The Journal of Primary Prevention, VoL 15, No. 1, 1994
Looking Backwards: A Personal Look at Community Mental Health Len Duhl 1
This paper is a personal review of the forces affecting community mental health over the past 50 years from a psychiatrist who played a significant role in the movement. KEY WORDS: Peace corps; model cities; healthy cities and community mental health; NIMH; participation; prevention; health promotion.
It is difficult to look backwards at one's life and find just what should be said. Choosing to do so in 1993, after these years have passed, I cannot completely trust my memory, Science has permitted me to live through many important changes in our world. There have been great changes; post World War II, through the Kennedy-Johnson years, and in the pull back years of Nixon-ReaganBush. The world has changed radically. So has the health field, the knowledge of the brain and community mental health. Over the years I have reconstructed my perceptual realities, my paradigms for understanding the world and much more. In doing so, everything falls into place in different ways than they did as I passed through the events. What was understood and went for community mental health in the past, has change radically. Indeed, the "map" of my concern is now so broad and inter-related, it is hard to separate my concern from the emerging notions of the world. New ideas have emerged. New voices heard and new definitions of what is right and good. So please forgive me, if I see and sense the world of the past differently than you do. 1Address correspondence to Len Duhl, M.D., School of Public Health, Department of Social and Administrative Health Sciences, University of California at Berkeley, Berkeley, CA 94720. 31 9 1994 Human SciencesPress, Inc.
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Some of you might feel my views of history and current events are fiction. So be it!
SOME HISTORY My community mental health journey started before the 1960's. There are two sides to this story, my own and what I perceived was happening in the world. I go back before 1964, and Gerald Caplan's book. Though the history can be traced to the 1800's and 1900's and events like World War I, the birth of Orthopsychiatry and the Child Welfare League, for me it started very personally. In one way, it had to do with my Dad taking me around the City of New York to explore every aspect of it. This, he did every week from ages 4-14. It gave me, then unknowingly a holistic view of the city. In another way, it was a gigantic extended family, orchestrated by my mother. Much developed in my education in high school and later college, it was my training first as a physician and later as a psychiatrist-psychoanalyst, that solidified the need to be concerned with the public's health. Another memory was working in Topeka, as part of my residency with William Menninger and Ed Greenwood. Both psychiatrists, one headed Army psychiatry in World War II and the other was involved in child psychiatry. Each encouraged me, in their own way to think beyond, but not ignore the individual. While in training, I spent time with children in a settlement house. I helped plan Kansas' participation in the White House Conference on Children and Youth, where Ed Greenwood introduced me to figures who became important in building the framework of community mental health. Eric Erikson, Fritz Redl, and Ben Spock were people who, along with social workers and community organizers, gave me ideas that I later used. It was the beginning of an entry into a larger mental health world than psychiatry. I was on the road to becoming a well trained psychiatrist and psychoanalyst when I was called for military service. Joining the Public Health Service, I was assigned to the Contra Costa Health Department, in California. There, I began a friendship with Henrik Blum, who later became the father of health planning. Most important was my work for the health department in North Richmond, an urban slum, where I found myself developing with the Quakers what later became the core of the Community Action Program of OEO. A paper I wrote then, "A Sick City" foretold many of my future publications.
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While raised with a concern for the underdog, it was in North Richmond, that I really became aware of "superfluous people," people not wanted or needed by society. The time I spent in Contra Costa Health Department was spent learning about public health. This meant, a chance to get to know the functioning of a large suburban county. Free to use my time, I explored every aspect of the community, and this exploration laid the groundwork for much of my later work with cities and those in poverty. It was also at this time, I met and studied with Saul Alinsky, who later in his career would become a major voice for community grassroots activism. Returning from my "military service" in Contra Costa, to psychiatric training in Topeka, I found myself torn between clinical psychiatry and public health. Though I trained as a psychoanalyst, I was drawn more and more into population based work. At the time I was accused by some of prostituting my knowledge, for this broader interest in the community. Karl Menninger, to his credit, later in our relationship apologized for this remark, and said I had been, "right all along."
NIMH
A major turning point in my life was joining the NIMH Professional Services Branch in 1954. It was, and later became the long range planning organization for mental health. My job, defined by Robert Felix, the Director of the Institute was to stay two years ahead of Congress. It is important to recall the NIMH charter, "the care, treatment and rehabilitation of the mentally ill, and the mental health of the population of the United States." The later phrase was, for me, a general welfare clause which pushed me more and more towards a broader community approach towards promoting health. As I understood the two dynamic areas, I found myself pulled to all the different ways to look at and to deal with mental illness. This meant looking at every way people dealt with their psychological concerns and crises. At the same time, I turned more and more to growth and development as a model for understanding prevention, and what we now call health promotion. Though, I had heard about Paul Lemkau's important work at Johns Hopkins, I was truly excited by Erich Lindemann's work with the Wellesley Human Relation's Service. In fact, I had considered going there, but went to NIMH instead. Gerald Caplan tells a story, that there was a flip of the coin as to where I would go. I always believed it was my choice. He said others felt NIMH was the better place for me. So much for free will.
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Having gone to Bethesda, I immediately chose to work with Erich at the time when he was developing psychiatry at Massachusetts General and Harvard. This was the origin of the West End study. Where we studied the impact of the crisis of urban renewal on a population of Italian-Sicilians and Jews. Erich using the basic concepts of grief, his experience at Wellesley Human Relations Service, and a great team of researchers began to formulate the basic concepts of community mental health. The impact of this research was felt within the field, and in urban redevelopment. It was my first awareness that the idea of supporting such a study, would without the research results even started, lead to a change in the urban relocation policy of the United States. Gerald Caplan building upon his own work in Israel, drew from Erich Lindemann's work at the Harvard School of Public Health and began to formalize activities in the Laboratory of Community Mental Health at Harvard. The original work of Lindemann at the Coconut G r o v e fire b e g a n to e x t e n d into both the hospital and into the community. Though, there was activity elsewhere, at this time, most of it was exploratory. With John Calhoun the animal ecologist at NIMH, I had brought together a large diverse group of distinguished people from many different fields to look at issues in a multi-disciplinary way. I believed that people in diverse fields had similar goals, but often worked separately. Rather than my synthesizing their work and creating new programs, I brought them together, twice a year, for 12 years. The group included both older experts, young and up-and-coming people from many diverse fields. They included federal judges, animal ecologists, newsmen, psychologists, philosophers, educators, religion, housing and public health experts, politicians and others. This group was interested, primarily in new ways to look at issues in diverse fields. With fondness I recall they renamed themselves, the Space Cadets; a group looking at issues in new, way-out ways. We would later call it a search for new paradigms. Studies varied, from community organization to mathematical theory, systems theory to a study of the mafia's investments, from planning to create the Peace Corps to urban issues, to psychiatry, to education and more. It was, a focal point for systems and multi-disciplinary, community thinking. Its impact has never fully been evaluated. However, many of the ideas formulated and discussed there found their way into many of the programs of the Great Society and, later, still other programs.
