As this article goes to press. Congress has just overridden, for the first time in 1975, a veto by President Ford, whereby an Omnibus Health Bill becomes law. Among a number of other provisions, it renews support for the funding of community mental health centers and reinstates the authorization for creating new centers.
Despite this forward move for community mental health centers, however, it is evident that the original goal of a sufficient number of federally supported centers to serve the entire nation by 1980 will not be met, nor will we have come dose to it.
The events that led to the conception of the community mental health center and the way in which it was implemented have been recited so often as to have become almost folklore. Is it necessary to recapitulate once more? I believe so, since the program now has a dozen years of history, and so a brief review of how it was bom, how it has grown, and what problems it has experienced may be useful.
Although it is not always recognized, development in mental health services has been continuous. A movement to create outpatient clinics took on particular momentum in the 1920s, and another movement, to provide psychiatric services in general hospitals, gained momentum after World War ?. Recognizing that various advances have been made in one area or another over the years, rather than in one fell swoop, we can proceed to delineate a historically valid beginning for what finally emerged as the federal community mental health centers program. The signal event was the call by Dr. Kenneth Appel in the mid-1950s, when he was president of the American Psychiatric Association, for the creation of a prestigious national body to survey mental health services, identify unmet needs, and propose the means of meeting those needs. Congress then chartered and sponsored the Joint Commission on Mental Illness and Health, whose constituency included not only all the groups fundamentally concerned with mental illness and mental health services but also a number of more generic groups, such as the Parent-Teacher Association, the American Legion, and the League of Women Voters. Representatives of these many organizations met over several years, and their work was complemented by that of a small staff. In 1961, the result of all this effort became available in the form of a report published as Action for Mental Health.1 It was greeted as a landmark volume.
In retrospect, Action for Mental Health is less awesome than it was felt to be when it appeared. It did argue constructively for an end to the massive state hospitals, some of which had more than 10,000 patients during the 1950s; for the development of much more accessible outpatient treatment, with each facility serving an area containing only 50,000 people; and for more research, more manpower, further development of general hospital psychiatry, and more efforts to prevent mental illness. On the other hand, it did not address itself particularly to the serious problem of fragmentation and discontinuity of care, nor did it pay much attention to the startling new competence in chemotherapy or the rapid deceleration in state hospital census that began in 1956. It did not deal with the needs of emotionally disturbed children. But it had important strengths, sufficient to lead President Kennedy to create a task force charged with reviewing the report and formulating a federal program in response to its findings.
Early in 1963, President Kennedy sent to Congress the only Presidential message directed solely to the problem of mental illness. In it he called for a "bold new approach" that would "return the care of the mentally ill to the mainstream of American medicine." The fastidious might ask when the care of the mentally ill had ever been in the rnainstream of American medicine. They might also ask how new the approach really was, since by that time the psychiatric capabilities of the general hospital had grown to the point where there were more admissions to these local facilities than to state hospitals. All in all, however, the message was characterized by minimal rhetoric, considering the customary style of such communications.
Members of Congress responded by introducing legislation that would, for the first time, put the federal government squarely into the business of providing financial support for mental health service programs. (Prior support had been mainly for manpower and research, with service support limited to pilot and demonstration programs.) The bills sought to provide funds both to erect buildings for communitybased mental health programs and to provide a limited period of financial aid for clinical personnel. Legislation that would provide $200 million in construction money over a four-year period passed easily in the autumn of 1963, but the provision of staffing money was defeated, largely as the result of intense and highly organized opposition from the American Medical Association.
By and large, the legislation dealt with purpose and intent; the specifics were left to regulations that were subsequently developed in the executive branch, with important contributions from the National Institute of Mental Health that included wide consultation with leading figures in the mental health field. The legislation's intent was to make a range of psychiatric services readily available to all who applied for them, within prescribed areas of responsibility. The regulations stated that the centers would meet the mental health needs of all the people living in their catchment areas; this was somewhat hyperbolic, considering the plurality of our health services and the number of people already obtaining services in the private sector, often with some financial aid from their health insurance policies.
