THE DELIVERY OF MENTAL HEALTH SERVICES IN THE
21st CENTURY: BRINGING THE COMMUNITY BACK IN
AUTHOR: MARK R. ROSENHECK
PUBLISHED IN: COMMUNITY MENTAL HEALTH JOURNAL, VOL. 36, NO. 1, 2000
DATE: 2000
PRESENTER: KAGABA NOLBERT
INTRODUCTION TO THE ARTICLE
Overview:
Rosenheck explores the evolving nature of mental health services, advocating for a community-centered
approach. He argues that integrating services into communities improves accessibility, effectiveness, and
outcomes.
Key Themes:
1. Historical Perspective: Shift from institutional to community-based care.
2. Community Integration: Mental health care must be embedded in local community systems.
3. Systemic Challenges: Issues like funding, organizational barriers, and coordination hinder progress.
• Policy Implications: Need for policy reforms supporting community-based models, including better funding
and cross-agency coordination.
ABSTRACT OVERVIEW
Failures of 1960s Community Mental Health Movement:
Despite strong public support, poor practices and ideological misalignments led to limited success in
addressing severe mental health conditions.
Improvements Over Time:
Professional practices have improved, but public support for mental health services has waned.
Declining Public Support:
Individualistic values and reduced civic engagement eroded support for disadvantaged groups in need of
mental health services.
• Proposal for a New Approach:
Rosenheck calls for rebuilding public support, focusing on expanding services for those with severe mental
health issues.
A GLANCE BACKWARD
Post-WWII Social Optimism:
The community mental health movement was shaped by a belief in scientific medicine
and government-led mental health care.
Challenges in Implementation:
Issues like professional disinterest, weak connections to state agencies, and lack of
accountability hindered the movement’s success.
IMPLEMENTATION CHALLENGES
Professional Disinterest:
The community mental health movement failed to address the needs of severely disabled patients, such as
housing and income support.
Disconnection from State Agencies:
Weak coordination between CMHCs and state mental health hospitals limited the effectiveness of services.
Social Activism:
By the 1960s, civil rights movements influenced mental health policies, which were seen as part of a larger
social justice initiative.
• Lack of Accountability:
NIMH struggled to monitor community mental health centers, leading to disorganization and poor service
delivery
CORRECTIVE REFOCUSING AND MATURATION
1970s and 1980s:
The movement shifted towards more measurable outcomes and a focus on the most severely mentally ill under
state government control.
Consumer Movements:
Advocated for expanded services but faced internal ideological divisions that limited their impact.
RESOURCES FOR MENTAL HEALTH SERVICES
1972-1992:
Mental health resources expanded, but inflation and rising demand led to a decline in per capita spending and
minimal growth in outpatient services.
Economic Strain:
Despite staffing and expenditure increases, inflation and population growth resulted in a net decline in mental
health funding.
CHANGING NEEDS AND DETERIORATING COMMUNITIES
1980s Increase in Demand:
As public hospital beds shrank, the number of individuals with severe mental illness in communities
increased.
Dual Diagnoses:
The rise of drug addiction and co-occurring mental health disorders further strained mental health services.
Homelessness:
The growing issue of homelessness among those with mental illness was exacerbated by state hospital
closures and economic changes.
A "MEAN SEASON" FOR THE LEAST WELL-OFF
Political and Social Context:
o Declining Welfare: 1990s cuts to SSI and AFDC impacted vulnerable populations.
o Reduced Government Intervention: Diminishing funding and support for social safety nets led to a
disproportionate effect on mental health services.
Impact on Mental Health:
o Funding Cuts: Affected low-income individuals, leaving them without proper mental health care.
o Increased Homelessness and Untreated Illness: As support services weakened, untreated mental health
issues escalated.
THE PRIVATIZATION OF MENTAL HEALTH CARE
Managed Care & Cost-Cutting:
o The rise of managed care in the 1990s aimed to control costs but often led to reduced service accessibility.
