Community Mental Health Journal Volume 2, Number 2, Summer, 1966
FUTURE
STEPS
IN IMPLEMENTING HEALTH PLANS
MENTAL
HERBERT C. SCHULBERG, PH.D., M.S.HYc.*
Nationwide planning efforts from 1963 to 1955 have created an almost evangelistic fervor. Aspirations and promises must now be converted into concrete deeds which will significantly benefit the mentally ill and promote mental health. Varying conceptions of community mental health programs are spelled
out together with the unique implications of each. To achieve the goals toward which we are striving, major and minor changes will be needed in the deployment of available resources. These realignments will affect nonmental health as well as mental health caregiving agents. The role of citizen committees will assume fresh importance in helping to implement our goals. A future historical analysis of significant trends in the mental health field will have to note that the period of 1963-1965 was marked by an unprecedented amount of nationwide activity in the planning of new programs. Thousands of professionals as well as lay citizens participated in intensive efforts to redirect traditional patterns of care for the mentally ill into a new pattern of community mental health programs. The nature of these planning activities, the types of procedure which they followed, and the gamut of problems encountered have been, and will continue to be, discussed for some time to come (Fogelson, 1964; Glasscote and Kanno, 1963; H.E.W., 1964; Schulberg, 1965). The tremendous accomplishment of planning projects during the past two years bears ample testimony to our nation's concern for the mentally ill and is, hopefully, equally indicative of the pro-
found interest which will continue to be displayed during the coming years. And yet, while the numerous participants in the recently completed planning projects are permitting themselves a well-deserved sense of satisfaction at getting a job well done, there must also remain a gnawing sense of curiosity and concern as to what happens next. Various reports have emanated that a feeling of revulsion is being expressed toward planning in several parts of the country. It seems that you can talk to people about planning for just so long before you have to start doing. People can be involved at a feverish pitch for only a limited period of time before they start demanding results. Planning projects around the country have successfully developed an almost evangelistic fervor and it behooves us all to now start converting our aspirations and promises into concrete deeds which will tangibly benefit the mentally ill and promote mental health. This paper briefly outlines some thoughts about community mental health programs and some of the steps which may be necessary to bring projected plans to fruition. THE NATURE OF COMMUNITY MENTAL HEALTH
It would not he unreasonable to assume after two years of planning for community mental health programs that there is a reasonable sense of agreement among
*Dr. Schulberg, a clinical psychologist, is a Research Associate, Laboratory of Community Psychiatry, Harvard Medical School. A brief version of this paper was presented at the Maine Mental
Health Planning Conference, June 3, 1965.
157
158
THE COMMUNITY MENTAL HEALTH JOURNAL
planners as to what these programs are all about. And yet, strangely enough, this assumption is far from valid. In spite of the widespread support which is now being evinced for community mental health programs, this concept still represents many different things to different people (Dunham, 1965; Whittington, 1965). To some, the essence of a community mental health service is its physical location in the very midst of an urban population center, thus bringing regular psychiatric services closer to patients and permitting the utilization of facilities such as the general hospital. To others, the distinguishing feature of the community mental health service is not so much its actual physical propinquity to the mass population, although this is certainly necessary. Rather, the essence of the program lies in its philosophy that provision of comprehensive mental health services (direct and indirect) requires the cooperation and participation of all segments of the community's power structure and caregiving system. Consequently, the skills of more than the traditional psychiatric team are utilized. To still others, the essential quality of a community mental health program is not rooted primarily in the character of the services which it provides, but more importantly in the fact that a local citizen group assumes responsibility for program planning and development. Program direction by a local board rather than by the central office of the Department of Mental Health is the primary criterion of a community mental health program to this third group. In view of the fact that we are treading on relatively new ground in the field of community mental health, it is strongly urged that the issues remain open to discussion and the programs flexible. In effect, we are functioning with considerable experience but not with completely informed judgment. We must insure the likelihood of increased knowledge and improved programs through (a) a systematic and wellsupported program of basic research in mental health, (b) a careful evaluation of
