Planning for Mental Health Alice A. Leeds, M.D. Jon E. Gudeman, M.D. Kent S. Miller, Ph.D. Alan I. Levenson, M.D.
ABSTRACT: This report is based on a study of comprehensive mental health state plans submitted to the National Institute of Mental Health in i965 , interviews with mental health planners in selected states, discussions with professionals and citizens involved in the planning, and a review of the pertinent literature. This study was made to bring together observations about the outcome of this massive planning effort, to comment on the current status of mental health planning, and to develop some directions for facilitating planning at the state level. Mental health has been the subject of considerable planning under a federally sponsored program for comprehensive mental health planning in I963-1965 in which each state studied its own needs and developed a formal state plan (NIMH, Department of Health, Education, and Welfare, 1963 , 1964). This report attempts to bring together some observations about the outcome of this comprehensive mental health planning effort, to comment on the current status of mental health planning, the need for continued evaluation and planning, and to suggest some direction for facilitating planning at a state level. It is based on a study of the state plans submitted to the National Institute of Mental Health in 1965 , interviews with mental health planners in selected states where planning is ongoing, discussions with professionals and citizens involved in the planning effort, and a review of pertinent literature on mental health planning. A word needs to be said about the meaning of the concept "planning." A general definition is that planning is the process of effecting changes which otherwise might not occur, an attempt to identify desired end results and devise ways to accomplish them. Used in this context, c o m p r e h e n s i v e planning implies a lesser concern with targets and a greater concern with direction. In contrast to this, operational planning involves day-to-day, year-toAt the time this article was written, the authors were staff members at the National Institute of Mental Health. Dr. Leeds is nozo chief, International Reference Center for Information on Psychotropic Drugs, Psychopharmacology Research Branch, Dr. Gudeman is staff psychiatrist, and Dr. Levenson is director, Division of Mental Health Service Programs, National Institute of Mental Health, 5454 Wisconsin Ave., Chevy Chase, Md. 2o2o3. Dr. Miller is professor of psychology and sociology, Institute for Social Research, The Florida State University, Tallahassee, Fla. Community Mental Health Journal, Vol. 5 (3), 1969
206
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year decisions on specific activities directed toward a specific objective. Frequently there is a failure to recognize the distinction between comprehensive and operational planning. While both types need to go on simultaneously, the difference should be kept in focus. The rapid growth in the provision of mental health services in the United States highlights the equally growing need for planning and evaluation. Major questions arise as increasing sums are invested in the mental health care of Americans, and these demand the most careful consideration. Evidence of this expansion of services can be seen in a variety of ways. To state the growth in terms of funds being expended, an estimated $2o billion now are being invested annually in mental health services. State level mental health budgets often rank next to education and welfare in size. In New York, for example, the annual state mental health budget exceeds $5oo million. New services are becoming available to the aged and to indigent children under Medicare and Medicaid. A Federal program of support for the construction and staffing of community mental health centers has led the way to an unprecedented expansion of services. As mental health service programs expand, several questions arise. First, how effective are these new programs in meeting the need of the mentally ill and in promoting mental health? Second, since planning for future needs depends greatly on an evaluation of existing programs and resources, how much planning is based on systematic evaluation of the current status of mental health programs? Directly related to these questions is a third. Who are the people concerned with the problems of evaluation and planning for mental health? Clearly, without mental health professionals designated to evaluate and plan mental health programs, the effective utilization of these programs will not develop. The present need for evaluation and planning for mental health services arises from a variety of sources. To a certain extent mental health professionals have convinced the public that they are ready to take giant strides in the treatment of mental illness, especially through the concept of the community mental health center. Legislators and the public are in a position to ask if their money is well spent. This question can only be answered through a systematic evaluation of the effectiveness and the impact of these services. The need for evaluation of current programs and long-range interagency planning :becomes even more imperative when one considers the changing models of mental health and the new methods for the delivery of services. Through new techniques of evaluation and planning, such as program planning and budgeting (PPB), systems analysis, and computer-based simulation, tools for a precise and modern approach are now available. COMPREHENSIVE MENTAL HEALTH PLANNING FROM z963 TO I9@ Comprehensive mental health planning at the Federal level was authorized by the 87th Congress in 1963. Mental health planning
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activity was supported from July 1, I963 until June 3 ~, 2965 . For each year $4.2 million as grants-in-aid were available to the states on a formula basis. The move toward planning in the mental health field was rooted in prior developments. In 2946 the National Mental Health Act established the National Institute of Mental Health with authority for programs in community mental health. In 1965 the Joint Commission on Mental Illness and Health was established and their report "Action for Mental Health" (1961) emphasized "the development of a community atmosphere that is receptive to new ideas for the treatment of mental patients." In I962 the Conference of State and Territorial Mental Health Authorities and the Governors' Conference at Hershey, Pennsylvania, both recommended that states undertake comprehensive mental health planning. Although the concept of community mental health had been identified as early as x952, patient-referral, diagnosis, evaluation, treatment, rehabilitation, aftercare, and long-term follow-up, in other words a continuum of care in the community, were almost nonexistent. A survey of 234 facilities