Community Mental Health Centers

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Community Mental Health Centers

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Mental illness and mental retardation are among our most critical health problems. They occur more frequently, affect more people, require more prolonged treatment, cause more suffering by the families of the afflicted, waste more of our human resources, and constitute more financial drain upon both the Public Treasury and personal finances of the individual families than any other single condition.

President John F. Kennedy, Message to Congress, February 5, 1963

The figures describing the incidence of mental illness have been repeated so often that they have become commonplace: Half the hospital beds in the country are occupied by mental patients. One family in three will at some time place one of its members in a mental hospital. At some time in his life, one person in 10 will be sufficiently ill mentally or emotionally to require professional help. "Unfortunately, these are not exaggerations or slogans but the simple truth."¹

However, the prevalence of mental disorders does not necessarily mean that the public sees it as a matter of concern. It took many years to identify mental illness as an important problem in the United States, and even after it happened, the typical response was to ignore it. During the last 20 years, however, increased knowledge of the medical and social nature of mental illness has altered the climate of opinion in the United States and has stimulated significant changes in public policy. These include the enactment by Congress of a number of laws to help the states and local communities in their efforts to deal with mental illness. The first law, passed in 1948, created the National Institute of Mental Health which is now part of the U.S. Department of Health, Education, and Welfare. The most recent law is the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 (Public Law 88-164), amended in 1965 by Public Law 89-105. Title II of the 1963 Act, the Community Mental Health Centers Act as amended, furthers the trend toward treating the mentally ill within the community by appropriating federal funds for the construction and staffing of community mental health centers.

The community mental health center (CMHC) represents a basic change in social and governmental attitudes as to where and how the mentally ill will be treated. In the past, and to a certain extent today, those suffering from mental disorders have been rejected by society and isolated from it. Before the establishment of hospitals, the mentally ill were sent to jails and poor houses; later, they were confined in large state institutions built expressly for this purpose. There, the mentally ill person remained until he was either restored to normal functioning or, more likely, died.

The CMHC is designed to move treatment of the mentally ill into the community. This means that responsibility for care of the mentally ill, more than ever before, will be shared by government and private organizations at the local level. And most likely urban planners will be called upon to offer advice or data concerning the location or need for such centers.

The purpose of this report is to discuss the community mental health center as defined by Title II of Public Law 88-164 and the ideas leading to its development. The report emphasizes the expanding role of planning in providing effectively for community mental health care, and it outlines appropriate planning and zoning considerations.

TREATMENT OF THE MENTALLY ILL

Until recently the hospital was the major, if not the only, resource for treating the mentally ill. Usually, mental patients were placed in special state institutions which, when first established, offered individualized care conducive to the recovery of the patient. However, by the late 19th or early 20th century, they began to increase in size in order to accommodate increased numbers of mental patients. At the same time, the ratio of professional and semiprofessional personnel to patients decreased, and it became impossible for state hospitals to offer more than custodial care.

By 1955, there were nearly 560,000 resident patients in public mental hospitals. But then, with the increased use and understanding of psychotherapy and the development and application of psycho-active drugs (tranquilizers and energizers), the long-term upward trend in in-patient population was reversed. The drugs could modify the disturbing behavior of the mentally ill and, when properly administered, permitted many patients to leave mental hospitals.

One problem which remained was that many discharged patients were unable to cope with life outside the institution. And, because there were no alternative forms of treatment available in the community, they had to return to the hospital. Although the need for care in the community had been felt before, this made it even more acute. New psychiatric clinics began to develop and in a few states half-way house and foster home programs were instituted. By 1964, over 1,600 community-based out-patient clinics were in existence and the trend was away from long-term treatment in institutions and toward care in the community (combined with short periods of hospitalization if needed).

Community care is based on the philosophy "that a patient should remain with his family and his community to the maximum extent possible in order to avoid alienation and de-habilitation, such as had occurred in state hospitals."² It eliminates or ameliorates some of the worst side effects of institutional care; for example, the basic problem of re-integrating the long-term mental patient into the community is avoided simply because the mentally disordered person is never totally removed from the community. It permits the utilization of a variety of therapeutic techniques such as family therapy, part-time hospitalization, and crisis intervention. Community care also provides certain important benefits not possible with institutional care: by being readily available, it permits the early diagnosis and treatment of mental disorders; it allows an individual to be helped promptly at the peak of an emotional crisis (crisis intervention); it may also help to shorten the time a person is an unproductive member of the community.

