Community Mental Health Journal Volume 2, Number 2, Summer, 1966
DEVELOPING
MENTAL
HEALTH
PROGRAMS
IN
AREAS
LACKING PROFESSIONAL FACILITIES: THE COMMUNITY CONSULTANT APPROACH IN NEW MEXICO
LESTER M. LIBO, PH.D. ANYCHARLES R. GRIFFITH, PH.D.*
New Mexico has devised a district consuhant approach to initiate mental health services in outlying, professionally "underdeveloped" areas. Each multicounty district is served by one locally based, fulltime professional consultant--a psychologist, social workers, or mental health nurse---augmented by a part time traveling psychiatrist. The program has emphasized community development, mainly through consultation, inservice training, and interagency coordination.
PREEXISTING RESOURCES In 1959, when the project started, only 17 psychiatrists and five clinical psychologists were in private practice in the state. Of these 22 professionals, 19 had their offices in Albuquerque. In the public field, New Mexico operated the state hospital at Las Vegas (for the mentally ill) and the Los Lunas Hospital and Training School (for the retarded). The hospital had an adequate plant but chronic staffing problems. The training school was critically
overcrowded, with a waiting list so long that admission of prospective patients was often delayed for years. Outpatient facilities were also virtually nonexistent. The state hospital operated a clinic one day a week in Las Vegas. A guidance clinic in Albuquerque offered limited services for children. In total, the state was served by only 90 persons working in professional mental health roles. Less than half of these were fully trained representatives of their re-
*Dr. Iibo is a psychologist and Dr. Grifl~th a cultural anthropologist at the University of New Mexico. Respectively, they were Director and Social Scientist, Division of Mental Health, New Mexico Department of Public Health. The work was supported in part by a grant from the National Institute of Mental Health (MH-286). The collaboration of the project staff is gratefully acknowledged: G. Gliva, C. E. Madore, E. Mariani, W. Sears, R. Fortier, B. Douglas, E. Rowe, L. Puente, and A. Hillerman (editorial consultant). 163
164
THE COMMUNITY MENTAL HEALTH JOURNAL
spective disciplines. Only two of the state's 91 school districts provided psychological services for their students. Only three of the state's ten judicial districts used mental health services in relation to probation-these on a part time basis. Professional mental health resources, scanty as they were, tended to be concentrated in the Albuquerque - Santa Fe - Las Vegas area. Other parts of the state were almost entirely without local professional help, either private or public. NEED FOR LOCALLYBASEDRESOURCES
After surveying the situation and discussing the problem with knowledgeable persons in various parts of the state, it seemed clear that a mental health program in New Mexico must involve the development of local resources. This might be done, it was decided, by placing qualified and experienced professionals in locations from which they could serve an extended territory as leaders in community development and as consultants in mental health. In this role they would give local persons interested in, or involved with, mental health problems, a trained person to turn to for consultation. They would help organize and coordinate existing resources and develop new ones. If the application was new, the idea was not. It had been thoroughly proved by the "county agent" program of the nation's land grant colleges. These locally based agricultural specialists had revolutionized American farming simply by demonstrating scientific methods to farmers and making the latest scientific data on food and fiber production available to them. While the problems which confronted the Division of Mental Health were markedly different, it was decided that the same general strategy might be effective. Based on this "extension agent" approach, it was decided that t h e Division of Mental Health would place one mental health professional in each outlying district of the state and give him the responsibility of developing an indigenous pro-
gram befitting local needs, customs, and resources. MAJOR FUNCTIONSOF THE DISTRICT CONSULTANTS
Project strategy called for these "lone mental health workers" to devote themselves to four types of services. These services were: 1. Consultation to health, welfare, education, recreation, correction, rehabilitation, religious, industrial, and other agencies and individuals on the mental health aspects of their programs and the mental health problems of those they served. 2. Guidance to community agencies and organizations in planning and establishing mental health services. 3. Dissemination of information concerning available mental health facilities, practitioners, and reference materials. 4. Conducting education, orientation, and training programs in mental health for professional and lay groups. CRITERIA FOR SELECTINGSERVICE AREAS
A grant from the National Institute of Mental Health, supplemented by matching funds from each district, provided sufficient financing to support a project with four consultants in the field. The selection of the four districts, each of a size which might be served by a single person, was based on the following criteria: 1. Lack of existing mental health professional services and facilities. 2. Distance from urban areas and centers of professional practice. 3. A contrast between districts in cultural, economic, and geographic factors, including substantial differences in the distances the consultants would have to travel to serve their territories. 4. Jurisdiction in each territory of a state health department district health officer willing to accept the program and participate in it. 5. Indications of sufficient interest among local civic leaders to assure organ-
LESTER M. LIBO AND CHARLES R. GRIFFITI-I
ization of a representative citizen's advisory committee to the project and to make possible the raising of $4,800 in annual matching funds from district sources (approximately 25% of the cost).