published by the Joint Information Service (1964) showed that while all had certain elements of a community mental health program, none had the ideal dimensions of comprehensiveness. While the Federal guidelines for comprehensive mental health planning left much room for individual state variations and autonomy, the ultimate national goal was stated as "the improvement of the mental health of the people." The planning activities that were to be performed under the grant included: (a) gathering of information on patients and families, general population characteristics, facilities, health manpower, research programs and resources, training programs and resources; (b) integration and coordination of information; (c) selection of goals, priorities, and methods; (d) allocation and distribution of available resources. Additional objectives were expressed or implied; First, comprehensive mental health planning would insure interagency cooperation in planning. This first objective was a grass roots approach to planning, in that all types of people would be involved in planning with both professional and lay representation. Second, mental health planning was to lead to the development and strengthening of community-based programs. This goal focuses on the current belief that mental health must be brought physically, psychologically, and socially, back into the community. Third, implicit in the Federal guidelines was the notion that this money would provide seed money for planning which could then be continued by the states. Fourth, each plan would establish broad long-range objectives which would mobilize the state's resources for treatment, prevention, and research in a graded way to reach priority objectives. These were the expressed and implied goals, but what actually did evolve? In view of all the social forces operating during this period, it is difficult to ascribe specific results to the planning process, but the following generalizations seem warranted.
Leeds, Gudeman, Miller, end Levenson
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2. There can be no question about citizen involvement s'ince 20,000 to 25,0oo people participated in the planning process (U. S. Department of Health, Education, and Welfare, 2965). They became informed, involved in programs, and active supporters of the mental health movement. This development of an informed and interested mental health public was clearly the most obvious outcome arising from the national planning effort. z. There was the beginning development of state data banks. The information collected at local levels was often unreliable, but some of the state level data did provide a base for the systematic collection of data which had pertinence for planning, and it underscored the lack of relevant data. 3. Permanent planning offices were established in some states. The initial hope was that this would be the common outcome but, with the termination of Federal support for planning in ~965, staff tended to move on to other jobs. 4. There were some developments in mental health services which were directly related to the planning effort. There seems to be general agreement that the final state plans were homogeneous, that goals were usually expressed in global terms, and that unique state and area characteristics tended to bear little relationship to the final recommendations. In part this may be a reflection of the fact that, in initial planning, states focused on broad comprehensive goals rather than on moving from these goals to more specific objectives and methods of obtaining them. This was not disturbing to most of the planners who were questioned. They readily acknowledged that better plans could have been developed at the state level but they saw the process as the important element. A citizenry which was informed and concerned was seen as the major vehicle for implementing programs. Its impact has been felt in a variety of direct and indirect ways. State departments of mental health have been strengthened, state hospitals have been forced to reconsider their role, and community mental health acts have been passed.
CURRENT STATE PLANNING OPERATIONS During the period of federally assisted comprehensive planning, I963-2965, some 25o to 3oo professionals were recruited for state level planning and data collection. Their responsibilities were comprehensive in that they were charged with examining all aspects of mental health services-those which were operated privately as well as those which were operated publicly, those supported locally as well as those supported at state level. When the Federal program ended in July I965, it appeared that a majority of states were well on the way to maintaining such planning as part of regularly budgeted activities of their mental health authorities. Permanent planning offices under the jurisdiction of the mental health authorities had already been established by 19% of the states and territories. An additional 5x% of the states indicated that the creation of such an office and the continuation of comprehensive planning were likely to occur. Only 3O~o
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of the states and territories indicated that it was either doubtful or unlikely that such mental health planning would continue. The study being reported here was conducted two years after the Federal mental health planning program had ended. It was apparent that in this two-year period state mental health planning efforts had in many respects become quite different from earlier expectations. By July 2967 there were permanent planning offices in the mental health authorities of only 34% of the states, and only ~6 of these ~8 offices were staffed with professional mental health planners. Clearly in 2967 mental health planning offices were not functioning in the 7o~o of the states where establishing such offices had been contemplated in 2965 . It must be noted, however, that the absence of a mental health planning office does not necessarily imply a total absence of mental health planning activities within the state government. In the states without mental health planning offices, specific planning efforts have been carried on in connection with the states' participation in two federally supported mental health service programs. One is the Community Mental Health Centers Program (Public Law 88-264); the other is the grant-in-aid portion of the Comprehensive Health Planning Program (Public Law 89-749). At the time of the present study, all but two states had developed plans for the construction of community mental health centers, and 5o states had developed plans for participation in the grant-in-aid program. Thus it appears that the states are engaged in the process of planning for mental health centers and projects under the grant-in-aid mechanism, and it is equally apparent that many of the states have undertaken these planning efforts