A Developmental View of the Comprehensive Community Mental Health Concept Michael J. Austin, M.S.W.
ABSTRACT: Apprehension and doubt about the Comprehensive Community Mental Health Center (CCMHC) service programs are felt by both mental health professionals and local and state government officials who have yet to see the comprehensive center operate independent of Federal financial support and consistent with the concept of total service. Critics and pessimists must recognize that the CCMHC must initially establish and maintain itself amid a network of local social and rehabilitation agencies before the goals spelled out as essential elements of service can be achieved. It is suggested that there are critical factors that affect the evolvement from Phase z, in which the CCMHC directs attention to its own survival, to Phase 2, when the CCMHC can begin to deal effectively with the local problems of mental health. The various mental health service models developed under the stimulus of Federal legislation, by their very nature, suggest both the uncertainty and the hope of the mental health professions and the local communities as to the best way to handle the problems of mental illness. Will the new comprehensive centers reduce the need for state hospitals? Is it possible that the comprehensive centers will make their most significant impact in making services available to a new and unserved segment of society? Or will the centers serve to reduce the custodial and welfare functions of state hospitals by helping people remain in their communities for treatment and thus leave the state hospitals to develop into specialized treatment facilities? In any event, with the recent reaffirmation of Congress on continuing Federal support for another five years, it appears that communitybased mental health services have received the interest and sanction of the American public to continue with the further development of comprehensive local mental health centers. Mr. Austin, 2363 Sherbrook St., Pittsburgh, Pa. I5~z 7, is a doctoral candidate in social work research and public health, University of Pittsburgh. At the time this paper was written he was a consultant in social work at the National Institute of Mental Health, Region VIII, Denver, Colorado. This paper was presented, in part, to the third annual Joint Meeting of the Clinical Society and the Commissioned Officers Association of the U.S. Public Health Service, San Francisco, March 1968. The author is indebted to Dr. Melvin B. MoguIof for the conceptual framework and schema developed in the paper. Community Mental Health Journal, Vol. 5 (2), 1969 156
Michael J. Austin
157
Little can be found in the Federal legislation about the concept of citizen participation. However, as a result of administrative policy developed by the National Institute of Mental Health, the concept of "community involvement" has been defined as involvement in planning, participation, and financing the community mental health center. It is interesting to note that in the earlier stages of putting the key mental health laws into operation, much time was spent in defining "comprehensive," "community" and "center," along with the on-going debate about what constitutes mental health. In addition, debate still continues over the concepts of accessibility of services (catchment areas to serve populations of 75,0oo to 2oo,ooo), continuity of care (flexible use of the elements of service to meet the changing needs of patients), and the issues of a reasonable volume of services to persons unable to pay. These concepts are slowly becoming operational in successful comprehensive centers. The concept of on-going citizen participation in program development and implementation has generally not received the same attention as has the establishment of specific elements of service. Often efforts to operationalize these concepts on the local level have been far from comprehensive and many appear, at present, to reflect more of a piecemeal approach. In fact, what seems to be taking place is the expansion of traditional local outpatient services to meet the needs of a population with mildly impaired mental health. To effect meaningful social change, the mental health system, both local and state, must change or be changed. Evidence is seen with the rising budgets of state hospitals, and the declining resident populations, of the lack of understanding of how to reconstruct a mental health system (state and local) to meet current community needs. Even locally, the comprehensive centers have tended to adapt the local mental health patient population to the interests of the professionals and not to alter the service delivery system to meet the needs of the patients. As a result, a frequent initial occurrence is that comprehensive centers seem to be aimed at adapting patients to current arrangements rather than at changing the arrangements. RHETORIC SURROUNDING A NEW PROGRAM While it is not difficult to cite the problems and inadequacies of the local comprehensive center, the various accomplishments can be cited with ease, as well. Innovations in local adolescent treatment programs as seen in specialized foster treatment homes, decentralized neighborhood-based outpatient services, and 24-hour emergency services and suicide prevention programs, can be cited as innovations in service delivery which have evolved in large part from the comprehensive center experience (Kellam & Schiff, 2966 ). These developments, as well as expanded uses of consultation and education, have broadened a community's capacity to deal with mental health problems. Both the criticism and praise of the comprehensive center concept with respect to the goals cited in the Federal legisla-
