The Community Mental Health Act was signed into law by President John F. Kennedy on Oct 31, 1963, 23 days before he was assassinated. His intention was to move mental health care for patients from long-term, deplorable institutional settings that housed people living in horrific conditions without any hope of treatment and subsequent release to the community. This act was designed to use federal monetary support for deinstitutionalization, the process of moving patients from these long-term psychiatric hospitals to community settings.
Federal funding was authorized to build centers offering a range of services, including inpatient and outpatient care, emergency services, consultation, and education for the community.
The act laid the groundwork for a shift in mental health care. But it had to climb obstacles to become realized. Sixty-two years after its implementation, this idea has continued to face challenges, including continual funding reductions and a lack of effective community-based services.
Looming Medicaid cuts and the prospect of the indigent losing access to both medical and psychiatric care have changed the nature of the original intent of President Kennedy. There are fewer extended-stay hospitals for those who require further stabilization. There exist few places to house and feed these souls upon discharge.
Care coordination services have had to readjust to the nature of the individuals we see in 2025. Community care has shifted their focus from an office meeting model to becoming a safety net provider for those seriously and persistently mentally ill individuals who are either homeless or living in subsidized housing but cannot maintain their homes even at the most basic levels. Those dually diagnosed who seek relief in drugs and alcohol are increasingly more difficult to place.
Many states, like Colorado, have created regional networks of crisis, substance use, and mental health centers to provide care coordination services, so that anyone, no matter where they are in the state, has a streamlined path to the care that they need.
Assertive Community Treatment (ACT) refers to services provided by community-based, mobile mental health treatment teams to serious and persistent mentally ill or personality disordered individuals who suffer severe functional impairments.
A team is comprised of professionals like social workers, rehabilitation counselors, counselors, psychiatric nurses, psychologists, and psychiatrists who provide case management, assessments, employment and housing assistance, family support and education, substance abuse services, and other supports as needed to help people in the community.
The Crisis Intervention Teams (CIT) are tasked with working within communities to respond to individuals experiencing mental health crises. Their primary goal is to de-escalate volatile mental health situations, provide immediate support, and connect individuals with appropriate resources. The goal is to redirect individuals from the criminal justice system to behavioral health services and avoid inadvertent violence.
Purchased recreational vehicles travel to different sites. Inside are psychiatric nurse practitioners and counselors who deliver medication and support to those who are homeless and unable or unwilling to keep appointments at offices.
Community mental health in Colorado has taken their programs one step further. In Dusky v. United States, 362 U.S. 402 (1960), the court ruled that to be competent to stand trial the defendant must have a “sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding” and a “rational as well as factual understanding of the proceedings against him.”
Evaluations for competence to stand trial have historically been conducted in locked forensic facilities where individuals can be housed from 20 to 40 or up to 60 days, depending on the state. Since competency to stand trial is evaluated and must remain stable until the person returns to the court, it may be at times tenuous, as psychiatric symptoms wax and wane or become exacerbated.
In Colorado, a unique program has been instituted and is provided by those safety net community mental health centers. Outpatient competency restoration (OPR) services are available for individuals who have been found incompetent to proceed in legal cases. These services, provided by the state’s Outpatient Restoration Program, aim to restore competency-based skill sets in a community-based, least restrictive setting. This allows individuals to remain in their communities, maintain housing and employment if possible.
The goal is to provide structured services that allow clients to return to the community with coordinated treatment plans that can include housing, case management services, medications, and outpatient services. Most importantly, these individuals have less future involvement with the criminal justice system. It further ensures education with various learning tools to help clients develop competence-based skills and return to court to adjudicate their criminal charges.
I would like to close with a real example where the identities of the participants and some historical facts have been altered to protect confidentiality.
John and Mary were homeless and living in their car. John was Mary’s caretaker. Mary was known to the community police for behaving inappropriately while walking on the streets by screaming and yelling at herself and others. There had been no signs of violence. Over time, her behaviors began to deteriorate as her symptoms became exacerbated, and she began to voice threats to harm people. She had recently struck her boyfriend with a soda can.
She often left the car and wandered aimlessly. Her boyfriend was worried. He called the area mental health center crisis team. They were informed of these circumstances. Mary had had intermittent contact with the center, but would simply vanish after contact. Because it was difficult to ascertain her location, the crisis team was unable to contact the police for intervention. Periodically, Mary would appear in her community and just as quickly disappear.
One afternoon, she was pacing and yelling while on one of the college campuses, acting threateningly. Campus police were notified and approached her. She fought being detained and assaulted an officer in the process. She was taken to jail overnight, and the crisis team was notified the next day, as they had been in touch with the officers.
The crisis team orchestrated the filing of a legal document that enabled the police to transport her to a hospital for evaluation (which the police are often reticent to do, but did so in this case). She was admitted to an inpatient unit to try to stabilize her on medication as well as provide a safe environment, treatment, and meals, and she was not behind bars. Having been charged with Assault and Battery, her case had to be heard in court. Her competency to stand trial was compromised.
The ACT team was informed by the hospital concerning her release, and they began to explore options around housing, monitoring, visits, and medication management. When she was discharged, the court was petitioned for a three-month certification to begin (a court order permitting a short-term mental health treatment period after a mental health crisis) that included involuntary medication. This could have been extended to six months if necessary. Violation of such an order automatically triggers the court’s re-involvement.
OPR was also contacted. She was admitted to the program. With the safety net community services and placement, work with a case manager toward community stabilization, consistent medication, and outpatient competency restoration, Mary had an excellent chance to maintain her home in the community. This indicated to the court her progress towards stability and consistency and did not result in criminal incarceration.
This one model of treatment has the highest potential to be a win-win in returning individuals to the community rather than the criminal justice system.
Hopefully, it will not be imperiled by reductions in federal subsidies. Perhaps this model was not JFK’s vision, but it was undoubtedly his intention.
