Worth and Dignity: 50 years of mental health reform

By Cheryl Arndt

In a statement made to Congress, a U.S. president defined mental illness (and it’s “twin problem” of mental retardation) as so critical and tragic as to deserve a wholly new national approach because it occurs more frequently, affects more people, requires more prolonged treatment, causes more suffering by the families of the afflicted, wastes more of our human resources and constitutes more financial drain than any other single condition. The president was John F. Kennedy. The speech was his 1963 “Special Message to the Congress on Mental Illness and Mental Retardation.” That speech, part of the civil rights movement of the early and mid- 1960s, marked the beginning of modern mental health reform. It occurred 50 years ago this year (Kennedy, 1963).

At the time of his speech, Kennedy noted that 20 percent of the existing 279 “state mental institutions” were known fire and health hazards, and nearly half of them housed more than 3,000 patients, making individual care and consideration almost impossible. Many of the institutions had less than half the professional staff required, including less than one psychiatrist for every 360 patients. Additionally, 45 percent of those institutionalized had been there continuously for 10 years or more.

In his speech, President Kennedy proposed a three-pronged approach to improving the care for those with mental illness, specifically by:

  1. Seeking out and eradicating causes of mental illness, 
  2. Strengthening underlying resources of knowledge and skilled personnel and
  3. Strengthening and improving programs and facilities.

Kennedy advocated for those with mental illness to be “retained in and returned to” the community. His plan called for services and centers in people’s own communities where there would be a focus on prevention as well as treatment, a cordial atmosphere and a continuum of care including diagnosis, treatment and rehabilitation as well as tie-ins to physical health care and specialized therapies and services. Following Kennedy’s February 1963 speech, Congress passed the Mental Retardation Facilities and Community Health Centers Construction Act of 1963 in October. The purpose of the act was to provide the treatment and the facilities that Kennedy had called for creating.

The past 50 years have brought a mixture of successes and failures in the attempt to realize President Kennedy’s vision. As a result of deinstitutionalization, the population rate of those in psychiatric hospitals decreased by 94 percent between the mid-1950s and the mid-1990s. However, this extreme rate of deinstitutionalization has at times meant that clients have been discharged to an unprepared and unwelcoming community. Additionally, in a phenomenon referred to as transinstitutionalism, some mentally ill people have found themselves in jail instead of in longer-term treatment settings (PBS, 2005). It has been estimated that the prevalence of those with serious mental illness has been three to five times higher in jail than in the larger community (Levin, Petrila, & Hennessy, 2010). On the positive side, many individuals with mental illness enjoy substantially more rights, better treatment and better outcomes as compared to similarly diagnosed individuals just 50 years ago.

The “Mental Health Act” was not the only factor that impacted client care in the 1960s and beyond. Advances in treatment have also emerged in the past 50 years (Frank & Glied, 2006). One area of improved treatment has been psychopharmacology. Following the introduction of Thorazine as an effective anti-psychotic in the 1950s, pharmacological treatment for many mental illnesses became both more effective and safer (Levin, Petrila, & Hennessy, 2010). Psychotherapy also became more effective in those years, and clinicians are now expected to apply techniques that are known to succeed and to demonstrate the results of their work with clients (Frank & Glied, 2006). The field’s current focus on evidence-based practices and on observable, quantifiable changes in clients is reflected in the use of the term “behavioral health” which, in recent years, has often replaced the term “mental health.” In 2006, the American Psychological Association (APA) defined evidence-based practices as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences” for the purpose of enhancing public health.

Philosophically, as we have moved from “mental health” to the measurable “behavioral health,” we have also moved from the term “patient” to that of “client.” Another seemingly small change, this important rewording reflects the active role individuals play in their own treatment. It also implies that individuals can choose where to take their business and from whom to receive their services. This empowerment of clients is a result of the recovery movement, which started in the 1990s and became prominent in 2000 when the U.S. Department of Health and Human Services published a detailed, step-by-step guide to the development of the participatory dialogues between clients, families, communities, mental health providers, advocates and government agencies that are key to the approach. The recovery movement is based on hope and the assumption that individuals can and do improve and that they can lead happy and productive lives (Sowbel & Starnes, 2006). Whereas recovery is the term used to describe integrated treatment of adult clients, resiliency is the term that describes the process that children and youth undergo in their journeys toward wholeness. In providing children’s services that promote resiliency, the focus is on building skills, incorporating strengths and increasing collaboration among local service providers (City of Philadelphia, 2011).

