A retrospective analysis of the effectiveness of a community mental health center program in improving patient well-being

From programs to systems: Implications for program evaluation illustrated by the Community Mental Health Centers program experience

Community participation is a frequently discussed and controversial aspect of the community mental health center program. To many professionals and lay people, the community mental health center concept includes a basic commitment to a participatory process of the community in the planning and implementation of the community mental health center program. However, this commitment is not readily evident in the federal and Pennsylvania regulations. This paper presents an approach taken by the Philadelphia Office of Mental Health and Mental Retardation to insure that its 13 centers and base service units have a meaningful partnership with their catchment area communities. Specifically the paper presents the community participation regulations developed by the Philadelphia office, as well as the conditions that led to the development of these regulations. A conclusion of the paper is that additional regulations are needed to insure that community participation becomes an integral part of the community mental health center program.

Back to table of contents Previous article Next article LettersFull AccessWhat Shaped My Career: In ReplyE. Fuller Torrey, M.D.E. Fuller TorreySearch for more papers by this author, M.D.Published Online:1 Nov 2019https://doi.org/10.1176/appi.ps.701106AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleIN REPLY: I thank Dr. Sharfstein for his comments. He was one of the best of the “young, idealistic” mental health professionals at the National Institute of Mental Health (NIMH) to whom I referred in my personal account (1). His subsequent career has proven his dedication to providing services for persons with serious mental illness. Dr. Sharfstein tried to salvage the federal community mental health center (CMHC) program, but he inherited a program that was fatally flawed. One major mistake had been the selection and funding of centers directly by the National Institute of Mental Health (NIMH), completely bypassing the state mental health agencies that had had the primary responsibility for seriously mentally ill individuals for 150 years. Dr. Lucy Ozarin, who was a member of the 1963 CMHC planning task force, said that Dr. Robert H. Felix [first NIMH director] had made that decision even before the task force met (personal communication, interview with L. Ozarin, July 21, 2010).Editor's Note: Clearly, there are many perspectives, and I am pleased to use the Personal Accounts column as a way to elucidate the influences that have shaped our leaders.—L.B.D.Another major mistake was to not require the federally funded CMHCs to provide care for the patients being discharged from state hospitals. Most CMHCs therefore did not do so. As described in my 1988 book, Nowhere to Go, the longer a CMHC was in operation, the smaller was the percentage of its referrals from public mental hospitals. “In 1976, for example, CMHCs that had been operational for 1 to 2 years had 5.5 percent of their admissions referred from public mental hospitals, whereas CMHCs that had been operational for 6 to 7 years had only 2.6 percent of their admissions referred from public mental hospitals” (2). A 1979 NIMH report emphasized the problem: “The relationships between the CMHCs and public psychiatric hospitals are difficult at best, adversarial at worst” (2; emphasis in original). It has been widely claimed that President Reagan killed the federal CMHC program, but it can be equally argued that the program was stillborn.It is important not to conflate deinstitutionalization with the federal CMHC program. Driven by the availability of chlorpromazine, the emptying of state mental hospitals was inevitable and had begun in 1955. By the time that President Kennedy proposed his new program in 1963, the state hospitals had already been downsized by more than 54,000 patients, 10% of the total. Community psychiatry was also underway. A few good mental health centers existed prior to the federal program, such as the Prairie View Mental Health Center in Newton, Kansas, which opened in the 1940s. Similarly, the Fountain House Clubhouse in New York had opened in 1948. Thus, community psychiatry predates the federal CMHC program and has continued to thrive since the demise of that program.References1 Torrey EF: What shaped my career. Psychiatr Serv 70:961–962, 2019. https://ps.psychiatryonline.org/doi/10.1176/appi.ps.70901Google Scholar2 Torrey EF: Nowhere to Go: The Tragic Odyssey of the Homeless Mentally Ill. New York, Harper & Row, 1988Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 70Issue 11 November 01, 2019Pages 1074-1075 Metrics History Published online 1 November 2019 Published in print 1 November 2019

This paper traces the development of theory and public awareness of mental health from 1900 to 1960, with particular stress on the rise of social psychiatric models and the impact of events in and around World War Two. The federal legislative history of the Community Mental Health Center (CMHC) program through 1976 is then outlined with regard to particular social problems (e.g., alcoholism) and to domestic politics as they influenced the program's regulations and mandates. A brief critique of the CMHC program from both viewpoints follows, with emphasis on poor administration, lack of community control, and poor evaluation and accountability. This is the basis of an argument for a more egalitarian, explicitly political viewpoint and methodology as a start toward solving problems that chronically afflict the mental health system.

The 18-year Community Mental Health Center (CMHC) Program of the National Institute of Mental Health (NIMH) was a complex and ambitious social experiment. This review identifies nine of the major goals of the program and examines available evaluative information on how well each was achieved. The most significant achievements of the program include increasing the quantity and range of public mental health services. Equality of access to services was also improved but all inequities were not removed. Problems continue to exist in funding services on the basis of need, in providing services to chronic clients, and in coordinating services. Prevention efforts suffered from uncertainties and perhaps overly optimistic expectations. The achievements of the program are currently threatened by third-party reimbursement mechanisms, the loss of federal leadership and oversight, and the loss of a community orientation in public mental health services. A great deal can be learned from the achievements and the shortfalls of the CMHC program that may be useful in state and federal mental health planning.