programs so that we may learn from our successes and failures, and (c) an opportu. nity for experimental demonstrations that can depart from conventional procedures and provide new knowledge. Although differences should continue to exist about the central emphasis and precise functions of a community mental health program, certain principles are accepted by all and they will lead to profound program changes in the coming years. It is thought that widespread agreement could be reached about these points: First, the patient must be the focus of a multifaceted program designed to meet his current needs; the patient must not be fitted into an institution's administrative needs. Second, a community mental health program must be comprehensive. It should include inpatient, outpatient, emergency and partial hospitalization services, and education and consultation services. The program must serve all age groups, all diagnostic groups, and especially those unable to afford private care. Third, continuity of care must be provided from the beginning to the end of psychiatric intervention. Private practitioners have long adhered to this principle and it is time that we incorporate this principle into institutional practice as well. Many crucial implications stem from the envisioned changes in program practices and some of them should be highlighted. Since all appropriately trained personnel must be used in an optimum fashion, a fresh analysis of job descriptions is vital. All mental health professionals will be required to function in new ways. Currently defined areas of interest will be broadened and one may expect a redefinition of the particular prerogatives now assumed by psychiatrists, psychologists, social workers, nurses, etc. Individual competence rather than disciplinary prerogative must become the criterion used to define ability. In developing necessary programs, the community mental health professional accepts responsibility for helping those of all ages and diagnostic categories wherever problems arise in the community. He
HERBERT C. SCHULBERG does not wait for patients to come to his office. Professionals participating in community mental health programs will differ from traditional colleagues in providing direct and indirect service, to large numbers of people with whom they have no personal contact. New programs will not be able to wait for patients to come to them since responsibility is assumed for populations at risk and not only for individual patients. Such an ambitious program cannot be undertaken by the mental health center alone, certainly not upon the traditional basis of diagnosis and treatment of individuals. The use of complementary resources in the health and welfare system will be imperative. Mental health professionals must utilize other resources not as a second best choice but rather out of sincere recognition that the mental health center is just one of the appropriate resources in the community. Thus, in addition to using a direct approach to patients, mental health specialists will utilize indirect methods such as consultation to foster and support the contributions of other caregiving resources. Many other implications in this concept of community mental health have occurred to planners during the course of their deliberations. Let us return for the moment, however, to the substance of future programs. Most of the states in the country have followed the Federal Guidelines in defining comprehensive community mental health programs. Thus, at least the five essential services will be provided to populations of approximately 75,000 to 200,000 people. In most communities, especially rural ones, it will not be feasible or appropriate for a single facility to alone provide all of the essential elements in a comprehensive program. It may be much more practical for a number of existing, and possibly new, agencies to coordinate their programs in such a manner as to provide a complete range of services. A statewide planning project can concern itself only with the general nature of comprehensive programs. Local people
159
must determine the specific character of their community's services. The precise manner in which publicly and privately supported agencies coordinate their services can only be determined at the local level. In most states, regional planning committees have been grappling with these very issues during recent months. The solutions which are arrived at through local deliberations will ensure that services are provided as they are clinically indicated and not as they are administratively regulated. THE NEXT STEPS Widespread hope has been raised by the planning goals of establishing community mental health programs in which patients stay at home, are treated at home, and become well at home. What are the next steps necessary to achieve these goals? Two broad necessary approaches can be focused upon. The first deals with the manner in which we deploy our limited resources, and the second with the future need for citizen participation in program planning and implementation.
