American Psychosis (16 page)

Nixon’s suspicion of psychiatry had deep roots. The Southern California district from which he had been elected to the House of Representatives in 1946 became the nidus for a national anti–mental health movement that attempted to link psychiatry and communism. A large billboard in Los Angeles carried the following message in the 1950s:

It is amazing and appalling how many supposedly intelligent people have been duped by such COMMUNIST SCHEMES as FLUORIDATION and “Mental Health” especially since both the AMERICAN LEGION and the D.A.R. have publicly branded “Mental Health” as a COMMUNIST PLOT to take over our country.

The John Birch Society and the Daughters of the American Revolution (DAR) led the anti-psychiatry troops, the latter with a series in its magazine describing mental health as a “Marxist weapon” and claiming that 80% of American psychiatrists were foreigners, “most of them educated in Russia.” The alleged link between mental health and Communism resonated with Nixon, who in 1948 had been a member of the House Un-American Activities Committee, which had investigated Alger Hiss as a Communist agent.
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Nixon’s suspicion of psychiatrists, especially psychoanalysts, was further reinforced by their pattern of voting. In 1956, only 15% of psychoanalysts cast votes for Dwight Eisenhower, the Republican presidential candidate. In 1960 Nixon received only 6% of their vote, and in 1964 Barry Goldwater received only 5%. Even more damning for Nixon was a survey published by
Fact
magazine in 1964. The magazine had sent a questionnaire to psychiatrists asking whether they thought Goldwater, the Republican candidate, was psychologically fit to become president. Among the respondents, 657 psychiatrists said that he was psychologically fit, but 2,417 said that he was not. Some of the published responses labeled Goldwater “immature,” “narcissistic,” “paranoid,” and “megalomaniac,” and a few offered a diagnosis of schizophrenia. This blatant attempt by psychiatrists to discredit a political candidate was widely condemned by the media.
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Thus, when Nixon assumed the reins of government in January 1969, he arrived with an enduring suspicion of psychiatrists. This became further magnified as Nixon became aware of the activities of the NIMH and its federally funded CMHCs. The government’s chief psychiatrist, Stanley Yolles, was openly encouraging centers to become involved in social and political issues, even advocating voter registration among poor people who, Nixon knew, were not likely to vote Republican. Among Yolles’s staff was Matthew Dumont, the psychiatrist who was advocating “a redistribution of wealth and resources of this country on a scale that has never been imagined.” Here indeed was proof of a Communist conspiracy among those left-leaning, federally funded mental health subversives.
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COMMUNITY MENTAL HEALTH CENTERS

As the battle between Nixon and NIMH got underway, the discharge of seriously mentally ill patients from the state hospitals was accelerating. In January 1969, when Nixon took office, there were 399,152 mentally ill patients remaining in state hospitals. By the end of the Nixon and Ford administrations in late 1976, only 170,619 patients remained. First, individual wards closed, then whole buildings, and finally entire hospitals; between 1970 and 1973, at least 12 state hospitals were shuttered. Hospitals that had been cities unto themselves, such as New York’s Pilgrim State Hospital with 14,000 patients, were progressively depopulated, and abandoned buildings began outnumbering those being used. In the two decades since deinstitutionalization had begun in 1956, almost 400,000 state hospital beds had been closed; it was an ongoing exodus of biblical proportions.
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Meanwhile, CMHCs continued to open despite efforts of Nixon administration officials to phase out the program. By the end of 1976, 548 centers were in business and almost 200 more had been funded but were not yet operational. If any federal or state official at that time had asked who was supposed to provide treatment for the patients
being discharged from the state hospitals, the reflex reply would have been the CMHCs. Yet both federal and state officials were well aware that this was not happening.