without the establishment of a designated planning office within the state mental health authority. On the other hand, just as the absence of a designated planner does not preclude the possibility of planning, the presence of such a person does not guarantee that planning will occur. The results of our study indicate that many of the planning offices which have been created had to assum~e responsibility for a variety of activities in addition to the planning function. Our interviews revealed that planning offices have a wide range of functions and responsibilities. While state planning offices tend to be located at a high level in the organizational chart, other generalizations are difficult to make. Mental health planners' backgrounds are heterogeneous and their spheres of operation are varied. Most of them have some responsibility for data collection and for operational planning. Some get involved in community organization work, in writing grant applications, in providing information for legislative committees, in coordination functions, and occasionally they assume direct program responsibility. Even the most sophisticated planning offices tend to get caught up in operational planning and have little time for comprehensive planning. Since the states vary widely with respect to the nature of mental health services offered, it is not surprising that they vary with respect to their plan-
Leeds, Gudeman, Miller, and Levenson
211
ning functions. It may be possible to identify three phases or stages in the development of a planning operation at a state level: ~. Funding a planning office; officially designating a planner; getting someone present to do the job. a. The development of a data collection system; analysis and evaluation of current operations; establishmentof mechanismsfor processing information. 3. Planningin the major sense that the concept is being used in this paper. These three stages do not follow in a narrow sequential manner--the second and third will always be closely related. But it is apparent that even the most sophisticated operation is devoting only a limited effort to phase 3. One example of this fact follows. Without exception, the planners the authors spoke to saw a definite shift occurring in regard to the basic models of mental illness. They saw a rapidly increasing concern with social competence; increased interaction with other health and welfare agencies; concern with low-income groups, model cities, and vocational rehabilitation. They envisioned a shift from the disease model and a focus on the individual patient. But at the same time, this was not apparent in most of the operations of their offices, and there was little evidence of concrete plans in this direction. It was of interest to us to find that operating planning organizations are becoming increasingly aware of the importance of evaluation (Milbank Memorial Fund, 2966 ) . As noted at the outset of this paper, mental health has seen an upsurge at the Federal and state level with regard to increased budgets and expenditures. With this has come the growing realization that there must be more accountability for programs. Evaluation involves the careful assessment of the extent to which a particular program or course of action is approximating the goals of the program. While the importance of evaluation is widely recognized, the reality is that few planning organizations are actively involved in this endeavor. At present, two of the large states surveyed have begun moving in this direction, one by publication of a manual for evaluation and the other by hiring experts to work on evaluation of state programs. NEED FOR CONTINUED MENTAL HEALTH PLANNING Formal planning is necessary for any large-scale effort. It could be argued that in terms of the history of mental health services, planning has been a luxury which we have comfortably done without. If there ever was any merit to this position, it certainly does not apply at this point in time (Schulberg, 5965; GAP, I964; Vail, 5965). A number of forces combine to make the establishment of planning activities at the state level crucial. i. Although the development of services varies with each state, the mental health service system is large and involves sizable budgets. This alone is sufficient reason for considerable planning activity.
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2. The range of disorders and behaviors falling under the heading of mental illness continues to broaden, and basic models are in a state of flux. Entirely different services are going to be demanded and different populations will have to be served by other than the traditional manpower. 3. There is a trend toward the establishment of statewide planning commissions with at least 46 states creating planning agencies by statutes (Chikfield, "r967). Mental health authorities will have to provide these commissions with much more specific data and plans than in the past. There are some suggestions that state legislatures will ask for hard data regarding programs and their effectiveness. This is an inevitable outgrowth of the increases in funds which the states had to allocate for services in recent years. 4- Public Law 89-749, Comprehensive Health Planning and the Public Health Services Amendments, provides funds for comprehensive health planning at state and regional levels. It will call for more, not less, mental health planning. There will be competition for some of these funds, and the quality of the plans submitted may well determine who will gain additional support. 5. The Federal program for the construction and staffing of community mental health centers is rapidly evolving, with approximately 275 such centers already funded. The intention of the legislation behind this program was to provide a base for a variety of integrated mental health services. There are already some indications that a number of these centers are settling down to rather conventional methods in the delivery of services and that the model as presently conceived may not be appropriate for all communities. Continued planning is necessary to evolve more meaningful alternatives, as well as a more effective use of these centers. RECOMMENDATIONS FOR A STATE MENTAL HEALTH PLANNING OFFICE If our argument about the importance of a formal mental health planning effort is valid, the next question relates to the manner in which it should be organized. The most appropriate place for planning would seem to be in the state mental health authority. Comprehensive planning below this level may be ineffective. Only a handful of the states currently have a comprehensive planning office, and they could use additional support. The goal of a viable planning office in each state is not unrealistic. The planning process will call for a specific staff and earmarked funds. The director of the office should be a senior professional appointment with status as an adviser to the departmental director. The long-range purpose of such an office would be that of providing alternative goals and programs for policy-makers, and evaluation of program effectiveness. Of course, each state would not be starting at the same point in development, and thus there would be some range in emphasis. Some would have to focus on establishing data collection systems; others could readily move on to operational analysis and evaluation of programs in terms of outcome. There should be safeguards
