PUBLIC HEALTH LIBRARY NATIONAL CLEARINGHOUSE FOR MENTAL HEALTH INFORMATION COMMUNITY MENTAL HEALTH Individual Adjustment or Social Planning fl] fH [| & CAT. You PUBLIC HEALTH A Symposium eb Ninth Inter-American Congress of Psycholog 9, ge | 7964 fen: i U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service | / 15h J.5.5.D. NATIONAL CLEARINGHOUSE FOR MENTAL HEALTH INFORMATION COMMUNITY MENTAL HEALTH INDIVIDUAL ADJUSTMENT OR SOCIAL PLANNING A Symposium Ninth Inter-American Congress of Psychology December 18, 1964 Miami, Florida U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Institute of Mental Health Bethesda, Md. 20014 Public Health Service Publication No. 1504 For sale by the Superintendent of Documents, Government Printing Office Washington, D.C., 20402 - Price 50 cents PA790 Us 3 PUBLIC HEALTH LIBRARY FOREWORD Institutions in a soclety are reflections of the desires and atti- tudes of the society. Patterns of provision of care are among such in- stitutions. Thus, it is no accident that the mid-twentieth century American scene has spawned, along with other social developments, the philosophy and practices that are included under the term community mental health. The soclety increasingly became concerned with the unfortunate, the disadvantaged, the underprivileged, and no longer was willing complacently to tolerate the discrepancies in patterns and quality of care between those who could and those who could not provide for themselves and their relatives. The war on poverty was required largely because of the failure of existing services to answer the problems of now no-longer-to-be-neglected groups in the population. Thus, the mental health field was moved to assume responsi- bility for all of the population rather than selected and privileged groups. In, however, doing so, the possibility of providing effective care by traditional methods was manifestly remote. Added to this there was increasing question about the effectiveness of traditional service methods, Out of this combination of events and attitudes has grown the movement called community mental health. Because so little had prepared the professions for this vastly increased responsibility there exists alongside a push for expanded service a vacuum of appropriate theory. This presents the movement, then, with certain challenges. There is a challenge to remain flexible but to avoid being nebulous, to base service provision on conviction of overall value while still requiring inten- sive investigation of effectiveness. There is the challenge to enlist a multi- plicity of disciplines, to preserve their individual identities and skills, to attract professionals of the highest calibre and to train those who can truly cross discipline lines, There 1s the challenge to borrow from other disciplines whatever 1s appropriate but to give hostages to none. There is the challenge to be so focussed on the processes of change that change is built into the institution itself. There is the final challenge to make manifest in practice what is implied in the title; to be of the community and not just in the com- munity; yet to avoid the tendency to attract to centers of operation all the activities of the community. To be a change agent is appropriate; to be governor of the community's attitudes, is not. This movement has flourished in the United States and in Western European countries. It emphasizes the total use of resources and the judicious deploy- ment of limited professional personnel. Its application in emerging countries would therefore seem more appropriate than approaches that depend almost solely on highly skilled and scarce professionals. Clearly, for each community the answer is idiosyncratic and should grow out of the community. What can be derived from practice and experimentation are not cookbook recipes but ways to 389 identify problems and to approach their solutions. The present papers dis- cuss in great frankness both the potentials and the present limitations of community mental health in theory and in fact. There is, throughout, a clear dedication to improve service for all with a simultaneous realization that only by changes in practice based on sound research can community mental health develop its own appropriate theoretical constructs and modes of operation. There is also reflected a clear concern to now move to the promotion of better mental health and optimal use of human resources while simultaneously taking care of those who have become the casualties of the system. Behind the move- ment, at the moment, there is a considerable momentum of social mandate and financial support. While the temptation to be swept along with this may be strong, it is only by continual examination of issues, by the developing and testing of new methods of practice and training, such as are instanced in the papers, that the movement can stay in the forefront of service provision and help present and future societies to take care of those problems of which they have for too long been cognizant but for which they have been either unable or reluctant to devise solutions. Quentin A. F, Rae-Grant, Director Mental Health Study Center National Institute of Mental Health PREFACE This symposium was designed to present a general view of community mental health to an Inter-American audience of psychologists and other dis- ciplines primarily interested in psychology. To serve the purpose of gener- ality, the topics of theory, practice, research and training were selected for presentation. All the papers were prepared by psychologists from the United States because of the presumably advanced state of the art in that country, The discussants were then selected from professionals primarily concerned with mental health affairs not in the United States in order that the meaningfulness and applicability of the ideas expressed in the papers could be evaluated from the perspective of Latin Americans. When studying these papers the reader is asked to bear in mind the fact that these are not exhaustively representative of the field called "community mental health," but are examples of work being carried on within it. The organization of the symposium and preparation of this report was carried out with support of the Mental Health Study Center, National Institute of Mental Health. A Spanish language version of the report has been prepared. J. R. Newbrough Mental Health Study Center National Institute of Mental Health 2340 University Blvd., E. Adelphi, Maryland 20783 March, 1966 FOREWORD . . . + « « « « oo « « oo oo SYMPOSIUM PARTICIPANTS . . . . «+ « « « « « + COMMUNITY MENTAL HEALTH: A MOVEMENT IN SEARCH OF A THEORY, by J. R. Newbrough. . . . . . . . + + + + + . COMMUNITY MENTAL HEALTH SERVICES: FOR WHAT AND TO WHOM?, by A, J. Simmons . . . . . « + + «+ . . . THE COMMUNITY MENTAL HEALTH CENTER AND THE STUDY OF SOCIAL CHANGE, by James G. Kelly . . . . . . . «+ =. . GRADUATE TRAINING IN COMMUNITY MENTAL HEALTH, by John C., Glidewell . . . . . . . . . +. . . DISCUSSANT'S COMMENTS, by Rene Gonzales . . . . +. +. + + + + + + by Mauricio Knobel. . . . . . . .. +. . . . Page iii ix 19 39 53 67 71 Chairman : Presenters Discussants: Symposium Participants Rene Gonzales, M.D., M.P.H., Regional Advisor in Mental Health for Pan American Health Organization. J. R. Newbrough, Ph.D,, Chief, Community Projects Section, Mental Health Study Center, National Institute of Mental Health. Read in absentia by Leslie Phillips, Ph.D., Director Psychology Department, Worcester State Hospital. Alvin J. Simmons, Ph.D., S.M. Hyg., Associate Director, John F. Kennedy Family Service Center, Inc., Charlestown, Massachusetts, and Assistant Professor, Department of Psychology, Boston College. James G, Kelly, Ph.D., S.M. Hyg., Associate Professor, Department of Psychology, Ohio State University. John C. Glidewell, Ph.D., Director, Community Mental Health Research Training Program, The Social Science Institute, Washington University. Read in absentia by Robert M. Taylor, M.S., Associate Director of Research & Development, St. Louis County Health Department. Mauricio Knobel, M.D., Professor Titular De Psicologia De La Ninez Y De La Adolescencia, De La Universidad Nacional De La Plata. Rene Gonzales, M.D., M.P.H., Regional Advisor in Mental Health for Pan American Health Organization. COMMUNITY MENTAL HEALTH: A MOVEMENT IN SEARCH OF A THEORY! J. R. Newbrough Mental Health Study Center National Institute of Mental Health Mental Health, as a descriptive phrase, means many things depend- ing upon the speaker, the context, and the audience. It is constantly used in several different ways: 1. Mental health as a goal. This is a set of ideas and beliefs that life in the future can be a better and more satisfying experience than it is now. This is the definition used for programs to promote mental health. Mental health as an euphemism for mental illness. Mental health is often used to refer to work by professionals and citizens groups alike to help people in trouble or to prevent them from getting into trouble. Mental health as a personality characteristic. Jahoda (1958) describes two ways of viewing mental health in personality terms. It may be seen as a relatively constant and enduring function of per- sonality yielding classifications of the health of a person; or it may be seen as a less permanent function of personality and the situation yielding a classification of the adequacy of actions or behavior. 11 am indebted to D. N. Lloyd, F. V. Mannino, & Howard J. Ehrlich for critically reading this paper. I wish also to extend my appreciation to Leslie Phillips for reading this paper at the Symposium in my absence. 4. Mental health as a characteristic of society. Situations or societies are often called healthy or sick. Frank's Society as the Patient (1948) and The Sane Society by Fromm (1955) are examples of this. With this meaning, one talks about society either: 1) as a unit which is ill or 2) as an en- vironment which makes people ill. I cite these uses as evidence for the ambiguity of the term mental health. For purposes of this discussion, I will talk about mental health as referring to mentally ill or mentally disordered behavior, and will consider the definitions of such problems as: 1) health problems, and 2) social problems. Community Mental Health has become a term which refers to all the activities carried out in the communi ty? in the name of mental health. These activities include diagnosis and treatment in clinics and agencies, @ day or night care in hospitals, consultation around various personal and behavioral problems, research on mental problems through such means as case registers or surveys, training of professionals to work on mental health problems. It is the purpose of this symposium to provide a rather general view of community mental health as it is conceived in the United States; a view of services, research and training. The function of the discussants is to consider what the implications of these activities and ideas are for applica- 2The community here means the places in which the person carries on his daily life - of being with his family, or earning a living, or living among friends and neighbors. tion in their own work and in the mental health work of their countries. Mental Illness as a Health Problem The history of mental ill-health first as insanity and, more recently as mental illness, shows that the problem has, for nearly two centuries, been regarded as a biological malady which requires medical treatment (Dain, 1964; Lewis, 1959). The mind was thought to have a neurological base; mental disorder was then considered to be a biological disorder. In professional medicine, a major concern has been to define mental disorder properly so that the appropriate treatments could be devised. Benjamin Rush in 1783 began a life of work which approached mental illness scientifically to understand and treat it. He was apparently the first physician in the U.S. to do so, and thus the organic tradition in psychiatry was begun (Lewis, 1959). Prior to 1800, however, the general climate of opinion held that insanity was virtually incurable and thus did not warrant serious attention or work (Dain, 1964). Over the next decade or two, however, the effects of the Enlighten- ment began to be felt in the United States. There was a growing convic- tion that man was perfectible, that he could control the environment and that life on earth could be perfected (Dain, 1964). Out of this grew the "moral treatment approach, a social treatment similar to what is now called milieu therapy or therapeutic community. It was designed to appeal to the moral sense of the patient through example and to teach him to return good for good; it gave value to the physical setting and the social influences of the hospital or educative agents (Dain, 1964). Development of moral treatment was limited to a few institutions and enlightened practitioners. Diffusion of the new knowledge was un- certain and not widespread to either the general medical practitioners or the lay public. Dain (1964) describes the 19th century lay thought as similar to that of 18th century medicine; insanity could not be cured and lunatics suffered long and severe confinements. Dorthea Dix came upon the national scene in 1841 to provide a major impetus for a redefinition of insanity by the lay public. Up to that time, asylums were privately funded and existed only for the wealthy. Treatment institutions for the poor would require funding from public moneys. There- fore Miss Dix set about emphasizing insanity as a social problem. She, in fact, blamed society for almost all insanity and held it responsible for its victims, the mentally ill. Her work built on the professional thought be- gun by Rush, and led to the widespread recognition of the need for public mental hospitals. The next major social event to further the cause of the movement to reform the care of the mentally ill was the publication of the book, The Mind That Found Itself by Clifford Beers. This was supported by a number of eminent men of the day (including Adolph Meyer and William James) and was the beginning of a formal citizens organization, now called the National Association for Mental Health. : | Adolph Meyer was an important figure in the development of the defi- nition now used for Community Mental Health. His conceptions of psycho- biology represented a formal attempt to see mental illness as a condition where environmental aspects were as important as individual biological ones. He viewed the unit of concern (man-in-nature) as an ecological one; that is, man in his natural settings (Muncie, 1959). This system of thought has led to the interest in sociology by workers in mental health - and to an interest in the effects of the environment upon mental disorder (Mora, 1959; Rossi, 1962). " and "Community Mental "Social Psychiatry," "Community Psychiatry, Health" are ways of referring to the fact that sociological thinking is increasingly permeating the mental health field. A recent bibliographic . effort, attempting to prepare a reference guide to the field, found that social science concepts were pervasive in the writing on, and were of rele- vance to, community mental health (Harvard Medical School, and Psychiatric Service, Massachusetts General Hospital, 1962). There has also been the realization that since this health problem occurs in the community it be- comes a public health problem. As a public health problem mental health takes on the status of a major social problem; a social problem, however, with the concepts of prevention and cure taken from an orientation toward individual health. Most of the applied professional writings in community mental health talk about the social aspects of individual health problems. Mental Illness as a Social Problem Mental illness is nowadays regarded both by professional workers and the general public as a national social problem as well as a health problem. The effects of the lay movement as well as the professional climate of opinion can be seen in the following facts: 1. There is a National Mental Health Week designated by the President of the United States to call attention to the problem. 2. There have been a series of national laws to provide for programs in mental health: a. National Mental Health Act of 1946 established the National Institute of Mental Health and its program of services, grants and research on problems of mental maladjustment. b. National Mental Health Study Act of 1955 established the Joint Commission on Mental Illness and Health to analyze and evaluate the needs and re- sources of the mentally ill and to make recommenda- tions for a national mental health program. c. Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 provided local services to deal with problems of mental retardation and mental ill-health. The legislation has been supported with massive amounts of public money, and represent a major investment of national resources in the recognition and solution of problems of people. Most of this activity received its major push into public conscious- ness with World War II. Here the problems of mental ill-health became very apparent with 850,000 men rejected by the draft as unfit for military service, and the large number of psychiatric casualties from the war which had to be cared for by the Veterans Administration.3 Over the twenty years since the war, mental illness has experienced the momentum of the increased Federal and citizen support as mentioned above. The terms of mental dis- order - anxiety, depression, compulsion, schizophrenia - have become com- mon household words. Where mental health is defined as a social problem, problems of be- havior are seen to be signs of social disorder. The behavior of the mental- ly ill represents socially intolerable deviance from patterns of normal or expected behavior. Treatment from this approach is then organized to deal with the deviation - either to make it conform or to separate it from the rest of society.’ Community Mental Health as the Final Common Path) It would appear that the mental health movement® has been a unifying force, a final common path, for these two rather different orientations toward mental illness. The health problem orientation is one where there is concern about individual well-being, with curing illness, and with 3Forty-three percent of all Army discharges were for neuropsychiatric dis- orders (Mora, 1959). “For more discussion of this orientation see Becker, 1963; Erikson, 1962; Scheff, 1963a, 1963b. 5For a more extensive discussion of the two separate orientations and their interaction, see Sanford (1957). He also deals with the difficulties en- countered in planning for mental health services which arise from "these two viewpoints." 6By movement is meant the activities (public, private and individual) carried out in the name of mental health. establishing a state which has been called "high-level-wellness" (Dunn, 1961; Kaufman, 1963). There are themes of individualism which have appealed to the general public and have been consonant with the national ideal of the good man. The social problem orientation has the efficient functioning of the society as its goal. It is concerned with the social cost of deviant be- havior. The monetary cost, as one aspect of the total social cost, has been well calculated by Fein (1958) in Economics of Mental Illness. Social disorganization, as another cost, has been discussed by Leighton in My Name is Legion (1959), People of Cove & Woodlot (Hughes, et al., 1960) and the Character of Danger (Leighton, D., et al., 1963). The goal is the balance of the system; problems are thought about in terms of deviance and conformity. There is often the situation where the public official planning pro- grams views mental disorders as problems of society and of moral turpitude. He seeks support from the citizen who thinks about the programs as being helpful to the solution of personal problems. Whether the two goals can be served in this one movement is entirely an open question; especially when there is no special distinction drawn between them and where services are dis- cussed generally as "mental health" programs. The Lack of Theory Mental health has been an ambiguously defined term since the movement began. Kingsley Davis (1938), almost thirty years ago, discussed this as a major problem - a problem which kept the movement from being very suc- cessful in achieving a goal of prevention. The problem seems to reside in the minds of the mental health workers. While they think and say that they are working to prevent mental disorder, Davis (1938) argues that they actually are engaged in the prevention of moral delinquency. Pres- sures are exerted on people to behave properly in the name of scientific knowledge; but proper behavior is judged by the values of the social group. If one looks closely at what is going on within the mental health movement, one sees various groups of people with differing training engaged in different activities with differing goals. The general orientation, however, is that they are working against ‘mental illness. They may want mental health as a positive state for different reasons but all can agree to being against mental illness. In the United States, as in all industralized societies where the standards of living are generally high, the people are faced with a new problem. This new problem is the planning for the future in such a way that positive improvements will take place. Planning has been extremely difficult to do; it becomes involved with the selection of philosophical goals, and uses scientific knowledge mainly in the process of getting to the goals. Science, per se, is not very helpful in deciding just what the goals should be. Decisions are more usually made when all the inter- ested parties can agree to some compromise direction. The history of the world has been based on a continual struggle for survival. With this, the emphasis in society was on ''getting rid of the bad." Marginal groups like the aged, the crippled, the retarded, and the in- sane were, in some societies, expendable.’ Industrially based affluence has allowed society to retain marginal groups - but its philosophy, as a carry- over from the past, is still to do away with them. There is either pressure to change their behavior, so that the problematic people will stop causing trouble or to maintain them separately, as in prisons or mental hospitals. The more sophisticated techniques now include ways to change other people's views of the behavior as well as to change the behavior itself. The possibili- ity that the marginal or deviant group might be used as a functional and con- structive part of the society has not yet occurred to most people. At the present stage in the development of programs for dealing with mental health problems there is no specific theory about mental health which overrides all others. The approaches to prevention and treatment of 71 am grateful to D. N. Lloyd for bringing this thinking about cultural evolu- tion to my attention. For a more general treatment of cultural evolution see Mackie & Rafferty (1964). Such a teleological interpretation of evolution may offend many readers especially cultural anthropologists, but I have used this oversimplification to highlight the point that while the technology and re- sources of our society have advanced to a point where life patterns can be radically altered, the ideas and values of people stand in the way. 8The U.S. seems still to be eradicate-the-bad oriented. Community Action and Development, Preventive Medicine and Public Health programs are often viewed with suspicion. A war on poverty, however, is eminently understandable and receives widespread support. Erikson (1962) has begun to think about how the state of deviance is useful to society and discusses the possibility that society recruits and maintains people into this status in order to maintain its identity. If this be the case, then perhaps deviance can be defined so that it is a more pleasant experience for people, or so that they can rejoin the general society without social stigmata after serving their time as a deviant. 11 conditions in a population have come from public health. This orienta- tion has worked well for the eradication of communicable disease since the system components of host, agent and environment approximate rather well the way the biological system of the human individual functions and the way it responds to disequilibria. In the application of public health thinking to mental health, it has been found that the concept of a disease entity with causal agents has not been very helpful in studying or treating mental disorder. This failure has led, I think, to the in- creased interest by medicine in psychological and sociological theory. It has been asserted with increasing frequency that the biological model (called by some, the medical model) is inapplicable to mental dis- order, and should be replaced by social or cultural models. I will offer an interpretation of the biological model which makes it compatible with other systems theory whether it is mechanical or social. To begin with, biological, organic and medical practitioners, it seems, have come to re- gard the biological functioning of the human as based on a number of in- variant relationships. Introduction of drug A will yield effect B. These strong relationships, however, are imposed by the extremely limited varia- tions within the living organism. Temperature, blood sugar and oxygen levels are examples of processes that can vary only over a restricted range without threatening the identity of the entire unit. Very small devia- tions from the norms can be detected and are called symptoms of systemic “disequilibria, or disease. 12 But consider the entity of a social system such as the family. Variation is tremendous. Time and space locations of the entity and its sub-parts are extremely variable. Everyone, for example, is together only for brief times such as at meals, in the evening, on weekends, when going on trips. Most of the functioning, therefore, is between subparts of the unit - with some members away from the interaction process for long periods. The subparts do not have the same history of experience. Coping can be brought about with many different means that are not necessarily harmful to the entity. If two family members do not get along with each other, they can set up schedules by which they reduce or avoid contact. Such separate functions biologically could not be tolerated. Consider the serious effects on the system of such a separation between one's head and his hand. The result would be palsy or paralysis. With the variations so much greater within the social system, the determination of regularities within it is a much more complicated affair. One must try to keep constant a multitude of things; the number of people, their ages, background experiences, etc., etc. Similarities between natural- ly organized social units are difficult, perhaps even impossible, to find. Perhaps the only way to experiment with such social groups is with the simulation of them in the laboratory so that the important variables may be controlled.9 First, however, the important job is the systematic identifi- 9Simulation with an electronic computer as the integrating force has become popular in such areas as business management training, the study of political processes, and the training of military personnel to operate a radar station (Guetzkow, 1962). Probably the next set of developments in community mental health will be the use of simulation to study the development and control of mentally disordered behavior. cation, description, and classification of the social units in man's natural environment and the ways in which they interrelate. When this has been done, one then should have sufficient knowledge about how to go into experimentation, 10 My contention here has been that systems theory is a productive way of looking at social functioning; it is consonant, not disjunctive, with the biological model. The Ecological Model Building upon the systems theory approach to the study of human be- havior, I would like to propose an ecological model as being both helpful in conceptually dealing with the complexities of social systems and in mounting descriptive research inquiries into man's social behavior. First, one must begin by accepting the fact that each social system is unique: that it is organized in a particular way, that it has a per- sonality like a person and that no other system is like it. This is the psychology of individual differences applied to a social group. The regularities for which one searches are patterns of function and inter~- relationships; not patterns of individual behavior. Symptomatology in physical illness often seems invariant because of the very restricted vari- ability within the biological system; therefore, one can have generally 10perhaps what is needed is a kind of Human Relations Area Files for the communities in which we carry out our research. 14 applicable symptoms across different people. Symptomatology of social system dysfunction can be regarded as a similar process in that some behaviors or patterns of behavior can reflect systemic dysfunction. But first one must know what the regular functions of the system are. Before we can tell whether a husband's physical aggres- sion toward his wife is appropriate, we must establish what are the usual patterns of interaction within that household. To generalize, the point, then, mentally ill behavior can be so judged only in relationship to the context in which it occurs; its expression will tell us: (1) that its form is a deviation from expectations in that particular environment, and (2) will tell us something about the nature of those expectations. Thus, the standards or norms for behavior are specific to the social group; the modes of deviance are expressions of those norms. The extent to which people outside the family (e.g., physician or clergyman) are called to help deal with deviant behavior provides indications of the variability of behavior which is tolerated by the community. Ecology has its roots in plant and animal biology in the study of the adaptation of organisms to their environment. Human ecology is derived from geography and sociology as well. These go together to provide a means for studying the unit of man-in-his environment. Theodorson (1961) dis- tinguishes the biotic level of human organization where the struggle for existence is primary, and the cultural level, where human behavior is in- terrelated in social forms. We must be concerned with both in our ecological model in order to provide a basis for inquiries into the nature of man's living patterns, and their disruption into mentally disordered behavior (Kelly, 1963). The major reason for using the model of ecology in community mental health is to begin from a point which assumes that virtually all problems of people are specific to themselves and their particular situation. From this position, there is no general mental health problem. Communities must be seen as personalities, as unique organizations of forces, needs and re- sources. Services should be custom tailored, research should tell us how the tailoring might be done and training should provide the skillful tailor. The following papers will go into detail on each of these matters. References Becker, H. S. Qutsiders: studies in the sociology of deviance. New York: Free Press, 1963. Dain, N. (Concepts of insanity in the United States, 1789-1865. New Brunswick, N.J.: Rutgers University Press, 1964. Davis, K. Mental hygiene and the class structure. Psychiatry, 1938, 1, 55-65. Dunn, H. L. High level wellness: a collection of twenty-nine short talks on different aspects of the theme "High-level wellness for man and society." Arlington, Virginia: R. W. Beatty Co., 1961. Erikson, K. T. Notes on the sociology of deviance. Social Problems, 1962, Spring, 307-314. Fein, Rashi. Economics of mental illness. New York: Basic Books, 1958. Frank, L. K. Society as the patient: essays on culture and personality. New Brunswick, N. J.: Rutgers University Press, 1948. Fromm, E. The sane society. New York: Rinehart, 1955. Guetzkow, H. S. (Ed.) Simulation in the social sciences. Englewood Cliffs, N.J.: Prentice-Hall, 1962, Harvard Medical School and Psychiatric Service, Massachusetts General Hospital. Community mental health and social psychiatry. Cambridge, Massachusetts: Harvard University Press, 1962. Hughes, Charles C., Tremblay, M. A., Rapoport, R. N., & Leighton, A. H. People of cove and woodlot. New York: Basic Books, 1960. Jahoda, Marie. Current concepts of positive mental health. New York: Basic Books, 1958. Kaufmann, Margaret A, High-level wellness, a pertinent concept for the health professions. Mental Hygiene, 1963, 47, 57-62. Kelly, James G. A preface for an eco-system analysis of community mental health services. 