Deinstitutionalization Through Optimism: The Community Mental Health Act of 1963

One Flew Over the Cuckoo's Nest, The Snake Pit, The Shame of the States, "Titicut Follies," and Life Magazine's "Bedlam 1946": these articles, films, and books—and books that were made into films—are cultural touchstones of the state mental hospital era. They epitomize a negativism—regarding insanity, imprisonment, terror, chaos, and disgrace—associated with life in American psychiatric institutions in the first half of the 20th century (1, 2). Although critical attention has been paid to the relationship between publicized atrocities and the movement for state hospital deinstitutionalization, fewer efforts have highlighted the federal idealism underlying deinstitutionalization. The Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963—more commonly known as the Community Mental Health Act (CMHA) (3)—provides a critical historical lesson on the roles of optimism and structure in outpatient care for serious mental illness.

In 1946, the federal government entered mental health policy with the passage of the National Mental Health Act. In 1949, it established the National Institute of Mental Health (NIMH). With both, the government promoted visions of progress and community in mental health care—a stark contrast to stagnant connotations of state hospital institutionalization (2). By the 1960s, in terms of policies from the environment to education, the public largely believed in the federal government's ability to meet society's needs (4). In this political context, the Joint Commission on Mental Illness and Health, a federal organization charged with surveying the resources and diagnostic and treatment methods for mental illness, published its findings as Action for Mental Health. This document detailed inadequacies in national mental health services and called for improvements in both state mental hospitals and community mental health care (2). In 1963, Congress then passed and President Kennedy signed the CMHA. With the CMHA, Kennedy and Congress sought to decrease the number of institutionalized individuals by incubating self-sufficient and local mental health care centers.

Kennedy's personal motivations illustrate the federal idealism in community mental health care. With his New Frontier platform, Kennedy sought improvements in the nation's mental and physical health. He also aimed to unburden society of chronically dependent persons. In particular, he hoped to liberate the population of confined mentally ill patients through advancements in psychopharmacology and supportive housing. He was emotionally drawn to issues of mental illness and intellectual disability because of his sister Rosemary, who underwent a lobotomy that significantly worsened her quality of life (2). Politically, Kennedy grasped the negative public sentiment around an increasing institutionalized population and its associated cost to the states. Kennedy's special message to Congress on February 6, 1963, captured his sense of optimism as he promoted a plan to, "Cut by half, within a decade or two, the 600,000 persons now institutionalized for psychological disorders" (5).

An overwhelmingly Democratic Congress (Senate 65% and House 59%) aligned with Kennedy on political and ideological sentiments (6). The Senate and House of Representatives introduced identical bills that outlined terms of temporary federal financial support for the initial construction and staffing of community mental health centers (2). Despite financial concerns, illustrated by a Bureau of Budget internal memo that read, "The real question is who is going to finance operating costs once the federal subsidies are ended or indeed if they can be ended" (2), bipartisan belief existed within both chambers that the CMHA's vision was a more hopeful and humanistic alternative to institutional care. This belief was rooted in a deep trust in medicine's promise to eliminate illness. Congressional members generally lacked medical knowledge, and many accepted claims about community mental health centers without probing (2). As preeminent mental health historian Gerald Grob wrote, a "euphoric atmosphere" (2) existed within Congress surrounding the possibilities of community mental health care. In the end, the Senate (72-1) and House (335-18) wholly approved the CMHA (2).

Apart from national politics, psychiatry was experiencing intraspecialty ideological discord in the 1960s. Those stressing biological influences on mental illness and those emphasizing social determinants and psychotherapy divided the field. As a collective profession, however, psychiatry sided with President Kennedy and Congress on the importance of enhancing community mental health care. With the recent development of medications, including chlorpromazine, reserpine, iproniazid, and imipramine, psychiatrists were optimistic that severe psychotic and mood states, previously viewed as recalcitrant to medical treatment, could be treated in community settings (1, 2). However, in a council position paper from the American Psychiatric Association (APA), the profession hedged on strengthening community mental health at the expense of state mental hospitals, which psychiatrists knew continued to care for patients with the most serious mental illnesses (2). APA president C. H. Hardin Branch best summarized the profession's overall stance in comments made at the APA's 119th annual meeting in St. Louis on May 6, 1963. In a New York Times article about the meeting, titled "Parley of Psychiatrists Hails Support of Mental-Health Plan," Branch commented on psychiatry's "double-barreled proposition." On the topic of community mental health care, he stated that there are "Great community acceptance, matching community demands and vast community opportunities. However, … this great amount of support is based on the assumption that psychiatry will be able to find answers to many social problems, rather than to continue merely to treat them … psychiatrists must try to distinguish between those areas in which social forces rather than psychiatric illness are at fault … then the psychiatrist must be willing to try to meet social needs and handle the wide range of psychiatric problems" (7). As illustrated in Branch's comments, many psychiatrists—and their elected leaders—rejoiced at the public attention being paid to mental illness. Yet these same psychiatrists cautioned that commitment to community models required mental health professionals to fully address the social problems—such as poor socialization and lack of housing, food, and clothing—that exacerbate mental illness in community settings.

The CMHA funded 3 years of federal grant payments to the states, totaling $150 million, for the physical construction and initial staffing of 1,500 community mental health centers to provide five essential services: consultation and education for community and professional organizations, inpatient facilities, outpatient clinics, emergency response, and partial hospitalization (2). Once enacted, however, the CMHA did not fulfill its optimistic promise. Ultimately, states built a variety of community mental health centers, producing a heterogeneity that made it difficult for NIMH to effectively assess and regulate. Local concerns often translated into treatment for those with less serious mental illnesses. This focus on persons who had little or no connection with prior state hospital care was at the expense of individuals who required assistance to function in daily life. Most community mental health centers, moreover, did not provide the expensive basic provisions that individuals with serious mental illness needed to live in the community (1, 2).

Because of construction and long-term funding impediments, states built approximately half of the 1,500 centers outlined in the CMHA (2). The nationwide state mental hospital census decreased by over 90% by the early 2000s (8), from a peak of 558,922 in 1955 (2). Individuals with diagnoses of serious mental illness were scattered across the mental health treatment system, with no single organization accepting longitudinal responsibility to address their basic needs. Funding for care fell to programs such as Supplemental Security Income, Social Security Disability Insurance, and food stamps. Because of age, financial, and bureaucratic application barriers, many did not qualify for Medicaid and Medicare, the landmark safety net insurance programs established in 1965 (1, 2). Care often fell to families, friends, and associates. Those without homes often ended up on the streets, with many entering an institutional circuit of acute care hospitals, jails, prisons, and forensic facilities (1).

An optimistic federal belief in locally sustained community mental health care in part drove deinstitutionalization. The CMHA and its failings teach us that optimism without infrastructure slows the path to success. Evidence-based outpatient programs, such as assertive community treatment, coordinated specialty care, and Housing First, channel the optimism of the CMHA (9–11). Such programs also counteract a modern atrocity of care: too little structure. We must provide the resources needed for each person with serious mental illness to thrive in an individualistic and meritocratic society. Perhaps this bit of healthy realism can continue to drive a movement as revolutionary as deinstitutionalization itself: the structuring of outpatient care for serious mental illness.