The State as Healer: Mental Health as Public Policy

Taking charge of unpredictable emotions and reactions in persons and populations had not been merely, or even mainly, a humanitarian effort during the war years, nor would it be one after 1945. If at times it was presented as a matter of sheer altruism, it really was not. The job of maintaining mass emotional control was decisively taken up by the federal government in the postwar decades because it was understood that mental health was necessary to the efficacy of the armed forces in the short run and national security, domestic tranquillity, and economic competitiveness in the long run. Who could forget the shocking epidemic of emotional disorder and disability exposed during World War II? Ensuring a sufficient threshold of mental stabil-

ity, because that threshold undergirded the integrity of social institutions, became a new and important sphere of federal action in the postwar decades.^[3]

Prior to the war, public accountability for disturbed psychological life had rested largely with individual states, which provided an uneven patchwork of custodial services to the mentally ill in segregated institutions. After the war, federal policy-makers absorbed the lesson that it was more efficient, forward-looking, and quite possibly cheaper to take preventive action on behalf of mental health than face the demoralizing, long-term prospect of treating the chronically sick. Asylums would continue to exist, of course, and states would have to sustain and even improve them. The federal government, however, would design its new role on the basis of what clinicians believed they had learned during World War II: that mental health and illness were relative, rather than fixed states; that mental illness could be prevented with early, assertive clinical intervention; that normal adjustment to internal and external strains was a lifelong project, never permanently accomplished and always in need of vigilance.

Above all, federal mental health policy after 1945 was built on and furthered the integration of clinical and social-scientific insights, helping to merge the concerns of emotional guides and social engineers, so that by the late 1960s, movements for community mental health had effectively undermined the legitimacy of distinctions between private emotions and public policy, between clinical work and the business of politics and government.

The Role of the Veterans Administration

Even before the end of World War II, the record of the Veterans Administration (VA) clearly indicated that some federal agencies were prepared, even eager, to support vast new programs in the mental health field. The VA, of course, had little choice in the matter; next to the armed forces themselves, it was the agency whose primary job was to care for war casualties. Since huge numbers of those casualties had suffered psychiatric breakdown, the VA found itself in charge of binding more mental than physical wounds and picking up the emotional pieces of military conflict.

The number of psychiatric cases in VA hospitals almost doubled between 1940 and 1948.^[4] Right after the war, in April 1946, around 60

percent of all VA patients were neuropsychiatric cases of one sort or another: forty-four thousand out of a total of seventy-four thousand.^[5] Fifty percent of all disability pensions were being paid to psychiatric casualties and, by June 1947, the monthly cost of such psychiatric pensions was $20 million, with each case running the government something more than $40,000.^[6] The VA's fifty-seven outpatient clinics served over one hundred thousand additional people. By the mid-1950s, half of all the hospital beds in the country were being occupied by persons with mental illness, a fact called the "greatest single problem in the nation's health picture" by the March 1955 Hoover Commission study of federal medical services.^[7] The VA, alone responsible for 10 percent of the inpatient total and providing ongoing treatment to thousands upon thousands of outpatients, was making ambitious plans for new construction of hospitals and clinics.^[8] Waiting lists for clinical services were long and growing rapidly.

Because personnel shortages had been so severe during the war, and psychiatrists, psychologists, and other clinicians were so scarce, professional training soon became "the most pressing medical problem" facing the agency, according to Dr. Daniel Blain, chief of psychiatry in the VA.^[9] Indeed, more open positions existed in the VA at war's end for clinical psychologists than there were clinical psychologists in the entire country. In order to cope with the prospect of drastic, long-term personnel shortages, programs of professional education were swiftly put into place.