Several critical issues involved in successfully initiating and maintaining a community mental health center program in a rural setting are discussed. These include the necessity of accurately assessing the existing social, cultural, and political system, and of fitting the mental health center program into these systems as smoothly as possible; the special problems faced in maintaining confidentiality; and the importance of recognizing and dealing with the front-line pressures on professional staff that are peculiar to the rural setting. Advantages as well as disadvantages of working in a rural program are considered.

Using a quasi-experimental design, changes in the numbers of mental health facilities between 1964 and 1974 were examined for a sample of 50 nonmetropolitan catchment areas that established a Community Mental Health Center (CMHC) before January 1973 and a sample that did not. Compared to non-CMHC areas, CMHC areas had a slightly greater number of general hospital psychiatric units in 1974. Nevertheless, the rate of increase in such units over the 10-year period was not significantly different between the two types of areas. Other findings supported the conclusion that the number of outpatient and day/night facilities continued to increase in areas not participating in the CMHC program, but that the program produced even greater numbers of such facilities in areas that did participate. This growth, though, occurred both through introducing additional facilities and supplanting existing ones.

Sociodemographics, clinical characteristics, and life stressors of community-dwelling suicidal risk and nonsuicidal risk elders referred to a community aging and mental health provider were compared in this study. Information was collected through case manager surveys and agency records on 683 older adults referred to the Elder Services Program of Spokane Mental Health in 1994 and the first 6 months of 1995. This sample included 109 individuals who were clinically judged to be at suicide risk by case managers at the time of initial assessment. Comparisons between suicidal risk and nonsuicidal risk elders indicated that suicidal elders were younger, more likely to be separated or divorced, and more likely to report a previous history of suicidal behavior. Results of a logistic regression analysis indicated that living alone, depression or anxiety disorder, and higher levels of emotional disturbance predicted suicide risk status. In addition, medical problems, family conflict, and relationship loss predicted suicide risk status in this particular sample. Individuals at suicide risk were also more likely to have a family physician than others. Implications of findings for identification and treatment of suicidal elders are discussed.

Back to table of contents Previous article Next article Professional NewsFull AccessBattles Over Money, Mission Limited CMHCs’ SuccessKate MulliganKate MulliganSearch for more papers by this authorPublished Online:6 Feb 2004https://doi.org/10.1176/pn.39.3.0007aThe concept of community mental health centers (CMHCs) has been an important part of discussions about how to provide mental health services at least since 1960, when the federal Joint Commission on Mental Illness and Health proposed one “fully staffed, full-time mental health clinic” for each 50,000 of population.In that year, the Democratic Party voted at its convention in favor of a plank in support of “greatly increased federal support for psychiatric research and training and community mental health programs to [help hospitalized mentally ill live in communities].”President John F. Kennedy attempted to fulfill that campaign promise with the appointment of a National Institute of Mental Health (NIMH) study group, which recommended “comprehensive” CMHCs offering inpatient, outpatient, and rehabilitative services, as well as education and public information.A coalition of mental health organizations supported a Kennedy proposal for CMHCs that would have provided funding for construction of CMHCs and limited staffing grants.Congress approved the construction costs but not the staffing grants until President Lyndon B. Johnson requested them with legislation, the Community Mental Health Centers Act Amendments, which passed in 1965.The NIMH mandated that CMHCs were to provide five essential mental health services: inpatient, emergency, partial hospitalization, outpatient, and education.Henry Foley, Ph.D., and Steven Sharfstein, M.D., wrote in Madness and Government (APPI, 1983), “In the beginning, then, CMHC services plus those of the state hospitals theoretically represented a balanced array, but the CMHC program alone did not. . . . The unanticipated consequence. . .was the failure of most CMHCs to develop even minimal rehabilitation and aftercare services for the mentally ill being discharged or diverted from state hospitals.”In 1972 President Richard M. Nixon argued that federal support for the CMHC program should be phased out and replaced with local support.Instead, in 1975 with new legislation, seven new services were added to the definition of “essential service.”“The enactment of PL 94-63 in July 1975 over a presidential veto climaxed a seven-year struggle for program survival, which included appropriation battles and impoundment suits,” wrote Foley and Sharfstein.By 1977, 650 CMHCs had been funded, covering 43 percent of the population and serving 1.9 million people that year. The $1.5 billion federal investment generated another $2.5 billion in other sources of funds.In 1977, however, the average length of stay for a patient in a state hospital was three weeks, down from six months in 1955.“The bold new CMHC approach had little time and too meager resources to test its mettle before being overtaken. . .by the urgent needs of patients with chronic mental illness,” wrote Foley and Sharfstein. In 1977, President Jimmy Carter established the President’s Commission on Mental Health, which ultimately made more than 100 major recommendations and findings.After considerable debate within the administration, Carter submitted the Mental Health Systems Act to Congress in 1979, where it was subjected again to much debate.“The primary mission of community mental health has been disputed since the beginning: the Systems Act forcefully restated each of three missions without resolving priorities,” according to Foley and Sharfstein.The missions are adequate clinical care, particularly for those with serious mental illness; supportive services; and prevention.President Ronald Reagan, who was elected in 1980, recommended that Congress cut the level of funding for the act by 25 percent and convert it into a block-grant program.In August 1981 he signed the Omnibus Budget Reconciliation Act, which “substantially repealed the Mental Health Services Act. . . . The federal government was entirely removed from the direction of the program and became a mere conduit of funds to the states.” ▪ ISSUES NewArchived