158
Community Mental Health Journal
tion tend to obscure the important need of viewing the development of such centers within the context of some realistic expectations with respect to what a comprehensive community mental health center (CCMHC) can do within a given period of time. It is crucial to recognize the initial scope of influence possessed by a CCMHC and its necessary preoccupation "to deal initially with the need to establish and maintain itself." As Mogulof points out in similar fashion with respect to the OEO community action program, "it must demonstrate its credibility as an agency by winning funds; it must legitimate itself with the organizations in its environment" (Mogulof, i967). The parallels between the CAP and the CCMHC are striking and, as McNeil points out, "as far as society is concerned, poverty and community mental health are opposite sides of the same coin" (McNeil, I966 ). A DEVELOPMENTAL VIEW The focus of this paper is to point out the merit of a developmental view in an effort to counter the criticism, the over-optimism, and the frustrations experienced by professionals and laymen alike in establishing and maintaining a CCMHC. It is suggested that during the initial organizational phase of a CCMHC, it is "entirely normal for the concepts of 'establishment' and 'maintenance' to dominate the agency's efforts" (Mogulof, i967). With "establishment" and "maintenance" concepts as key elements of Phase 5, it is then conceivable to suggest that Phase 2 will be devoted to the realization of such concepts as "comprehensive," "accessible," "innovation," "continuity of care," and "citizen participation." In an effort to describe this developmental view, several critical factors will be cited as key influences affecting the evolution of the CCMHC from Phase 5, in which the CCMHC directs its attention to its own survival, to Phase 2, when it can begin to deal effectively with the local mental health problems. The factors selected as relating to the developmental phases indude: (a) policy-making structure, (b) state of program development, and (c) relationship of the CCMHC to organizations in its environment (Mogulof, i967). POLICY-MAKING STRUCTURE In the early stages of the development of a CCMHC, its future direction can be easily foreseen by noting the chief social engineers. In many programs the chief designer usually proves to be a mental health professional. The design of the CCMHC evolves as part of the orientation and conviction of one or several mental health professionals. In the early drafting stage, consensual support and validation are sought from both the health establishment and the political establishment. While the key health officials will lend their support and advice on the basis of a public health and/or medical model approach, the political leadership must be sold
Michael J. Austin
159
TABLE Characteristics of Phases I and 2 Phase
Phase 2 Policy-making Structure
-T. Key mental health professionals 2. Key health professionals 3. Key political leadership (mayor, county commissioner, etc.) 4. Key board members of prior mental health service
1. Broader representation of mental health professionals 2. Initial involvement of lay leaders and consumers 3. More active involvement of other agency professionals
Program Development
1. Reactive to program ideas of key mental health professionals 2. More concerned with program quantity than with visibility 3. No revealed strategy with regard to dealing with overall local mental health problems 4. Program marked by doing what is feasible 5. Program seeks to fit patients to existing arrangements
1. Reactive to program ideas of other mental health professionals and to environment z. More concerned with quality and visibility 3. Development of a priority statement and an understanding of the unique problems of mental health (introduction of prevention approaches) 4. Bolstering initially funded programs with new programs which bring in new financial resources 5. Programs consider alterations in existLag institutional arrangements for the sake of comprehensiveness and coordination 6. Program focuses on expansion of constituency for CCMHC
Relation of CCMHC to Organizations in its Environment
1. Existing organizations ignore or combat CCMHC on basis of past unreliability or fear that jurisdiction is being violated
1. CCMHC aggressively plans programs with those organizations central to its mental health program strategy z. CCMHC tends to exclude those organizations whose programs are not relevant to those people with needs for mental health services
in terms of its financial merits and will tend to "rubber stamp" the program content. The political leader will also note the benefits of services to his constituents which is a primary component (making services available to all, despite financial resources) of the CCMHC. If the CCMHC is an outgrowth of a more limited mental health service, either private or public, k e y m e m bers of a board of directors will be involved in the design. However, this role also tends to be one of consensual support and "rubber-stamping" the design of the program. The primary characteristic of Phase ~ regarding the policy-making structure is that the professionals predominate, with almost the total exclusion of citizen participation either by interested lay leadership or by consumer representatives (Table 5). In Phase 2, more attention is given to the involvement of various sectors
