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UPON DELIVERY

CURRENT TRENDS IN DEALING WITH MENTAL ILLNESS ~ ARE WE ON THE RIGHT TRACK?

Albert Deutsch Memorial Lecture
93rd Annual Forum, National Conference on Social Welfare

11:15 AM, Wednesday, June 1, 1966

Conrad Hilton Hotel, Chicago, 111.
by

MIKE GORMAN, Washington, D. C.
Executive Director, NATIONAL COMMITTEE AGAINST MENTAL ILLNESS
Fellow, AMERICAN PSYCHIATRIC ASSOCIATION (Hon.)
Fellow, AMERICAN PUBLIC HEALTH ASSOCIATION

I regard it as a singular honor -- one of the treasured assignments of a lifetime --
to have been chosen to deliver this lecture honoring the memory and noble works of my
fellow journalist and beloved friend, Albert Deutsch,

In preparing for this charge, I read or re-read many of the earlier Deutsch articles
which appeared in professional journals in the 1930's and the 1940's before he had
acheved a wide lay audience. I was struck again by the catholicity of his approach --
the truly enormous reach of his heart and his pen in an age when the pursuit of social
welfare was not exactly in full flower. He wrote topically of matters of slowly emerging
public concern ~~ the aged, the unemployed, the dependent child, the delinquent and,
yes, even the misunderstood policeman on the beat, But he wrote with even greater
penetration of the deep-seated welfare goals of a democratic society, and of how the
various helping professions might work together toward their consummation if only they

would take leave of their jurisdictional rigidities and subdue some of their status-

seeking manipulations.
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A constant champion of the profession of social work, he staked out an ever-
widening claim for its employment in ameliorating the manifest injustices of society.
In "The Convergence of Social Work and Psychiatry", written in 1940, he reminded us of
the pivotal role of the social worker in the latter half of the 19th century in reaching
out to the indigent insane in poorhouses which confined far more of these unfortunates
than did the isolated mental hospitals. Paying tribute to that gallant band of social
workers who took a leading part in improving the conditions of the mentally ill and in
establishing after-care committees for them in hostile communities, he wrote in measured
tones that “while psychiatry has offered the social worker an insight into individual
personality, social workers in turn have repaid the debt by supplying the psychiatrists
with an understanding of the cultural conditioning of personality."

Of course, his great classic was "The Mentally Ill in America", published in 1937.
In one monumental sweep of inspired sociological research, this alumnus of the harsh
poverty of the lower East Side of New York, who had never finished high school, brought
into the mainstream of our social concern the agonizing history and the current plight
of these legions of people who were sorely beset and troubled of mind. The successor
volume, "The Shame of the States", (1948) was a more detailed expose” -- ward by ward and
heartbreak by heartbreak -- of how the states were neglecting the mentally ill. A
persistent Deutsch theme runs as an undercurrent through both volumes -- the imperative
need for medicine, social welfare and the public at large to join forces against the
twin conspiracies of silence and distance which had kept the victims of mental illness

in thralidom on this bright continent for almost two centuries.
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It was a long, hard, fiercely-contested battle. The large mental hospitals --
monasteries of the mad -- dominated the psychiatric landscape in a most oppressive
manner. Many superintendents -- self-anointed Keepers of the Keys -- rattled them in
defiance at those few progressive spirits trying to smuggle a breath of the community
beyond the feudal walls. An English psychiatrist, after visiting some of our intimate
hospitals in the 10,000-bed range, described them as "like Victorian castles washed out
by the sea and deposited on remote sandbanks."

Because they were not intensive treatment facilities -- because their overseers
were arrogantly indifferent to the social welfare reforms sweeping across other parts
of the body politic after World War II -- the seemingly inevitable yearly increase in
the resident census of these institutions continued, and even accelerated. In the
period from 1945 to 1955 alone, 130,000 additional mental patients were jammed into the
already over-crowded wards of our state hospitals.

At the high point of this dreadful exodus, a few influential voices were raised in
protest.

In 1953, the Expert Committee on Mental Health of the World Health Organization
predicted that "many countries will be burdened for a long time to come with large,
obsolete hospitals built years ago to fit a conception of the role of the mental hospital
which is now completely rejected." Its report argued that no psychiatric hospital should
exceed 1,000 beds, with the optimum size somewhere between 250 and 400 beds.