MENTAL HEALTH CONSULTATION DISTRICTS IN NEW MEXICO 5~:.~~r
~tllr : .
: SA~ JUA~
9 Ga.up
~KJ.Lt~
~
.
if"
.........!i
.i:i ~UAY
........
r ..
~tatl
t~OO$s
LEA
Lovl~Qt,
_
I
CHARACTERISTICS OF THE FOUR DISTRICTS
Figure 1 is a map of tile state of New Mexico. The state's largest community (Albuquerque) as well as the state capital (Santa Fe) and the sites of the two mental institutions (Las Vegas and Los Lunas) are in the central area, while the numerous small cities are at the periphery. Therefore, the district mental health program was designed to serve the outlying areas, which were markedly distant from the centers of professional practice, both private and public, in mental health. The four districts selected had a total area somewhat larger than New York State. Each district was comprised of a three to four county area, for a total of 13 counties. They varied in economic base from agricultural to industrial and in ethnic background from largely AngloAmerican, to a mixture of Anglo and Spanish-American, to an Anglo-Spanish
165
mixture mixed in turn with a large percentage of Indians. For purposes of the project, the chosen areas were labeled A, B, C, and D. District ,4, extreme northwest corner of the state, included San Juan and McKinley Counties and the Grants-Bluewater uranium mining district in adjoining Valencia County. Some 12,385 square miles (approximately the combined size of Maryland and Delaware) were involved, with a population of 101,000. The consultant was based at the County Health Department in Gallup, population 14,089, and from here would also serve Farmington (population 23,786), 123 miles to the northwest, and adjoining small communities. The only other major community to be served was Grants (10,274) some 60 miles to the east. Population of the district included a high proportion of Navajo Indians, with the white residents largely newcomers drawn by booming oil, gas, and uranium operations. District B, in the south central portion of the state, included Sierra, Dona Aria, and Otero Counties with 14,621 square miles (about twice the size of New Jersey) and a population of 103,000. The consultant, based in the Health Department at Las Cruces (population 29,367), would also serve Truth or Consequences (4,269), 77 miles north, and Alamogordo (21,723), 69 miles northeast. In this district, the population was a mixture of Anglo and Spanish-Americans, with a smaller but still significant proportion of newcomers drawn into the area by defense research installations in the Las Cruces and Alamogordo areas. District C, in the southeastern corner of New Mexico, included Lea, Eddy, and Chaves Counties with 14,650 square miles (the combined area of Connecticut and New Hampshire) and a population of 162,000. The consultant, based in the Health Department at Roswell (population 39,953), would also serve Artesia (12,000), 44 miles south; Carlsbad (25,541), 36 miles beyond Artesia; Hobbs (26,275), 70 miles east of Carlsbad, and Lov-
166
THE COMMUNITY MENTAL HEALTH JOURNAL
ington (9,660), 20 miles southwest of Hobbs. The economy of this district was based on oil, potash mining, ranching, and irrigation farming. Its population was largely Anglo-American, with a much smaller percentage of newcomers to the area. District D included Roosevelt, Curry, Quay, and DeBaca Counties and adjoined District C on the north. It included 9,099 square miles (slightly larger than Massachusetts) with a population of 64,000. From a base in the Health Department at Clovis (23,731), the consultant also served Portales (9,695), 20 miles to the southwest; Tucumeari (8,184), 84 miles northwest; and Fort Sumner (1,809), 62 miles west. The economy of the area is based on farming and ranching, and population is almost solely "old family" AngloAmerican. RECRUITMENT AND ORIENTATION OF PERSONNEL In addition to the four consultants and the director, the staff included a cultural anthropologist as the project social scientist, a part time psychiatrist to complement the work of the consultants-in-residence in the districts, and two research analysts. Clinical psychologists were selected to staff Districts A and C, with a psychiatric social worker as the District D consultant, and a nurse mental health consultant in District B. It was decided to set standards for project positions unusually high in terms of both professional and personal qualifications. The nature and the philosophy of the project dictated a minimum of centralized structure and a maximum of local autonomy. Success of the program in each district would depend almost solely on the individual consultant's breadth of professional skill and upon his energy, imagination, tact, and flexibility. In addition to requiring a Ph.D. for the clinical psychologists and a master's degree for the psychiatric social worker and nurse mental health consultant, applicants were also required to have a minimum of five years
experience with strong foundations in diagnostic and therapeutic skills and a background in community work. An analysis of recruiting efforts is limited to the psychologist and social worker positions, since the project psychiatrist and the consultant nurse were employed almost immediately. For the other two disciplines (three positions), a total of 70 applications (and many informal inquiries) were received. This high level of interest was remarkable in view of the salaries being offered (only average) and the nonurban character of the communities and the state. It was an interesting demonstration of the attraction of an unorthodox and pioneering effort to those in the mental health professions. Local services began officially in January, 1960, when the nurse mental health consultant checked into the county health office at Las Cruces and started work. But before this happened, she (and the three consultants hired later) had undergone an intensive two month orientation program on the state, the district, and on community mental health philosophy and method. Discussions, readings, and site visits to numerous agencies, institutions, and practitioners were included. Consultants were provided with references, educationaI materials, and names of potentially helpful leaders in their districts.
