Fifty years ago this week, on October 31, 1963, President John F. Kennedy signed legislation creating a federally funded Community Mental Health Centers (CMHC) program. The CMHC program was the last piece of major legislation signed by Kennedy and thus became a symbol of his legacy. The legislation and subsequent additions authorized the use of federal funds to construct and staff CMHCs to “provide comprehensive mental health services” to local communities. Kennedy had high hopes for the program, claiming that it would replace “the shabby treatment of the many millions of the mentally disabled in custodial institutions.”
Sadly, JFK’s dream of federalizing public services for mentally ill persons was subverted by the law of unintended consequences. The program has been an unmitigated disaster, both for those who suffer from severe mental illnesses such as schizophrenia and bipolar disorder and for the communities in which they live. Untreated mentally ill individuals have usurped hospital emergency rooms, parks, streets, and other public spaces. According to Department of Justice data, approximately 15 percent of prison inmates and 20 percent of jail inmates, or 388,600 prisoners, are seriously mentally ill; similar studies prior to 1960 reported the figure to be 3 percent or less. Untreated mentally ill individuals are now responsible for at least 10 percent of all homicides and half of the mass killings such as those at Virginia Tech, Tucson, Aurora, Newtown, and the Washington Navy Yard. We did an excellent job of emptying state hospitals but an atrocious job of providing treatment in the community, in large measure because Kennedy’s mental-health centers focused on the worried well rather than the suffering sick.
Until 1963, states could be held accountable for such failed services. Governors and state legislatures — and therefore state commissioners of mental health –were responsible to, and could be replaced by, the voters. Now, however, such services are funded by a bewildering variety of federal and state programs and nobody claims to be responsible. When nobody is responsible, nobody can be held accountable.
The CMHC legislation was a major departure from existing federal and state responsibilities. For 150 years, the care of mentally ill persons had been vested in the states; a few states, such as Iowa and Wisconsin, passed the responsibility on to the counties. Prior to 1963, there had been only one attempt to federalize such services. In 1854, Congress passed legislation authorizing the use of federal funds to build state psychiatric hospitals, but President Franklin Pierce vetoed the bill because, he said, “I cannot find any authority in the Constitution that makes the Federal Government the great almoner of charity throughout the United States.”
Skeptical voices were raised during the 1963 congressional hearings on the proposed CMHCs. Minnesota representative Ancher Nelsen, a Republican, said that the proposed “start-up funds” were merely a foot in the door: “I have never seen a temporary government program that didn’t become permanent and I see no way that you can terminate this financing of staffing in the future.” The New York state commissioner of mental hygiene said flatly that the CMHC program would be ineffective for the sickest mentally ill individuals. Most damning was that a model CMHC program, which had been run by the National Institute of Mental Health (NIMH) for 15 years, had been a failure. Nevertheless, the CMHC legislation was approved by Congress.
In fact, in 1963, at the time of the proposed federal legislation, most states had already begun making provisions for community psychiatric services for patients being deinstitutionalized from state hospitals. Twenty states had passed or proposed state mental-health legislation, and 234 mostly state-funded programs were operational. Following the implementation of the federal CMHC program, state efforts gradually ceased. With the subsequent passage of the Medicare, Medicaid, Supplemental Security Income, and Social Security Disability Insurance programs, the financing of mental-health services effectively shifted from the states to the federal government. In 1963, federal funds contributed approximately 2 percent of the costs of services for mentally ill persons; today federal funds contribute over 75 percent of those costs.
What can be done? The obvious answer is to call this 50-year federal experiment a failure and reverse course. The responsibility — and accountability — for public mental-health services should be vested at the state level. Large states may wish to devolve this responsibility to the counties but, in either case. the accountability for the programs should be legislatively mandated. The federal government’s role should be restricted to funding research on the causes and treatment of mental illness as well as services demonstration projects under NIMH. This division of responsibility was wisely suggested in 1946 by Representative Clarence Brown (R., Ohio) during hearings on the creation of NIMH.
The saddest part of JFK’s legacy is that we now have much better treatment and rehabilitation programs than we had in 1963, but they are unused for the majority of the sickest individuals. Reversing JFK’s shift toward federalization and holding states accountable is, ironically, our best hope for fulfilling his original dream.
— E. Fuller Torrey, M.D., is the founder of the Treatment Advocacy Center and author of American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System.