The Deployment o~Resources In most areas of any state, a comprehensive mental health program will require the coordination of several resources. To be truly effective, major and minor realignments must be undertaken in agency relationships and it is suggested that some are crucial. Relationships between mental health and non-mental health resources have generally developed more by chance than through any mutual recognition of the benefits that planned cooperation could produce. As mental health programs assume responsibility for the provision of services to all members of the community, the collaboration of a wider range of non-mental health resources must be obtained. Mental disorders of lower socioeconomic groups are so intertwined with real social problems that they rarely can be solved through the skills of the psychiatrist alone. In the foreseeable future, it is possible that the mental health problems of these groups
160
THE COMMUNITY MENTAL HEALTH JOURNAL
will be the responsibility of agencies such pointed up the need for resolution of outas the welfare department, settlement house, standing differences. and public health nursing organization. In In seeking a resolution of these differthese instances, the primary job of the ences, the basic principle which must be mental health professional could very well adhered to is that active participation of all be to provide other community resources publicly, voluntarily, and privately supwith consultation, training, and additional ported mental health resources is imperatypes of direct and indirect support. The tive for the provision of comprehensive mental health center itself will be focusing services to any community. No single sysless of its resources upon patient care, and tem can cope with the vast extent of current more upon the indirect techniques of con- needs. This situation will continue for many sultation and community organization with years to come. non-mental health resources. This type of With the program goal of local inpatient approach would seem to have particular units in all service areas throughout the merit in rural parts of the country. state, the facilities of the general hospital As mental health programs develop in- will be critical, especially in non-metroterest in the area of primary prevention and politan areas. Inpatient services of a cominitiate activities which traditionally have munity mental health program should be been within the domain of social and wel- located so they are accessible to the medical fare agencies, inevitable conflicts will arise services of general hospital and thus avoid which could be potentially detrimental to duplicating scarce resources. Private practitioners should be permitted effective program coordination. A realignment of agency relationships can minimize to hospitalize and treat their patients in this conflict if meaningful communication the facilities operated by state-supported and increased mutual trust are exercised by programs when clinically indicated. Such a procedure has been opposed in some all participants. Mental health facilities should routinely states on the grounds that granting private participate in local community councils as practitioners staff privileges would produce one way of promoting mutual trust and major disrupting results. However, a Masestablishing communication. This step will sachusetts survey of psychiatrists in private also enhance the integration of mental practice (Schulberg, in press) revealed that health services with related programs such only a minority routinely participated in as housing, poverty, and delinquency con- the hospital treatment of their patients and trol. It is vitally necessary that staff mem- their effect upon hospital routines was minbers at the mental health center initiate imal. The use of general hospitals and private the reaching out to other significant compractitioners is recommended for providing munity resources rather than waiting to be specific elements of a comprehensive proinvolved. gram. These resources will not replace the Components of the publicly, voluntarily, other facilities which still will be necessary and privately supported mental health systo provide other essential services. General tems have coordinated their efforts harmohospitals and private practitioners must coniously, but by and large relationships have operate with the total systems so that their not been cultivated as carefully as is neces- services become an effective part of a comsary. A history of legal and attitudinal prehensive program. obstacles has limited the role of volunVoluntary and private social service agentarily and privately supported resources cies will be confronted by a variety of posand prevented their being used in an opti- sibilities if they choose to become integral mal fashion. The Federal appropriation of members of their community's comprehenconstruction funds for new mental health sive mental health program. The fact that centers has again focused attention upon such agencies already do provide major the cleavages between these systems and mental health services has been clearly
HERBERT C. SCHULBERG
demonstrated in a number of studies. Any of the following options might be considered by a particular facility in determining its future roles: 1. Continue current intake and treatment practices, with the agency determining its own policy, and patients making financial arrangements directly with the agency.
