A Failed 'Solution' to 'America's Mental Health Crisis'
The Times revisits a failed approach from the 1960s to solve America’s “mental health crisis.”
The New York Times editorial board claims the "solution to America’s mental health crisis already exists."
The Times makes the familiar argument that deinstitutionalization—the process of closing or downsizing public psychiatric hospitals—was a righteous cause betrayed by officials who did not fund "community-based" alternatives. To the extent there is a "crisis" in caring for people with serious mental illnesses such as schizophrenia and bipolar disorder, the Times argues, "the policies and programs that could undo this crisis have existed for decades." Their solution is to fund community mental health centers (CMHCs), a program outlined in the Community Mental Health Act of 1963.
John F. Kennedy signed the Community Mental Health Act after calling for states to gradually replace state mental hospitals with a network of community-based centers to provide inpatient, outpatient, and other services in patients' "communities" rather than faraway asylums. States took Kennedy up on the first half of his vision, closing or downsizing their public mental hospitals in the years after the act was signed. When Medicaid was passed in 1965, there were more than 500,000 inpatients in public mental hospitals; by 1975, that number had more than halved, and by 1990, there were fewer than 100,000 remaining state hospital patients.
The state hospitals that remain operational today house fewer than 95 percent of their peak patient population, and a significant number of the patients they house are criminals adjudicated not guilty by reason of insanity. It's almost impossible for a long-term psychiatric patient to get admitted to the state hospital today unless he commits a crime or has deteriorated to the point of being an immediate danger to himself or someone else. As one official put it in 2013, “It’s easier to get your kid into Harvard Medical School than find a psychiatric bed in a state hospital.”
Congress drafted the Medicaid statute to pressure states to downsize their mental hospitals in favor of CMHCs, barring Medicaid dollars from paying for patients at hospitals with 16 or more adult psychiatric beds. States had an incentive to dump former mental patients into non-psychiatric settings, such as nursing homes, where there were 15 or fewer psychiatric beds, ensuring those patients would be eligible for Medicaid. Some states even changed patients' medical records to keep the number of patients with psychiatric diagnoses at a particular facility below 15. A 1998 Chicago Tribune report, for example, found that Illinois had “modified at least 1,000 psychiatric patient files at 20 other nursing homes" and collected "an extra $30 million from Medicaid since 1995.”
The Times suggests that the CMHC model, which was supposed to "serve as a single point of contact for patients in a given catchment area who needed not just access to psychiatric care but help navigating the outside world," failed because the federal government "did not provide long-term funding to sustain these new clinics." But CMHCs still exist; there are about 3.6 community mental health centers for every one psychiatric hospital, and the gap is even starker when you restrict "psychiatric hospitals" exclusively to the remaining public mental institutions, which typically handle the state's hardest cases.
As a practical matter, CMHCs didn't fail for lack of funding—the equivalent of $20 billion were allocated for their construction and staffing—they failed because they were ill-equipped to serve people with serious mental illness. From an interview I conducted with schizophrenia researcher E. Fuller Torrey in 2020, the notion that CMHCs failed for lack of funding is
a very popular myth among my colleagues. They love to use it because it ignores the fact that the centers that were funded were failing. I described that in great detail in my book, Nowhere to Go, which was the first book that I wrote about these things. In that book, published in the 1980s, I described in great detail how these “mental health centers,” which we funded — and we funded over 700 of them! — were not taking care of the people coming out of the hospitals. They were taking care of the “worried well,” and that was part of the plan from the very beginning. The people who planned the CMHC movement felt that you could prevent schizophrenia if you provided psychotherapy for people while they were young, and that therefore, we wouldn’t even need the state hospitals because these people wouldn’t get sick in the first place. So the whole basis for the community mental-health centers was flawed from the very beginning. Many well-meaning people were involved in the program; I have a good friend who worked in a CMHC. He will tell you that most of its failures were a money problem, but the data — which I collected at the time and have published — are very clear. Community mental-health centers were not taking care of the people who were coming out of the hospital, who most needed the care. There was very little interest in these patients’ well-being. It was a flawed system from Day One, but my liberal friends would prefer to believe it was just a question of money, and that Reagan destroyed our mental-health system [by block-granting mental-health funding to the states.] It’s just not true.
The psychiatrists who staffed the CMHCs were reacting, with some justification, against the abuses of the asylum model. They believed that serious mental illnesses could be "prevented" by implementing "mental health" programs in schools and alleviating social problems such as homelessness, and spent significant resources lobbying politicians for things like housing reform and labor rights on that theory. But they continued to do so even as many former state hospital patients roamed the streets, stopped taking their medication, and spiraled into psychosis. The Times concedes the centers "tried tackling an array of nonpsychiatric crises," but suggests there is nothing inherent to the CMHC model that should have led them to do so.
While it should be said that community-based alternatives were and remain an important lifeline for people who don't require short- or long-term inpatient care, the CMHCs were founded on an anti-asylum vision that prevented a true continuum of care from developing after their creation. Stanley Yolles, one of the architects of the CMHC system, reportedly "hated the state hospitals and wanted to shut down those g-ddamn warehouses." That antagonism, which infected many of the CHMC workers who thought themselves superior to the old "ward psychiatrists," prevented the centers from using the important resource provided by state hospitals—a secure, therapeutic campus for the hardest cases—and from coordinating with state hospitals as those hospitals discharged patients during the height of deinstitutionalization.
The CMHCs are, by their nature, part of "the community"—the antithesis of the asylums, which were set in faraway rural areas. They have the effect of keeping patients "in vivo." And as a homelessness advocate once said about people with serious substance-abuse issues, the in vivo approach can be "counterproductive" if "your vivo is killing you.” Some patients discharged from the state hospitals detached themselves from the mental health system after their discharge, only to spiral into psychosis and have no place of "asylum" to turn.
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At the end of the editorial, the Times concedes that "a truly robust mental health system will have to include a range of services" including "some congregate institutions for the small portion of people who can’t live safely in the community." But that concession swallows their argument. The people whom the Times describes as having "serious mental illness"—particularly the ones who require intensive monitoring, are a persistent danger to themselves and others, and to whom "freedom" to live in "the community" amounts to the freedom to be insane and deteriorate to violence—are the very people whom community-for-all ideologues insist have an inalienable human right to live in "the community." That was the predicate for the Community Mental Health Act of 1963, and the same Foucaldian spirit that led progressives to reject federal asylum funding in 1965 would lead their successors to reject it today.
The upshot of the Times's editorial is that true community-based mental health care has never been tried. But it is "community mental health"—the idea that every single person with a mental illness, no matter how severe, at every point in the arc of their illness, can be treated in a "community-based" setting—that created the "crisis" the Times is trying to solve.
The editorial board is right, in a way, that the "solution to our mental health crisis already exists." Every state still operates at least one public mental hospital, many of which are the very same "asylums" from the early 20th century. Before they were packed beyond capacity in the middle of the 20th century, many were serving their intended purpose of providing "retreat" to those with serious mental illnesses. Expand those hospitals, coordinate their services with the community centers, and create a continuum of care that rejects the ideology that emptied the asylums in the first place.