Community Mental Health as an Expression of Clinical Social Responsibility
In the years after the passage of the NMHA, several other developments within the professions and on the federal level sustained the forward motion of clinical experts by further institutionalizing opportunities for professional training and fostering clinicians' social influence through a process of integration with the social and behavioral sciences. The formation of the Group for the Advancement of Psychiatry (GAP) in the spring of 1946 embodied the reforming zeal of "young Turks" with a background in military mental health. Led by William Menninger, GAP was initially conceived as a pressure group within the American Psychiatric Association. During the next couple of years, GAP members captured most of the top posts in the American Psychiatric Association, including the presidency. But GAP soon blossomed into an autonomous organization whose influential working groups and published reports championed social conscience and liberal political activism and whose professional campaigns carried the banner of community mental health.
In July 1950 GAP's Committee on Social Issues published a mani-
festo, rifled "The Social Responsibility of Psychiatry," which made GAP's political proclivities explicit. In draft form, the committee pledged itself to social reform: "We feel not only justified, but ethically compelled to advocate those changes in social organization which have a positive relevance to a program of mental health." The final document was somewhat more moderate in tone, but its activist commitment was indisputable.
The Committee on Social Issues has the conviction that social action . . . implies a conscious and deliberate wish to foster those social developments which could promote mental health on a community-wide scale. . . . We favor the application of psychiatric principles to all those problems which have to do with family welfare, child rearing, child and adult education, social and economic factors which influence the community status of individuals and families, inter-group tensions, civil rights and personal liberty. The social crisis which confronts us today is menacing; we would surely be guilty of dereliction of duty did we not make a conscientious effort to apply whatever partial knowledge we now possess in the interests of counteracting social danger and promoting healthier being, both for individuals and groups. This, in a true sense, carries psychiatry out of the hospitals and into the community.
Although there was some resistance to GAP's emphatically social interpretation of psychiatric responsibility within the profession at large, which had a long history of concern for the somatic causes of mental disorder as well as for severely ill individuals, no such resistance existed within the surging ranks of psychology.
Clinical psychology, after all, was practically a brand-new profession after World War II. It was searching for a fresh identity within a newly reorganized American Psychological Association (APA) that had defined its general purposes in unmistakably visionary terms from the very first. As Robert Yerkes put it, at the APA's Intersociety Constitutional Convention in 1943,
The world crisis, with its clash of cultures and ideologies, has created for us psychologists unique opportunity for promotive endeavor. What may be achieved through wisely-planned and well-directed professional activity will be limited only by our knowledge, faith, disinterestedness, and prophetic foresight. It is for us, primarily, to prepare the way for scientific advances and the development of welfare services which from birth to death shall guide and minister to the development and social usefulness of the individual. For beyond even our wildest dreams, knowledge of human nature may now be made to serve human needs and to multiply and increase the satisfactions of living.
Clinical psychologists found that the "birth to death" ideology of the welfare state corresponded perfectly with their own aim to normalize
clinical practice and expand their sphere of social authority, even when those aims—the autonomous practice of psychotherapy was perhaps the most striking—conflicted directly with the interests of organized psychiatry.
GAP's record illustrated that advocating social change in the name of improved mental health could produce both very rewarding professional and very unpredictable political results. By insisting that mental balance involved a constant state of adjustment and exchange between self and society, clinical experts could, and did, lay claim to defining what was normal in environments as well as in people. "This view of the fluidity of the interaction of the individual with society," GAP pointed out, "tends inevitably to broaden the concepts of mental illness and mental health."
They did not add that it inevitably broadened the authority of psychological experts as well by giving them power to designate exactly how social institutions—economic, familial, educational, and so on—might prevent mental trouble and nourish emotional well-being. Doing so, needless to say, was extremely controversial. GAP's impeccable liberal credentials led members to endorse a social program of racial harmony, literacy, economic security, and family happiness, among other things—all founded on an expanded role for psychologically enlightened federal government. One of the best known and most widely circulated GAP reports, for example, was issued in 1957. Titled "Psychiatric Aspects of School Desegregation," there was no mistaking its immediate relevance, and support for school integration, in the face of the fierce white resistance that followed Brown v. Board of Education .