Patterns o] Emphasis in Consultants' Work Program format provided for the keep. ing of daily activity logs by the consultants and for the categorizing of activities into ten classifications to allow intradistrict and interdistrict comparisons over time. The ten classifications of activities were: 1. Getting acquainted, establishing rapport. 2. Becoming visible as a mental health resource.
3. Expediting interagency communication. 4. Conducting case consultation. 5. Providing information. 6. Developingmental health facilities. 7. Rendering direct clinical services. 8. Conducting training programs. 9. Administration. 10. Conducting administrative consultation.
LESTER M. LIBO AI~D CHARLES R. GRIFFITH
167
Daily logs for the first three months re- seriously retarded, while the other suffered vealed that consultants in three districts an emotional disturbance which affected had devoted approximately 15% of their her voice. The consultant advised the contacts to the first two categories: getting school principal concerning handling of acquainted with local persons and making the cases and closed his day by calling on the communities in their districts aware a new physician in town to introduce himthat they were available to help with men- self and explain his activities. tal health projects. Significantly, the DisIn District B, the consultant spent much trict C consultant had found it necessary of her day in Truth or Consequences (77 to use almost 30% of his time in prelim- miles north of her base in Las Cruces). inary rapport building activity. In this She visited the local school to arrange the district, militant conservatives were vocal second in a series of sessions with teachers and effective opponents of community on the handling of classroom emotional mental health programs. problems. Then she called on the county As the program developed, the goal of welfare director to decide how problems improving communication and cooperation resulting from a family's desertion by its between the various individuals, agencies, father should be handled. She also paid and institutions involved in activities re- a "keep in touch" visit with a welfare lated to mental health received more atten- caseworker. Her next call was at the comtion than any other phase of the project, munity recreation center, which was inoccupying from 25 to 48% of the consult- volved in a large scale program for elderly ants' time. Conducting case consultations, persons. Back at Las Cruces, she attended another major purpose of the project, a meeting of the Community Fact Finding rated second among activities. Significant Council, which she had been instrumental consultant attention was also devoted to in organizing. Here plans were completed developing new facilities and conducting for compiling and distributing a directory training programs. of health and welfare services available The most marked divergence from the for the community. average pattern came in District A. The The District C consultant started the consultant, a clinical psychologist, spent day at the county welfare office in Roswell approximately 25% of his efforts upon discussing an Aid to Dependent Children clinical type services. In District C, the client with serious emotional problems. consultant was forced by bitter opposition Arrangements were made for the consultto continue devoting much time to explain- ant to interview the boy. He then made ing his program and seeking support for it. arrangements with another caseworker for the admission of another child to the state The Consultant's Day institution for the retarded. Next stop was The District A consultant opened the at a meeting of directors of the community day with a meeting at Grants (58 miles council. The consultant made an unsuceast of his base at Gallup) with the presi- cessful attempt to interest another member dent of the association of parents of re- of the board in mental health projects. He tarded children. Details of a fund raising then kept an appointment with a promand publicity program were worked out. inent local physician to explore interest He next met with parents and teachers in a periodic clinic for retarded children. involved in a program for trainable re- The log entry indicates a negative reaction tarded children advising this group con. from the physician. cerning a variety of classroom problems. The consultant then drove to Carlsbad, After this meeting, he had an individual a distance of 80 miles, and spoke at a conference with one teacher. He then drove meeting of the local child guidance assoback to Gallup, answering a request from ciation. He contacted an official of a potash a school principal to see two students. The mining company to discuss a proposed log entry indicates that one proved to be program for screening employees who
168
THE COMMUNITY MENTAL HEALTH JOURNAL
might be subject to emotional problems. In District D, the consultant's first appointment was at Tucumcari, where he helped officers of the Travelers' Aid Society make plans for a mental health program for transients. He then received an urgent call which involved him most of the morning in a problem resulting from the impending release of a mental patient from the state hospital. The patient eventually agreed to delay his homecoming until the family could be better prepared to care for him. Next, the consultant visited a former mental hospital patient to resolve her doubts concerning the medication she was receiving. He then called on the local police chief to discuss a workshop for training officers in the handling of emotionally disturbed persons. An agreement was reached to schedule the course. Last call of the day was on an officer of the local chapter of the American Association of University Women. The consultant sought the support of the A.A.U.W. to offset attacks by antimental health factions. His log notes that while the woman was "against psychology," she provided the names of other officers of the organizatiota whom she felt would cooperate with him. CHANGES IN EMPHASES AS PROJECT PROGRESSED