1963. mimeo. Leighton, A, H. My name is legion: foundations for a theory of man in relation to culture. New York: Basic Books, Inc., 1959. 17 Leighton, Dorothea C., Harding, J. S., Machlin, D. B., Macmillan, A. M., & Leighton, A, H. The character of danger. New York: Basic Books, 1963. Lewis, N. D. C. American psychiatry from its beginnings to World War II. (In) Arieti, Silvano (Ed.) American Handbook of Psychiatry, Vol. I. New York: Basic Books, 1959. Mackie, J. B., & Rafferty, F. T. Specific & general evolution: the psychological implications of two kinds of cultural change. Mimeo- graphed paper available from the Psychiatric Institute, University of Maryland Medical School, Baltimore, Maryland, 1964. Mora, G. Recent American psychiatric developments (since 1939). (In) Arieti, Silvano (Ed.) American Handbook of Psychiatry, Vol. I. New York: Basic Books, 1959. Muncie, W. The psychobiological approach. (In) Arieti, Silvano (Ed.) American Handbook of Psychiatry, Vol. IIL. New York: Basic Books, 1959. Rossi, A. M. Some pre-World War II antecedents of community mental health theory and practice. Mental Hygiene, 1962, 46, 78-94. Sanford, F. The rising tide of mental health. Public Health Reports, 1957, 72, 605-608. Scheff, T. J. Social support for stereotypes of mental disorder. Mental Hygiene, 1963, 47, 461-469. Scheff, T. J. The role of the mentally ill and the dynamics of mental disorder: a research framework. Sociometry, 1963b, 26, 436-453. Theodorson, G. A. (Ed.) Studies in human ecology. New York: Row, Peterson, 1961. COMMUNITY MENTAL HEALTH SERVICES: FOR WHAT AND TO WHOM? A. J. Simmons! Massachusetts General Hospital Human Relations Service of Wellesley, Inc. Many new kinds of community mental health services have been estab- lished since the second World War. These services reflect different ap- proaches and principles as well as new knowledge, methods and skills. There is no simple consensus about the scope of community mental health. In com- munities throughout the land a broad range of mental health services has been developed to control and prevent mental illnesses where possible, to diagnose them promptly and treat them effectively when they do occur, and to rehabilitate those who have suffered from these disorders. In the remarks which follow, I shall report on three of the community mental health services provided by a local community mental health facility to a population of 26,000 people in a suburb of Boston, Massachusetts. The nature of these services is determined by a public health philosophy and popu- lation focussed orientation and the ultimate goal is the prevention of mental illness and the promotion of mental health. Therefore, a few explanatory words of the types of preventive programs in public health seems pertinent. lNow Associate Director, John F. Kennedy Family Service Center, Inc., Charlestown, Mass. and Assistant Professor, Department of Psychology, Boston College. 19 Types of Preventive Programs in Mental Health Public health has distinguished three types of preventive programs. Prevention is designated as primary when measures are designed to promote general optimum health to protect man against disease, or to establish bar- riers against noxious agents in the environment. Measures designed to deal with early pathogenesis by prompt and adequate treatment are referred to as secondary prevention. The term tertiary prevention is used when measures are designed to manage or correct the disease, prevent sequelae or limit the disability, Although primary prevention is most efficient when endangered cases can be recognized, there does not necessarily have to be successful antici- pation of trouble. If any substantial proportion of people is likely to be influenced adversely, alertness to the opportunity for prevention is war- ranted. There are two general methods of primary prevention. One is to in- fluence the occurrence or the extent of a traumatic event or predicament (i.e. to avoid it entirely or reduce its intensity). For example, instead of avoiding stress it may be possible to time it in order to avoid multiple crises: one kind of event is deferred so that two upsetting incidents do not occur simultaneously. The second method, applicable when one is unsure of being able to forestall or modify the event itself, is to circumvent or minimize undesirable reactions to it and, in some cases, to substitute desir- able responses. There are several ways of minimizing pathologic responses to unavoidable events. Among the ways to achieve this goal are: 1. preparing prospective victims in advance for an experience that may be stressful; 2. providing means of relief for tensions that may become aroused; 3. making a person stronger so he is less distressed when ten- sion occurs that must be borne. In seeking to accomplish this goal, the issue is not one of relieving people of their normal responsibilities or allowing them to escape the appro- priate challenges of life. It is ome of protecting especially vulnerable individuals from exceptional stresses the reactions to which are likely to be in the form of immature behaviors rather than constructive mastery. The services described in this paper exemplify programs of primary and secondary prevention. It should be borne in mind that there are no cook-book recipes available. Therefore, I can only share our experiences with you and relate those practices to which we subscribe. A Pre-School Check Up Program The remarkable success which we have witnessed in the control and pre- vention of communicable diseases is a challenge to scientific ingenuity to tackle problems of mental illness with a preventive orientation. Some impli- cations of this orientation for mental health programs are: 1. turning away from the exclusive concern with individual patients for purposes of therapy, toward concern with popula- tions and social groupings; 2. learning about incidence and prevalence of disorders and behavior characteristics; 3. studying the natural history of emotional disorders from their earliest beginnings; and 4. concerning oneself with community-wide measures which might contribute to the maintenance of mental health and prevention of mental ill-health. With these aims in mind mental health professionals must: 1. explore the possibilities for preventive work at times of emotional disturbances occurring in families or other community groups; 2. discover early danger signals for later more serious dis- turbances; and 3. determine auspicious times in the life of an individual when future crises might be anticipated and untoward reactions be prevented. In learning to control certain diseases, public health workers have studied the characteristics of persons who are immune. A similar assumption for prevention of mental illness is that all persons, at various points in their life history, experience stress when they are confronted by major changes in their lives; that most persons make a successful adaptation to the new demands; that some do so only with great difficulty; and that the adaptive efforts break down altogether in a few. A preventive mental health program, therefore, will depend on the identification of as many com- mon stress situations as possible as well as on finding ways to help in- 23 dividuals who would otherwise fail to master them. The pre-school emotional check-up program is an example of a direct method of primary prevention conducted on the assumption that the transi- tion from home to school is a stressful life event involving rapid role change or redistribution of role relationships among groups of people and, therefore, representing potential hazards for those experiencing it. This program has been conducted by the Human Relations Service in collaboration with the Wellesley public schools for the past several years, It is con- ducted each Spring and is based on earlier experiences with a doll play screening technique and parent interviews. The program is modelled after the routine physical and dental examina- tions customarily given children prior to school entry, It offers each family an opportunity to participate in a review of the child's social and emotional development. A brief description of the service is included in a packet of materials sent out by the schools each Spring to acquaint parents with school procedures and the like. Participation is voluntary and the check-ups are given at the agency without charge. They are conducted in a manner designed to leave both parent and child with a favorable reaction to the experience. For most of the families this represents their first con- tact with the agency and its operations. The child is brought to the center by ome or both parents. A trained observer notes parent-child interactions in the waiting room. Soon the 24 parent (usually mother) and child are requested to separate and accompany a pre-assigned staff person to a designated room. Each child is observed by a staff person especially trained in child development and experienced in working with children. The setting is a playroom which, among other things, is fitted out with doll-play arrangements. This observation lasts approximately 45 minutes. Since this is con-= sidered a screening contact, no effort is made to arrive at a definitive diagnostic evaluation. However, special attention is paid to; (1) the ease with which the child separates from his parent and accompanies a strange adult; (2) the child's ability to tolerate continued separation; (3) the child's approach to a play "task" involving the doll house material; (4) the extent to which the child controls his emotions; (5) the amount of un- usual behavior exhibited by the child; and (6) the number and kind of special demands the child makes on the examiner. Meanwhile, the parent is interviewed by another staff member. While certain standard developmental and family information is gathered for each parent-child unit, interviewers also are encouraged to respond to parental needs of the moment, Following completion of the single observation of the child and the contact with the parent, a team conference is held in order to complete a summary sheet of recommendations and comments. An additional visit is ar= ranged, at which time both parents are encouraged to share and discuss the staff's impressions. In some instances one or more follow-up interviews Mental Health Consultation 25 are arranged and devoted to a problem area brought up by the parent. Parents are awarded a "certificate of attendance" which, at their discre- tion, is given to the kindergarten teacher as an indication of parental readiness to have the school communicate with the agency regarding the | child. This is viewed as a way for the schools to benefit from the pre- ® school check-up without destroying the confidential nature of the contact with the family. Through this screening service it has been possible to accomplish the following health purposes: 1. detect emotional disturbance at a time when families are easily motivated to seek treatment and before the child has embarked on a period of cumulative school failures; 2. encourage certain families to bring to our attention concerns which otherwise would have remained outside of professional at- tention; 3. reach parents, in the context of a simple "check-up", regard- ing benign conditions or minor problems which have seemed to yield readily to one or more focused interviews; 4, provide reassurance to competent parents regarding quite un- necessary but fairly prevalent worries about their own com- petence as parents; 5. include teachers as well as parents in the consideration of the child's individual development and emotional needs; and 6. acquire considerable amount of data regarding normal children's approaches to a common emotional "hazard." Mental health consultation to community "caretakers", "caregivers", or "urban agents", that is, those persons such as physicians, clergymen, school personnel, etc., who provide helping functions to local citizens, is another example of a community mental health service provided by the Human Relations Service of Wellesley. This kind of service is an illustra- tion of an indirect method of preventive intervention mediated through com- munity caretakers. : The mental health consultant adopts an "ecological theory of emo- tional health" and assumes a dynamic equilibrium between the consultee and his psychologically relevant environment. Within this framework the focus of interaction shifts from individual diagnosis, sickness, and treatment, to appraisal of situations, health promotion and collaboration. The con- sultee, therefore, is not viewed as a client or patient but rather as a collaborator and co-professional. Similarly, the consultant is not viewed as a therapist or the giver of prescriptive advice. Instead, the consultant seeks to assist a co-professional deal more effectively with that segment of the population which he serves, by helping the consultee solve those problems in his work which have mental health implications. The consultant also attempts to enhance the growth of the consultee so that his professional activities will become more attuned to the emotional needs of his clientele in the future. The consultant relates to the consultee in terms of the latter's previous background, history and needs. He also seeks to understand the setting within which the consultee functions and the relationships which he maintains within that setting. 27 Three major components may be discerned from a review of the litera- ture on mental health consultation. These three major components are: (1) an ecological theory of emotional health or crisis theory; (2) health promotion; and (3) situational analysis. Crisis theory provides the framework from and through which the consultant operates. This theory expounds a state of dynamic equilibrium between the consultee and his psychologically relevant environment. The ultimate health of the consultee is viewed as related not only to his own inner psychological and biological structure, but also to his relationships with his family, circle of acquaintances, other personnel and colleagues, and his community. Moreover, all these structures upon which his indivi- dual health depends are intimately inter-related, for changes in any of them cause changes in all the others. A balance of these forces between normal limits is maintained by healthy individuals but, at any one point in time and under certain circumstances, the consultee may be displaying "'symptomatic' behavior as a result of an imbalance of forces or temporary "disequilibrium." As a co-professional and collaborator, the consultant uses his know- ledge of psychodynamics and clinical skills in analyzing and helping with the interpersonal relationships and intrapersonal functioning of the con- sultee. In contrast to therapy, however, the consultant works with those feelings of the consultee that are pan-individual and not with those 28 personality characteristics that are idiosyncratic. To be more specific, the consultant's aim is to present a more objective picture of the client; one in which his undesirable behavior is neither condemned nor condoned but removed from the focus in which the consultee's anxiety has placed it. This enables the client to be viewed as a complex human being with strengths and weaknesses, and as one who may be able to function satisfactorily re- gardless of his particular handicaps. In restoring equilibrium to the situation and reducing tension, the con- sultant, through acceptance of and empathy for the consultee, tries to en- courage a positive relationship. This process should allow the consultee to develop or strengthen more healthy defenses, adopt a more objective appraisal of the situation through re-orientation and re-education, and develop at least partial insight. The ultimate goal is to shift the reason for consul- tation from a crisis on the part of the consultee to one which is more task oriented. Implied in crisis theory is that the consultant is more concerned with promoting health than in treating illness. As yet, most of the con- sultations result from a consultee in crisis rather than one who initiates consultation because of an imminent or pedicted crisis. This kind of help is often referred to as secondary prevention. In promoting the healthy aspects of the consultee's personality and/or his