Community mental health service
Encyclopedia
Community mental health services (CMHS), also known as Community Mental Health Teams (CMHT) in the United Kingdom, support or treat people with mental disorders (mental illness or mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...

 difficulties) in a domiciliary setting, instead of a psychiatric hospital
Psychiatric hospital
Psychiatric hospitals, also known as mental hospitals, are hospitals specializing in the treatment of serious mental disorders. Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialise only in short-term or outpatient therapy for low-risk patients...

 (asylum). The array of community mental health services vary depending on the country in which the services are provided. It refers to a system of care in which the patient’s community, not a specific facility such as a hospital, is the primary provider of care for people with a mental illness. The goal of community mental health services often includes much more than simply providing outpatient psychiatric treatment.

Community services include supported housing with full or partial supervision (including halfway house
Halfway house
The purpose of a halfway house, also called a recovery house or sober house, is generally to allow people to begin the process of reintegration with society, while still providing monitoring and support; this is generally believed to reduce the risk of recidivism or relapse when compared to a...

s), psychiatric wards of general hospitals (including partial hospitalization
Partial hospitalization
Partial hospitalization, also known as PHP , is a type of program used to treat mental illness and substance abuse. In partial hospitalization, the patient continues to reside at home, but commutes to a treatment center up to seven days a week...

), local primary care
Primary care
Primary care is the term for the health services by providers who act as the principal point of consultation for patients within a health care system...

 medical services, day centers or clubhouses
Clubhouse Model of Psychosocial Rehabilitation
The of Psychosocial Rehabilitation is a comprehensive and dynamic program of support and opportunities for people with severe and persistent mental illnesses...

, community mental health centers, and self-help groups for mental health
Self-help groups for mental health
Self-help groups for mental health are voluntary associations of people who share a common desire to overcome mental illness or otherwise increase their level of cognitive or emotional wellbeing. There are several international mental health self-help organizations including Emotions Anonymous, the...

.

The services may be provided by government organizations and mental health professionals, including specialized teams providing services across a geographical area, such as assertive community treatment
Assertive Community Treatment
Assertive community treatment, or ACT, is an intensive and highly integrated approach for community mental health service delivery. ACT programs serve people whose symptoms of mental illness result in severe functional difficulties that interfere with their ability to achieve personally meaningful...

 and early psychosis teams. They may also be provided by private or charitable organizations. They may be based on peer support
Peer support
Peer support occurs when people provide knowledge, experience, emotional, social or practical help to each other. It commonly refers to an initiative consisting of trained supporters, and can take a number of forms such as peer mentoring, listening, or counseling...

 and the Psychiatric consumers movement.

The World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

 states that community mental health services are more accessible and effective, lessen social exclusion
Social exclusion
Social exclusion is a concept used in many parts of the world to characterise contemporary forms of social disadvantage. Dr. Lynn Todman, director of the Institute on Social Exclusion at the Adler School of Professional Psychology, suggests that social exclusion refers to processes in which...

, and are likely to have less possibilities for the neglect and violations of human rights
Human rights
Human rights are "commonly understood as inalienable fundamental rights to which a person is inherently entitled simply because she or he is a human being." Human rights are thus conceived as universal and egalitarian . These rights may exist as natural rights or as legal rights, in both national...

 that were often encountered in mental hospitals. However, WHO notes that in many countries, the closing of mental hospitals has not been accompanied by the development of community services, leaving a service vacuum
Vacuum
In everyday usage, vacuum is a volume of space that is essentially empty of matter, such that its gaseous pressure is much less than atmospheric pressure. The word comes from the Latin term for "empty". A perfect vacuum would be one with no particles in it at all, which is impossible to achieve in...

 with far too many not receiving any care.

New legal powers have developed in some countries, such as the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...

, to supervise and ensure compliance with treatment of individuals living in the community, known as outpatient commitment
Outpatient commitment
Outpatient commitment refers to mental health law that allows the compulsory, community-based treatment of individuals with mental illness.In the United States the term "assisted outpatient treatment" or "AOT" is often used and refers to a process whereby a judge orders a qualifying person with...

 or assisted outpatient treatment or community treatment orders.

Origins

Community mental health services began as an effort to contain those who were “mad” or considered “lunatics.” Understanding the History of mental disorders is crucial in understanding the development of community mental health services. As medical psychology developed as a science and shifted toward the treatment of the mentally ill, psychiatric institutions
History of psychiatric institutions
The story of the rise of the lunatic asylum and its gradual transformation into, and eventual replacement by, the modern psychiatric hospital, is also the story of the rise of organized, institutional psychiatry...

 began to develop around the world, and laid the groundwork for modern day community mental health services.

