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Community Mental Health Centers Construction Act of 1989

Community Mental Health Centers Construction Act of 1989

Official document

By: Library of Congress

Date: January 23, 1989

Source: Library of Congress. THOMAS. "Community Mental Health Centers Construction Act of 1989. One hundred and first Congress, first session. S. 225 IS." 〈http://thomas.loc.gov/cgi-bin/query/z?c101:S.225.IS〉 (accessed November 12, 2005).

About the Author: The Community Mental Health Centers Construction Act of 1989 was introduced by New York senator Daniel Patrick Moynihan (1927–2003) and passed by the 101st Congress of the United States.

INTRODUCTION

The treatment of persons who are severely and chronically mentally ill has undergone several revolutions in the United States. Prior to the widespread availability of hospitals and other facilities in which to house such patients, they were cloistered at home, often confined to attics or basements, and kept locked away from other people. There was enormous social and cultural stigma associated with "insanity," due in part to confusion about its causes. Much fear and superstition reigned, with varying beliefs that such conditions might be due to a curse or spell, possession by demons or evil spirits, or even the nefarious influence of the moon, which gave rise to the term "lunacy." Because no one understood its genesis, and there were no effective treatments, mentally ill patients were either left to suffer or subjected to harsh, extreme measures intended to drive the source of the illness from the patient: exorcism, purging, bleeding, near-drowning, and freezing. There was neither widespread belief in nor expectation of recovery in mentally ill patients until at least the mid-twentieth century.

In the middle of the eighteenth century, facilities to house individuals unable to care for themselves began to appear, particularly in urban areas. The development of such institutions was due in large measure to societal changes wrought by the industrial revolution: As demand for a ready workforce grew, fewer people were left at home to care for those unable to live independently. This led to the growth of orphanages, alms- and poorhouses, as well as asylums for the mentally ill, cognitively challenged, and physically impaired. These facilities warehoused large groups of people for long periods of time, often with minimal care—because there was no real concept of treatment or rehabilitation. Through the end of the eighteenth century, the institutionalized mentally ill were often chained or shackled, restrained in beds or cell-like rooms, and generally incarcerated like the most hardened and dangerous criminals.

During the nineteenth century, "moral management" therapy, begun in England by William Battie (1703–1776), was introduced in the United States. In this model, the mentally ill were no longer chained or sequestered. Although still institutionalized, they were put in calm and familiar settings, with the belief that such surroundings increased the likelihood of a cure. Early treatment was encouraged, in the belief that this greatly increased the possibility of remediation. For those who were not severely ill or did not suffer from a psychotic disorder, this treatment was sometimes helpful, allowing them to return to some measure of normalcy.

Unfortunately, moral management was not at all effective for severe mental illnesses; in fact, its lack of restraints led to a sharp increase in aggressive behavior among patients. Furthermore, a large, new, and frequently aggressive segment was added to the severely and chronically mentally ill population after the American Civil War, when a syndrome emerged among returning soldiers that would likely be characterized today as posttraumatic stress disorder.

In the twentieth century the advent of the public health system produced a proliferation of asylums, which dispensed a disturbingly wide spectrum of care, along with an increasing patient population. In 1963 President John F. Kennedy (1917–1963) signed the Community Mental Health Centers Act, which was intended to end human warehousing; fund, create, and build a system of community mental health centers to provide comprehensive mental health services nationwide; and to ensure timely, efficient, and effective treatment of mental illness in outpatient settings. The act, amended in 1989, is excerpted below.

PRIMARY SOURCE

Community Mental Health Centers Construction Act of 1989 (Introduced in Senate)

S 225 IS

        101st CONGRESS
          1st Session
            S. 225

To amend title XIX of the Public Health Service Act to provide for the construction of community mental health centers, and for other purposes.

    IN THE SENATE OF THE UNITED STATES

January 25 (legislative day, JANUARY 3), 1989

Mr. MOYNIHAN introduced the following bill; which was read twice and referred to the Committee on Finance

               A BILL

To amend title XIX of the Public Health Service Act to provide for the construction of community mental health centers, and for other purposes.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the 'Community Mental Health Centers Construction Act of 1989'.