Complementing the development of out-patient clinics, more and more general hospitals have begun to add wards for the treatment of the mentally ill. These permit many persons who require in-patient care to be hospitalized close to their homes rather than be sent to distant state hospitals. Generally, these wards are oriented toward active, intensive treatment of acute disorders. Patient turnover is rapid; few patients remain more than a couple of weeks, and 90 days of care is an absolute maximum in some hospitals. "Today the number of admissions of patients with psychiatric diagnoses to general hospitals is nearly as great as the number of patients admitted to state and county [mental] hospitals."³ And it is assumed that this trend will continue as more and more standard health insurance plans cover patients who enter general hospitals for psychiatric treatment.

There is some question of course as to the possibility of treating all mentally disturbed persons in the community, even if both out-patient and in-patient facilities are utilized. A number of mental health professionals suggest that there will always be a "resident mental patient" population (apart from the criminally insane), and that custodial institutions will never disappear entirely. Because community-based care is still relatively new, figures are not available to support or disprove this view. Actually, the precise mental patient population treated by existing out-patient facilities is still uncertain. It is impossible to tell whether a completely new patient population is being served by community mental health centers or whether the population served is the same as was previously treated in state mental hospitals.⁴

Although the development of community mental health services is assured, the role of these services vis-a-vis the mental institution has yet to be defined. Certainly, the large state mental hospitals will never disappear, but they will probably change (many have already changed) from purely custodial hospitals to active treatment centers which provide intensive care for the most difficult cases of mental illness.

THE COMMUNITY MENTAL HEALTH CENTERS ACT OF 1963 (Title II of P.L. 88-164)

In authorizing funds for the construction of community mental health centers, Congress did not enter upon an untried experiment; rather, it gave impetus to an already existing trend. In Europe, much work had been done in treating the mentally ill in the community, and the success of the European experiments was well known. In the United States, a number of outpatient clinics were already operating, although none offered anything close to comprehensive care for all members of the community nor was there continuity of care. The legislative history of the Community Mental Health Centers Act can be traced back to the work of the Joint Commission for Mental Illness and Health which was established in 1956. Their final report, Action for Mental Health, provided the inspiration for this "bold, new approach" to treatment.

The 1963 Act (and its amendment) added further innovations. Previously, states had been encouraged to improve their mental health programs in whatever way seemed most appropriate, in part by utilizing funds available under the Hill-Burton (hospital construction) program for the construction of some mental health facilities. The 1963 Act, on the other hand, emphasized the development of community-based facilities which provide continuity of care. It authorized $150 million for the three fiscal years 1965 through 1967 to be allocated to the states for the construction of community mental health centers and additional funds to be allocated for the initial staffing of these centers. (A bill to renew funds under this Act has been introduced into the 90th Congress).

The community mental health center as envisioned in the Community Mental Health Centers Act is a program of mental health services under a unified system of care with the following goals:

1. Providing a varied and comprehensive range of services near the patients' homes.
2. Providing these services to all persons in the community regardless of ability to pay.
3. Permitting a patient to transfer easily from one type of service to another as his needs change (continuity of care).
4. Strengthening community resources for the prevention of mental illness.

Each center will have its own characteristics, reflecting the special needs and resources of the community. However, when fully developed, all centers will provide at least the following essential services:

1. In-patient services
2. Out-patient services
3. Partial hospitalization, such as day care or night care
4. Emergency services provided 24 hours per day
5. Consultation and educational services available to community agencies and professional personnel

The following optional services complete the comprehensive program:

6. Diagnostic services
7. Rehabilitative services including educational and vocational programs
8. Pre-care and after care including foster homes and half-way houses
9. Training
10. Research and evaluation

These services will not necessarily be provided by a single agency within the community, nor will they necessarily be housed in a single building. For example, it is likely that inpatient services will be provided by a general hospital in the community — either by making use of existing beds or building new facilities attached to the existing plant — while outpatient services may be provided by a separate agency, perhaps in a completely separate facility. However, if more than one agency is involved, the agencies must guarantee that a patient accepted for one service will be eligible for all, and they must ensure that patients will be transferred from one element of service to another as their needs change. This is what is meant by continuity of care.