Pre-Deinstitutionalization

On July 3, 1946 President Harry Truman
Harry S. Truman
Harry S. Truman was the 33rd President of the United States . As President Franklin D. Roosevelt's third vice president and the 34th Vice President of the United States , he succeeded to the presidency on April 12, 1945, when President Roosevelt died less than three months after beginning his...

 signed the National Mental Health Act
National Mental Health Act
On July 3, 1946, Harry Truman signed the National Mental Health Act, which called for the establishment of a National Institute of Mental Health. The first meeting of the National Advisory Mental Health Council was held on August 15...

 which, for the first time in the history of the United States, generated a large amount of federal funding for both psychiatric education and research. The passing of this Act eventually led to the founding of the National Institute of Mental Health
National Institute of Mental Health
The National Institute of Mental Health is one of 27 institutes and centers that make up the National Institutes of Health...

 (NIMH) in 1949. At the end of the 1940s and moving into the beginning of the 1950s, the governor of Minnesota Luther Youngdahl
Luther Youngdahl
Luther Wallace Youngdahl was an American politician and judge from Minnesota. He served as an associate justice of the Minnesota Supreme Court from 1942 to 1946, then as Minnesota's 27th Governor from January 8, 1947 to September 27, 1951, and finally as a judge for the U.S...

 initiated the development of numerous community-based mental health services. He also advocated for the humane treatment of people in state institutions.

Deinstitutionalization

Philippe Pinel
Philippe Pinel
Philippe Pinel was a French physician who was instrumental in the development of a more humane psychological approach to the custody and care of psychiatric patients, referred to today as moral therapy...

 played a large role in the ethical and humane treatment of patients and greatly influenced Dorothea Dix
Dorothea Dix
Dorothea Lynde Dix was an American activist on behalf of the indigent insane who, through a vigorous program of lobbying state legislatures and the United States Congress, created the first generation of American mental asylums...

. Dix advocated the expansion of state psychiatric hospitals for patients who were at the time being housed in jails and poor houses. Despite her good intentions, rapid urbanization
Urbanization
Urbanization, urbanisation or urban drift is the physical growth of urban areas as a result of global change. The United Nations projected that half of the world's population would live in urban areas at the end of 2008....

 and increased immigration led to a gross overwhelming of the state’s mental health systems and because of this, as the 19th century ended and the 20th century began, a shift in focus from treatment to custodial care was seen. As quality of care declined and psychotropic drugs were introduced, those with mental illnesses were reintroduced to the community, where community mental health services were designated as primary care providers.

Mental Health Movements

Reform Movement Era Setting Focus of Reform
Moral Treatment 1800–1850 Asylum Humane, restorative treatment
Mental Hygiene 1890–1920 Mental hospital or clinic Prevention, scientific orientation
Community Mental Health 1955–1970 Community mental health center Deinstitutionalization, social integration
Community Support 1975–present Communities Mental illness as a social welfare problem (e.g. treatment housing, employment)


Post-Deinstitutionalization

Following deinstitutionalization
Deinstitutionalisation
Deinstitutionalization or deinstitutionalization is the process of replacing long-stay psychiatric hospitals with less isolated community mental health service for those diagnosed with a mental disorder or developmental disability. Deinstitutionalization can have multiple definitions; the first...

, many of the mentally ill ended up in jails, nursing homes, and on the streets as homeless individuals. It was at this point in history that modern community mental health services started to grow and become influential.
In 1955, following a major period of deinstitutionalization, the Mental Health Study Act
Community Mental Health Act
The Community Mental Health Act of 1963 was an act to provide federal funding for community mental health centers in the United States...

 was passed. With the passing of this Act, the U.S. Congress called for “an objective, thorough, nationwide analysis and reevaluation of the human and economic problems of mental health.” Following Congress’ mandate, the Joint Commission on Mental Illness conducted numerous studies. For the next four years this Commission made recommendations to establish community mental health centers across the country. In 1963 the Community Mental Health Centers Act was passed, essentially kick-starting the community mental health revolution. This Act contributed further to deinstitutionalization by moving mental patients into their “least restrictive” environments. The Community Mental Health Centers Act funded three main initiatives:
  1. Professional training for those working in community mental health centers
  2. Improvement of research in the methodology utilized by community mental health centers
  3. Improving the quality of care of existing programs until newer community mental health centers could be developed.

That same year the Mental Retardation Facilities and Community Mental Health Centers Construction Act was passed. President John F. Kennedy
John F. Kennedy
John Fitzgerald "Jack" Kennedy , often referred to by his initials JFK, was the 35th President of the United States, serving from 1961 until his assassination in 1963....

 ran part of his campaign on a platform strongly supporting community mental health in the United States. Kennedy’s ultimate goal was to reduce custodial care of mental health patients by 50% in ten to twenty years. In 1965, the Community Mental Health Act was amended to ensure a long list of provisions. First, construction and staffing grants were extended to include centers that served patients with substance abuse disorders. Secondly, grants were provided to bolster the initiation and progression of community mental health services in low-SES areas. Lastly, new grants were established to support mental health services aimed at helping children.
As the 20th century progressed, even more political influence was exerted on community mental health. In 1965, with the passing of Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...

 and Medicaid
Medicaid
Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...