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Other work at N I M H exposed me to issues affecting the mentally retarded; those with substance abuse problems and with special populations like college students. Gradually, all these experiences provided me with a clearer picture of what community mental health might be. In each case, it was clear, that a focus on treatment was not enough. Indeed, a full system of interrelated services and activities was a major part of the solution. One important experience I remember was William Soskin's paper for NIMH, "Harlem, Riots and the Ghetto" where he tied racism and poverty to mental health concerns. Bill had followed the civil rights movement to see how people were finding new voices for themselves, changing their self image, and affecting their own mental health. The NIMH served to stimulate major shifts in this direction. With 1960 and the Joint Commission on Mental Health report, many efforts into community health occurred. When the R e p o r t was published, there began a shift from hospital to community settings. Though, this seemed to be the direction for the future, many other events conspired to turn it in other directions. For example, the creation of fee for service Medicare and Medicaid, important as it was, prevented neighborhood health centers from fully emerging as service providers.
PEACE CORPS During the heady days of the Kennedy presidency, many things seemed possible. Concern for the mentally retarded and mentally ill, along with great increases in NIH budgets blazed new programs trails. Here I have to recall a memory, from the Kennedy election. During the campaign, it came to my attention that the future President was going to announce the Peace Corps. By the time he did at the famous speech in Michigan, I was trying to figure out how to be involved. My interest was simple. I believed that non-professionals could play an important role in mental health and other programs. The Peace Corps was an ideal place to test this hypothesis. I spent some time, trying to figure out who might be chosen to head the organization. By piecing together a series of diverse leaks from many data sources, I thought it might be Sargent Shriver. Parenthetically, it is important to acknowledge the fact that being at NIMH, and having the freedom I had offered a chance to link into many information networks.
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I had worked with Shriver before, on problems of mental retardation, and knew something of his and the Kennedy style of recruitment. He would call key people and ask their advice. Slowly, sorting through a sociometric technique, he would focus down on a few people, and then make his decision. In designing a Peace Corps, I knew that one publicly perceived problem, might be, how not to send "mentally sick" people overseas. I proceeded to call about thirty people, and mentioned my interest both in the Peace Corps and in the concern for who would be selected by service. On Thanksgiving Day or thereabouts, I received a phone call. "This is Sargent Shriver. Do you knowwho I am? I am about to set up the Peace Corps, and I want to make sure no mentallyill people are sent overseas. I talked to many people, and they all said you were the expert. Can you help?" This was the beginning of Peace Corps psychiatry. Using my position at NIMH, I brought a group of people together to help, both in selection and in psychological support. Among them were R o b e r t Leopold, a psychiatrist who was working with the American Friends Service Committee and their overseas volunteers. More than anyone else he set the stage for the development of the program. Another person I enlisted was Gerald Caplan, who trained many people in consultation and mental health. His work had an important long standing impact on the field. I was asked, along with Leopold to construct the mental health side of the medical program. In addition, I helped recruit Nicholas Hobbs, a leader in American psychology, to be in charge of selection. Nick was active in the "educateur" program which was called Project Re-Ed, a way to train non-professionals to work with the retarded. The program was shaped by my increasingly broad view of mental health, Leopold's ability to turn ideas into operations, plans and policies, and Caplan's ability to train. The strong support of Shriver, the exciting atmosphere of political change, and the Peace Corps began. My world understanding was subtly changed by all the interesting people we were in touch with. I was originally, going to meet the needs of the Peace Corps, but it became a strategy of using this experience as a way of training people for community mental health leadership in the country. When the Joint Commission Report and Mental Health and Retardation Act was converted into community mental health programs by people like Bert Brown, experts were ready. The ultimate result was that many of the people we worked with and trained became key leaders, academically and elsewhere.
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Within the Peace Corps, the results were very positive. I recruited Joe English, a psychiatrist from the Clinical Center at NIMH based upon his college mental health experience, and his being single and free to travel extensively, which I wasn't. Joe prospered in the job and later extended his broadening concerns to the OEO, which Shriver later led. The lessons for me were many. It included the ability, using minimally trained volunteers to anticipate crises overseas, and well-timed, informal sessions to diminish casualties of all kinds. It also served as a way to do systemic analyses of programs by gathering diverse data, following patterns of information and effecting decisions that were both administratively helpful, but also mentally healthy. Many more things were learned that are reported elsewhere by the diverse groups of mental health professionals involved in the Peace Corps. Like the experience in Korea and later in Viet Nam, a network of support could emerge for soldiers with much energy on preventive activities. AI Glass' work with the army was a major contribution to this emerging view of community based mental health.