In that same year, Dr. Kenneth Appel, President of the American Psychiatric Associa-
tion and a native of that city in which the Declaration of Independence was composed and

the Constitution adopted, sounded the trumpet blast for a new revolution. Noting that
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the traditional policy of herding mental patients into massive human warehouses was both
therapeutically and morally bankrupt, he called for a fresh, anthropological look at
the manner in which we were handling the mentally ill on these shores.

His eloquent plea led to the creation of a Joint Commission on Mental I]lness and
Health, empowered by the Congress to examine the existing state of affairs and come up
with alternatives to a social institution which was no longer meeting even the most
elementary needs of its beleaguered clients.

The Commission labored for six years; the anguished cries of the threatened pro-
fessional jurisdictions could be heard far and wide, but the final report sounded the
death knell of the isolated cities of the mad. President Kennedy embraced the major
principles of the Commission report; in his historic 1963 mental health message to the
Congress, he called for a network of community mental health centers designed to replace
eventually the backwater, insulated institutions of the past.

The care and treatment of the mentally ill in the heart of the community is not
exactly new. One can go back to Gheel, Belgium in the llth century -- and possibly
before that -- to find examples of communities which accepted and housed the mentally ill.
In the 20th century a remarkable Dutch psychiatrist, Dr. Arne Querido, began in 1930 to
develop regional psychiatric services throughout the city of Amsterdam as a viable
replacement for the large hospital, Ina retrospective look at the Amsterdam experiment,
now in its 35th year, Dr. Querido wrote:

"Any removal of a mentally disturbed patient from his social background implies

the sidestepping of the nucleus of the problem... I should like to defend the

thesis that, in the last analysis, the cure or the adaptation of the mentally

disturbed can only be established in society and that a successful stay in
society is the only real test of any therapeutic endeavor."
page five

The unique aspects of the American experiment, as exemplified in both 1963 and
1965 federal legislation and in comparable state and local action, are its clear repudia-
tion of a deeply entrenched custodial system and its forthright declaration of a
national policy emphasizing joint federal, state and local efforts to handle mental
illness in the community wherever possible,

In simple terms, it is our contention that the sequestering of the mentally ill
through most of our history prevented them from drawing upon the very personnel and
social agency resources which could have bolstered their ability to remain in society.

In the mental health center concept, we stress flexibility and continuity of services

much more than the building of a discrete physical facility. We want to be part of

the mix which includes general hospitals, social welfare services, the schools, the

courts and the private sector of medicine. In a reversal of past practices, we are looking
for specific strengths in the patient, his family, his neighbors and his job situation
which can keep him out of the hospital, as opposed to the assiduous search for diagnosible
symptoms to prove that he must be hospitalized to protect the populace from him.

We believe that a number of trends, which developed so imperceptibly over the past
twenty years that they have received little attention in the sociological literature, are
establishing solid foundations for the new wave of community psychiatry.

For example, the so-called "inevitable" annual rise in mental patients confined in
state hospitals has been arrested. Over the past decade, there has been an historic,
unprecedented drop of 83,000 patients resident in these facilities. In 1965, just over
four million Americans were treated for mental illness; of this number, only one in five
was treated in a state institution. Compare this with the situation just two decades ago,

when these same institutions handled three out of every four mental patients.
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The general hospitals of this nation, one almost totally off limits to the mentally
afflicted, treated and discharged almost 600,000 psychiatric patients in 1965. The
approximately one thousand hospitals which either have separate psychiatric units, or
treat psychiatric patients on their medical wards, last year discharged more than twice
as many mental patients as did state and county mental hospitals. Furthermore, part-
time hospitalization, which possesses the advantage of retaining the identification of
the patient with his family and other anchor points of social living, has increased
remarkably over the past decade -- there are now 175 day-night hospital programs in
operation in all parts of the land, and many more on the drawing board.

Local government, which for almost two hundred years: dumped its unwanted mentally
ill upon the doorsteps of state institutions, is now assuming a growing proportion of
the burden of their care. ‘Twenty-six states have now formalized this shared responsibility
in community mental health laws which provide state and local matching monies in support
of augmented psychiatric services.