Yet even more disagreement accompanied any definition of "normal" social structure than did the definition of "normal" individual psychology. (Whether or not racial integration qualified as one component of a normal environment was just the tip of the iceberg.) The climate of domestic anticommunism in the late 1940s and early 1950s also emboldened GAP's critics. At various points, the organization was accused of being a "radical sectarian group" full of Communist sympathizers intent on seizing control of the psychiatric profession. GAP members responded to McCarthyism by dashing off a report, "Considerations Regarding the Loyalty Oath as a Manifestation of Current Social Tension and Anxiety," but political name-calling caused barely a momentary interruption in their crusade to have clinical experts act on their social responsibilities, as GAP saw them.
In 1955 Congress passed the National Mental Health Study Act,
paving the way for the Joint Commission on Mental Illness and Health (JCMIH). GAP members and others who shared an activist clinical philosophy believed the government had taken another decisive and enlightened step toward broadening its jurisdiction over mental health, superseding the decentralized tradition that had left policies in the hands of bungling and backward state politicians. The purpose of the JCMIH (which, although a nongovernmental body, was almost entirely funded by the NIMH) was to conduct an encyclopedic survey of mental illness and health in preparation for innovative new national policy initiatives. Thirty-six participating organizations (which included the Department of Defense, the American Legion, and the American Psychiatric Association) spent several years and $1.5 million on this project and published ten scholarly monographs in addition to its final report, Action for Mental Health. The final report reiterated at the outset the fundamental equation between democracy and mental health that had been a constant refrain during and after World War II. Their assigned task of developing mental health policy, wrote the authors, "is our responsibility as citizens of a democratic nation founded out of faith in the uniqueness, integrity, and dignity of human life. . . . Good mental health. . . is consistent with this higher responsibility and with our professional and political ideals. It is also consistent with what the American people should want—not simply peace of mind but strength of mind."
During its tenure, the JCMIH compiled a mass of data with numerous possible interpretations, but its staff and major constituencies all wished to promote the delivery of community-based services geared to prevention. According to the JCMIH studies, new, milder forms of psychotherapeutic intervention in communities across the country were worth a real try, even though intensive custodial care was in dire need of improvement. Several of its core recommendations were used by the Kennedy and Johnson administrations in the years that followed to move the federal government toward the next policy phase: establishing community mental health centers throughout the country. In this regard, an especially significant suggestion was that funding more outpatient services through community centers would result in cutting hospitalization rates (i.e., prevent at least some cases of incapacitating mental illness). The JCMIH proposed one center for every fifty thousand people.
In 1963 President Kennedy (whose younger sister Rosemary had
undergone psychosurgery after being diagnosed with mild retardation) became the first U.S. president to make mental illness and retardation the subjects of a special address to Congress (fig. 16). Surely this was conclusive proof that the mental and emotional status of U.S. citizens had become a pressing government concern. Kennedy's speech elated the boosters of a socially active and expansive federal policy because the president highlighted the criticisms and proposals that advocates of preventive and community mental health had been repeating for years: during World War II, in the course of passing the NMHA, and in organizations like GAP.
First, Kennedy disparaged a decentralized policy approach and accused states of neglectful reliance on "shamefully understaffed, overcrowded, unpleasant institutions from which death too often provided the only firm hope of release." Then he proclaimed that "an ounce of prevention is worth more than a pound of cure." Only a new federal campaign to fund research, professional training, and community-based services would replace "the cold mercy of custodial isolation" with "the open warmth of community concern and capability" and, Kennedy optimistically projected, reduce the number of institutionalized patients by 50 percent in "a decade or two." Shortly afterwards, the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 was passed. Federal grants for the construction of community mental health centers were its main feature; a total of $150 million was appropriated for this purpose during the following three fiscal years. The long-term goal (never to be realized) was to establish a national network of two thousand centers, one for each geographically defined community of 75,000 to 200,000 people. Even observers who worried that care for the most severely ill might suffer endorsed the expanded sphere of authority that the act gave to clinical professionals and pronounced it "the most significant development in recent history in the provision of services for the mentally ill."
The combined efforts of policy-makers and professional advocates, and the tenor of national mental health legislation in the decades after 1945, turned the ideology of community mental health into an expression of clinical experts' social responsibility. Based on the sunny supposition that mental health could be manufactured (and illness prevented) if only the environmental conditions were favorable, clinicians marched boldly into a variety of fields—from criminal justice to education—to guarantee that they would be.
