American Journal of Communizy Psychology, Vol. 4, .No. 1, 1976

State Planning of Mental Health Services 1 S. Richard Sauber Department o f Psychiatry and Human Behavior Brown University

Planning is the vital process that links needs to solutions. The interorganizational field of human services constitutes a "turbulent environment," a condition o f rapid change, and there needs to be greater receptivity toward comprehensive planning on the part o f state departments of mental health. Increased overlap with various welfare and educational services, advances in scientific knowledge, and shifts in general attitudes and social philosophy lead to demands for new and different types of service and require changes in approach and method. Generaiized findings of a stud), of 14 state departments of mental health are presen ted.

Comprehensive mental health planning is now a familiar, commonly used phrase. However, not very many years ago the mere mention of the approach conjured up visions of governmental regimentation, creeping socialism, and infringement of institutional and personal freedom. The opposition of yesteryear concerning planning must now fade into the background with the course of contemporary social, economic, and political events. Although resistance to state and local mental health planning still exists among those with strong ties to the status quo, the process is generally becoming recognized in almost all circles as a legitimate function. Citizen and consumer groups, businessmen, legislators, and newspapers are among its strongest advocates. Even those pressure groups who were originally most hostile to the concept have reluctantly come to accept the

1This paper was adapted from a research study conducted by the author while he was a Community Mental Health Fellow at the Laboratory of Community Psychiatry, Harvard Medical School. Boston. 35 © 1976 Plenum Publishing C o r p o r a t i o n , 227 West 17th Street, N e w Y o r k , N . Y . 10011. No part o f this p u b l i c a t i o n may be reproduced, stored in a retrieval system, or t r a n s m i t t e d , in any f o r m o r by any means, electronic, mechanical, p h o t o c o p y i n g , m i c r o f i l m i n g , recording, or otherwise, w i t h o u t w r i t t e n permission o f t h e publisher.

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fact that planning for mental health, previously left to the decisions of the market and the ingenuity of its participants, must now be subjected to responsible private (voluntary) and public study. In the nation, as in the mental health field, the role of planning is pfim a n y a long-range one, looking backward at trends, looking around at current developments, but primarily looking forward to problems, issues, and their positive resolution in the future. What are the major reasons for the lack of comprehensive mental health planning at the national, state, and local levels? There seems to be an increasing number of issues and problems becoming even more difficult to resolve, with some of the major factors being as follows: "optimum" mental health services; goals and objectives; composition of planning-group governing boards; shortage of professionally trained planners; shortage of community planning funds; shortage of and distribution of personnel; and state and federal legislation. For example, more intensive study and research needs to be given to defining in quantitative and qualitative terms "optimum services" and "effective delivery system." Otherwise, the planners are never quite sure what is being planned and for whom. Further, without having the most accurate measures of mental health needs, it is frequently difficult to plan goals and objectives 5, 15, and 25 years hence. Although the methodology and tools for such an analysis are far from being refined, there are some available approaches, particularly management information systems, that can be utilized in the interim to help give answers to individual alternatives.

METHOD Within the framework of comprehensive mental health planning and the larger spirit of creative federalism, the states have a major planning role. A study was conducted by the writer to assess and better determine if state officials of departments of mental health were, in fact, inclined to follow in the reassertion of historic state leadership responsibilities encouraged by current policies in intergovernmental affairs. The following states participated in this investigation: Arizona, California, Colorado, Illinois, Indiana, Maryland, Massachusetts, PennsYlvania, and Rhode Island. Other states contributing data to the study on an informal basis included Florida, Kentucky, New Hampshire, New York, and Virginia. Interviews were conducted with state officials from all of the aboVementioned states except New York and Florida. In these two states, interviews were held at the city and county level in the state of New York and at the State Training and Research Institute in Florida. Considerable amounts of information were collected and analyzed: impressionistic data based on personal interviews (group and individual), and published data contained in public documents and

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reports. However, disclosure of certain state information was contingent upon prior agreement of confidentiality. Thus, only general and summarized findings devoid of value judgments are presented in this article. Examples of questions raised during the interviews are presented in this article: t. Describe the State Department of Mental Health (i.e., history, major events, organizational structure). 2. Describe the impact of national policy such as revenue sharing on the state planning of mental health services (i.e., funding sources, deinstitutionalization, decentralization, comprehensive coordinated human services). 3. Describe the forces of influence, unique to your state, which affect the planning, organization, and delivery of mental health services (i.e., geography, high-risk populations, government). 4. Describe major issues and trends-- past, present, and future (i.e., administrative practices, service delivery systems, manpower development, prevention).

