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with community betterment but from different vantage points: councils of social agencies, poverty program councils, labor groups, business organizations, and the like. To promote coordination, representatives of such groups should normally be included in the board responsible for the center's policies.
Communities may find that they want and need to provide for a variety of services not specifically listed among the additional services in the regulations issued by the United States Public Health Service: for example, a special service for the aged, or a camping program, or, unfortunately, residences for people who do not respond to the best we can do for them. The regulations are permissive with respect to additional services, and communities will have to give close and realistic attention to their own needs and priorities. For many rural areas, On the other hand, and for communities in which existing mental health services are so grossly inadequate that the components of a comprehensive program must be assembled from scratch, the present regulations in regard to “essential services” may prove unduly restrictive. Communities without traditions of strong mental health services may need to start with something short of the full, prescribed package. So long as their plan provides for both direct and indirect services, goes beyond the traditional inpatient-outpatient facility, and involves commitment to movement in the direction of greater comprehensiveness, the intent of the legislation might be regarded as fulfilled.
Many of the services that are relevant to mental health will naturally be deyeloped under auspices other than the comprehensive center. That is desirable. Even the most comprehensive center will have a program that is more narrowly circumscribed than the community’s full effort to promote human effectiveness. What is important is that the staff of the center be in good communication with related community efforts and plan the center's own undertakings so as to strengthen the totality of the community's investments in the human effectiveness of its members.
Facilities should be planned to fit a program and not vice versa. The comprehensive community mental health center should not be thought of as a place, building, or collection of buildings—an easy misconception—but as a peopleserving organization. New physical facilities will necessarily be required, but the mistake of constructing large, congregate institutions should not be repeated. The danger here is that new treatment facilities established in medical centers may only shift the old mental hospital from country to town, its architecture changed from stone and brick to glass and steel. New conceptions are needed even more than new facilities.
Small units of diverse design reflecting specific functions and located near users or near other services (such as a school or community center) might be indicated and can often be constructed at a lesser cost than a centralized unit linked to a hospital. For example, most emotionally disturbed children who require residential treatment can be effectively served in small residential units in a neighborhood setting removed from the hospital center. Indeed, there is the possibility that the hospital with its tense and antiseptic atmosphere may confirm the child’s worst fears about himself and set his deviant behavior.
Each community should work out the pattern of services and related facilities that reflects its own problems, resources, and solutions. The needs and resources of rural areas will differ radically from those of urban ones. Every state in the nation has its huge mental hospitals—grim monuments to what was once the latest word in treatment of the mentally ill, and a major force in shaping treatment programs ever since. It should not be necessary to build new monuments.
CoNTINUITY OF CONCERN
Effective community action for mental health requires continuity of concern for the troubled individual in his involvements with society, regardless of awkward jurisdictional boundaries of agencies, institutions, and professions. A major barrier to effective mental health programing is the historical precedent of separating mental health services from other people-serving agencies—schools, courts, welfare agencies, recreational programs, etc. This is partly a product of the way of thinking that follows from defining the problem as one of illness and thus establishing the place of treatment and the professional qualifications required to treat it. There are thus immense gaps in responsibility for giving help to people in trouble. Agencies tend to work in ignorance of each other's programs, or at cross purposes. For example, hospital programs for emotionally disturbed children often are operated with little contact with the child's school; a destitute alcoholic who would be hospitalized by one community agent is jailed by another.
Current recommendations that a person in trouble be admitted to the total mental health system and not to only one component of it fall short of coming to grips with the problem. The laudable aim of these recommendations is to facilitate movement of a person from one component to another—from hospital to outpatient clinic, for example, within minimum red-tape and maximum communication among the professional people involved. Such freedom of movement and of communication within the mental health system is much to be desired. But freedom of movement and of communication between systems is quite as important as it is within a system.