social system, the consultant enhances the potential for: a) generali- zation to more effectively deal with other crises of the same or similar 29 nature in the future and, b) transmission and utilization of healthy personality traits thereby sanitizing the consultee and his psychological environment from further dis-equilibrium. The mental health consultant concentrates upon helping the consultee directly in his attempt to increase understanding of the problem and to plan some approach to the problem on the basis of the consultee's increased knowledge and broadened perspective. One of the primary goals is to increase the consultee's ability to perform his professional functions thereby adding a meaningful increment to the capacity of the social environment to offer support and assistance to all individuals in the population. It is important to emphasize that the con- sultant tries to avoid consultative procedures primarily for purposes of diagnostic study or other psychiatric assessment. The clinical learnings of the mental health consultant, whose training has been primarily, if not solely, concerned with pathology, may have negative or no transfer to such a process of health promotion. The third major component is that the consultant makes a multi- dimensional appraisal of the crisis, this is, a situational analysis. This emphasizes that all the emotionally relevant factors of the consultee and his setting are viewed as playing an actual, or at least potential role in the genesis and development of the presenting concern(s). This means there is a shift in perspective from the event per se to the larger social system and the complex networks of relationships within it. This does not mean to imply a more superficial appraisal. On the contrary, considering the rela- 30 tively short period of contact and the high degree of felt need, the test to which the clinical acumen of the consultant is put is now much more intricate and the task becomes correspondingly more complex. The mental health consultant needs to make his appraisal in terms of intrapsychic dynamics, interpersonal relations, human development, role and role con- flict, group structure and process, and the cultural milieu as these re- late to the consultee and the existing situation. In the practice of mental health consultation with groups, agencies, and institutions in the community, it is our belief that it is helpful for the consultant to come from a base of operation outside the institution of the consultee, for among other things, he is (1) less subject to pressures from within the social system of the consultee; (2) therefore, more easily able to maintain objectivity; and (3) less apt to be viewed as a person whose evaluations may affect the consultee's present professional status or future career. In summary, it must be emphasized that one of the important aims of mental health consultation is that of helping the consultee and other in- terested and involved people be most helpful to the concerned person (client) and thus prevent the emotional handicap from leading either to de- terioration or superimposed acute emotional illness as a result of inappro- priate environmental demands on the concerned person. This work is based on the conviction that great advances in the prevention of mental illness are made only as various professional people in different settings carry on 31 their work in such a way as to meet the emotional needs of those with whom they are in contact. Brief Clinical Service It is perhaps useful to think of the field of prevention as being many little things and not to think that one has to start right away by stopping schizophrenia. This truism is especially highlighted in the preventively oriented clinical work of the Human Relations Service. This service, often designated as a direct method of preventive intervention, seems most often indicated in emotional predicaments where there is a crisis as the result of an emotionally hazardous situation. An attempt is made to change the emo- tional forces in a person's environment or the way he solves his life's problems by direct interaction with that person and the significant others in his emo- tional milieu. Successful preventive intervention usually includes an attempt to help the individual alter his perception of the predicament. It is almost essential to do so when the client is immobilized by the secondary tensions that often arise when the individual feels he has been made the victim of inner or outer forces not under his control. For most, such redefinition is all that is needed. With increased understanding and reduced feelings of helplessness and anxiety, the individual is then able to bring his own strengths and acquired social skills to bear upon the problem. This brief clinical service is so conceived that, while predicaments may be resolved, a '"case' is never closed. The community mental health agency, concerned as it is with the population of the community, is always open for contact by any individual in that population. By judicious use of staff time and the avoidance of long term treatment responsibilities with those already sick, it has been possible to maintain a service that is available promptly to all those requesting help, without resort to selective intake or waiting lists. The assessment of each predicament is initiated within a few days of the request for service. When necessary, emergencies are seen on the same day or even within the same hour. Those persons in need of and desiring long-term treatment are helped to find it elsewhere. A few situations in which chronic pathology is involved are car- ried on a follow-up basis, often in collaboration with one or more such pro- fessional caretakers as a physician, clergyman, or family case worker in the community. As a specific series of encounters draw to a close, it is made clear that the service will be available in the future should a similar or other difficulty arise. The attempt is made to interrupt the contact at a point where the proposed limited goals have been optimally attained and where a feeling of continued confidence exists towards the clinician and the agency. It is hoped that the image of the clinician as a sympathetic but objective person may help the client assume a similar attitude when future challenges are met. 33 The ending phase usually is marked by a review with the client of what has been accomplished by him in the analysis and working through of the predicament. Implications are drawn, when possible, to preferred modes of coping with future emotional hazards. In some instances arrange- ments are made for one or more follow-up visits or telephone contacts. Preventive intervention shares with remedial efforts, such as the several brief psychotherapies or focussed casework, the importance of making a careful assessment of the intrapsychic structure and dynamics of person- ality. In contrast, however, it extends this assessment to an equally im- portant appraisal of the relevant human environment of the person and the significant role relationships in which he is involved. Hence the weight of emphasis as well as the focus shifts from the individual alone to the individual enmeshed in a network. The unit of inquiry, analysis, planning, and intervention is, therefore, not the individual patient alone but rather the individual and one or more of the significant segments of his social milieu. The ingredients of this kind of brief clinical intervention may be likened to the concept of emotional first aid. By emotional first aid, I am referring to measures taken after upset has occurred or is suspected to have occurred. The goal is one of secondary prevention, to keep further sickness from developing by minimizing the existing turmoil and circumvent- ing or eradicating unhealthy responses to stress. First aid is intended not for ''meurotic' individuals with chronic ailments but for normal persons with an illness, particularly for illnesses just beginning or upsets that may continue if no help is given. By this, it is not meant to imply nor suggest that every person needs help in stressful situations. There are great differences among individuals in their susceptibility to distress and the nature and duration of consequent neurotic development that may follow. Some events, under certain circumstances, may induce emotional crisis in some (ultimately predictable) proportion of those exposed. The consensus is that certain experiences are at least temporarily disorganizing for most. On this observable fact is founded the essentially optimistic bias of the work. The disorganization offers the opportunity to re-examine and, if neces- sary, abandon old ways of coping with problem situations. It provides motiva- tion for change, for the assumption of new, emotionally more satisfying roles and relationships. The ability of the clinical service to work preventively at times of crisis has, of course, been greatly enhanced by the development of close, effective working relationships with a variety of professional caretakers in the community. Intensive programs of education and interpretation as well as mental health consultation with both professional and lay groups has led to ever-increasing community understanding and acceptance of the goals of primary prevention. Thus, it has become possible to broadly participate with the population and to be available to an increasingly high proportion of those coping with emotional hazards before a psychiatric casualty has en- sued. The governing principle of this brief clinical service is the desire to make this kind of assistance available to as many citizens of the town as possible. Both the staff and community now realize what this implies, namely, that only relatively limited help will be provided. The goal of this therapy in a community program is restricted to providing the patient with enough help to enable him to carry on from there on his own. As one of my British colleagues put it, "to help the person live happily and construc- tively with his neurosis." The point here is that major restructuring of the personality through lengthy psychotherapy will be hardly possible. However, at the same time, we believe that in order to be truly effective, this technique must be based on a profound understanding of intrapsychic dynamics, a discerning use of clinical knowledge and its application and modification to a multifactorial system of people and events. Summary It is understood that there are many other varied professional activities that a community mental health program encompasses such as in- patient services, rehabilitation programs, psychiatric programs in general hsopitals and the like. What I have described in this paper are three of the ways in which the community mental health facility in Wellesley has succeeded in accumulating knowledge of the interrelationships between man and his environment. This knowledge has been acquired only as a result of being given permission to assume the role of "privileged witnesses" in a New England suburb. This current role has evolved only as the 36 ‘outcome of the partnership in cooperation and collaboration between the citizens and their mental health unit. The staff now looks out of the windows of the consulting rooms out to the activities of their clients aware that social factors are important in psychodynamics and that the sociocultural context is vital in preventive in- tervention. Moreover, the staff, in adopting the public maxim of the great- est good for the greatest number realizes that this implies a framework of action in which economy of effort is a prime consideration. Therefore, for the mental health professional, these services have to be viewed as being more than old wine in new bottles and that his successful participation and con- tributions involve new learnings in addition to new ways of applying old knowledge. Suggested References Bellak, L. (Ed.) Handbook of community psychiatry and community mental health. New York: Grune & Stratton, Inc., 1964. Bindman, A. (Ed.) Roles and Functions in School Mental Health. Boston University Journal of Education, February, 1964 (whole issue). Bindman, A. Bibliography on mental health consultation. (In) Cohen, L. D. (Ed.), Consultation: a community mental health method - report of a survey of practices in sixteen Southern states. Washington, D. C.: Research Utilization Branch, National Institute of Mental Health, Department of Health, Education and Welfare, 1964. Caplan, G. An approach to community mental health. New York: Grune & Stratton, Inc., 1961. Caplan, G. Principles of preventive psychiatry. New York: Basic Books, Inc., 1964. 37 Gildea, M. C. L. Community mental health: a school centered program and a group discussion program. Springfield, Illinois: Charles C. Thomas, 1959. Harvard Medical School and Psychiatric Service Massachusetts General Hospital. Community mental health and social psychiatry: a reference guide. Cambridge, Massachusetts, Harvard University Press, 1962. Joint Information Service of the American Psychiatric Association and the National Association for Mental Health. The community mental health center: an analysis of existing models. Washington, D. C.: 1964. Kelly, J. G. The mental health agent in the urban community. Unpublished manuscript. Department of Psychology, Ohio State University, Columbus, Ohio, 1963. Klein, D. and Lindemann, E. Preventive Intervention in Individual and Family Crisis Situations. (In) Caplan, G. (Ed.) Prevention of mental disorders in children. New York: Basic Books, Inc., 1961. Kotinsky, R. and Witmer, H. L. (Eds.) Community programs for mental health. Cambridge, Massachusetts: Harvard University Press, 1955. Leavell, H. R. and Clark, E. G. Preventive medicine for the doctor in his community: An epidemiologic approach. New York: McGraw-Hill Book Co., Inc., 1958 (2nd ed.) Lindemann, E. The Wellesley project for the study of certain problems in community mental health. (In)Interrelations between the social environ- ment and psychiatric disorders. New York: Milbank Memorial Fund, 1953. Lindemann, E. The meaning of crisis in individual and family living. Teachers College Record, 1956, 57, 4. MacMahon, B., et al. Principles in the evaluation of community mental health programs. American Journal of Public Health, 1961, 51, 936-968. Milbank Memorial Fund. The elements of a community mental health program. New York: 1956. Milbank Memorial Fund. Programs for community mental health. New York: 1957. Milbank Memorial Fund. Planning evaluations of mental health programs. New York: 1958. 