Leeds, Gudeman, Miller, and Levenson
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to avoid having the planning effort become purely an operational analysis. In the larger states, the state level office might function as a facilitator for conveying this overall process to each of the large units in the field. This discussion proposes that planning and evaluation must become an integral part of any mental health program. Yet in the face of the demand for services, these activities frequently receive a low priority. A first step in implementation would be convincing department directors of the payoff to come from a planning office. Individual members of the mental health professions must lend their support to this concept if the necessary goals are to be accomplished. It is also submitted that efforts should be directed toward more sophisticated planning techniques and evaluation methodologies. The new organizational patterns which admit no separation of prevention, treatment, and rehabilitation, the merging of public and private efforts both of service and finances, and the entire question of how medicine as a whole and psychiatry in particular fit into the pattern of comprehensive care, demand a more upto-date approach to planning. Planning techniques such as those used in other fields, e.g., industry or city planning, should be investigated for usefulness in the health field, and additional new techniques and methodologies for evaluation must be developed. The necessity for the use of planning and evaluation techniques carries with it a concurrent need for professional planners. As stated above, the background of the current planners is as varied as the tasks they must perform. Since organized planning for comprehensive health services is a rather recent addition to other existing planning areas, training for planners is almost nonexistent. Admittedly, there are occasional regional or statewide meetings for such planners, a few week-long symposia which permit an exchange of experiences and ideas. Very rarely are such meetings made more effective through successive meetings to evaluate progress made individually in the interim and to discuss problems which have arisen since the last meeting. Another approach might be the development of curricula for mental health planners at universities and colleges. Since this would not meet the immediate crisis in planning manpower, some specifically structured workshops or seminars should be held at regular intervals to facilitate the tasks of the planners, at least at the technical end of planning. It should be noted here that the Federal Comprehensive Health Planning and Services Program offers assistance for the training of planners as well as for the development of plans. One portion of the program makes available grants for the establishment of training programs for all types of health planners. The grants are intended to enable universities to create the specialized curricula needed by those entering the health planning field. General programs in health planning can be supported and specialized courses in curricula in mental health planning can be developed with such Federal assistance. Today's and tomorrow's programs are complex. A continuous feedback system must be created to assure that tasks planned or in operation are worth-
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while and the procedures effective. Neither clinical nor administrative staff, regardless of specific skills and experiences, are generally trained to think in terms of the systems concept. While data collection and analysis can often be done under contract, it still remains the planner's responsibility to develop a comprehensive plan and frequently to offer alternative courses of action to certain parts of the program to reach goals more effectively. Familiarity with PERT (Program Evaluation Review Technique) as well as with gaming techniques (as in war games and business games) will enable him to better understand interrelationships within the program and the interdependence of program components. The far-reaching social adjustments that must be made due to the change in American life demand preparation to cope with ever-increasing problems. The move from rural to urban areas and the ensuing transitional type of family and social situation have focused attention on problems associated with these changes. Alcoholism, juvenile delinquency, crime, mental illness, family disruption, and a host of other ills have grown to menacing proportions. Comprehensive planning, followed as soon as feasible by implementation and evaluation, seems a reasonable solution. It is essential that planning be strengthened at all levels, Federal, regional, state, and local, that a cadre of health planners be developed, and that planning be moved up from a fringe activity to the position of prestige and importance it deserves. REFERENCES Action for Mental Health. Final Report of the Joint Commission on Mental Illness and
Health. ScienceEditions, New York, 296i. Chickfield, B. Special letter to Governors, cited by W. H. Stewart in ComprehensiveHealth Planning, presented at the National Forum of the National Health Council, Chicago, March 2i, i967 . Evaluating the effectiveness of mental health services. Milbank Memorial Fund Quarterly, XLIV, i, Part 2, i966. Schulberg, H. C. State planning for community mental health programs: implications for psychologists. Community Mental Health Journal, I965, z, I, 37-42. The Community Mental Health Center. Joint Information Service, American Psychiatric Association, Washington, D. C., 1964. U. S. Department of Health, Education, and Welfare. National Institute of Mental Health. State mental health planning grant proposals, I963 . Bethesda, Md., August, i963. U. S. Department of Health, Education, and Welfare, National Institute of Mental Health. Progress reports on state mental health planning, i964. Bethesda, Md. August, I964. U. S. Department of Health, Education, and Welfare. National Institute of Mental Health. Citizen participation in state comprehensive mental health planning. Unpublished report prepared by Office of Program Analysis, Bethesda, Md., I965. Urban America and the Planning of Mental Health Services. Group for the Advancement of Psychiatry. Symposium No. ~o, Vol. V, November, 1964. Vail, D. Beyond psychiatric diagnosis in social planning. Mental Hygiene, ~965, 49, 274280.