THE OEO AND HUD For me however, it was the development of the Poverty Program, which became OEO, that launched me onto a larger stage. It was here that I became more and more aware that participatory involvement of consumers and others truly affected their health. I also began to connect deprivations of all kinds, including economic poverty, as a cause not only of mental but social and physical problems as well. My concern with the socalled "superfluous" people reemerged. Robert Kennedy was in part interested in poverty through his concerns with crime and delinquency. However, his family preoccupation with mental retardation, allowed him to be shown that poverty can cause retardation as well. His classic speech on the GNP shows some of his broad concerns. In it he said, "If we, as Americans, are b o u n d together by a c o m m o n concern for each other, t h e n an urgent national priority is upon us. W e m u s t begin to end the disgrace of the o t h e r A m e r i c a . . . . T o o m u c h and too long, we seem to have surrendered c o m m u n i t y excellence and c o m m u n i t y values to the m e r e accumulation of material things. O u r gross national product, now (March 1968) is over eight h u n d r e d billion dollars a year, but that G N P - - i f we s h o u l d j u d g e A m e r i c a by t h a t - - c o u n t s air pollution, cigarette advertising, and a m b u l a n c e s to clear o u r highways of carnage. It counts special locks for o u r doors and jails for those who break them. It counts the destruction of o u r redwoods and the loss of o u r natural wonders in chaotic sprawl. It counts n a p a l m
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and the cost of a nuclear warhead, and armored cars for police who fight riots in our streets . . . Yet the gross national product does not allow for the health of our children, the quality of their education, or the joy of their play. It does not include the beauty of our poetry, or the strength of our marriages, the intelligence of our public debate or the integrity of our public officials. It measures neither our wit nor our courage; neither our wisdom nor our learning; neither our compassion nor our devotion to our country; it measures everything, in short except that which makes life worthwhile. And it can tell us everything about America, except why we are proud that we are Americans." M o r e than anything else the poverty p r o g r a m led to the awareness that mental illness and it's prevention was part of a larger concern. T h e old N I M H Act, which was c o n c e r n e d with "the mental health o f the population of the United States" was a clue to how b r o a d the issues were. The m a n d a t e to u n d e r s t a n d the multiple factors in optimizing people's development, no matter what their cultural or economic status was critical. For me, increasingly community mental health was beyond the borders of our professions. I had to learn more. In my office, the staff at N I M H , primarily Antonia Chayes, wrote a proposal to develop D e m o n stration Cities. These would be cities, where we would use the total of the currently fragmented resources in a coherent, systemic way. W h e n H U D was created, Paul Ylvisaker, and Bob W o o d a m o n g others made it part of the program of our only city-oriented agency. W h e n the Secretary, r e s p o n d i n g to the riots of the 60's, said he " h a d e n o u g h d e m o n s t r a t i o n s , " the n a m e was c h a n g e d to M o d e l Cities. T h e goal here was simple. U n d e r the O E O , p r o g r a m s were e m e r g i n g to deal with p e o p l e ' s needs, especially the poor. H o w e v e r , the political structures o f the cities were incapable and resistant to the d e m a n d s for c h a n g e . T h o u g h m u c h was d o n e , t h e r e was little ability to c r e a t e change. I spent several years as the Special Assistant to Secretary W e a v e r , in an a t t e m p t to learn how cities worked. I soon realized that the basic decisions that effect mental health, c o m e from m a j o r decisions and not f r o m o u r n a r r o w s p e c i a l i n t e r e s t fields o f the social a n d m e d i c a l services. The backlash to H U D and Model Cities was great indeed. With it came in a related way a backlash to community mental health. It began to die. The reasons I believe were complex. On one hand there was the rise in interest with the p s y c h o - p h a r m a c e u t i c a l . Mike G o r m a n and M a r y Lasker, strong proponents of tranquilizing medication to be given by general practitioners, were being heard by the Congress.
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If available a magic bullet was always the desired goal. The search for it was also the beginning of a major, powerful and effective research effort on the brain and its actions. The turn to biological and genetic interpretations of illness occurred. This appeared, at first to be counterproductive to community mental health, but events later proved that it gave community mental health a scientific base. However, at the same time, an economic backlash occurred. In California, the left and the right for separate reasons closed the mental hospitals. The left closed the hospitals for civil rights reasons, and the right closed them because of an anti-mental illness paranoia. The promise was community mental health centers, supported by the saved money. The cruel reality was that Governor Ronald Reagan, took the money away. It was the beginning of the street as the place for the mentally ill. Much later, when the country moved into an economic depression, we saw a full blown epidemic of homelessness. Community mental health no longer held any power in academic circles. Nor did dynamic psychiatry. The old psychoanalytic leaders were replaced by the biologically oriented. However, as many including Caplan have stated, community mental health does exist in the small towns. It didn't die off completely. Psychologists and social workers maintained bits and pieces of their programs. Centers remained, as did some publications like the Journal of Primary Prevention.
SYSTEMS AND ECOLOGICAL THEORY I believe that community mental health did not die, but it was transformed. The ideas became part of the accepted ideas, without the private language. Corporations absorbed it as part of their Employee Assistance Programs. More important though, was the emergence of the so called New Age concerns we associate with The Esalen Institute. Carl Rogers, among others, had an important impact on socializing medical students. The language of the New Age contains much that was in the mental health literature, albeit with a different twist. New languages of holistic health began to develop. Within communities, each field of interest was extending its boundaries. We found that education meant more than the three R's. Housing meant day care. Law was into mediation and arbitration; just as advocacy appeared in divorce and other courts. Everyone was reaching beyond their parameters, all of which began to overlap. Systems theory began to emerge with explosive force. Our field felt it through the work of Gregory Bateson and Virginia Satir. Family therapy became not only systems therapy, but a concern for mental health and prevention.
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Here, it is worth returning to the Space Cadets. In 1962, we took over a piece of the program of the American Orthopsychiatric Association, and presented an eclectic set of papers on health systems and the city. It was later published as the Urban Condition (1963). This book, though not labeled as community mental health has become a seminal volume concerned with an ecological view of health and cities. Health promotion is as important as economics or transportation. It is my belief that Soskin's paper on "Harlem, Riots and the Ghetto" was in the forefront of understanding the relationship of mental health and racism. I believe Matthew Dumont in the Metro Center at NIMH did much to, not only push the limits in this area, but also to open up questions of social policy. Matthew Dumont is one of the great community psychiatrists in the United States. His work on the streets of Charlestown is unprecedented and unfortunately not supported or repeated. His grant to the University of California, laid the groundwork for training in city planning and social policy. It was here that I went after NIMH and HUD. During my years at the University of California, from 1968 through the 90's concern with community mental health and the psychiatric disciplines laid dormant. Programs existed with limited funds. For a few years social policy grew, but it was soon replaced by an economic analysis that posed as planning. It was, as if such an analysis could replace all the other issues of human behavior. Along with the upsurge of systems theory in corporations and elsewhere, there was an emergence of environmental concerns. This by itself, sold many on the concept of holism, ecology, and systems. For a long time, human and health issues sat on the periphery.
