In the early 1960’s, history was being made in public mental health policy as then President John F. Kennedy signed into law the Community Mental Health Act of 1963 (CMHA). A new national direction in the care of persons with serious mental illness was established.
By the end of the 19th century, hundreds of thousands of persons with mental illness were housed across the various states in large mental institutions. Early care in these large institutions was generally considered as humane for the patient while public safety was protected through segregation of such persons into locked and secure facilities.
By the middle of the 20th century, most of these large institutions had deteriorated into nothing more than large warehouses with no treatment and where the “care” was anything but humane. Strained state budgets, coupled with the development of early medicines for the treatment of mental illness, made the passage of the Community Mental Health Act possible and timely.
At the time of the passage of the CMHA, the State of Alabama operated two large institutions for the “care” of the mentally ill; Bryce Hospital in Tuscaloosa for white individuals and Searcy Hospital in Mount Vernon for African Americans. More than 5,000 Alabama citizens were confined to Bryce and Searcy Hospitals in 1963 in what all too often resulted in a “life sentence” in the institution in horrid conditions with virtually no treatment and little hope of ever being released.
Within just a few years after passage of the CMHA, community mental health centers were created nationwide to facilitate the transition of individuals out of the large state hospitals into community based services ranging from outpatient and day services to group homes. Community mental health centers were also envisioned to act as “public safety nets” to assure that the state’s most vulnerable citizens were afforded access to treatment and care in programs and services in or near their home communities.
The Alabama Legislature passed the state’s version of the CMHA in 1967. Within a few years, all 67 Alabama counties were configured into community mental health centers serving one to five counties each. The federal government provided the seed money to develop community mental health centers. Funding for CMHC’s was expected to be a partnership between the federal, state and local governmental authorities. Coming on the heels of passage of the CMHA was federal litigation establishing a “right to treatment” for individuals confined to state mental hospitals. Alabama was the state where the right to treatment decision was rendered by United States Federal Judge Frank M. Johnson (Wyatt v. Stickney).
During the 1970’s, Regional State Hospitals were opened in Decatur and Montgomery bringing the number of hospitals for civil commitments to four. Over time specialty hospitals were opened for forensic patients (Tuscaloosa), adolescents (Eufaula), geriatric patients, (Tuscaloosa), and another hospital for civilly committed patients (Thomasville). By the early 1990’s, the state mental hospital census had been reduced to around 2,500 beds through substantial expansion of community based services. While the treatment mandated in Wyatt was necessary and appropriate, it was also very costly. Increased efforts were initiated to reduce the hospital census even further which ultimately resulted in a reduction of the number of state hospital beds to a fewer than 1,000 by 2008. During this period the hospitals in Eufaula and Thomasville were closed as were four of the state’s facilities for persons with Developmental Disabilities.
State funding increased for community based services during the 80’s, 90’s, and from 2000 until 2009. Expansion of community based services was enhanced significantly by matching state dollars with federal Medicaid funds at approximately a 2 to 1 match. The downturn in the economy that began in late 2008 resulted in a severe strain on state budgets. Federal Stimulus Funds delayed the impact of the economic downturn until such funds were exhausted around 2010. Significant reductions in the General Fund appropriation to the Department of Mental Health beginning in 2009 ultimately resulted in the closure of the state hospitals in Mount Vernon near Mobile and Montgomery. Community services were correspondingly increased to serve the persons formerly served by these hospitals. With the closure of these two hospitals, the state hospital census has been reduced to around 600.
The future of state funding for mental health services is on a downward spiral. The State General Fund Budget is woefully inadequate to meet the essential needs of state government such as mental health, Medicaid, human resources, public health, public safety, and corrections. Further savings from closing state mental hospitals will not be sufficient to offset expected additional reductions in the GF Budget. It does not appear that the State of Alabama will take advantage of Medicaid expansion through the Affordable Care Act. As the nation prepares to celebrate 50 years of community based mental health services, the future of the public system of mental health care stands at a crossroad. Should the community system of safety net services be dismantled, the public interest and safety of all Alabama citizens will be compromised.