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The United States Public Mental Health System

The United States Public Mental Health System

Not enough people get the mental health care they need. Part of the problem is that people don't know what their options are or how to access those options.

 

One of the least understood options for mental health care is the public mental health system. To help you understand whether it might be a good option for you, we've researched essential facts about the system in your state. Our state guides answer the following questions:

 

  • Who is eligible for public mental health services in this state?
  • Which programs provide publicly-funded mental health services in this state?
    1. Where are they physically located?
    2. What are their phone numbers?
    3. What are their webpages?
  • What number can you call to find out more about mental health services in this state?



You can go to your state's page to learn more about your state's system. Keep reading this article to learn more about how the United States public mental health system works as a whole.

 



What We Learned About the Mental Health System: A Quick Overview

 

One of the first things we learned is that there are huge differences among state mental health systems.

 In some states, publicly-funded providers offer therapy to just about anyone who wants it. Other states have almost impossibly strict eligibility criteria for public mental health services.

 

Some states don't offer individual therapy through their public mental health programs at all, focusing instead on providing crisis intervention and high-intensity services.

 

The good news is that in every state, the public mental health system has valuable resources that are available to everyone, regardless of their condition or income. This is true even in states where eligibility criteria are strict. In every state, crisis and information services provided by the public mental health system are open to everyone.

 

One of the most important things to know about the public mental health system is that in every state, it functions as a mental health emergency response system. Think of it as a kind of mental health 9-1-1. It's where people can get help quickly when they're in crisis, whether they need emergency admission to inpatient care, fast access to outpatient care, or even just someone to talk to on the phone.

 

The public mental health system also acts as an information clearinghouse where you can learn about local mental health resources. It's often a great place to start when you're looking for affordable mental health care near you.

 

The people who answer crisis lines and work at walk-in clinics have comprehensive knowledge of local mental health resources. Even if you're not eligible for public mental health services, they can often help you find other affordable local options and give you free referrals.

 

You can find the numbers for your local, regional, and state mental health crisis and information lines in your state's article.

 


What Is the United States Public Mental Health System?


The public mental health system is a network of mental health agencies and professionals that provide mental health services to eligible people regardless of their ability to pay.

 

These services are publicly funded. This means they are financed by Medicaid and grant funds which are in turn financed by taxes and other types of state and local revenue.

 

Each state's system is managed on the state level. This means that the services the public mental health system provides, and who is eligible for them, vary widely from state to state.

 

In some states, the mental health system is partially or mostly privatized. This means the state mental health department licenses privately-owned agencies to provide publicly-funded services and distributes public funds to them.

 

In other states, the system is partly or fully public. This means the agencies that provide publicly-funded services are directly run and funded by the state and are staffed by state employees.

 

Regardless of how a state's system is set up, publicly-funded mental health agencies share the same mission and serve the same purpose. Important facts about them include:

 

  • They are among the most affordable places to get mental health services in America. Grant funds help publicly-funded agencies keep their sliding scale fees relatively low.
  • They consistently accept Medicaid—a public insurance plan that many other mental health providers won't accept. Medicaid often covers all of the services they provide. (They also usually accept a full range of public and private insurance plans.)
  • They are some of the only providers that serve remote areas of the United States. You can find publicly-funded mental health providers everywhere from the Mojave Desert to parts of Alaska accessible only by airplane. This makes them a great resource in remote and rural areas.
  • They are often the only local agencies that provide emergency mental health services. They have crisis lines that function as a "mental health 911" for people who are in crisis and need immediate care.

 

The community-based public mental health system in the United States has a rich history of public service dating back to the 1960s. It was designed to be, and remains, a "safety net" to get people the help they need no matter what their financial circumstances might be.

 


What Services Are Available in the Public Mental Health System?

 

The public mental health system offers essential clinical mental health services like therapy and medication management. It also provides intensive and specialty services that aren't available anywhere else or that are hard to find at private agencies, like assertive community treatment. You can find the following services in most state mental health systems:

 

  • Mental health assessments including:
    1. Eligibility assessments,
    2. Diagnostic assessments,
    3. Functional assessments, and
    4. Psychosocial assessments;


  • Emergency mental health services including:
    1. 24/7 mental health crisis lines,
    2. 24/7 mobile crisis response services,
    3. Emergency mental health evaluations,
    4. Immediate crisis intervention and counseling,
    5. Assistance with inpatient psychiatric admission, 
    6. Help with immediate referrals to outpatient care, and
    7. Pre-screening for involuntary inpatient treatment;