A major dividend of this penetration into the community is our increasing ability
to attract skilled personnel to work with these patients. The conventional remote mental
institution, even under the most enlightened management, found it almost impossible to
recruit psychiatric personnel willing to immure themselves in a massive warren whose
patient load was forbidding, and whose ties to professional stimulation and enrichment
were tenuous at best. As a result, foreign born physicians comprise more than 50% of
the total complement of doctors in a number of our state mental hospital systems, and
shortages of registered nurses, psychologists and social workers are legendary and almost

too painful to contemplate.
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As we move out of the cloister, we find that we not only attract a significant
number of health professionals -- many of whom are willing to devote a portion, if not
their full time, to these tasks ~-- but we have opened the gates to both new and pre-~
viously unused personnel resources in the community. Realizing that most people in need
of psychiatric care are individuals who have not had any really warm, close, inter-
personal relationships, we are developing a whole host of training programs for people
who care about, and can care, for distressed people -~ community mental health workers,
child care aides, teacher-counsellors, teacher-moms, and the like.

A significant segment of the leadership of American psychiatry is convinced that
the hallowed clinical model of the practitioner and the patient locked in suffocating
transference is insufficient for the broader challenges implicit in helping large blocs
of our people find a degree of adjustment and identity in this very complex society.
Psychiatry is beginning to face up to the fact that its standard methodology and encrusted
theoretical orientations do not equip it to meet the demands for psychological and social
help from the poor, the underachieving in our schools, the frustrated among our blue
collar workers, the claustrophobic residents in our crowded cities, and so on. As TI
told the American Psychiatric Association Convention just a year ago:

"Many of its most thoughtful leaders are giving increasing thought to the

new role which psychiatry must play in the next several decades, in not only

broadening its own parochial training, but in joining with other behavioral

disciplines on an equal footing in establishing training programs for the

thousands upon thousands of new mental health workers we will need if we are

to achieve the goals which President Kennedy proclaimed in his historic 1963

mental health message."

We are also making considerable headway in opening up avenues for the payment of

the costs of psychiatric care. In the long run, this may be the most revolutionary of

all recent trends affecting the mentally ill.
page eight

Until quite recently the resistances to coverage of mental illness, either through
government social insurance or through private carriers, were fierce and formidable. For
example, leading spokesmen for Blue Cross and for commercial insurance companies expressed
annoyance that we should be seeking coverage equal to that given the physically ill when
it was so easy to "send them away for a dollar a day". As Helen Avnet has noted in her
book, "Psychiatric Insurance":

“Mental illness was traditionally a responsibility of the government; along

with tuberculosis, workman's compensation cases and care provided by veterans '

facilities, it was classified as ‘otherwise covered' and automatically ex-

cluded from most medical insurance policies."

Even the very liberal people who drafted the Wagner-Murray~Dingell National Health
Insurance bill reflected these aboriginal prejudices when they excluded mental illness
from the broad spectrum of its intended coverage. No wonder, then, that public officials
bracketed the mentally ill under the eleemosynary functions of government -~ a character~
ization right out of Charles Dickens.

The pervasive nature of this financial exclusion has seldom been properly appreciated
as a prime cause in preventing mental illness from being viewed as a rightful concern of
general hospitals, social agencies and other resources of the health and welfare sector.
In fact, the stigma surrounding mental illness drew much of its staying power from the
widespread assumption that opening the doors to its victims would invite financial ruin
for any organization, Walter J. McNerney, the President of the Blue Cross Association,
has referred very frankly to the lack of purchasing power of mental patients as having
had long-term adverse effects, not only upon their treatment, but upon the recruitment of
health manpower into what was always described as a most penurious field.

The biggest breakthrough in the reversal of these discriminatory practices has been

the inclusion of the mentally ill under several important sections of the 1965 Medicare
page nine

legislation. The extension of general hospital coverage to all mentally ill over 65
years of age will, I am confident, have the most profound effect upon the overall
attitude of these hospitals toward the mentally ill. The inclusion of outpatient
psychiatric care for these patients -- although limited by a yearly dollar ceiling --
is of crucial importance because it gives them the very purchasing power with which to
open new treatment doors in the community.

Over the long run, the provisions of Title 19 of the Medicare legislation may prove
of equal significance, State plans have the option of not only covering the medically
indigent psychiatric patient over the age of 65, but of providing a wide variety of
general hospital and alternate community services for those under 65 years of age.

There has been an exciting corollary development in the new militancy of American
labor regarding the provision of psychiatric services for its membership. As the 5th
Constitutional Convention of the AFL-CIO noted in a policy statement in November, 1963:

"The incidence of mental illness among low income groups is the highest in

the nation. Existing methods of reaching low income workers with appropriate

mental health services have been shown to be inadequate."