Construction of facilities to house one or more of the five essential or five optional services will be partially financed by funds authorized by Public Law 88-164. The federal grant will cover between one-third and two-thirds of the cost of construction, depending on the per capita income of the state. These funds can be used for the construction of new buildings or expansion, remodeling, and alteration of existing buildings. (The proposed 1967 amendment suggests that federal grants cover the acquisition of older buildings, as well.)

Funds for the initial staffing of new services were made available under the 1965 amendment to the Community Mental Health Centers Act. These grants cover "a portion of the costs of compensation of professional and technical personnel for the initial operation of new community mental health centers or of new services in mental health centers"⁵ and are available to any center eligible for construction grants. They are made over a period of four and one-fourth years and cover a maximum of 75 per cent of the costs for the first 15 months, 60 per cent for the next 12, 45 per cent for the following 12, and 30 per cent for the final 12 months.

The Act requires all states which want to take advantage of the available funds to: designate a single state agency to administer the program, appoint a state advisory committee, and prepare a plan for the construction of the centers. This has been done by all 50 states and three territories.

Among other things, the state plan must: (1) set forth a program for the construction of community mental health centers; (2) determine the relative need of proposed projects; (3) provide minimum standards of construction; and (4) provide an annual review of the state plan.⁶ The plan should be closely connected with the state's comprehensive plan for mental health services and with other planning programs which affect it, such as mental retardation and Hill-Burton (hospital) programs.⁷

After the state plan for community mental health centers has been approved, any combination of public and private nonprofit agencies can submit applications for construction and staffing grants. Only those projects are eligible for funds which are compatible with the state plan and which carry out the goals of the program.

Each application must contain certain information about the project including: plans and specifications for the center; a description of the site of the project and reasonable assurance that title to the site will be vested in the applying agencies; and reasonable assurance of the financial feasibility of the project.⁸ The applications are submitted to the Surgeon General through the state agency.

As of March 1967, the federal government had supported 173 community mental health centers with grants for both construction and staffing totaling $73 million. One hundred of the centers have received only a construction grant, 47 have received only a staffing grant, and 26 have received grants for both construction and staffing. The average cost of new construction funded by the federal government is just over $1 million of which the federal government contributed about 45 per cent, state governments about 5 per cent, and local sources the remaining 50 per cent.⁹ By the end of fiscal year 1967 286 centers offering services to 47.2 million people will have been supported.

A bill to extend the appropriations for both construction and staffing through 1972 has been introduced in the 90th Congress. This bill (R.R. 6431) recommends the appropriation of $50 million for construction grants for 1968 and "such sums as may be necessary for the next four fiscal years." It also recommends the appropriation of $30 million for staffing grants for 1968 and "such sums as may be necessary for the next four fiscal years."

PLANNING FOR COMMUNITY MENTAL HEALTH CENTERS

Until quite recently, planning for mental health services and facilities required little assistance from the planning profession. Mental institutions were owned and operated by the states, and planning, to the extent that there was any, was done by appropriate state health agencies. Each mental hospital was a self-contained community and there was little, if any, interaction between the hospital and nearby towns. Nor was there much public concern for mental hospitals and the mentally ill, and this negative attitude is reflected in both master plans and local zoning ordinances.

Discussion of mental health facilities in master plans has been slight. An unpublished ASPO survey of 103 recent master plans (1958 to 1965) found that only 34 contained any mention of health services or facilities, and only four specifically mentioned psychiatric facilities. Of these, one merely mentions psychiatric short-term hospitals and psychiatric long-term hospitals as two types of health care facilities in the area. Another suggests a ratio of five mental hospital beds per 1,000 population. And a third says that there is a "significant need'' for specialized health facilities such as psychiatric hospitals.

Treatment of mental health facilities is equally negative in zoning ordinances. Some make no provision at all for psychiatric facilities. Others which do provide for their location discriminate against them in comparison with other health facilities, for example, by treating psychiatric facilities as special uses where other health facilities are permitted as of right. The most common distinction is in the definition of general hospitals and special hospitals, as follows:

Hospital, General: A hospital which does not primarily treat communicable diseases, insane or feeble-minded patients, epileptics, drug addicts, or alcoholic patients.