Data collected by NIMH were especially damning. It showed that between 1968 and 1978 patients who had been discharged from state mental hospitals who then were followed up in CMHCs made up only 3.6% to 6.5% of all CMHC patients. Moreover, the longer a CMHC was in business, the fewer state hospital patients it saw. In 1976, for example, CMHCs that had been operational for 1 to 2 years had 5.5% of their admissions referred from state hospitals, whereas CMHCs that had been operational for 6 to 7 years had only 2.6% of their admissions referred from these hospitals. Other NIMH studies also documented the failure of the federally funded centers to provide care for patients being released from the state hospitals. A 1972 study concluded that “relationships between community mental health centers and public mental hospitals serving the same catchment area exist only at a relatively minimal level between the majority of the two types of organizations.” A 1979 assessment stated this even more strongly: “
The relationships between CMHCs and public psychiatric hospitals are difficult at best, adversarial at worst
,” with the emphasis in the original.
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The fact that the federally funded mental health centers were not working cooperatively with state mental hospitals surprised no one. NIMH had failed to mandate any relationship between the two in its original guidelines. Its message to the centers was to prevent new cases of mental illness, not worry about existing cases. CMHCs received praise from NIMH officials when they became involved in a community’s social problems, not when they provided follow-up care for patients released from state hospitals. State hospitals, likewise, had no incentive to cooperate with the CMHCs, which, state hospital officials were told, were being built to replace them. Thus, state hospitals largely ignored the CMHCs, and the latter were happy to reciprocate. An extreme example of the behavior that inevitably ensued was a state hospital in Kansas that, when ordered to inform the local CMHC each time it discharged a patient, dutifully did so by sending to the CMHC the patient’s discharge sheets but with the patient’s name, address, and all other identifying information blacked out. Surveying the scene in 1972, Harry Schnibbe, head of the organization representing state mental health directors, called it “a disaster situation. . . . follow-up service [for discharged patients] is our number one headache.”
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If community mental health centers were not taking care of the thousands of patients being discharged from state mental hospitals, who were they seeing? According to NIMH records, the largest numbers of CMHC patients were diagnosed with “social maladjustment or no mental disorder” (22%) or “neuroses and personality disorder” (21%). Childhood disorders, mostly behavioral problems (13%) and depressive disorders (13%) followed, with substance abuse (10%) and schizophrenia (10%) at the bottom. A catchall category of “all other diagnoses” comprised the others.
Probably representative of the largest group of CMHC patients was “a middle class clergyman . . . recently divorced and having trouble with his children. . . . He told us that he came to the center looking for some ‘sound perspective and advice.’ “Such patients, often referred to as the “worried well,” fit the original vision of Robert Felix, who believed that by treating small problems early you would prevent large problems later.
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The skewing of CMHC patients toward those with less severe diagnoses became more pronounced the longer CMHCs were in existence. According to the 1978 report of President Carter’s Commission on Mental Health, “the major trend in the diagnostic composition of the centers’ clients has been the decreasing percent of those diagnosed with depressive disorders and schizophrenia, counterbalanced by an increase of those classified as socially maladjusted, no mental disorder, deferred diagnosis, or nonspecific disorder.” One psychiatrist described the process as follows:

In some instances mental health centers tended to select attractive, easy patients to treat, and referred to the state hospital patients that the staff and community wanted to reject.

A 1977 study of CMHCs in Washington, D.C., confirmed that 90% of the patients being sent to St. Elizabeths Hospital “could have been treated at a CMHC or other alternative” to the hospital. Most CMHCs saw very few patients with serious mental illnesses. Anthony Lehman, chairman of the Department of Psychiatry at the University of Maryland, recalled his disappointment in the mid-1970s when, as a resident at UCLA, he asked to work in a CMHC to gain experience. He was assigned to a CMHC in Santa Monica that was said to be highly regarded:

