The Outlook for Mental Health Services
by Seward Hiltner
This article appeared in The Christian Century, October 29, 1975 pp. 965-970Copyright by The Christian Century Foundation; used by permission. Current articles and subscription information can be found at www.christiancentury.org. This material was prepared for Religion Online by Ted and Winnie Brock.
News being what it is, even a conscientious reader of the New York Times can get only scraps of information about the state of mental health services today. Such a reader would know, for instance, that already there have been some judicial decisions requiring mental hospitals to give treatment, and not just custodial care, to all patients -- and that others are likely to follow. While seeing the potential value in such decisions, the reader would not have to be a cynic -- realism would suffice -- to wonder whether the results might be a mere shuffling of labels; unless sufficient additional personnel and funds were made available, "treatment" would be no more than a euphemism. One who reads fine print would have learned that various levels of government have cut training funds for mental health workers. But all the news stories together would not go far in illuminating the situation.
In attempting here a broad-scale analysis, I am assuming that mental health services are a concern of the churches and churchpeople, over and above any special interest we may have in religious ministry to patients or clients.
Voices of Conscience
It was not until the 1920s and ‘30s that mental hospitals in the U.S., even expensive private ones, offered differential diagnosis and treatment based, at least in part, on scientific understandings. Until this century most such institutions were called insane asylums. As Albert Deutsch showed in his monumental history of care of the mentally ill, some 19th century institutions did provide humane care, as well as general medical and surgical treatment for patients who needed it. Dorothea Dix was the "voice of conscience" of that century. By influencing state legislatures and citizens alike, she did much to advance the humane quality of care. But, as Deutsch notes, the figures she gave as to the number of people who got well were thoroughly overstated, not through bad intent but as a consequence of that period’s poor statistical methods. Diagnoses were made on the basis of symptoms, and persons with a certain cluster of symptoms were given a label in the conviction that a particular cause might be found for that "disease."
Such diagnostic thinking was spurred, early in this century, when paresis (or general paralysis, as it was called) was found to be a late-flowering -- usually after ten years or so -- result of syphilitic infection. Until Paul Ehrlich’s discoveries, however, syphilis could not be treated effectively; indeed, not until the development of penicillin could such treatment be carried out easily and safely. There is little paresis today because its syphilitic origin is usually treated successfully in early stages. So the discovery of the bacteriological cause of paresis brought few cures; more often it only reinforced the hope that specific cures (or diagnoses inviting means for cure) could be found for the other "diseases." Today only a few psychiatrists believe that most mental illnesses are disease entities in the sense that pneumonia, scarlet fever or even cancer is.
After Dorothea Dix, the next "voice of conscience" was Clifford Beers. Following a spontaneous recovery from a severe illness for which he had been hospitalized, he founded the Connecticut Society for Mental Hygiene in 1907, and a year later, with the help of psychiatrists and others, the National Committee for Mental Hygiene. Like Dix, his concern was to ameliorate the conditions of the hospitalized mentally ill, but he also wanted to foster prevention of and education about mental illness. His organizational legacy is the National Association for Mental Health and many state and local associations. These groups were very much under psychiatrists’ thumbs until after World War II. Since then they have become lay movements, with the professional concerns left to psychiatrists and their colleagues.
From World War II until the late 1960s, no voice raised on behalf of mental patients was more audible and respected than that of William C. Menninger, who talked to at least as many state legislatures as did Dorothea Dix in the previous century. As a result of his efforts, along with those of the mental health societies (the change from "hygiene" to ‘health" came in the 1940s) and many other groups, including the professionals, it is safe to say that most mental hospitals are better now than they were a generation ago.
Yet we must be cautious. Every step forward has usually been followed, sooner rather than later, by at least a half-step backward. Some of the reasons for the retrogressions are obvious. For instance, state mental hospitals improved greatly in Illinois when Adlai Stevenson was governor. However, his successor’s policies in regard to state hospitals prompted many of the best hospital personnel to leave the state as though it were plague-infested. Illinois eventually made a comeback, but it took years.
About 1950, the state of Kansas asked the Menninger Foundation to help improve its hospitals. William and Karl Menninger had more than knowledge alone; they had enthusiasm and leadership, and they attracted able young professionals for training. Seemingly miraculous recoveries were brought about. Some persons who for many years had been in back wards, out of contact with people, responded to the treatment and got well enough to live outside.
At the Topeka State Hospital alone, the number of resident patients in their 60s was reduced from about 600 to less than 50 in only 20 years. The total population was cut in half (possibly more), a phenomenon that has occurred in many good hospitals. But legislators and sometimes governors were accustomed to give money according to the number of resident patients per day. As resident populations declined, these officials thought hospital budgets could be cut (and they often have been). This attitude, of course, overlooks the fact that the improvement and the higher discharge rates have been possible only by means of more and better personnel and equipment, with the result that the cost per patient per day inevitably increased. This basic misunderstanding still plagues every tax-supported hospital in some fashion.