SOCIAL CHANGE Another phenomena was taking place at the same time. The information age was spreading. Ideas, aspirations and an anthropological view of diversity osmotically passed through national and personal boundaries, via all forms of communication, especially television. Travel became fast, cheaper and open to more people. The world's diversity became part of our neighborhoods and communities. What we saw as revolutionary in 1954, the Brown vs Topeka case in civil rights, spread so that all groups began to deal with their own self esteem. Is this not mental health? Racism, sexism, and more became bywords. Broad social concerns were, indeed, part of concerns with the "mental health of the population of the United States."
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The world began to change rapidly. The ability to control populations declined. Tools became available to people who were illiterate a few decades ago. New ideas emerged. Concepts from traditional healing of balance and harmony competed with simple causal theories. Medicine absorbed new ideas from science. Our skills improved. The basic ideas of psycho-neuro-immunology began to point to the relationship of psychological and social states to brain and immune chemistry. The more simplistic notions of community mental health and prevention began to get a scientific base. The boundary between body, mind, and soul began to lessen. Ethics, morality and even basic spiritual ideas began to become part of the new conceptual mix. I had spent some years looking at alternative healing. I felt that with the diversity of our populations, people would bring different philosophies and healing traditions to our cities. In doing so, they would change social policies and practice. I saw great changes for the health practices we were involved in.
HEALTHY CITIES In 1985 there was a bringing together of many of these ideas, in a conference in Toronto. Entitled, "Beyond Health Care" Trevor Hancock a public health physician asked what were the factors that affect health other than medical care. At that meeting I talked about Healthy Cities. It was as if, all the things that were part of my life converged. The idea that a city or community was as important as an institution or family in affecting people's health had received recognition. The ideas, expressed in 1963, in The Urban Condition were suddenly part of the accepted thinking. Very quickly, The World Health Organization (WHO) in Europe, under the leadership of Ilona Kickbush, created Healthy Cities programs. They were local in focus, created by participation and multi-sectoral in principle. The old boundaries began to break down and special interests appeared to begin to cooperate. To date, more than 1500 cities around the world have begun programs. Most of these are independent of WHO. Many American and Canadian cities are active, spreading ideas and programs. I hardly thought this possible in the heyday of community mental health. For me it is community mental health at its truest level. The players are the community and every type of activity within them. They include concerns with housing and transportation, jobs, education, healing and communication. They are a form of governance and mutual cooperation. I could not ask for more.
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In December 1993, a major conference brought all these local players and leaders from around the world to meet in San Francisco. Whether labelled Healthy Cities or Healthy Communities, mental health or community participation, they gathered to share experiences. It was the beginning --a new way to look both at cities and at health. So with that Conference, community mental health was not dead after all. Community mental health is being reinvented. Mental health has changed. The economics and politics of the past have faded. From it, I see new forms of mental health. Writing this in 1993, I see us at a major turning point. The values that we call human ones. Concern for health, welfare and education are returning to the scene. After all, community mental health was an attempt to change values, shift priorities, and to create new ways of doing things. With these values reemerging in the Healthy Cities concept, it takes on a moral force. A sense of community is returning to the United States, and elsewhere. This concern is expressed in new measures of our development, which are beginning to put greed and economics aside, and allow concern for the common good to reemerge. I say reemerge, because de Tocqueville found those values imbedded in our people. In the early 1800's, he saw barn raisings and mutual aid. These qualities seemed to disappear in the era of greed for most of the United States. Still small pockets of health existed during those years, I found it in the healthy Hutterites and Amish and other people that maintained community, and prospered. Governance in the world is becoming more local. Rationality and analytic skills are increasingly supplemented by the arts and intuition. Yes! The unconscious was okay, along with science. Concern, as expressed in 1968 by Robert Kennedy turned from the world of the market, to the needs and day-by-day concerns of people. We may come to a time when taxes will be paid because there is a return. Diversity flourishes and I relish in the richness of diverse cultures, beliefs and practices. Our land is being refurbished and hopefully, by environmental and ecological concerns, allowed to continue to sustain us. It is reciprocal maintenance, caring for all that cared for us. Ecology has more meaning than a fancy word. The theories of change are emerging. Findings are coming from studies of the brain and human behavior. The central finding is that out of apparent chaos, and a multitude of minuscule decisions, a set of patterns emerge that controls larger group behavior. The large flocks of birds fly in groups, as if under control by the leader. In truth, mini-rules governing each birds' actions leads to flock
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behavior. Self organization occurs out of apparent chaotic complexity. Complex systems follow rules that permit a continuous learning process. Learning leads to new perceptions and new responses. It may also work for the superfluous people, who need to live in a world where they are wanted, needed and have a place. Bringing m o r e and m o r e p e o p l e into a diverse dialogue is a key to the s o l u t i o n s n e e d e d . T h e myriad o f micro-issues, the v a r i e d att e m p t s at solution and the increasing chaos, are p a r t o f the ultimate solution. I cannot be sure that our leaders understand the processes o f change that are occurring. I suspect some may be aware of chaos theory, and artificial life studies where the cutting edge of research is being done. Awareness however, does not explain everything that is going on in the society at large. What I can say is that research in itself, is a reflection of the context. For example, systems theory arose in World War II out of the needs of the times to explain those times. This new form of leadership is occurring in the same way. While many turn to past failed solutions, only new concepts and new paradigms can lead to new solutions. O f course all is not perfect. That is mental health too. T h a n k God, the ideas of mental health have been absorbed into the day by day world. It is not the idea of treating people, communities or society as patients, as I was accused of by Irving Kristol in the late 1950's. It is a society where mental health is part of universal values. I used the word God here, very purposefully, not to signify a religion. Rather, that the values and ethics of our new world, contain the basic spiritual beliefs of many religions. The ideas have been here a long time. The religious saw it. The philosophers saw it. We, in mental health saw it. Now it is part of our daily life, and not just on holy days.
REFERENCE Duhl, L. (1963). Urban Condition, NY: Basic Books.
