American Psychosis (14 page)

And 1 year later:

Through community planning on a comprehensive basis, through crisis intervention and other methods, mental health professionals can share with other community leaders in environmental manipulation to eliminate known producers of stress as well as loci of stress such as urban slums and rural depressed areas—potential breeding grounds of mental disease. All of these are perfectly legitimate methods of treatment and no longer have the overtones of quackery which have in the past been attributed to them.

Therefore, added Yolles, the primary responsibility of psychiatrists is “to improve the lives of the people by bettering their physical environment, their educational and cultural opportunities, and other social and environmental conditions. In accepting such a responsibility, mental health professionals do not claim omnipotence. . . . Our first priority must be to expand our newly established policy of treating the mentally ill into a policy of enhancing mental health.” Yolles was thus trying to follow in the footsteps of his predecessor, Robert Felix, who, as he retired from NIMH, had urged that CMHCs be used to provide “a climate in which each citizen has optimum opportunities for sustained creative and responsible participation in the life of the community, and for the development of his particular potentialities as a human being.”
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Consistent with his rhetoric, Yolles encouraged the newly emerging mental health centers to focus their resources on social problems as a means of preventing mental illness. Because NIMH was the source of their federal funding, the center directors got the message. In an NIMH-sponsored survey of 198 CMHCs carried out between 1970 and 1972, center directors were asked to rank by priority six activities. The activity ranked most important by the center directors was “the reduction of the incidence
of mental disorders (prevention).” Ranked second was to “increase the rate of recovery from mental disorders.” Ranked third was to “raise the level of mental health and improve the quality of community.” Ranked last was “the reduction of the level of disability associated with chronic mental disorders.”
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Despite paying lip service to the importance of prevention, few community mental health centers actually did much in this regard. A 1970 NIMH survey reported that the average CMHC spent between 3% and 4% of staff time on preventive activities, mostly teaching classes on parent and teacher effectiveness. A few centers took on more ambitious agendas. Woodlawn CMHC in Chicago hired noted community organizer and activist Saul Alinsky to help plan their program. Sound View CMHC in New York “helped establish a mini-park, assisted a church in receiving funds for a nursery program, . . . helped form a few block associations, . . . [and] organized picketing at a difficult [street] crossing which eventually led to the installation of a traffic light.” Central City CMHC in Los Angeles also organized parents to get a traffic light installed at a busy crossing; the center’s staff led a group “down to the city councilman’s office and from there to the Division of Traffic.” Temple CMHC in Philadelphia “became significantly involved in such work as rent strikes with escrow accounts, stimulation of voter registration, and other political activism.” The community board of Temple CMHC defined the center’s mission as working “to resolve the underlying causes of mental health problems such as unequal distribution of opportunity, income, and benefits of technical progress.”
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Yolles and the NIMH staff praised such prevention efforts as carrying out the vision of Felix and the true mission of the CMHC program. In a 1969 paper, Yolles wrote:

Besides treating the classic range of mental illnesses, the center staffs are helping clients with such matters as housing, finances, reading difficulties, and the misuse of marijuana, LSD, and other drugs. Such problems seem to be side effects of affluence as well as of deprivation.

Those on the CMHC front lines who were actually doing the work, however, quickly realized the absurdity of their task. Jack Wilder, director of the Sound View CMHC, noted that his center’s resources “had to be allocated to treating those who had an ‘existing illness’ and clamored for help.” Similarly, Anthony Panzetta, director of the Temple CMHC, observed that “doing a good job of comprehensive and continuous care of the psychotic and mental retardates of the base population group of from 75,000 to 200,000, may very likely absorb every available manhour of resource and then some.” Moreover, added Panzetta, the prevention of mental illnesses depends on knowing the causes, and “we are at a level of understanding of most human events which rivals the
level of cosmic understanding enjoyed by the amoeba.” Panzetta then summarized the task of a preventive psychiatrist as follows:

The preventive psychiatrist is a bits and pieces practitioner with built-in chutzpah. He takes this piece and that, fills the gap with maybe, packages his war on evil so that it will be funded, and sets out. . . When we in psychiatry wave our preventive banners, we must look ridiculous to even the gods on Mount Olympus who once held the key to the causal mysteries of human events.
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THE NATION’S MENTAL HEALTH CENTER

It is important to note that these experiments in preventive psychiatry were taking place during an especially turbulent time in American history. Between April 1963, when Martin Luther King Jr. was arrested in Birmingham, and April 1968, when he was assassinated in Memphis, a continuous series of racial confrontations rocked the nation—Selma, Watts, Newark, Chicago, Atlanta, Detroit, New York. Simultaneously, antiwar demonstrations were taking place, and Johnson’s War on Poverty was highlighting conditions in Appalachia and elsewhere. One might have been excused for thinking that the nation itself needed psychiatric help.

Yolles and his NIMH staff were eager to try to provide such help, essentially transforming the institute into a mental health center for the nation. For the “mass violence on the streets of our cities and student demonstrations on the campuses of our colleges,” Yolles claimed that “behavioral science research does provide a framework for effective
preventive
action.”
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Yolles’s chief of planning at NIMH was Leonard Duhl, a psychiatrist and psychoanalyst. Duhl viewed whole cities as potential patients:

The city . . . is in pain. It has symptoms that cry out for relief. They are the symptoms of anger, violence, poverty, and hopelessness. If the city were a patient, it would seek help. . . . The totality of urban life is the only rational focus for concern with mental illness. . . . our problem now embraces all of society and we must examine every aspect of it to determine what is conducive to mental health.