No one system can comprise the range of mental health concerns to which we are committed in America, extending from serious neurological disorders to include the whole fabric of human experience from which serious—and not so serious—disorders of living may spring. Mental health is everyone's business, and no profession or family of professions has sufficient competence to deal with it whole. Nor can a mental health center, however comprehensive, encompass it. The center staff can and should engage in joint programing with the various other systems with whom “patients” and people on the verge of trouble are significantly involved—school, welfare, industry, justice and the rest. For such joint programing to reflect the continuity of concern for the individual that is needed. information must flow freely among all agencies and systems. The staff of the center can play a crucial role in monitoring this flow to see to it that the walls that typically restrict communication between social agencies are broken down.
REaCHING THoSE WHO Most NEED HELP
Programs must be designed to reach the people who are hardly touched by our best current efforts. for it is actually these who present the major problems of mental health in America. The programs of comprehensive community mental health centers must be deliberately designed to reach all of the people who need them. Yet the forces generated by professional orthodoxies and by the balance of publie initiative or apathy in different segments of the community—forces that have shaped current model community mental health programs—will tend unless strenuously counteracted to restrict services to a favored few in the community. The poor. the dispossessed, the uneducated, the poor treatment risk, will get less service—and less appropriate service—than their representation in the commuInity warrants, and much, much less service than their disproportionate contribution to the bedrock problem of serious mental illness would demand.
The more advanced mental health services have tended to be a middle-class IIIxury: chronic mental hospital custody a lower-class horror. The relationship between the mental health helper and the helped has been governed by an affinity of the clean for the clean, the educated for the educated, the affluent for the affluent. Most of our therapeutic talent, often trained at public expense, has been invested not in solving our hard-core mental health problem—the psychotic of marginal competence and social status—but in treating the relatively well-to-do educated neurotic, usually in an urban center. Research has shown that if a person is poor, he is given some form of brief, mechanical, or chemical treatment: if his social. economic, and educational position is more favored, he is given long-term conversational psychotherapy. This disturbing state of affairs exists whether the patient is treated privately or in a community facility, or by a psychiatrist. psychologist, or other professional person. If the community representatives who take responsibility for policy in the new community mental health centers are indignant at this inequity. their indignation would seem to be justified on the reasonable assumption that mental health services provided at publie expense ought to reach the people who most need help. Although regulations stipulate that people will not be barred from service because of inability to pay. the greatest threat to the integrity and usefulness of the proposed comprehensive centers is that they will nonetheless neglect the poor and disadvantaged, and that they will simply provide at public expense services that are now privately available to people of means.
Yet indignation and good will backed with power to set policy will not in themselves suffice to bring about a just apportionment of mental health services. Inventiveness and research will also be indispensable. Even when special efforts are made to bring psychotherapy to the disturbed poor, it appears that they tend not to understand it, to want it, or to benefit from it. They tend no to conceive of their difficulties in psychological terms or to realize that talk can be a “treatment” that can help. Vigorous experimentation is needed to discover ways of reaching the people whose mental health problems are most serious. Present indications suggest that methods hold most promise which emphasize actions rather than words, deal directly with the problems of living rather than with fantasies, and meet emergencies when they arise without interposing a waiting list. Much more attention should also be given to the development of nonprofessional roles for selected “indigenous” persons who in numerous ways could help to bridge the gulf between the world of the mental health professional and that of the poor and uneducated where help is particularly needed.
Since current patterms of mental health service are intrinsically and logistically inadequate to the task, responsible programming for the comprehensive community mental health center must emphasize and reward innovation. What can the mental health specialist do to help people who are in trouble? A recent survey of 11 most advanced mental health centers, chosen to suggest what centersin-planning might become, reveals that the treatment of choice remains individual psychotherapy, the 50-minute hour on a one-to-one basis. Yet 3 minutes with a sharp pencil will show that this cannot conceivably provide a realistic basis for a national mental health program. There simply are not enough therapists—nor will there ever be—to go around, nor are there enough hours, nor is the method suited to the people who consistute the bulk of the problem—the uneducated, the inarticulate. Given the bias of existing facilities toward serving a middle-class clientele, stubborn adherence to individual psychotherapy when a community could find and afford the staff to do it would still be understandable if there were clear-cut evidence of the superior effectiveness of the method with those who find it attractive or acceptable. But such evidence does not exist. The habits and traditons of the mental health professions are not a good enough reason for the prominence of one-to-one psychotherapy, whether by psychiatrists, psychologists, or social workers, in current practice and programing.