2. Continue to function independently but develop a contract with the area mental health board to provide treatment to selected patients on a fee-for-servicebasis. 3. Continueto function as an independentfacility but arrange a contract with the area mental health board whereby publicly-supported personnel are assigned to the facility to treat patients unable to pay for private services. 4. Alter the facility's administrative structure so that it is financed and operated as a publiclysupported mental health resource and is thus brought under the control of the area mental health board. Other options are possible and the choice of a particular one will be dependent upon local circumstances. The manner in which existing state hospitals will be utilized in comprehensive programs represents one of the most serious challenges confronting planners throughout the country. It is suggested that within a statewide scheme for comprehensive services, mental hospitals be viewed as serving two distinct purposes. The first is the provision of the five essential services in a comprehensive mental health program to the geographic area in which it is located. This will be possible when new local inpatient programs relieve state hospitals of much of their current admission loads. The second purpose of a mental hospital would be to provide continued treatment facilities for its own local area as well as for neighboring community mental health programs. It will be important to facilitate the free movement of patients between outpatient clinics, acute inpatient services, and continued care facilities. In those instances where a state hospital provides continued care for several community programs, the hospital might well consider estabishing a geographic unit system on the continued treatment service as one way of facilitating two-way communication and transfer of
161
patients with local centers. When geographical distance is not an issue, the state hospital and its neighboring community mental health centers could experiment with an arrangement whereby each center is responsible, or participates, in the professional staffing of its unit.
Citizen Participation The goal of statewide community mental health centers will not be achieved within one or two years but is rather a goal to be pursued during the coming decade. A phasing process will be necessary and the speed with which it proceeds is dependent upon such factors as community participation, citizen interest, the availability of financial support, and the recruitment of necessary manpower. What is the role of citizen committees in helping to implement the plans which are being formulated? First it should be noted that the very idea of citizen volunteers and local participation in the shaping and operating of community programs is not a new one. Public welfare boards, public health boards, public school committees, and most recently, the federal requirement of citizen participation in urban renewal and poverty programs attest to this concept. The mental health field, although relatively recent in its development, is no exception. Planning projects have devoted much thought to the creation of optimal administrative structures which will enhance the opportunities for citizen participation. Varying patterns will be tested relative to the role of citizens on the governing boards of mental health centers and their authority will range from decision-making to being purely advisory in nature. In addition, regional citizen groups will be called upon to assume major responsibility in developing grass root support for recently promulgated plans. Public information programs will have to be directed at two prime audiences: the mass media and civic organizations. An organizational campaign must be mounted to enlist the cooperation of such groups as mayors and selectmen, service clubs, PTA's, labor unions, and chambers of commerce. A
162
THE COMMUNITY MENTAL HEALTH JOURNAL
speakers' bureau should be developed and trained in every program area to reach widespread audiences. Mental health associations, which have long engaged in these activities, can be instrumental in helping planning groups achieve ultimate success. A technique which has proved particularly effective in some parts of the country has been the holding of a series of public hearings in major communities. It is suggested that regional committees in every state initiate, or continue, public hearings at which they would present their recommendations and explictly indicate how pro. posed plans would affect various groups and facilities. Giving local citizens and representatives of community agencies the opportunity to express their reactions is of considerable value in airing the issues and moving toward consensus. Community mental health centers--no matter how well fi; nanced, how efficiently administered, and brilliantly staffed---cannot translate the late President Kennedy's request for "a bold new approach" into a job well done unless residents of the community accept its existence, its purpose, and the patients whom it treats.
Much has been accomplished in the last two years through comprehensive planning but even more remains to be undertaken in the coming decade. It is believed that we are now in the midst of a long, historical social evolution. The thrust is clearly with us. It is hoped that we will do it justice. REFERENCES DUNrlAM, H. W. Community psychiatry: the newest therapeutic bandwagon. Arch. gen. Psychiat., 1965, 12, 303-313. FOCELSON, F. Statewide planning in mental health --an early report. Soc. Wk., 1964, 9, 26-33. GLASSCOTE,R., & KANNO, C. The plans for planning: a comparative analysis of the state mental health planning proposals. Washington: Joint
Info. Service, 1963.
