Innovation Without Change by Franklin D.Chu and Sharland Trotter

 

Summary and Conclusions of Ralph Nader’s Study Group Report on the National Institute of Mental Health; N.Y. 1974

 

[The Community Mental Health Centers Act passed by Congress in 1963, marked an unprecedented public commitment to provide comprehensive mental health services to all Americans without regard to race, creed, or ability to pay. Borrowing a phrase President John F. Kennedy’s February, 1963, address on mental health, the legislation proclaimed the program a ‘bold new approach’ to mental health care and placed it under the authority of the National Institute of Mental Health (NIMH) within the Department of Health, Education, and Welfare (HEW).]

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Those centers which are doing a better job are doing so because of their leadership, not because NIMH has required them to do so. The lack of accountability of the Centers means that all Centers, no matter what they are doing, continue to receive public money from NIMH. If a Center is not doing what it said it would, NIMH  is not really interested in knowing. This is the heart of the problem – the slow, sad steps which lead to a minuet of mutual deception.
                                  -Internal NIMH memo

 

A decade after Congress passed the legislation that was intended to dramatically transform and humanize the care of the mentally ill in America, many of the program’s staunches supporters have come to recognize its failures. Yet most of them urge critics to refrain from mentioning the program’s deficiencies. The Nixon Administration has its knives well sharpened for the purpose of trimming the ‘bureaucratic fat’ off a number of liberal social programs and community health centers have already lost a considerable amount of muscle along with the fat. But those who would transform the community-care ideology into a workable reality would do well to start asking some hard questions about whether the budget limitations are deserved. Indiscriminate requests for more money will no longer work. Effectiveness will have o be demonstrated, which ,means that the coming battles over which pieces of the program are to be salvaged will have to be carefully chosen. Not only the Nixon Administration but also state and local governments, which will bear a greater financial burden for t

As this report documents, the community mental health model as it was conceived at the federal level is often seriously at odds with reality at the community level. In part, the failure can be attributed to the phenomena that psychologist Anthony M. Graziano has termed ‘innovation without change.’ Although many innovative ideas have been conceived, says Graziano,

 

‘The conception of innovative ideas in mental health depends upon humanitarian and scientific forcers, while their implementation depends, not on science or humanitarianism, but on a broad spectrum of professional and social politics!

. . . these two aspects, conceiving through science and humanitarianism on the one hand, and implementing innovation through politics on the other, are directly incompatible and mutually inhibiting factors; .  .  . our pursuit of political power has almost totally replaced humanitarian and scientific ideals in the mental health field. Innovations, by definition, introduce change,  political power structures resist change. Thus, while the cry for innovation has been heard throughout the 1960s, we must clearly recognize that it has been innovative ‘talking’ which has been encouraged, while innovative action has been resisted.’

In retrospect, the community mental health centers program was vastly oversold, the original goals quickly perverted – possibly because change could be successfully wrought by those professionals and politicians with a vested interest in maintaining the status quo. At any rate, NIMH feebly communicated the original intent of the program to state and local officials; failed to coordinate the location of centers with other HEW health and social welfare efforts; made little attempt to train (or retain) people for community work; avoided funding centers outside the narrow interests of the medical profession; did not engage consumers in the planning and operation of the centers; and made only the most perfunctory evaluation of the program’s  performance. As the result, community mental health centers tend to involve only a renaming of conventional psychiatry, a collection of traditional clinical services that are in most cases not responsive to the needs of large segments of the community, and which often leave community people indifferent, sometimes antagonistic.

The short life of the community mental health centers program already bears the familiar pattern of past mental health  reforms that were initiated amid great moral fervor, raised false hopes of imminent solutions, and wound up only recapitulating the problems they were to solve. The development of state mental hospital’s offers an  apt, if ironic, comparison. Started in reaction to the practice of locking up the poor and mentally disturbed in decaying county jails, poorhouses, and bloch-house (barns in VT), the state hospital system was established to ensure more humane treatment of society’s castoffs. These new institutions were strongly advocated from the beginning by all the ‘enlightened’ professionals of the day. But little thought was given to the consequences of creating ten-to-fifteen-thousand-bed cities of the ‘mad,’ and there was no flexibility for change once the hospitals were found not to provide the most ideal setting for patients. Instead of offering humane and effective treatment to the mentally ill, state hospitals became another enormous bureaucracy catering to vested interests and embodying the worse of care and societal stigma.

 

Community mental health centers seem to fit the same mold. Amid flowery orations intended to generate great excitement and renewed hope, they were initiated as a reaction to the scandalous degeneration of state hospitals. Had NIMH or Congress responded to the underlying lessons of past failures, or even heeded the report of the Joint Commission on Mental Illness and Health, a far more sober approach might have been adopted. There are no known, foolproof answers as to how best to care for those labeled ‘mentally ill’ – just as there are no widely accepted answers to the question of what ‘mental illness’ is.

Any program aimed at reducing human suffering can only be looked upon as an experiment, a tentative step in providing better services, discovering answers. More important, any program as broad in scope as the community mental health centers program must have built-in evaluation from the start, and enough flexibility to change ,to accommodate new methods, perhaps even to disband. This was a sober and ultimately honest policy. It was not adopted. Instead, NIMH officials falsely fired public expectations, tagging the program not only as a ‘bold, new approach’ to the care of the mentally ill, but suggesting that community mental health centers (and by extension, the professionals suddenly renamed ‘community psychiatrists’) could effectively tackle problems of poverty, racism, drug addiction, crime and delinquency.