ABSTRACT: This report is based on a study of comprehensive mental health state plans submitted to the National Institute of Mental Health in i965 , interviews with mental health planners in selected states, discussions with professionals and citizens involved in the planning, and a review of the pertinent literature. This study was made to bring together observations about the outcome of this massive planning effort, to comment on the current status of mental health planning, and to develop some directions for facilitating planning at the state level. Mental health has been the subject of considerable planning under a federally sponsored program for comprehensive mental health planning in I963-1965 in which each state studied its own needs and developed a formal state plan (NIMH, Department of Health, Education, and Welfare, 1963 , 1964). This report attempts to bring together some observations about the outcome of this comprehensive mental health planning effort, to comment on the current status of mental health planning, the need for continued evaluation and planning, and to suggest some direction for facilitating planning at a state level. It is based on a study of the state plans submitted to the National Institute of Mental Health in 1965 , interviews with mental health planners in selected states where planning is ongoing, discussions with professionals and citizens involved in the planning effort, and a review of pertinent literature on mental health planning. A word needs to be said about the meaning of the concept "planning." A general definition is that planning is the process of effecting changes which otherwise might not occur, an attempt to identify desired end results and devise ways to accomplish them. Used in this context, c o m p r e h e n s i v e planning implies a lesser concern with targets and a greater concern with direction. In contrast to this, operational planning involves day-to-day, year-toAt the time this article was written, the authors were staff members at the National Institute of Mental Health. Dr. Leeds is nozo chief, International Reference Center for Information on Psychotropic Drugs, Psychopharmacology Research Branch, Dr. Gudeman is staff psychiatrist, and Dr. Levenson is director, Division of Mental Health Service Programs, National Institute of Mental Health, 5454 Wisconsin Ave., Chevy Chase, Md. 2o2o3. Dr. Miller is professor of psychology and sociology, Institute for Social Research, The Florida State University, Tallahassee, Fla. Community Mental Health Journal, Vol. 5 (3), 1969
206
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year decisions on specific activities directed toward a specific objective. Frequently there is a failure to recognize the distinction between comprehensive and operational planning. While both types need to go on simultaneously, the difference should be kept in focus. The rapid growth in the provision of mental health services in the United States highlights the equally growing need for planning and evaluation. Major questions arise as increasing sums are invested in the mental health care of Americans, and these demand the most careful consideration. Evidence of this expansion of services can be seen in a variety of ways. To state the growth in terms of funds being expended, an estimated $2o billion now are being invested annually in mental health services. State level mental health budgets often rank next to education and welfare in size. In New York, for example, the annual state mental health budget exceeds $5oo million. New services are becoming available to the aged and to indigent children under Medicare and Medicaid. A Federal program of support for the construction and staffing of community mental health centers has led the way to an unprecedented expansion of services. As mental health service programs expand, several questions arise. First, how effective are these new programs in meeting the need of the mentally ill and in promoting mental health? Second, since planning for future needs depends greatly on an evaluation of existing programs and resources, how much planning is based on systematic evaluation of the current status of mental health programs? Directly related to these questions is a third. Who are the people concerned with the problems of evaluation and planning for mental health? Clearly, without mental health professionals designated to evaluate and plan mental health programs, the effective utilization of these programs will not develop. The present need for evaluation and planning for mental health services arises from a variety of sources. To a certain extent mental health professionals have convinced the public that they are ready to take giant strides in the treatment of mental illness, especially through the concept of the community mental health center. Legislators and the public are in a position to ask if their money is well spent. This question can only be answered through a systematic evaluation of the effectiveness and the impact of these services. The need for evaluation of current programs and long-range interagency planning :becomes even more imperative when one considers the changing models of mental health and the new methods for the delivery of services. Through new techniques of evaluation and planning, such as program planning and budgeting (PPB), systems analysis, and computer-based simulation, tools for a precise and modern approach are now available. COMPREHENSIVE MENTAL HEALTH PLANNING FROM z963 TO I9@ Comprehensive mental health planning at the Federal level was authorized by the 87th Congress in 1963. Mental health planning
208
Community Mental Health Journal
activity was supported from July 1, I963 until June 3 ~, 2965 . For each year $4.2 million as grants-in-aid were available to the states on a formula basis. The move toward planning in the mental health field was rooted in prior developments. In 2946 the National Mental Health Act established the National Institute of Mental Health with authority for programs in community mental health. In 1965 the Joint Commission on Mental Illness and Health was established and their report "Action for Mental Health" (1961) emphasized "the development of a community atmosphere that is receptive to new ideas for the treatment of mental patients." In I962 the Conference of State and Territorial Mental Health Authorities and the Governors' Conference at Hershey, Pennsylvania, both recommended that states undertake comprehensive mental health planning. Although the concept of community mental health had been identified as early as x952, patient-referral, diagnosis, evaluation, treatment, rehabilitation, aftercare, and long-term follow-up, in other words a continuum of care in the community, were almost nonexistent. A survey of 234 facilities published by the Joint Information Service (1964) showed that while all