SEC. 2. FINDINGS AND PURPOSE.

(a) FINDINGS—Congress finds that—

(1) in 1955 Congress established a Joint Commission on Mental Illness and Health to provide an 'objective, thorough, and nationwide analysis and reevaluation of the human and economic problems of mental illness', and at that time three out of every four individuals treated for mental illness were institutionalized with a total of some five hundred and fifty-nine thousand individuals in public mental hospitals;

(2) in 1960, the Joint Commission report, 'Action for Mental Health', recommended that the mentally ill be cared for in the community, and that Federal financial assistance be provided to the States to accomplish this;

(3) in 1962, President Kennedy established the Interagency Task Force on Mental Health, and the Task Force recommended that Federal aid should be provided to assist States in constructing a nationwide network of such centers;

(4) in 1963 the Kennedy Administration recommended before Congress that a goal, by 1980, of one community mental health center per one hundred thousand individuals, or two thousand such centers nationwide, be established, and the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 began the Federal commitment to build this nationwide network of community mental health centers;

(5) in 1967 Congress specifically reaffirmed the goal of having a nationwide network consisting of two thousand community mental health centers in place by 1980;

(6) the mentally ill were to receive treatment, not from large institutions, but from community mental health centers to be built with the assistance provided as a result of the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 and subsequent legislation;

(7) however, the total number of community mental health centers, which could provide mental health services in the community, that have been built with the help of the Federal Government up to the present time is only seven hundred and sixty-eight;

(8) even so, from 1963 to 1980 the number of residents in public mental hospitals declined from five hundred and five thousand in 1963 to one hundred and fifty thousand in 1980; and

(9) even so, as a result of the Federal Government's failure to meet its commitment to build two thousand community mental health centers by 1980, many of the Nation's mentally ill individuals cannot be adequately cared for in the community, and today such individuals comprise at least 1/3 of the homeless population of the United States.

(b) PURPOSE—It is the purpose of this Act to—

(1) restate the commitment began by the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 to build one community mental health center for every one hundred thousand individuals;

(2) provide the funding necessary to meet the commitment to build a community mental center for every one hundred thousand Americans; and

(3) provide mental health services to homeless mentally ill and chronically mentally ill individuals.

SEC. 3. MENTAL HEALTH CONSTRUCTION BLOCK GRANTS.

Title XIX of the Public Health Service Act (42 U.S.C. 201n et seq.) is amended by adding at the end thereof the following new part:

'PART D—MENTAL HEALTH CONSTRUCTION BLOCK GRANTS

'Sec. 1930. Definitions.

'As used in this part:

'(1) COMMUNITY MENTAL HEALTH CENTER—The term 'communnity mental health center' means a facility providing services for the prevention or diagnosis of mental illness, or care and treatment of mentally ill patients, including homeless mentally ill and chronically mentally ill patients, or rehabilitation of such persons, which services are provided principally for persons residing in a particular community or communities in or near which the facility is situated.

'(2) CONSTRUCTION—The term 'construction' includes construction of new buildings, expansion, remodeling, and alteration of existing buildings and the initial equipment of any such buildings (including medical transportation facilities, and architect's fees), but excludes the cost of off-site improvements and the cost of the acquisition of land.

'(3) STATE—The term 'State' includes the District of Columbia, the Virgin Islands, the Commonwealth of Puerto Rico, Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, and the Trust Territory of the Pacific Islands.

'Sec. 1931. Community Mental Health Center Construction Grants.

'(a) IN GENERAL—For each of the fiscal years 1990 through 1994, the Secretary, in consultation with the National Institute of Mental Health, shall make allotments to States from the sums appropriated under subsection (f), to assist such States in constructing community mental health facilities.

'(b) Allotments—

'(1) IN GENERAL—The Secretary shall allot to each State an amount that bears the same ratio to the total amount available as the number of individuals residing in a State, bears to the total number of individuals residing in all States.

'(2) MINIMUM AMOUNT—No State shall receive an allotment of less than $250,000.

'(3) USE OF AMOUNT—Funds allotted to a State under this subsection shall be used for the purpose of—

'(A) building or renovating structures that shall be used as community mental health centers; and

'(B) providing for the adequate staffing and maintenance of community mental health centers that have been constructed or renovated using funds provided under this section.