FINDINGS

Ideologies Most fundamental to mental health are ideologies held by commissioners and state officials- namely, the commonly adhered to system of ideas or beliefs which serves to justify one's position and acts as a behavior rationale for mental health administrators, educators, and practitioners. Consider, for example, the following ideologies: 1) patient management in mental hospitals--"custodialism" and "humanism"; 2) treatment orientations--°'psychotherapy," '%ociotherapy," "somatotherapy;" 3) intervention strategies-"clinical psychiatric" and "public health" approaches; 4) service delivery systems--"community mental health" and "human services." All state officials, but for a few individuals, scattered loners or old-timers, were concerned with and committed to the ideological thinking in the latter two categories, intervention strategies and service delivery systems. The organizational models and program variables of these ideologies are shown in Table I (Sauber, 1973, p. 18). 2 Most states classified their program variables as somewhere between the clinical psychiatric and public mental health organizational models. Notable exceptions to this were the states of California, Colorado, Illinois, and Massachu2Based upon the speech by Dr. Raquel E. Cohen, "Models in search of community mental health programs: The function of psychiatrists as a variable," presented at the 126th annual meeting of the American Psychiatric Association in Honolulu, 1973.

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setts. These states exhibited program variables lodged in the organization models of public mental health and human services. Only these states (to greater and lesser extents) offered evidence of comprehensive community mental health planning which incorporated all aspects of the program variables in each of the organizational models, striving to achieve a human services delivery system.

Organizational Structure There is a strong appeal in shifting focus from the level of a single organization, a state department of mental health, to that of a complex network of organizations, human services, and to speak of a state interorganizational system in which individual departments constitute components or subsystems. However, all organizational systems need not be assumed to be subsystems or components in some well-defined suprasystem. A general intersystem model assumes that relations between state departments in an interorganizational field may differ qualitatively as well as quantitatively as a function of the types of interaction which are being used to assess interdependence. For example, two departments may be highly interdependent in terms of information flow, but may be mutually autonomous with regard to financial exchange. At the federal level, service integration legislation has been under development at HEW which would enable and encourage states and localities to unify the various programs and resources available to provide human services. Legislation would assist and support the reorganization, reassignment of functions, and entrance into new cooperative arrangements at different levels in the system of delivery of services (Washington Report on Medicine and Health, January 10th and October 2nd, 1972). The movement toward developing coordinated comprehensive patterns of service which cut across traditional organizational and administrative boundaries is apparent in the actions of many state governments to combine several separate health and social service programs in one new department. O'Donnell (1969) notes that approximately 20 states have already combined several services, and many other states are seriously considering similar reorganizations. In Massachusetts, for example, the new Executive Office of Human Services combines the traditionally separate public health, mental health, and social welfare programs of the state under one administrative control. Interdepartmental reorganizations are exemplified in the states of Arizona and California, following the pattern set forth by the National Institute of Mental Health, and these states have created a Division of Mental Health within the larger Department of Health. Maryland established a Department of Health and Mental Hygiene. State inter- and intradepartmental trends toward mental health service reorganization in the 1970s favor a close association with the field of health, as contrasted with its heritage and evolutionary growth from departments of public welfare in the early 1960s.

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Interdepartmental changes include (1) new organizational structures, (2) developing new positions in the areas of planning, evaluation, prevention, and community services, (3) resetting priorities (i.e., deinstitutionalization and the reallocation of existing state hospital funds for community-based program development), (4) new plans for service delivery, such as regional offices, county departments, and catchment area centers, (5) new staffing requirements and contract management. An example highlighting these changes is the creation of State Offices of Prevention and funded positions for'mental health educators in the states of California, Florida, Kentucky, Massachusetts, New York, and Pennsylvania.