Hospital, Special: A hospital which does primarily treat communicable diseases, insane or feeble-minded patients, epileptics, drug addicts, or alcoholic patients.

Such a distinction is usually followed by more stringent requirements for special hospitals than for general hospitals, In fact, it seems that zoning ordinances have often been assigned the role of protecting the community from mental patients and mental institutions, This reflects a generally unsympathetic attitude toward mental illness on the part of the public and a residue of fear of the mentally ill person which, in spite of greater understanding in recent years, still persists. While most people would agree, in principle, that the mentally ill should not be shipped off to some institution where they will be forgotten, that instead they should be treated in the community, these same people would not necessarily welcome a psychiatric treatment facility as a neighbor.

It is obvious from the foregoing discussion that a change in attitude is a prerequisite for the development of community mental health centers. To be effective, these centers must be located in the heart of communities, not relegated to uninhabited wastelands as custodial and correctional institutions traditionally have been. The planning profession has a major role to play both in promulgating the concept of community-based treatment, in providing basic data to mental health agencies, and in devising planning and zoning criteria which accord with the characteristics and locational requirements of community mental health centers. It is essential, therefore, that planners have knowledge of these characteristics.

A few planning agencies have already participated in planning community mental health centers. Their primary contribution has been to provide basic planning data and assistance in the site selection process.¹⁰ As the national program gains momentum, it is probable that local and state mental health planning agencies will increasingly seek the assistance of urban planners.

Planning Considerations

Planning for a CMHC, like planning for a variety of other public services and facilities, usually begins with an identification of need. This involves balancing the anticipated rate of mental illness against available mental health resources in a community. Basically, this is the method for determining the "relative need" required by the Community Mental Health Centers Act. It was also the method used in a recent study by the Center for Planning and Development Research at the University of California in Berkeley to determine a pattern of community mental health services for San Gabriel Valley.¹¹

Taking an inventory of existing treatment resources is probably the least difficult aspect of calculating the need for mental health services. Such an inventory should include information on a number of categories of psychiatric facilities in both the private and public sectors, such as: psychiatric hospitals, psychiatric wards in general hospitals, outpatient clinics, and halfway houses, or foster-care homes. Relevant information about these facilities includes: kinds of services performed; geographic area served; patient eligibility requirements (age, type of disorder); number of patients served; size of staff by professional discipline; cost of services; and relationships between various types of facilities. The inventory should also include information on manpower resources, mental health professionals (psychiatrists, clinical psychologists, psychiatric social workers, psychiatric nurses), various ancillary personnel (psychiatric aides and indigenous sub-professionals), and school resources for their training.

An inventory of non-psychiatric agencies which come into contact with mentally ill people and may assist them would probably also be useful. Such agencies include groups and organizations in the fields of health, education, welfare, and recreation. An inventory of these facilities is difficult because of the problems involved in determining the mental health component of their work.

It is much more difficult to assess the other half of the equation: the extent of mental illness. Usually the number of diagnosed cases of mental illness, i.e., patients undergoing treatment, is used as a base. This figure can be obtained from records of general and psychiatric hospitals, outpatient clinics, as well as psychiatrists and other mental health professionals in private practice.

However, this procedure has numerous shortcomings. First, the number of known cases is directly proportional to the availability of treatment resources. Thus, as treatment services increase, so do the number of known cases. Second, the degree of overlap caused by counting a case more than once, because the patient is using more than one facility, cannot be determined. Under the present system, patients are counted each time they enter a service. Only "a community-wide register of psychiatric patients where data consists of dates of arrival in the overall system, dates and types of services performed, movement among the facilities or parts of facilities, and final disposition of cases..." will eliminate this problem.¹² Third, and probably most important, the number of the mentally ill undergoing treatment represents only a portion (and probably a small portion) of those needing care. The larger group of people is composed of those who have disruptive, but nondisabling problems.

For this reason, federal regulations for Public Law 88-164 require that in determining "relative need" the state consider such related indexes as:

(i) the existence of low per capita income, chronic unemployment, and substandard housing.

(ii) the extent of problems related to mental health, such as alcoholism and drug abuse, crime, and delinquency.

(iii) the special needs of certain groups within the area, especially the physically and mentally handicapped, the aged, and children.¹³

It is more likely that information on the size and distribution of this group can be obtained from health and welfare departments, family and social agencies, marriage counselors, schools, courts, police, physicians, and other community caretakers than from the psychiatric services.