160
Community Mental Health Journal
of the community, as well as agency representatives, in program planning and implementation. There is also a greater sampling of opinion from mental health professionals, both working in the new CCMHC and working in related settings. As the program grows, the key mental health professionals begin to recognize the need for a constituency in order to guarantee the continuation of the new and sometimes controversial program. In Phase 2, the notions of citizen and professional advisory committees begin to take on a new meaning for the CCMHC. As a result, the policy-making structure begins to expand. The direction taken in both Phases 9 and a is highly dependent upon the professional discipline and orientation of the key mental health professional involved in the direction of the CCMHC program. As Black points out, It is true that the direction of the mental health center in setting policy will be influenced strongly by the interests of the director. If he is a clinician, the extent to which he exercises central control of core and auxiliary programs will determine for that community how broadly illness is defined. If he becomes, as Leonard Duhl suggests, "consultant to a community, an institution, or a group without being patient-oriented," a different set of middle-level policies may ensue. If he is not a psychiatrist at all, but a psychologist, social worker, or, as has been suggested by others, a newly trained medical or health administrator, a quite different set of policies based on practice may evolve (Black, I967).
PROGRAM DEVELOPMENT As has been suggested, program development in Phase is reactive primarily to the program ideas of the key mental health professionals. The distinct factors affecting the program development of Phase I can be viewed as part of the weakness of the CCMHC. Like many new programs, the CCMHC suffers initially from a lack of balanced involvement between the professionals and the lay community. P h a s e "f
In &is phase the mental heal& professionals are guided by their own conceptions of the mental heal& problems. There appears to be a greater concern with productivity and the number of recipients in their new program. This emphasis is accompanied by a de-emphasis on visibility, with the claims that "we've got more patients than we can handle" and the perennial problem of adequately staffing a program. While the key mental health professional may have ideas pertaining to the future direction of his program, there is no revealed strategy with regard to dealing with overall mental health problems in the community. Programs of prevention and the utilization of "community gate-keepers" appear to be future considerations. In dealing with the initial difficulties of getting a program off the ground, the mental health services are marked by doing what is feasible until better arrangements can be worked out. As a result of the push to get services moving, the program tends to fit the patients and their individual needs to the existing arrangements. These, then, are some of the characteristics of program development in Phase 5.
Michael J. Austin
161
Phase 2
This phase is marked by an atmosphere of "settling in." The key mental health professional is able to be more reactive to his staff and the ideas of other mental health professionals. There is a growing concern for quality of service, now that quantity has been demonstrated as feasible to the powers that be. With quality of service, there is a concern for visibility based, in part, on desire to see whether all the people have an equal opportunity to receive services. Phase 2 includes a redirection of attention toward some of the initial goals of the CCMHC and a development of a priority statement, and an understanding of the community's unique mental health problems. With such an awareness, it is then possible to introduce ideas and plans for various levels of prevention. In this phase there is a bolstering of initially funded programs with new programs which serve newly discovered program needs and bring in, as well, new financial resources. The CCMHC program also begins to consider alterations in existing institutional arrangements for the sake of more comprehensive and coordinated services to a geographically or functionally defined segment of the population, e.g., a neighborhood or children. And in this atmosphere of "settling in" there is a new-found concern for the development and expansion of a constituency for the CCMHC. It is at this point that citizen participation becomes important and new citizen and professional advisory councils are formed. Like the need for comprehensive and coordinated services, these councils are defined both geographically and functionally. The contrast and sometimes disparity between Phases x and 2 provide a basis for some of the continuing apprehension and doubt about the validity of the CCMHC. Phase I is characterized by the center's need to establish and maintain itself and to demonstrate its credibility. The process of legitimizing itself carries over into Phase z where the CCMHC can refocus its attention on its original goals, less focused on itself and survival, and more focused on "increasing the rationality" of its program with respect to its capabilities and the mental health needs of the community. RELATION TO ORGANIZATIONAL ENVIRONMENT In Phase x there is a tendency for existing organizations to either ignore or combat the CCMHC on the basis of either the past unreliability of mental health services or out of fear that the jurisdiction of their agency domain is being violated. Much energy is devoted to both explaining and defining the CCMHC program on the basis that there is plenty of work for everyone and that coordination and collaboration are crucial for the delivery of effective mental health services. In sum, Phase a is involved with separating the men from the boys on the basis of who can deliver the most effective and efficient mental health