The United Auto Workers is the first major union to achieve comprehensive nation-
wide psychiatric benefits for its members as a result of the bargaining process, Covering
two and a half million workers and their dependents the UAW plan, which goes into effect
on September Ist of this year, entitles each member to $400 a year in out-patient benefits.
Its emphasis upon treatment in the doctor's office or in day hospitals, community mental
health centers or clinics; its coverage of the services of various members of the mental
health team, including psychologists and social workers, and its use of group psycho-
therapy and family counselling embody the most enlightened and most eclectic principles

of progressive mental health coverage. In implementing this contract in 77 cities, there
page ten

has been an exciting alliance of labor and mental health professional leadership in
breaking out of antiquated molds and creating additional services in the core of the
community.

And then we have the challenge of the poor. We seem to have just discovered them
these past several years, but Albert Deutsch knew them and wrote feelingly about their
deprivations for many, many years. His historical vignettes on the poor laws -- going
back to a classic study of the Elizabethan Poor Law of 1601 -- can now be seen as pioneer
attempts to deal with a great social problem. Sixteen years ago, he wrote of "abolishing
that social disease we call poverty". He often talked to me abcut his great dream -- to
write a history of the poor in America -- and it is tragic that his untimely death
prevented its achievement.

Psychiatry has been slow in coming to grips with the poor, a somewhat ironic
deficiency since the acknowledged father of modern psychiatry, Sigmund Freud, touched
frequently upon the inability of his profession to reach out to the large masses of
people who were impoverished. In 1919, for example, he wrote:

"One may reasonably expect that at some time or other the conscience of the

community will awake and admonish it that the poor man has just as much right

to help for his mind as he now has for the surgeon's means of saving his life;

and that the neuroses menace the health of the people no less than tuberculosis,

and can be left as little.as the latter to the feeble handling of individuals."

In recent years, a number of epidemiological studies have demonstrated the high
positive correlation between schizophrenia and poverty. There is a growing band of
young Turks in the psychiatric profession which is putting its elders on notice that
psychiatry must move out into the community or risk bankruptcy as an effective therapy.

"The poor neither know about us nor can they afford our expensive care", the

young psychiatrist Robert Coles wrote recently. ‘And often we do not know about

the poor and seem little concerned about getting to know them, There are the

facts, plain to see but not so easy to change. Nevertheless, the medical pro-

fession and its several specialities will have to serve the large numbers who
need them most and can afford them least."
page eleven

In this iconoclastic era in which many of the ancient walls are tumbling down, we
are discovering the emotionally disturbed child hidden away in a state mental hospital or
pushed about from one agency to another in the community. We don't really have any firm
estimate of how many emotionally disturbed children there are in this country, although
there is a consensus that it may run as high as four million. Only 300,000 of these
were seen in mental health clinics last year, most of them for diagnostic purposes and
only the briefest of treatment. A study of the first year of Operation Head Start indicates
that approximately 10% of the more than 600,000 children enrolled last summer were so
emotionally disturbed that they were unable to benefit from the program.

As you in the social welfare field know, statistics like these tell only a small
part of the story. At a conference on emotionally disturbed children in California
recently, I listened to the case history of a boy who, between the ages of five and
seven, had been buffeted about among 17 social agencies.

We are now launching the first national effort to do something about this frightful
human and social wastage. As a result of legislation passed in 1965, the federal
government has provided one million dollars over the coming two years to a Joint Com~
mission on Mental Health of Children which will, hopefully, assess the size of the problem
and come up with some mechanisms for attacking it.

Because of limitations of time, I have been able to touch upon just a few of the
trends which are beginning to bring the care of the mentally i11 within the spectrum
of our communal concern. After living in the shadows for almost two centuries, some
are walking in the sunshine for the first time, and the light is sometimes blinding.

In this difficult transitional period, they need your help and your understanding. You
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are deeply rooted in the social agencies of the community; your knowledge and your

compassion are crucial in building the many bridges over which they can travel back to

a new life.

We in the mental health field, and you in the social welfare field, have a common
goal -- beautifully expressed by Albert Deutsch in one of his last newspaper columns:

"If I have frequently attacked conditions I regard as evil, it is only because
I would like to see everyone get a chance at the wonderful variety of pleasing
experiences that our marvellously rich society affords -- potentially. The

basic tragedy of our time, it has seemed to me, is that we should tolerate so
much misery, friction and unhappiness when there is a potential abundance that

all could share in peace."

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