Innovations are clearly required. One possibility with which there has been considerable experience is group therapy; here the therapist multiplies his talents by a factor of six or eight. Another is crisis consultation: a few hours spent in active intervention when a person reaches the end of his own resources and the normal sources of support run out. A particularly imaginative instance of crisis consultation in which psychologists have pioneered is the suicide-prevention facility. Another very promising innovation is the use under professional direction of people without professional training to provide needed interpersonal contact and communication. Still other innovations, more radical in departure from the individual clinical approach, will be required if the major institutional settings of youth and adult life—school and job—are to be modified in ways that promote the constructive handling of life stresses on the part of large numbers of people.
Innovation will flourish when we accept the character of our national mental health problem and when lay and professional people recognize and reward creative attempts to solve it. Responsible encouragement of innovation, of course, implies commitment to and investment in evaluation and research to appraise the merit of new practices.
In contrast with current practice, major emphasis in the new comprehensive centers should go to services for children. Mental health programs tend to neglect children, and the first plans submitted by states were conspicuous in their failure to provide a range of services to children. The 11 present community programs described as models were largely adult-oriented. A recent (1965) conference to review progress in planning touched occasionally and lightly on problems of children. The Joint Commission on Mental Illness and Health bypassed the issue; currently a new Joint Commission on Mental Health of Children is about to embark upon its studies under Congressional auspices.
Most psychiatric and psychological training programs concentrate on adults. Individual psychotherapy through talk—the favored method in most mental health programs—is best suited to adults. What to do with an enraged child on a playground is not normally included in curricula for training mental health specialists. It would seem that our plans and programs are shaped more by our methods and predilections than by the problems to be solved. Yet an analysis of the age profile of most communities—in conjunction with this relative neglect—would call for a radically different allocation of money, facilities, and mental health professionals. We do not know that early intervention with childhood problems can reduce later mental disorder, but it is a reasonable hypothesis, and we do know that the problems of children are receiving scant attention. Sound strategy would concentrate our innovative efforts upon the young, in programs for children and youth, for parents, and for teachers and others who work directly with children. The less than encouraging experience of the child guidance clinic movement a generation and more ago should be a stimulus to new effort, not an occasion for turning away from services to children. The old clinics were small ventures, middle-class oriented, suffering from most of the deficiencies of therapeutic approach and out-reach that have been touched upon above. A fresh approach to the problems of children is urgently needed. We feel that fully half of our mental health resources—money, facilities, people—should be invested in programs for children and youth, for parents of young children, and for teachers and others who work directly with children. This would be the preferable course even if the remaining 50% would permit only a holding action with respect to problems of adults. But our resources are such that, if we care enough, we can move forward on both fronts simultaneously. The proposal to place the major investment of our mental health resources in programs for children will be resisted, however much sense it may make, for it will require a thoroughgoing reorientation of the mental health establishment. New facilities, new skills, new kinds of professional people, new patterns for the development of manpower will be required. And new and more effective ways must be found to reach and help children where they are—in families and schools—and to assist these critically important social systems in fostering the good development of children and in coming to the child's support when the developmental course goes astray. This is one reason why community leaders and other nonprofessionals concerned with the welfare and development of people should be centrally involved in establishing the goals of community mental health centers. They can and should demand that the character of the new centers be determined not by the present habits and skills of professional people but by the nature of the problem to be solved and the full range of resources available for its Solution.
PLANNING FOR PROBLEM GROUPS THAT NOBODY WANTS
As a focus for community planning for mental health, the comprehensive center should assure that provision is made to deal with the mental health component in the problems of various difficult groups that are likely to fall between the stools of current programs. Just as good community programming for mental health requires continuity of concern for the troubled individual across the many agencies and services that are involved with him, so good programing also requires that no problem groups be excluded from attention just because their problems do not fit neatly into prevalent categories of professional interest, or because they are hard to treat.