Looking Backwards: A Personal Look at Community Mental Health Len Duhl 1
This paper is a personal review of the forces affecting community mental health over the past 50 years from a psychiatrist who played a significant role in the movement. KEY WORDS: Peace corps; model cities; healthy cities and community mental health; NIMH; participation; prevention; health promotion.
It is difficult to look backwards at one's life and find just what should be said. Choosing to do so in 1993, after these years have passed, I cannot completely trust my memory, Science has permitted me to live through many important changes in our world. There have been great changes; post World War II, through the Kennedy-Johnson years, and in the pull back years of Nixon-ReaganBush. The world has changed radically. So has the health field, the knowledge of the brain and community mental health. Over the years I have reconstructed my perceptual realities, my paradigms for understanding the world and much more. In doing so, everything falls into place in different ways than they did as I passed through the events. What was understood and went for community mental health in the past, has change radically. Indeed, the "map" of my concern is now so broad and inter-related, it is hard to separate my concern from the emerging notions of the world. New ideas have emerged. New voices heard and new definitions of what is right and good. So please forgive me, if I see and sense the world of the past differently than you do. 1Address correspondence to Len Duhl, M.D., School of Public Health, Department of Social and Administrative Health Sciences, University of California at Berkeley, Berkeley, CA 94720. 31 9 1994 Human SciencesPress, Inc.
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Some of you might feel my views of history and current events are fiction. So be it!
SOME HISTORY My community mental health journey started before the 1960's. There are two sides to this story, my own and what I perceived was happening in the world. I go back before 1964, and Gerald Caplan's book. Though the history can be traced to the 1800's and 1900's and events like World War I, the birth of Orthopsychiatry and the Child Welfare League, for me it started very personally. In one way, it had to do with my Dad taking me around the City of New York to explore every aspect of it. This, he did every week from ages 4-14. It gave me, then unknowingly a holistic view of the city. In another way, it was a gigantic extended family, orchestrated by my mother. Much developed in my education in high school and later college, it was my training first as a physician and later as a psychiatrist-psychoanalyst, that solidified the need to be concerned with the public's health. Another memory was working in Topeka, as part of my residency with William Menninger and Ed Greenwood. Both psychiatrists, one headed Army psychiatry in World War II and the other was involved in child psychiatry. Each encouraged me, in their own way to think beyond, but not ignore the individual. While in training, I spent time with children in a settlement house. I helped plan Kansas' participation in the White House Conference on Children and Youth, where Ed Greenwood introduced me to figures who became important in building the framework of community mental health. Eric Erikson, Fritz Redl, and Ben Spock were people who, along with social workers and community organizers, gave me ideas that I later used. It was the beginning of an entry into a larger mental health world than psychiatry. I was on the road to becoming a well trained psychiatrist and psychoanalyst when I was called for military service. Joining the Public Health Service, I was assigned to the Contra Costa Health Department, in California. There, I began a friendship with Henrik Blum, who later became the father of health planning. Most important was my work for the health department in North Richmond, an urban slum, where I found myself developing with the Quakers what later became the core of the Community Action Program of OEO. A paper I wrote then, "A Sick City" foretold many of my future publications.
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While raised with a concern for the underdog, it was in North Richmond, that I really became aware of "superfluous people," people not wanted or needed by society. The time I spent in Contra Costa Health Department was spent learning about public health. This meant, a chance to get to know the functioning of a large suburban county. Free to use my time, I explored every aspect of the community, and this exploration laid the groundwork for much of my later work with cities and those in poverty. It was also at this time, I met and studied with Saul Alinsky, who later in his career would become a major voice for community grassroots activism. Returning from my "military service" in Contra Costa, to psychiatric training in Topeka, I found myself torn between clinical psychiatry and public health. Though I trained as a psychoanalyst, I was drawn more and more into population based work. At the time I was accused by some of prostituting my knowledge, for this broader interest in the community. Karl Menninger, to his credit, later in our relationship apologized for this remark, and said I had been, "right all along."
NIMH
A major turning point in my life was joining the NIMH Professional Services Branch in 1954. It was, and later became the long range planning organization for mental health. My job, defined by Robert Felix, the Director of the Institute was to stay two years ahead of Congress. It is important to recall the NIMH charter, "the care, treatment and rehabilitation of the mentally ill, and the mental health of the population of the United States." The later phrase was, for me, a general welfare clause which pushed me more and more towards a broader community approach towards promoting health. As I understood the two dynamic areas, I found myself pulled to all the different ways to look at and to deal with mental illness. This meant looking at every way people dealt with their psychological concerns and crises. At the same time, I turned more and more to growth and development as a model for understanding prevention, and what we now call health promotion. Though, I had heard about Paul Lemkau's important work at Johns Hopkins, I was truly excited by Erich Lindemann's work with the Wellesley Human Relation's Service. In fact, I had considered going there, but went to NIMH instead. Gerald Caplan tells a story, that there was a flip of the coin as to where I would go. I always believed it was my choice. He said others felt NIMH was the better place for me. So much for free will.
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Having gone to Bethesda, I immediately chose to work with Erich at the time when he was developing psychiatry at Massachusetts General and Harvard. This was the origin of the West End study. Where we studied the impact of the crisis of urban renewal on a population of Italian-Sicilians and Jews. Erich using the basic concepts of grief, his experience at Wellesley Human Relations Service, and a great team of researchers began to formulate the basic concepts of community mental health. The impact of this research was felt within the field, and in urban redevelopment. It was my first awareness that the idea of supporting such a study, would without the research results even started, lead to a change in the urban relocation policy of the United States. Gerald Caplan building upon his own work in Israel, drew from Erich Lindemann's work at the Harvard School of Public Health and began to formalize activities in the Laboratory of Community Mental Health at Harvard. The original work of Lindemann at the Coconut G r o v e fire b e g a n to e x t e n d into both the hospital and into the community. Though, there was activity elsewhere, at this time, most of it was exploratory. With John Calhoun the animal ecologist at NIMH, I had brought together a large diverse group of distinguished people from many different fields to look at issues in a multi-disciplinary way. I believed that people in diverse fields had similar goals, but often worked separately. Rather than my synthesizing their work and creating new programs, I brought them together, twice a year, for 12 years. The group included both older experts, young and up-and-coming people from many diverse fields. They included federal judges, animal ecologists, newsmen, psychologists, philosophers, educators, religion, housing and public health experts, politicians and others. This group was interested, primarily in new ways to look at issues in diverse fields. With fondness I recall they renamed themselves, the Space Cadets; a group looking at issues in new, way-out ways. We would later call it a search for new paradigms. Studies varied, from community organization to mathematical theory, systems theory to a study of the mafia's investments, from planning to create the Peace Corps to urban issues, to psychiatry, to education and more. It was, a focal point for systems and multi-disciplinary, community thinking. Its impact has never fully been evaluated. However, many of the ideas formulated and discussed there found their way into many of the programs of the Great Society and, later, still other programs.
