Vision Revisited: 50 Years of the Community Mental Health Act

Fifty years ago on October 31—and just 23 days before he would be assassinated in Dallas—President John F. Kennedy signed the “Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963.”

The act was designed to usher in a new era of community-based treatment of mentally ill individuals, and around the country advocates celebrated the legacy of a vision that—although very incompletely realized—did manage to help transform the care of those with mental illness. The legislation grew out of a major study of the care of people with mental illness undertaken under President Eisenhower, and resulting in 1961 in the report “Joint Commission on Mental Illness and Health: Action for Mental Health.”

In an essay in the October American Journal of Psychiatry (AJP), former Congressman Patrick Kennedy, the president’s nephew, remarked upon the legacy of what is often referred to as “the CMH Act.”

“The law catalyzed a number of positive changes for millions of Americans: the deinstitutionalization of mental health care and the building of community mental health centers throughout the United States to improve access, improve research funding, increase attention to the needs of those with mental retardation, train physicians and other mental health professionals in community-based care, educate about the importance of working in an interdisciplinary manner to serve patients and families, and integrate medical, social, and environmental factors to enhance recovery,” Kennedy wrote.

But almost everyone agrees, in retrospect, that the realization of this vision has been thwarted by a variety of obstacles. In an article in Psychiatric Services (May 1, 2000) titled “Whatever Happened to Community Mental Health,” past APA President Steven Sharfstein, M.D., outlined a history marked by a national ambivalence about the role of the federal government in caring for mentally ill people.

Commitment to that role waxed and waned over the years, but while state hospitals were largely emptied out, dollars didn’t follow the patients into the community. Moreover, Sharfstein noted, citizen governing councils at CMHCs tended to give priority to treatment of less severely ill patients. The vision was revived under President Carter with First Lady Rosalynn Carter’s “Presidential Commission on Mental Health” and passage of the Mental Health Systems Act in 1980. But the law was later repealed under President Ronald Reagan, and what had been a federal categorical grant program to local communities became block grants to states.

But Sharfstein, who was director of the Division of Mental Health Service Programs at the National Institute of Mental Health from 1976 to 1981, told Psychiatric News that celebrating the vision of the 1963 legislation is entirely appropriate. “This was landmark legislation and a bold new approach that initiated for the first time federal leadership and a role in the public mental health care,” he said. “The core idea is that to the extent possible people should be taken care of close to where they live and work. I credit the visionaries of that era for thinking about how we might move to a different mode of care.”

Kennedy, in his AJP essay, suggested that now may be a time to revisit the vision behind the 1963 legisaltion. “An updated vision is required,” he concluded. “[T]he time has come for America to boldly explore the `inner space’ of our brains with the same verve and collective energy we used to explore outer space under President Kennedy’s goal to land a man on the moon by the end of the 1960s…. Indeed, while it may be a half-century late, such an initiative could finally achieve another of his dreams, stated as he signed the CMH bill: ‘[T]oday, under present conditions of scientific achievement, it will be possible for a nation as rich in human and material resources as ours to make the remote reaches of the mind accessible. The mentally ill and the mentally retarded need no longer be alien to our affections or beyond the help of our communities.’ ” ■