162
Community Mental Health Journal
services. In this phase, the CCMHC aggressively plans programs with those organizations which are central to its mental health program strategy. In contrast, the CCMHC tends to exclude or withdraw support from those organizations whose programs are not relevant to those people with needs for mental health services. If Phase a experiences some success, the CCMHC will begin to assume a coordinating function for new programs with mental health content and thereby assume a broker or consultant role in the creating, operating, and funding of new programs. It will also be in a position to monitor all related programs developed by other agencies in the community. In this respect, the CCMHC will have a reverberating impact on many of the health and welfare agencies in defining policies affecting the mental health of the community and in developing and promoting new agency and professional practices. LEADERSHIP PROBLEMS In a most astute fashion, Albee (x965) has noted that in the CCMHC there is "no magic here . . . . There is nothing on the Inside except the same old performers going through the same old routines." While there is some hope found in those mental health professionals who have been able to incorporate a community organization approach into their leadership of a CCMHC program, there is a predominance of mental health personnel ill-equipped for their new roles as community clinicians. Straetz and Padilla (~966) have aptly pointed out that: Each of these professional positions has strong political consequences since the aim is obviously to restructure the mental health establishment in order to permit extensive shifts in role relationships and administrative patterns. This observation points up the need for both program evaluation and inservice training as crucial elements in the transition from Phase x to Phase z. The training component becomes essential for the mental health practitioners in Phase x as they begin to assume new practices, from expanding their skills in group treatment to learning more about community organization process as they begin to staff advisory councils. In Phase 2 even more training will be required as the mental health professionals begin to come to grips with the manpower problem. With new modes of treatment and service delivery, there will need to be employment of paraprofessionals to carry out some of the direct service and community organization functions. The effective utilization of such personnel will rely heavily on the inservice training of the professionals. The use of VISTA volunteers in some agencies has been a precursor to the problems and issues to be foreseen in the utilization of such personnel. CONCLUSION It can be assumed that no CCMHC can be clearly classified in either Phase I or 2 at any given time and that what actually happens is that the CCMHC represents a continuous mixture of the factors in either
Michael J. Austin
163
phase. What is important is the fact that the CCMHC does experience developmental phases and that the factors of survival and legitimacy plague the initial phase, with program rationality and hopefully maturity found in the second phase. It is suggested that the potential of the CCMHC lies in Phase a with the possibility of the CCMHC serving as a focal point for future social planning of the broadly defined mental health needs of a community. The concept of developmental phases is based on perception and observation and has yet to be validated. Only through thorough evaluation, documentation, and the dissemination of experience can we really know the validity and impact of a comprehensive community mental health center. The multitude of changes taking place in the community mental health movement, from new treatment modes to new types of personnel, to new types of intervention, to new definitions of mental health, and to new emphasis on rehabilitation and prevention, require all mental health professionals to be aware of the developmental view and to even speculate on the future unknown characteristics of a possible Phase 3. REFERENCES Albee, George W. No magic here. Contemporary Psychology, i965, io, 497-498. Black, Bertram J. Comprehensive community mental health services: setting social policy. Social Work, I967, ~2, 51-58. Kellam, Sheppard, & Schiff, Sheldon. The Woodlawn Mental Health Center: A Community Mental Health Center Model. Social Service Review, 5966 , 4 ~, 255-263. Mogulof, Melvin B. A developmental approach to the community action program idea. Social Work, ~967, 12, I2-2o. McNeil, Etton B. How healthy can the great society be? Transaction, i966, 3, 3 z-33. Straetz, Ralph, & Padilla, Elena. Problem oriented political science in mental health. Community Mental Health Journal, 5966, 2, zog-I:t 3.