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Other work at N I M H exposed me to issues affecting the mentally retarded; those with substance abuse problems and with special populations like college students. Gradually, all these experiences provided me with a clearer picture of what community mental health might be. In each case, it was clear, that a focus on treatment was not enough. Indeed, a full system of interrelated services and activities was a major part of the solution. One important experience I remember was William Soskin's paper for NIMH, "Harlem, Riots and the Ghetto" where he tied racism and poverty to mental health concerns. Bill had followed the civil rights movement to see how people were finding new voices for themselves, changing their self image, and affecting their own mental health. The NIMH served to stimulate major shifts in this direction. With 1960 and the Joint Commission on Mental Health report, many efforts into community health occurred. When the R e p o r t was published, there began a shift from hospital to community settings. Though, this seemed to be the direction for the future, many other events conspired to turn it in other directions. For example, the creation of fee for service Medicare and Medicaid, important as it was, prevented neighborhood health centers from fully emerging as service providers.
PEACE CORPS During the heady days of the Kennedy presidency, many things seemed possible. Concern for the mentally retarded and mentally ill, along with great increases in NIH budgets blazed new programs trails. Here I have to recall a memory, from the Kennedy election. During the campaign, it came to my attention that the future President was going to announce the Peace Corps. By the time he did at the famous speech in Michigan, I was trying to figure out how to be involved. My interest was simple. I believed that non-professionals could play an important role in mental health and other programs. The Peace Corps was an ideal place to test this hypothesis. I spent some time, trying to figure out who might be chosen to head the organization. By piecing together a series of diverse leaks from many data sources, I thought it might be Sargent Shriver. Parenthetically, it is important to acknowledge the fact that being at NIMH, and having the freedom I had offered a chance to link into many information networks.
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I had worked with Shriver before, on problems of mental retardation, and knew something of his and the Kennedy style of recruitment. He would call key people and ask their advice. Slowly, sorting through a sociometric technique, he would focus down on a few people, and then make his decision. In designing a Peace Corps, I knew that one publicly perceived problem, might be, how not to send "mentally sick" people overseas. I proceeded to call about thirty people, and mentioned my interest both in the Peace Corps and in the concern for who would be selected by service. On Thanksgiving Day or thereabouts, I received a phone call. "This is Sargent Shriver. Do you knowwho I am? I am about to set up the Peace Corps, and I want to make sure no mentallyill people are sent overseas. I talked to many people, and they all said you were the expert. Can you help?" This was the beginning of Peace Corps psychiatry. Using my position at NIMH, I brought a group of people together to help, both in selection and in psychological support. Among them were R o b e r t Leopold, a psychiatrist who was working with the American Friends Service Committee and their overseas volunteers. More than anyone else he set the stage for the development of the program. Another person I enlisted was Gerald Caplan, who trained many people in consultation and mental health. His work had an important long standing impact on the field. I was asked, along with Leopold to construct the mental health side of the medical program. In addition, I helped recruit Nicholas Hobbs, a leader in American psychology, to be in charge of selection. Nick was active in the "educateur" program which was called Project Re-Ed, a way to train non-professionals to work with the retarded. The program was shaped by my increasingly broad view of mental health, Leopold's ability to turn ideas into operations, plans and policies, and Caplan's ability to train. The strong support of Shriver, the exciting atmosphere of political change, and the Peace Corps began. My world understanding was subtly changed by all the interesting people we were in touch with. I was originally, going to meet the needs of the Peace Corps, but it became a strategy of using this experience as a way of training people for community mental health leadership in the country. When the Joint Commission Report and Mental Health and Retardation Act was converted into community mental health programs by people like Bert Brown, experts were ready. The ultimate result was that many of the people we worked with and trained became key leaders, academically and elsewhere.
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Within the Peace Corps, the results were very positive. I recruited Joe English, a psychiatrist from the Clinical Center at NIMH based upon his college mental health experience, and his being single and free to travel extensively, which I wasn't. Joe prospered in the job and later extended his broadening concerns to the OEO, which Shriver later led. The lessons for me were many. It included the ability, using minimally trained volunteers to anticipate crises overseas, and well-timed, informal sessions to diminish casualties of all kinds. It also served as a way to do systemic analyses of programs by gathering diverse data, following patterns of information and effecting decisions that were both administratively helpful, but also mentally healthy. Many more things were learned that are reported elsewhere by the diverse groups of mental health professionals involved in the Peace Corps. Like the experience in Korea and later in Viet Nam, a network of support could emerge for soldiers with much energy on preventive activities. AI Glass' work with the army was a major contribution to this emerging view of community based mental health.