Especially vulnerable to cutting are funds for training and education. The reasoning here is particularly strange when applied to psychiatric residents, for they, like interns and resident physicians in general hospitals, contribute important service while advancing their education. Yet state legislatures seesaw as to whether these residents are liabilities or assets, as they do in regard to allocating training funds for psychologists, social workers and others, including clergy trainees. Equally threatening to good hospital care and treatment is a similar attitude about the importance of training nonprofessional or paramedical personnel.
In mental hospitals as in general hospitals, intelligent treatment of patients is always better where education and research are going on. Funds for research ride the same roller coaster as do those for training. For some years federal funds were on the rise, but they have been declining over the past five or six years.
Another anomaly appeared in mental hospitals with the advent of drugs, especially the types that reduce anxieties and make patients more manageable. Wisely and sparingly used, such drugs can open patients to various forms of therapy. With wholesale usage, they may extinguish that spark of suffering or uneasiness without which a patient will not seek change. Used by themselves alone, with no supporting therapies, they simply ease the burden for personnel by making patients more tractable. There is aggressive cruelty only on occasion in modern mental hospitals, but relatively indiscriminate drugging is a passive concentration-camp approach of a sort, in fact if not in intention. This condition is all the more tragic because professional personnel, who know better and would like to do more, are likely to be without enough time and assistance to undertake positive therapies.
Community Centers: Creative Adjuncts
During John F. Kennedy’s administration, and with his strong sponsorship, a bill was passed to make possible the creation of community mental health centers. Had the original plans been followed, there would have been about 1,500 such centers by 1970. The actual number by that date was probably not much more than a third of that total; furthermore, despite the good that existing centers have done and are doing, the plan’s most imaginative features -- those that would bring such centers into close contact with schools, churches, the police, and other responsible community organizations -- are the ones that have been least realized.
The centers were designed for several purposes: to admit emergency patients and help them for a brief period, discharging them if improved and sending them to hospitals if extended care was called for; to provide out-patient treatment to individuals and families; to serve as a coordinating or focal channel for many kinds of problems, referring clients to other agencies when indicated; and above all to take mental health services into the community more and more.
These centers were to be encouraged in connection with any kind of reputable auspices: a general hospital or medical center, a private hospital, a clinic, a social-work agency and the like. They could also arise indigenously under their own auspices if stability of the founding group could be established. In practice, well-established institutions have generally been the sponsors. Ghetto groups have almost never been able to demonstrate enough stability to be granted funds. Although ghetto and other poor people are being served by many centers (one condition is that they must give help to anyone within a certain geographic area), minority groups in particular have often viewed such services as being offered by an alien "university whitey" who, in their opinion, fails to consult them about the kinds of services they need.
Even in the centers that have given valuable service, and often in ways the mental hospitals have rarely tried, there has been a two-step temptation, yielded to at times: first toward disillusionment when the early vision of doing so well that mental hospitals would no longer be needed has had to be qualified by the complex and sometimes stubborn resistance of mental illness; then, after disillusionment, sometimes a reversion to old patterns. Church history is of course full of just such idealistic new starts and, not infrequently, some degree of disillusionment followed by routine performance without much zest or imagination.
What has suffered most is the opportunity to bring mental health services into the community. Whatever the provocation, it becomes a tragedy when the very institutions designed to rectify the errors of the mental hospital system move into the kind of business-as-usual attitude originally thought to be the worst aspect of mental hospitals. By no means is it true that all -- or even most -- centers have gone in this direction; but all have been tempted, and some have fallen.
It is difficult to escape the conclusion that some people who went into the community mental health centers had a kind of elitist motivation; that is, the conviction that theirs would have "open" organization over against the "closed" organization of the hospitals, and hence that they would ride mental health’s "white horses," dealing with the "interesting" people at early stages while Dr. Whocares could work in hospitals with the derelicts who had not been fortunate enough to find a center early in their illness. Of course, the fact is that, in mental health as in religion and other areas of institutional life, no horse stays white very long.
The Lure of Private Practice
In my opinion, a mental hospital, if it has good leadership and morale and a reasonable assurance of its economic base, is capable not only of providing excellent diagnosis and treatment for its resident patients but also of performing a variety of services that bring it close to its community. And a community mental health center, given the same conditions, is capable of performing valuable functions largely for a different segment of the population and probably at less cost. The two types of institutions, with relatively ideal conditions, should complement each other and not be competitive.