ABSTRACT: Apprehension and doubt about the Comprehensive Community Mental Health Center (CCMHC) service programs are felt by both mental health professionals and local and state government officials who have yet to see the comprehensive center operate independent of Federal financial support and consistent with the concept of total service. Critics and pessimists must recognize that the CCMHC must initially establish and maintain itself amid a network of local social and rehabilitation agencies before the goals spelled out as essential elements of service can be achieved. It is suggested that there are critical factors that affect the evolvement from Phase z, in which the CCMHC directs attention to its own survival, to Phase 2, when the CCMHC can begin to deal effectively with the local problems of mental health. The various mental health service models developed under the stimulus of Federal legislation, by their very nature, suggest both the uncertainty and the hope of the mental health professions and the local communities as to the best way to handle the problems of mental illness. Will the new comprehensive centers reduce the need for state hospitals? Is it possible that the comprehensive centers will make their most significant impact in making services available to a new and unserved segment of society? Or will the centers serve to reduce the custodial and welfare functions of state hospitals by helping people remain in their communities for treatment and thus leave the state hospitals to develop into specialized treatment facilities? In any event, with the recent reaffirmation of Congress on continuing Federal support for another five years, it appears that communitybased mental health services have received the interest and sanction of the American public to continue with the further development of comprehensive local mental health centers. Mr. Austin, 2363 Sherbrook St., Pittsburgh, Pa. I5~z 7, is a doctoral candidate in social work research and public health, University of Pittsburgh. At the time this paper was written he was a consultant in social work at the National Institute of Mental Health, Region VIII, Denver, Colorado. This paper was presented, in part, to the third annual Joint Meeting of the Clinical Society and the Commissioned Officers Association of the U.S. Public Health Service, San Francisco, March 1968. The author is indebted to Dr. Melvin B. MoguIof for the conceptual framework and schema developed in the paper. Community Mental Health Journal, Vol. 5 (2), 1969 156
Michael J. Austin
157
Little can be found in the Federal legislation about the concept of citizen participation. However, as a result of administrative policy developed by the National Institute of Mental Health, the concept of "community involvement" has been defined as involvement in planning, participation, and financing the community mental health center. It is interesting to note that in the earlier stages of putting the key mental health laws into operation, much time was spent in defining "comprehensive," "community" and "center," along with the on-going debate about what constitutes mental health. In addition, debate still continues over the concepts of accessibility of services (catchment areas to serve populations of 75,0oo to 2oo,ooo), continuity of care (flexible use of the elements of service to meet the changing needs of patients), and the issues of a reasonable volume of services to persons unable to pay. These concepts are slowly becoming operational in successful comprehensive centers. The concept of on-going citizen participation in program development and implementation has generally not received the same attention as has the establishment of specific elements of service. Often efforts to operationalize these concepts on the local level have been far from comprehensive and many appear, at present, to reflect more of a piecemeal approach. In fact, what seems to be taking place is the expansion of traditional local outpatient services to meet the needs of a population with mildly impaired mental health. To effect meaningful social change, the mental health system, both local and state, must change or be changed. Evidence is seen with the rising budgets of state hospitals, and the declining resident populations, of the lack of understanding of how to reconstruct a mental health system (state and local) to meet current community needs. Even locally, the comprehensive centers have tended to adapt the local mental health patient population to the interests of the professionals and not to alter the service delivery system to meet the needs of the patients. As a result, a frequent initial occurrence is that comprehensive centers seem to be aimed at adapting patients to current arrangements rather than at changing the arrangements. RHETORIC SURROUNDING A NEW PROGRAM While it is not difficult to cite the problems and inadequacies of the local comprehensive center, the various accomplishments can be cited with ease, as well. Innovations in local adolescent treatment programs as seen in specialized foster treatment homes, decentralized neighborhood-based outpatient services, and 24-hour emergency services and suicide prevention programs, can be cited as innovations in service delivery which have evolved in large part from the comprehensive center experience (Kellam & Schiff, 2966 ). These developments, as well as expanded uses of consultation and education, have broadened a community's capacity to deal with mental health problems. Both the criticism and praise of the comprehensive center concept with respect to the goals cited in the Federal legisla-