SCHULBERC,H. C. State planning for community mental health programs: Implications for psychologists. Community ment. Hlth. l., 1965, 1, 37-42. SCHULSERC,H. C. Private psychiatric services in a community mental health program. Hosp. Comm. Psychiat., in press. U. S. DEPARTMENT OF HEALTH, EDUCATION,AND WELFARE,NIMH Progress reports on state mental health planning 1964. Bethesda: HEW, August,
1964. WmTTINCTON,H. G. The third psychiatric revolution-really? Community merit. Hlth. J., 1965, 1, 73-80.
FUTURE
STEPS
IN IMPLEMENTING HEALTH PLANS
MENTAL
HERBERT C. SCHULBERG, PH.D., M.S.HYc.*
Nationwide planning efforts from 1963 to 1955 have created an almost evangelistic fervor. Aspirations and promises must now be converted into concrete deeds which will significantly benefit the mentally ill and promote mental health. Varying conceptions of community mental health programs are spelled
out together with the unique implications of each. To achieve the goals toward which we are striving, major and minor changes will be needed in the deployment of available resources. These realignments will affect nonmental health as well as mental health caregiving agents. The role of citizen committees will assume fresh importance in helping to implement our goals. A future historical analysis of significant trends in the mental health field will have to note that the period of 1963-1965 was marked by an unprecedented amount of nationwide activity in the planning of new programs. Thousands of professionals as well as lay citizens participated in intensive efforts to redirect traditional patterns of care for the mentally ill into a new pattern of community mental health programs. The nature of these planning activities, the types of procedure which they followed, and the gamut of problems encountered have been, and will continue to be, discussed for some time to come (Fogelson, 1964; Glasscote and Kanno, 1963; H.E.W., 1964; Schulberg, 1965). The tremendous accomplishment of planning projects during the past two years bears ample testimony to our nation's concern for the mentally ill and is, hopefully, equally indicative of the pro-
found interest which will continue to be displayed during the coming years. And yet, while the numerous participants in the recently completed planning projects are permitting themselves a well-deserved sense of satisfaction at getting a job well done, there must also remain a gnawing sense of curiosity and concern as to what happens next. Various reports have emanated that a feeling of revulsion is being expressed toward planning in several parts of the country. It seems that you can talk to people about planning for just so long before you have to start doing. People can be involved at a feverish pitch for only a limited period of time before they start demanding results. Planning projects around the country have successfully developed an almost evangelistic fervor and it behooves us all to now start converting our aspirations and promises into concrete deeds which will tangibly benefit the mentally ill and promote mental health. This paper briefly outlines some thoughts about community mental health programs and some of the steps which may be necessary to bring projected plans to fruition. THE NATURE OF COMMUNITY MENTAL HEALTH
It would not he unreasonable to assume after two years of planning for community mental health programs that there is a reasonable sense of agreement among
*Dr. Schulberg, a clinical psychologist, is a Research Associate, Laboratory of Community Psychiatry, Harvard Medical School. A brief version of this paper was presented at the Maine Mental
Health Planning Conference, June 3, 1965.
157
158
THE COMMUNITY MENTAL HEALTH JOURNAL
planners as to what these programs are all about. And yet, strangely enough, this assumption is far from valid. In spite of the widespread support which is now being evinced for community mental health programs, this concept still represents many different things to different people (Dunham, 1965; Whittington, 1965). To some, the essence of a community mental health service is its physical location in the very midst of an urban population center, thus bringing regular psychiatric services closer to patients and permitting the utilization of facilities such as the general hospital. To others, the distinguishing feature of the community mental health service is not so much its actual physical propinquity to the mass population, although this is certainly necessary. Rather, the essence of the program lies in its philosophy that provision of comprehensive mental health services (direct and indirect) requires the cooperation and participation of all segments of the community's power structure and caregiving system. Consequently, the skills of more than the traditional psychiatric team are utilized. To still others, the essential quality of a community mental health program is not rooted primarily in the character of the services which it provides, but more importantly in the fact that a local citizen group assumes responsibility for program planning and development. Program direction by a local board rather than by the central office of the Department of Mental Health is the primary criterion of a community mental health program to this third group. In view of the fact that we are treading on relatively new ground in the field of community mental health, it is strongly urged that the issues remain open to discussion and the programs flexible. In effect, we are functioning with considerable experience but not with completely informed judgment. We must insure the likelihood of increased knowledge and improved programs through (a) a systematic and wellsupported program of basic research in mental health, (b) a careful evaluation of
