The History of Community Mental Health Care
Shannon Bradford 
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More than a third of incarcerated individuals in the United States today have a diagnosed mental illness. In the 1960s, this population constituted fewer than 5% of all inmates. How did having a mental health condition become criminalized? A well-meaning policy intervention called the Community Mental Health Act (CMHA) of 1963 provides some answers. The main goal of the CMHA was to provide community-based solutions for people with mental health challenges so that they could integrate with society during and after treatment. However, this aim went unrealized due to policy failures. Recent research on providing community mental health care shows that the original aim of the CMHA was sound. These findings suggest that mental health care access is an essential tool in decreasing the disproportionate criminal legal system contact the CMHA helped create. Understanding how the CMHA got it wrong last time around will be critical for getting it right today.
On the heels of the emergence of the first effective antipsychotic medication, President Kennedy promoted the CMHA as a chance to welcome people with mental health conditions back into their communities. Previously, these individuals were sent to state psychiatric hospital settings where they were being warehoused away for extended periods and potentially subjected to inhumane conditions like lobotomies and shock therapy. Federal grant funding for community mental health and research centers alongside the adoption of Medicaid incentivized states to cut their budgets for expensive hospital programs in favor of government dollars. States eagerly seized at the opportunity to defund programs for which they had once footed the entire bill. The legislation led to the successful closure of state psychiatric hospitals in the 1960s and 70s. Closing state hospitals was a half-step; the CMHA intended for states and localities to step in to fund the ongoing operations of the community mental health centers, but this was not enforced by the federal government. By the 1980s, what money was left for the program was turned into a mental health block grant that states could spend at their discretion. Thus only half of the centers were built and none were ever fully funded to continuously operate.
As individuals returned to their homes, many jurisdictions did not have the resources to support their returning residents’ needs, which led to untreated mental health conditions, homelessness and substance abuse, which can often be comorbid with mental illness, and ultimately disproportionate contact with the criminal legal system. For Black, Indigenous, and people of color (BIPOC) communities, they were even less likely to return home to the community services they needed. Mental health care was, and continues to be, difficult to access for BIPOC individuals, and this is reflected in the racial disparities in jail and prison populations we see today.
Lack of community care has resulted in overreliance on the police to respond to both mental health crises and everyday interactions with people with mental illnesses. Police preemptively arrest individuals with mental health disorders for things like “wandering aimlessly,” entangling them in the system instead of connecting them to care. For the ill-fated interactions that rapidly escalate, outcomes can be deadly. While statistics vary, different studies suggest that between 25% and 50% of police fatalities involved individuals with a severe mental illness.
In the wake of police murders of people with mental health challenges like Nathaniel Pickett II and Patrick Warren Sr., the nation is demanding increased investments in supporting mental health care service needs and decreasing interactions with law enforcement. Research from July 2020 by Deza, Maclean, and Solomon use Uniform Crime Reports and Census Bureau County Business Patterns data to show that investments in mental health services can serve as an avenue to reduce police interactions. In particular, the authors find that the addition of ten mental health offices in a given county is associated with a reduction of 1.7 crimes per 10,000 residents. Greater investments in community health also led to cost savings for the government. The authors’ findings translate into a 2.1% reduction in the expected cost of total crimes per capita. These are modest reductions, but Deza et al. point out that even one averted murder saves taxpayers $10.9 million.
These results are limited by the assumption that, while many types of mental illness are treatable in an office-based setting, not all are. Moreover, the study can only assess how mental health care access impacts people who seek out treatment in office-based settings. The authors hope this study spurs future research that corrects for these limitations.
Their results validate what CMHA tried to achieve through its deinstitutionalization objective. As advocates and activists call for similar national funding priorities to recenter mental health services in the community, it is imperative that they reflect on the failures of CMHA and seek legislation that addresses long-term funding for mental health services while encouraging states to maintain or increase their own spending levels. Furthermore, constituents must hold their state leaders accountable to truly spending federally allocated dollars for community care on the programs they are intended to fund.
Should public attention on this issue wane, states are liable to cut mental health spending when money gets tight. By implementing community programs with fidelity, we can begin to decriminalize mental health and fulfill President Kennedy’s original vision as expressed in a special message he gave to Congress on February 5, 1963: “[R]eliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability. Emphasis on prevention, treatment and rehabilitation will be substituted for a desultory interest in confining patients in an institution to wither away.”
Deza, Monica, Johanna Catherine Maclean, and Keisha T. Solomon. 2020. “Local Access to Mental Healthcare and Crime.” Cambridge: National Bureau of Economic Research. Working Paper. https://www.nber.org/papers/w27619.