, there was an intense growth of skilled nursing homes and intermediate-care facilities that alleviated the burden felt by the large-scale public psychiatric hospitals.

The 20th Century

From 1965 to 1969, $260 million was authorized for community mental health centers. Compared to other government organizations and programs, this number is strikingly low. Unfortunately, the funding drops even further under Richard Nixon
Richard Nixon
Richard Milhous Nixon was the 37th President of the United States, serving from 1969 to 1974. The only president to resign the office, Nixon had previously served as a US representative and senator from California and as the 36th Vice President of the United States from 1953 to 1961 under...

 from 1970–1973 with a total of $50.3 million authorized. Even though the funding for community mental health centers was on a steady decline, deinstitutionalization continued into the 1960s and 1970’s. The number of state and county mental hospital resident patients in 1950 was 512,501 and by 1989 had decreased to 101,402. This continuing process of deinstitutionalization without adequate alternative resources led the mentally ill into homelessness, jails, and self-medication through the use of drugs or alcohol. In 1975 Congress passed an Act requiring community mental health centers to provide aftercare services to all patients in the hopes of improving recovery rates. In 1980, just five years later, Congress passed the Mental Health Systems Act, which provided federal funding for ongoing support and development of community mental health programs. This Act strengthened the connection between federal, state, and local governments with regards to funding for community mental health services. It was the final result of a long series of recommendations by Jimmy Carter
Jimmy Carter
James Earl "Jimmy" Carter, Jr. is an American politician who served as the 39th President of the United States and was the recipient of the 2002 Nobel Peace Prize, the only U.S. President to have received the Prize after leaving office...

’s Mental Health Commission.
Despite this apparent progress, just a year after the Mental Health Systems Act was passed, the Omnibus Budget Reconciliation Act of 1981 was passed. The Omnibus Act was passed by the efforts of the Reagan administration
Reagan Administration
The United States presidency of Ronald Reagan, also known as the Reagan administration, was a Republican administration headed by Ronald Reagan from January 20, 1981, to January 20, 1989....

 as an effort to reduce domestic spending. The Act rescinded a large amount of the legislation just passed, and the legislation that was not rescinded was almost entirely revamped. It effectively ended federal funding of community treatment for the mentally ill, shifting the burden entirely to individual state governments. Federal funding was now replaced by granting smaller amounts of money to the individual states.
In 1977, the National Institute of Mental Health (NIMH) initiated its Community Support Program (C.S.P.). The C.S.P.’s goal was to shift the focus from psychiatric institutions and the services they offer to networks of support for individual clients. The C.S.P. established the ten elements of a community support system listed below:
  1. Responsible team
  2. Residential care
  3. Emergency care
  4. Medicare care
  5. Halfway house
  6. Supervised (supported) apartments
  7. Outpatient therapy
  8. Vocational training and opportunities
  9. Social and recreational opportunities
  10. Family and network attention

(Turner & Tenhoor, 1978)

This conceptualization of what makes a good community program has come to serve as a theoretical guideline for community mental health service development throughout the modern-day United States psychological community.
In 1986 Congress passed the Mental Health Planning Act of 1986, which was a Federal law requiring that at the state government level, all states must have plans for establishing case management under Medicaid, improving mental health coverage of community mental health services, adding rehabilitative services, and expanding clinical services to the homeless population. More specifically, community mental health providers could now receive reimbursement for services from Medicare and Medicaid, which allowed for many of the centers to expand their range of treatment options and services.
As the 1990s began, many positive changes occurred for people with mental illnesses through the development of larger networks of community-based providers and added innovations with regards to payment options from Medicare and Medicaid. Despite these advancements, there were many issues associated with the increasing cost of health care. Community mental health services moved toward a system more similar to managed care as the 1990s progressed. Managed care as a system focuses on limiting costs by one of two means: either keeping the total number of patients using services low or reducing the cost of the service itself.
Despite the drive for community mental health, many physicians, mental health specialists, and even patients have come to question its effectiveness as a treatment. The underlying assumptions of community mental health require that patients who are treated within a community have a place to live, a caring family, or supportive social circle that does not inhibit their rehabilitation. These assumptions are in fact often wrong. Many people with mental illnesses, upon discharge, have no family to return to and end up homeless.
While there is much to be said for the benefits that community mental health offers, many communities as a whole often harbor negative attitudes toward those with mental illnesses. Historically, people with mental illnesses have been portrayed as violent or criminal and because of this, “many American jails have become housing for persons with severe mental illnesses arrested for various crimes.”
In 1999 the Supreme Court ruled on the case Olmstead v. L.C.  The Court ruled that it was a violation of the Americans with Disabilities Act of 1990
Americans with Disabilities Act of 1990
The Americans with Disabilities Act of 1990 is a law that was enacted by the U.S. Congress in 1990. It was signed into law on July 26, 1990, by President George H. W. Bush, and later amended with changes effective January 1, 2009....

 to keep an individual in a more restrictive inpatient setting, such as a hospital, when a more appropriate and less restrictive community service was available to the individual.