programs so that we may learn from our successes and failures, and (c) an opportu. nity for experimental demonstrations that can depart from conventional procedures and provide new knowledge. Although differences should continue to exist about the central emphasis and precise functions of a community mental health program, certain principles are accepted by all and they will lead to profound program changes in the coming years. It is thought that widespread agreement could be reached about these points: First, the patient must be the focus of a multifaceted program designed to meet his current needs; the patient must not be fitted into an institution's administrative needs. Second, a community mental health program must be comprehensive. It should include inpatient, outpatient, emergency and partial hospitalization services, and education and consultation services. The program must serve all age groups, all diagnostic groups, and especially those unable to afford private care. Third, continuity of care must be provided from the beginning to the end of psychiatric intervention. Private practitioners have long adhered to this principle and it is time that we incorporate this principle into institutional practice as well. Many crucial implications stem from the envisioned changes in program practices and some of them should be highlighted. Since all appropriately trained personnel must be used in an optimum fashion, a fresh analysis of job descriptions is vital. All mental health professionals will be required to function in new ways. Currently defined areas of interest will be broadened and one may expect a redefinition of the particular prerogatives now assumed by psychiatrists, psychologists, social workers, nurses, etc. Individual competence rather than disciplinary prerogative must become the criterion used to define ability. In developing necessary programs, the community mental health professional accepts responsibility for helping those of all ages and diagnostic categories wherever problems arise in the community. He
HERBERT C. SCHULBERG does not wait for patients to come to his office. Professionals participating in community mental health programs will differ from traditional colleagues in providing direct and indirect service, to large numbers of people with whom they have no personal contact. New programs will not be able to wait for patients to come to them since responsibility is assumed for populations at risk and not only for individual patients. Such an ambitious program cannot be undertaken by the mental health center alone, certainly not upon the traditional basis of diagnosis and treatment of individuals. The use of complementary resources in the health and welfare system will be imperative. Mental health professionals must utilize other resources not as a second best choice but rather out of sincere recognition that the mental health center is just one of the appropriate resources in the community. Thus, in addition to using a direct approach to patients, mental health specialists will utilize indirect methods such as consultation to foster and support the contributions of other caregiving resources. Many other implications in this concept of community mental health have occurred to planners during the course of their deliberations. Let us return for the moment, however, to the substance of future programs. Most of the states in the country have followed the Federal Guidelines in defining comprehensive community mental health programs. Thus, at least the five essential services will be provided to populations of approximately 75,000 to 200,000 people. In most communities, especially rural ones, it will not be feasible or appropriate for a single facility to alone provide all of the essential elements in a comprehensive program. It may be much more practical for a number of existing, and possibly new, agencies to coordinate their programs in such a manner as to provide a complete range of services. A statewide planning project can concern itself only with the general nature of comprehensive programs. Local people
159
must determine the specific character of their community's services. The precise manner in which publicly and privately supported agencies coordinate their services can only be determined at the local level. In most states, regional planning committees have been grappling with these very issues during recent months. The solutions which are arrived at through local deliberations will ensure that services are provided as they are clinically indicated and not as they are administratively regulated. THE NEXT STEPS Widespread hope has been raised by the planning goals of establishing community mental health programs in which patients stay at home, are treated at home, and become well at home. What are the next steps necessary to achieve these goals? Two broad necessary approaches can be focused upon. The first deals with the manner in which we deploy our limited resources, and the second with the future need for citizen participation in program planning and implementation.