  • Clinical outpatient mental health services including:
    1. Psychiatric medication management,
    2. Individual counseling and therapy,
    3. Group counseling and therapy,
    4. Specialty mental health services,
    5. Educational and support groups, and
    6. Dual diagnosis treatment groups;


  • Clinical inpatient mental health services including:
    1. Voluntary psychiatric hospitalization,
    2. Involuntary psychiatric hospitalization (also known as civil commitment),
    3. Forensic psychiatric hospitalization (for justice-involved individuals), and
    4. Crisis stabilization (short-term inpatient stabilization services);


  • Psychosocial rehabilitation and community support services including:
    1. Case management services,
    2. Mental health support services,
    3. Assertive community treatment,
    4. Clubhouse and peer support services,
    5. Supported housing and housing assistance,
    6. Supported social and recreational activities,
    7. Psychoeducation and family support services, 
    8. Supported employment and vocational training, and
    9. Day treatment and partial hospitalization programs.

 

As this list shows, the public mental health system provides a comprehensive range of mental health services. Some services, like assertive community treatment, are designed primarily for people with severe mental health conditions, while some services, like therapy, serve a wider range of clients. As part of the intake process, clinicians at publicly-funded mental health agencies help clients figure out which services they need.

 

In most states, public mental health services and publicly-funded substance use disorder services are managed by the same state behavioral health department. While our listings focus on mental health treatment providers, some of the providers in our listings offer both mental health and substance use disorder treatment. The crisis and information lines we list provide referrals for substance use treatment as well as for mental health treatment.

 

 

Who Can Use the Public Mental Health System? Who Is Eligible?

 

Eligibility for public mental health services varies widely from state to state. Some publicly-funded providers offer mental health services to just about anyone who wants help with a personal issue and lives in the area they serve. Other state systems limit services to people who:

 

  • Have severe and persistent mental illness (SPMI), which means they have
    1. A severe mental health condition such as major depressive disorder, bipolar disorder, or schizophrenia; and
    2. That disorder significantly impacts their ability to function, putting them at risk of homelessness or hospitalization; and/or people who
  • Have significantly limited financial resources (often meaning their income places them just above, at, or below the Federal Poverty Level).

 

You can find out how strict or open eligibility is in your state by checking out our article on your state's system. Go here to find a list of links to all of our state mental health system articles.

 


When Should You Consider Using the Public Mental Health System?

 

It's hard to make a sweeping recommendation about who the public mental health system is for (and when to use it), because each state is so different.

 

Systems vary not just from place to place, but over time. Some state systems have changed their areas of focus, the services they offer, and their eligibility criteria just in the last ten years.

 

Many states cut mental health funding after the 2007-2009 recession. This means they limited or eliminated public mental health services they once provided. (On the other hand, some states increased mental health funding to address social issues that worsened after the recession.)

 

As a result, some publicly-funded agencies no longer offer mental health services to people with milder problems. Some don't offer individual therapy at all any more. Instead, they focus on emergency services and intensive services for people with SPMI.

 

(So, if you just want to see a therapist once a week, you may or may not be able to do that at your local publicly-funded mental health agency. It depends on the state you live in.)

 

Given all these differences between states, we can't make a single set of recommendations for everyone. However, there are some things that all (or nearly all) state systems have in common. We can generally recommend using the public mental health system when:

 

  • You're experiencing a mental health crisis and need help right away;
  • You have a severe mental health condition and need multiple or intensive mental health services (especially if you need or want more than just medication and weekly therapy);
  • You can't access mental health care in the private sector due to your diagnosis or financial situation (i.e. private providers turn you away or charge more than you can afford);
  • You have extremely limited financial means, to the point your income is at, below, or up to 200 percent over the Federal Poverty Level;
  • You want a specific service that's not available in the private sector where you live, such as psychosocial rehabilitation, assertive community treatment, or case management;
  • You live in an area with limited mental health resources, such as a rural town, remote region, frontier county, or underserved urban area with sparse mental health services; or
  • You're tired of Googling and would like to talk to someone face to face about what you're going through so they can help you find a local provider who can help you.

 

Publicly-funded outpatient mental health programs provide eligibility assessments, and some provide them for free. So, if you're frustrated or stuck in your search, they can be a great place to go. Even if you're not eligible, you can often get a referral to another affordable local provider.

 

Before you go, you should call the agency to explain what you're looking for and to ask whether they can help you and give you an assessment or a referral. (Be sure to ask if the assessment is free, and if not, what it costs. Phone assessments are nearly always free.)

