Abstract
The community mental health movement in the US peaked in 1963 with the passage of the Community Mental Health Centers (CMHC) Act. The movement had its origins in the two decades before 1963 beginning with World War II. The 20 years that followed marked the maturation of that movement. The CMHC legislation stood at the mid-point of a cycle of reform – in the midst of a movement that profoundly altered services for people with mental illness. We discuss the origins of the community mental health movement and elaborate on the next turning of the cycle of reform – the late 1970s until the present. The focus is on the community support reforms that re-emphasized the care of individuals with severe and persistent mental illnesses. We intend to complement the paper by Saul Feldman, who primarily discusses the period of the maturation of the community mental health movement from 1963 until the 1980s. Our analysis uses the framework introduced by Morrissey and Goldman to describe ‘cycles of reform’ in the delivery of US mental health services. They describe a recurrent pattern of reforms that was marked by public support for a new environmental approach to treatment and an innovative type of care [1–4]. The first cycle of reform in the early 19th century introduced moral treatment and the asylum [5–8]. The second cycle in the early 20th century was associated with the mental hygiene movement and the psychopathic hospital [9–13]. Each innovation proved successful with acute and milder, not chronic, forms of mental disorder, yet failed to eliminate chronicity or to fundamentally alter the care of the severely mentally ill. In each of the first two cycles, the optimism of reform gave way to pessimism and nihilism toward the increasing numbers of incurable patients.
The third cycle of reform which emerged in the mid- 20th century supported community mental health centres as the optimal locus of care [14–17]. Beginning in World War II several new ideas emerged. First, crisis intervention and community involvement were viewed as important as a result of psychiatrist Erich Lindemann's experience with post-traumatic psychiatric care following the Coconut Grove fire [18]. This experience led Lindemann to create the first community mental health centre in 1948. A similar thrust arose from military psychiatric practices that involved rapid treatment at the front (i.e. within the ‘community’ of combatants) and the return of transiently emotionally disabled soldiers into the line. The notion that the community could be both the site of the trauma and healing reinforced community practice and provided the underpinnings of the rationale for the CMHC. This movement also took on issues of poverty, racism, civil unrest, violence and criminality as threats to mental health [19, 20].
The first CMHCs were devoted principally to consultation and education with community agencies. Mental health professionals offered treatment to new groups of previously untreated, acutely ill, and emotionally troubled patients. Few persons with severe and chronic disorders were treated at many of the centres [2, 20].
Only later did they offer outpatient services and develop inpatient agreements with community hospitals. Facilitated by postwar optimism, and the introduction of antipsychotic and antidepressant medications in the 1950s, lengths of stay at state hospitals began to decline. The so-called movement to ‘deinstitutionalization’, propelled by a variety of forces, was gathering momentum. Community mental health centres, often sponsored by state mental hospitals (as early as the 1950s), focused on ambulatory services, especially ‘aftercare’ and crisis intervention for a mix of disadvantaged and acute and chronic patients in the public sector. Several state hospital systems had elaborate networks of decentralized services for acute and chronic patients by the early 1960s [20, 21].
By the late 1950s and 1960s, social, political and cultural trends that made institutional treatment anathema and to be avoided at all costs came to a head with the report, Action for Mental Health, issued by The Joint Commission on Mental Health and Illness [14]. The report called for a massive federal investment in research on mental illness, a mental health awareness campaign, a tripling of service expenditures within a decade, and a new emphasis on early identification and treatment. The system would rely heavily on community clinics, emergency services and acute hospitals; public mental hospitals would never exceed 1000 beds. Mental institutions were often viewed as inhuman ‘snake pits’, factories for the manufacture of madness [22]. Evidence of social and functional deterioration following long-term care reinforced the notion that institutions caused chronic disorder. Community mental health reformers advocated to eliminate institutions. The result of this call for federal action and the ‘bold new approach’ promised by President John F. Kennedy was the Congressional passage in 1963 of the CMHC Act [2].
The federally funded community mental health centres merged the preventive ideology and acute treatment/ consultation philosophy of the early community-based centres with the service mix of the state hospital-based centres. The model required five services: inpatient, outpatient, partial hospitalization, emergency and consultationeducation services. The approach was predicated on an integrated model, promoting continuity of care through an episode of illness [17, 21]. In the end, the community mental health movement did change services dramatically – for acute and chronic patients. Between 1950 and 1980, for example, the population of state mental hospitals diminished from 560 000 to 140 000; admissions to other inpatient psychiatric facilities increased dramatically; and outpatient services expanded 12-fold. Since the mid 1960s, more than 700 CMHCs have been created, serving catchment areas representing 50% of the US population [2, 23–25]. The use of nursing homes expanded dramatically, diverting the path of chronically mentally ill older people from the state hospital to the nursing home [2].