The Deployment o~Resources In most areas of any state, a comprehensive mental health program will require the coordination of several resources. To be truly effective, major and minor realignments must be undertaken in agency relationships and it is suggested that some are crucial. Relationships between mental health and non-mental health resources have generally developed more by chance than through any mutual recognition of the benefits that planned cooperation could produce. As mental health programs assume responsibility for the provision of services to all members of the community, the collaboration of a wider range of non-mental health resources must be obtained. Mental disorders of lower socioeconomic groups are so intertwined with real social problems that they rarely can be solved through the skills of the psychiatrist alone. In the foreseeable future, it is possible that the mental health problems of these groups
160
THE COMMUNITY MENTAL HEALTH JOURNAL
will be the responsibility of agencies such pointed up the need for resolution of outas the welfare department, settlement house, standing differences. and public health nursing organization. In In seeking a resolution of these differthese instances, the primary job of the ences, the basic principle which must be mental health professional could very well adhered to is that active participation of all be to provide other community resources publicly, voluntarily, and privately supwith consultation, training, and additional ported mental health resources is imperatypes of direct and indirect support. The tive for the provision of comprehensive mental health center itself will be focusing services to any community. No single sysless of its resources upon patient care, and tem can cope with the vast extent of current more upon the indirect techniques of con- needs. This situation will continue for many sultation and community organization with years to come. non-mental health resources. This type of With the program goal of local inpatient approach would seem to have particular units in all service areas throughout the merit in rural parts of the country. state, the facilities of the general hospital As mental health programs develop in- will be critical, especially in non-metroterest in the area of primary prevention and politan areas. Inpatient services of a cominitiate activities which traditionally have munity mental health program should be been within the domain of social and wel- located so they are accessible to the medical fare agencies, inevitable conflicts will arise services of general hospital and thus avoid which could be potentially detrimental to duplicating scarce resources. Private practitioners should be permitted effective program coordination. A realignment of agency relationships can minimize to hospitalize and treat their patients in this conflict if meaningful communication the facilities operated by state-supported and increased mutual trust are exercised by programs when clinically indicated. Such a procedure has been opposed in some all participants. Mental health facilities should routinely states on the grounds that granting private participate in local community councils as practitioners staff privileges would produce one way of promoting mutual trust and major disrupting results. However, a Masestablishing communication. This step will sachusetts survey of psychiatrists in private also enhance the integration of mental practice (Schulberg, in press) revealed that health services with related programs such only a minority routinely participated in as housing, poverty, and delinquency con- the hospital treatment of their patients and trol. It is vitally necessary that staff mem- their effect upon hospital routines was minbers at the mental health center initiate imal. The use of general hospitals and private the reaching out to other significant compractitioners is recommended for providing munity resources rather than waiting to be specific elements of a comprehensive proinvolved. gram. These resources will not replace the Components of the publicly, voluntarily, other facilities which still will be necessary and privately supported mental health systo provide other essential services. General tems have coordinated their efforts harmohospitals and private practitioners must coniously, but by and large relationships have operate with the total systems so that their not been cultivated as carefully as is neces- services become an effective part of a comsary. A history of legal and attitudinal prehensive program. obstacles has limited the role of volunVoluntary and private social service agentarily and privately supported resources cies will be confronted by a variety of posand prevented their being used in an opti- sibilities if they choose to become integral mal fashion. The Federal appropriation of members of their community's comprehenconstruction funds for new mental health sive mental health program. The fact that centers has again focused attention upon such agencies already do provide major the cleavages between these systems and mental health services has been clearly
HERBERT C. SCHULBERG
demonstrated in a number of studies. Any of the following options might be considered by a particular facility in determining its future roles: 1. Continue current intake and treatment practices, with the agency determining its own policy, and patients making financial arrangements directly with the agency.
2. Continue to function independently but develop a contract with the area mental health board to provide treatment to selected patients on a fee-for-servicebasis. 3. Continueto function as an independentfacility but arrange a contract with the area mental health board whereby publicly-supported personnel are assigned to the facility to treat patients unable to pay for private services. 4. Alter the facility's administrative structure so that it is financed and operated as a publiclysupported mental health resource and is thus brought under the control of the area mental health board. Other options are possible and the choice of a particular one will be dependent upon local circumstances. The manner in which existing state hospitals will be utilized in comprehensive programs represents one of the most serious challenges confronting planners throughout the country. It is suggested that within a statewide scheme for comprehensive services, mental hospitals be viewed as serving two distinct purposes. The first is the provision of the five essential services in a comprehensive mental health program to the geographic area in which it is located. This will be possible when new local inpatient programs relieve state hospitals of much of their current admission loads. The second purpose of a mental hospital would be to provide continued treatment facilities for its own local area as well as for neighboring community mental health programs. It will be important to facilitate the free movement of patients between outpatient clinics, acute inpatient services, and continued care facilities. In those instances where a state hospital provides continued care for several community programs, the hospital might well consider estabishing a geographic unit system on the continued treatment service as one way of facilitating two-way communication and transfer of
161
patients with local centers. When geographical distance is not an issue, the state hospital and its neighboring community mental health centers could experiment with an arrangement whereby each center is responsible, or participates, in the professional staffing of its unit.