had certain elements of a community mental health program, none had the ideal dimensions of comprehensiveness. While the Federal guidelines for comprehensive mental health planning left much room for individual state variations and autonomy, the ultimate national goal was stated as "the improvement of the mental health of the people." The planning activities that were to be performed under the grant included: (a) gathering of information on patients and families, general population characteristics, facilities, health manpower, research programs and resources, training programs and resources; (b) integration and coordination of information; (c) selection of goals, priorities, and methods; (d) allocation and distribution of available resources. Additional objectives were expressed or implied; First, comprehensive mental health planning would insure interagency cooperation in planning. This first objective was a grass roots approach to planning, in that all types of people would be involved in planning with both professional and lay representation. Second, mental health planning was to lead to the development and strengthening of community-based programs. This goal focuses on the current belief that mental health must be brought physically, psychologically, and socially, back into the community. Third, implicit in the Federal guidelines was the notion that this money would provide seed money for planning which could then be continued by the states. Fourth, each plan would establish broad long-range objectives which would mobilize the state's resources for treatment, prevention, and research in a graded way to reach priority objectives. These were the expressed and implied goals, but what actually did evolve? In view of all the social forces operating during this period, it is difficult to ascribe specific results to the planning process, but the following generalizations seem warranted.
Leeds, Gudeman, Miller, end Levenson
209
2. There can be no question about citizen involvement s'ince 20,000 to 25,0oo people participated in the planning process (U. S. Department of Health, Education, and Welfare, 2965). They became informed, involved in programs, and active supporters of the mental health movement. This development of an informed and interested mental health public was clearly the most obvious outcome arising from the national planning effort. z. There was the beginning development of state data banks. The information collected at local levels was often unreliable, but some of the state level data did provide a base for the systematic collection of data which had pertinence for planning, and it underscored the lack of relevant data. 3. Permanent planning offices were established in some states. The initial hope was that this would be the common outcome but, with the termination of Federal support for planning in ~965, staff tended to move on to other jobs. 4. There were some developments in mental health services which were directly related to the planning effort. There seems to be general agreement that the final state plans were homogeneous, that goals were usually expressed in global terms, and that unique state and area characteristics tended to bear little relationship to the final recommendations. In part this may be a reflection of the fact that, in initial planning, states focused on broad comprehensive goals rather than on moving from these goals to more specific objectives and methods of obtaining them. This was not disturbing to most of the planners who were questioned. They readily acknowledged that better plans could have been developed at the state level but they saw the process as the important element. A citizenry which was informed and concerned was seen as the major vehicle for implementing programs. Its impact has been felt in a variety of direct and indirect ways. State departments of mental health have been strengthened, state hospitals have been forced to reconsider their role, and community mental health acts have been passed.
CURRENT STATE PLANNING OPERATIONS During the period of federally assisted comprehensive planning, I963-2965, some 25o to 3oo professionals were recruited for state level planning and data collection. Their responsibilities were comprehensive in that they were charged with examining all aspects of mental health services-those which were operated privately as well as those which were operated publicly, those supported locally as well as those supported at state level. When the Federal program ended in July I965, it appeared that a majority of states were well on the way to maintaining such planning as part of regularly budgeted activities of their mental health authorities. Permanent planning offices under the jurisdiction of the mental health authorities had already been established by 19% of the states and territories. An additional 5x% of the states indicated that the creation of such an office and the continuation of comprehensive planning were likely to occur. Only 3O~o
210
Community Mental Health Journal
of the states and territories indicated that it was either doubtful or unlikely that such mental health planning would continue. The study being reported here was conducted two years after the Federal mental health planning program had ended. It was apparent that in this two-year period state mental health planning efforts had in many respects become quite different from earlier expectations. By July 2967 there were permanent planning offices in the mental health authorities of only 34% of the states, and only ~6 of these ~8 offices were staffed with professional mental health planners. Clearly in 2967 mental health planning offices were not functioning in the 7o~o of the states where establishing such offices had been contemplated in 2965 . It must be noted, however, that the absence of a mental health planning office does not necessarily imply a total absence of mental health planning activities within the state government. In the states without mental health planning offices, specific planning efforts have been carried on in connection with the states' participation in two federally supported mental health service programs. One is the Community Mental Health Centers Program (Public Law 88-264); the other is the grant-in-aid portion of the Comprehensive Health Planning Program (Public Law 89-749). At the time of the present study, all but two states had developed plans for the construction of community mental health centers, and 5o states had developed plans for participation in the grant-in-aid program. Thus it appears that the states are engaged in the process of planning for mental health centers and projects under the grant-in-aid mechanism, and it is equally apparent that many of the states have undertaken these planning efforts without the establishment of a designated planning office within the state mental health