American Psychosis (5 page)

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2.1 Robert H. Felix, M.D.., the architect of the federal mental health program and first director of the National Institute of Mental Health (NIMH) from 1946 to 1962. In 1984, he acknowledged that the program’s “result is not what we intended.” Photo courtesy of the National Library of Medicine.

Following his training, Felix entered the United States Public Health Service and worked in the federal prison in Springfield, Missouri; the federal narcotics treatment center in Lexington, Kentucky; and the Coast Guard Academy in New London, Connecticut. He became known for his expertise in treating alcoholism and drug addiction but apparently had little experience with other psychiatric disorders or state mental hospitals. In 1944 he became chief of the Mental Hygiene Division of the Public Health Service. At the time, the Mental Hygiene Division reflected the very limited involvement of the federal government in mental illness issues. The government screened immigrants for mental illness, provided services to federal prisons, ran two narcotics treatment hospitals, and ran St. Elizabeths Hospital, which provided psychiatric services for residents of the District of Columbia, merchant seamen, and Native Americans. Other than these, all other psychiatric services were provided by state and county governments.

In 1945, following congressional testimony on the disabling effects of mental illness on America’s fighting forces, the Surgeon General “asked Felix to design a national mental health program.” Felix merely had to take his master’s degree thesis off the shelf. He was ideally suited to lead such an effort; medical historian Gerald Grob described him as “a gregarious, humorous, and charismatic personality . . . one of the shrewdest and most effective federal bureaucrats of his generation.” Psychiatrist Alan Miller, who worked under Felix, remembered him as “one of the most engaging, persuasive, energetic, wide-visioned rascals I have ever met. A man of virtue, but nevertheless a rascal. He had strong principles, and when necessary he could rise above them.” Bertram S. Brown, who also worked under Felix, likened his interpersonal skills to those of former president Bill Clinton and called Felix “an enormous human rolodex.” Felix understood, Brown added, “that members of Congress and their families get sick too, and if you help them, then they will help you.” Felix was an expert at cultivating key members of Congress, and when he went to Congress to get his programs passed, it was often a mutual admiration society. The following, for example, is an exchange between Senator Lister Hill and Felix, after Felix had become the Director of the National Institute of Mental Health:

Senator Hill: “I will give him [Felix] another quotation, if I may. ‘An institution is but the length and shadow of an individual.’ Here is the head of the National Institute of Mental Health and what you have just commented on shows this wonderful leadership there.”

Dr. Felix: “Sir, shadows are cast by light and were it not for the glowing light that comes from this house [the Senate] and the House of Representatives, I would have no shadow at all.”
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A RADICAL DEPARTURE

The plan outlined by Robert Felix in 1941 and then formally proposed in 1945 was “to employ the prestige and resources of the national government to redirect mental health priorities.” It is difficult today to comprehend just how radical such a plan was at that time. Since 1766, when the governor of Virginia asked the House of Burgesses for funds to open the first public psychiatric hospital in the United States, the care of mentally ill individuals had been the exclusive responsibility of state and local governments. This was in accord with the tenth amendment to the Constitution, which explicitly stated that “powers not delegated to the United States by the Constitution . . . [are] reserved to the States respectively, or to the people.”
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The first half of the nineteenth century saw an ongoing debate among states, cities, and counties regarding their respective fiscal responsibilities for mentally ill individuals. Worcester State Hospital, opened in Massachusetts in 1833, was the first state hospital supported exclusively with state funds. Largely because of the advocacy of Dorothea Dix, 28 of the existing 33 states subsequently built one or more state psychiatric hospitals by 1860. Fiscal responsibility varied from state to state; Wisconsin, for example, built “a system of county asylums for persistently mentally ill patients and provided a [state] subsidy to cover part of the costs that were involved.” Over time the states assumed increasing fiscal responsibility from the counties and cities, and in 1890 New York State passed legislation providing “for removal of all the insane from local poorhouses and jails to state hospitals, where they were to be supported and treated at state expense.” Many states followed suit, so that “after 1900 state care of the mentally ill, with a few notable exceptions, became the general rule.”
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Prior to 1945 there had been only one attempt to transfer state responsibility for mentally ill individuals to the federal government. In the first half of the nineteenth century, the federal government sometimes raised funds by selling federal lands. Beginning in 1847, Dorothea Dix and her supporters lobbied the federal government to use the proceeds of 12,225,000 acres of federal land to build state psychiatric hospitals. A bill was introduced and passed by Congress in 1854. However, it was immediately vetoed by President Franklin Pierce, who viewed it as contrary to the Constitution and a foot in the federal door for states to transfer their responsibility for mentally ill and other needy individuals. In his veto message, Pierce noted:

If Congress have power to make provision for the indigent insane . . . the whole field of public beneficence is thrown open to the care and culture of the Federal Government. . . . I readily . . . acknowledge the duty incumbent on us all . . . to provide for those who, in the mysterious order of Providence, are subject to want and to disease of body or mind, but I cannot find any authority in the Constitution that makes the Federal Government the great almoner of public charity throughout the United States. To do so would, in my judgment, be contrary to the letter and spirit of the Constitution . . . [and] be prejudicial rather than beneficial to the noble offices of charity.