In reality, community mental healthy centers as they are  currently structure will never supplant state hospitals, much  less cater to the mental health needs of all citizens. Nor is there much likelihood that they will provide any significant diminution of the problems of addiction, poverty, labor unrest, or crime. The reason is, in part, lack of resource. In fiscal 1973, NIMH obligated about $125 million for the staffing  of community mental health centers ( in the same year states spent more than $2 billion, more than ever before, in maintaining state hospitals) and future appropriations , of approved, will be even more Spartan. But the primary reasons go far beyond the simple lack of money for the centers, or for the NIHM, or for the mental health professions. Putting an end to the state-hospital system requires much more than the intervention of mental health professionals in the community.

Most important, the system of patronage and corruption which helps to perpetuate state hospitals must be challenged directly. A change in our economic priorities is essential if we are to provide jobs, housing, and social support programs which are vitally important to any effort to rehabilitate the victims of long-term hospitalizations. Mental health professionals can act as important catalysts of social change –both through personal interaction and by identifying institutional influences on psychological development. But social and economic justice are desirable because they are essential elements of a real democracy,  not just because they are demanded by some sort of mental health imperative. Of course, such changes will be a long time coming.

In the meantime, public policy must reflect very careful determination of how best to allocate our limited resources in mental health care. And this determination must be based on ab ruthlessly honest appraisal of the limits of psychiatric (as well as related professional) expertise. Reformers, with the best of intentions, have sought to place an ever-greater number of categories of ‘sick’ people and ‘behavioral problems’ within  the province of mental health care. Although many of these problems are undeniably more social or economic than psychological or medical, and despite the lack of evidence that psychiatric intervention can do much about drug addiction, alcoholism, crime, or poverty, mental health professionals have uncritically accepted these new tasks. In doing so, they have obtained greater social  prestige as well as generous federal subsidies, but at the risk of losing their credibility before the public.

All of this follows a familiar historical trend in the mental health field. Few tangible successes have glimmered in a history composed largely of failures to produce ‘cure’ or even very precise knowledge about the origin, nature, or treatment of ‘mental illness’;. Yet this has led only to an ever-expanding realm wherein psychiatric intervention is deemed appropriate – a realm which by now may have extended far beyond the skills and the combined knowledge of the mental health professions. David L. Brazelon, Chief Justice of the U. S. Court of Appeals for the District of Columbia Circuit, has given the matter a very concise formulation: ‘The question is not whether mental health professionals are any good, but what they are good at.’ Judge Bazelon’s seemingly simple question is not merely academic. As one who has written a number of landmark legal opinions regarding the insanity defense and the role of ‘expert’ psychiatric testimony, Brazelon is concerned about the encroaching power of professionals to decide a host of legal, moral and ethical questions.
[ https://en.wikipedia.org/wiki/David_L._Bazelon ]

If the decade of the sixties has taught us nothing else, it should have taught us that the difficult problems will not go away simply because they are turned over to ‘experts’ or placed under a new label. The growing tendency to attach medical labels to (and thus presumably to seek medical solutions for) a range opf social problems helps obscure the moral and legal issues of good and bad, fails to acknowledge the validity of competing personal values and political convictions which are the lifeblood of a democratic society, and enhances the possibility that mental health professionals will be used to legitimate subtle methods of control and retribution by making them appear to be instruments of treatment.

 

It is clear that out of tens of millions of individuals whom NIMH officials and others estimate need psychiatric care, only a tiny minority suffer from problems that most authorities would agree constitute ‘mental diseases.’ The much larger group of individuals who constitute the bulk of ‘patients’ in mental institutions have problems that fall outside any rigorously defined categories of ‘diseases’;. As William Ryan notes, ‘the logical error we made is in dealing with such non-diseased persons in the same setting and with the same conceptual terminology that we have constructed for the truly diseased person. . . .We should concern ourselves not with the  training of more ‘mental health’ professionals, but with the development of a total coherent system of care and service delivery that will answer the basic social welfare needs of the people- of which healthy and mental health are only a part. . . We must recognize that humane care given by sympathetic people is more important than the cursory ‘treatment’ currently  provided by a pool of overworked, often over-credentialed professionals, many of who are, by temperament and training, ill-suited to meet the real needs of most ‘mental patients.’

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This report, of course, says nothing about the HEW and NIMH  social programs today but demonstrates past failures. Besides failing to establish clear goals for its programs or strong accountability for the  performance of community mental health centers here follows a brief account of the problems this led to.

In many cases the establishment of mental health centers led to an increase in admissions to state mental institutions and were often placed in those  same forbidding buildings. Sometimes centers were built adjacent to existing hospitals and simply served to expand their out and in patient mental health services primarily as a space for psychiatrists to grow their private practices. Many free-standing centers were located in remote or outside  places  within the population areas (‘catchments)’ they were designated to serve. More centers were built closer to middle class neighborhoods at the expense of poor neighborhoods in more desperate need of social services. In some Cities storefront satellite  outreach centers were attempted- to help address the many problems faced by residents that could not be classified as ‘mentally’ related ( like helping people to handle being evicted, unemployment, food scarcity, childcare and other legal problems) but these outreach centers were defunded and such efforts abandoned.  The Congressional Act  proposed the establishment of boards of directors composed of members of the communities the centers  were intended to serve but this turned out to be more about rhetoric than effective control or direction, which stifled innovation and healthy community relations. Surveys by the study group often showed few residents even knew of their existence. The centers were  largely run by medical specialists with little experience in public administration which even reduced the time they could provide direct treatment.