 


What Is Therapy Like in the Public Mental Health System?

 

Many state mental health programs provide therapy to eligible clients. Some provide therapy to anyone in the local area who wants it, even if they don't have a mental health condition and just want help dealing with everyday issues like stress or relationship conflicts.

 

Others only provide therapy to people with moderate to severe mental health conditions. Some don't provide individual therapy at all.

 

While every provider is different, there are a few things you can expect if you get therapy from a publicly-funded provider:

 

  • Therapy will likely be time-limited and solution-focused, lasting only as long as is needed to address the problem(s) you came to therapy seeking to address.
  • Therapy will likely be evidence-based. Popular therapy methods at publicly-funded agencies include cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), trauma-focused CBT, solution-focused brief therapy, and motivational interviewing.
  • Therapy will be focused on clinical treatment of mental health symptoms, conditions, or issues rather than on open-ended personal growth or analysis.

 

Because publicly-funded agencies focus on clinical mental health treatment, they probably aren't the best choice if you're looking for a therapist to help you with personal growth goals that aren't related to a mental health condition.

 

On the other hand, they can absolutely be a great choice if you need clinical treatment to address a mental health condition. Publicly-funded agencies provide updated training to clinicians to ensure they are providing effective, evidence-based services. For example, many public agencies provide the full suite of DBT services, including individual therapy, skills training, and DBT groups.

 

 

How Can You Find Out More About Your State's Mental Health System?

 

If you want to find out about your state's mental health system, we can't recommend any better website than our own. That's not really a brag—we took on this project because no other site was providing this information.

 

Every state mental health department has a webpage about their mental health system. However, these pages are confusing to navigate and often fail to answer important questions. Many don't tell you who is eligible or even which providers are actually part of the public system!

 

We wanted to create a webpage that answered all the practical questions you might have about where to access care and whether the system is right for you. So, we deeply researched each state's system and wrote an article answering these questions. Go here to find your state's page.

 

If you need more information than we have on the public mental health page for your state, don't worry. On each of our state pages, we list the following resources you can use to learn more:

 

  • Numbers for state and local mental health crisis and information lines
  • Links to the more useful parts of state mental health department websites
  • Numbers and links for individual providers and agencies in the state mental health system

 

We also share what we learned about current issues affecting that state's system, an overview of its history and background, and news about any active work being done to improve the system.

 

 

Why Do We Have a Public Mental Health System?

 

From the beginning, the purpose of the public mental health system has been to provide a safety net to keep individuals and the public safe and healthy. A social safety net ensures that people who need care can get it regardless of their income or ability to pay.

 

Many people with severe mental illness (SMI) cannot live in the community without support. Many elements of the public system were designed with them in mind. The earliest psychiatric hospitals provided a safe place for people with SMI to live. The system we have now focuses on helping people with SMI live in the community instead of in an institution.

 

Over time, the public mental health system has expanded its vision and purpose to serve a wider range of people. The outpatient and community-based services we have now can help people with mild to moderate mental health needs as well as people with SMI.

 

Unfortunately, not all states have embraced this expanded vision of a mental health system that's for everyone. Whether a state's mental health system serves a full range of clients depends on that state's philosophy of care and the level of funding it invests in its mental health system.

 

 

Where Did the Public Mental Health System Come From?

 

The first efforts to provide publicly-funded mental health care in the United States began in the 1800s, when the first asylums were built. Public need for mental health care inspired state governments to step in and provide public facilities for people who couldn't afford private ones.

 

In the ensuing decades, these facilities were converted into state psychiatric hospitals. Some older state hospitals have been renovated and remain in use, while others have been replaced and rebuilt. In either case, while the type of care they provide has changed, state hospitals continue to provide publicly-funded inpatient mental health care to this day.

 

Most states now provide most of their publicly-funded mental health care in outpatient settings. The shift from institutional to community-based care began in the 1950s with innovations in treatment that made it possible to manage severe mental illness outside of institutions. The shift to community care picked up pace during the deinstitutionalization movement of the 1960s.

 

The first publicly-funded outpatient mental health agencies in the U.S. were called community mental health centers (CMHCs). Most of them were established in the 1960s after President John F. Kennedy signed the 1963 Community Mental Health Centers Act into law. This created federal funding for states to build CMHCs or to convert established outpatient facilities into CMHCs.

 

As more CMHCs were built, funding for psychiatric hospitals was reduced. This was reinforced when Medicaid was established in 1965. Medicaid provides funding for community-based care but not for mental health care delivered in institutional settings. While hospitals are still a necessary part of the mental health system, their purpose has changed from providing long-term custodial care to providing short-term acute psychiatric hospitalization.

