As India struggles with a burgeoning mental health crisis with very few response and support systems in place, Gitanjali Mahanti, a licensed social worker in the US, shares the structure of and her experiences with the community mental health model established in the US. It gives us food for thought and explains one of the many ways in which mental health support can be made more local and accessible.
Community mental health centers in the United States provide essential mental health care in underserved communities for everyone, regardless of their ability to pay. On October 31, 1963, President John F. Kennedy signed into law the Community Mental Health Act (also known as the Mental Retardation and Community Mental Health Centers Construction Act of 1963), which drastically altered the delivery of mental health services and inspired a new era of optimism in mental healthcare. This law led to the establishment of comprehensive community mental health centers (CMHC’s) throughout the country. Community mental health refers to a system of care in which the individual’s community, not a specific facility such as a hospital, is the primary provider of care for people with mental illness. These centers helped people with mental illnesses who were ‘warehoused’ in hospitals, psychiatric institutions and jails move back into their communities (NCBH, 2019) and receive superior quality care. The underlying assumptions of community mental health require that individuals who are treated within a community have a place to live, a caring family, or supportive social circle that does not inhibit their rehabilitation.
Over the years since the passage of the law, as services offered to people with mental illnesses became more diverse and comprehensive, it also became clear that helping people function at optimal levels would require the addition of treatment services for addiction disorders. This coordinated brand of service was labeled as ‘behavioral healthcare’ — and providing comprehensive mental health and addictions services is the goal of community-based behavioral health organizations today. Community-based behavioral healthcare is delivered by a mix of government and county-operated organizations, as well as private non-profit and for-profit organizations. These mental health and addiction services are funded by a patchwork of sources, including Medicaid; Medicare; county, state, and federal programs; private insurance; and self-pays.
People of all ages may receive mental health care services at a community mental health center. Anyone who does not have health insurance with mental health benefits can use the community mental health center. The centers have specialized services for people belonging to low income families with limited resources, the homeless population, children, the elderly, individuals with serious mental illness, addiction and individuals who have recently been discharged from an inpatient psychiatric hospital, drug treatment program or mental health program.
Services offered at CMHC’s
Community mental health centers offer a wide range of outpatient services to patients. CMHC’s typically have an integrated team of experts including psychiatrists, psychologists, counselors and social workers. Individual and group therapy sessions are offered. These sessions might be themed around a particular topic such as anger management or identifying triggers. Group activities such as arts and crafts, games or puzzles may be held. These activities help patients develop healthy social skills such as assertiveness that enhance their abilities to communicate better with others. Social skills training is especially helpful for individuals with severe mental illness to improve social functioning and the quality of their social relationships which are often impaired by their symptoms of mental illness. It bolsters their ability to establish new relationships and strengthen existing ones combatting feelings of loneliness and alienation. Patients can also get their community services streamlined. They may be able to apply for other assistance programs such as food or housing during their appointments with the center’s social workers. This is extremely helpful as more often than not, when an individual’s basic needs such as food are unmet, that essentially may be the stressor leading to the exasperation of mental health symptoms. Workshops with age-appropriate activities are available for children and seniors. For example, children’s workshops at a community mental health center might include playing with puppets or painting with watercolors.
Treatment begins with a full assessment of mental health and safety concerns. In the next step, a mental health professional recommends a type of treatment to best serve the individual. The goal is to help the individual return to their normal level of functioning. Based on the severity of an individual’s mental illness, a community mental health provider might offer referrals to a higher level of care such as an inpatient or residential facility. There are in general, three primary types of treatment settings for receiving mental health care or services: 1) hospital inpatient, 2) residential and 3) outpatient. Community mental health services typically offer services in an outpatient setting for a few hours every day with no overnight stay. Residential mental health treatment environments generally provide longer-term care for individuals. Most residential treatment settings provide medical care but are designed to be more comfortable and less like a hospital ward in inpatient hospitals. A good example would be psychiatric residential centers which are tailored for people with chronic psychiatric disorders, such as schizophrenia or bipolar disorder, or who have a dual diagnosis (i.e., a mental disorder and substance abuse problems), which impairs their ability to function independently. Hospital inpatient settings involve an overnight or longer stay in a psychiatric hospital or psychiatric unit of a general hospital. The facility can be privately owned or public (government-operated). Inpatient hospitals provide treatment to more severely ill mental health patients, usually for less than 30 days (NTH,2019).