38 Milbank Memorial Fund. Progress and problems of community mental health services. New York: 1959. National Institute of Mental Health. Evaluation in mental health: a review of the problem of evaluating mental health activities. Washington, D.C.: Public Health Service Publication, No. 413, 1955. Querido, A. Mental health programs in public health planning. Mental Hygiene, 1962, 46, 626-654, Ryan, W. Urban mental health services and responsibilities of mental health professionals. Mental Hygiene, 1963, 47, 365-371. Simmons, A. J. A preschool emotional check-up program. Unpublished manu- script. Human Relations Service of Wellesley, Inc., Wellesley Hills, Massachusetts, 1960. Simmons, A. J. (Consultation through a community mental health agency. Unpublished manuscript. Human Relations Service of Wellesley, Inc., Wellesley Hills, Massachusetts, 1960. Tenth Anniversary Report of the Wellesley Human Relations Service, Inc., 1948-1958. Unpublished manuscript. Human Relations Service of Wellesley, Inc., Wellesley Hills, Massachusetts, 1959. Vaughan, W. and Downing, J. Planning for early treatment psychiatric services. Mental Hygiene, 1962, 46, 486-497. Walter Reed Army Institute of Research. Symposium on preventive and social psychiatry. Washington, D. C.: 1957. THE COMMUNITY MENTAL HEALTH CENTER AND THE STUDY OF SOCIAL CHANGE James G. Kelly The Ohio State University The passage of Title II, Public Law 88464, known as the Community Mental Health Construction Act, is the most recent attempt in the United States to develop mental health services which are comprehensive and unique for each local setting (Federal Register, 1964). This legislation, as a statement of our current professional values, provides guidelines for ser- vices considered to be specific for the needs of our society. This morning I would like to present some of the principles underlying this recent legislation and discuss examples of research activities that derive from these principles. I view such research not only as a contribu- tion for the effective operation of a community mental health program, but primarily as a source for the analysis of change; change in ourselves, our mental health services, and our communities. The guidelines of the federal legislation indicate that a community mental health center will offer a broad range of services to all citizens (Principle of Comprehensiveness), that such services are interdependent (Principle of Coordination) and that there is available, if needed, an easy succession of multiple services for each person (Principle of Continuity). While each of these principles have been emerging as the aims for all mental health services in the United States, the recent guidelines offer more as- 39 40 surance that we can attain these goals much sooner (Harvard Medical School and Psychiatric Service, Massachusetts General Hospital, 1962.) Principle of Comprehensiveness The Principle of Comprehensiveness emphasizes that effective mental health services will be inclusive rather than restrictive. The proposed centers will offer services for the discharged hospital patient including a variety of follow-up services, along with educative and consultative services, focusing upon early screening and detection. This increase in the range of services will make quality control of treatment more difficult, particularly since the services may be located in separate administrative units, For the first time in the history of the mental health movement, accurate reporting of mental health work will approach the magnitude of the record keeping and evaluation activities of a large metropolitan general hospital. Until recently we have had very few data collection systems in operation for psychological problems similar to case registries in the fields of cancer control (Gardner et al, 1963; Gardner et al, 1963; Gorwitz et al, 1963). The automated record keeping functions of these emerging case registries are designed to tabulate the interaction between types of individuals who do or do not benefit from various services as well as specify the assignment of persons between services. Such registries provide a systematic method for routine and continuous analysis of the social and com- munity characteristics of those persons receiving service. Consecutive analyses of these data can document not only a comparison of persons who are receiving different treatments, but such data provide a basis to identify changing functions of the mental health center in the community. As the structure and functions of communities change, it is assumed that such changes will be reflected in the expression of disruptive behavior, the accessibility of such behavior for service and the effectiveness of such services. For example, communities undergoing rapid population changes will expect to increase demands for services. Not only the new immigrant but those citizens who are socially mobile or displaced through urban renewal are also expected to manage the stress of such events by requesting mental health services. Until recently mental health agencies in the United States have determined informally what kinds of patients were to be seen and what types of services were to be offered. As the Principle of Comprehensiveness is implemented, and each center offers more services to a broader base of the population, the local community will have a basis to understand more ac- curately the complex interrelationships between the expression of disruptive behavior and characteristics of the social environment (Kelly, J. G., 1964a, 1964b). Principle of Coordination The Principle of Coordination affirms that the community mental health center will provide services that are unduplicated and integrated with other existing health and welfare services. Our mental health programs in the 42 United States have been notorious in not offering optimal services to a maximum of the population. Instead, two population groups have received proportionately the majority of the services, the well educated and members of the lower social class (Hollingshead and Redlich, 1958; Miller and Mishler, 1959; Kelly, 1964a). The latter group largely have been recipients of public care with the well educated receiving private care. Each of these groups have received different types of services; psychotherapeutic benefits have been offered to the higher social classes, with more medicinal and non- verbal treatments to the lower socio-economic groupings. The principle of coordination has had limited application in the United States because persons in both social strata who were receiving treatment often had re- ceived similar services from different resources. Hopefully as the new centers begin operation, and are effectively coordinated, less duplication will result. Particularly, less duplication is expected whenever services are based upon realistic appraisals of the extent and severity of social problems rather than prescriptions for treatments that are independent of the unique conditions of the local region. To the degree that a local com- munity is able to plan effectively across different types of services, the analysis of service usage can directly reflect changes in the status of individuals or factors in the social environment which are affecting service, If the informal biases of the facility can be clarified then the analysis of service usage can concentrate upon the question of effectiveness of services. Principle of Continuity The Principle of Continuity encourages each community mental health program to develop services so that the client will make an easy transition from one service to another. This principle is directly related to the Principle of Comprehensiveness. If services are comprehensive then recipients will have a greater likelihood of receiving an effective service. If services are continuous they are successive and administered with a mini- mum delay. The continuity principle, which most directly deals with the quality control of therapeutic activities, affirms that decisions for treat- ment will be made with the intent of viewing a person as having available the therapeutic program of the entire center rather than being a recipient of a specific service or any particular therapist. This principle assumes that mental health services are optimal when an individual receives a mini- mum number of alternative services. It also assumes that the provision of mental health services for a metropolitan area cannot be effective unless services are administered in a planned sequence (Kelly, 1964b). Services which are discrete, prolonged or fragmented are contrary to the operation of the principle of a community mental health program. The allocation of mental health services in the United States has lacked continuity. Not only have we lacked comprehensive and coordinated programs, contributing to a reduction in continuity, but we have supported a model of individual or group psychotherapy which easily leads to fragmenta- tion particularly when one person can receive one type of treatment from one 44 therapist for an extended period of time irrespective of an analysis of benefits. This model is considered inefficient and opposite to the purpose of community oriented mental health services. Establishing a continuous program of services, however, is extremely difficult because it requires a declaration of explicit criteria for successful benefits. While specifying such criteria is not an impossible task, it does mean that evaluation and research activities increasingly become a basic component of the operation of the center. These three principles not only reflect emerging consensus in the mental health professions, but they reflect a standard for evaluation of programs that is independent of any particular philosophy of treatment. Even more significantly these principles also give each community a new method for studying the development of changes in patterns of living. A significant mission of a community mental health program is to provide a systematic basis for the local community to plan for its future. Such work would include the analysis of shifts in the population due to relocation or migration, the differential expression of morbidity at different points in time and in various segments of the population, as well as changes in the structure and functions of social organizations in the local area. Although each local metropolitan government has the major responsibility for the collec- tion and analysis of baseline or denominator data for systematic planning, the community mental health program does have a supplementary function in the col- lection .and analysis of numerator data. The major task is to concentrate on the development of propositions about numerator data which identifies those groups of the population that show significant changes in the admission, retention or discharge from services. Research Programs of the Community Mental Health Center Achievement of each of these principles makes it possible to develop three equivalent and complementary research programs. The Principle of Comprehensiveness emphasizes research on the interaction between specific segments of the population and types of services that have been administered. The Principle of Coordination emphasizes the study of the social organiza- tion of local health and welfare services.- The Principle of Continuity focuses upon research on the specific treatment process. The present discussion of such research work will be based upon hypo- theses about the effects of migration upon the adaptation of children. These examples will illustrate specifically how a community mental health program can assist in the study of social change. When proposing hypo- theses about the effects of geographical or social mobility upon adaptation of children, the social and economic characteristics of the population, the type of parental social mobility and the specific expression of adaptation must be considered. At the present time, it is not clear in what ways such factors are interrelated. The relationship between number of moves, type of moves, time of entry and subsequent adjustment in the classroom is unclear, While past research has indicated that the more the child moves the poorer 46 the adjustment, a study by Downie (1953) reported by Kantor (1965) found that either one or two moves, or being in a school system from one to three years after moving, seems to lead to greater social acceptance than either being in the school during the entire academic life, moving a great deal, or being in a school less than a year. This study suggests that there is operating at least in some children a constructive response to change. What is ambiguous is the effect of the social organization of the class- room upon a new student, parents' expectations and attitudes about any move and whether the move for the child is of an upward or downward direc- tion. Kantor's own research (1962) indicates that families who change residence within a community have less well adjusted children than the families who remain stationary. But factors other than a change in resi- dence appear to be related to the status of the child's adjustment. Specifically, Kantor found that upward or horizontal changes in the father's occupation appear to be associated with the retention or development of behavior problems by the child. As Kantor has suggested, occupational mobility apparently either makes it more difficult for a child to recover from old symptoms or facilitates the development of new ones. In order to effectively test alternative hypotheses for the deter- minants of negative or positive responses to residential changes in a local community, the research must be able to include a wide sample of different population groups. Of particular value is the inclusion of students who, as members of a particular sub-group of the population, have already de- monstrated a high risk of social problems or of physical disease. For example, Wilner et al (1962) found that rates of infectious, parasitic conditions, digestive disturbances, and accidents were consistently lower for the group of children which had moved to a new public housing project than for the group which had elected to remain in a deteriorated section of the city. Wilner et al also found after a two year period that the group which had moved were more likely to be promoted in school at a normal rate, while the non-movers were more often retained for ome or two semesters. Although these studies were developed as major research pro- jects outside of a mental health center, the data illustrates, however, the type of research that is integral to their operation. Such data also suggest that community mental health research and services requires close liaison with the operation of other health and welfare services to enhance the study of persons who are potentially high users of all community ser- vice. The availability of a broad range of services can more specifically {1luminate whether children of different social characteristics and with varying migratory histories receive a few or all of the services of a mental health program. With the existence of a coordinated program of metropolitan services it will be possible to know something about how many of those children who did not receive mental health services also did not receive help or assistance from other health services. This kind of resource material can assist the development of more precise testing of specific hypotheses. I am proposing, then, that knowledge about the patterns and organizations of community services not only informs us about the relative effectiveness or ineffectiveness of our total mental health program but this knowledge is also a basis for creating hypotheses about those events or processes in the community which contribute to changes in the utiliza- tion of community services. More definitive interpretations can then be made of alternative responses to the stress of migration and the risk for service usage for specific segments of the migrating population. To the extent that any mental health program has a continuum of services, there is a basis to study more intensively the relationship of the effects of different types of treatment upon various children under stress conditions (Klein and Lindemann, 1961). After we have collected and processed this information what then? The provisions of continuous, coordinated and comprehensive mental health services to a non-mobile elementary school child in an urban area, such as Wilner et al studied, is a definite challenge. After identification of such children, services initially would need to be intensive and remedial with a definite emphasis on programmed instruction rather than psycho- therapeutic services. For the equivalent urban youth who has moved from deteriorated housing to public housing, it is expected that mental health services here in the U.S. would emphasize development of interpersonal skills as well as basic learning skills, Service to this migrant group would be oriented to help the child meet the social demands connected with his new home, and help him to understand the likely increase in community regulations for more self control. Confirmation of such hypotheses re- quires the availability of mental health services that have close liaison with non-mental health services, as well as the administrative structure to create innovative services for a wide spectrum of any local population. Also required is a research program which is equipped and dedicated to take advantage of emerging events. Research and services for mobile persons is an example of the type of work that can contribute to the planning func- tions of mental health programs. Conclusion Research activities which are concerned with understanding the eco- logical relationships between the mental health center, the local population groups, and the social organization of the community can contribute along with other community resources to planning and managing emerging social problems. A community mental health program can function as an additional planning resource to assist communities to clarify objectives and to identify alternative approaches for the solution of problems. The aim, of course, is for each local community to be able to develop optimal services for its uni- que social and health problems (Perloff, 1963). Because of all of the un- knowns in the field of community mental health, a comprehensive community research program is an integral step to help identify problem areas and propose tentative solutions. To the extent that the community mental health center can be an effective resource for developing new knowledge it can also contribute to the planning of specific action programs. This interchange between community research, action programs, and continuous evaluation of current services is viewed as one model for the analysis of social change. Most of us in the United States have been increasingly aware that the longer we live the more changes we are expected to make. Some of us believe that social changes will modify our beliefs, our norms and our aims, Others of us affirm that by anticipating change we can more directly determine the ways in which we choose our values and how we are going to develop our goals. No matter which position we take, our knowledge is sparse. My comments this morning were based upon my conviction that a community mental health program is pivotal for the active, systematic development of a community rather than solely as a passive resource for helping the troubled. If the proposed community mental health center be- come an active component for community planning, there may be less need in the future for a continued accelerated expansion of services. References Downie, N. M. A comparison between children who have moved from school to school with those who have been in continuous residence on various factors of adjustment. Journal of Educational Psychology, 1953, 44, 50-53. Federal Register, May 6, 1964. Community mental health centers act of 1963, Title II, P. L. 88-164. Regulations, 5951-5956. Gardner, E. A,, Miles, H. C., and Bahn, Anita K. All psychiatric ex- perience in a community - a cumulative survey: report of the first year's experience. A,M.A. Archives of General Psychiatry, 1963, J, 369-378. Gardner, E. A,, Miles, H. C., Iker, H. P., and Romano, J. A cumulative register of psychiatric services in a community. American Journal of Public Health and the Nation's Health, 1963, 53, 1269-1277. Gorwitz, K., Bahn,Anita K., Chandler, Caroline A., and Martin, W. A, Planned uses of a statewide psychiatric register for aiding mental health in the community. American Journal of Orthopsychiatry, 1963. 