The Evolution of
Community Mental Health Centers in Kansas

by Jacqueline L. Heckman-James,
MSW Washington University, St Louis
November 2005

The evolution and development of CMHCs in Kansas is an outgrowth of the Menninger story and psychiatry. The 1920s produced Freud and Psychoanalysis and the emerging belief, particularly among social workers, that environment played an important role in Mental Health. The interdisciplinary practice as a team involving medicine, psychology, social work, nursing and occupational therapy in treating mental illness evolved.During the 1940s all Kansas mental facilities received niggardly appropriations. Conditions at Topeka State Hospital (TSH) in 1948 were: 2000 patients, five doctors, two nurses, one psychologist, and 120 aides. TSH was described as having many rooms lacking lighting and heat, with obsolete and hazardous wiring, dark and gloomy wards, and having wooden stairs that were firetraps.World War II produced many psychiatric casualties, and post-WW II saw a recognition of the need for treatment of the mentally ill. This recognition resulted in the Institute of Mental Health in The National Institutes of Health, the passage of the Hill Burton Act, and the development by Menninger of the Winter General Hospital training program. By 1948 Winter General (WG) had 1700 employees, remodeled buildings, a program for training in psychology, social work, and psychiatric nursing. WG became a model for the entire VA system as a training facility and from then on all 69 of the constructed VA hospitals had a psychiatric unit. Almost overnight Topeka and WG became the citadel of American Psychiatry. Of WG’s 1400 beds, 900 were psychiatric. This program expanded to TSH where buildings were remodeled and programs initiated where, with a greatly enlarged staff of physicians, residents, psychologists, social workers, nurses, and ancillary therapists, students of all aspects of the mental health residential program were trained. A 30-bed residential program for children was also initiated in a separate building. Kansas was a mecca for Psychiatry and treatment of the mentally ill and as such became a national model.With the advent of expanded knowledge and understanding of the mentally ill and the development of psychotropic medications there was less need for long term hospital care and patients were returning to their communities. Therefore the 1950s saw the inception of the mental health centers in the community. An example would be the incorporation of the Mental Health Center of East Central Kansas (MHCECK) in November 1959 as a not for profit corporation located in Emporia, Kansas for the purpose of studying and promoting mental health in East Central Kansas. There were 21 incorporators who were a mix of citizens: attorneys, judges, physicians, business men, teachers, nurses, and housewives. The center was governed by a Board of Citizens, as it is to this day. The rural areas had little or no service agencies at this time, so CMHCs became a primary/only service agency, and with the advent of Federal grants in the late 60s and early 70s, these individual centers developed as regional CMHCs servicing a catchment area of counties. The core CMHC was in a community of some population and satellite offices and services were set up in each county in the catchment area. These federal grants called for comprehensive services which included adults, children, seniors, acute and chronic conditions (every DSM diagnosis). The service requirements were: Prevention, Treatment Assessments, Aftercare, Referral, and Continuity of Care Services regardless of ability to pay, which is a cornerstone of the CMHCs. There is a continuing effort to meet the goals of Accessibility, Acceptability, and Availability.CMHCs have grown in staff and service demands with the deinstitutionalization (1955) of state psychiatric hospital beds and the advent of Medicare and Medicaid. The impetus toward deinstitutionalization has taken place nationwide. This has been fueled by the IMD exclusion which bars Medicaid payment for psychiatric hospitalization for severe mental illness for ages 21 through 65. Medicaid will pay for hospitalization in a psychiatric ward of a general hospital or in a nursing home. The consequences of Medicaid IMD exclusion are staggering for the severely mentally ill. The United States has lost effectively 93% of its state psychiatric hospital beds since deinstitutionalization began in 1955. The race for Medicaid dollars has in fact reduced the total number of state psychiatric hospital patients to less than 60,000 today, compared to 500,000 in 1965 when Medicaid was enacted. In Kansas we have Ossawatomie and Larned State Hospitals still in operation. In the early 1990s the state recommended that the focus for mental health care be in CMHCs rather than in state institutions. The psychiatric wards of general hospitals and private care psychiatric hospitals have diminished greatly since private insurers do not pay on a parity for psychiatric treatment as they do on other treatments.At the present the Medicaid funding for Kansas CMHCs is over 60% of their revenue. The remainder comes from county, state, and fees for service. This funding pattern is reflected in the national picture also. In 1962, for example, Federal dollars comprised just 2% of the total funds in the mental illness treatment system, with state and local governments contributing the remaining 98%. By 1994, however, the federal share had increased to 62% of the total money spent.These figures are a stark statement regarding the state and location of services for the mentally ill. CMHCs of Kansas are the providers of services which are grounded in our local communities but are shaped by their dominant revenue sources, i.e. federal and state. The CMHCs have Boards made up of citizens from each county plus several at-large members. They remain quasi-public institutions and in recent years consumers of service have been added to their Boards.Resources1. A Comprehensive Community Mental Health Program, by Robert H. Felix, M.D., Director of NIMH, Bethesda, Md, from
M. H. & Social Welfare by Robert H. Felix, et. al. 1961, Columbia University Press, N. Y.2. The Chronic Mental Patient II, ed by Walter Menninger, M.D. and Gerald Hannah, PhD., American Psychiatric Press, Washington D.C., 1987.3. Outline of History of Mental Illness and Societal Response Kansas 1920s – 1950s, by Jules Cohen, retired, Director of
High Plains CMHC, Treatment Advocacy Center, 1999.4. True Parity Means Eliminating IMD Exclusion, by Bruce Rheinstein, J.D., Policy Analyst, Treatment Advocacy Center, 1999.

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