Claiming that all aspects of community life potentially affected individual mental health, psychiatrists redefined their clinical mission as follows: "Within our definition, all social, psychological, and biological activity affecting the mental health of the populace is of interest to the community psychiatrist, including programs for fostering social change, resolution of social problems, political involvement, community orga-
nization planning, and clinical psychiatric practice." A typical formulation of community psychology simply identified it with the "optimal realization of human potential through planned social action."
That something as undeniably positive as mental health could justify a process of social reform had obvious appeal during a period of dynamic grassroots and governmental activism. During the late 1950s and 1960s, an array of progressive social movements repeatedly called for equalizing changes in the distribution of political power and material resources, and the federal government responded with nothing less than the War on Poverty and the Great Society. The impetus for community mental health had, after all, come from clinicians with liberal political sympathies in the 1940s and 1950s. When the political climate shifted further to the left in the 1960s, clinicians moved a bit further to the left as well, but they continued to advance a vision that merged psychological change with social activism and responsibility. Community mental health, they were convinced, was intimately bound up with campaigns to eliminate racism, poverty, and oppression and forge a better, more humane, society. Mental health was all but synonymous with equality, prosperity, and social welfare.
It was not long, however, before radicals began to question these happy political assumptions, a process we have already seen at work in the case of psychological approaches to the problems of rioting and revolution confronted by police forces and militaries. "Sick" social environments stubbornly resisted clinicians' most well intentioned cures; ghettos remained poor and schools impoverished. How could adjustment between self and society be accomplished, or even advocated, when so many people led such wretched lives? Perhaps psychological adjustment only adjusted people to habits of powerlessness, inequality, and anguish?
By the late 1960s, the frustrating slowness of change had generated the beginnings of a skeptical, even cynical, countermovement that turned the heady idealism of the postwar years on its head. Suspicions that psychological expertise might have oppressive consequences diametrically opposed to stated intentions spread, sometimes as a result of organizing by former mental patients who bluntly denounced the treatment they had received at the hands of the mental health professionals, sometimes as a result of the advocates of "radical therapy," who aimed to merge therapeutic insight and leftist politics. Under the harsh light of this new criticism, the community mental health movement no longer appeared as an enlightening crusade, but rather as one element
of a multifaceted scheme to subvert genuine democracy through a disguised program of social control. One writer, Chaim Shatan, speculated in 1969 that "the clinicians will provide emotional first aid, while the government-subsidized conveyor belt feeds manpower directly into federally sponsored operations—from the space race to community mental health itself. . . . In 1984, Big Brother may be a community psychiatrist."
In March 1969 Lincoln Hospital Mental Health Services, located in the South Bronx, was taken over by its nonprofessional staff members, most of them black and Puerto Rican. The center epitomized the ideals of the community mental health movement; there was a walk-in clinic for neighborhood residents, a program of consultation with community organizations, and so forth. But the protesters were fed up with the paternalism of well-intentioned white psychiatrists, as the text from their flyer made clear.
We're gonna see what you do with what you think is your center. You honkies complain that we don't respect authority and we don't want any compromise. Damn right. Your authority is no good and we've been compromising too damn long. So now you listen to what working people are saying loud and clear. And you better listen: Cause now we're not working for the center anymore. We and the community are the center.
After fifteen days of occupation, during which the protesting workers appointed new department heads and issued a lengthy list of demands, the administration caved in. The center promptly changed its name, hired a new director, and severed its ties to the hospital (and the department of psychiatry at Albert Einstein College of Medicine, with which it was affiliated).
This episode, now famous as a turning point in the history of the community mental health movement, propelled forward the new spirit of negativity about the political function of clinicians and strengthened the view that community mental health was so much rhetoric plastered over an unattractive reality of domination by elites. Significantly, however, the target of the most withering criticism was the inequality between professionals and nonprofessionals. Even the Bronx protest re-emphasized the liberating potential of psychological knowledge in the hands of disenfranchised people. As long as it was not monopolized by experts, community psychology "gave a voice to people who had been kept outside of history." For a number of years after the 1969 takeover, the Lincoln Community Mental Health Center offered a range of
alternative, largely nonprofessional mental health services to residents in the South Bronx.