21st Century & Modern Day Trends

In 2002 President George W. Bush
George W. Bush
George Walker Bush is an American politician who served as the 43rd President of the United States, from 2001 to 2009. Before that, he was the 46th Governor of Texas, having served from 1995 to 2000....

 increased funding for community health centers. The funding aided in the construction of additional centers and increased the number of services offered at these centers, which included healthcare benefits. In 2003, the New Freedom Commission on Mental Health
New Freedom Commission on Mental Health
The controversial New Freedom Commission on Mental Health was established by U.S. President George W. Bush in April 2002 to conduct a comprehensive study of the U.S. mental health service delivery system and make recommendations based on its findings...

, established by President Bush, issued a report. The report was in place to "conduct a comprehensive study of the United States mental health delivery system..." Its objectives included assessing the efficiency and quality of both public and private mental health providers and identifying possible new technologies that could aid in treatment.
As the 20th century came to a close and the 21st century began, the number of patients diagnosed with a mental health or substance abuse disorder receiving services at community mental health centers grew from 210,000 to approximately 800,000. This nearly four-fold increase shows just how important community mental health centers are becoming to the general population’s wellbeing. Unfortunately, this drastic rise in the number of patients was not mirrored by a concomitant rise in the number of clinicians serving this population. The staggering new numbers of patients then are being forced to seek specialized treatment from their primary care providers or hospital emergency rooms. The unfortunate result of this trend is that when a patient is working with his or her primary care provider, he or she is more likely for a number of reasons to receive less care than with a specialized clinician.
Politics and funding have always been and continue to be a topic of contention when it comes to funding of community health centers. Political views aside, it is clear that these community mental health centers exist largely to aid areas painfully under resourced with psychiatric care. In 2008, over 17 million people utilized community mental health centers with 35% being insured through Medicaid, and 38% being uninsured. As the 2000s continued, the rate of increase of patients receiving mental health treatment in community mental health centers stayed steady.

The Future

On one hand, despite the field’s movement toward community mental health services, currently “insufficient empirical research exists regarding the effectiveness of community treatment programs, and the evidence that does exist does not generalize to all types of community treatment.” In addition to the fact that community mental health’s overall success must be further evaluated, in the times when it has proved effective, very little research exists to help in understanding what exact aspects make it effective. Effective and insightful research will be crucial in not only evaluating, but also improving the techniques community mental health utilizes.
On the other hand, the demand for and necessity of community mental health is driving it into the future. With this seemingly unrelenting increase in the number of people experiencing mental health illnesses and the number of people reporting these problems, the question becomes what role will community mental health services play? In 2007, almost 5% of adults in the United States reported at least one unmet need for mental health care. Funding has historically been and continues to be an issue for both the organizations attempting to provide mental health services to a community and the citizens of the community who are so desperately in need of treatment. The community mental health system’s goal is an extremely difficult one and it continues to struggle against changing social priorities, funding deficits, and increasing need. Community mental health services would ideally provide quality care at a low cost to those who need it most. In the case of deinstitutionalization, as the number of patients treated increased, the quality and availability of care went down. With the case of small, private treatment homes, as the quality of the care went up their ability to handle large numbers of patients decreased. This unending battle for the middle ground is a difficult one but there seems to be hope. For example, the 2009 Federal Stimulus Package and Health Reform Act have increased the funding for community health centers substantially. Undoubtedly as community mental health moves forward, there will continue to be a juggling act between clinical needs and standards, political agendas, and funding.

See also

  • American Association of Community Psychiatrists
    American Association of Community Psychiatrists
    The American Association of Community Psychiatrists is a member organization of recovery-oriented and recovery focused psychiatrists, psychologists and social workers who primarily work in community-based settings. Founded in 1985, the AACP is based in the United States, and its founding president...

  • Community health
    Community health
    Community health, a field of public health, is a discipline that concerns itself with the study and betterment of the health characteristics of biological communities. While the term community can be broadly defined, community health tends to focus on geographic areas rather than people with shared...

  • Recovery model
    Recovery model
    The Recovery Model as it applies to mental health is an approach to mental disorder or substance dependence that emphasizes and supports each individual's potential for recovery...

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