PUBLIC
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NATIONAL CLEARINGHOUSE FOR MENTAL HEALTH INFORMATION
COMMUNITY
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Individual Adjustment
or Social Planning
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PUBLIC HEALTH
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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
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PUBLIC
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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
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