THE OEO AND HUD For me however, it was the development of the Poverty Program, which became OEO, that launched me onto a larger stage. It was here that I became more and more aware that participatory involvement of consumers and others truly affected their health. I also began to connect deprivations of all kinds, including economic poverty, as a cause not only of mental but social and physical problems as well. My concern with the socalled "superfluous" people reemerged. Robert Kennedy was in part interested in poverty through his concerns with crime and delinquency. However, his family preoccupation with mental retardation, allowed him to be shown that poverty can cause retardation as well. His classic speech on the GNP shows some of his broad concerns. In it he said, "If we, as Americans, are b o u n d together by a c o m m o n concern for each other, t h e n an urgent national priority is upon us. W e m u s t begin to end the disgrace of the o t h e r A m e r i c a . . . . T o o m u c h and too long, we seem to have surrendered c o m m u n i t y excellence and c o m m u n i t y values to the m e r e accumulation of material things. O u r gross national product, now (March 1968) is over eight h u n d r e d billion dollars a year, but that G N P - - i f we s h o u l d j u d g e A m e r i c a by t h a t - - c o u n t s air pollution, cigarette advertising, and a m b u l a n c e s to clear o u r highways of carnage. It counts special locks for o u r doors and jails for those who break them. It counts the destruction of o u r redwoods and the loss of o u r natural wonders in chaotic sprawl. It counts n a p a l m
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and the cost of a nuclear warhead, and armored cars for police who fight riots in our streets . . . Yet the gross national product does not allow for the health of our children, the quality of their education, or the joy of their play. It does not include the beauty of our poetry, or the strength of our marriages, the intelligence of our public debate or the integrity of our public officials. It measures neither our wit nor our courage; neither our wisdom nor our learning; neither our compassion nor our devotion to our country; it measures everything, in short except that which makes life worthwhile. And it can tell us everything about America, except why we are proud that we are Americans." M o r e than anything else the poverty p r o g r a m led to the awareness that mental illness and it's prevention was part of a larger concern. T h e old N I M H Act, which was c o n c e r n e d with "the mental health o f the population of the United States" was a clue to how b r o a d the issues were. The m a n d a t e to u n d e r s t a n d the multiple factors in optimizing people's development, no matter what their cultural or economic status was critical. For me, increasingly community mental health was beyond the borders of our professions. I had to learn more. In my office, the staff at N I M H , primarily Antonia Chayes, wrote a proposal to develop D e m o n stration Cities. These would be cities, where we would use the total of the currently fragmented resources in a coherent, systemic way. W h e n H U D was created, Paul Ylvisaker, and Bob W o o d a m o n g others made it part of the program of our only city-oriented agency. W h e n the Secretary, r e s p o n d i n g to the riots of the 60's, said he " h a d e n o u g h d e m o n s t r a t i o n s , " the n a m e was c h a n g e d to M o d e l Cities. T h e goal here was simple. U n d e r the O E O , p r o g r a m s were e m e r g i n g to deal with p e o p l e ' s needs, especially the poor. H o w e v e r , the political structures o f the cities were incapable and resistant to the d e m a n d s for c h a n g e . T h o u g h m u c h was d o n e , t h e r e was little ability to c r e a t e change. I spent several years as the Special Assistant to Secretary W e a v e r , in an a t t e m p t to learn how cities worked. I soon realized that the basic decisions that effect mental health, c o m e from m a j o r decisions and not f r o m o u r n a r r o w s p e c i a l i n t e r e s t fields o f the social a n d m e d i c a l services. The backlash to H U D and Model Cities was great indeed. With it came in a related way a backlash to community mental health. It began to die. The reasons I believe were complex. On one hand there was the rise in interest with the p s y c h o - p h a r m a c e u t i c a l . Mike G o r m a n and M a r y Lasker, strong proponents of tranquilizing medication to be given by general practitioners, were being heard by the Congress.
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If available a magic bullet was always the desired goal. The search for it was also the beginning of a major, powerful and effective research effort on the brain and its actions. The turn to biological and genetic interpretations of illness occurred. This appeared, at first to be counterproductive to community mental health, but events later proved that it gave community mental health a scientific base. However, at the same time, an economic backlash occurred. In California, the left and the right for separate reasons closed the mental hospitals. The left closed the hospitals for civil rights reasons, and the right closed them because of an anti-mental illness paranoia. The promise was community mental health centers, supported by the saved money. The cruel reality was that Governor Ronald Reagan, took the money away. It was the beginning of the street as the place for the mentally ill. Much later, when the country moved into an economic depression, we saw a full blown epidemic of homelessness. Community mental health no longer held any power in academic circles. Nor did dynamic psychiatry. The old psychoanalytic leaders were replaced by the biologically oriented. However, as many including Caplan have stated, community mental health does exist in the small towns. It didn't die off completely. Psychologists and social workers maintained bits and pieces of their programs. Centers remained, as did some publications like the Journal of Primary Prevention.
SYSTEMS AND ECOLOGICAL THEORY I believe that community mental health did not die, but it was transformed. The ideas became part of the accepted ideas, without the private language. Corporations absorbed it as part of their Employee Assistance Programs. More important though, was the emergence of the so called New Age concerns we associate with The Esalen Institute. Carl Rogers, among others, had an important impact on socializing medical students. The language of the New Age contains much that was in the mental health literature, albeit with a different twist. New languages of holistic health began to develop. Within communities, each field of interest was extending its boundaries. We found that education meant more than the three R's. Housing meant day care. Law was into mediation and arbitration; just as advocacy appeared in divorce and other courts. Everyone was reaching beyond their parameters, all of which began to overlap. Systems theory began to emerge with explosive force. Our field felt it through the work of Gregory Bateson and Virginia Satir. Family therapy became not only systems therapy, but a concern for mental health and prevention.
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Here, it is worth returning to the Space Cadets. In 1962, we took over a piece of the program of the American Orthopsychiatric Association, and presented an eclectic set of papers on health systems and the city. It was later published as the Urban Condition (1963). This book, though not labeled as community mental health has become a seminal volume concerned with an ecological view of health and cities. Health promotion is as important as economics or transportation. It is my belief that Soskin's paper on "Harlem, Riots and the Ghetto" was in the forefront of understanding the relationship of mental health and racism. I believe Matthew Dumont in the Metro Center at NIMH did much to, not only push the limits in this area, but also to open up questions of social policy. Matthew Dumont is one of the great community psychiatrists in the United States. His work on the streets of Charlestown is unprecedented and unfortunately not supported or repeated. His grant to the University of California, laid the groundwork for training in city planning and social policy. It was here that I went after NIMH and HUD. During my years at the University of California, from 1968 through the 90's concern with community mental health and the psychiatric disciplines laid dormant. Programs existed with limited funds. For a few years social policy grew, but it was soon replaced by an economic analysis that posed as planning. It was, as if such an analysis could replace all the other issues of human behavior. Along with the upsurge of systems theory in corporations and elsewhere, there was an emergence of environmental concerns. This by itself, sold many on the concept of holism, ecology, and systems. For a long time, human and health issues sat on the periphery.