Barriers to accessing services
The demand for mental health services is stronger than ever, with nearly six in 10 (56%) Americans seeking or wanting to seek mental health services either for themselves or for a loved one. These individuals are skewing younger and are more likely to be of lower income. A large majority of Americans (76%) also believe mental health is just as important as physical health. Despite this strong demand and growing societal awareness of the importance of mental health in the U.S., America’s Mental Health 2018 – a study, revealed that an overwhelming majority of Americans (74%) do not believe such services are accessible for everyone, and about half (47%) believe options are limited (NCBH, 2019). In essence, despite the existence of a well integrated mental health system, America is in the midst of a mental health crisis. One out of 5 adults (20.6%) with a mental illness reported that they were not able to receive the treatment they needed. This number has not declined since 2011 (MHA, 2019).
There are several barriers that contribute to an individual’s inability to access services. First, recent governments have been slashing federal funding for state CMHCs. There is an overall shortage of psychiatrists, counselors and an undersized mental health workforce. Having had the experience of working at a community mental health center for over a year, I was able to experience this first hand. I worked in the capacity of a group counselor and individual counselor. I facilitated about 6 groups a week and had a case-load of 25 clients which was excessive. In addition, I was constantly inundated with copious amounts of tedious paperwork to be completed as required by the State to maintain compliance with laws.The stress levels were very high due to the tremendous work pressure and it was hard to retain staff for long periods due to burn out.
Secondly, there appears to be a lack of available treatment types (inpatient treatment, individual therapy, intensive community services) and a scarcity of CMCH’s to meet the growing number of individuals who need access to services. Fortunately at the CMHC that I worked at, we had excellent support services besides individual counseling to address the needs of housing, unemployment etc. and several referral sources when there was a need to refer out to a higher level of care such as inpatient care. That being said, however, there were very few CMHS’s in the community that we were serving and we had long waiting lists with interested individuals having to wait for 3-4 months before they could access our services. We received a significant number of clients discharged from hospitals who needed to seek services immediately to maintain continuity of care and jumped the waiting list. We were short staffed and were required to carry massive caseloads of clients as management would not decline services to anyone who walked through our doors.
Third, compared to middle- and high-income households, low-income Americans are less likely to know where to go for treatment and more likely to use a health center which is more generalist and limited in the array of services they offer versus a community mental health center. Finally, a disconnect exists between primary care systems and behavior health systems. Some researchers argue that If mental health becomes an integral part of primary care, we can begin to treat mental health issues the same way we do smoking, diabetes, and asthma, as conditions that can be prevented and treated through a combination of medical interventions and behavioral changes. (MHA, 2019).
Inarguably, community mental health centers are key players in providing quality mental health care for millions of Americans. The question before us is not, “where are we now?” but “where do we need to be?” Indeed, more must be done to improve access to care for everyday Americans. There is a need for the U.S government and insurers to increase funding and support for access. This is critical to help attract new providers into the field and more must be done to train and retain providers to help ensure people can get help when they need it. Finally, we must ensure that standards of care are consistent through continued adoption of evidence-based practices. Given a choice, in a heartbeat, I would return to working in community mental health in the event that it was a healthier work environment. Essentially, that would mean hiring more social workers, reducing the caseload of clients per worker, more scheduled breaks, self care activities and being creative in rewarding employees and demonstrating appreciation. Comprehensive, community-based mental health services are vital for individuals with mental illness living in underprivileged communities to help them achieve their maximum level of functioning, minimize symptoms, reduce the frequency of hospitalizations and enhance their recovery.
Gitanjali Mahanti is a licensed social worker in the US. She currently works as a counselor, helping adolescents and adults who struggle with mental illness and substance use issues. Gita is also part of the TCC Family