American Psychosis (11 page)

Felix’s other method of preventing mental illnesses, as he explained to the Interagency Committee, was to alter social, economic, and cultural factors that were thought to be causing the illnesses. As early as 1948, he had written that “the content and the orientation of personality are powerfully influenced by the social setting,” including factors such as a “disorganized community life.” Caplan called the alteration of such factors “primary prevention,” which included “inducing community change by administrative action.” Felix agreed that social action should be part of the job description for a community psychiatrist:

To be fully effective, a good mental health program must include some provision for social action so that the total community environment is a mentally healthy one. This is particularly important for those areas, such as family life and school experience, which affect the individual most closely.

By the use of such preventive measures, mental illness would be reduced and fewer individuals would require hospitalization.
²⁷

It is unknown whether any member of the Interagency Committee questioned Felix’s plan to use community mental health centers to prevent mental illness. How did he know it would work? If they had, Felix would almost certainly have described the pilot mental health clinic he had set up in 1948 in Prince George’s County, Maryland, on the outskirts of Washington. In congressional testimony, both Felix and Yolles sometimes alluded to this clinic as an “operational model” for community mental health centers.
²⁸

When Felix had set up the clinic in 1948, he had described its goals as developing “case finding techniques” to achieve the “goals of early diagnosis and treatment.” Ultimately, he said, the clinic should play a role in “supplementing and unifying all community forces working toward better mental health.” Yolles had worked at the clinic for 6 years, after which he had been appointed deputy director of NIMH by Felix. Brown had also begun his NIMH career at the Prince George’s clinic.
²⁹

However, by 1962, although the clinic had been in existence for 14 years, there is no evidence that it had prevented a single case of mental illness. Clinic personnel had provided traditional outpatient psychotherapy, mostly to children and adolescents, and had undertaken studies on such things as the mother–child relationship, the number of children in schools with reading disabilities, and how many adults join community voluntary organizations. Yolles, for example, had been the senior author on a paper on the “epidemiology of reading disabilities.” No study had been done to demonstrate that the early treatment of minor problems would prevent the later emergence of major problems. And virtually no efforts had been made to provide services to individuals with schizophrenia or other major psychiatric disorders. According to Dr. Alan Miller, an NIMH psychiatrist who worked at the Prince George’s County clinic for 6 years: “We even tried to work with one of the Maryland State Hospitals, with the idea of providing what was called Aftercare to discharged patients. But I think the hospitals were not ready for us; I know we were not ready for them.” After 14 years as an “operational model” for community mental health centers, there was no evidence whatsoever that the mental health of Prince George’s County had been improved in any way.
³⁰

In fact, by 1962 there had been only one published study assessing whether the early treatment of minor problems prevents the later development of major problems. Given the findings of this study, it was not likely to have been discussed by Felix with the Interagency Committee. The study started in the 1930s as the Cambridge-Somerville Delinquency Prevention Project and involved more than 600 Boston-area boys judged likely to become delinquent. The boys were randomly assigned either to a “no-treatment” control group or to a “treatment” group that consisted of ongoing psychotherapy with a social worker. The social workers met with the boys an average of twice a month for 5.5 years. The social workers were said to use both traditional
psychoanalytic techniques and also nondirective, psychotherapeutic techniques based on the theory of Carl Rogers. In addition to the therapy, more than half the boys in the treatment group were tutored in academic subjects, half were sent to summer camps, and one-third were referred for “medical or psychiatric help.” The boys averaged 10 years of age at the start of the treatment program and almost 16 years at the end.

In 1948, 3 years after the project ended, an initial evaluation of the results revealed that “the boys who had received treatment were not less likely to have been brought to criminal court; nor were they committing fewer crimes.” It was predicted, however, that the effectiveness of the treatment would become evident over longer time. “The evaluation of the program in the 1950s . . . again revealed no benefits from the program.” In 1975 a 30-year follow-up was undertaken during which 95% of the study group was located. It was found that “as adults, equal numbers [of the treatment and no-treatment groups] had been convicted for some crime. . . . Unexpectedly, however, a higher proportion of criminals from the treatment group than of criminals from the control groups committed more than one crime,” and the difference was statistically significant. Further analysis of the study revealed that longer treatment had increased the chances of later criminal behavior and more intensive treatment, in which the social workers had focused on personal or family problems, had also increased the chances of later criminal behavior. Therefore, the one study that had attempted to prevent major problems by early identification and treatment of minor problems had been a resounding failure.
³¹

THE FEDERAL ROLE

Another major issue on which the Interagency Committee was asked to make recommendations was what the federal role should be in regard to the new mental health programs. Should federal funds be used to construct the mental health centers? Should federal funds be used for staffing the centers? And where should control of the centers lie along the spectrum of federal, state, and local government?

Regarding the first question, there was unanimous agreement on the committee that federal funds should be used to cover some of the construction costs. The Hill-Burton program, which was cited as a precedent, had provided federal funds to help construct general hospitals since 1946. The federal government contributed between 33% and 67% of the construction costs, depending on the state, with state and local governments picking up the remainder. In the end, the federal contribution for the mental health center construction program was recommended to be between 45% and 75%, thus somewhat more generous than the Hill-Burton program.

