Community mental health: A review

PREVENTIVE MEDICINE 4, 37-46 (1975)

Community Mental Health: A Review

DONALD SCHWARTZ

Neuropsychiatric Institute, UCLA Center for the Health Sciences, Los Angeles, California 90024

Community mental health is the public health aspect of the mental health field. It is inhabited by a variety of mental health professionals in addition to psychiatrists; but it is inhabited also by social scientists, economists, politicians, social reformers, ex-patients and their families, and ordinary citizens. It needs to be differentiated from community psychiatry (which is the kind of psychiatry practiced by social system-oriented psychiatrists) and social psychiatry (which is really an interdiscipline in academia, comprising social scientists and psychiatrists who are concerned with understanding the ways in which behavioral sci- ence data illuminate human behavior, ordered and disordered). Community mental health has developed in full form largely in the past two decades, although its roots go far back in history beyond our own era. The particular themes which are intertwined in the matrix of community mental health are: (1) moral treatment, the focus on humane and humanistic approaches to the mentally disordered, and protection of their rights as citizens; (2) prevention of illness or of its consequences, the preventive medicine of psychiatry; (3) new devel- opments and improvements in the techniques of clinical services in mental health care; and (4) The social concept of the right to health care, as it pertains to mental health programs and needs. The process by which these themes have been interwoven is one which has gone on at both federal and state-local levels, but the more enduring and significant process is that at the state-local level, as most extensively exemplified in the California system.

INTRODUCTION

The idea of prevention is certainly not new in American psychiatry. It goes back many years (3,&z). But the systematic application of clinical styles and methodologies for the purpose of prevention on a broad national scale is new. And this preventive focus is one major element of the social process which has come to be called community mental health.

Community mental health is sometimes confused with community psychiatry and social psychiatry, two related fields which are not, however, the same thing. Unfortunately, those three labels, social psychiatry, community psychiatry and community mental health, have been used by different people in rather different ways. Let me begin, then, by saying how I will use them in this article. I see social psychiatry as the least clear and most difficult thing to define. It is not a kind of psychiatry at all but rather an illustration of the egocentric tendency of psychiatry to conceive of everything it touches as being a part of itself. Social psychiatry, as I will use it, designates the point of intersection of psychiatry, anthropology, sociology, psychology and (to a lesser extent) of other academic disciplines which may have contributions to make to the attempt to understand the many-faceted expression of human behavior-in-the-social-milieu. It is a pre- dominantly academic creature since it exists largely in university settings where the many disciplines involved come into close contact with each other. Its

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38 DONALD SCHWARTZ

primary products are theoretical and research endeavors rather than pragmatic human services. But social psychiatry has fostered a point of view: the notion that the social systems and the broad culture in which humans exist play significant parts in determining their behavior.

Since psychiatry is very much concerned with that behavior and the un- derlying psychological and biological determinants of it, many psychiatrists have been influenced by the social psychiatric point of view. The influence of that point of view on the nature of clinical psychiatric practice has led to the emergence of what I would call community psychiatry. It is a form of psychiatric (medical) practice. Clinical psychology has also been influenced by what I am calling the social psychiatric point of view and many clinical psychologists, therefore, practice community psychology, a term which may be understood as precisely analogous to my definition of community psychiatry, just above. Social workers have even stronger roots in the social sciences than either psychiatrists or psychologists. But it would be absurd to suggest the pertinance of a “community social work” because all social work has been influenced by the social psychiatric point of view. In a sense, community psychiatry and community psychology represent invasion into the territory of classical social work by a couple of professions which did not grow up there.

Implicit in the preceding discussion is the fact that the three traditional mental health disciplines, psychology, social work, and psychiatry, are involved together in efforts which are influenced by the social psychiatric point of view. But so are a variety of other professionals. Nursing has always been involved with hospital psychiatry but it has been becoming more and more involved with psychiatry in the community. The ministry has been closely concerned with human distress and a survey for the Joint Commission on Mental Illness and Health (7) noted that people with mental health problems were more likely to seek out religious practitioners than health practitioners. The attempts to develop better and more community-based mental health programs have involved public agencies and government apparatuses, since the latter were charged with the responsibility for operating such programs. Politicians and political scientists, economists and fiscal experts became involved, as did social and political activists and representatives of the news media. The involvement of so many and such different kinds of people in the area of mental health service delivery has led to a conglomerate field inhabited by many of the laity, including ex-patients, along with mental health clinicians, social scientists, and all those others whose fields of expertise and concern touch on mental health service delivery. It is to this conglomerate field, labeled “community mental health,” that the balance of this article will be addressed.

