American Psychosis (12 page)

As patients were discharged from state hospitals in the late 1950s, states began experimenting with various aftercare programs. Most such programs were funded by state and local governments, with a few funded by NIMH grant funds or private foundations such as the Milbank Memorial Fund. What should be stressed is that there was a lot of activity and experimentation with mental illness services taking place at the state and county levels at the same time that Felix and his colleagues were attempting to implement a national plan. Indeed, according to medical historian Gerald Grob, “by 1959 there were more than 1,400 clinics” providing outpatient psychiatric services to approximately 294,000 adults.
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An example of such activity was documented in the “First National Report on Patients of Mental Health Clinics,” which identified 1,294 existing outpatient psychiatric clinics in 1955 in the United States. Two-thirds of the clinics received state funds, and one-third were funded locally or privately. A diagnostic breakdown of the patients being seen in 1956 reported that 20% had serious mental illnesses (“psychotic disorders”). Another report in 1959 noted that there had been a 32% increase in patients seen at the outpatient psychiatric clinics in the previous 4 years, from 379,000 to 502,000 patients, and that 15% of the patients were diagnosed with a “psychotic disorder.” Thus, even as the Joint Commission on Mental Illness and Health had been meeting between 1955 and 1959, the states on their own initiative had been rapidly expanding the psychiatric outpatient clinics, with almost no assistance from the federal government. And the percentage of seriously mentally ill patients seen in the state-funded clinics
was 15% to 20%, whereas the percentage in the federally funded community mental health centers would never rise above 5%. Thus, in the 1950s, state-funded psychiatric outpatient clinics were doing a significantly better job of providing care for the sickest patients than the federally funded CMHCs would do later.
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By 1960, as patients were being discharged from the state hospitals, many states had accelerated their aftercare activities. Starting with New York in 1954, 7 states had passed community mental health legislation, and 13 more would do so by 1964. In 1957 the Joint Commission on Mental Illness and Health began a project that identified 234 psychiatric programs that were said to have “certain of the elements of a community mental health program.” Among the programs were the Massachusetts Mental Health Center (1950), California’s San Mateo County Mental Health Services (1958), Colorado’s Fort Logan Mental Health Center (1961), and the Prairie View Hospital in Newton, Kansas (1961). All of these were regarded as model psychiatric centers well before they received federal funds as community mental health centers.
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All of this information was, of course, known to Drs. Felix, Yolles, and Brown. The data on the state clinics were, in fact, being collected by the Biometrics Branch of NIMH, and the agency’s files contain extensive reports of attempts by states to improve psychiatric services prior to the implementation of the federal CMHC program. The following are selected samples:

• In
  California
  , the first Fairweather Lodge, a model rehabilitation program for released state hospital patients, was begun in the late 1950s.
  
• In
  Georgia
  , four psychiatric units in general hospitals were opened.
  
• In
  Illinois
  , a pilot program showed that patients could be treated in psychiatric units in general hospitals for half the cost of state hospitals.
  
• In
  Kansas
  , the first American day hospital had opened at the Menninger Clinic in 1949. By 1964 the effectiveness of such facilities, as alternatives to full-time hospitalization, had been clearly established.
  
• In
  Kentucky
  , the Louisville Homecare Project was started in 1961 and demonstrated that many individuals with schizophrenia could be treated at home using daily visits by public health nurses and guaranteed medication compliance.
  
• In
  Maine
  , eight mental health clinics were funded with equal shares state and local money.
  
• In
  Massachusetts
  , a Psychiatric Home Treatment Service was established at Boston State Hospital in 1957.
  
• In
  Minnesota
  , 16 community mental health clinics were established by the state. Services included outpatient clinics and rehabilitation programs primarily for discharged state mental hospital patients.
  
• In
  New Jersey
  , there had been an increase in state-funded community psychiatric clinics from 17 to 43.
  
• In
  New York
  , Fountain House, the first clubhouse, had been established in 1948 for patients discharged from Rockland State Hospital. Also in New York, in a pilot program half the psychotic patients who would have been admitted to a state hospital were referred to a clinic for treatment, instead.
  
• In
  Oregon
  , a special intensive treatment hospital had opened and reported that it could treat patients at less than one-third the cost of the state hospitals.
  
• In
  Vermont
  , mental health programs had been established in 7 of the state’s 11 areas, using matching state and local funds.
  
• In
  Wyoming
  , six community mental health centers had been established.
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Although these psychiatric programs were all underway in 1962, at the same time that the Interagency Committee was discussing the new federal mental health program, the new state programs were almost certainly not brought up for discussion by Felix and his colleagues. To do so would have invited unwanted questions. For example, wouldn’t it be prudent to assess the outcome of the state experiments and model programs before implementing a massive new federal program? This was not the kind of question Felix wanted to hear. He had a president who needed a new mental illness program, and he had a program ready to go. This was his moment, and he was determined to seize it.

THE FEDERAL MENTAL HEALTH PLAN IS PASSED

By late 1962 all the pieces were finally in place. The President’s Panel on Mental Retardation had completed its list of recommendations, and the Interagency Committee on Mental Health had accepted Felix’s national plan for community mental health centers. In October, President Kennedy had stared down Nikita Khrushchev in the Cuban Missile Crisis. Then, in November, the Democrats had retained their majority in both the House and Senate in the midterm elections.