The experience was quite disappointing. The CMHC was seeing very few individuals with serious mental illnesses. I’m not sure I even saw one. Instead, the patients were people from the community with various personal crises—marital, job-related, housing, etc. The staff was using a crisis consultation model in which it was believed that most such crises could be resolved with twelve sessions of psychotherapy.
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Among the 789 community mental health centers ultimately funded by the federal government, a few actually did provide significant care for patients being discharged from state hospitals, despite NIMH’s lack of encouragement to do so. Most such centers were run by directors who had a special interest in providing services for individuals with serious mental illnesses; examples included the Sacramento County and Santa Barbara County CMHCs in California, Salt Lake Valley CMHC in Utah, and Range CMHC in Minnesota. Several other centers that did good work had been started
with state or private funds prior to the beginning of the federal CMHC program, as described in
Chapter 3
; they took the federal money and continued doing what they had previously been doing. Examples of such centers were Prairie View CMHC, which had been founded by Mennonites in 1954 in Newton, Kansas; San Mateo County CMHC in California; Fort Logan CMHC in Colorado; and Massachusetts CMHC in Boston. Overall, however, probably no more than 5% of the federally funded CMHCs made any significant contributions to the care of patients being released from state mental hospitals.

By contrast, there is a long list of federally funded CMHCs that delivered almost no public psychiatric services and were grossly out of compliance with federal regulations to deliver the five essential services they had agreed to provide. Many of these received CMHC construction money and built the buildings but then used them for other purposes. For example, in Michigan the Battle Creek Adventist hospital received $709,988 ($4.0 million in 2010 dollars) to build a CMHC; it instead used the building as a private psychiatric hospital, and the CMHC, in federal parlance, “never materialized.” In Minneapolis, the Metropolitan CMHC received $1.8 million ($10.1 million in 2010 dollars) for the construction and staffing of a CMHC. The facility was instead used as a private psychiatric hospital, complete with swimming pool and gymnasium; in 1969, only 11% of its patients even lived in its catchment area. In New Orleans, the DePaul Hospital CMHC received $474,484 ($2.7 million in 2010 dollars) in federal construction funds, built the building, and a year later sold it to a for-profit hospital chain. Hospitals in Philadelphia used CMHC construction money to build a business office, data processing room, operating room, and inhalation therapy room.
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Such abuses of CMHC funds were widespread and well known. In 1968 Lawrence Kubie, a professor of psychiatry at Johns Hopkins University School of Medicine, publicly commended what he called this “benevolent profiteering” on the CMHC “fad”:

Several department heads have stated frankly that they are glad to take federal money . . . To get this money, they are forced to call their new facilities “community mental health centers.” They do not hesitate to add that within a dozen years the words will have dropped into innocuous desuetude.
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In this laissez-faire atmosphere, almost everything appeared to be acceptable to NIMH as long as it labeled itself a CMHC. The Orlando Regional Medical Center in Florida demonstrated how far the funds could be abused. With more than $2.8 million ($15.7 million in 2010 dollars) of CMHC construction and staffing funds, it built space for what was essentially a private psychiatric hospital as well as a swimming pool, tennis court, and volleyball court. With its federal staffing funds it hired four surgical technicians, a cosmetic and fashion counselor, six maids, six porters, a gardener, a pool
lifeguard, and a swimming instructor. NIMH records and site visit reports suggest that at least 10%, and probably 20%, of all federally funded CMHCs were similar to these centers and grossly out of compliance with federal regulations.
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Because the federally funded CMHCs were seeing neither the patients being discharged from the state hospitals nor many of the patients being admitted to the hospitals, there was essentially no relationship between the opening of CMHCs and the decreasing state hospital population. From the late 1960s onward, the exodus of state hospital patients was on autopilot, driven by the availability of antipsychotic drugs, which got the patients well enough to be discharged; the availability of federal Medicaid and Medicare funds, which effectively saved state funds; and court rulings, which encouraged patient discharge. NIMH’s own studies verified the lack of any effect of CMHCs on the census of the state hospitals. A 16-state study published in 1976 reported “no consistent relationship between the openings of centers and changes in state hospital resident rates.” The following year, a report from the Government Accounting Office similarly concluded that “the CMHC program was having only a limited impact on reducing public mental hospital populations.” NIMH was so desperate for any data suggesting the CMHCs were responsible for decreasing state hospital populations that a 1975 study suggesting a possible relationship in a single state was titled “Is NIMH’s Dream Coming True?” Perhaps most damning was a survey of 175 CMHC directors who were asked to rank order 10 CMHC goals and objectives. The goal of reducing the utilization of state mental hospitals was ranked next to last.
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