HISTORICAL ROOTS

History, it has been claimed (I), unfolds in a spiral fashion, alternating con- stantly between poles while it slowly advances with each revolution. Moral treatment in psychiatry is an apt illustration of that process of evolution through revolution. Moral treatment is thought of chiefly as the method of Philippe Pine1 in France in the late eighteenth century, Pine1 unchained the lunatics of the

COMMUNITY MENTAL HEALTH 39

French asylums and urged that they be treated with human kindness. But the treatment of the mentally disordered in the Greek temples of the pre-Christian era and the Arabian asylums of the middle ages were as much applications of moral treatment as was the work of Pine1 and the Tukes in England. And the current concern for restoration of freedom and civil rights of the hospitalized mentally ill (which is a part of the community mental health movement that we know) is moral treatment rediscovered.

I will not attempt to be exhaustive in this review but only to tease out some of the roots of the movement which has arisen over the past three quarters of a century and achieved full bloom in the past decade and a half. There are four principal themes that need to be examined. These are: (1) moral treatment; (2) prevention; (3) improved clinical services; and (4) the right to health care. The current state of the field can be best understood by understanding the process of those four elements.

MORAL TREATMENT

The mentally ill in American institutions were not chained in dungeons. But many of them had been committed for indeterminate periods of time to under- budgeted over-crowded state hospitals whose stat% had come to be demoralized by the lack of societal concern for and support of the facilities where they worked. Treatment was little available and the state hospitals in most states had come to be custodially oriented. Illnesses which might have been treatable under better circumstances had been allowed to become chronic. Facilities for treating acute illnesses in the community were available primarily for those who could af- ford private treatment. Not only the mentally ill were sent to state hospitals. A variety of other people for whose problems there were no adequate community facilities were also sent there. And since they were sent to state hospitals, there was no need to develop facilities for them in the community. They included the elderly who were senile or otherwise disabled, the delinquent, and those with alcoholism and related problems. There were instances of cruelty in many state hospitals. But the greatest problem was not overt abuse; it was apathy and mindlessness in the institutions, reflecting the unconcern out in the broader community.

The community mental health movement began around the turn of the century with the work of social reformers and ex-patients who joined with professionals to form the National Committee for Mental Hygiene, the forerunner of the National Association for Mental Health. It was a social crusade aimed at improving the lot of the mentally ill. Initially social reform supported the build- ing of more state mental hospitals in order to be able to serve the needs of those uncared for. But eventually it became clear that state mental hospitals had become part of the problem.

In World War I it was discovered that immediate treatment of acute, psychiatric casualties, without displacement to rear area hospitals and delays con- sequent on that, led to less need for hospitalization. Little was done about that or other lessons of military psychiatry until World War II when they were discovered all over again. The social climate of the nation in the late 1940’s was

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very different from that in the early 1920’s. Psychoanalysis had had a consider- able impact on American psychiatrists by 1946. There had been more focus in World War II on psychiatric disqualifications from military service and on psychiatric disorders and disabilities in the service. Many physicians became inter- ested in psychiatry during their military service in the 1940’s and went into psychoanalytic training following the war. The center of gravity of American psychiatry moved from physicians in hospital practice to those in community outpatient practice. Veterans Administration psychiatric hospitals and clinics burgeoned to care for returning veterans.

Meantime the temper of the times had changed from isolationism to interven- tionism and involvement with the plight of others. The economic depression of the 1930’s which had been finally ended by the War had also changed the domi- nant American zeitgeist from rugged individuahsm to a more welfare-dominated ethos.

In this atmosphere, people became more aware of the mental hospitals and those in them. Efforts were renewed to keep people out of mental hospitals or to get them out if they had been admitted. Concern for the nature of the hospitals’ environments grew. Attention was paid to the civil disabilities imposed on invol- untary patients. Albert Deutsch continued the leading role that members of the press had earlier played in the community mental health movement. His two books (5,6) traced the history of and laid bare the distressing conditions of the country’s mental institutions. Some of those in community mental health later came to denounce the use of hospitals under any circumstances and they became seen as evils in themselves, rather than as evil because of what had been often done in them. By now a degree of overkill has developed in the area of hospital reform in that hospitals have been made more therapeutic while, at the same time, less accessible to people.

For years, it had been a repeated cry that half of the hospital beds in the country were psychiatric beds. Although one still hears this statement being made, it is no longer true. By 1972 (la), the percentage had gone from 50% to 33% and the decrease is continuing for the most part. It should be pointed out that not all of this decrease has resulted from the substitution of more effective community-based treatment for hospital care. A great deal was probably a result of the revolution in psychopharmacology that has been one element of the community mental health scene.