33, 494-500. Harvard Medical School and Psychiatric Service, Massachusetts General Hospital. Community mental health and social psychiatry: a reference guide. Cambridge, Massachusetts: Harvard University Press, 1962. Hollingshead, A. B., and Redlich, F. C. Social class and mental illness. New York: Wiley and Sons, 1958. Kantor, Mildred B. Some consequences of residential and social mobility for the adjustment of children. (In) Kantor, Mildred B. (Ed.) Mobility and Mental Health. Springfield, Ill.: C. C. Thomas, 1965. Kelly, J. G. The mental health agent in the urban community. (In) Duhl,L.J. (Ed.) Urban America and the Planning of Mental Health Services. New York: Group for the Advancement of Psychiatry. 1964 (a). Kelly, J. G. Community mental health services as efficient controls for disruptive behavior. Mimeo., 1964 (b). Klein, D. C., and Lindemann, E. Preventive intervention in individual and family crisis situations. (In) Caplan, G.(Ed.) Prevention of Mental Disorders in Children: Initial Explorations. New York: Basic Books, 1961. Miller, S. M., and Mishler, E. G. Social class, mental illness and American psychiatry. Milbank Memorial Fund Quarterly, 1959, 37, 174-199. Perloff, H. S. Social planning in the metropolis. (In) Duhl, L. J.(Ed.) The urban condition. New York: Basic Books, 1963. Wilner, Daniel M., Walkley, Rosabelle P., Pinkerton, Thomas C., and Tayback, Matthew. The housing environment and family life. Baltimore: The Johns Hopkins Press, 1962. GRADUATE TRAINING IN COMMUNITY MENTAL HEALTH John C, Glidewelll Social Science Institute Washington University Training in community mental health presents a variety of knotty problems for the university and the field training center, Community mental health is sometimes seen as a professional practice based upon a rigorous scientific discipline; it is often defined and discussed in quite impressionistic terms; it has no clear boundaries; it has no body of or- ganized knowledge specifically applicaktle to its problems; it has no professional consensus of good practice amenable to inculcation by a professional school. It includes an incredible variety of roles: consul- tant, group therapist, social diagnostician, counselor, advisor, scientist, researcher, collaborator, social change agent, public health officer, edu- cator, trainer, and, yes, reformer. In spite of its vague boundaries and its diverse functions, I and many others are undertaking to train psycho- logists to function in at least a few of the roles included in this amor- phous field of work. This paper is based upon several sources: ten years of work in re- 3 conversation and search and training in the field? and in the university, conferences with others similarly engaged, and a recent analysis of the of- ferings of universities in the United States. In the autumn of 1964 I had lRobert M. Taylor read this paper at the Symposium. I very much appreciate his willingness to do so. 2At the St. Louis County Health Department, Clayton, Missouri, USA, 3At the Social Science Institute, Washington University, St. Louis, Missouri. 53 54 an opportunity to analyze descriptions of community mental health courses, practica, field training, research, and integrated training programs of most of the universities offering graduate training in psychology in the USA. The analysis was completed just two years after Golann and his as- sociates completed their survey of the content of graduate instruction in community mental health in a sample of fifty-two departments of psychology in the USA (Golann, et al., 1963). They found that, in 1962, twenty per- cent of their sample of psychology departments provide some ''focused atten- tion'" on community mental health, sixty percent provided incidental atten- tion, and twenty percent provided no attention at all. Only one department made available a full program in community mental health. The current analysis indicates little or no increase in attention after two years. In 1964 only about thirty percent of the sample of psycho- logy departments offered what Golann defined as "focused attention' on com- munity mental health. As an incidental but interesting comparison, the 1964 analysis showed that none of the schools of public health in the USA offered any graduate training leading to a speciality in community mental health. Most of the schools of public health offered what Golann would define as "incidental attention." On the other hand, every major university offered an organized research training program for social scientists, supported by the NIMH. The offerings of the psychology departments were analyzed in terms of their objectives, their curricula, their research activities, and their training in professional practice. Objectives and Philosophy The general purpose of graduate training in the sciences and the pro- fessions is to augment the scientific and professional resources available to society and to provide opportunities for the growth and development of promising individuals seeking such opportunities. The specific purposes of graduate training in community mental health are to augment the fund of resources in the psychology applicable to research, practice, education, and training relevant to problems of community mental health, and to provide opportunities for the growth and development of promising scientists and practitioners who are seeking such opportunities. The particular resources which such training seeks to augment can be classified -as people, ideas, and skills. With respect to people, the training is designed to increase the now quite insufficient number of competent psychologists who are engaged in research, practice, and training in community mental health. With respect to ideas, this training provides two sorts of augmentation-- the integration of current ideas and the stimulation of new ideas. Most community mental health training programs are designed to provide an orga- nized body of the current knowledge relevant to specified community mental health problems and they are designed to indicate the gaps and needs for the creation of new knowledge. 56 In all activities--courses, practica, large conferences, small con- ferences, seminars, field work, and consultation activities--an attempt is made to create conditions conducive to the conception, development and communication of new ideas--by established scholars, young scientists, staff, and students. Rogers has proposed that most graduate training in- hibits the development of creativity, and he has stimulated a lively and useful controversy (Rogers, undated mss., Marston, undated mss.). The is- sues raised are especially cogent in community mental health training. With respect to skills, current programs provide training in the methodology and techniques of psychological research, practice, and train- ing. Almost all the experiences available to the trainees involve demon- stration, experimentation, practice, evaluation, and analysis of research methods. In addition to the skills of research methodology, most community mental health training programs give regular attention to the skills of interdisciplinary collaboration and consultation. Community mental health research and practice often must be interdisciplinary--because more dif- ferent ideas and skills are required than one man can ordinarily develop. Under such conditions the members of the various disciplines must learn how to be validly helpful to one another, in the timing, form, and content of suggestions, criticisms, contributions--given and received. Practice and analysis of attempts at interdisciplinary collaboration and consultation are recurrent elements in most programs--for staff, consultants, and conferees, as well as for trainees. Development of interpersonal skills in inter- disciplinary work is often considered to be as important for the professors from the several disciplines as it is for the trainees. Another skill is widely considered to be of crucial importance. Community mental health work often requires the psychologist to establish and maintain special relationships with the working social systems within which he must carry out his work. Entry into the social systems of a com- munity and the building of a series of authentic complimentary and recipro- cal relationships with its citizens requires sensitive and comprehensive skills--in communication, in interpersonal interaction, in the frank and open coping with group emotionality, and in the assessment of the psycho- logist's own motives and methods. The development of such sensitivities and skills is not typically the focus of widespread or continuing practice, analysis, and evaluation. Some universities make use of the laboratory training methods of the National Training Laboratories in the development of these sensitivities and interpersonal skills. Curricula General, Pre-doctoral trainees usually enter specialized training after at least one year of general graduate work. During the first year of graduate work the trainee should have completed the basic study of general psychology. Advanced graduate students often become interested in community mental health after several years of study. Post-doctoral trainees enter at quite varying points in their career. Specialization. Without exception, training centers expect each trainee to design an individual program in conference with his faculty advisor. There is wide variation in the exerted influence of the faculty advisor. The first requirements for pre-doctoral trainees are those re- quirements established for all psychologists - - usually in the areas of clinical, social, educational, or counseling psychology. These require- ments are set in an attempt to insure a high level of scholarship in both the special field and the’particular application--community mental health. When the courses are relevant to the trainee's program provisions are usu- ally made for trainees to audit or undertake certain courses in the School of Medicine (for example, epidemiology), the School of Social Work (for example, community organization), the Graduate School of Nursing (for example, therapeutic hospital social milieu), and other Schools of the Uni- versity. Post-doctoral trainees ordinarily audit some courses, but more often participate in research activities especially relevant to the particular substantive knowledge and research skills they seek to develop more fully. Typically, faculty are used as consultants to these post-doctoral trainees. Supervision. There is considerable variation in types of super- vision, but one traditional component is quite constant. Each trainee re- quests from the faculty of his department a major professor to chair his graduate committee and supervise his graduate training. Typically, this supervision varies widely in its style, its intimacy, and its demands, but 59 it is clearly the most salient supervisory relationship the student ex- periences, Integration. In addition to other course work, most programs in- clude a seminar on problems of community mental health. The general pur- poses of such seminars are orientation, clarification, integration, and evaluation of the concepts, data, and interdisciplinary methods employed in community mental health. Theory, research, and current practices from the several disciplines are reviewed. Almost universally the seminar method is used to provide students and staff an opportunity to present their current research plans and problems for review. Occasionally, in some programs visitors are invited to present papers and to participate in the seminar and in university colloquia. Again, particular attention is given to problems of communication, consultation, and collaboration among the several disciplines--both with and without much success in the develop- ment of both individual creativity and interpersonal skills. Professional Practice Application. Theory, method, and empirical knowledge are applied in most centers by participation in some form of clinical work and in some form of field work. Field work typically involves group and individ- ual assignments in community agencies, service projects, or research pro- jects. Examples of such projects include: comparative general studies of communities; community contact and communication patterns; role rela- tionships between the community psychologist and schools, churches, hospitals, health and welfare agencies; correlates of variations in at- titudes toward mental illness and toward mental health resources. In field work projects special attention is given to practicing a variety of research and service methods and to predicting and assessing community re- actions to the research and service activities. Mental health consulta- tion has become a most popular form of professional practice in the field of community mental health. When combined with clinical training, com- munity mental health practices are included as a sub-specialty. It has been the psychologists in the clinical specialty who have most typically become involved in community mental health. In the last several years, however, social psychologists, educational.psychologists, industrial psycho- logists, and school psychologists have become more involved. Scientific and Professional Orientation. From time to time, in all universities, trainees are asked to attend and participate in special conferences involving professional and scientific discussion of current mental health research and service problems. Such conferences provide an opportunity for participant-observation of points of functional contact among psychiatrists, psychologists, social workers, nurses, and social scientists =-- dealing with clinical, educational, consultation and re- search problems in community mental health. Examples of such conferences include: psychiatric grand rounds, psychology colloquium, medical psychology staff conferences, case conferences in public schools, health department case conferences, hospital rounds, mental hospital case conferences, and staff training conferences. Research Activities