As a preventive psychiatrist, Duhl consulted with city mayors and urged other psychiatrists to do likewise:

If we can reach the mayors and the people concerned about the cities in their crises with assistance in the acute problems they are facing, they will begin to use us and we can help bring about change. I suggest that we begin to take them on as clients. We cannot wait for them to request our services, because they are not going to ask us. We must begin right now to fill in and be of assistance to them with the issues they are facing.

Duhl recognized that the role of psychiatrist as change agent meant that he would become involved in community politics: “Such a role requires that he undertake action to persuade a majority to support his decision, and to involve people in implementing his ideas. This, by any definition, is political action.”
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Another member of Yolles’s staff at this time was Matthew Dumont, also a psychiatrist and psychoanalyst, who was assistant chief of the NIMH Center for Studies of Metropolitan Mental Health Problems. Dumont also viewed the city “as an ecological unit, as an organism capable of health or suffering.” For Dumont, there was “little doubt that the urban organism is indeed distressed; it is feeling symptoms.” Like Duhl’s, Dumont’s solution involved political action in which psychiatrists should play a prominent role: “In short, the changes I am talking about, the treatment for the ailing organism, involves a redistribution of wealth and resources of this country on a scale that has never been imagined. We should be constructing a society for the urban poor of such beauty and richness, with so many options for behavior, that it becomes nothing less than a privilege to be called poor.”
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In retrospect, such statements appear fatuous, but they should be considered in their historical context. American psychiatry in general was grandiose at this time. For example, Howard Rome, a past president of the American Psychiatric Association, in 1968 urged psychiatrists to become involved in foreign affairs, poverty, violence, and unemployment. “If psychiatry is to move into the avant-garde of meaningful social reform,” wrote Rome, “it will have to greatly extend the boundaries of its present community operations. Actually no less than the entire world is a proper catchment area for present-day psychiatry, and psychiatry need not be appalled by the magnitude of this task.” Such thinking was also consistent with many social scientists working in the Kennedy and Johnson administrations. For example, the federal program to combat juvenile delinquency, a favorite of Attorney General Robert Kennedy, was run by two sociologists who viewed such delinquency “not as individual pathology but as community pathology”:

For delinquency is not, in the final analysis, a property of individuals or even of subcultures; it is a property of social systems in which these individuals and groups are enmeshed. . . . The target for preventive action, then, should be defined, not as the individual or group that exhibits the delinquent pattern, but as the social setting that gives rise to delinquency.

Presidents Kennedy and Johnson were going to lead Americans to a brave new world, of which the community mental health centers were merely one part.
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During the 1960s, NIMH thus viewed itself and its federally funded community mental health centers as important players in the war on racism and poverty. NIMH provided special funding to CMHCs set up in poverty areas and at one point explored a “mental health tie-in” between NIMH and “both the Appalachia and poverty programs.” Political action, such as that advocated by Drs. Duhl and Dumont, was consistent with the mission of community psychiatry to change social systems to promote mental health.
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By 1969 NIMH had virtually abandoned the treatment of mental illness as its primary mission in favor of promoting mental health. Consistent with its self-perceived calling, NIMH left the aegis of the disease-oriented National Institutes of Health and became an independent institute under the Alcohol, Drug Abuse, and Mental Health Administration. At the time, Yolles even explored the possibility of building a new campus in Columbia, Maryland, to accommodate his expanding mental health institute as part of a collection of institutes for the behavioral sciences. It was to become a behavioral sciences rival to the National Institutes of Health. NIMH, wrote Yolles, “has long and successfully argued the necessity of viewing its programmatic efforts on a total and comprehensive basis with an emphasis on mental health rather than mental illness. What is needed now is an even greater effort and utilization of the behavioral sciences in achieving that goal of mental health.”
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THE PASSING OF PREVENTION

The attempts of Yolles and the NIMH to prevent mental illnesses by intervening in social and political issues were criticized even in their earliest stages. In 1965, prior to the opening of the first federally funded CMHC, sociologist Warren Dunham labeled community psychiatry “the newest therapeutic bandwagon” and said it was attracting “those who jump on any bandwagon as long as it is moving.” He noted:

There is no doubt that the word “prevention” falling on the ears of well-intentioned Americans is just what the doctor ordered. . . . But, of course, there is a catch. How are we going to take the first preventive actions if we are still uncertain about the causes of mental disorders?

Dunham reminded his readers that the Cambridge-Somerville Delinquency Prevention Project, the only major study in which psychiatry had been used to try to prevent future criminal behavior, had produced “mainly negative” results.
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Other skeptical voices followed. Psychiatrist Bernard Rubin noted that “the concept of prevention in psychiatry is limited by little knowledge of etiology. . . . there is no evidence that any particular interventive activity with individuals or groups of individuals reduces or has reduced the incidence of any mental illness. . . . A move to the social fields within the community implies an unlimited expansion of the boundaries of psychiatry to encompass all social ills.” Sociologist Morton Wagenfold could find no evidence to support “the notion that mental illness is etiologically or sequentially associated with social conditions such as poverty and racism.” Psychiatrist William Davidson wondered whether “the ultimate goal of community psychiatry . . . will be to produce a psychiatrist who never sees a patient.” And sociologist Dale DeWild asked perhaps the most embarrassing question of all: “If mental health professionals are given some control over how social systems are organized, who is going to control the mental health professionals?”
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