authority. On the other hand, just as the absence of a designated planner does not preclude the possibility of planning, the presence of such a person does not guarantee that planning will occur. The results of our study indicate that many of the planning offices which have been created had to assum~e responsibility for a variety of activities in addition to the planning function. Our interviews revealed that planning offices have a wide range of functions and responsibilities. While state planning offices tend to be located at a high level in the organizational chart, other generalizations are difficult to make. Mental health planners' backgrounds are heterogeneous and their spheres of operation are varied. Most of them have some responsibility for data collection and for operational planning. Some get involved in community organization work, in writing grant applications, in providing information for legislative committees, in coordination functions, and occasionally they assume direct program responsibility. Even the most sophisticated planning offices tend to get caught up in operational planning and have little time for comprehensive planning. Since the states vary widely with respect to the nature of mental health services offered, it is not surprising that they vary with respect to their plan-
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ning functions. It may be possible to identify three phases or stages in the development of a planning operation at a state level: ~. Funding a planning office; officially designating a planner; getting someone present to do the job. a. The development of a data collection system; analysis and evaluation of current operations; establishmentof mechanismsfor processing information. 3. Planningin the major sense that the concept is being used in this paper. These three stages do not follow in a narrow sequential manner--the second and third will always be closely related. But it is apparent that even the most sophisticated operation is devoting only a limited effort to phase 3. One example of this fact follows. Without exception, the planners the authors spoke to saw a definite shift occurring in regard to the basic models of mental illness. They saw a rapidly increasing concern with social competence; increased interaction with other health and welfare agencies; concern with low-income groups, model cities, and vocational rehabilitation. They envisioned a shift from the disease model and a focus on the individual patient. But at the same time, this was not apparent in most of the operations of their offices, and there was little evidence of concrete plans in this direction. It was of interest to us to find that operating planning organizations are becoming increasingly aware of the importance of evaluation (Milbank Memorial Fund, 2966 ) . As noted at the outset of this paper, mental health has seen an upsurge at the Federal and state level with regard to increased budgets and expenditures. With this has come the growing realization that there must be more accountability for programs. Evaluation involves the careful assessment of the extent to which a particular program or course of action is approximating the goals of the program. While the importance of evaluation is widely recognized, the reality is that few planning organizations are actively involved in this endeavor. At present, two of the large states surveyed have begun moving in this direction, one by publication of a manual for evaluation and the other by hiring experts to work on evaluation of state programs. NEED FOR CONTINUED MENTAL HEALTH PLANNING Formal planning is necessary for any large-scale effort. It could be argued that in terms of the history of mental health services, planning has been a luxury which we have comfortably done without. If there ever was any merit to this position, it certainly does not apply at this point in time (Schulberg, 5965; GAP, I964; Vail, 5965). A number of forces combine to make the establishment of planning activities at the state level crucial. i. Although the development of services varies with each state, the mental health service system is large and involves sizable budgets. This alone is sufficient reason for considerable planning activity.
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2. The range of disorders and behaviors falling under the heading of mental illness continues to broaden, and basic models are in a state of flux. Entirely different services are going to be demanded and different populations will have to be served by other than the traditional manpower. 3. There is a trend toward the establishment of statewide planning commissions with at least 46 states creating planning agencies by statutes (Chikfield, "r967). Mental health authorities will have to provide these commissions with much more specific data and plans than in the past. There are some suggestions that state legislatures will ask for hard data regarding programs and their effectiveness. This is an inevitable outgrowth of the increases in funds which the states had to allocate for services in recent years. 4- Public Law 89-749, Comprehensive Health Planning and the Public Health Services Amendments, provides funds for comprehensive health planning at state and regional levels. It will call for more, not less, mental health planning. There will be competition for some of these funds, and the quality of the plans submitted may well determine who will gain additional support. 5. The Federal program for the construction and staffing of community mental health centers is rapidly evolving, with approximately 275 such centers already funded. The intention of the legislation behind this program was to provide a base for a variety of integrated mental health services. There are already some indications that a number of these centers are settling down to rather conventional methods in the delivery of services and that the model as presently conceived may not be appropriate for all communities. Continued planning is necessary to evolve more meaningful alternatives, as well as a more effective use of these centers. RECOMMENDATIONS FOR A STATE MENTAL HEALTH PLANNING OFFICE If our argument about the importance of a formal mental health planning effort is valid, the next question relates to the manner in which it should be organized. The most appropriate place for planning would seem to be in the state mental health authority. Comprehensive planning below this level may be ineffective. Only a handful of the states currently have a comprehensive planning office, and they could use additional support. The goal of a viable planning office in each state is not unrealistic. The planning process will call for a specific staff and earmarked funds. The director of the office should be a senior professional appointment with status as an adviser to the departmental director. The long-range purpose of such an office would be that of providing alternative goals and programs for policy-makers, and evaluation of program effectiveness. Of course, each state would not be starting at the same point in development, and thus there would be some range in emphasis. Some would have to focus on establishing data collection systems; others could readily move on to operational analysis and evaluation of programs in terms of outcome. There should be safeguards