Effects of National Policy The impact of recent national policies on state planning of mental health services has brought about several changes. State departments of mental health are experiencing a new status and prestige as (1) necessary intermediaries between national and local program administration and development, (2) funders of community services and programs 3, and (3) leaders in the improvement and innovation of service delivery systems. For example, while the National Institute of Mental Health has interacted with states on many different levels, it had no effective way to coordinate and maximize its resources and priorities with those of the state in continuing mutual effort. Planning grants provided funds for planning but none for staff to implement the plans. State surveys (there have been 10 between 1956 and 1968) were limited in time and scope and did not involve the surveyors in the difficult task of implementing the recommendations. A new approach of the National Institute of Mental Health, known as "State Program Development," is to work collaboratively with the states. Already, Ohio and Maine have shown many successful changes resulting from this close working relationship; the National Institute of Mental Health has helped each state to better manage the myriad of agencies, systems, resources, financing, and programs which comprise their overall mental health plan. Adopting this model at the local level, state technical assistance is becoming available, encouraging "Community Program Development." As federal mental health professionals are now reaching out to state representatives to take the leadership role in planning mental health services, local municipalities and counties are approaching state officials as friends and funders for guidance and grants. The state-local reimbursement formula for the provision of local mental health services is as high as 90%/10% (e.g., California and Indiana). However, most matching funds are respectively between 50% and 75% 3Traditionally,the financialsupport for mental health serviceshas been the responsibilityof state government, which is overshadowedby the advent of direct federal financingand the increasing role of local government.

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state and 50% to 25% local. With changes in federal spending and the ending of the National Institute of Mental Health categorical grants, much hope has been directed toward revenue sharing. Its promise is "cash and freedom" for the states and cities, but, to date, revenue sharing has been extremely disappointing as a viable funding mechanism for community mental health programs. Relying mostly on state funds, California has encouraged local option and local control, carefully avoiding the imposition of fixed program priorities or criteria other than minimal staffing standards, which were developed in the fullest possible collaboration with county program directors. This approach is ideal for establishing a community mental health program that reflects the needs and realities of its own locale to the extent that professional staff, community planners, and local knowledge can be mobilized for that purpose. Unfortunately, this policy of localism was not practiced in most of the states visited. For these states, planning, administering, program philosophy, districting 4, monitoring, and fiscal and political considerations are state controlled and operated.

Service Delivery Systems The boundaries of the fields of mental health and other human services have been changing over time as influenced by historic events, the changing power of vested interests, the political situation of the times, the changes in professional ideologies and values. Periodically, all of these factors in interaction give rise to a readiness to review boundaries of the service network and to reconceptualize a systemic pattern of service. Developments in the 1970s are challenging the existing boundaries separating health, mental health, and social services. Several recent publications have described the trend toward a comprehensive human service system which integrates traditionally separate services into comprehensive programs for human assistance (Demone, 1973 ; Schulberg, Baker, & Roen, 1973). Community mental health and human service approaches include redefinition of boundaries defining the domain of both traditional organizations and professional disciplines. These boundary changes have primarily been of two types: In boundary spanning, the emphasis is on the coordination across existing boundaries of the activities of separate professional caregivers and caregiving agencies. In boundary expansion, the emphasis is on incorporation of a wider variety of functions within a single organization or, at the professional individual level, the development of generalist activities which cut across traditional disciplinary lines. Applying the term "system" to a state department of mental health implies interdependence in the sense of necessary input and output link*Districting refers to epidemio-demographicanalysis of natural community groupings, transportation patterns, agency utilization patterns, and indexes of social disorganizations.