The regulations then identified 10 services that would be required of a mental health facility calling itself "comprehensive." The first five of these - inpatient, outpatient, emergency care, partial hospitalization consisting of at least a day hospital, and consultation and education - were "essential" services that would have to be provided by any facility receiving federal construction funds.*
The specifics came in for their share of criticism. The catchment-area concept was realized through delineation of population units of at least 75,000 but no more than 200,000 persons, and both ends were attacked. In rural areas, the catchment had to extend over many counties; in dense urban settings, even a medium-size city, such as Rochester, New York, had to have several mental health centers. These criticisms were mainly beside the point, however, since the regulations stated that exceptions could be made, and in fact were made for about 13 per cent of the catchments that have received grants. The five essential services were attacked by some on the grounds that they were too illness oriented, since four of them were direct clinical services.
I find little to quarrel with in the five essential services. One might be more concerned about the other five services, which (since they were not essential) were optional. Some, such as rehabilitation, should have been essential. Others, such as diagnostic services and precare and aftercare, should not have been there at all. Let me explain. People should not usually be treated without being diagnosed; and, if the community mental health center was truly intended to be a definitive treatment resource that would work towards eliminating admissions to state hospitals, one may ask what the precare was pre and what the aftercare was after. In fact, we know. Those who formulated the regulations were tradition bound; the separate designation of aftercare, for example, turned out to mean "after discharge from the state hospital."· But since the regulations start out by stipulating that all the people are to be served, that proviso would automatically include people who had gone back to their communities from state hospitals. The very fact that aftercare was set forth as an optional service gave the centers the possibility of refusing to provide follow-up care for such people, and some, perhaps many, availed themselves of this loophole.
In a word, it might have been better if the regulations had been more inclusive, more comprehensive, more basic in concept, and tidier. Some of the problems have been fairly well resolved througih revision of the regulations during ensuing years.
Two years later, legislation was introduced that would add matching funds for staffing. The fervency of the A.M.A. concerning the use of federal money to pay physicians had cooled, and the bill easily passed. It provided "project grants" that were made directly to the centers rather than via state government, with each center getting the same percentage (in contrast to construction funds, which varied from state to state, depending on population and per capita income). At first the staffing money provided a maximum of 75 per cent, phased down over a 51-month period to 30 per cent. Later on, when it had become evident that the poorer catchment areas were having a hard time amassing the necessary matching money, a special provision was made whereby they would receive funds for eight years, starting at 90 per cent and phasing down only to 70 per cent. Still later, all grants were extended to the eight-year period. There were further special provisions. After it had become evident that some of the centers were not serving very many children, alcoholics, or drug abusers - perhaps because their small resources were being fully used up by service to the general adult psychiatric population - special "subcategorical" grants were made available to mount programs for these particular groups. The aged also appeared to be underserved, and the new legislation requires special services for them.
Despite the evident intention of health leaders in Congress that the program should grow until the entire population was being served, the authorizing legislation was never introduced on a permanent basis. It would probably have been unwise to try to do so, since there was growing concern about the eventual cost to the federal government. Even under the Johnson administration, which heavily emphasized categorical service programs, people within the Office of Management and Budget were alarmed that, if the number of centers grew steadily, the eventual cost might become prohibitive. Consequently, the authorizing legislation was renewed variously for two- and three-year terms and eventually, in 1973, for only a one-year term.
The stance of the Kennedy and Johnson administrations in favor of centers was supplanted by the anticenter stance of the Nixon administration. This was mainly because of a blanket dislike for categorical aid programs, and perhaps also because two of the President's principal advisers had little enthusiasm for health legislation. A struggle ensued between the White House and Congress over the centers program. The President wanted the program to die; Congress was intent on its continuation. But tiie boggle of Congressional procedure was such that no renewal legislation had been enacted by the time the authorizing law was terminated in mid-1974. Although the executive branch had acknowledged from the start its obligation to continue funding through the eightyear period for the centers already authorized, there was now no authority for new centers. Not until December, 1974, did Congress pass a bill to extend (or, rather, reinstate) the program. The President, by then Gerald Ford, allowed the legislation to die through a pocket veto.
