American Psychosis (13 page)

Thus, by 1963, when the community mental health centers legislation was being debated by Congress, there was evidence that a significant number of patients being discharged from mental hospitals required ongoing supervision, especially in regard to their medication, to stay well. By this time, almost 50,000 more patients had been discharged from state hospitals than had been admitted, so many state authorities had become aware of the readmission problem. In addition, according to medical historian Gerald Grob, “data collected by the NIMH’s own Biometric Branch . . . raised troubling questions” regarding whether the patients being discharged had homes to go to or, if they did, whether their families accepted them. “The assumption that patients would be able to reside with their families while undergoing rehabilitation was hardly supported by these data.”
⁵¹

In response to criticism of the mental health centers proposal, Felix and his colleagues again invoked the promise of prevention. The centers, they said, would detect cases of mental illness early in development and, by treating them, prevent more severe cases from developing. Thus, there would ultimately be fewer chronic cases and less need for beds in state hospitals. There was, of course, no evidence to support this claim.

* * *

Ultimately, none of the criticisms of the community mental health centers program received serious consideration. Felix’s 1941 dream of a federal mental health program had met the needs of the Kennedy family for “a bold new approach,” a tacit tribute to Rosemary. Shorn of federal money for staffing, Public Law 88-164, the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963, passed Congress easily and was signed by the president on October 31, 1963 (
Figure 3.3
). Would it be a treat or a trick?

Felix was ecstatic, saying, “We have come further than I ever dreamed that in my life we would come. . . . This has been my blood, it has [been] my life, it has all the energy I have been able to muster.” He envisioned the future:

The frontier of community psychiatry has been won, and the time has come when the colonists and organizers can begin to function effectively. . . . We are now concerned with a framework of service which admits to no separation of prevention, treatment, and rehabilitation. This is the crux of the new concept of community medicine which focuses on the social functions of medicine as well as on the specific actions intended to prevent or cure disease in the individual patient. . . . We have passed the point of no return in our long journey from a helter-skelter system of mental health services divorced from community life, without real grass roots support, crippling to the patient, and self-defeating in terms of the state of our medical and scientific knowledge. Whatever difficulties we shall face in the future cannot be more difficult than those of the past—and the seeds of the future which we have sown and are now nurturing give every promise of bearing good fruit.
⁵²

Unfortunately, the mental health centers legislation passed by Congress was fatally flawed. It encouraged the closing of state mental hospitals without any realistic plan regarding what would happen to the discharged patients, especially those who refused to take medication they needed to remain well. It included no plan for the future funding of the mental health centers. It focused resources on prevention when nobody understood enough about mental illnesses to know how to prevent them. And by bypassing the states, it guaranteed that future services would not be coordinated. “The seeds of the future” had indeed been sown, but they would not bear good fruit.

FIG
3.3 President Kennedy, after signing the federal mental retardation and mental health legislation in October, 1963, handing the pen to his sister, Eunice Shriver, who had championed federal funding for mental retardation. Vice-President Lyndon Johnson can be seen on the left. This was the last piece of major legislation signed by Kennedy before his assassination. (AP Photo)

President Kennedy’s signing of the mental retardation and mental health bill on October 31 was to be the last public bill-signing ceremony in which he would participate. Twenty-two days later in Dallas, he was assassinated.

4
THE SHORT, UNHAPPY LIFE OF THE FEDERAL MENTAL HEALTH PROGRAM: 1964–1970

When it was signed on October 31, 1963, the legislation creating federally funded community mental health centers was a reliquary for Rosemary Kennedy. One month later, the legislation had also become a memorial for Jack Kennedy, a cairn that marked his concern for individuals who are mentally ill or mentally retarded. Like the Peace Corps program, the community mental health centers represented the spirit of Jack Kennedy and merged with his persona. To disavow, or even criticize, the program was a repudiation of Kennedy and all that he stood for.

One of the effects of Kennedy’s death was the purchase of five politically halcyon years for the mental health centers program. President Lyndon Johnson, always looking for ways to capture some of Kennedy’s magic dust, vowed to fully support the centers program. “We must step up the fight on mental health and mental retardation,” Johnson announced. “I intend to ask for increased funds for research centers, for special teacher training, and for helping coordinate state and local programs.” Following Johnson’s demolition of Barry Goldwater in the 1964 presidential election, with the largest plurality in American history, Kennedy’s mental health programs were incorporated into Johnson’s Great Society legislative agenda, alongside job training, low-income housing, community action programs, civil rights, and Medicare and Medicaid. As historian Alonzo Hamby noted, Johnson “transformed a feeling of national mourning into a feeling of national unity directed toward enactment of the Kennedy legislative program as a memorial to a national martyr.”
¹