Another problem in determining need for mental health services, which was discussed in the Berkeley study, is: "whose definition of need is to be used? There are bureaucratic and client perceptions of need, as well as individual and community preconceptions."¹⁴ Bureaucratic definitions are drawn from professional standards or requirements and are usually normative, defining desirable levels of service. Frequently they do not take into account the available supply of resources, either financial or manpower. At the same time, client perceptions of need are highly variable: as the number and scope of programs increase, the demand for services also increases. To date, the question of definition is unresolved.

The identification of major trends in the mental health field is also an important part of planning for community mental health services. Each of these trends must be analyzed and its implications for mental health services must be considered. The trends described in Chapter IV of the Berkeley study include:

1. Changes in the general attitude of the public toward the field of mental health. "Many of the stigmas attached to persons with emotional problems have vanished, and in well-informed sectors of the population to consult a specialist for an emotional problem is becoming as customary as consulting a specialist for any other physical ailment."¹⁵
2. Changes in therapeutic approaches. Traditional long-term psychotherapy is no longer the only treatment method used. It is giving way to other types of therapy including crisis intervention, group therapy, family therapy, and part-time hospitalization.
3. Trends in manpower training, utilization, and availability. It has been found that community caretakers (e.g., teachers, police, social workers) and indigenous sub-professionals can perform some of the counselling work previously thought to require psychiatrists.
4. Trends in financing of services. With the decrease in the average length of hospitalization for mental patients, it seems likely that psychiatric care, at least in general hospitals, will be covered by standard health insurance plans.
5. Changes in physical plant and accessibility of services to clients. Community facilities are becoming more prevalent, replacing large institutions located in rural areas.
6. New trends in communication, information, and data processing techniques, and the coordination of mental health services with other health, education, welfare, and correctional agencies.

A comprehensive planning program for mental health centers clearly requires the collection and analysis of large amounts of data. Although urban planning agencies are unlikely to have the more specialized data on hand, they may provide valuable assistance in locating and collecting basic data. Much relevant information may in fact be collected by the planning agency in the normal pursuit of its responsibilities.

Locational Criteria

The Community Mental Health Centers Act of 1963 does not represent a solely "bricks and mortar" approach to mental health. Indeed, its emphasis is primarily on the provision of community-based services which offer care that is continuous. Thus, if mental health agencies with adequate facilities already exist in a community, a CMHC can be formed merely by coordinating the services presently provided and perhaps adding one or more new services. (Under Public Law 89-105 funds are available for staffing these services). However, in some communities there is a very definite need for appropriate facilities in which to house these services.¹⁶ Where there is a need for new construction, certain criteria should be considered in choosing a site.

First, the site itself should be large enough to contain facilities adequate for present needs as well as allow for future expansion. This is especially important because of the difficulty of calculating the actual need for the center's services and the likelihood that overall demand will increase once new services are provided.¹⁷ Second, the location of the site should reflect the goals of the mental health center.

One of the goals is to provide treatment while permitting the patient to reside in and remain a citizen of his community. In order to achieve this, patients themselves, as well as their families and friends, must be able to travel from their homes to the center and back again in the course of the day. The center, therefore, must be located close to the residential districts of the community and must be easily accessible.

Another goal of the center is to give comprehensive community care to those who could not otherwise afford it. Therefore, the center should be easy to reach by public transportation as well as by private cars. A location should not be chosen without careful investigation of bus and rapid transit routes.

Another consideration in locating the center is that "the more easily the center can be reached, the greater will be the flow of activity through it and consequently the greater the acceptance of the center into the community."¹⁸ The center, therefore, should be located in the main stream of daily activity. In suburban areas, the shopping center provides an ideal location. An example is the North Center in Daly City, California, which is located on the second floor of a shopping center. In a large city, location on a major commercial street offers similar benefits. For example, Albert Einstein College of Medicine, Brooklyn, New York is presently experimenting with "store front" mental health centers located along well-traveled streets in an effort to provide mental health services for a five-square-mile area of one of New York City's worst slums.

Location is also important for the staff. Psychiatrists and other mental health professionals are often hired by a center on a part-time basis and may have a private practice and/or a university appointment as well. They, therefore, prefer a location convenient to their own offices or the university.