158
Community Mental Health Journal
tion tend to obscure the important need of viewing the development of such centers within the context of some realistic expectations with respect to what a comprehensive community mental health center (CCMHC) can do within a given period of time. It is crucial to recognize the initial scope of influence possessed by a CCMHC and its necessary preoccupation "to deal initially with the need to establish and maintain itself." As Mogulof points out in similar fashion with respect to the OEO community action program, "it must demonstrate its credibility as an agency by winning funds; it must legitimate itself with the organizations in its environment" (Mogulof, i967). The parallels between the CAP and the CCMHC are striking and, as McNeil points out, "as far as society is concerned, poverty and community mental health are opposite sides of the same coin" (McNeil, I966 ). A DEVELOPMENTAL VIEW The focus of this paper is to point out the merit of a developmental view in an effort to counter the criticism, the over-optimism, and the frustrations experienced by professionals and laymen alike in establishing and maintaining a CCMHC. It is suggested that during the initial organizational phase of a CCMHC, it is "entirely normal for the concepts of 'establishment' and 'maintenance' to dominate the agency's efforts" (Mogulof, i967). With "establishment" and "maintenance" concepts as key elements of Phase 5, it is then conceivable to suggest that Phase 2 will be devoted to the realization of such concepts as "comprehensive," "accessible," "innovation," "continuity of care," and "citizen participation." In an effort to describe this developmental view, several critical factors will be cited as key influences affecting the evolution of the CCMHC from Phase 5, in which the CCMHC directs its attention to its own survival, to Phase 2, when it can begin to deal effectively with the local mental health problems. The factors selected as relating to the developmental phases indude: (a) policy-making structure, (b) state of program development, and (c) relationship of the CCMHC to organizations in its environment (Mogulof, i967). POLICY-MAKING STRUCTURE In the early stages of the development of a CCMHC, its future direction can be easily foreseen by noting the chief social engineers. In many programs the chief designer usually proves to be a mental health professional. The design of the CCMHC evolves as part of the orientation and conviction of one or several mental health professionals. In the early drafting stage, consensual support and validation are sought from both the health establishment and the political establishment. While the key health officials will lend their support and advice on the basis of a public health and/or medical model approach, the political leadership must be sold
Michael J. Austin
159
TABLE Characteristics of Phases I and 2 Phase
Phase 2 Policy-making Structure
-T. Key mental health professionals 2. Key health professionals 3. Key political leadership (mayor, county commissioner, etc.) 4. Key board members of prior mental health service
1. Broader representation of mental health professionals 2. Initial involvement of lay leaders and consumers 3. More active involvement of other agency professionals
Program Development
1. Reactive to program ideas of key mental health professionals 2. More concerned with program quantity than with visibility 3. No revealed strategy with regard to dealing with overall local mental health problems 4. Program marked by doing what is feasible 5. Program seeks to fit patients to existing arrangements
1. Reactive to program ideas of other mental health professionals and to environment z. More concerned with quality and visibility 3. Development of a priority statement and an understanding of the unique problems of mental health (introduction of prevention approaches) 4. Bolstering initially funded programs with new programs which bring in new financial resources 5. Programs consider alterations in existLag institutional arrangements for the sake of comprehensiveness and coordination 6. Program focuses on expansion of constituency for CCMHC
Relation of CCMHC to Organizations in its Environment
1. Existing organizations ignore or combat CCMHC on basis of past unreliability or fear that jurisdiction is being violated
1. CCMHC aggressively plans programs with those organizations central to its mental health program strategy z. CCMHC tends to exclude those organizations whose programs are not relevant to those people with needs for mental health services
in terms of its financial merits and will tend to "rubber stamp" the program content. The political leader will also note the benefits of services to his constituents which is a primary component (making services available to all, despite financial resources) of the CCMHC. If the CCMHC is an outgrowth of a more limited mental health service, either private or public, k e y m e m bers of a board of directors will be involved in the design. However, this role also tends to be one of consensual support and "rubber-stamping" the design of the program. The primary characteristic of Phase ~ regarding the policy-making structure is that the professionals predominate, with almost the total exclusion of citizen participation either by interested lay leadership or by consumer representatives (Table 5). In Phase 2, more attention is given to the involvement of various sectors