SOCIAL CHANGE Another phenomena was taking place at the same time. The information age was spreading. Ideas, aspirations and an anthropological view of diversity osmotically passed through national and personal boundaries, via all forms of communication, especially television. Travel became fast, cheaper and open to more people. The world's diversity became part of our neighborhoods and communities. What we saw as revolutionary in 1954, the Brown vs Topeka case in civil rights, spread so that all groups began to deal with their own self esteem. Is this not mental health? Racism, sexism, and more became bywords. Broad social concerns were, indeed, part of concerns with the "mental health of the population of the United States."
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The world began to change rapidly. The ability to control populations declined. Tools became available to people who were illiterate a few decades ago. New ideas emerged. Concepts from traditional healing of balance and harmony competed with simple causal theories. Medicine absorbed new ideas from science. Our skills improved. The basic ideas of psycho-neuro-immunology began to point to the relationship of psychological and social states to brain and immune chemistry. The more simplistic notions of community mental health and prevention began to get a scientific base. The boundary between body, mind, and soul began to lessen. Ethics, morality and even basic spiritual ideas began to become part of the new conceptual mix. I had spent some years looking at alternative healing. I felt that with the diversity of our populations, people would bring different philosophies and healing traditions to our cities. In doing so, they would change social policies and practice. I saw great changes for the health practices we were involved in.
HEALTHY CITIES In 1985 there was a bringing together of many of these ideas, in a conference in Toronto. Entitled, "Beyond Health Care" Trevor Hancock a public health physician asked what were the factors that affect health other than medical care. At that meeting I talked about Healthy Cities. It was as if, all the things that were part of my life converged. The idea that a city or community was as important as an institution or family in affecting people's health had received recognition. The ideas, expressed in 1963, in The Urban Condition were suddenly part of the accepted thinking. Very quickly, The World Health Organization (WHO) in Europe, under the leadership of Ilona Kickbush, created Healthy Cities programs. They were local in focus, created by participation and multi-sectoral in principle. The old boundaries began to break down and special interests appeared to begin to cooperate. To date, more than 1500 cities around the world have begun programs. Most of these are independent of WHO. Many American and Canadian cities are active, spreading ideas and programs. I hardly thought this possible in the heyday of community mental health. For me it is community mental health at its truest level. The players are the community and every type of activity within them. They include concerns with housing and transportation, jobs, education, healing and communication. They are a form of governance and mutual cooperation. I could not ask for more.
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In December 1993, a major conference brought all these local players and leaders from around the world to meet in San Francisco. Whether labelled Healthy Cities or Healthy Communities, mental health or community participation, they gathered to share experiences. It was the beginning --a new way to look both at cities and at health. So with that Conference, community mental health was not dead after all. Community mental health is being reinvented. Mental health has changed. The economics and politics of the past have faded. From it, I see new forms of mental health. Writing this in 1993, I see us at a major turning point. The values that we call human ones. Concern for health, welfare and education are returning to the scene. After all, community mental health was an attempt to change values, shift priorities, and to create new ways of doing things. With these values reemerging in the Healthy Cities concept, it takes on a moral force. A sense of community is returning to the United States, and elsewhere. This concern is expressed in new measures of our development, which are beginning to put greed and economics aside, and allow concern for the common good to reemerge. I say reemerge, because de Tocqueville found those values imbedded in our people. In the early 1800's, he saw barn raisings and mutual aid. These qualities seemed to disappear in the era of greed for most of the United States. Still small pockets of health existed during those years, I found it in the healthy Hutterites and Amish and other people that maintained community, and prospered. Governance in the world is becoming more local. Rationality and analytic skills are increasingly supplemented by the arts and intuition. Yes! The unconscious was okay, along with science. Concern, as expressed in 1968 by Robert Kennedy turned from the world of the market, to the needs and day-by-day concerns of people. We may come to a time when taxes will be paid because there is a return. Diversity flourishes and I relish in the richness of diverse cultures, beliefs and practices. Our land is being refurbished and hopefully, by environmental and ecological concerns, allowed to continue to sustain us. It is reciprocal maintenance, caring for all that cared for us. Ecology has more meaning than a fancy word. The theories of change are emerging. Findings are coming from studies of the brain and human behavior. The central finding is that out of apparent chaos, and a multitude of minuscule decisions, a set of patterns emerge that controls larger group behavior. The large flocks of birds fly in groups, as if under control by the leader. In truth, mini-rules governing each birds' actions leads to flock
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behavior. Self organization occurs out of apparent chaotic complexity. Complex systems follow rules that permit a continuous learning process. Learning leads to new perceptions and new responses. It may also work for the superfluous people, who need to live in a world where they are wanted, needed and have a place. Bringing m o r e and m o r e p e o p l e into a diverse dialogue is a key to the s o l u t i o n s n e e d e d . T h e myriad o f micro-issues, the v a r i e d att e m p t s at solution and the increasing chaos, are p a r t o f the ultimate solution. I cannot be sure that our leaders understand the processes o f change that are occurring. I suspect some may be aware of chaos theory, and artificial life studies where the cutting edge of research is being done. Awareness however, does not explain everything that is going on in the society at large. What I can say is that research in itself, is a reflection of the context. For example, systems theory arose in World War II out of the needs of the times to explain those times. This new form of leadership is occurring in the same way. While many turn to past failed solutions, only new concepts and new paradigms can lead to new solutions. O f course all is not perfect. That is mental health too. T h a n k God, the ideas of mental health have been absorbed into the day by day world. It is not the idea of treating people, communities or society as patients, as I was accused of by Irving Kristol in the late 1950's. It is a society where mental health is part of universal values. I used the word God here, very purposefully, not to signify a religion. Rather, that the values and ethics of our new world, contain the basic spiritual beliefs of many religions. The ideas have been here a long time. The religious saw it. The philosophers saw it. We, in mental health saw it. Now it is part of our daily life, and not just on holy days.
REFERENCE Duhl, L. (1963). Urban Condition, NY: Basic Books.