In all districts the relationships between consultants and consuhees and the level of effort being expended tended to fall into patterns. Each consultant in his first months of operations was involved in a hectic flurry of work, making an extremely large number of contacts in all strata of community life. This opening period of exploration was followed in every case by a marked slowdown--occurring around the twelfth month. Consultants then reevaluated their approaches and discarded plans which had proved impractical. This slowdown, in turn, was followed by resumption of numerous contacts on a narrower and more selective basis reaching a new height of intensity in about the eighteenth month. Throughout the project, this pattern repeated itself, reflecting, among other
things, improving knowledge of district conditions. This pattern of successive narrowing on fewer projects in fewer communities suggested that future mental health consultant programs should be staffed sequentially. The original consultant might develop a territory alone for a year, then receive an assistant who would follow through on one or a few programs. This would free the consultant to continue his broad-based, district wide developmental efforts. COMMUNITY RECEPTIVITY
Both before and during the project, community receptivity to the mental health program was carefully gauged. Although details varied substantially between districts, the following generalizations can be made: 1. The attitude of private practitioners was checkered and uncertain. Only a few private physicians gave the consultants wholehearted support. There was a general coolness, stemming from militancy against publicly supported health programs, from convictions regarding the privacy of the doctor-patient relationship, from a lack of enthusiasm for psychology, social work, or nursing professionals in positions of authority, and from other motives. 2. The clergy, on the whole, welcomed and supported the program. However, a few ministers of small fundamentalist sects were among its outspoken critics. 3. With the exception of a few schools which had already been the target of militant conservative groups, the school systems were extremely receptive of consultant services and cooperative with the project. 4. Consultant services for children attracted a more positive response than those for adults. Parents of retarded children proved enthusiastic in their support and cooperation. 5. Public health nurses were effective allies. 6. The reception by local officials of the Department of Public Welfare was
LESTER M. LIBO AND CHARLES R. GRIFFITH
spotty, ranging from wholehearted cooperation to hostile opposition. 7. Local law enforcement and probation agencies in three of the four districts were cooperative. 8. There were widespread misunderstandings of the consultant's role early in the project. Agencies, practitioners, and the public expected the new arrival to accept referrals and devote himself to traditional treatment. Each consultant sought to keep community practitioners involved in case management rather than simply allow them to transfer clients to him. Accepting a caseload would have kept the consultant from his primary functions of resource development and consultation. This misunderstanding caused some initial disappointment and required considerable effort to overcome. 9. The level of cooperation a consultant received throughout a community tended to depend to a remarkable degree on whether he drew the support or enmity of a few strong willed and influential residents. In one district, a highly respected "old timer" in the county welfare office did much to gain a broad level of cooperation for the consultant with her visible and vocal support of his efforts. In another, a long time school employee was so effective in undercutting and casting doubt on the consultant's programs that his progress was critically retarded. ACCOMPLISHMENTS
By December, 1963, when the NIMH project grant period officially ended, it was clear that an effective and economical way had been found to provide mental health services to the public in professionally underdeveloped areas. Successes in District C had been limited by a high level of opposition and the early resignation of the consultant. Programs in the other dis. tricts had produced an impressive list of services performed and an array of solidly established local programs continuing in operation. These included (to mention only a few) coordinated local evaluation,
169
case management, and referral resources; a family casework agency; active and well informed lay organizations; college extention courses on mental health; community care programs for the emotionally disturbed (including home visits, supportive counseling, and the use of local medical, nursing, and volunteer services in specially organized teams); an alcoholism rehabil. itation program; and cooperative interagency training programs on the mental health aspects of public health, welfare, corrections, education, recreation, pastoral counseling, and other caregiving resources. These programs, of course, varied from district to district. In one, a research and service project was aimed at curbing drinking problems among Navajo Indians who had come to the attention of law enforcement agencies. In another, a pilot psychiatric screening project was in operation for second grade students, accompanied by advisory and referral services for parents and school personnel. While these programs represent major steps toward meeting mental health needs within the districts, it has since become apparent that the statewide impact of the project promises even more significant long term results. State agencies and institutions, which faced problems identical in many ways to those which had confronted the Division of Mental Health, watched the progress of the project with understandable interest. When it became apparent that this "home town approach" was both effective and accepted by the communities, they were quick to apply the lesson to their own problems. Though there have been shifts in personnel and in areas served, the community consultant approach is still being used effectively. New districts have been added, and interagency cooperation in supporting the local coordinators and consultants has been effected. There is still a long way to go before adequate mental heahh services are available to the public, but we now have concrete evidence that one practical way to begin has been found.