Citizen Participation The goal of statewide community mental health centers will not be achieved within one or two years but is rather a goal to be pursued during the coming decade. A phasing process will be necessary and the speed with which it proceeds is dependent upon such factors as community participation, citizen interest, the availability of financial support, and the recruitment of necessary manpower. What is the role of citizen committees in helping to implement the plans which are being formulated? First it should be noted that the very idea of citizen volunteers and local participation in the shaping and operating of community programs is not a new one. Public welfare boards, public health boards, public school committees, and most recently, the federal requirement of citizen participation in urban renewal and poverty programs attest to this concept. The mental health field, although relatively recent in its development, is no exception. Planning projects have devoted much thought to the creation of optimal administrative structures which will enhance the opportunities for citizen participation. Varying patterns will be tested relative to the role of citizens on the governing boards of mental health centers and their authority will range from decision-making to being purely advisory in nature. In addition, regional citizen groups will be called upon to assume major responsibility in developing grass root support for recently promulgated plans. Public information programs will have to be directed at two prime audiences: the mass media and civic organizations. An organizational campaign must be mounted to enlist the cooperation of such groups as mayors and selectmen, service clubs, PTA's, labor unions, and chambers of commerce. A
162
THE COMMUNITY MENTAL HEALTH JOURNAL
speakers' bureau should be developed and trained in every program area to reach widespread audiences. Mental health associations, which have long engaged in these activities, can be instrumental in helping planning groups achieve ultimate success. A technique which has proved particularly effective in some parts of the country has been the holding of a series of public hearings in major communities. It is suggested that regional committees in every state initiate, or continue, public hearings at which they would present their recommendations and explictly indicate how pro. posed plans would affect various groups and facilities. Giving local citizens and representatives of community agencies the opportunity to express their reactions is of considerable value in airing the issues and moving toward consensus. Community mental health centers--no matter how well fi; nanced, how efficiently administered, and brilliantly staffed---cannot translate the late President Kennedy's request for "a bold new approach" into a job well done unless residents of the community accept its existence, its purpose, and the patients whom it treats.
Much has been accomplished in the last two years through comprehensive planning but even more remains to be undertaken in the coming decade. It is believed that we are now in the midst of a long, historical social evolution. The thrust is clearly with us. It is hoped that we will do it justice. REFERENCES DUNrlAM, H. W. Community psychiatry: the newest therapeutic bandwagon. Arch. gen. Psychiat., 1965, 12, 303-313. FOCELSON, F. Statewide planning in mental health --an early report. Soc. Wk., 1964, 9, 26-33. GLASSCOTE,R., & KANNO, C. The plans for planning: a comparative analysis of the state mental health planning proposals. Washington: Joint
Info. Service, 1963.
SCHULBERC,H. C. State planning for community mental health programs: Implications for psychologists. Community ment. Hlth. l., 1965, 1, 37-42. SCHULSERC,H. C. Private psychiatric services in a community mental health program. Hosp. Comm. Psychiat., in press. U. S. DEPARTMENT OF HEALTH, EDUCATION,AND WELFARE,NIMH Progress reports on state mental health planning 1964. Bethesda: HEW, August,
1964. WmTTINCTON,H. G. The third psychiatric revolution-really? Community merit. Hlth. J., 1965, 1, 73-80.