160
Community Mental Health Journal
of the community, as well as agency representatives, in program planning and implementation. There is also a greater sampling of opinion from mental health professionals, both working in the new CCMHC and working in related settings. As the program grows, the key mental health professionals begin to recognize the need for a constituency in order to guarantee the continuation of the new and sometimes controversial program. In Phase 2, the notions of citizen and professional advisory committees begin to take on a new meaning for the CCMHC. As a result, the policy-making structure begins to expand. The direction taken in both Phases 9 and a is highly dependent upon the professional discipline and orientation of the key mental health professional involved in the direction of the CCMHC program. As Black points out, It is true that the direction of the mental health center in setting policy will be influenced strongly by the interests of the director. If he is a clinician, the extent to which he exercises central control of core and auxiliary programs will determine for that community how broadly illness is defined. If he becomes, as Leonard Duhl suggests, "consultant to a community, an institution, or a group without being patient-oriented," a different set of middle-level policies may ensue. If he is not a psychiatrist at all, but a psychologist, social worker, or, as has been suggested by others, a newly trained medical or health administrator, a quite different set of policies based on practice may evolve (Black, I967).
PROGRAM DEVELOPMENT As has been suggested, program development in Phase is reactive primarily to the program ideas of the key mental health professionals. The distinct factors affecting the program development of Phase I can be viewed as part of the weakness of the CCMHC. Like many new programs, the CCMHC suffers initially from a lack of balanced involvement between the professionals and the lay community. P h a s e "f
In &is phase the mental heal& professionals are guided by their own conceptions of the mental heal& problems. There appears to be a greater concern with productivity and the number of recipients in their new program. This emphasis is accompanied by a de-emphasis on visibility, with the claims that "we've got more patients than we can handle" and the perennial problem of adequately staffing a program. While the key mental health professional may have ideas pertaining to the future direction of his program, there is no revealed strategy with regard to dealing with overall mental health problems in the community. Programs of prevention and the utilization of "community gate-keepers" appear to be future considerations. In dealing with the initial difficulties of getting a program off the ground, the mental health services are marked by doing what is feasible until better arrangements can be worked out. As a result of the push to get services moving, the program tends to fit the patients and their individual needs to the existing arrangements. These, then, are some of the characteristics of program development in Phase 5.
Michael J. Austin
161
Phase 2
This phase is marked by an atmosphere of "settling in." The key mental health professional is able to be more reactive to his staff and the ideas of other mental health professionals. There is a growing concern for quality of service, now that quantity has been demonstrated as feasible to the powers that be. With quality of service, there is a concern for visibility based, in part, on desire to see whether all the people have an equal opportunity to receive services. Phase 2 includes a redirection of attention toward some of the initial goals of the CCMHC and a development of a priority statement, and an understanding of the community's unique mental health problems. With such an awareness, it is then possible to introduce ideas and plans for various levels of prevention. In this phase there is a bolstering of initially funded programs with new programs which serve newly discovered program needs and bring in, as well, new financial resources. The CCMHC program also begins to consider alterations in existing institutional arrangements for the sake of more comprehensive and coordinated services to a geographically or functionally defined segment of the population, e.g., a neighborhood or children. And in this atmosphere of "settling in" there is a new-found concern for the development and expansion of a constituency for the CCMHC. It is at this point that citizen participation becomes important and new citizen and professional advisory councils are formed. Like the need for comprehensive and coordinated services, these councils are defined both geographically and functionally. The contrast and sometimes disparity between Phases x and 2 provide a basis for some of the continuing apprehension and doubt about the validity of the CCMHC. Phase I is characterized by the center's need to establish and maintain itself and to demonstrate its credibility. The process of legitimizing itself carries over into Phase z where the CCMHC can refocus its attention on its original goals, less focused on itself and survival, and more focused on "increasing the rationality" of its program with respect to its capabilities and the mental health needs of the community. RELATION TO ORGANIZATIONAL ENVIRONMENT In Phase x there is a tendency for existing organizations to either ignore or combat the CCMHC on the basis of either the past unreliability of mental health services or out of fear that the jurisdiction of their agency domain is being violated. Much energy is devoted to both explaining and defining the CCMHC program on the basis that there is plenty of work for everyone and that coordination and collaboration are crucial for the delivery of effective mental health services. In sum, Phase a is involved with separating the men from the boys on the basis of who can deliver the most effective and efficient mental health