Since Kennedy’s 1963 speech and the Mental Health Act of the same year, there have been continued changes in policy and funding processes. In 1965, Medicare and Medicaid bills were passed, which allowed many people to purchase treatment services in their community. In the 1990s, managed care strategies emerged to control the cost of services through prior authorization, discharge planning and case management. Initially, many managed care organizations took an “exceptionalism” approach to mental and behavioral health care, carving it out separately from physical health care policies (Frank & Glied, 2006). However, in 2008, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA). MHPAEA required most insurance plans to provide equal coverage for physical and mental/behavioral health care (U.S. Department of Labor, 2010). Even more recently, the Affordable Care Act (ACA) was signed into law in 2010, then upheld by the Supreme Court in 2012. The ACA built on MHPAEA to ensure parity protection to 60 million Americans who were not covered by MHPAEA and to prevent denial of coverage to those with pre-existing conditions. Further, the ACA requires new health plans to cover preventive services such as depression and other mental health screening for all and behavioral screenings for children (Munoz, 2013).

Policy, funding, philosophy and treatment have all changed a great deal since Kennedy’s 1963 speech to Congress. Much progress has been made, and many opportunities for improvement still exist. Despite Kennedy’s call for increasing skilled personnel, recruiting and retaining the best and the brightest to our relatively low-paid field remains a particular challenge.
Despite this and other challenges, every day mental health professionals work to break down stigma, advocate for effective treatment and ensure for our clients, family members, friends and community members with mental illness their civil right to “life, liberty and the pursuit of happiness.”

American Psychological Association. (2006). Evidence based practice in psychology: APA presidential task force on evidence-based practice. American Psychologist, 61(4), 271 – 285. Retrieved from http://www.apa.org/practice/resources/evidence/index.aspx
City of Philadelphia. (2011). Practice guidelines for recovery and resilience oriented treatment. Retrieved from http://www.dbhids.org/assets/Forms--Documents/transformation/PracticeGuidelines.pdf
Frank, R.G., & Glied, S.A. (2006). Better but not well: Mental health policy in the United States since 1950. Baltimore, MD: The Johns Hopkins University Press.
Public Broadcasting System. (2005, May 10). Frontline. Deinstitutionalization: A psychiatric “Titanic.” Retrieved from http://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html
Kennedy, J. F. (1963, February 5). Special message to the Congress on mental illness and mental retardation. Retrieved from The American Presidency Project. http://www.presidency.ucsb.edu/ws/?pid=9546.
Levin, B.L., Petrila, J., & Hennessy, K.D. (2010). Mental health services: A public health perspective (3rd ed.). New York, NY: Oxford University Press.
Mental Retardation Facilities and Community Health Centers Construction Act of 1963. Pub. L. No. 88-164, 77 Stat. 282 (1963). Retrieved from http://research.archives.gov/description/299883
Munoz, C. (2013, August 21). The Affordable Care Act and expanding mental health coverage. [Weblog comment]. Retrieved from http://www.whitehouse.gov/blog/2013/08/21/affordable-care-act-and-expanding-mental-health-coverage
Sowbel, L. & Starnes, W. (2006). Pursuing hope and recovery: An integrated approach to psychiatric rehabilitation. In J. Rosenberg & S. Rosenberg (Eds.), Community mental health: Challenges for the 21st century, (25-34). Routledge: New York, NY.
United States Department of Labor. (2010). Fact sheet. The Mental Health Parity and Addiction Equality Act. (Public Law 88-164, 77 STAT 282). Retrieved from http://www.dol.gov/ebsa/newsroom/fsmhpaea.html

With roots in Expressive Arts Therapy, Cheryl Arndt has spent many years in mental health program development and management. Several years ago, she re-discovered her love of data, and shifted her focus to research and performance improvement. Her position as Quality Assurance and Compliance Manager at KidsPeace’s Orchard Hills Campus allows for a perfect blend of her two loves: children’s mental health and data. Cheryl is a Ph.D. candidate in Psychology. Given the appropriate behavioral reinforcers, she can, at times, be pried away from her keyboard.