But how can the conditions of leadership, high morale and a reasonable economic base be secured? On that score the image of the roller coaster is scarcely an exaggeration in describing what every such hospital or center has to confront these days. Good administrators and professional people can be driven out not solely because their salaries are lower than they can command elsewhere but also because they may be deprived of the challenge of teaching students and/or doing some research. Nonprofessional personnel may either leave or perform perfunctorily on the job if their leadership seems to have lost hope and zest or if in-service training programs are not available to increase their understanding and convince them that they genuinely are partners with professional persons committed to using every available resource.
For psychiatrists who are competent (or who can convince potential patients of their competence), private practice has been a more lucrative alternative to hospital or center work ever since the public accepted psychiatrists as experts on the problems of living rather than merely on psychoses. Since World War II clinical psychologists increasingly have had a similar option. Still more recently, social workers and marriage and family counselors have sometimes developed private practices. Until very recently, competent people found that entering private practice was not difficult except during the early period in which they are developing a reputation. The kinds of people served by such private practitioners are, rather clearly, those above the midsection of the economic middle. All such reputable helpers I know -- especially the psychiatrists -- do give service to people at lower rates, in many instances working part-time in a clinic or hospital for less than they would receive in private practice.
These professional persons who earn their living in private practice for the most part do not charge improper fees -- even if a 50-minute hour costs $40. It should be remembered that a good surgeon may earn $200, or even $500, in an hour, and physicians in some specialties may see as many as four to six patients in the space of an hour. Moreover, conducting a competent private practice is not easy; increasingly, there seems to be the possibility of malpractice suits for which even physicians have a hard time making provision. For the other helping professions, such protection is even more difficult to obtain.
The obvious lure that takes competent mental health professionals away from hospitals and centers is money; and if the professional can tolerate the process of finding an accountant, a receptionist, nurses, and dealing with other necessary details, the money can be made. But if they had their choice, the best professionals would prefer working on teams. They know that they continue to learn more in that way, that their idiosyncrasies are checked by colleagues, and that they can spend less time and energy worrying about the accountant and the billing.
Money is by no means the sole incentive for entering private practice. Such practice carries a kind of mystique about it. Compare the statement, "Did you hear that Jones has set up shop in the Crystal Towers?" with this one: "I heard Jones has decided to hang on with his schizzies." I gravely doubt that Dr. Jones and his professional colleagues can be held wholly accountable for that evaluation system. It is public opinion, at least indirectly, that feeds the mystique to the professionals. And it is the same public opinion, often expressed through complaints about taxes, that makes it impossible -- or at least very difficult -- for a Dr. Jones to continue in a hospital or a center.
By an ironic twist, private practice may become less attractive, at least financially, if current economic trends continue. Salaries for full-time professional workers in hospitals and centers have gone up, and they are not likely to decline much. True, the number of people a hospital or center can employ may be reduced, but some competent people are now finding difficulty of a new order in making a living from private practice. If the public had the imagination to see the opportunity, and knew that the best professionals want to work on teams and not in isolation, this would be an ideal time to bring some of them back to hospitals and centers.
More Ups Than Downs?
I have focused on the mentally ill who need hospital or clinic-type care and treatment. Quantitatively, they are the largest group, provided alcoholics are left out of consideration -- which is just about what is actually happening today. The most conservative estimates put the number of serious problem drinkers at not less than 7 or 8 million, and no one knows better than Alcoholics Anonymous that there are many alcoholics they cannot reach. Also omitted are the mentally retarded, even though John F. Kennedy made it clear that community mental health centers were to be as much concerned for them as for any other group with mental or emotional problems. Care, treatment, rehabilitation and education for them has improved, but here too the roller-coaster tendency is operating.
If the future of mental health services is considered to depend on complete elimination of the roller coaster, then I should be pessimistic indeed. No matter how hard we try, there are going to be ups and downs in financing, training and research, in idealism, disillusionment and mystiques -- in fact, in all the topics discussed above. I am sanguine enough to believe that the dips on the roller coaster can be leveled out somewhat if the public understands just a little better that doing so will ease more human suffering even than finding a single cure for cancer (which is not to denigrate the importance of that).
The future also depends on what professional people do and how they reflect upon their situation. It is, so to speak, society’s responsibility to see that there is not too large a discrepancy in income between hospital and center work and private practice. If the sacrifice were not extremely large, then the professional people would have a viable choice. In that case, many of them would, I believe, be willing to risk a moderate roller-coaster effect in return for the benefits of genuine interprofessional team practice.
Mental health, of course, consists of more than helping those with mental or emotional problems. But excessive emphasis on positive mental health can turn into a sneaky way of avoiding social responsibility for persons now suffering. Also, too much focus on positive mental health, to the neglect of the negative, can easily become a secular religion of sorts. At any rate, we first need to consider mental health services for the sufferers who need them -- the earlier the better, but certainly at all stages where help is needed.