President Kennedy's "bold new approach" remains compelling 15 years after it was first announced. Mental health services at the community level have come a long way since the community mental health center program's establishment in 1963. Mental health manpower, advances in treatment technology, and volumes of service all have grown remarkably; but much still remains to be done to integrate community mental health services into the communities they serve in the planning of human services generally, and particularly in emphasis on preventive care. The National Council of Community Mental Health Centers Environmental Assessment Task Force has two closely related charges in these latter areas. First, to inquire into the "environmental" aspects of mental health at the community level; and, second, to explore environmental perspectives for the establishment of prevention initiatives in the delivery of services. This paper explores that charge by seeking a perspective on environment that traces the intersection of the built environment and social-interpersonal behavior with special attention to the implications for mental well-being. Implications of this perspective for community mental health center roles in community planning are considered, with reference to the establishment of preventive services.

Ciarlo and Dowell indicate that " I t may not be too extreme to consider the shift in the primary locus of public mental health care to C M H C s as a 'revolutionary' change that has occurred in the last decade and a half." We agree that they have given us a thoughtful and systematic summary which should stimulate the mental health field toward further study of this "revolut ionary" e ighteen-year Federal experiment with community mental health. The authors use nine goals to organize information about community mental health centers (CMHCs) . The goals are reasonable and generally related to the comprehensiveness, availability , accessibility, efficiency and effectiveness of C M H C services. They are similar to the goals which have been articulated by Federal evaluators, such as Windle, Stockdill and Sharfstein, during the history of the Federal evaluation of the program. In relation to the success of the C M H C program as measured by achievement of the goals, the authors find that the program has been most successful in ~'increasing the range and quality of public mental health services" and has achieved significant success in "making services equally available and accessible to all." They find only partial success in "providing services in relation to existing community needs." The greatest weaknesses cited in the C M H C program relate to a failure in general to meet the needs of severely and chronically disabled clients and a failure of "most C M H C s to mount significant and credible prevention programs." The authors also point out the need in mental health for better needs assessment tools and for better measures of clinical outcomes. While we agree in general with the findings of the authors, we take issue with some findings and want to emphasize others with which we agree strongly. We do this to stimulate further study to encourage improvement in the future delivery of community mental health services.

A new system for delivering mental health services in the United States is now being developed. The system depends on the establishment of a new organizational form, the comprehensive community mental health center. The program of such a center offers a comprehensive range of available and accessible services including as a minimum inpatient, outpatient, partial hospitalization and emergency services as well as consultation and education to community organizations and professional workers. Continuity of patient care is maintained for as long as required by the patient. Federal funds in addition to State and local monies support the construction of new facilities and certain operating costs. The center program is tailored to the needs of each community and catchment area and coordinates its activities with other public and private agencies and practitioners. The program is still too new to evaluate but experience thus far indicates ready public and professional acceptance and improved patient services.

An effective Community Mental Health Center (CMHC) program in entrepreneurship--the provision of services in the marketplace at a profit to subsidize other programs--requires the support and encouragement of the state-level mental health authority. This paper discusses potential financial, programmatic, political, and managerial risks and rewards to CMHCs and to state authorities from such efforts. As each party faces certain risks as well as rewards from such efforts, it is important that they participate in a process of mutual risk reduction involving: Documenting and legitimizing the entrepreneurship program; Separating funding for seed monies and working capital for ventures, Restructuring the Centers' finances and/or corporate structure to reduce the problems of funds diversion and comingling, Negotiating in advance how the proceeds of the ventures will be used to benefit programs, and Providing technical assistance to enhance the probabilities of success in such ventures. For these steps to work the state authorities must be willing to give up some financial and programmatic control to motivate entrepreneurship on the part of CMHCs.

In this progress report on the community mental health centers program, the Director of the National Institute of Mental Health reviews existing patterns of support, community organization, staffing, and practice in the 256 centers funded during the past two years under the federal grants program. Early pessimism regarding rigidity of the federal regulations now seems unwarranted: diversity of local needs has resulted in a diversity of methods and flexibility in meeting those needs. The emerging profile of services now being offered provides a foundation upon which other communities can act as the program expands.

Evaluation in the community mental health centers program: A bold new reproach?