DEVELOPING
MENTAL
HEALTH
PROGRAMS
IN
AREAS
LACKING PROFESSIONAL FACILITIES: THE COMMUNITY CONSULTANT APPROACH IN NEW MEXICO
LESTER M. LIBO, PH.D. ANYCHARLES R. GRIFFITH, PH.D.*
New Mexico has devised a district consuhant approach to initiate mental health services in outlying, professionally "underdeveloped" areas. Each multicounty district is served by one locally based, fulltime professional consultant--a psychologist, social workers, or mental health nurse---augmented by a part time traveling psychiatrist. The program has emphasized community development, mainly through consultation, inservice training, and interagency coordination.
PREEXISTING RESOURCES In 1959, when the project started, only 17 psychiatrists and five clinical psychologists were in private practice in the state. Of these 22 professionals, 19 had their offices in Albuquerque. In the public field, New Mexico operated the state hospital at Las Vegas (for the mentally ill) and the Los Lunas Hospital and Training School (for the retarded). The hospital had an adequate plant but chronic staffing problems. The training school was critically
overcrowded, with a waiting list so long that admission of prospective patients was often delayed for years. Outpatient facilities were also virtually nonexistent. The state hospital operated a clinic one day a week in Las Vegas. A guidance clinic in Albuquerque offered limited services for children. In total, the state was served by only 90 persons working in professional mental health roles. Less than half of these were fully trained representatives of their re-
*Dr. Iibo is a psychologist and Dr. Grifl~th a cultural anthropologist at the University of New Mexico. Respectively, they were Director and Social Scientist, Division of Mental Health, New Mexico Department of Public Health. The work was supported in part by a grant from the National Institute of Mental Health (MH-286). The collaboration of the project staff is gratefully acknowledged: G. Gliva, C. E. Madore, E. Mariani, W. Sears, R. Fortier, B. Douglas, E. Rowe, L. Puente, and A. Hillerman (editorial consultant). 163
164
THE COMMUNITY MENTAL HEALTH JOURNAL
spective disciplines. Only two of the state's 91 school districts provided psychological services for their students. Only three of the state's ten judicial districts used mental health services in relation to probation-these on a part time basis. Professional mental health resources, scanty as they were, tended to be concentrated in the Albuquerque - Santa Fe - Las Vegas area. Other parts of the state were almost entirely without local professional help, either private or public. NEED FOR LOCALLYBASEDRESOURCES
After surveying the situation and discussing the problem with knowledgeable persons in various parts of the state, it seemed clear that a mental health program in New Mexico must involve the development of local resources. This might be done, it was decided, by placing qualified and experienced professionals in locations from which they could serve an extended territory as leaders in community development and as consultants in mental health. In this role they would give local persons interested in, or involved with, mental health problems, a trained person to turn to for consultation. They would help organize and coordinate existing resources and develop new ones. If the application was new, the idea was not. It had been thoroughly proved by the "county agent" program of the nation's land grant colleges. These locally based agricultural specialists had revolutionized American farming simply by demonstrating scientific methods to farmers and making the latest scientific data on food and fiber production available to them. While the problems which confronted the Division of Mental Health were markedly different, it was decided that the same general strategy might be effective. Based on this "extension agent" approach, it was decided that t h e Division of Mental Health would place one mental health professional in each outlying district of the state and give him the responsibility of developing an indigenous pro-
gram befitting local needs, customs, and resources. MAJOR FUNCTIONSOF THE DISTRICT CONSULTANTS
Project strategy called for these "lone mental health workers" to devote themselves to four types of services. These services were: 1. Consultation to health, welfare, education, recreation, correction, rehabilitation, religious, industrial, and other agencies and individuals on the mental health aspects of their programs and the mental health problems of those they served. 2. Guidance to community agencies and organizations in planning and establishing mental health services. 3. Dissemination of information concerning available mental health facilities, practitioners, and reference materials. 4. Conducting education, orientation, and training programs in mental health for professional and lay groups. CRITERIA FOR SELECTINGSERVICE AREAS
A grant from the National Institute of Mental Health, supplemented by matching funds from each district, provided sufficient financing to support a project with four consultants in the field. The selection of the four districts, each of a size which might be served by a single person, was based on the following criteria: 1. Lack of existing mental health professional services and facilities. 2. Distance from urban areas and centers of professional practice. 3. A contrast between districts in cultural, economic, and geographic factors, including substantial differences in the distances the consultants would have to travel to serve their territories. 4. Jurisdiction in each territory of a state health department district health officer willing to accept the program and participate in it. 5. Indications of sufficient interest among local civic leaders to assure organ-
LESTER M. LIBO AND CHARLES R. GRIFFITI-I
ization of a representative citizen's advisory committee to the project and to make possible the raising of $4,800 in annual matching funds from district sources (approximately 25% of the cost).