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ages, but also independence in the sense of maintenance of the integrity of system elements through boundary control processes. There are five kinds of or approaches to service delivery systems: (1) federal, (2) state, (3) regional, (4) county, (5) catchment area. Traditionally, the most significant and influential role was played at the federal level, and so on down the line. Currently, a complete reversal has taken place and the trend of the future is toward community mental health program development and administration at the local catchment area level. An open-system formulation of organizational structure and dynamics is helpful to understand each state as a bounded interaction set of components engaging in an input-output commerce with an external environment in the processing of material objects, information, and people. For example, Rhode Island is geographically small with a population of less than 1,000,000 people, and so it operates exclusively at the state level, relying on the state hospital and private institutions servicing the entire state. Pennsylvania has many urban centers as well as large rural areas. Its staff at the State Department of Public Welfare, Office of Mental Health, consists of two mental health professionals and two business administrators. Therefore, the determination of services comes through the regional and catchment area administrators who adopt a "business management" as opposed to "mental health" model of service delivery. The Massachusetts Department of Mental Health, with a current budget of $168 million, employs 18,000 people in various areas, regions, hospitals, schools, community residences, and the central office. There are seven regions, each with a director and several staff members, and there are 39 catchment areas. The area director may direct a comprehensive community mental health center or coordinate a service linking system or integrated services. In contrast to Pennsylvania, state, regional, and area directors of Massachusetts are mental health professionals. This administrative and professional difference is very much reflected in both theory and practice; therefore, the question of p r e f e r e n c e - the "clinician executive" versus the "business m a n a g e r " - i s a major issue confronting state departments of mental health across the country. The state of Illinois was a forerunner and leader in demonstrating the value of regionalism. In order to forge a partnership with the community, the Illinois Department of Mental Health has brought the resources of state institutions closer to the populations in need through a decentralized plan. There are seven geographic regions (formerly called zones), each with state facilities, new mental health centers, and private grant-aided agencies. For example, Region 2 is largest, encompassing the city of Chicago and nine counties, with a population of more than 7,000,000. Region 2 services are divided into 13 smaller geographic divisions called subregions which include 53 smaller divisions, called planning areas. It is the responsibility of subregion staff to coordinate present public and stateaided mental health resources within each of its planning areas to meet the needs of each population. The goal of the Illinois Department of Mental Health in

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providing community based service is not to create haphazard duplication, but to construct an effective network of public and private services through planning, negotiating, and grant awarding. Regional staff coordinate, monitor, evaluate, and assist in the planning of community performed services. However, during the last 2 years, the state of California chose to dissolve its regionalized system in favor of decentralized county programs with liaison functions in the state headquarters. A major shortcoming to a regionalized system of mental health services is that the systems of corrections, social and rehabilitative services, health, and education have different regional boundaries. Fragmentatipn and service gaps make planning, collaboration and coordination extremely difficult. An exception is Colorado where the state legislators have planned to set common boundaries for all service providers. This decision was based on geographic considerations rather than any conception of an integrated service delivery system; nonetheless, in each regional office, coordinators from mental health, education, welfare, criminal justice, and health will be represented and plan collaborately. Systemic linkages will be developed whereby the elements of the systems come to be anticipated so that in some ways they function as a unitary system. However, it is impractical to itemize the many determining factors which make for contrast in the many kinds of approaches to state service delivery across the country. However, state departments are "open systems," and the planning of mental health services must not overlook the importance of examining the internal interdependencies of the components of their department as they relate to the environment within which their system must adapt to survive and develop. The following major sectors (transactions of input and output constituencies) are important considerations in understanding the differences in planning at all levels: a) clients and consumer groups (both potential and current users); b) supplies of staff, materials, technology, finances, and information; c) other individual, group, and agency service providers who may compete and cooperate with regard to clients and resources; and d) organizations and regulators, including governmental agencies and professional associations.