'(4) LIMITATION—At least 75 percent of the funds allotted to a State under this subsection shall be used to provide services for the homeless mentally ill and chronically mentally ill.

'(5) MATCHING FUNDS—In order to be eligible for an allotment under this subsection the State must certify that it will provide matching funds in an amount equal to such amount.

'(6) DATA—The Secretary shall obtain from the Bureau of the Census, and any other appropriate Federal agency, the most recent data and information necessary to determine the allotments provided for in this subsection.

'(c) Application—

'(1) IN GENERAL—In order to receive an allotment for a fiscal year under this section each State shall submit an application to the Secretary.

'(2) FORM—An application submitted under this subsection shall be in such form, contain such information, and be submitted by such date as the Secretary shall require.

'(d) REALLOTMENTS—Any portion of the allotment to a State under subsection (b) that the Secretary determines is not used by a State in the period that the allotment is made available, shall be reallocated by the Secretary to other States in proportion to the original allotment to such States.

'(e) DISTRIBUTION OF FUNDS—The Secretary shall make the State allotment available to the Governor of such State who shall distribute such funds.

'(f) AUTHORIZATION OF APPROPRIATIONS—There are authorized to be appropriated to carry out this section such sums as are necessary in each of the fiscal years 1990 through 1994.

'(g) ADMINISTRATION—A State shall not use more than 10 percent of the funds allotted to such State under this section for administrative expenses.'

SIGNIFICANCE

In large measure, the practice of warehousing the chronically mentally ill continued into the twentieth century, although available treatment options continued to expand and improve, particularly for those able to benefit from psychotherapy. In the 1930s the now-controversial practice of lobotomy came into vogue, followed shortly by electroconvulsive therapy (ECT), or shock treatment.

After World War II, the institutionalized patient population rose again; this increase, however, was tempered slightly by the 1946 National Mental Health Centers Act, which introduced the community mental health center paradigm and promoted the idea of outpatient treatment. The use of psychotropic drugs began in 1954 with the use of Thorazine to treat psychotic disorders. This was followed by a virtual explosion of psychotropic drugs. For the first time, it appeared that severely mentally ill patients might be treated successfully with medication and eventually be able to leave institutions. Hospital stays began to decrease, and patients were treated more effectively and humanely while they were there.

The Community Mental Health Centers Act heralded the era of "deinstitutionalization," which reduced the nationwide psychiatric inpatient population from a high in excess of one-half million in 1960 to fewer than one hundred thousand by the mid 1980s. A year later the 1964 Comprehensive Mental Health Bill and the Medicare, followed by the Medicaid Acts of 1966, made sweeping changes in the ways federal, state, and local governments paid for mental health care.

Although outpatient treatment centers have been tremendously successful and effective in many ways, their advent has had a significant downside as well. Because most inpatient facilities no longer provide long-term care, options to treat severe or chronic mental illnesses are often limited. Many communities, particularly those that are impoverished or isolated, lack sufficient means to provide comprehensive services. As a result, individuals often end up homeless and wandering; living in shelters, bus, or train stations; or simply existing in the outdoors. It is also quite common for the mentally ill to be victims of violent crime, or to be arrested. Many end up in prison, where they may or may not receive adequate care.

The model envisioned by the original Community Mental Health Centers Act has yet to be created: a truly nationwide, comprehensive, multidimensional system that provides medication, housing assistance, physical health care, education, job training, support programs, care management, and wraparound services. The act's 1989 amendment is one step toward realizing that vision.

FURTHER RESOURCES

Periodicals

Drake, R. E., A. I. Green, K. T. Mueser, and H. H. Goldman. "The History of Community Mental Health Treatment and Rehabilitation for Persons with Severe Mental Illness." Community Mental Health Journal 39, no. 5 (2003): 427-440.

Web sites

National Mental Health Association. "NMHA and the History of the Mental Health Movement." 〈http://www.nmha.org/about/history.cfm〉 (accessed January 5, 2006).

Treatment Advocacy Center. 〈http://www.psychlaws.org/default.htm〉 (accessed January 5, 2006).

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