The National Mental Health Act of 1946

The most tangible evidence that citizens' mental health had been elevated to a major priority of federal government came with passage of the National Mental Health Act (NMHA) of 1946.^[18] This landmark piece of legislation was inspired in large part by the dismal record of military mental health during World War II, the performance of such agencies as the VA, and vocal demands by veterans and their families for therapeutic services. Clinicians too mounted persistent advocacy efforts on their own behalf, convinced that gains in professional visibility and prestige would result from increased federal funding. For them, as for their ambitious colleagues who wished to influence postwar foreign and military policy, military experiences and mandates were both genuinely transforming and politically expedient. War had been, and would continue to be, a great persuader.

Called the National Neuropsychiatric Institute Act when it was first introduced in Congress in March 1945, the legislation's final title incorporated the term "mental health," an alteration that captured the pivotal role of World War II and its marked clinical drift toward normalization. Indeed, leading figures in wartime clinical work were conspicu-

ous in the lobbying effort for the NMHA, and the lessons they had learned on the job, maintaining military mental health, were the most frequently heard arguments in favor of government action in this area.

Robert Felix, a psychiatrist who had been appointed director of the Public Health Service's (PHS) Division of Mental Hygiene in 1944, put most of his own energy, and his bureaucracy's muscle, into passing the bill. William Menninger, Lawrence Kubie, and others testified about how shortages of trained clinicians had sometimes thwarted military morale and how early therapeutic intervention had eventually helped the war effort by conserving personnel. They promised that federal support for professional training, research, and preventive services to the public would ease the postwar transition, humanize the face of government, and save lots of tax dollars. General Lewis Hershey, director of the Selective Service System, trotted out statistics on rejection and discharge rates from the armed services.^[19] These numbers became something of a mantra during the congressional deliberations on the NMHA. It was a fact that mental illness cost a lot of money. It was simply presumed that mental health would not. The chief of Bellevue Hospital's Psychiatric Division, S. Bernard Wortis, put it as follows: "Health, sir, is a purchasable commodity, and it seems to me that if more money were put into services and brains, rather than into bricks . . . much miser), and much mental illness could be saved in this country."^[20]

Advocating that mental health, rather than mental illness, be the centerpiece of federal policy also embodied clinicians' crusade for a larger jurisdiction for psychological expertise. That clinical insights should be applied to most or even all areas in need of government planning in the postwar era—from employment and housing to race relations—was assumed to be self-evident. Rarely did advocates offer concrete reasons why clinicians should be granted standing in such matters, but then, they were hardly ever asked to do so. A solitary dissenting voice at the congressional hearings on the NMHA illustrated the extent of expert consensus on the importance of expanding clinicians' social authority.^[21] Lee Steiner, a member of the American Association of Psychiatric Social Workers, cautioned, "If we include these [diverse social policy] problems as 'preventive psychiatry,' then all problems of life and living fall into the province of the practice of medicine."^[22] Her reservations, although they stand out to the contemporary reader, were buried at the time in the avalanche of certainty that clinicians could be trusted to discover the solutions to "all problems of life and living."

Almost as rare as dissenting expert testimony was nonexpert opinion. One consumer, a Marine Corps aviator, added the drama of personal witness to the congressional proceedings. Captain Robert Nystrom, who had recently recovered from manic depression, described what he had learned during his five-month hospitalization at St. Elizabeth's. He contrasted the worthless "loafer's delight" treatment he received initially with the "sort of streamlined psychoanalysis" that eventually helped him develop insight and recover function during two weekly sessions with a therapist.^[23] If the NMHA were not passed, he warned, do-nothing remedies would be the awful fate of all Americans afflicted with debilitating mental troubles, and the country would be the worse for it. His story made a deep impression.^[24]