Kennedy was at the height of his power and popularity and determined to push his new programs through Congress. The mental retardation proposals were expected to pass easily. However, problems were anticipated for the mental health centers proposal, because it “represented a major departure in the national approach to mental illness and would involve considerable input of federal resources in the years to come.” Despite this, Kennedy personally instructed HEW secretary Celebrezze to include in the proposed legislation the provision for federal funds for staffing the centers, to which Celebrezze was strongly opposed. When it was pointed out to Kennedy that the 5-year cost of the program was estimated to be $850 million ($6.1 billion in 2010
dollars), Kennedy simply responded that the 5-year cost of the defense budget was $250 billion ($1.8 trillion in 2010 dollars). According to one observer, “this sort of stunned Celebrezze.”
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On December 11, the major players from both programs met at the White House to coordinate their plans and outline the president’s message. According to notes from that meeting, the definition of community mental health centers and the role of the states were still under discussion. Predictably, Eunice Shriver did everything she could to favor the mental retardation programs. When the president’s message had been finally drafted, Eunice sat with the president’s aides and “for six hours straight she went over every word, every nuance, struggling to advance her cause.”
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On February 5, 1963, President Kennedy delivered his historic speech to Congress. Significantly, it was titled “Mental Illness and Mental Retardation,” because everyone acknowledged that “mental illness” would be a much easier sell to Congress than “mental health.” With his own family almost certainly in mind, Kennedy said that mental illness and mental retardation “cause more suffering by the families of the afflicted . . . than any other single condition.” He called for the use of federal funds to increase research, increase the training of mental health professionals, and create community mental health centers to replace the “shamefully understaffed, overcrowded, unpleasant institutions from which death too often provided the only firm hope of release.” The mental health centers would be “a bold new approach. . . . When carried out, reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability.”
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One month after the president’s special message to Congress, hearings on the proposed legislation opened before the Senate Committee on Labor and Public Welfare; Lister Hill—Felix and Gorman’s old friend—was chairman of the committee. Passage of the legislation seemed likely, but as insurance Edward Kennedy, who had been elected as a senator from Massachusetts 4 months earlier, was given a seat on the committee. As in previous congressional hearings on mental health issues, state mental hospitals were excoriated. Gorman even claimed to have had “a fantasy of borrowing a bulldozer and running it . . . right smack through the walls of the State institution.” By contrast, community mental health centers were depicted as the great hope for the future. Felix assured the committee “as certain as I am that I am sitting here that within a decade or two we will see . . . the population of these mental hospitals cut in half.”
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Hearings on the House side before the Committee on Interstate and Foreign Commerce began 3 weeks later. The chairman of the committee was Oren Harris, a Democrat from Arkansas. He was known to be less enthusiastic than Senator Hill about the proposed legislation, so President Kennedy asked his brother Robert, who was the U.S. Attorney General, to visit Harris and personally let him know that “the new [community mental health] concept originated with the Kennedys.”
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Several members of Harris’s committee strongly opposed the use of federal funds to staff the proposed mental health centers, arguing that it would “set a new federal precedent.” There was also a concern that the funds would become a permanent federal subsidy. Anchor Nelson, a Republican from Minnesota, expressed these doubts most forcefully:

I think it is very difficult to assume that your plan will work, because I have never seen a temporary government program that didn’t become permanent and I see no way that you can terminate this financing of staffing in the future. It seems to me the very reason that you propose it be terminated at a future date is an admission of the fact that it shouldn’t continue, and if it shouldn’t continue, why start?

Ultimately, the House committee voted against the inclusion of federal staffing funds but approved the use of construction funds, although in a reduced amount.
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At the same time that some members of Congress were raising doubts about the proposed federal mental health plan, several state mental health officials were also doing so. Representative of such doubts was a letter from Dr. Paul Hoch, commissioner of the New York State Department of Mental Hygiene, to New York senator Jacob Javits, who was a member of Senator Hill’s committee. “On the basis of first-hand experience in New York State,” said Hoch, “I maintain that it will not be feasible to treat all the mentally ill or even most of the mentally ill in community mental health centers.” Hoch had hard data to support his position, as a paper had been published the previous year reporting a 50% increase in readmissions to the New York state mental hospitals. This suggested that some discharged patients were more liable to “recirculation,” and for such patients “drugs may have to be maintained indefinitely afterward.”
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Hoch also criticized the proposed funding of the mental health centers’ program for bypassing the states and not taking state differences into account. “It is essential,” he said, “that all federal funds be channeled through state government to insure integration and coordination of services within the state.” Further, “each state has its own problems and its own level of development . . . [yet] so unalterable is the federal concept of a state program that its chief feature is incorporated into the proposed legislation.” Finally, Hoch questioned whether “families would be willing to tolerate these patients in the home,” especially because “the behavior of many schizophrenics can be trying and disruptive.”
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Felix and his NIMH colleagues were asked to respond to the criticisms being raised by Hoch. As had become their custom in such circumstances, they referred to the recent research of Dr. John Wing et al. in England, implying that such research had already established the validity of their mental health center concept. In fact, Wing in 1960 had published a study in which 20 young males with non-severe schizophrenia
had been placed in an industrial workshop, and at the end of 1 year, 40% of them had been discharged. Wing et al. had also studied 113 patients with schizophrenia who had been discharged from hospitals in 1959; within 1 year, 56% had deteriorated and 43% had been readmitted. In still another study, published in 1962, the same research group reported that 44% of patients with schizophrenia did not take their medication after discharge, and most required readmission. When the administration of medication was supervised by a relative, however, most patients took their medications and remained well. In 1961 Ewalt had also written about problem patients who refused to take medication once discharged from the hospital. “Not simple is the problem of how one obtains a medical certificate when the patient is disturbed and stubborn in his refusal of help,” wrote Ewalt.
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