An ambitious four-year training program in clinical psychology, for example, was launched in 1946 to train two hundred individuals in twenty-two different universities.^[10] Under the terms of the program, students were given free educations and prorated salaries in exchange for half-time work in a VA facility while they pursued their doctoral degrees. This instantly made the VA the single largest employer of these professionals in the entire country. In 1946, the VA's chief of clinical psychology wrote, "The significant and inevitable consequence of this development is that a large portion of the whole profession of clinical psychology will come under Governmental control. . . . The field is rapidly expanding and the opportunities for service and research are almost limitless."^[11] The VA continued to produce hundreds of new clinicians each year, all of whom could expect interesting work and substantial pay in a job market where their skills were in high demand. Just three years into the clinical psychology program, it had expanded to seven hundred students in forty-one universities.^[12] This pattern of steady

growth, which lasted for decades, ensured that the VA would remain the source of plentiful, exciting professional opportunities and contributed to a massive shift in employment patterns within psychology away from academia and toward clinical work. The year 1962 was, R. C. Tryon noted, "a real turning point" because psychologists employed outside of universities outnumbered their academic colleagues for the first time.^[13] Opportunities were not limited to clinical psychology. By the mid-1950s, the VA was employing 10 percent of all psychiatrists in its 35 psychiatric hospitals, 75 general hospitals with psychiatric services, and 62 mental health clinics; another 10 percent of psychiatrists worked as VA consultants.^[14]

The VA proved a bonanza not only for clinical professionals. It was also the site of increased consumer demand. Veterans and members of veterans' families, most exposed to clinical expertise for the first time during the war, were the first to come looking for assistance with the ordinary—if still extremely difficult—problems of postwar living. It must be recalled that the vast majority of veterans who received discharges for psychiatric reasons were classified as suffering from the lower orders of mental disturbance: psychoneurosis rather than psychosis. These veterans and others tended to bring "normal" problems to the attention of VA clinicians: marital tensions and parenting difficulties were especially common.^[15]

Some veterans undoubtedly remained skeptical that professional helpers could be of any practical use. If the statistics on skyrocketing numbers of VA outpatients are any indication, however, many others had received the message that had been directed at them repeatedly as soldiers: nothing was wrong with seeking psychological help; in fact, to do so was a sign of unusual strength and maturity. Quite a few clinicians who worried about the logistical headaches of servicing millions of returning soldiers reminded themselves that offering clinical assistance to the civilian masses was the logical follow-up to their earlier patriotic contributions in the military. Dispensing psychotherapy to veterans was the link connecting clinicians' past to their future.

Psychotherapy could also advance the process of social readjustment to peacetime democracy. Carl Rogers, for example, was a clinician who would become a well-known advocate of humanistic psychology in the postwar decades. In 1946 he coauthored a counseling manual, Counseling With Returned Servicemen, that he hoped would put simple, do-it-yourself therapeutic techniques into the hands of thousands of new clinicians so that they might ease the adjustment traumas of returning

servicemen whose subjection to strict military authority had temporarily unfitted them for their postwar roles as free-thinking, independent citizens. He spelled out the social relevance of their collective task as follows: "No longer is he just another G. I. Joe. Instead he again becomes Bill Hanks or Harry Williams. In contrast to marching troops who are 'men without faces,' the client begins to resume selfhood as a specific, unique individual."^[16] Not only did Rogers promise that his particular brand of sensitive, nonjudgmental clinical help could facilitate the resumption of selfhood and individuality. It could also help to recapture any democratic impulses that had been lost in the crush of wartime regimentation, and perhaps even generate attractive new styles of democratic conduct and decision making in individuals who had never previously possessed them. "All the characteristics of this type of counseling," Rogers contended, "are also tenets of democracy."^[17] Surely a voluntary therapeutic relationship consciously imbued with tolerance and respect, based on confidence in individual maturity, freedom, and responsibility, might succeed in communicating some of these virtues to veterans.

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.

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.^[38] 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."^[39] 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.^[40]

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.^[41]

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."^[42]

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 .^[43]

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.^[44] 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.^[45]

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.^[46] 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."^[47]

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.^[48]

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."^[49] Then he proclaimed that "an ounce of prevention is worth more than a pound of cure."^[50] 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."^[51] 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.^[52] 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."^[53]

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.^[54]

[Full Size]

Figure 16. President Kennedy addressing Congress on 5 February
1963 on the subject of mental illness and retardation.
Photo: No. AR 7698A in the John F. Kennedy Library.

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."^[55] A typical formulation of community psychology simply identified it with the "optimal realization of human potential through planned social action."^[56]

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."^[57]

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.^[58] 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.^[59]

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."^[60] 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.