Early in 1975 Senator Kennedy, Representative Paul Rogers, and others introduced authorizing legislation for community mental health centers and a number of other health programs. This recently enacted renewal raises the number of essential services from five to 12. The additional ones consist of specialized programs for children and the elderly and, where there is an unmet need, for alcoholics and drug abusers. Aftercare services are required, as are screening services and alternatives to state hospital treatment. Centers already in existence are given two years in which to expand their programs to include all of the above; otherwise all federal support will be terminated, and a new category of funding, "conversion grants," will become available to finance the added services.
One of the original five essential services, consultation and education, has not been fully understood, and the personnel of the centers (most of whom are without specific framing or experience in consultation and education) have been wary of moving in that direction. But since it is the one service that can be defined as primary prevention, it continues to be important; consequently, the legislation that was recently passed provides special consultation and education grants. The legislation also authorizes funds for "distress grants" to centers that have used up their allotted eight years of federal support and appear to be in jeopardy of having to shut down. The staffing money will henceforth be called "operations money," signifying that it may be used not only to help meet payroll but also to cover the cost of various supplies, travel, conferences, telephone bills, and other such items that could not previously be charged to the federal grant. Finally, the construction funds wul henceforth be known as "facilities grants," emphasizing that they may be used not just for new construction but to buy or lease and renovate existing structures.
Over the years, the centers program has come in for its share of lumps. Some young workers from the Ralph Nader organization were given the job of assessing the centers, with an evident built-in predisposition to find that everything was wrong. During two and a half years of labor, they seemed to grasp the intent and rationale very well, but their report, published as The Madness Establishment/ concludes that practically everything is wrong and virtually nothing is right. It is not clear that these diligent young people were aware of the complexities, the resistances, and the difficulties of shifting orientation that apply in any effort to mount a new social program. Rather than denying that there have been problems in getting the centers developed, it might be more pertinent to ask whether the centers program exhibited any problems or distortions beyond what seasoned political scientists would anticipate of an innovative approach. The problems of comprehension, of finding suitable personnel, and of monitoring, among others, were real enough. But in comparison with some of the other social programs that emerged during the 1960s, the track record of the centers seems a fairly good one.
Another critical but considerably more constructive appraisal of the centers emerged from a study made by the General Accounting Office, a federal body that serves as a watchdog for Congress over all federal programs. The GAO concluded that better planning was needed, including periodic reviews of the catchment areas and more emphasis on community participa.tion. It was of the opinion that there should be better coordination in arranging referrals between the center and other community organizations; that the centers needed more help in working toward financial self-sufficiency; and that the programs should be more effectively monitored, using standard procedures that should be developed for the 10 HEW regional offices responsible for the monitoring process. HEW concurred that these criticisms were warranted and described some of the steps that NIMH had already taken towards improvement in these areas. HEW also pointed out, incidentally, that only about 30 per cent of the centers' support was coming from the federal government; a similar percentage was coming from state governments, about 10 per cent from local governments, and the remaining percentage from third-party payments and fees for service.
As with other service facilities in the mental health field, community mental health centers have not been intensively evaluated. Not much is known about the quality of their services or about their effects on the mentally ill specifically or the society generally. The legislation that was recently passed requires that at least 2 per cent of federal funds be spent on evaluative efforts. In the meantime, we have mainly quantitative data. The number of centers in operation has grown from one in mid-1966 to 240 in 1970 and 505 in March, 1975. As of that date, an additional 86 had been approved for funding but were not yet in operation.
