American Psychosis (15 page)

Such criticisms did not deter NIMH, which continued encouraging CMHCs to become involved in social issues to prevent mental illnesses. Lincoln CMHC in the South Bronx was cited by NIMH in 1968 as one of eight model centers, and the center received a prestigious award from the American Psychiatric Association. The center’s directors, Drs. Harris Peck, Seymour Kaplan, and Melvin Roman, were strongly committed to the NIMH goal of using CMHCs to improve the lives of “the relatively neglected—the disadvantaged urban community with predominantly minority ethnic populations.” Accordingly, the Lincoln CMHC staff became involved in such problems as garbage collection services, rat control, housing code enforcement, and organizing tenant councils to force absentee landlords to make improvements to their buildings. The ultimate goal of the Lincoln program was to improve the mental health of residents by teaching “the dispossessed how to use the political process to ameliorate their own conditions.” This was exactly what Yolles was encouraging.
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On March 4, 1969, a few residents of the South Bronx improved their own mental health dramatically by taking over the offices of Drs. Peck, Kaplan, and Roman and locking them out. Almost 200 local residents, including 70% of the Lincoln CMHC staff, declared a strike and installed a nonprofessional mental health worker as the new CMHC director. The event was widely covered by the media, including the
New York Times
, which headlined “Community Takes over Control of Bronx Mental Health Services.” Because the Lincoln CMHC directors had encouraged community control, the logic of the takeover was inescapable and emphasized by the news accounts:

Dr. Harris B. Peck of the Lincoln Hospital Mental Health Service, used to pound the table at staff meetings and call for a “revolution.” He urged community workers, one of them recalled, to wrest control of their South Bronx mental health project from him and other professional administrators and put him out of a job.

Yesterday, they did.

The strike continued for 3 weeks and became increasingly contentious as the Black Panthers, the Students for a Democratic Society, and other radical political action groups became involved. Finally, police were sent in and arrested 23 strikers.
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The Lincoln CMHC strike almost instantaneously discredited the idea of using CMHCs to prevent mental illness. To be locked out of your office by your own employees was humiliating enough, but to be hoisted on the petard of your own rhetoric and ridiculed by the
New York Times
went beyond the pale. The Lincoln CMHC directors summarily resigned. NIMH, which had watched the events with growing horror, tried to disassociate itself from its model CMHC as quickly as possible. Elsewhere, CMHC directors who had been moving toward increasing preventive services made a rapid about-face.

The Lincoln CMHC fiasco in 1969 was a major setback for the idea of using CMHCs to prevent mental illnesses. Events of 1970 extinguished any remaining coals of prevention that were still aglow at that time. Dr. Leopold Bellak was one of the leaders of the CMHC movement. His 1964 book,
Community Psychiatry and Community Mental Health
, had claimed that “community psychiatry is designed to guarantee and safeguard, to a degree previously undreamed of, a basic human right—the privilege of mental health.” Bellak proposed that a national psychiatric case register be created:

There the social, emotional, and medical histories of every citizen who had come to attention in any way because of emotional difficulties would be tabulated by computer. When these persons were divorced or widowed or encountered other difficulties, they could be offered guidance and treatment.

Bellak acknowledged that his proposals “may arouse violent reactions” and “invoke the image of Big Brother. . . . But I am reminded that income taxes were once considered basic violations of personal freedom and fluoridation of water was held to be a subversive plot.” Why shouldn’t there be a “Sound Mind Bill?”
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Given the assumptions of preventive psychiatry as propounded by NIMH, the logic of Bellak’s proposal was as compelling as its potential consequences were chilling. Richard Nixon had assumed the presidency in January 1969 and thus would theoretically be the ultimate authority overseeing a national psychiatric case register. This fact became salient a few months later when Nixon’s former personal physician, Dr. Arnold A. Hutschnecker, proposed that all high school students in the United States be
psychologically tested. Those who were found to be deviant would be “weeded out.” Hutschnecker also suggested that a “mental health certificate” be required for all adults before being allowed to assume “any job of political responsibility.”
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Yolles and the staff of the NIMH suddenly questioned whether preventing mental illnesses was such a good idea after all. It had seemed to be, under a predictably liberal president like Lyndon Johnson, who presumably would have appointed psychiatrists like Yolles to oversee the program. But with a conservative president like Nixon in charge, who could predict what conditions might be labeled as needing treatment? The cumulative effect of the demise of the Lincoln CMHC program and the proposals by Nixon’s former personal physician effectively terminated the prevention dreams of the NIMH psychiatrists. Their federal attempts to prevent mental illnesses would become a mere footnote in history but would have profound and long-lasting effects on the nation’s mental illness treatment system.

COURT RULINGS AND MEDICAID

During the decade of the 1960s, therefore, public psychiatric care in the United States changed markedly. At the beginning of the decade, states and counties had been actively developing programs to provide follow-up care for patients already being discharged from the state hospitals. By the end of the decade, state and local efforts had largely ceased, usurped by the federal community mental health centers program. States and counties had been told that they no longer needed to worry about such matters because Superman, disguised as NIMH, had arrived and would prevent these psychiatric conditions from developing. By 1969, however, it had become clear that prevention, the centerpiece of the federal mental health program, was without substance.

Meanwhile, patients with serious mental illnesses were progressively being discharged from state mental hospitals to live in the community, despite the fact that there had been virtually no planning for meeting their needs. The census of the hospitals decreased by 165,571 patients between 1960 and 1969. Each year, the exodus increased, and even accelerated, because of two unrelated events.