The experience of military psychiatry had demonstrated that brief intervention at moments of stress and breakdown led to more rapid improvement and dimin- ished chronicity and disability. This was true even if the intervenor was less well trained and professionally competent than were the personnel who would have taken care of the patient had his treatment been delayed until he could be moved to the rear. In other words, it began to be felt that the best treatment with respect to outcome criteria was that which was quickest and which displaced the patient least from the familiar settings of his life.

PREVENTION

Mental hospital reform is closely related to the preventive theme for several reasons. In the first place, to the extent that hospitalization and hospital life


promote chronicity and dependency, the avoidance or shortening of hospitalization and the improvement of the quality of hospital life prevent the development of that chronicity and dependency. The early treatment programs (such as crisis intervention centers) which have been set up as ways of averting hospitalization are typical of the preventive approach in community mental health.

The experiences of military psychiatry are all aspects of preventive psychiatry. They have led, in community mental health, to the idea that immediate and nondislocating treatment programs for people under stress are preventive of illness and disability. It is implicit but should perhaps be made more explicit that “prevention” in this sense means the whole of Gerald Caplan’s (2) hierarchy of preventions: primary, secondary, and tertiary. Primary prevention, the prevention of the occurrence of illness, is honored more in rhetoric than in the delivery of mental health services. Community mental health has delivered more in the realms of prevention of chronicity by prompt treatment (secondary prevention) or the minimization of handicap and disability resulting from chronic illness (tertiary prevention).

One reason for the focus on prevention is the problem of resources and their limitations. Community mental health advocates have tried to apply the lessons and precepts of public health to psychiatry. Recognizing that the great advances in physical health stemmed from public health measures which promoted immu- nity from diseases or elimination of environmental hazards, they have looked for ways of developing a public health psychiatry. There will never be enough pro- fessional personnel to treat all the mental disorders that exist in the community. Therefore, prevention becomes an urgently needed means of bringing the level of need into correspondence with the level of resources for service-provision. Effectiveness of treatment is one form of prevention, leading us to that theme in community mental health.

IMPROVED CLINICAL SERVICE

Improvement in clinical service subsumes several issues. There have been new methodologies of treatment developed which have contributed; there have been improved methods of delivering service to those who need it; and there have been efforts at better organization and coordination of services. (The last will be dealt with later in this paper.)

The development of major tranquilizers was a giant step in the emptying of the mental hospitals, since those drugs permitted control of the major behavioral concomitants of psychoses. This enabled brief hospitalization to suffice for many patients in bringing their illnesses under some degree of control. Though still psychotic, patients may be able to be returned to their homes while treatment proceeds. Many chronically ill patients have been able to be transferred from mental hospitals to community residential facilities for ongoing care and manage- ment.

Crisis intervention services have been a major element of community programs. They grew out of expediency for the most part but a body of theory has developed to explain why they are effective. The basic concept of crisis intervention was derived from the military experience cited above that quick treatment on the spot was better than longer and more expert intervention provided

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only after delays and sequestration from familiar surroundings. As more and more was seen of crisis intervention, it was hypothesized that the crisis state was an unstable state in which character defenses had broken down, permitting intervention to have much greater effect than would be the case in the person with all his usual defenses around him. This has been intensively expounded by G. Caplan (2).

One of the outgrowths of crisis intervention has been mental health consultation, another approach which represents both improved service delivery and the preventive focus. In brief the idea behind mental health consultation was that non-mental health personnel in a variety of community agencies and settings served as the first line of support in life crises that either had led to or could lead to mental disorders. If those “community caregivers” could be provided consultation with mental health experts, perhaps they could serve the mental health needs of their clients themselves. Moreover, many people who might really need specialized mental health care would rzor accept it; yet they were willing to continue in contact with family doctor, minister, welfare worker or other supportive resource people in the community.

The development of behavioral treatment methods has been another move in the direction of spreading resources more widely, although behavioral treatment is not generally thought of as part of community mental health. Behavior modification is most often a brief treatment method. It is often more acceptable to patients than are other modes of therapy, since behavior modification uses a teaching and learning model and can be thought of as adult education. Modifica- tion of behavior generally does not require expertise in its application, but primarily in its prescription. It can be taught to subprofessionals or paraprofessionals, or to family members and patients themselves. Some workers have made behavior treatment the keystone of community mental health programs (9).