Although physical proximity to a general hospital which provides psychiatric services is by no means a requirement, it does offer certain advantages to a CMHC. For example, it makes following patients in both the in-patient and outpatient stages easier, and facilitates continuity of care.

Zoning Considerations

The community mental health center consists of a series of services which must be joined administratively, but may or may not be connected physically. Thus, a CMHC may take a variety of physical forms. In one community, the CMHC may consist of a single facility which houses both in-patient beds and clinic services. In another community, in-patient services may be provided by a general hospital while the other services may be housed in an entirely separate facility. In a third community, all services might be housed in an existing community hospital. In still other areas the CMHC may merely link administratively already existing services housed in separate facilities.

Because the community mental health center is not a building or even a definable group of buildings but a set of services, zoning provisions must deal with its component parts rather than the center as such. Flexibility is of utmost importance to allow zoning regulations to adapt to whatever form the center may take and still provide zoning protection to both the center and the community. A few basic principles are offered.

1. The zoning ordinance should not differentiate between psychiatric and other health facilities.

The trend in medical care is toward general hospitals with provisions for special types of treatment, and toward medical clinics which provide a variety of physical or mental health services. There is no reason for distinguishing between hospitals or clinics classified by type of patient for purposes of differential zone locations. Restrictions which specify what kinds of patients may or may not be treated serve only to inhibit the development of a full medical program at a general hospital. The following zoning definitions are appropriate:

Hospital shall mean any institution providing physical or mental health services, in-patient or overnight accommodations, and medical or surgical care of the sick or injured. Hospital includes sanitariums and sanitariums.

Medical Clinic shall mean any facility providing physical or mental health service and medical or surgical care of the sick or injured but shall not include inpatient or overnight accommodations. Medical clinic includes health center, health clinic, and doctors' offices.

Mental health facilities should be permitted in the same zoning districts in which general health facilities are now permitted. If a general hospital is permitted as of right in a certain district, a mental hospital should be permitted as of right in the same district. (An exception might be made for mental institutions which are reserved solely for the treatment of chronically ill patients, i.e., custodial institutions.) For a detailed discussion of zoning for health facilities, see Planning Advisory Service Report No. 50, Zone Locations for Hospitals and Other Medical Facilities, May 1953.

2. General hospitals should not be prohibited from providing psychiatric outpatient services as an auxiliary function.

Many zoning ordinances implicitly suggest that outpatient and inpatient services should be treated separately by differentiating clinics (outpatient services) from hospitals (inpatient services). For the most part, this distinction is valid; however, it should not be so strict as to prevent a hospital from becoming a community mental health center and providing outpatient psychiatric services, General hospitals have received the majority of the 173 construction and staffing grants already made under the Community Mental Health Centers Act. Some of these hospitals will provide the outpatient as well as the inpatient services. Outpatient psychiatric treatment should be considered a natural extension of the hospital's activities. The definition of a hospital from the Denver, Colorado, zoning ordinance (1964) acknowledges this fact:

Hospital: an institution providing health services, primarily for inpatients, and medical or surgical care of the sick or injured, including as an integral part of the institution, such related facilities as laboratories, outpatient departments, training facilities and staff offices.

3. Community mental health centers should be permitted by right in medical center districts.

The trend today is toward the medical center complex: one or more hospitals surrounded by the offices of doctors and dentists, by nursing homes and long-term care homes, clinics, perhaps medical and nursing schools and other health-related facilities. This arrangement is quite convenient for both doctors and patients: for doctors, proximity to a hospital makes watching the progress of a hospitalized patient and attending hospital staff meetings easier; for patients, the existence of hospitals and many doctors in one center makes it somewhat easier to obtain an entire range of medical treatment. A community mental health center logically belongs in this complex.

Standards for Mental Health Facilities

Mental Health Facilities are unique in some respects and should therefore at times be subject to zoning standards different from those which apply to general health facilities. Applying different standards does not violate the basic principle that psychiatric facilities are part of the general health facilities, and care should be taken that special conditions attached to mental health facilities are not exclusionary in effect.

Psychiatric Hospitals. The same standards which are presently applied to general hospitals can also be applied to hospitals offering short-term, intensive treatment for mental patients. Off-street parking requirements, site standards, and locational considerations are identical.