Independent Research Each trainee plans and executes his doctoral dissertation, an independent research project of his own design. The project involves research on a theoretical problem of psychological science having relevance and applica- tion to a problem of community mental health. The major portion of the last year of training is devoted to the design and execution of the individual doctoral research project. Such research generally falls into the following areas: Illness, Deviancy and the Role of the Patient. A most compelling issue in both practice and research has been the question of the applica- bility of the medical model of illness to the field of mental illness and health. Many stimulating research projects are being carried out to: distinguish, if possible, non-conformity from mental illness; to identify the social interaction dimensions of "adjustment' of school children; to further analyze cross-cultural comparisons of symptoms of mental illness; to distinguish the popular conceptions of mental illness in different social classes, different ethnic and racial groups, and in different age groups. Resource Utilization. From the standpoint of professional practice, the social stigma of psychiatric treatment is still a significant problem, and the stigma is assumed to be a barrier to the person needing treatment. From the standpoint of social psychology the dynamics of patient-practitioner community relations is only partly a matter of stigma and social norms; it is also a matter of the nature of the practitioner-patient interaction and its social-emotional reciprocity. These issues are under investiga- tion in a number of training courses. Socialization. Perhaps the oldest interest of preventive mental health activities is the impact of child rearing practices on the mental health of the child and subsequently the adult. Some research relating to this problem is underway in nearly all the universities offering training in community mental health. The school as a socializing agent is almost as popular a focus as the family. Again some research on social structure and socialization in the classroom and school is being attempted in nearly every training pro- gram. Early Detection. On the assumption (as yet unsubstantiated by science) that early diagnosis facilitates the effectiveness of treatment, many investigators and students are engaged in testing the effectiveness of a variety of screening techniques for neonates, kindergarten, and elemen- tary school children. Screening for adults is receiving very little atten- tion. Epidemiology. It has been rather difficult to apply the tradi- tional methods of the epidemiology of communicable diseases to mental ill- ness, but almost all university faculty and students are engaged in some attempt to analyze the appearance and course of mental illness in defined 63 populations, communities, and their sub-strata. Professional and Scientific Opportunities There is a regular increasing demand for psychologists trained in community mental health. Not only in the traditional university position, but also, in federal, state, and local mental health agencies, in volun- tary national agencies, in private business and industry, in labor organiza- tion, and in other health, education, and welfare agencies. The growing demand is due to accelerate -- or even explode -- as the new program of con- struction of community mental health centers gets underway. Summary Organized training programs in -- or even with focussed attention on - - community mental health are now offered by about one-fourth of the uni- versity training centers in the United States. The education and training which is offered does have some common elements. A general attempt is made to integrate psychological knowledge and to focus the body of knowledge on problems of community mental health. In a variety of forms an educational climate conducive to the development of creativity in students (and faculty) is attempted. Special emphasis is given to the development of interpersonal skills needed to work collaboratively with other disciplines. Special attention is also given to the process of intervention by psycho- logists in on-going communities and the consequences of such interventions. The research interests of the staff and students are most frequently re- 64 lated to concepts of mental health and illness, the role of the mental patient and former mental patient in the community, the interpersonal and social organizational factors influencing the use of community mental health resources, the socializational process in the family and in the schools, epidemiology and the problems of early detection of mental ill- ness in children. There is a regularly increasing demand for psycho- logists trained in theory, research, and practice in community mental health, and the demand is expected to accelerate within the next two years. Selected Bibliography Bindman, A. J. Mental health consultation: theory and practice. Journal of Consulting Psychology, 1959, 23, 473-482. Caplan, G. Principles of preventive psychiatry. New York: Basic Books, Inc., 1964. Clark, J. V. Education for the use of behavioral science. Los Angeles: Institute of Industrial Relations, UCLA, 1962, Cook, S. W. Beyond law and ethics: a proposal for collaboration in psychological practice. American Psychologist, 1947, 12, 267-272. Education for research in psychology. (Report of a seminar group spon- sored by the Education and Training Board of the APA,) American Psychologist, 1959, 14, 167-179. Harvard Medical School and Psychiatric Service, Massachusetts General Hospital. Community mental health and social psychiatry. Cambridge, Massachusetts: Harvard University Press, 1962. Golann, S., E. and Wurm, Carolyn Ann. Community mental health content in the graduate programs of instruction and research among departments of psychology. Paper read at American Psychological Association, Philadelphia, Pennsylvania, 1963. 65 Iscoe, L. The final report of the Joint Commission on Mental Health and Illness: implication for clinical psychology. Journal of Clinical Psychology, 1962, 18, 110. Joint Commission on Mental Illness and Health. Action for mental health. New York: Basic Books, Inc., 1961. Libo, L. M. and Griffith, C. R. The initiation of mental health consulta- tion in communities lacking psychiatric facilities. The New Mexico Project. Paper read at Western Division of American Psychiatric Association, Salt Lake City, September 1961. Marston, A. R. A reply to Roger's statement concerning graduate education in psychology. Mimeographed paper available from the author at the University of Wisconsin, undated. Rogers, C. R., Ph.D. Graduate education in psychology: a passionate state- ment. Mimeographed paper available from the author at Western Behavioral Sciences Institute, La Jolla, California, undated. Rossi, A. M., Klein, D. C., von Felsinger, J. M. and Plaut, T. F. A. A survey of psychologists in community mental health: activities and opinions on education needs. Psychological Monographs, 1961, 74, No. 4, whole No. 508. Shellow, R. S. and Newbrough, J. R. Working with the juvenile police- a possible role for the psychologist in community mental health. Paper read at the Seventh Interamerican Congress of Psychology, Mexico City, December, 1961. DISCUSSANT'S COMMENTS Symposium on Community Mental Health: Individual Adjustment or Social Planning? Rene Gonzales! Pan American Sanitary Bureau The papers presented here today are, I feel, very relevant to the situation which exists in some of the Latin American countries. On many occasions, it has been stated that developing countries are in a favourable position to introduce new programs on mental health, mainly since very little has yet been done in this specific field, with the con- sequent result that few changes, if any, are necessary. In addition, develop- ing countries can benefit substantially from the experience gained by those more advanced, and thus avoid repetition of similar mistakes. In Latin America, in essence, this statement is partially correct. The facilities existing are still very few, and in consequence, only a small section of the population can be served. By tradition, mental treatment is still centered around the mental hospital, and in general, physicians, nurses and public health workers continue to think that mental hygiene is limited to the old classical psychiatric hospital. LThe opinions expressed here are those of the author and do not reflect the opinions nor the policies of the Pan American Sanitary Bureau. 67 68 For these reasons, I think it is necessary to start educating people at all levels on the new concept of mental hygiene, especially at the Universities and Ministries of Health. It is not only a matter of enlighten- ing those people in this new concept, but also to promote among them a change in their attitudes towards mental patients. When communicable diseases are a big problem, infant mortality rates are high and overwhelming problems of sanitation and housing and education exist, it is a difficult task to convince Governments of the vital and urgent necessity for mental health programs. Naturally, survival must have first priority; on the other hand, we have to bear in mind, and remind ad- ministrators that, it is essential to start working towards a better mental health for the community without delay, and not wait for the eradication of all communicable diseases, nor the complete solution of all other health problems. Neglecting mental health is a mistake as serious as neglecting physical health, especially in the young, and it is important to note that among the Latin American countries, 507% of the population is under the age of 20. To start any action for the mental health of the community, it is neces- sary that this community really exists -- I mean as a living organism. This is not always the case. In the United States, it would seem to me that "belonging" to a community is a feeling which is deeply rooted in the souls of the citizens -- something acquired prior to school years, when the pro- cess of a child's character becoming social minded is so active. 69 At the risk of making a generalization, I question whether these feelings and attitudes exist in Latin America, or if they do, perhaps to a very minor degree. The causes of this situation are numerous and complex, and there ap- pears to be no single explanation for it. It has been stated that one of the causes is the system of government; governments are very centralized and so is administration. Almost all the action for the common welfare of the community is taken by‘ the government, thus destroying, or at least hindering any private initiative. Only when there is a strong emotional component like in the case of Polio or TB one can observe movements centered around the community. In the peripherical slums -- 'villas miseria", '"favelas'" -- of the big cities in which the socioeconomic conditions are very peculiar, we can see the development of groups with some special features and we can say that in a sense they are communities, but of a very special kind and of course very different from those in the United States. Latin American countries, I feel confident, can benefit from the experience of other countries operating community mental health programs, but when we are planning for mental health services for our communities, we must be careful to take into account the cultural differences and the deep social changes taking place today, in addition to our limited resources. Newbrough mentioned the main activities which constitute a community mental health program. In developing countries, however, our first priorities 70 are, of course, the training of professionals and the education of the public. Shortage of skilled workers in this field also presents a con- siderable problem. In regard to Simmons' presentation I want to make an observation re- garding primary prevention. In those countries where communicable diseases are very frequent and infant mortality and morbidity rates are very high, one way of making effective primary prevention is by improving the maternal and child health services. This will eventually produce a decrease in the rate of brain damage. In some places illegitimacy is a serious problem; mothers are very young and emotionally immature, unfitted for motherhood. The child is frequently exposed to psychological deprivation from the mother and total deprivation from the father, for he usually abandons the mother. If we could correct this situation, we would be making primary pre- vention, but unfortunately, it is not an easy task. We could look for legal procedures, but that is not all, it will be necessary to accomplish a change in the social structure, and this 1s far beyond the limits of our pro- fession. The program of emotional check-ups in the pre-school age (as presented by Simmons) I fully support, and I am wondering how this idea could be adapted in our countries. Should we risk to do something similar covering a substantial part of the population, no doubt this would have to be carried out following the echelon scheme. Unfortunately personnel available is in- 71 sufficient to provide the same services as those rendered at the Human Relations Service of Wellesley, but I think that, working with public health and school nurses (provided the necessary training could be given) it might be possible to equip schools with an acceptable preventive service. I do not believe that in our countries psychiatrists and psychologists alone can cover the whole population in the fields of care and prevention, but I feel that a substantial part of their time should be devoted to con- sultation. In this way, it would be possible to reach, indirectly, most of the population. Mauricio Knobel Universidad Nacional de La Plata, Argentina Although I was invited to discuss the papers of this Symposium I have unfortunately received only the papers of Newbrough and Simmons.* I will therefore limit my comments to these papers and will in addition ex- press some of my own ideas on this subject. With reference to Simmons' paper I was impressed by the description of a technique for primary pre- vention at the preschool level. This seems to me to be a very positive approach which could be utilized in our own sociocultural environment. This technique should be studied further, expanded and repeated in order to be able to establish its applicability. I have great doubts about the second part of the paper because it seems to me to be excessively optimistic and to deny the very important experiences of the first years of *Ed. Note. These comments were revised slightly following the Symposium, Dr. Knobel added a brief discussion of the papers by Kelly and by Glidewell near the end of his remarks. 