MENTAL HEALTH CONSULTATION DISTRICTS IN NEW MEXICO 5~:.~~r
~tllr : .
: SA~ JUA~
9 Ga.up
~KJ.Lt~
~
.
if"
.........!i
.i:i ~UAY
........
r ..
~tatl
t~OO$s
LEA
Lovl~Qt,
_
I
CHARACTERISTICS OF THE FOUR DISTRICTS
Figure 1 is a map of tile state of New Mexico. The state's largest community (Albuquerque) as well as the state capital (Santa Fe) and the sites of the two mental institutions (Las Vegas and Los Lunas) are in the central area, while the numerous small cities are at the periphery. Therefore, the district mental health program was designed to serve the outlying areas, which were markedly distant from the centers of professional practice, both private and public, in mental health. The four districts selected had a total area somewhat larger than New York State. Each district was comprised of a three to four county area, for a total of 13 counties. They varied in economic base from agricultural to industrial and in ethnic background from largely AngloAmerican, to a mixture of Anglo and Spanish-American, to an Anglo-Spanish
165
mixture mixed in turn with a large percentage of Indians. For purposes of the project, the chosen areas were labeled A, B, C, and D. District ,4, extreme northwest corner of the state, included San Juan and McKinley Counties and the Grants-Bluewater uranium mining district in adjoining Valencia County. Some 12,385 square miles (approximately the combined size of Maryland and Delaware) were involved, with a population of 101,000. The consultant was based at the County Health Department in Gallup, population 14,089, and from here would also serve Farmington (population 23,786), 123 miles to the northwest, and adjoining small communities. The only other major community to be served was Grants (10,274) some 60 miles to the east. Population of the district included a high proportion of Navajo Indians, with the white residents largely newcomers drawn by booming oil, gas, and uranium operations. District B, in the south central portion of the state, included Sierra, Dona Aria, and Otero Counties with 14,621 square miles (about twice the size of New Jersey) and a population of 103,000. The consultant, based in the Health Department at Las Cruces (population 29,367), would also serve Truth or Consequences (4,269), 77 miles north, and Alamogordo (21,723), 69 miles northeast. In this district, the population was a mixture of Anglo and Spanish-Americans, with a smaller but still significant proportion of newcomers drawn into the area by defense research installations in the Las Cruces and Alamogordo areas. District C, in the southeastern corner of New Mexico, included Lea, Eddy, and Chaves Counties with 14,650 square miles (the combined area of Connecticut and New Hampshire) and a population of 162,000. The consultant, based in the Health Department at Roswell (population 39,953), would also serve Artesia (12,000), 44 miles south; Carlsbad (25,541), 36 miles beyond Artesia; Hobbs (26,275), 70 miles east of Carlsbad, and Lov-
166
THE COMMUNITY MENTAL HEALTH JOURNAL
ington (9,660), 20 miles southwest of Hobbs. The economy of this district was based on oil, potash mining, ranching, and irrigation farming. Its population was largely Anglo-American, with a much smaller percentage of newcomers to the area. District D included Roosevelt, Curry, Quay, and DeBaca Counties and adjoined District C on the north. It included 9,099 square miles (slightly larger than Massachusetts) with a population of 64,000. From a base in the Health Department at Clovis (23,731), the consultant also served Portales (9,695), 20 miles to the southwest; Tucumeari (8,184), 84 miles northwest; and Fort Sumner (1,809), 62 miles west. The economy of the area is based on farming and ranching, and population is almost solely "old family" AngloAmerican. RECRUITMENT AND ORIENTATION OF PERSONNEL In addition to the four consultants and the director, the staff included a cultural anthropologist as the project social scientist, a part time psychiatrist to complement the work of the consultants-in-residence in the districts, and two research analysts. Clinical psychologists were selected to staff Districts A and C, with a psychiatric social worker as the District D consultant, and a nurse mental health consultant in District B. It was decided to set standards for project positions unusually high in terms of both professional and personal qualifications. The nature and the philosophy of the project dictated a minimum of centralized structure and a maximum of local autonomy. Success of the program in each district would depend almost solely on the individual consultant's breadth of professional skill and upon his energy, imagination, tact, and flexibility. In addition to requiring a Ph.D. for the clinical psychologists and a master's degree for the psychiatric social worker and nurse mental health consultant, applicants were also required to have a minimum of five years
experience with strong foundations in diagnostic and therapeutic skills and a background in community work. An analysis of recruiting efforts is limited to the psychologist and social worker positions, since the project psychiatrist and the consultant nurse were employed almost immediately. For the other two disciplines (three positions), a total of 70 applications (and many informal inquiries) were received. This high level of interest was remarkable in view of the salaries being offered (only average) and the nonurban character of the communities and the state. It was an interesting demonstration of the attraction of an unorthodox and pioneering effort to those in the mental health professions. Local services began officially in January, 1960, when the nurse mental health consultant checked into the county health office at Las Cruces and started work. But before this happened, she (and the three consultants hired later) had undergone an intensive two month orientation program on the state, the district, and on community mental health philosophy and method. Discussions, readings, and site visits to numerous agencies, institutions, and practitioners were included. Consultants were provided with references, educationaI materials, and names of potentially helpful leaders in their districts.