Mental Health Clinics. For the most part, mental health clinics can be treated like any medical or dental clinic. The major differences concern minimum site and off-street parking requirements.

The length of time a patient may spend at the mental health clinic should be considered in determining minimum lot size. While patients of doctors and dentists located in medical arts buildings usually remain for only short consultations, patients attending community mental health centers may spend long periods of time each day at the center. Therefore, the site for the community mental health center should be large enough to provide certain amenities not required by a medical clinic. These include such items as landscaped grounds where individual or group therapy sessions may be held, an area for sports, and perhaps a swimming pool.

Off-street parking requirements for a community mental health center are more difficult to calculate than those for medical or dental clinics. Parking requirements for a medical or dental clinic are usually based either on the number of doctors' and dentists' offices in the building, or on the number of square feet of floor space (see PAS Report No. 182, Off-Street Parking Requirements, January 1964). These requirements vary from two per staff doctor (Lake County, Illinois, 1963) to five per staff doctor (Santa Clara, California, 1960) and from one per 100 square feet of floor area (Ithaca, New York, 1960) to one per 400 square feet of floor area (Seattle, Washington, 1962).

Although off-street parking requirements for community mental health centers have not yet been standardized, a number of factors suggest that requirements should be higher than those for a medical clinic. These factors include: utilization of part-time personnel which means that one office may be shared by two or more professionals who are scheduled to be at the center at different times during the day, but whose presence may accidentally coincide; group therapy sessions in which a single professional may meet with up to 10 patients; and professionals who often work in teams which may include a psychiatrist, psychologist, psychiatric social worker, and a psychiatric nurse.

Half-way Houses. The half-way house or foster home for mental patients is a relatively new development and, therefore, presents special zoning problems. These institutions are usually defined as providing treatment for six or fewer patients and are designed as an intermediate step between the mental hospital and the community. In many cases, the half-way house is designed to help reintegrate the patient into the community after hospitalization. He lives here while he is looking for a job and until he finds an apartment of his own. Some treatment services may be offered, but the half-way house is mainly designed to give the patient additional security.

Half-way houses should be considered more as a special variation of the rooming house than as a medical facility. Because of the number of people residing in such a facility and because they will be in and out of the house during the day, the half-way house, like the rooming house, belongs in a multi-family residential district.

FOOTNOTES

1. Paul H. Hoch, "State Care," Atlantic Monthly, July 1964, page 82.

2. Lucy D. Ozarin and Bertram S. Brown, "New Directions in Community Mental Health Programs," American Journal of Orthopsychiatry, January 1965.

3. Robert H. Felix, "Bright New Era for Mental Health Care," Hospitals, February 1, 1964, page 2.

4. Gwen Andrew, "Uses of Data in Planning Community Psychiatric Services," American Journal of Public Health, December 1965.

5. Public Law 89-105, Section 220A.

6. Public Law 88-164, Section 204.

7. In most states, comprehensive mental health planning was launched by a federal appropriation to the states for fiscal years 1963 and 1964 which was designed to stimulate the development of the state planning process and eventually comprehensive state plans for mental health.

8. Public Law 88-164, Section 205.

9. Hearings on R.R. 6431 before the Subcommittee on Public Health and Welfare of the Committee on Interstate and Foreign Commerce, House of Representatives, 90th Congress, First session, April 4 and 5, 1967, page 25.

10. American Society of Planning Officials, "Questionnaire on the Relationship Between Urban Planning and Planning for Health Services and Facilities," December 1966. (Unpublished.)

11. S. Guillermo Lehmann and John W. Dyckeman, A Pattern of Community Mental Health Services: Development Plan for Mental Health in the San Gabriel Valley, Los Angeles Metropolitan Area, 1965–1975. Institute of Urban and Regional Development, University of California, Berkeley, October 1965.

12. Gwen Andrew, "Uses of Data in Planning Community Psychiatric Services," American Journal of Public Health, December 1965, page 1,933.

13. Public Law 88-164, Title II, Community Mental Health Centers Act of 1963, Regulations, Section 54.204 (D-1).

14. Berkeley Study, page 9.

15. Berkeley Study, page 107.

16. Dr. Stanley F. Yolles. Testimony before the Subcommittee on Public Health and Welfare, Hearings, page 38.

17. In a case study conducted by the Western Institute for Research and Mental Health, a team of architects and mental health professionals chose a 230 foot by 400 foot (2.1 acres) site. This was to house a hypothetical center serving a population of approximately 195 people with an estimated case load of 2,550.