 

Since the 1960s, many laws have been passed that have changed how the system is funded and run. However, the structure of the system has remained the same since the mid-1960s. States are required to provide comprehensive community-based mental health services to be able to receive matching federal funding for their public mental health programs.

 

In addition, states that fail to provide adequate community-based public mental health care can be found in violation of the 1990 Americans with Disabilities Act (ADA). With the 1999 Olmstead decision, the United States Supreme Court ruled that unnecessarily confining people with mental health conditions to institutions violated the ADA.


 

What Is the Future of the Mental Health System? Will It Change?

 

Nearly every state's mental health system has been in crisis at least once, if not continually, over the last two decades. The main reason is that many states chose to reduce mental health funding in the wake of the 2007 recession, even as demand for mental health services was increasing.

 

These recurrent crises have spurred a flurry of efforts to update and improve the mental health system. States are seeking to make their systems more efficient, serving a wider range of people while controlling costs.

 

This is similar to what influenced system change in the 1950s and 1960s. Institutional care was not only becoming increasingly publicly unpopular then, it was also becoming unmanageably expensive. Mid-century innovations in mental health treatment not only made the system more effective—they cost states less, too.

 

Once again, advancements in technology and treatment are allowing states to offer better care to more people for less money. Two trends that nearly every state is embracing right now are:

 

  • Telehealth and
  • Integrated care.

 

State mental health programs are using telehealth to address long-standing issues with access to care, especially in remote areas. Telehealth technology has been especially helpful in addressing the nationwide shortage of psychiatrists, which is particularly acute outside of major cities.

 

With telehealth technology, states can expand psychiatric and specialty care to remote locations. It also helps them cut back on travel time and costs. Many states expanded tele-mental health options in their public mental health systems during the 2020-2021 coronavirus pandemic.

 

Thanks to the integrated care movement, states are increasingly funding efforts to embed mental health care in primary care clinics and to offer primary care in specialty mental health clinics. These efforts intensified after the passage of the 2010 Affordable Care Act, which increased funding for federally-qualified health centers (FQHCs) that offer mental health care.

 

This has almost created a second publicly-funded mental health system as integrated mental health services are becoming standard in FQHCs. This has been particularly effective in expanding publicly-funded mental health services to people who don't have SMI. In fact, if your state's traditional mental health system isn't the right fit for you, we recommend looking up local FQHCs and learning about other integrated care providers in your area as an alternative option.

 

 

How We Learned About the System

 

We spent over two years working on our epic project to cover the entire United States public mental health system. We're proud of what we've accomplished. We've published 52 state mental health guides—one for every single state in the U.S., as well as for the District of Columbia and Puerto Rico.

 

We took on this huge project because we knew it was essential to cover the public system to cover all of your options for affordable mental health care. When we started, we thought we could simply write an overview of the system and link to other websites with clear information about where and how to access it. But we couldn't—because those websites didn't exist.

 

We now know why. It took a lot of time and work to answer even the most basic questions about the mental health system in the United States. Many state mental health department websites didn't even say who is eligible or the physical locations where you can go to access state-funded mental health care. We had to read hundreds of newspaper articles, academic research papers, and e-books, along with those government websites, to figure out:

 

  • How the system works,
  • Who the system is for, and
  • Where you actually go to access it.

 

Before us, no one had ever done that research (at least no one that we know of). While we've done it now, and are proud, we know we can't rest on our laurels. It will take ongoing work to check for when there are changes to each state's system and to update our articles accordingly.

 

We encourage you to let us know if you find that anything on our state pages is wrong or has changed. We're a small team, and your information and feedback will help us keep our articles up to date. Our ultimate hope with this project is to increase access to mental health care for people all across America. By helping us keep our pages up to date, you help us realize this vision!



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Stephanie Hairston, MSW
Posted on 10/04/2021 by Stephanie Hairston, MSW

Stephanie Hairston is a freelance mental health writer who spent several years in the field of adult mental health before transitioning to professional writing and editing. As a masters-level clinical social worker, she provided group and individual therapy, crisis intervention services, and psychological assessments. She has also worked as a technical writer for a medical software company and as an editor for a company that appeals denials of insurance coverage for behavioral health treatment. As a writer, she is motivated by the same desire to help others that brought her into the field of social work and believes that knowledge is one of the most essential recovery tools. She strongly believes in the mission of OpenCounseling and in making therapy accessible for everyone.