Supports for Community-Based Mental Health Care: An Optimistic Review of Federal Legislation
Bentley, Kia J., Health and Social Work
For 50 years, federal legislation has been a key force in shaping the delivery of public mental health services. The Community Mental Health Services Act of 1963 and its amendments, in conjunction with advances in treatment, philosophy of care, and mental health law, are often credited with being a major factor in deinstitutionalization and the rise of community-based services.
Community-based care has for some time been clearly articulated as a desired national goal (Chandler, 1991; Talbott, 1985). In spite of an ambitious vision, however, the community mental health movement and community support programs in the 1970s and 1980s, called the third and fourth "cycles of reform" by Morrissey and Goldman (1984), have been associated with periods of "exaggerated expectations" as well as pessimism, akin to earlier cycles of reform such as "moral treatment" and mental hygiene. The consensus among policy analysts (Brown, 1985; Foley & Sharftstein, 1983) is that the much-analyzed and disappointing results of deinstitutionalization and community mental health services are, at least in part, related to the period of retrenchment and even reversal of the federal leadership and support ushered in by the Reagan administration. However, there is evidence that in spite of the inaction on the part of recent Republican leadership in advancing community-based mental health care, cumulative gains have been made, largely because of the family and consumer movements and legislation they helped to create. Although predictions of impact should not be overstated, there is now good reason to be hopeful about the potential of federal legislation to once again move the mental health service delivery system forward.
This article reviews, describes, and summarizes federal legislation initiatives that have provided support for a system of community-based care for adults with mental illness. Through this legislation, the federal government has fulfilled its revised roles, predicted 10 years ago by Andrulis and Mazade (1983), to determine the "pace and direction" of the service system, allowing the states to assume more responsibility for actual services components.
Admittedly, legislative mandates and incentives are merely one force that facilitates movement toward a community-based system of care. Today, in addition to the strong advocacy movements and the historical commitment, well-controlled cost-effectiveness research and other factors serve as facilitating forces to community-based care (Bentley, 1994). However, formidable restraining forces exist as well: the employment security concerns of state hospital employees, inpatient care funding incentives, the long-term-care concerns of families, public fear and discrimination, a continued lack of sufficient funding for a truly adequate array of services, and ongoing state and federal battles over authority. These barriers, in essence, support continuation of the status quo--the underfunding of services and supports in communities to people with mental illness and the overreliance on inpatient solutions. Nevertheless it is important to consider how a range of federal legislative initiatives over the past 10 years support community-based care.
DEFINITION OF COMMUNITY-BASED CARE
Community-based care refers to a system in which the community, not a facility, is major locus of care for mentally ill people. Care includes the availability not only of outpatient mental health treatment, but also of other needed resources such as housing, employment, and recreation. The community, often through the community mental health center (CMHC), may be seen as having the ultimate responsibility and authority for an individual's care. The goal is to provide a continuum of services and supports that is flexible, tailored, coordinated, and most importantly consumer- and family-oriented (National Institute of Mental Health, 1987). A useful philosophical approach is to view the community as a nontoxic environment. …