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c h a p t e r 8 In 1963 President Kennedy set out a “to-do list” for improving the quality of mental health care in the United States and the lives of people with mental disorders : We must act to bestow the full benefits of our society to those who suffer from mental disabilities; to prevent occurrence of mental illness . . . wherever and whenever possible; to provide for early diagnosis and continuous care in the community, of those suffering from these disorders; to stimulate improvements in the level of care given the mentally disabled in our State and private institutions, and to reorient those programs to a community-centered approach; to reduce, over a number of years and by hundreds of thousands, the persons confined to these institutions; to retain in and return to, the community population with mental illness . . . and there to restore and revitalize their lives through better health programs and strengthened educational and rehabilitation services. (Kennedy, 1963) From the vantage point of the year 2006, it looks as though the United States took President Kennedy’s vision seriously. The nation has made notable progress toward nearly all the goals he articulated in 1963. The lives of people with mental disorders are much more similar to those of most Americans today than they were in 1960. The material lives of the majority of people with these conditions are measurably improved. Their chances of clinical recovery and of regaining or maintaining the ability to function in society are greater now than ever in the past. Today people with severe mental disorders share more completely in the freedoms offered by U.S. society than they did in 1950, 1960, or 1970. Americans with mental disorders now have claims on material resources and human rights that simply did not exist thirty years ago. The path taken to these outcomes has differed remarkably from the vision Looking Forward Improving the Well-being of People with Mental Illness Looking Forward 141 offered by President Kennedy and by advisors such as Robert Felix (1965). Their vision was of a mental health care system led by specialty mental health professionals and by institutions such as community mental health centers (CMHCs), built on the therapeutic advances of the 1950s and early 1960s. The forces that actually drove the field were quite different. Technical advances in psychopharmacology and to a lesser extent psychotherapy did drive therapeutic gains in the period after 1965, but these gains involved increased “user-friendliness,” not the improved therapeutic efficacy that the architects of community mental health care expected. Innovations in the financing and delivery of community-based care originated not in specialty mental health care, but in mainstream social insurance. The enactment of Medicare and Medicaid in 1965 gave most people with severe mental illnesses the ability to purchase a relatively rich array of clinical services in the community. The initiation of Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) provided sources of income support to people disabled by a mental disorder that made it possible for them to buy food, obtain housing, and pay for other goods and services. Together, these policies gave people the ability to subsist in the community. This difference between the vision and its realization sheds light on the ongoing tension between calls for mental health exceptionalism and calls to “mainstream” the care and support of people with mental illnesses. The dynamics of mental health care during the latter half of the twentieth century reflected these currents of thought. Mental health exceptionalism has been invoked most frequently as a means of protecting the basic needs and rights of people with mental disorders. Maintaining an exceptional, dedicated public mental health system ensures the existence of caregivers of last resort. Exceptionalism inspires the creation of special provisions—exceptions—in mainstream social insurance programs to protect people with mental disorders.1 The most obvious example of such exceptionalism in mainstream social programs is the use of managed behavioral health care carveout programs for Medicaid managed care arrangements. Mainstreaming, by contrast, is advocated as a means of expanding the level and extent of mental health services and support for people with mental disorders . Our review of the past fifty years provides considerable evidence that is consistent with this argument. Inclusiveness and mainstreaming of people with even the most serious mental illnesses has resulted in tremendous gains in economic support for mental health care through SSI, SSDI, Medicare, and Medicaid. The economic tide created by...


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