Patterns o] Emphasis in Consultants' Work Program format provided for the keep. ing of daily activity logs by the consultants and for the categorizing of activities into ten classifications to allow intradistrict and interdistrict comparisons over time. The ten classifications of activities were: 1. Getting acquainted, establishing rapport. 2. Becoming visible as a mental health resource.
3. Expediting interagency communication. 4. Conducting case consultation. 5. Providing information. 6. Developingmental health facilities. 7. Rendering direct clinical services. 8. Conducting training programs. 9. Administration. 10. Conducting administrative consultation.
LESTER M. LIBO AI~D CHARLES R. GRIFFITH
167
Daily logs for the first three months re- seriously retarded, while the other suffered vealed that consultants in three districts an emotional disturbance which affected had devoted approximately 15% of their her voice. The consultant advised the contacts to the first two categories: getting school principal concerning handling of acquainted with local persons and making the cases and closed his day by calling on the communities in their districts aware a new physician in town to introduce himthat they were available to help with men- self and explain his activities. tal health projects. Significantly, the DisIn District B, the consultant spent much trict C consultant had found it necessary of her day in Truth or Consequences (77 to use almost 30% of his time in prelim- miles north of her base in Las Cruces). inary rapport building activity. In this She visited the local school to arrange the district, militant conservatives were vocal second in a series of sessions with teachers and effective opponents of community on the handling of classroom emotional mental health programs. problems. Then she called on the county As the program developed, the goal of welfare director to decide how problems improving communication and cooperation resulting from a family's desertion by its between the various individuals, agencies, father should be handled. She also paid and institutions involved in activities re- a "keep in touch" visit with a welfare lated to mental health received more atten- caseworker. Her next call was at the comtion than any other phase of the project, munity recreation center, which was inoccupying from 25 to 48% of the consult- volved in a large scale program for elderly ants' time. Conducting case consultations, persons. Back at Las Cruces, she attended another major purpose of the project, a meeting of the Community Fact Finding rated second among activities. Significant Council, which she had been instrumental consultant attention was also devoted to in organizing. Here plans were completed developing new facilities and conducting for compiling and distributing a directory training programs. of health and welfare services available The most marked divergence from the for the community. average pattern came in District A. The The District C consultant started the consultant, a clinical psychologist, spent day at the county welfare office in Roswell approximately 25% of his efforts upon discussing an Aid to Dependent Children clinical type services. In District C, the client with serious emotional problems. consultant was forced by bitter opposition Arrangements were made for the consultto continue devoting much time to explain- ant to interview the boy. He then made ing his program and seeking support for it. arrangements with another caseworker for the admission of another child to the state The Consultant's Day institution for the retarded. Next stop was The District A consultant opened the at a meeting of directors of the community day with a meeting at Grants (58 miles council. The consultant made an unsuceast of his base at Gallup) with the presi- cessful attempt to interest another member dent of the association of parents of re- of the board in mental health projects. He tarded children. Details of a fund raising then kept an appointment with a promand publicity program were worked out. inent local physician to explore interest He next met with parents and teachers in a periodic clinic for retarded children. involved in a program for trainable re- The log entry indicates a negative reaction tarded children advising this group con. from the physician. cerning a variety of classroom problems. The consultant then drove to Carlsbad, After this meeting, he had an individual a distance of 80 miles, and spoke at a conference with one teacher. He then drove meeting of the local child guidance assoback to Gallup, answering a request from ciation. He contacted an official of a potash a school principal to see two students. The mining company to discuss a proposed log entry indicates that one proved to be program for screening employees who
168
THE COMMUNITY MENTAL HEALTH JOURNAL
might be subject to emotional problems. In District D, the consultant's first appointment was at Tucumcari, where he helped officers of the Travelers' Aid Society make plans for a mental health program for transients. He then received an urgent call which involved him most of the morning in a problem resulting from the impending release of a mental patient from the state hospital. The patient eventually agreed to delay his homecoming until the family could be better prepared to care for him. Next, the consultant visited a former mental hospital patient to resolve her doubts concerning the medication she was receiving. He then called on the local police chief to discuss a workshop for training officers in the handling of emotionally disturbed persons. An agreement was reached to schedule the course. Last call of the day was on an officer of the local chapter of the American Association of University Women. The consultant sought the support of the A.A.U.W. to offset attacks by antimental health factions. His log notes that while the woman was "against psychology," she provided the names of other officers of the organizatiota whom she felt would cooperate with him. CHANGES IN EMPHASES AS PROJECT PROGRESSED