Consequences for Care Recipients:
o Shorter Hospital Stays: Patients were discharged prematurely, with insufficient follow-up care.
o Limited Access: Insurance restrictions limited treatment options and access to care.
THE END OF COMMUNISM AND ITS CULTURAL IMPACT
Post-Cold War Era:
o The end of the Cold War led to a more market-driven approach to healthcare, focusing on individual
responsibility.
Shift in Attitudes Toward Social Services:
o Ideological shifts favored privatization, reducing public mental health services and increasing reliance
on the private sector.
DECLINING CIVIC ENGAGEMENT IN THE U.S.
Robert Putnam's "Bowling Alone":
o Putnam's research highlighted the steep decline in civic engagement between 1945-1990.
Impact on Mental Health Services:
o Weakening community bonds and reduced collective action led to diminished support for mental health
reforms.
CIVIC CULTURE AND HEALTH: LOSS OF FAITH IN AUTHORITY
Trust in Institutions:
o A growing skepticism toward public and private institutions deepened, especially in healthcare.
Impact on Mental Health:
o Reduced trust in healthcare providers discouraged individuals from seeking help, further isolating them
from essential services.
CIVIC CULTURE, HEALTH, AND MENTAL HEALTH
Positive Civic Culture & Mental Health:
o Studies show areas with strong community engagement exhibit better mental health outcomes.
Need for Civic Renewal:
o Rosenheck advocates for rebuilding social capital, with mental health professionals fostering community
ties to strengthen care delivery.
DOES CIVIC CULTURE HAVE A DIRECT RELATIONSHIP TO MENTAL
ILLNESS?
Research Insights:
o Weakened civic culture correlates with higher mental illness rates.
o Rural areas with strong community ties show lower psychiatric comorbidity than urban areas.
(2) IS A STRONG CIVIC CULTURE ASSOCIATED WITH DELIVERY OF SUPERIOR MENTAL
HEALTH SERVICES OR WITH MORE INTEGRATED DELIVERY OF DIVERSE HEALTH
CARE AND SOCIAL SERVICES TO THOSE WITH MULTIPLE NEEDS?
Improved Outcomes:
o Studies suggest that areas with high civic engagement show better integration of mental health and
social services.
Civic Culture in Mental Health:
o Strong community systems can enhance service delivery and support for people with severe mental
illness.
(3) DOES THE EMERGENCE OF MANAGED CARE REFLECT THE DECLINE IN CIVIC
CULTURE AND THE ABANDONMENT OF YET ANOTHER INSTITUTION OF
COMMUNITY LIFE TO CORPORATE DOMINANCE?
Corporate Influence:
o The rise of managed care has led to corporate dominance, reducing service quality for severely
mentally ill populations.
Advocacy and Civic Engagement:
o Weakened social capital and limited competition in managed care systems have hindered effective
advocacy for better care.
(4) DOES THE MENTAL HEALTH COMMUNITY HAVE ANY ROLE TO
PLAY IN RESTORING CIVIC CULTURE IN AMERICAN SOCIETY?
Modern Psychiatry:
o Although community psychiatry focuses on individual care, it has largely abandoned
efforts to strengthen broader societal engagement.
Call to Action:
o Mental health professionals need to re-engage with the community to help restore
social cohesion and improve mental health outcomes.
(5) WHAT IMPLICATIONS DO NEW CONCEPTUALIZATIONS OF
COMMUNITY AND SOCIETY HAVE FOR BUILDING COALITIONS TO
PROMOTE CONCERN FOR THE MENTALLY ILL?
Balancing Local and National Needs:
o Mental health services need to balance local involvement with national oversight to
support marginalized individuals.
Breaking Down Divides:
o Effective services must integrate mental health and addiction care, addressing dual
diagnoses more effectively.
CONCLUSION
Challenges of the 21st Century:
o The community mental health movement faces significant challenges, including
funding cuts and a more complex political environment.
Future Prospects:
o Advancements in treatment and management technologies may help, but substantial
societal and policy changes are needed to support the movement effectively.
THE END.
•Thank You!
