tions from members of the American Psychological Association who have been involved in planning at local, state, and national levels.

The community mental health center, 1966 model, cannot be looked to for a unique or final solution to mental health problems: varied patterns will need to be tried, plans revised in the light of evaluated experience, rigidities avoided. Even as plans are being drawn for the first comprehensive centers under the present Federal legislation, still other bold approaches to the fostering of human effectiveness are being promulgated under the aegis of education and of economic opportunity programs. A single blueprint is bound to be inadequate and out of date at the moment it is sketched. The general approach underlying these guidelines may, it is hoped, have somewhat more enduring relevance.

Throughout, the comprehensive community mental health center is considered from the point of view of members of a community who are seeking good programs and are ultimately responsible for the kind of programs they get. The mental health professions are not to be regarded as guardians of mental health, but as agents of the community-among others-in developing and conserving its human resources and in restoring to more effective functioning people whose performance has been impaired. Professional people are valuable allies in the community's quest for the health and well-being of its members, but the responsibility for setting goals and major policies cannot be wisely delegated.

COMMUNITY INVOLVEMENT AND COMMUNITY CONTROL

For the comprehensive community mental health center to become an effective agency of the community, community control of center policy is essential. The comprehensive community mental health center represents a fundamental shift in strategy in handling mental disorders. Historically, and still too much today, the preferred solution has been to separate the mentally ill person from society, to put him out of sight and mind, until, if he is lucky, he is restored to normal functioning. According to the old way, the community abandoned its responsibility for the mental patient to the distant mental hospital. According to the new way, the community accepts responsibility to come to the aid of the citizen who is in trouble. In the proposed new pattern, the person would remain in his own community, often not even leaving his home, close to family, to friends, and to the array of professional people he needs to help him. Nor would the center wait for serious psychological problems to develop and be referred. Its program of prevention, detection, and early intervention would involve it in many aspects of community life and in many institutions not normally considered as mental health agencies: the schools, churches, playgrounds, welfare agencies, the police, industry, the courts, and community councils.

This spread of professional commitment reflects in part a new conception of what constitutes mental illness. The new concept questions the appropriateness of the term "illness" in this context, in spite of recognition that much was gained from a humanitarian viewpoint in adopting the term. Mental disorders are in significant ways different from physical illnesses. Certainly mental disorder is not the private misery of an individual; it often grows out of and usually contributes to the breakdown of normal sources of social support and understanding, especially the family. It is not just an individual who has faltered; the social systems in which he is embedded through family, school, or job, through religious affiliation or through friendship, have failed to sustain him as an effective participant.

From this view of mental disorder as rooted in the social systems in which the troubled person participates, it follows that the objective of the center staff should be to help the various social systems of which the community is composed to function in ways that develop and sustain the effectiveness of the individuals who take part in them, and to help these community systems regroup their forces to support the person who runs into trouble. The community is not just a catchment area from which patients are drawn; the task of a community mental health center goes far beyond that of purveying professional services to disordered people on a local basis.

The more closely the proposed centers become integrated with the life and institutions of their communities, the less the community can afford to turn over to mental health professionals its responsibility for guiding the center's policies. Professional standards need to be established for the centers by Federal and state authorities, but goals and basic policies are a matter for local control. A broadly based responsible board of informed leaders should help to ensure that the center serves in deed, not just in name, as a focus of the Com77-607-67- 12

munity's varied efforts on behalf of the gerater effectiveness and fulfillment of all its residents.

RANGE OF SERVICES

The community mental health center is "comprehensive" in the sense that it offers, probably not under one roof, a wide range of services, including both direct care of troubled people and consultative, educational, and preventive services to the community. According to the administrative regulations issued by the United States Public Health Service, a center must offer five essential services to qualify for Federal funds under the Community Mental Health Centers Act of 1963: (a) inpatient care for people who need intensive care or treatment around the clock; (b) outpatient care for adults, children, and families; (c) partial hospitalization: at least day care and treatment for patients able to return home evenings and weekends; perhaps also night care for patients able to work but needing limited support or lacking suitable home arrangement; (d) emergency care on a 24-hour basis by one of the three services just listed; and (e) consultation and education to community agencies and professional personnel. The regulations also specify five additional services which, together with the five essential ones, "complete" the comprehensive community mental health program: (f) diagnostic service; (g) rehabilitative service including both social and vocational rehabilitation; (h) precare and aftercare, including screening of patients prior to hospital admission and home visiting or halfway houses after hospitalization; (i) training for all types of mental health personnel; and (j) research and evaluation concerning the effectivenes of programs and the problems of mental illness and its treatment.

That the five essential services revolve around the medically traditional inpatient-outpatient core may emphasize the more traditional component of the comprehensive center idea somewhat at the expense of full justice to the new conceptions of what is crucial in community mental health. Partial hospitalization and emergency care represent highly desirable, indeed essential, extensions of the traditional clinical services in the direction of greater flexibility and less disruption in patterns of living. Yet the newer approach to community mental health through the social systems in which people are embedded (family, school, neighborhood, factory, etc.) has further implications. For the disturbed person, the goal of community mental health programs should be to help him and the social systems of which he is a member to function together as harmoniously and productively as possible. Such a goal is more practical, and more readily specified, than the elusive concept of cure, which misses the point that for much mental disorder the trouble lies not within the skin of the individual but in the interpersonal systems through which he is related to others. The emphasis in the regulations upon consultation and public education goes beyond the extension of direct patient services to open wide vistas for imaginatve experimentation.

The vanguard of the community approach to mental health seeks ways in which aspects of people's social environment can be changed in order to improve mental health significantly through impact on large groups. Just as a modern police or fire department tries to prevent the problems it must cure, so a good mental health center would look for ways of reducing the strains and troubles out of which much disorder arises. The center might conduct surveys and studies to locate the sources of these strains; it might conduct training programs for managers, for teachers, for ministers to help them deal with the problems that come to light. By providing consultation on mental health to the governing agencies of the community, to schools, courts, churches, to business and industry, the staff of the center can bring their special knowledge to bear in improving the quality of community and family life for all citizens. Consultation can also be provided to the state mental hospitals to which the community sends patients, to assist these relics of the older dispensation in finding a constructive place in the new approach to mental health. Preferably, revitalized state hospitals will become integral parts of the comprehensive service to nearby communities.

In performing this important and difficult consultative role, the mental health professionals of the center staff do not make the presumptuous and foolish claim that they know best how the institutions of a community should operate. Rather, they contribute a special perspective and special competencies that can help the agencies and institutions of community life-the agencies and institutions through which people normally sustain and realize themselves-find ways in which to perform their functions more adequately. In this endeavor, the center staff needs to work in close cooperation with other key agencies that share a concern

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 developed 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

The compre

Facilities should be planned to fit a program and not vice versa. hensive 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 pro

grams, 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. 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 public 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 community 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 luxury; 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 public 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. In

ventiveness 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. 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.

INNOVATION

Since current patterns 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.

CHILDREN

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.