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to avoid having the planning effort become purely an operational analysis. In the larger states, the state level office might function as a facilitator for conveying this overall process to each of the large units in the field. This discussion proposes that planning and evaluation must become an integral part of any mental health program. Yet in the face of the demand for services, these activities frequently receive a low priority. A first step in implementation would be convincing department directors of the payoff to come from a planning office. Individual members of the mental health professions must lend their support to this concept if the necessary goals are to be accomplished. It is also submitted that efforts should be directed toward more sophisticated planning techniques and evaluation methodologies. The new organizational patterns which admit no separation of prevention, treatment, and rehabilitation, the merging of public and private efforts both of service and finances, and the entire question of how medicine as a whole and psychiatry in particular fit into the pattern of comprehensive care, demand a more upto-date approach to planning. Planning techniques such as those used in other fields, e.g., industry or city planning, should be investigated for usefulness in the health field, and additional new techniques and methodologies for evaluation must be developed. The necessity for the use of planning and evaluation techniques carries with it a concurrent need for professional planners. As stated above, the background of the current planners is as varied as the tasks they must perform. Since organized planning for comprehensive health services is a rather recent addition to other existing planning areas, training for planners is almost nonexistent. Admittedly, there are occasional regional or statewide meetings for such planners, a few week-long symposia which permit an exchange of experiences and ideas. Very rarely are such meetings made more effective through successive meetings to evaluate progress made individually in the interim and to discuss problems which have arisen since the last meeting. Another approach might be the development of curricula for mental health planners at universities and colleges. Since this would not meet the immediate crisis in planning manpower, some specifically structured workshops or seminars should be held at regular intervals to facilitate the tasks of the planners, at least at the technical end of planning. It should be noted here that the Federal Comprehensive Health Planning and Services Program offers assistance for the training of planners as well as for the development of plans. One portion of the program makes available grants for the establishment of training programs for all types of health planners. The grants are intended to enable universities to create the specialized curricula needed by those entering the health planning field. General programs in health planning can be supported and specialized courses in curricula in mental health planning can be developed with such Federal assistance. Today's and tomorrow's programs are complex. A continuous feedback system must be created to assure that tasks planned or in operation are worth-
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while and the procedures effective. Neither clinical nor administrative staff, regardless of specific skills and experiences, are generally trained to think in terms of the systems concept. While data collection and analysis can often be done under contract, it still remains the planner's responsibility to develop a comprehensive plan and frequently to offer alternative courses of action to certain parts of the program to reach goals more effectively. Familiarity with PERT (Program Evaluation Review Technique) as well as with gaming techniques (as in war games and business games) will enable him to better understand interrelationships within the program and the interdependence of program components. The far-reaching social adjustments that must be made due to the change in American life demand preparation to cope with ever-increasing problems. The move from rural to urban areas and the ensuing transitional type of family and social situation have focused attention on problems associated with these changes. Alcoholism, juvenile delinquency, crime, mental illness, family disruption, and a host of other ills have grown to menacing proportions. Comprehensive planning, followed as soon as feasible by implementation and evaluation, seems a reasonable solution. It is essential that planning be strengthened at all levels, Federal, regional, state, and local, that a cadre of health planners be developed, and that planning be moved up from a fringe activity to the position of prestige and importance it deserves. REFERENCES Action for Mental Health. Final Report of the Joint Commission on Mental Illness and
Health. ScienceEditions, New York, 296i. Chickfield, B. Special letter to Governors, cited by W. H. Stewart in ComprehensiveHealth Planning, presented at the National Forum of the National Health Council, Chicago, March 2i, i967 . Evaluating the effectiveness of mental health services. Milbank Memorial Fund Quarterly, XLIV, i, Part 2, i966. Schulberg, H. C. State planning for community mental health programs: implications for psychologists. Community Mental Health Journal, I965, z, I, 37-42. The Community Mental Health Center. Joint Information Service, American Psychiatric Association, Washington, D. C., 1964. U. S. Department of Health, Education, and Welfare. National Institute of Mental Health. State mental health planning grant proposals, I963 . Bethesda, Md., August, i963. U. S. Department of Health, Education, and Welfare, National Institute of Mental Health. Progress reports on state mental health planning, i964. Bethesda, Md. August, I964. U. S. Department of Health, Education, and Welfare. National Institute of Mental Health. Citizen participation in state comprehensive mental health planning. Unpublished report prepared by Office of Program Analysis, Bethesda, Md., I965. Urban America and the Planning of Mental Health Services. Group for the Advancement of Psychiatry. Symposium No. ~o, Vol. V, November, 1964. Vail, D. Beyond psychiatric diagnosis in social planning. Mental Hygiene, ~965, 49, 274280.