Figures on service units rendered by centers were first gathered in 1967. In that year there were about 125,000 episodes of inpatient, outpatient, and day treatment care. The number grew to 373,000 in 1969 and 912,000 in 1972. In that year there were 145,000 inpatient admissions, 702,000 episodes of outpatient treatment, and 65,000 episodes of day treatment. These are the latest figures available. If the centers then in operation continued to provide care at the same rate, and if the newly approved centers were opened and provided about the same extent of service, then by the middle of 1975 the 591 centers would be providing 232,000 annual inpatient admissions, 1,123,000 annual episodes of outpatient treatment, and 104,000 annual epoisodes of day treatment, totaling just under one and a half million treatment episodes for these three modalities. By any standards, this is a great deal of care. It is not, however, the majority of psychiatric care, since hundreds of thousands of people are being seen in "freestanding" outpatient clinics, hundreds of thousands more are being admitted to the psychiatric services of general hospitals, and probably more than a million are being seen as outpatients on a private basis.
And what of the role of the psychiatrist in the mental health center? More than one critic of the program has charged that its greatest handicap has been its domination by psychiatry. I submit that such a statement reflects no understanding at all of psychiatry or psychiatrists and is simply rubbish. Of about 40,000 people working in community mental health centers, only 6 per cent are psychiatrists. Of all the psychiatrists who work in mental health facilities, only 12 per cent work in community mental health centers. It seems evident that most mental health center patients - perhaps the great majority - are never seen by a psychiatrist. And it appears that many of the psychiatrists working in the centers are atypical, at least in that they do not seem to feel any need for a psychiatric evaluation for all patients and are quite content to have psychotherapy performed by almost anybody. Since one major service to many emotionally troubled people is properly prescribed psychotropic medication, this situation suggests that medication procedures are perhaps not optimal.
Beyond all this, many of the 2,000 or so fulltime psychiatrists are in administrative positions and therefore spend little time in seeing patients. A Joint Information Service survey of a group of centers showed that psychiatrists spend less than half their time in clinical activities, a smaller percentage than that spent by any other category of personnel. Since hypothesizing is free, I will hypothesize that centers might be better places if in fact psychiatrists were more involved. Despite the numerous attacks on it, the medical model at its best does offer something in thoroughness of care and a desirable conservatism. But even if larger numbers of psychiatrists wished to become active in centers, it is perhaps too late. The reaction against them by other mental health professionals is not negligible, and those who draw up budgets may hold the view that psychiatrists have nothing much to offer that cannot be provided by less expensive personnel. The ranks may thus have been closed.
It is interesting to note a recent study showing that psychiatrists who score high on the Community Mental Health Index tend to be not those who recently completed training but the more experienced psychiatrists. They have probably been attracted to the eclecticism of community mental health centers in response to the frustration of unidimensional approaches.
What will happen to existing centers under the new legislation, with its distress grants? Will they survive when their eight years of federal funding have expired? Informed estimates are that about one-third of the centers will be able to continue with at least as full a service as they have now, a third will have to trim back somewhat, and the other third will have to trim back substantially. It is anticipated that very few centers will go out of business for lack of money. A number of states have enacted legislation providing state money to take up where the federal grants leave off. Although there are only about 600 centers, they are not an insignificant resource; there are almost twice as many centers as state hospitals, and about the same number of centers as general-hospital psychiatric units. It should also be noted that the federal investment in community mental health centers is not that vast. Over more than a decade, the total is slightly over a billion dollars. Averaged out, the annual expenditure represents less than 5 per cent of what the states are currently spending to operate their state mental hospitals.
The centers have developed an organization, the National Coordinating Council of Community Mental Health Centers, which has a program and a staff and is determined to lobby successfully for the continuation of the federal program.
If the centers have not become the "main" mental health resource of the country, they have, in a dozen years, grown to be one of the few major ones. If the rhetoric of the Kennedy message has not been fully realized, we must acknowledge that the centers have at least made mental health services more readily and conveniently available to a number of people who previously would have ended up in state hospitals or would have done without any psychiatric service at all.
1. Joint Commission on Mental Illness and Health, final report. Action for Mental Health. New York: Basic Books, 1961.
2. Chu, F.D., and Trotter, S. The Madness Establishment. New York: Grossman Publishers, 1974.