to quality mental health care. This vision is even more valid today because psychiatric treatment has become more effective. We should return to what was so right about this vision and implement it with all we have learned in the last 40 years.” ▪