However, numerous limitations of the 1963 Act soon emerged. There was no clear mandate for the CMHCs to coordinate efforts with the state mental hospitals or to care for chronic patients. In fact, federal policy makers intentionally created a program granting federal resources to local agencies, bypassing state mental health authorities [23]. This facilitated the tendency for ‘new’ rather than chronic patients obtaining support in state hospitals to receive care in CMHCs. Mental health centres thus primarily served new populations but failed to meet the needs of patients discharged in increasing numbers from public hospitals. Furthermore, centres were not required to provide housing or income support for discharged patients. Homelessness and indigency were predictable outcomes for many [2].
The limitations of the community mental health movement were recognized by the mid-1970s. In particular the CMHCs were criticized for their failure to provide appropriate services for individuals with disabling conditions [2]. In the third cycle of reform, institutions had been considered the villains. Fiscal conservatives interested in trimming state hospital budgets joined up with civil libertarians and mental health reformers, who believed that chronicity was a function of institutional care and that release from the hospital would eliminate the problem [2]. These groups eagerly supported deinstitutionalization and the resultant shift of fiscal burden from state to federal government. Twenty years later, a new villain had emerged, deinstitutionalization.
By the mid 1970s, deinstitutionalization was being criticized for neglecting the chronically ill, in journals [26–28], government publications [29–31], political white papers [32–34], the press and popular literature. The zeal of the activists in trying to solve problems without also focusing on the need for the humane care of the chronically ill had, in part, contributed to the problems associated with deinstitutionalization. Even the 1975 revisions of the CMHC Act, which mandated cooperation with state mental hospitals and encouraged care for chronic patients, did not address the social welfare and housing needs of the disabled. Expansion of social security disability to the indigent provided some assistance but was not equal to the growing problems of deinstitutionalization [2]. Substandard housing, criminalization and abject poverty were rampant. By the late 1970s, the General Accounting Office (GAO) deplored the lack of federal support for a rational deinstitutionalization policy. The GAO noted the lack of a coordinated system and the need for ‘government to do more’ to promote services for the neglected population, those with the most disabling conditions [31]. By 1978 the President's Commission for Mental Health called for a national policy focused on the chronically ill [34].
It is salutory to note that the third reform cycle, like the first two, promised that early treatment of acute cases would prevent chronic illness. This failure set the stage for the fourth cycle of reform, the community support movement, which refocused attention on chronic illness in its own right as a target for humane intervention [2].
Community support program
The Community Support Program (CSP) was the National Institute of Mental Health's (NIMH) response to the criticism of the federal role in deinstitutionalization. $3.5 million was allocated annually to 19 states for three-year pilot programs designed ‘to provide services for one particularly vulnerable population – adult psychiatric patients whose disabilities are severe and persistent but for whom long-termed skilled or semiskilled nursing care is inappropriate’. The CSP responded to ‘a much needed social reform’ by championing ‘community support systems’ – a network of crisis care, psychosocial rehabilitation, supportive living and working arrangements, medical and mental health care and case management. The federal program became a model for the states throughout the US [35, 36].
The CSP broke the cycle by focusing on individuals who were already severely and persistently impaired. This eliminated the historic over-emphasis on early detection and treatment as a putative means to prevent chronicity. Instead it embraced the ideas of rehabilitation and support for those who were disabled but could live in their communities and enjoy a semblance of recovery. The community support reform, however, did not solve the problem of a weak technology. The reform – like moral treatment, mental hygiene and community mental health before – did not have effective technology to make them succeed [2].
The important constraint, imposed by lack of effective treatment, rehabilitation and support technologies, changed with new evidence-based practices (EBP) from the late 1970s. Evidence-based practices are clinical practices for which scientific evidence of improvement in consumer outcomes has been consistent [37]. They represent a parallel track in the history of medical science. The importance of EBP as a guide that motivates change is demonstrated by its preeminence in the Institute of Medicine's (IOM) indictment of American health care (see ‘Crossing the Quality Chasm’ [38]). Delivery of EBP is a cornerstone of the IOM's call to improve quality of care. Optimal care and outcome must include careful and informed consideration of current scientific evidence.
How did the development of EBPs mesh with the community mental health and community support cycles of reform? While these cycles turned and policy makers focused on how to organize and finance care, clinicians in the trenches were becoming frustrated by the problems that remained unsolved. The dual diagnosis of mental illness and substance use, homelessness, criminalization and alienation of families complicated the clinical landscape. As a result, a creative group of clinicians understood not only that strong ideology and innovation in organization of care were necessary, but that clinical ideas needed to be supported scientifically. Proof or at least evidence of good effect was necessary before systematic change could be justified. The previous cycles were well meaning, but did not necessarily produce intended results. A more rational approach would require that the scientific method be used.
In the balance of this paper we discuss these EBPs that make progress possible within the ideals of the community mental health and community support movements. We use the story of assertive community treatment and its dissemination as a case study [39]. The example will demonstrate that those who developed EBPs were motivated by the wish to assist recovery by providing effective treatment and support in community settings.