The first of these events was a series of court rulings. In 1966 a 60-year-old woman, Mrs. Lake, was found wandering around Washington, D.C., in a confused manner. A court ruled that she was a danger to herself and ordered her committed to St. Elizabeths Hospital, the local public psychiatric hospital. Mrs. Lake appealed the decision, and the case was reviewed by David Bazelon, the chief judge of the U. S. Court of Appeals for the District of Columbia. In a landmark decision, Bazelon ruled that Mrs. Lake was entitled to be released if a less restrictive alternative to the hospital could be found. Unfortunately for Mrs. Lake, one was not, and she died in the hospital 5 years
later. However, the concept of least restrictive alternative had been introduced into the court system and would become a stimulus to the emptying of public mental hospitals. In a complementary decision, also issued in 1966 by Judge Bazelon, it was ruled that Mr. Rouse, another patient who had been committed to St. Elizabeths Hospital, must either be treated for his mental illness by the hospital or be released. This became part of the legal right-to-treatment concept that encouraged hospitals to release many patients, especially those who were difficult to treat.

At the same time that some courts were setting legal precedents facilitating the release of patients from mental hospitals, other courts were handing down decisions making it more difficult to get patients into the hospitals. One of the first of these decisions was also in the District of Columbia, where in 1964 the grounds for the involuntary commitment of psychiatric patients was changed from a need-for-treatment standard to a danger-to-self-or-others standard. Being in need of treatment is a more liberal standard and allows a person to be involuntarily hospitalized and treated before that person has demonstrated dangerousness. By contrast, danger-to-self-or-others is more restrictive, especially if it is interpreted strictly, which has happened in many states.

The second event that increased the discharge of patients from state hospitals was a fiscal one. In 1965 President Johnson persuaded Congress to enact, as centerpieces for his Great Society programs, Medicare and Medicaid—both being modifications of the existing Social Security Act. Medicare provides hospital insurance for individuals age 65 years and older and is completely funded by the federal government. Medicaid was designed to provide medical care for poor people and is funded jointly by the federal and state governments, utilizing a formula by which the federal government contributes a greater share to fiscally poorer states. At the time they were passed, almost all the attention was paid to Medicare, which American medicine opposed as being socialized medicine. Medicaid, by contrast, was not even included in the original legislation but, rather, tacked on to the bill by Wilbur Mills, chairman of the House Ways and Means Committee. Mills viewed it as a fiscal mechanism for getting additional federal funds to his poor constituents in Arkansas. A history of Medicaid claimed that “a legislative draftsman said that he doubted that more than half a day was devoted to consideration of its provision” and that “Medicaid seems to have received almost no consideration in the [congressional] Committees deliberations nor in floor debates in the House.” It was “a low profile item,” “a casual add-on” to the Medicare bill.
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Neither Medicare nor Medicaid was conceived of as a program for mentally ill individuals. Both programs, in fact, sought to exclude the mentally ill to avoid having the federal government usurp state fiscal responsibility. For Medicaid, this was done by decreeing that Medicaid funds could not be used for individuals in mental institutions, which became known as the Institutions for Mental Diseases (IMD) exclusion.
The fact that Medicare and Medicaid ultimately became two of the most important forces driving the emptying of state mental hospitals, although completely unintended, is a telling commentary on the lack of coordination and planning for human services at the federal level. According to Brown, who was the deputy director of the NIMH at the time, there was no discussion about the proposed Medicare and Medicaid programs between the Social Security Administration and the NIMH, despite the fact that both agencies were under the Department of Health, Education, and Welfare. This lack of consultation was confirmed in a 1977 report by the General Accounting Office in which another NIMH official described the lack of input by his agency on a proposed change to the Social Security Act:

While we were reviewing and commenting on issue papers we found out there were already draft regulations. When we were reviewing and commenting on draft regulations, we found out that regulations had already been published in the Federal Register.
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In addition to the absence of internal federal communication regarding possible effects of the proposed Medicare and Medicaid programs on individuals with mental illness, there was also apparently no discussion with state departments of mental health. The federal government was acting independently, seemingly unaware of the profound impact these new programs would ultimately have on state mental health programs.

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By 1970, the federally funded community mental health centers program was well underway, with 270 centers in operation. However, the program was saddled with multiple conceptual flaws, and its most important component—the prevention of mental illnesses—had already been proven to be unfeasible. In addition, courts had issued rulings that would facilitate the exit of patients from state mental hospitals, and Medicare and Medicaid had created additional fiscal incentives to discharge patients. Local communities were about to be inundated with released state hospital patients—the very patients the federally funded mental health centers had the least interest in serving.

Officials in the Department of Health, Education, and Welfare (DHEW) were aware that there were problems and proposed transferring some authority for the federally funded mental health centers from the NIMH to the 10 DHEW regional offices. Yolles and other NIMH officials, aware that the regional offices were sympathetic to state needs, strongly resisted the change. The CMHC program had been conceived as a federal program, they argued, and it should remain as a federal program. Shortly thereafter, when Yolles made an indiscreet public comment regarding federal drug policies, DHEW officials used the occasion to summarily fire him.
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5
THE DEATH OF THE FEDERAL MENTAL HEALTH PROGRAM: 1971–1980

It is possible that the federal program of community mental health centers might have survived in some modified form if Richard Nixon had not been elected president. Nixon disliked the program, and to repel assaults from the White House, the National Institute of Mental Health (NIMH) erected bulwarks of fictional success. For 8 years, fortress NIMH continued doing business as usual, unable to acknowledge that its programs were not working, lest that allow the White House barbarians into the breach. By the time Nixon’s successor, Gerald Ford, left office in January 1977, the community mental health centers (CMCHs) program was, in effect, undergoing rigor mortis.