There are a number of such groups of people, among whom problems of human ineffectiveness are obivous, yet whose difficulties cannot accurately or helpfully be described as mainly psychological: for example, addicts, alcoholics, the aging, delinquents, the mentally retarded. It would be presumptuous folly for mental health professionals to claim responsibility for solving the difficult social and biological problems that are implicated in these types of ineffectiveness. But it would also be irresponsible on the part of persons who are planning community mental health programs not to give explicit attention to the adequacy of services being provided to these difficult groups and to the adequacy of the attack that the community is making on those aspects of their problems that are accessible to community action.
Recently, and belatedly, national attention has been focussed on the mentally retarded. This substantial handicapped group is likely to be provided for outside the framework of the mental health program as such, but a good community mental health plan should assure that adequate provision is in fact made for them, and the comprehensive center should accept responsibility for serving the mental health needs of the retarded and their families. Some of the other problem groups just mentioned—e.g., the addicts and alcoholics—tend to get left out partly because treatment by psychiatric or psychological methods has been relatively unproductive. Naturally, the comprehensive center cannot be expected to achieve magical solutions where other agencies have failed. But if it takes the approach advocated here—that of focusing on the social systems in which problem behavior is embedded—it has an opportunity to contribute toward a rational attack on these problems. The skills that are required may be more those of the social scientist and community change agent than those of the clinician or therapist. In planning its role with respect to such difficult groups, the staff of the center might bear two considerations in mind: in the network of community agencies, is humanly decent care being provided under one or another set of auspices? and does the system-focused approach of the center have a distinctive contribution to make toward collaborative community action on the underlying problems?
The present and future shortage of trained mental health professionals requires ea'perimentation with new approaches to mental health services and with new divisions of labor in providing these services. The national effort to improve the quality of life for every individual—to alleviate poverty, to improve educational opportunities, to combat mental disorders—will tax our resources of professional manpower to the limit. In spite of expanded training efforts, mental health programs will face growing shortages of social workers, nurses, psychiatrists, psychologists, and other specialists. The new legislation to provide Federal assistance for the staffing of community mental health centers will not increase the supply of manpower but perhaps may result in some minor redistribution of personnel. If adequate pay and opportunities for part-time participation are provided, it is possible that some psychiatrists and psychologists now in private practice may join the public effort, adding to the services available to people without reference to their economic resources.
The manpower shortage must be faced realistically and with readiness for invention, for creative, solutions. Officially recommended staffing patterns for community mental health centers (which projected nationally would require far more professionals than are being trained) should not be taken as setting rigid limitations. Pediatricians, general medical practitioners, social workers other than psychiatric ones, and psychological and other technicians at nondoctoral levels should be drawn into the work of the center. Specific tasks sometimes assigned to highly trained professionals (such as administrative duties, follow-up contacts, or tutoring for a disturbed child) may be assigned to carefully selected adults with little or no technical training. Effective communication across barriers of education, social class, and race can be aided by the creation of new roles for specially talented members of deprived groups. New and important roles must be found for teachers, recreation workers, lawyers, clergymen. Consultation, in-service training, staff conferences, and supervision are all devices that can be used to extend resources without sacrificing the quality of service.
Mental health centers should find ways of using responsible, paid volunteers, with limited or extended periods of service. There is a great reservoir of human talent among educated Americans who want to contribute their time and efforts to a significant enterprise. The Peace Corps, the Vista program, Project Head-Start have demonstrated to a previously skeptical public that high level, dependable service can be rendered by this new-style volunteer. The contributions of unpaid volunteers—students, housewives, the retired—can be put to effective use as well.
Responsibility in the comprehensive community mental health center should depend upon competence in the jobs to be done. The issue of who is to be responsible for mental health programs is complex and is not to be solved in the context of professional rivalries. The broad conception of mental health to which we have committed ourselves in America requires that responsibility for mental health programs be broadly shared. With good will, intelligence, and