Assertive community treatment: development of an EBP
The predecessor of Assertive Community Treatment (AST) was the Training in Community Living model, developed at Mendota Mental Health Institute in Madison, Wisconsin. The name is descriptive. Marx, Stein, and Test, creators of ACT, wished to address the revolving-door phenomenon. They had to move away from the hospital and into the community [40]. Their pilot program was paradoxically based on the premise that some patients were too sick to be treated in hospital. Individuals with a limited repertoire of instrumental and problem-solving behaviours to handle stress and problems of daily life, those with powerful dependency needs, and those whose symptoms worsened under stress were vulnerable to becoming un-dischargable patients. Paradoxically, the community could offer greater safety [41]. The ‘patient as failure’ notion gave way to the creative idea that a community treatment group could improve upon the hospital.
The community group focused on helping persons with mental illness develop skills to cope with problems of living. Hospitalization was not viewed as a viable alternative; instead, the treatment team worked with community resources. Consistent with the notion of EBP, developers of this precursor to ACT understood the need to document effectiveness. They also understood the value of a randomized design. A five-month randomized controlled trial comparing community treatment with two inpatient groups found that the former was feasible and effective [41]. Community-treated patients had reduced hospital stays compared with controls. Further, they did not wind up in other institutions or back with their family; they often lived and worked autonomously. Symptoms did not worsen [42]. This early pilot study led to a program with a more sophisticated evaluation, funded by the National Institute of Mental Health (NIMH).
The NIMH study, a randomized trial evaluating ‘training in community living’ [43], had two phases. The first, 12-months long, compared the program with standard services. The training in community living program was superior, with markedly reduced hospitalization as well as better outcomes in terms of symptoms, employment, social relationships and life satisfaction [44]. Community and family burden were similar. The cost-benefit analysis also found that although the program cost more than standard services, it had more benefits, and these exceeded costs by $400 per patient year [45]. The researchers understood the need to assess a range of outcome indices.
The second phase of the evaluation followed a twomonth period in which training in community living was phased out. Patients then received the same services as the control group for 12 months. Improvements (except a gain in competitive employment) were eroded during this phase. The findings suggest that the program must not set arbitrary limits for participation. Although it was unclear whether patients needed continuing services, the 12-month, one-size-fits-all policy would potentially create its own revolving door [45].
Assertive community treatment (ACT)
The training in community program evolved into ACT. To quote Santos and Stein [40]: ‘ACT [assertive community treatment] is best conceptualized as a… system… to furnish the latest, most effective and efficient treatments, rehabilitation, and support services conveniently as an integrated package. It serves as the fixed point of responsibility for providing services to a group of individuals with severe and persistent mental illness identified as needing ACT… to achieve… desired outcomes (e.g. reduced use of the ‘revolving door’… increased quality and stability of community living, normalizing activities of daily living such as competitive employment). Services are not time-limited or sequenced. Service intensity varies with changes in desired outcomes. In the evolution of EBP the need to address the issue of scientific support for its effectiveness took on several challenges. The first was that of fidelity. As ACT has been adopted, varied outcome has been noted. This has raised a pivotal question: What are the critical ingredients that make ACT work [46–54]? McGrew and colleagues [47–49] developed a scale to assess fidelity to the ACT model. Three subscales measured organization, service and staffing. Higher fidelity has been consistently linked to better outcomes [47, 50, 54]. Fidelity is linearly related to program ‘generations’, suggesting ‘program drift’ [47]. Stein [53] argued that ACT is not just case management and, paradoxically, called for its abolition. If a program is not ACT, it will not produce the outcome of an ACT program.
A second challenge was cost effectiveness. Test and Stein anticipated that concerns about cost would be paramount. Although studies differ, ACT is more costeffective than other outpatient programs, assuming that two criteria are met [55–59]. First, the cost of hospitalization must be included in the analysis; second, patients must have reasonable hospital care to begin with – about 50 days a year in one study [55].
Finally, could ACT be discontinued safely? In the first study of the training in community living program, patient improvements was not sustained. The question remains whether a specific ‘dose’ of ACT can lead to stable change. Can some patients be moved to less intensive care? A criticism of ACT has been that it promotes dependence rather than motivating people to move beyond health services. Many programs do discharge patients in a stable way to make room for the newly referred. Stein et al. [59] compared stable participants in an ACT program with those in a clubhouse program on vocational activity, relationships and community integration. The groups did equally well. This supports the idea that stable patients in ACT can ‘graduate’ to a less intensive program, of which the clubhouse is an example. Studies of homeless mentally ill adults receiving ACT or comparable care suggest that at least a proportion can be discharged from the program and maintain gains [60, 61].
The legacy of ACT: newer EBPs
Mental health services continue to change, particularly for disabling conditions. Many failures in community mental health have been the failure of the social welfare system to provide for the mentally ill [62]. Problems with housing, education and employment all reflect inadequacies in both mental health and social services [63, 64]. Creative solutions have evolved in the form of EBPs, some of which derive from ACT – supported employment and integrated treatment for people with cooccurring substance abuse [37].
Undoubtedly we have more effective means than at any time in the past to implement community mental health reforms [37]. Their success will depend on political will and a policy to adopt EBP within the value system devised from the crisis of mental health care in the post WW II era.