National Institute of Mental Health officials saw their opportunity. They persuaded White House officials to reintroduce the piece of the original CMHC legislation that Congress had failed to pass—the use of federal funds for staffing the first 5 years of community mental health centers. In contrast to 1963, the legislation passed Congress relatively easily in 1965. Three years later, Congress increased the duration of federal staffing funds to 8 years. Philip Sirotkin, then deputy director of NIMH, later recalled: “We weren’t kidding ourselves about this. At the end of eight years, we’d renew.” The 1965 amendments also “authorized considerable regulatory
and rule-making discretion to NIMH.” As summarized in Foley and Sharfstein’s
Madness and Government
: “Indeed, the cup of NIMH runneth over.” The federal CMHC express had left the station and was headed for a mentally healthy new land. During the 1965 hearings, Congressman Horace Kornegay, Democrat from North Carolina, appeared to be one of the few members of Congress who understood where the train was really going: “I also recognize the tendency on the part of State and local officials that if someone in Washington will pay the bill, it is the easy way out for them.”
²

THE CMHC PROGRAM GETS UNDERWAY

The first federally funded community mental health center opened in 1966, followed by 53 others in 1967. Altogether, 789 centers would be funded in the following 13 years, with a total of $2.7 billion ($13.3 billion in 2010 dollars) in federal outlays. The majority of centers received both construction and staffing grants and were legally obligated for a period of 20 years to provide five essential services: inpatient beds, partial hospitalization beds, 24-hour emergency evaluations, outpatient services, and consultation/education. The last was the community outreach the centers were supposed to do to detect early cases of illness and alter community stressors, theoretically preventing mental illnesses.

The five essential services had been selected by Drs. Felix, Yolles, and Brown, with input from other NIMH staff. Felix retired shortly after the CMHC legislation passed, thereby elevating Yolles to be NIMH director, supervising Brown, who became CMHC’s first program director. Yolles was thus the “key architect of the centers program” implementation. As part of the CMHC regulations, NIMH also mandated that the centers serve catchment areas (a term borrowed from public health engineers) of between 75,000 and 200,000 people. This federal regulation led to numerous problems. As described by one CMHC director: “The boundaries of centers are seldom congruent with those of other public services, voluntary agencies, and the formal and informal political power structure. At times, there is almost a complete incongruity between the area and the location of important activities of its residents.” Thus, the catchment area regulation was to become one more impediment to the CMHC program, which was already severely conceptually challenged.
³

In the regulations written for community mental health centers, there was one glaring omission. Despite the abundant rhetoric of NIMH officials regarding how CMHCs would reduce the population of state mental hospitals, the CMHC regulations did not even mention the hospitals. This omission was highlighted by a 1974 evaluation of CMHCs:

Perhaps the most striking aspect of the regulations is what they omit. They describe no plans, mechanisms, nor procedures to guide centers in determining their relationship to state hospitals; no methods to divert potential state hospital admissions to community mental health centers; and no procedures whereby patients released from state hospitals could be rehabilitated and assisted back into the community. Indeed, the regulations contain not a single reference to the goal of supplanting state hospitals!

Medical historian Gerald Grob also commented on this deficiency: “The absence of any links between new, free-standing centers and the existing mental hospital system was striking. If centers were designed to provide comprehensive services and continuity of care, how could they function in isolation from a state system that provided care and treatment for most of the nation’s severely and chronically mentally ill population?”
⁴

The omission of state mental hospitals from the CMHC regulations was intentional. The hospitals were the past, CMHCs were the future. The hospitals were a state program, CMHCs were a federal program. As described by Brown in a 1972 interview, “Yolles hated the state hospitals and wanted to shut down those goddamn warehouses.” He “did not want the control of the [CMHC] operating costs to shift to the states by means of the regulations,” so he simply ignored the hospitals. Besides, Yolles argued, state hospitals would no longer be needed once CMHCs managed to prevent future cases of mental illness. Dr. Alan Miller, a special assistant to Yolles, recalled the intellectual ambiance of the period:

There was an optimism in the air, perhaps a carry-over from WWII, that we knew how to help people with such problems, especially if they were reached early. There was even a belief that serious problems could be prevented that way. . . . It was an exhilarating time for many of us who were caught up in this project. One of the most powerful intoxicants is the feeling that you are making history.
⁵

PREVENTING MENTAL ILLNESS

Stanley Yolles was 45 years old when he replaced the retiring Robert Felix as NIMH director in 1964. He was less capable and charismatic than his predecessor and tried to compensate by carrying Felix’s programs to extremes. Thus, said Yolles, “psychiatry is no longer concerned only with patients and only with illness . . . we have altered our professional horizons. . . . we are increasingly becoming involved in social planning and the contemporary issues of the day.”
⁶

Yolles was especially interested in the effects of poverty on mental health. This echoed President Johnson’s concurrent call for a war on poverty, a popular theme at
the time reflected in books such as Michael Harrington’s
The Other America
(1962) and Harry Caudhill’s
Night Comes to the Cumberlands
(1962). In 1965 Yolles wrote:

The psychiatrist is aware that a man’s mind, assaulted by poverty in either its acute or chronic form, is susceptible to mental disturbance, disorder or disease. . . . The conditions of poverty, since they constitute a breeding ground for mental disease, require the professional involvement of the modern psychiatrist. Working with community leaders and specialists in other professions, we, as specialists in the art of psychiatry, have skills and knowledge which can help the statesman, the politician, and the poor man himself to intervene in this condition of poverty before it creeps into the fiber and style of a man’s thoughts and behavior.