In all districts the relationships between consultants and consuhees and the level of effort being expended tended to fall into patterns. Each consultant in his first months of operations was involved in a hectic flurry of work, making an extremely large number of contacts in all strata of community life. This opening period of exploration was followed in every case by a marked slowdown--occurring around the twelfth month. Consultants then reevaluated their approaches and discarded plans which had proved impractical. This slowdown, in turn, was followed by resumption of numerous contacts on a narrower and more selective basis reaching a new height of intensity in about the eighteenth month. Throughout the project, this pattern repeated itself, reflecting, among other
things, improving knowledge of district conditions. This pattern of successive narrowing on fewer projects in fewer communities suggested that future mental health consultant programs should be staffed sequentially. The original consultant might develop a territory alone for a year, then receive an assistant who would follow through on one or a few programs. This would free the consultant to continue his broad-based, district wide developmental efforts. COMMUNITY RECEPTIVITY
Both before and during the project, community receptivity to the mental health program was carefully gauged. Although details varied substantially between districts, the following generalizations can be made: 1. The attitude of private practitioners was checkered and uncertain. Only a few private physicians gave the consultants wholehearted support. There was a general coolness, stemming from militancy against publicly supported health programs, from convictions regarding the privacy of the doctor-patient relationship, from a lack of enthusiasm for psychology, social work, or nursing professionals in positions of authority, and from other motives. 2. The clergy, on the whole, welcomed and supported the program. However, a few ministers of small fundamentalist sects were among its outspoken critics. 3. With the exception of a few schools which had already been the target of militant conservative groups, the school systems were extremely receptive of consultant services and cooperative with the project. 4. Consultant services for children attracted a more positive response than those for adults. Parents of retarded children proved enthusiastic in their support and cooperation. 5. Public health nurses were effective allies. 6. The reception by local officials of the Department of Public Welfare was
LESTER M. LIBO AND CHARLES R. GRIFFITH
spotty, ranging from wholehearted cooperation to hostile opposition. 7. Local law enforcement and probation agencies in three of the four districts were cooperative. 8. There were widespread misunderstandings of the consultant's role early in the project. Agencies, practitioners, and the public expected the new arrival to accept referrals and devote himself to traditional treatment. Each consultant sought to keep community practitioners involved in case management rather than simply allow them to transfer clients to him. Accepting a caseload would have kept the consultant from his primary functions of resource development and consultation. This misunderstanding caused some initial disappointment and required considerable effort to overcome. 9. The level of cooperation a consultant received throughout a community tended to depend to a remarkable degree on whether he drew the support or enmity of a few strong willed and influential residents. In one district, a highly respected "old timer" in the county welfare office did much to gain a broad level of cooperation for the consultant with her visible and vocal support of his efforts. In another, a long time school employee was so effective in undercutting and casting doubt on the consultant's programs that his progress was critically retarded. ACCOMPLISHMENTS
By December, 1963, when the NIMH project grant period officially ended, it was clear that an effective and economical way had been found to provide mental health services to the public in professionally underdeveloped areas. Successes in District C had been limited by a high level of opposition and the early resignation of the consultant. Programs in the other dis. tricts had produced an impressive list of services performed and an array of solidly established local programs continuing in operation. These included (to mention only a few) coordinated local evaluation,
169
case management, and referral resources; a family casework agency; active and well informed lay organizations; college extention courses on mental health; community care programs for the emotionally disturbed (including home visits, supportive counseling, and the use of local medical, nursing, and volunteer services in specially organized teams); an alcoholism rehabil. itation program; and cooperative interagency training programs on the mental health aspects of public health, welfare, corrections, education, recreation, pastoral counseling, and other caregiving resources. These programs, of course, varied from district to district. In one, a research and service project was aimed at curbing drinking problems among Navajo Indians who had come to the attention of law enforcement agencies. In another, a pilot psychiatric screening project was in operation for second grade students, accompanied by advisory and referral services for parents and school personnel. While these programs represent major steps toward meeting mental health needs within the districts, it has since become apparent that the statewide impact of the project promises even more significant long term results. State agencies and institutions, which faced problems identical in many ways to those which had confronted the Division of Mental Health, watched the progress of the project with understandable interest. When it became apparent that this "home town approach" was both effective and accepted by the communities, they were quick to apply the lesson to their own problems. Though there have been shifts in personnel and in areas served, the community consultant approach is still being used effectively. New districts have been added, and interagency cooperation in supporting the local coordinators and consultants has been effected. There is still a long way to go before adequate mental heahh services are available to the public, but we now have concrete evidence that one practical way to begin has been found.