The very fact that behavior modification programs are so effective has led to the development of fears of their misuse. The specter of political use of potent methods of behavior control haunts many who are concerned with the ethics of medical care. Companionate to the fear of behavioral control is the terror of biological modes of treatment which are around the corner, as equipment becomes ever more sophisticated and methodologies more refined.

THE RIGHT TO HEALTH CARE

Recently the issue has been raised that patients who are involuntarily hospitalized have the right to proper treatment; they cannot be hospitalized on the basis of a need for treatment and then provided only with custodial care. It may say something about our priorities that this issue has only been raised recently. Curran (4) pointed out that for years the law was only concerned with the issue of who might properly be hospitalized and who might not. But, he said, once it was determined that a person might properly be hospitalized, all legal interest in what happened to him disappeared.

The right to treatment for involuntarily hospitalized patients may be a matter of concern now because of the developing feeling that health care in general is a right of all people. Until recently, this was a disputed point in this country, perhaps largely because the idea that health care was a right seemed to carry


with it the idea that all people might be entitled to equity in the provision of health care. If it is a right, why should anyone get more of it than anyone else? That would suggest state medicine as the remedy for deprivation of health care rights, a solution that few of the powerful forces in the health field would en- dorse. In fact, the right to health care does nor connote the right to equity of care, at least not to most of those who now espouse it. (It is also of interest to the mental health professionals that many of the national health insurance proposals do not include mental health benefits.)

The right to health care is of special concern in the mental health field since the disparity of human resources and needs is very great there. Even if money could be found to pay for as much mental health care as everyone deserved, the existing mental health professionals could not supply it because there are not enough of them. This has led to expansions of the “therapist pool” in mental health. Mental health nursing has developed psychiatric nurses as therapists and psychiatric technicians and other nursing personnel have been trained for similar tasks. There has been great interest in the development of paraprofessional therapists, people with no formal academic preparation for providing health care but who are provided with academic and practicum instruction in human services and who then serve as direct care-givers to mental health patients. This has led to a host of problems, one of which is whether the solution to inadequate resources is to be the provision of a corps of “second class therapists” for the poor while the affluent retain the bulk of the high-status professionals.

The right to health care in the mental health field is, then, subject to the ques- tions: (1.) how much care?, (2) what kind?, and (3) from whom?

ORGANIZATION AND COORDINATION

The essence of the community mental health position is that services ought to be provided at the local community level, in context with other community services. One element of the community mental health movement has been the legislative and public administrative approaches toward promoting local mental health services of high quality and effectiveness. It needs to be recalled that Dorothea Dix and other mental health pioneers urged the development of state hospital systems largely because the care then being provided by local jurisdictions was inadequate, inhumane, and inequitable. By the 1950’s the states had been locked into responsibility for mental health services and local jurisdictions saw it as none of their affair. That all this has changed as much as it has in the past two decades has resulted from two principal political consequences of the social pressures for community mental health. On the federal level, the Kennedy and Johnson administrations picked up the recommendations of the Joint Com- mission on Mental Illness and Health (originally appointed by President Eisen- hower) and translated them into a national program to encourage and promote the development of community-planned and operated mental health programs aimed at small aliquots of population (75,000-200,000) and providing integrated services in multiple modalities. Although the Nixon administration has done its best to stop the expansion of the program, several hundred of the hoped-for 2000 community mental health centers have been built and staffed.

More substantial in actual size and scope have been the efforts of the states.

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New York was the first and California has developed the most extensive community mental health program, but most of the states have some kind of program. The standard approach is that the state encourages local jurisdictions to develop mental health programs, with the state sharing in or totally underwriting the ex- pense of doing so. The specific methods have varied tremendously. The Cali- fornia experience which Karno and I have reviewed extensively (86) represents the boldest approach, wherein the original encouragement to local jurisdictions eventually became a mundute with the force of law.

AND NOW WHERE?

Community mental health programs are now past their early momentum. It is appropriate to wonder where this field may be headed in its next few decades. In spite of the tendency for crystal balls to cloud up, I can hazard a few guesses at what may lie ahead.