Planning Issues The attitude among most state mental health professionals is that there now exists an unprecedented opportunity to develop mental health programs that are sound, effective, and realistic. In some quarters, a belief already exists that community mental health has been oversold. Yet "a bold new step into the future" has been mandated, and state planners must either establish mental health services that reflect the best combined thinking and resources of all concerned, or court profound public disappointment in the entire community mental health movement. Such an ignominious failure would produce reverberations of public mistrust in professionals and in governmental planning that

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would go far beyond community mental health programs. An earnest collaboration of all those concerned with mental health could serve as the most potent preventive agent against a dread possibility. The following planning issues were continually identified for consideration: (1) conceptual problems in mental health-illness and service delivery: philosophy and ideology; (2) increased politicization: politics inside and outside of the mental health profession; (3) accountability of service providers to clients; (4) indirect versus direct services - priority setting; (5) viable funding mechanisms; (6) prevention of mental illness versus promotion of mental health; (7) manpower development (professional, paraprofessional, and nonprofessional); (8) organizational structures: multiservice integration system versus linking-service network; (9) administrative practices -territorial versus functional;s (10) leadership qualificatiofls- medical versus nonmedical and clinician executive versus business manager; (11) institutionalization versus deinstitutionalization; (12) citizen participation - community control versus professional control; (13) generic characteristics of helping activities - natural talent versus professional training, and generalist versus specialist; (14) interdisciplinary versus multidiscipfinary; (15)centralization, decentralization, and recentralization; (16) contractual management versus staffing; (17) approaches to service delivery - state operated, regional control, or local ownership;(t8) human services versus mental health systems. A refined framework providing conceptually and empirically based definition, description, and classification of these issues and system variables is needed. State planning of mental health services is changing from a survey, forecast, and analysis based on mental health methodology requiring clinical trainingto understand and psychiatric knowledge to implement, to a more businessoriented approach. The latter view, a general theory of management, has been evolving, which focuses on the basic administrative processes of planning, organizing, coordinating, and controlling resources necessary for the accomplishment of primary organization goals and objectives. However, it is noteworthy that in the design, planning, and evaluation of human service organizations, as opposed to departments of mental health, systems concepts are gaining increasingly wide acceptance. Thus, planning can be defined as the process by which resources of an organizational system are adopted to the changing internal and environmental field of forces. Short-range planning is most aptly applied to relatively finite, elemental, and homogeneous operations in a stable and uniform environment (i.e., a small self-contained residential treatment program). However, in a complex, dynamic environment, such as that faced by most state departments of mental health and with the more complicated range of service operations required by the comprehensive mandate of a state agency, planning must take a long-range viewpoint. 5Territorial administration refers to the generalist approach, organized around a geographic, political base, whereas functional administration refers to the specialist approach, organized around single-servicefunctions based on social needs.

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At the same time, intermediate and distant priority-setting and resource allocation in turbulent interorganizational systems and uncertain environments make predictability more difficult and speculative. Thus, state departments of mental health must be flexibly adaptive and develop short-range plans related to longrange strategies.

CONCLUSION The field of mental health has been undergoing profound and extensive developments over the past two decades. It has been a period of transition, not only in the manner by which services are provided, but also in which professional concepts of mental disorders are being subjected to new dimensions of examination and critical analysis. The caliber of state and areawide leadership is the critical element in whether or not mental health planning will effect decisive and beneficial changes in the provision of comprehensive and coordinated community services- both personal and environmental - whose goal is to raise the mental health status and improve the social functioning of the population. A complete state plan is necessary for federal and local activities; it is the state's responsibility to stimulate, support, and coordinate planning within its regions and areas as well as to interpret national policy and relate to federal program administration and development. The leadership role of state mental health administrators in the burgeoning fields of community mental health may largely be determined in the next few years by their own planning capabilities and their ability to recruit, train, place, and retain experts in planning.

REFERENCES

Demone, H. Human servicesat state and local levels and the integration of mental health. In G. Caplan (Ed.), American handbook o f psychiatry, Volume 4. Boston: Little, Brown, & Co., 1973. O'Donnell, E. Organization for state administered human resources program in Rhode 1sland. Report to the General Assembly by special legislative commission to study social services. June, 1969. Sauber, S. R. Preventive educational intervention for mental health. Cambridge: Ballinger Publishing Co., a subsidiary of Lippincott, 1973. Schulberg, H. C., Baker, F., & Roen, S. (Eds.), Developments in human services, Volume 1. New York: Behavioral Publications, 1973. Washington report on medicine and health, January 10, 1972. Washington report on medicine and health October 2, 1972.