The possible use of federal funds for staffing the mental health centers proved to be a highly contentious issue. Staffing of mental health facilities had been a state and local responsibility for more than a century, and there was virtually no precedent for
using federal funds for this purpose. Publicly, Felix argued that federal funds should be used for staffing for only the first 4 years of the centers’ operation, to help centers get started. He referred to this in congressional testimony as “grub-stake money.” Following the withdrawal of federal funds, the centers’ staffing would then be funded by the state and local governments and “by the traditional financing patterns of the care of physically ill in the community. In other words, the individuals who would be served at the center would pay the costs of their care just as they pay a hospital bill.” Privately, however, Felix and his colleagues were in favor of permanent federal financing for the mental health centers. They reasoned that once federal financing had been established, it would be difficult to cut it off. In a 1972 interview, Atwell confirmed that the “seed money” concept being promoted by Felix was just “for effect—seed money was the way you had to go for political reasons.” The federal training also had political implications for the future power of NIMH. According to Henry Foley’s history of this period,
Community Mental Health Legislation
, “a federally financially-assisted system of approximately two thousand centers would provide NIMH with the same type of political power that the postal system possessed. A center located in every congressman’s district would increase the patronage power of Congress and enhance the political viability of NIMH as coordinating agency of this new system.”
³²

The Interagency Committee was, in fact, divided on the staff funding issue. According to Foley, “Fein argued that the states were not in the position adequately to support the care of mental patients . . . [and] had no objection to the position that financing mental health care should become a permanent federal subsidy.” In contrast, Jones represented the opinion of his boss, HEW Secretary Celebrezze, who was unalterably opposed to the use of federal funds for staffing the centers, arguing that it was a state responsibility. In the end, the issue of initial staffing was resolved by President Kennedy, who ordered Celebrezze “in November 1962 to put provisions for operating costs into the proposed legislation.”
³³

The issue of long-term financing for the mental health centers was, however, never resolved. Proponents of the program cited self-pay by users as one source, despite the fact that the purported target population of users would be mostly unable to pay. Local funds were suggested, without any evidence that cities or counties would be willing to put up funds. State funds were also suggested, especially the funds that would theoretically be saved as state hospitals discharged more patients and downsized. However, proponents of the centers’ program were simultaneously telling states officials that the states were going to be able to spend less money as the hospitals were downsized. In internal documents, NIMH officials acknowledged that “it is true that the assumption [of state funds for long-term CMHC staffing] is an optimistic one.”
³⁴

Of all the issues debated by the Interagency Committee, the most contentious was the relative roles of federal and state governments in control of the mental health
centers. Felix and his colleagues viewed the centers as a national program and thus expected that NIMH would retain ultimate authority over the centers. State mental health directors, by contrast, assumed that the ultimate control of the centers would rest with them. To maintain state support for their program, this assumption was encouraged by NIMH, which awarded them planning grants and projected optimistic scenarios about the money that the centers program would save them.

The members of the Interagency Committee debated the issue
in extenso
. Felix wanted NIMH to retain the ultimate control but believed that the state mental health authorities should also be involved; this opinion was shared by Jones and Moynihan, who were sensitive to the political implications of federal–state relations. Atwell, by contrast, was convinced that states had abdicated their responsibilities for the treatment of mentally ill individuals and “argued that the states should be bypassed because they were an obstruction.” “Why get involved with state bureaucracy,” he argued. “It would just mean more red tape and involvement with state politics.” Manley, whose experience was in the federal Veterans Administration program, also had no problem with bypassing the states, and Fein concurred. This later position ultimately prevailed, and it was decided that NIMH would award CMHC grants directly to cities, counties, and other local entities without the approval of state authorities. According to Yolles, when the state authorities “realized that they would not get the funds, they started screaming bloody murder.”
³⁵

It should be added that the assumption of partial federal authority for the problems of mental retardation and mental illness was consistent with other initiatives of the Kennedy administration. There was a belief that Washington could, and should, solve a host of problems that previously had been the primary responsibility of state and local governments. Thus, Kennedy proposed to solve the problem of juvenile delinquency through the Juvenile Delinquency and Youth Offenses Control Act; the loss of jobs in depressed areas through the Area Redevelopment Agency; unemployment through the Manpower Development and Training Act; housing problems through the Omnibus Housing Act; and education problems by giving “federal aid to every school district in America.” The Kennedy administration also “favored a strong federal role in stimulating and managing the economy.” Washington, in short, was going to be the source of solutions for many of the nation’s problems, including mental retardation and mental illness.
³⁶

STATE PROGRAMS ALREADY UNDERWAY

Given the fact that states had been responsible for the treatment of mentally ill individuals for more than a century, the decision of the Interagency Committee to bypass them in setting up a new mental health treatment program was a major mistake. In
fact, by the time the committee was debating the details of the new mental health centers program in 1962, many states were already developing innovative community treatment programs in response to deinstitutionalization, which was well underway.

As noted previously, the census of the state mental hospitals had shown its first downturn in 1956. For the 4 years from 1955 to 1959, the decrease in hospitalized patients was modest, averaging 4,259 per year. From 1959 to 1963, the average decrease was 9,320 patients, and from 1963 to 1967 it was 19,514 patients. Thus, the emptying of state mental hospitals was well underway before the first community mental health center was ever opened, and the rate of deinstitutionalization was accelerating. One of the most prominent promises made by advocates for the community mental health centers program was that the centers would result in the halving of the state hospital population in 10 or 20 years. This claim was even included in President Kennedy’s 1963 message to Congress: “If we launch a broad new mental health program now,” Kennedy asserted, “it will be possible within a decade or two to reduce the number of patients now under custodial care by 50 percent or more.” In fact, given the rate of accelerating deinstitutionalization already in progress, the state hospital population would have been halved in 10 years without any community mental health centers having ever been built.
³⁷