162
Community Mental Health Journal
services. In this phase, the CCMHC aggressively plans programs with those organizations which are central to its mental health program strategy. In contrast, the CCMHC tends to exclude or withdraw support from those organizations whose programs are not relevant to those people with needs for mental health services. If Phase a experiences some success, the CCMHC will begin to assume a coordinating function for new programs with mental health content and thereby assume a broker or consultant role in the creating, operating, and funding of new programs. It will also be in a position to monitor all related programs developed by other agencies in the community. In this respect, the CCMHC will have a reverberating impact on many of the health and welfare agencies in defining policies affecting the mental health of the community and in developing and promoting new agency and professional practices. LEADERSHIP PROBLEMS In a most astute fashion, Albee (x965) has noted that in the CCMHC there is "no magic here . . . . There is nothing on the Inside except the same old performers going through the same old routines." While there is some hope found in those mental health professionals who have been able to incorporate a community organization approach into their leadership of a CCMHC program, there is a predominance of mental health personnel ill-equipped for their new roles as community clinicians. Straetz and Padilla (~966) have aptly pointed out that: Each of these professional positions has strong political consequences since the aim is obviously to restructure the mental health establishment in order to permit extensive shifts in role relationships and administrative patterns. This observation points up the need for both program evaluation and inservice training as crucial elements in the transition from Phase x to Phase z. The training component becomes essential for the mental health practitioners in Phase x as they begin to assume new practices, from expanding their skills in group treatment to learning more about community organization process as they begin to staff advisory councils. In Phase 2 even more training will be required as the mental health professionals begin to come to grips with the manpower problem. With new modes of treatment and service delivery, there will need to be employment of paraprofessionals to carry out some of the direct service and community organization functions. The effective utilization of such personnel will rely heavily on the inservice training of the professionals. The use of VISTA volunteers in some agencies has been a precursor to the problems and issues to be foreseen in the utilization of such personnel. CONCLUSION It can be assumed that no CCMHC can be clearly classified in either Phase I or 2 at any given time and that what actually happens is that the CCMHC represents a continuous mixture of the factors in either
Michael J. Austin
163
phase. What is important is the fact that the CCMHC does experience developmental phases and that the factors of survival and legitimacy plague the initial phase, with program rationality and hopefully maturity found in the second phase. It is suggested that the potential of the CCMHC lies in Phase a with the possibility of the CCMHC serving as a focal point for future social planning of the broadly defined mental health needs of a community. The concept of developmental phases is based on perception and observation and has yet to be validated. Only through thorough evaluation, documentation, and the dissemination of experience can we really know the validity and impact of a comprehensive community mental health center. The multitude of changes taking place in the community mental health movement, from new treatment modes to new types of personnel, to new types of intervention, to new definitions of mental health, and to new emphasis on rehabilitation and prevention, require all mental health professionals to be aware of the developmental view and to even speculate on the future unknown characteristics of a possible Phase 3. REFERENCES Albee, George W. No magic here. Contemporary Psychology, i965, io, 497-498. Black, Bertram J. Comprehensive community mental health services: setting social policy. Social Work, I967, ~2, 51-58. Kellam, Sheppard, & Schiff, Sheldon. The Woodlawn Mental Health Center: A Community Mental Health Center Model. Social Service Review, 5966 , 4 ~, 255-263. Mogulof, Melvin B. A developmental approach to the community action program idea. Social Work, ~967, 12, I2-2o. McNeil, Etton B. How healthy can the great society be? Transaction, i966, 3, 3 z-33. Straetz, Ralph, & Padilla, Elena. Problem oriented political science in mental health. Community Mental Health Journal, 5966, 2, zog-I:t 3.