18. Clyde Dorsett, "New Directions in Mental Health Facilities," AIA Journal, November 1964.

BIBLIOGRAPHY

Andrew, Gwen, "Uses of Data in Planning Community Psychiatric Services," American Journal of Public Health, Vol. 55, No. 12, December 1965, pp. 1,925–1,935.

Brown, Bertram S., and Cain, Harry P., II, "The Many Meanings of Comprehensive: Underlying Issues in Implementing the Community Mental Health Center Program," The American Journal of Orthopsychiatry, Vol. XXXIV, No. 5, October 1964, pp. 834–839.

Fleming, Donald, "The Meaning of Mental Illness," The Atlantic Monthly, Vol. CCXIV, No. 1, July 1964, pp. 72–76.

Cain, Harry P., and Ozarin, Lucy D., "Hospitals and the Community Mental Health Centers Program," Hospitals, Vol. 39, December 16, 1965.

Dorsett, Clyde, "New Directions in Mental Health Facilities," AIA Journal, November 1964.

Felix, Robert H., "Bright New Era for Mental Health Care," Hospitals, Vol. 38, February 1, 1964.

Furman, Sylvan S., Community Mental Health Services in Northern Europe, Public Health Service Publication No. 1407, U.S. Department of Health, Education, and Welfare, U.S. Public Health Service, National Institute of Health, Bethesda, Maryland. Available from Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402. $1.75.

Glassote, Raymond M., et al., The Community Mental Health Center: An Analysis of Existing Models. Washington, D.C.: The Joint Information Service of the American Psychiatric Association and the National Association for Mental Health. 1964, $3 (paperback).

Hoch, Paul C., "State Care," The Atlantic Monthly, Vol. CCXIV, No. 1, July 1964, pp. 82–85.

Joint Commission on Mental Health and Illness, Action for Mental Health. Final Report of the Joint Commission on Mental Health and Illness, Basic Books, Inc., N.Y. 1961.

Kennedy, John F. Message from the President of the United States Relative to Mental Illness and Mental Retardation, House of Representatives, 88th Congress, 1st Session, Document No. 58, February 5, 1963.

Lehmann, F. Guillermo, and Dykeman, John W., A Pattern of Community Mental Health in the San Gabriel Valley, Los Angeles Metropolitan Area, 1965–1975. Institute of Urban and Regional Development, Center for Planning and Development Research, University of California, Berkeley in collaboration with the Los Angeles County Department of Mental Health, October 1965.

McCaffee, Kenneth M., "The Cost of Mental Health Care Under Changing Treatment Methods," American Journal of Public Health, Vol. 56, No. 7, July 1966, pp. 1,013–1,025.

A Model Health Facility Zoning Ordinance Program. Hospital Planning Association of Southern California, 1515 North Vermont Avenue., Room 616, Los Angeles, California 90027, November 1965.

Ozarin, Lucy D., and Brown, Bertram S., "New Directions in Community Mental Health Program," American Journal of Orthopsychiatry, Vol. XXXV, No. 1, January 1965, pp. 10–17.

Palmiere, Darwin, "Problems in Local Community Planning of Mental Illness Facilities and Services," American Journal of Public Health, Vol. 55, No. 4, pp. 561–567.

Planning, Programming, and Design of the Community Mental Health Center. Conducted by the Western Institute for Research in Mental Health, San Francisco, California and sponsored by National Institute of Mental Health, U.S. Public Health Facilities Branch, Bethesda, Maryland, 1966.

Department of Health, Education, and Welfare, Public Health Service, The Comprehensive Community Mental Health Centers Program: Fact Sheet. Issued by Public Information Section, National Institute of Mental Health, Bethesda, Maryland 20014.

U.S. Department of Health, Education, and Welfare, Public Health Service, The Community Mental Health Centers Act (1963): A Commentary. Available from Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402, $.15.

U.S. Department of Health, Education, and Welfare, Public Health Service, The Comprehensive Community Mental Health Center: Concept and Challenge. Available from the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402, $.15.

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Prepared by Gail Ornstein. Copyright © 1967 by American Society of Planning Officials.