The message that decisive federal action on mental health was both imperative and intelligent got through to policy-makers and politicians. According to Senator Claude Pepper (D-Fla.), the main sponsor of the legislation in the Senate, "the enormous pressures of the times, the catastrophic world war which ended in victory a few months ago, and the difficult period of reorientation and reconstruction, in which we have as yet achieved no victory, have resulted in an alarming increase in the incidence of mental disease and neuropsychiatric maladjustments among our people."^[25] With "the improvement of the mental health of the people of the United States" as its stated goal, the NMHA was signed into law by President Truman on 3 July 1946. It provided financial support for research into psychological disorders, professional training, and grants to states for mental health centers and clinics. According to William Menninger, the salutary results of federal largesse were felt almost immediately. Within one year, every state had designated a state mental health authority, 42 states had submitted comprehensive mental health plans to the federal government, 59 training and 32 research grants had been awarded, and 212 students were on their way to becoming clinical professionals thanks to federal stipends.^[26]

The NMHA also laid the groundwork for the National Institute of Mental Health (NIMH) and authorized funds for its construction. The NIMH, when it was formally established in 1949, replaced the Public Health Service Division of Mental Hygiene and was placed under the administrative umbrella of the National Institutes of Health. Robert Felix was named its first director. Publicly allied with reformers like Menninger and reform organizations like the Group for the Advancement of Psychiatry, Felix faithfully steered the new agency on the course that World War II and professional ambitions had specified. At

the outset, he summed up his purpose as follows: "The guiding philosophy which permeates the activities of the National Institute of Mental Health is that prevention of mental illness, and the production of positive mental health, is an attainable goal."^[27] This optimistic, preventive vision inspired Felix "to help the individual by helping the community"—an apt slogan for the community mental health movements that would shortly materialize on the cutting edge of clinical work.^[28] By the time he retired in 1964, Felix had been widely credited with prodding the federal government out of the dark ages of indifference toward mental illness and health.

As a result of its preventive, community-sensitive orientation, the NIMH became the key institutional patron of an expansive (and expensive) mental health program during the postwar decades, one that consciously mingled the insights of clinical expertise and behavioral science. Felix appointed a panel of social science consultants as soon as the NIMH was founded and charged members with recommending ways that interdisciplinary social research could further the goal of national mental health. He named several individuals to the panel who had played key wartime roles, championing the utilization of clinical theories to achieve practical policy aims. Margaret Mead, Ronald Lippitt, and Lawrence K. Frank were among them.^[29]

The abundant and ever-increasing funds that the NIMH offered to psychological professionals were an important reason for the healthy economy in mental health fields in the 1950s and 1960s. During 1950, its first year of operation, the NIMH budget was $8.7 million. Ten years later, it was over $100 million, and by 1967, it was $315 million.^[30] In 1947 total federal expenditures for health-related research of all kinds had been around $27 million.^[31] As the government's research program expanded in the years after World War II, far outstripping private sources of funding, the proportion devoted to mental health increased dramatically. In 1947 it was allotted a mere 1.5 percent of federal medical research dollars; just four years later, in 1951, its share had risen to almost 6.5 percent.^[32] Only four other areas of medical research were granted more money than mental health in the five years after the war: general medical problems, heart disease, infectious disease, and cancer.^[33] By the early 1960s, mental health had outpaced heart disease, but the precipitous rise in available dollars did little to silence critics of government spending priorities, who continued to insist that the public research investment in mental health was shortsighted and stingy when compared to the costs of mental illness.^[34]

Although hardly in a position to be as generous as the Department

of Defense, the NIMH was nevertheless a major benefactor of fundamental research in the social and behavioral sciences by the late 1960s. On the theory that any and all research related to mental health deserved support, the NIMH financed everything from anthropological fieldwork abroad to quantitative sociological "reports on happiness" at home.^[35] Its impact was felt on research concerned with racial identity, conflict, and violence and it gave staff and other resources to the Kerner Commission investigations, as we have already seen.

By the early 1960s, NIMH was spending significantly more on psychological and cultural studies of behavior than it was on conventional medical inquiries into the biological basis of mental disease.^[36] In 1964, 60 percent of NIMH research funds were given to psychologists, sociologists, anthropologists, and epidemiologists; only 15 percent of the budget went to psychiatry, with an additional 21 percent going to other biologically oriented sciences.^[37] Such conspicuously social priorities were compatible with the community emphasis of mental health research and practice, the enhanced status of behavioral science, and the dominance of psychodynamic perspectives among clinicians during the 1950s and early 1960s.