If the proposed legislation were enacted, Pierce predicted:

. . . the fountains of charity will be dried up at home, and the several States, instead of bestowing their own means on the social wants of their own people, may themselves, through the strong temptation, which appeals to States as to individuals, become humble suppliants for the bounty of the Federal Government, reversing their true relation to this Union.
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Pierce’s veto ended discussion of this idea for almost 100 years. As a consolation prize for Dix, in 1855 Congress established the Government Hospital for the Insane, which became known as St. Elizabeths Hospital, for residents of the District of Columbia and other federal dependents, such as merchant seamen and Native Americans.

THE NATIONAL PLAN

The 1945 plan of Robert Felix to involve the federal government in a wide range of mental illness-related activities was virtually without precedent. In 1906 Congress had passed the Pure Food and Drug Act, and in the 1930s it had set up the National Institute of Health and National Cancer Institute. Felix’s plan proposed that the federal government create a mental illness research center to be called the National Neuropsychiatric Institute, that it use federal funds to train more mental health workers, and that it use federal funds for the early detection, treatment, and ultimately prevention of mental illness.

The detection, treatment, and prevention of mental illness was to be accomplished by two related programs—community mental health clinics and the modification of the environment to prevent future cases of mental illness. In a 1945 paper, Felix said the proposed clinics would treat “the non-psychotic and pre-psychotic patients with personality problems of varying severity, and the convalescent psychotic patients who need guidance and help in making successful adjustment to home, occupation, and community environment.” To accomplish early detection and treatment, Felix added, “we must go out and find the people who need help,” focusing especially on “the schools, the courts, [and] the welfare department.” He likened his program for early detection and treatment to “the campaigns against venereal disease and tuberculosis” that were prominent at that time and widely regarded as having been successful. In
1947 Felix further quantified his plan, recommending “one out-patient mental health clinic for each 100,000 of the population” to provide “psychiatric treatment or psychological counseling for patients not in need of hospitalization and, most significant, for patients in the early stage of illness, when the prospect of cure is greatest.”
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The idea of early detection and treatment of psychiatric disorders was seductive in 1945, as it still is today. It assumes, however, that early cases can be identified. In 1945 Felix and many other American psychiatrists were enamored with the ideas of Sigmund Freud and the mental hygiene movement, and from 1951 to 1955, Felix undertook formal psychoanalytic training. Freud and mental hygiene advocates believed that small problems in childhood, if untreated, led directly to big problems in adulthood, including schizophrenia, bipolar disorder, and major depression. As Felix later wrote, “As a tree is bent so it grows. And we like to do what we can while the youth is, figuratively speaking, a sapling.” Thus, Felix supported and praised early experiments, such as one in the St. Louis public schools, “where the teachers are given mental health orientation so that they can help in case finding, and group therapy sessions are set up to work with and through the parents rather than the children.” Such early treatments, Felix assumed, would prevent major problems from developing later.
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The second part of Felix’s national mental health plan involved modifications of the social and cultural environment, which he believed would prevent the emergence of future psychiatric problems. As he wrote in a 1948 paper, “the content and the orientation of personality are powerfully influenced by the social setting.” Thus, serious mental illnesses were caused by social factors, such as “areas of high mobility and disorganized community life.” Felix believed that serious mental illnesses were also caused by cultural factors, and he cited the research of Margaret Mead, whom he was using as a consultant at the time. For example, the paranoid South Pacific culture described by Mead’s second husband, Reo Fortune, in
The Sorcerers of Dobu
was cited by Felix as an example of a mentally unhealthy culture. Mead’s claims were widely accepted in the United States at that time; it would not be until later that her cultural research would be shown to be fatally flawed and Reo Fortune’s cultural observations in Dobu shown to be a product of his own paranoid personality.
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Because he believed mental illness could be caused by social and cultural factors, Felix deemed it to be the legitimate task of mental health clinics to correct such factors. Thus, he wrote:

It should be made clear that mental hygiene must be concerned with more than the psychoses and with more than hospitalized mental illness. . . . Our research attention should be directed not only to the psychotherapeutic sessions between doctor and patient, but also to the social world out of which the patient came, in which he is now living, and to which he will return. This focus on the “individual in environment” means that psychotherapy should be supplemented in at least some of our experiments by what might be called “socio-therapy,” observation and treatment of the patient’s relevant social setting, both during his treatment and post-treatment periods.

As examples of such legitimate mental hygiene activities, Felix listed “parent education, the promotion of special classes for exceptional children, marriage counseling, therapeutic recreational activities, and cooperative projects with courts and other agencies.” Indeed, there was no problem too big for psychiatrists who wished to promote mental hygiene. Felix cited approvingly the claims of C. Brock Chisholm of the World Health Organization:

We have never had a really peaceful society in the world. . . . Can the world learn to live at peace? . . . With the other human sciences, psychiatry must now decide what is to be the immediate future of the human race. No one else can. And this is the prime responsibility of psychiatry.
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