In some areas of the country, the emphasis on alternatives to hospitalization has been pressed with such fervor as to deny the appropriateness of hospitalization under any circumstances. (California is probably the best example of that.) In those areas, we can expect some backswing of the pendulum. Indeed, in California, plans of the State Health Department for further closures of state- operated hospitals have been halted for the moment in response to citizen resis- tance as evidences of inappropriate avoidance of hospitalization have mounted. In most parts of the United States, however, the search for appropriate alternatives to inpatient treatment has not proceeded far enough and it should be expected to continue. Although the rhetoric of the community mental health movement argued decreased costs as a major justification for avoidance of hospitalization, the reality of community programs does not support that rationale. Community alternatives to traditional custodial hospitalization are more expensive, not cheaper, than simple custody. The more incisive reason to expect active development of alternatives to hospitalization is a newcomer to the mental health field: the class action suit. Suits to enforce patients’ rights to treatment, as opposed to mere custody, have been filed and won and court compulsion to make public hospitals truly therapeutic would threaten the financial stability of most states. Out of simple financial self-defense, state mental health authorities will need to find less expensive alternatives than therapeutic hospitalization.

One of the main props of community mental health has been psychopharmacology: the increasing availability of drugs that can control disabling symptoms of mental disorder. Pharmacology is only one aspect of the advancing edge of neuropsychiatry. As technology improves in the health field, the biological aspect of psychiatry will command more and more attention. This bio- logization of psychiatry will serve to bring it closer to the mainstream of medicine. It will also raise increasing anxiety among those concerned with the ethics of medicine. The current furor about the use of psychosurgery is one manifesta- tion of concerns about the dangers of biotechnology. As drugs and other physical modalities of psychiatric treatment become better developed, there will be increasing concern about their possible misuse.


As noted above, the effectiveness of behavioral treatment methods has raised similar concern about their possible misuse, as fictionally exemplified by the novel and its film version, A Clockwork Orange, by Anthony Burgess. Because people are sensitive to the idea of tampering with the human mind, we can expect that the only treatments whose ethical implications will escape scrutiny are the ineffective ones. Any effective treatment is subject to abuse and when the abuse involves the mind it will arouse anxiety.

Health care delivery in the near future will be greatly influenced by the form taken by national health insurance. How psychiatry and the other mental health disciplines will fare under such a system is not yet clear. Some proposals ignore mental health entirely and some propose coverage far more limited than that provided other specialty health areas. Psychiatrists will be driven closer to their medical brethren by financial considerations than they have been by more senti- mental appeals. How other mental health practitioners will be covered by national health insurance is even less clear. One aspect of mental health service delivery has been the use of paraprofessional mental health workers without conventional academic credentials. What status they will have under federal health programs is most unclear.

As the job market tightens, the comradeship of traditional mental health workers may become strained since there may not be enough jobs to go around. Under such circumstances, the paraprofessionals as the newest members of the team may well be squeezed back out of the labor market.

It is even harder to guess what organizational form the health system may take under national health insurance. The costs of providing broader coverage through individual practitioners may be so great as to lead to intense pressure by government to develop prepaid mechanisms or other organized forms of health delivery systems. If so, the future of the federally sponsored and encouraged community mental health centers may depend on the degree to which they can make themselves useful to and compatible with whatever overall health organi- zations are formed.

Whatever may be its fate in the coming decades, the community mental health movement has served a useful purpose in bringing the mental health disciplines and facilities closer to health care in general. It has developed a public health orientation in psychiatry and moved mental institutions back toward the principles of moral treatment. These are no mean accomplishments.

REFERENCES

1. Von Rertalanffy, L. “Robots, Men & Minds,” p. 60, Braziller, New York, 1969. 2. Caplan, G. “Principles of Preventive Psychiatry,” p. 34-55, Basic Books, New York, 1964. 3. Caplan, R. B. “Psychiatry and the Community in Nineteenth Century America,” (see, e.g., p.

14), Basic Books, New York, 1969. 4. Curran, W. J. Community mental health and the commitment laws: a radical new approach is

needed. Amer. J. Pub. Health 57, 1565-1570, (1967). 5. Deutsch, A. “The Mentally 111 in America,” Columbia University Press, New York, 1937. 6. Deutsch, A. “The Shame of the States,” Harcourt, Brace, New York, 1948. 7. Gurin, G., Veroff, J., and Feld, S. “Americans View Their Mental Health,” Joint Commission

on Mental Health, Monograph Series, No. 4, Basic Books, New York, 1960.

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8. Karno, M., and Schwartz, D. A. ‘Community Mental Health: Reflections and Explorations,” (a) pp. 7-12; (b) Chapter 3, Spectrum Publications, New York, 1974.

9. Liberman, R. Community mental health and behavior modification, in “Advances in Behavior Therapy” (R. Rubin, J. Henderson, and D. Pumroy, Eds.), Academic Press, New York, 1973.

10. Socioeconomic Issues of Health, Reference Data, Table 17, p. 48, American Medical Associa- tion, Chicago, 1972.

Community mental health: A review

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