72 life, particularly the basic experiences in the first months of life, and the effect of these over the personality in general and mental ill- ness in particular, I see this type of secondary prevention as something precarious and perhaps even dangerous because the formula which the author offers "live happy with your neurosis'' means in reality passive compliance and not a struggle for health. It brings to mind the joke about the enuretic who is pleased with his psychoanalysis for now he knows why he is an enuretic and doesn't worry about it. This is an area which should be very carefully evaluated because many of the techniques which are proposed in mental health especially those which have apparent easy applica- tion or are brief and therefore very superficial, are techniques which can make people sick instead of being preventive or curative. With this in mind I asked myself whether with such techniques in which we are looking for individual adaptation we are doing nothing more than creating false adapta- tions to established situations, true submissiveness to a social status; it is thus a pathological conditioning that in the final analysis only per- petuates illnesses. Returning to the first paper which sets the tone for this symposium I must admit that its reading has stimulated many questions and verified many of the uncertainties that are to be found when considering mental health as a movement or as a discipline. To Newbrough's systematization of the meanings or uses of the term mental health I would include a psychodynamic interpretation where we could consider mental health as a dynamic and structural result of the psychic nsdn prt ben AEA apparatus in good functioning. Following a Freudian point of view, when the instinctual drives seeking satisfactions meet the external reality that the environment of- fers, adjusting to it without severe conflicts, being able to postpone and to adapt the internal urges to the possibilities of an adequate social interaction, we could say that the psychic structures are functioning in a healthy balance between the classic pleasure principle and reality principle. It is important to point out that the progress of technified psycho- logy and the contribution of sociologists to psychology have in one way tended to move psychology away from dynamic psycho-analytic psychology and has in another way attempted to adapt to the supposed scientific psychology a deep dynamic content. It would seem that psychologists would like to hide the intrepid mother that they have in psychoanalysis even though their efforts show how much they would like to imitate her creative capacity, drive and exorbitant courage. Unquestionably mental health for society as well as for the in- dividual is an ideal. It 1s something to be wished for but if it has not been accomplished the pursuit should not be abandoned. The struggle to get it should not be stopped. We should not forget that society itself is a gestalt and that the total is more than the sum of the parts. The parts, i.e. the individuals, give to the total special characteristics which trans- 74 mit not only the structural and dynamic elements but also pathological traits. The excellent history of evolution that Newbrough presents to us places us in the psycho-social-biological criteria without our having to think that this is only an acquisition of ‘the contemporary psychologist, because this reality has previously been postulated. It is important to note that what we are seeing at the present time is the permeating in- fluence of sociological thought upon thinking in psychology and psychiatry. A proof of this was the recent convocation of the First World Congress of Social Psychiatry in London and the creation of the new International Society of Social Psychiatry where our SIP President, Professor C. A. Seguin and I are acting as members of its Executive Committee. There is a universal understanding of the necessity to intensify social studies in relationship to individual and collective psychology particularly with respect to mental health. Many times this influence from sociology as a technique of study and as a discipline confuses and distorts the clinical reality and it is in the final analysis the clinical reality within which we have to act. The overemphasis on the statistically significant forces us to rigorous plan- ning in methodology, but in actual practice this does not produce results which are very useful in dealing with human feelings and practical situations. Science 1s not the management of numbers alone. The greatest contributions of indisputable significance and scientific content have been made in the history of humanity without the pseudo-rigorousness of some sociologists; their psychosocial derivatives are now the object and theme of study of certain sociologists who have material for a long time to come in at- tempting to explain real phenomena thereby found. It is very important to return to clinical psychology and to the human being in his environ- ment and to integrate the knowledge and techniques for study. Social psychology cannot be an appendage to sociology. It must apply to clinical focus and to biophysiologic and classical experimentation in order to place itself where it can be useful to everyone. With respect to Newbrough's point that mental illness is to be seen as a social and national problem as well as a problem of health in general, I believe that the majority of papers published in this area con- firm this statement and I would add that both approaches have recourse to the same type of mechanism of defense, namely, projection and displacement outwards of what internally cannot be endured. We do not want to recognize the autodestructive capacity that a human being has and we want to see that everything that happens to an individual is a collective result of the community; we would not accept his capacity to generate his own destruction. From the social problem point of view, the monetary cost of illness has been emphasized; the economic means which are proposed carry with them a focus about the significance of deviation and conformity. But, as I said about Simmons' paper, a distinction between adaptation and submission is not made. I would like to emphasize that I consider it very important to be clear about what we understand as mental health. I believe that we can- not accept passive compliance (submissiveness)and that we must strive for 76 an active adaptation; that means struggle, which implies environmental modifications, progress and changes of norms and structures. Simple pas- sive acceptance of the external reality means a halting, a sick weakness, and destruction of the possibility of creativity which when well utilized will enable man to struggle against the destructive tendencies of the human specie. It is, I believe, true and quite lamentable that the majority of foci of mental health work is directed to a fight against mental illness. This deviates from the true preventive aspect that they should have if they would return to looking for medico-biological causes where the funda- mental purpose of hygiene is to prevent and not to treat. In addition, when trying to segregate or eliminate what could be considered bad or pernicious (e.g. the techniques against delinquency, drug addiction, prosti- tution, etc.) the collective knowledge emerging from sociological studies has been utilized. What actually has not been done is to follow the medical criteria of repair. Society functions more or less like the individual and we can com- pare individual psychic structure with social organization. Following what we might call a cellular model we may say that the individual and society as well are formed by nuclei which are the end result of inherited objects and objects obtained by means of adequate or faulty identifications with parts of an external reality. Some mental patients disassociate these internal nuclei putting all the bad objects in one side, generally projecting them in the outer-world, and the apparently good ones in another place within themselves or outside, worshipping society which they consider to be so valuable, This is what happens with using sociologic means of identify- ing "bad" or "pernicious" organs of society such as the above mentioned; a punishing, restraining approach or law appears as a ''solution." The problem apparently is divided and separated because of the fact that in reality the just mentioned mechanism of schizoid disassocia- tion is utilized with the result that all the disassociated nuclei continue to exist apparently encapsulated and isolated but just as active as the obsessive or psychotic nuclei within a sick individual who continues to function with increasing deterioration of his personality. Society itself maintains the disassociation and does not try to eliminate it (Jacques, 1957; Knobel, 1964; Knobel, Cortada de Cohan, and Marin de Rollas, 1962). Society tries to maintain it in order to avoid the anxiety of the collective psychosis which could emerge in the face of the total realization of its destructive and pernicious content. The similar point was made in Newbrough's reference to Erikson, that society maintains its identity through this mechanism and therefore no solution is possible. What is attempted is to only change the facade, to waste time in superficial management and to increase compliance and the pseudo-maniac happiness of submittance to a tremendously cruel and restrictive super ego that is perpetuated with in- creasing intensity in our culture (Garma, 1964). The comparison that Newbrough makes between the utilization of the biological-medical and social system seems inadequate because he is assuming a narrow and easily predictable set of variables which to my understanding is not correct. Biochemistry currently does not allow us to say that we have to cut off the hand or the head to produce a biological variable be- cause we know that a minimal lateral variation in arrangement of a bio- chemical nucleus is capable of modifying human behavior in many unpre- dictable ways as has been demonstrated in the study of psychotropic drugs. Furthermore I believe that one of our mistakes is perhaps to place our- selves in the same rigid mechanistic and rational schema (proof of our capacity of passive compliance) and yet we cannot allow ourselves to ac- cept that perhaps the psychic matter and the social matter that derive from it, are of a different nature and structure than the matter we are accustomed to managing in our present biological and economic conception of the world. If we could accept these new ways of looking on and valuing phenomena, then, as Newbrough wants, we might begin to identify, describe and classify the social units with which we have to deal. This conception brings us definitely closer to the ecological model proposed by the author. To study the psychology of individual differences applied to a social group we will have to put ourselves at this level of integration of the biological and cultural levels which, to my knowledge, is a new structure with its own modalities and not merely the sum of its parts (i.e. situations). The individual lives in society and if, as I previously said, society is the result of the action of individuals it also imposes on them the neces- 79 | sary obligations for certain common development which is established ac- cording to more or less rigid norms, the breaking of which is always con- ceived as dangerous and obediance to which permits one to exist within a schema of predetermined solutions which are not necessarily always convenient. I agree that there is an interdependency between the society and the individual that determines the cultural patterns of society and brings about the in- ternalization of these patterns in the individual whose superego is formed by the projections, introjections and primary identifications which begin to build it up very early in life (Klein, 1954). It happens similarly within society which begins by demanding a strong instinctive renunciation from its members and contains determining norms of life which vary not only within each society but also in different social classes within one particular society (Murray and Kluckhohn, 1956). The attitudes, so determined and well organized, give shape to what can be called social attitudes or subjective psychophysiological responses to social norms. These would be institutiona- lized aspects of the culture which respond to the basic requirements of in- dividual organisms that make up the social organs that integrate and con- figurate it as a society (Knobel, Cortada de Cohan, and Marin de Rolla, 1962). In the face of this the patient is an expression of a deviant conduct (Parsons, 1956), which is thus a social alteration. The patient responds to individual situations as well as the determinants of society and its norms (Hinkle, 1961). Social dynamics establish human relations with special characteristics and when in the individual, social demands forbid a correct channeling of its basic needs, illness emerges as a neurotic defense or it 80 leads directly to death. After reading the papers presented by Glidewell and Kelly, I would like to make a few comments in addition to the remarks made about the papers I have already analyzed. In regard to Glidewell's presentation I can only express my envy for such a wonderful on-going program in the United States of North America, where organized training programs are on their way in about "one fourth of the university training centers." In our part of the world, psychologists work mainly in the realms of psychodiagnosis and psychotherapy and it is not easy, indeed, to convey the needs, techniques, skills, methodology and basic knowledge necessary for working in the area of mental health. Furthermore, psychiatrists are still the resource professionals for official positions in mental health agencies and we can witness a sort of confusion between mental health and preventive psychiatry, with the ac- companying disputes about qualifications for playing corresponding roles. National or State agencies, private business organizations and other private institutions hesitate to hire psychologists. The whole concept of mental health is yet to be developed. We do not have a demand for trained psycho- logists in this matter and psychologists do not seem to be willing to be trained in mental health. It is my feeling that Glidewell's excellent presentation should be widely distributed among Latin-American countries. My desire would also be 81 that a transcultural program could be developed, in order to have leading community people and organizations better acquainted with the scope, pur- poses and possibilities of community mental health. Kelly's paper awakens the same type of ideas. It is certainly a great achievement for the United States to have passed a law with the characteristics so well analyzed by Kelly. His correlating the three basic principles of the law with possible research activities is certainly helpful in planning broader applications of the results achieved through the practice of the already available resources. I would like to consider one idea that is now coming to my mind. It would seem that action programs derived from these studies will come out as purposeful projects and solutions for a local community mental health center to use. However, I think that Kelly's conclusions can be broadened to a more extensive and wider program, where the American Continent can be con- sidered as a vast community and where transcultural studies might help in- tegrating all the findings into general programs for mental health develop- ment, There is an unbalanced mental health condition in the Americas and our communities are not in a very good shape in regard to mental health facilities. A great contribution to the future of our people can be made through an increase of knowledge on the subject considered in this Symposium. It is necessary to integrate and create a new focus in mental health in the community. Perhaps we should revise all these mental health problems in accordance with all the issues analyzed in this Symposium. I would pro- pose that one word in the Symposium title be modified to state "Individual Adaptation and Social Planning;" I do not believe that this is disjunctive. I believe that we must come from different viewpoints to converge on a common ideal which is the well-being of the individual within the framework of society; a society more receptive and permissive for the development of the community. References Garma, A. y E. Reacciones maniacas: alegria masoquista del yo, por el triunfo, mediante engagnos, del superyvo. Comunicacion al Primer Congreso Interno y IX Symposium de la Asociacion Psicoanalitica Argentina, Buenos Aires. Hinkle, L. S. Ecological observations of the relation of physical illness, and the social environment. Psychosomatic Medicine, 1961, 23, 289. Jacques, E. Social systems as defense against persecutory and depressive anxiety, in New Directions in Psycho-Analysis, M. Klein, P. Heimann and R. E. Money-Kyrle, (Eds.) New York: Basic Books, 1957. Klein, M. The psychoanalysis of children. Ebadon: The Hogarth Press, 1954. Knobel, M. Child psychiatry social action in underdeveloped countries. Acta Paedopsychiatrica, 1964, 31, 19. Knobel, M., Cortada de Cohan, N. y Marin de Rolla, J. Patrones sociales y enfermedades venereas. Acta Psiquiatrica y Psicologica Argentina (present name Acta Psiquiatrica y Psicologica de America Latina), 1962, 8, 305. Murray, H. A, & Kluckhohn, C. Outline of a conception of personality, (In) Kluckhohn, C., Murray, H. A. and Schneider, D. (Eds.) Personality in nature, society, and culture. New York: Alfred A. Knopf, 1956. Parsons, T. Illness and the role of the physician: a sociological perspective (In) Kluckhohn,C., Murray, H. A. and Schneider, D. (Eds.) Personality in Nature, Society and Culture. New York: Alfred A. Knopf, 1956. * U.S. GOVERNMENT PRINTING OFFICE : 1966 0—224-008 Public Health Service Publication No. 1504 BERKELEY LIBRARIES co0294198k7