American Psychosis (17 page)

NATIONAL INSTITUTE OF MENTAL HEALTH PUTS UP THE BARRICADES

In early 1970, when Bertram Brown was appointed director of NIMH following the firing of Stanley Yolles, he knew the Nixon years were likely to be problematic. Like Yolles, Brown regarded Robert Felix as a father figure and shared Felix’s vision of a federally funded network of CMHCs. Brown was intrigued by the fact that a network of two thousand CMHCs, with their community boards, might develop into “a powerful political organization.” Like both Felix and Yolles, Brown had been impressed by “the horrendous conditions in state mental hospitals” and believed that “employment, family interactions, mobility, environment and other conditions . . . were . . . central to the mission of the CMHC.” Psychiatrists, said Brown, had a “special position” to provide insight into social problems, and “it
is
our responsibility to interpret these matters.” Brown viewed the CMHC movement as “a grand experiment” and “a test of American democracy.”
¹³

Brown did not have to wait long to hear Nixon’s White House operatives knocking on his door. The CMHC program should be terminated, they said, and “states and localities should assume total responsibility for these programs.” The previous year, Yolles had told
Congress that federal funds from the 5-year staffing grants were running out for many centers and other funds had not materialized; thus, he said, the federal funding should be extended for an additional 3 years. Using his imagination, Yolles added that “largely because of the impetus of community mental health centers we have seen a startling reduction of patients in mental hospitals in the United States.” If that is the case, replied Nixon officials, why haven’t the states picked up the costs of staffing the centers? This was not a discussion that Brown, or anyone else at NIMH, wished to have. Politically astute, Brown simply went to Congress, which was controlled by the Democrats, behind the administration’s back and arranged to extend the staffing grant for an additional 3 years, also increasing the maximum federal share of the CMHC grants.
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Thus began a 6-year siege. In what became an annual ritual, first Nixon’s, and then Ford’s, administrators recommended terminating the CMHC program. Each year NIMH persuaded the Democratic Congress to restore Nixon’s proposed cuts. Nixon then impounded the appropriated CMHC funds, leading to court suits forcing their release. Brown continued to publicly extol the merits of the CMHCs, annually telling Congress that they were primarily responsible for the reduction in the state hospital patient population. In 1973, for example, Brown asserted that “where a center has been operational three years or longer, the possibility of a person being a mental patient in that area is reduced by a third.” A decade later, one of Brown’s staff acknowledged that the number had been the product of “a special analysis.” “You know,” he added, “we were all good soldiers then.”
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Each year the CMHC program became more heavily politicized and the discussion in Congress more heated. The CMHC standard bearer in the Senate was Ted Kennedy, who represented Jack Kennedy’s legacy. In 1973, Caspar Weinberger, secretary of the Department of Health, Education, and Welfare, again advocated a phase out of the CMHC program because “the Federal Government is ill equipped and the wrong agency to provide health care treatment and services”:

Kennedy: “It appears quite clear that you have made up your own mind, and the Congress be damned . . . ”

Weinberger: “If you wish to misquote me continually, of course you are free to do so.”
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Within such an atmosphere, a constructive analysis of the CMHC program was impossible. Saul Feldman, who was the NIMH deputy director of the CMHC program at that time, recalled:

During the early 70s, a common enemy in the form of the Nixon administration caused many in the community mental health movement to become even more strident and perhaps defensive in their advocacy of the program. As the efforts to discontinue federal support for the centers increased, so did the claims for them, and the interest in critical self-examination seemed to diminish substantially. In the struggle for survival the virtues of the community mental health centers were magnified, the defects were overlooked, and there was a tendency to perceive the environment in two simple dimensions—the “good guys” who supported them and the “bad guys” who opposed them.

Similarly, in 1976 Frank Ochberg, then director of the CMHC program, wrote: “We are virtually in a state of siege.” Everyone at NIMH associated with the centers program had abundant evidence that the program was not working and that abuse of the federal CMHC funds was widespread. But nothing was done.
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NIMH was not, in fact, interested in evaluating its premier program. Until 1969, when Congress mandated that evaluation be done and earmarked 1% of the CMHC appropriations for such studies, NIMH had done nothing. In
The Madness Establishment
, Franklin Chu and Sharland Trotter explained why:

Perhaps the fundamental reason that NIMH did not begin evaluation efforts on its own initiative is that evaluation does not serve the Institute’s bureaucratic self-interests. Like any government agency, NIMH is primarily concerned with the maintenance and expansion of its programs. Because the Institute has from the start claimed great success for the center’s program, evaluation is a great liability, since any negative findings can be used by opponents of the program as evidence of ineffectiveness and failure. Moreover, as Bertram Brown has confessed, there is an inherent embarrassment in asking Congress for more money to evaluate a program whose success was all but guaranteed in order to obtain congressional approval in the first place.

Between 1969 and 1973, NIMH spent $2.9 million in congressionally mandated dollars ($15.6 million in 2010 dollars) on contracts related to evaluation efforts. In 1974 the General Accounting Office issued a scathing assessment of NIMH’s evaluation efforts, citing examples such as the following:

A contract was awarded for $356,650 to develop a program for evaluating patient care. After almost 3 years of work and expenditures of over $330,000, the contractor did not succeed in developing a manual useful for conducting patient care reviews. NIMH said that the contractor did not set a goal of developing a specific product useful to NIMH but rather was inclined to treat the project as a grant for basic research.
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If NIMH was uninterested in seriously evaluating the effectiveness of its CMHCs, it was even more averse to doing anything about the abuse of the federal construction and staffing grants. As early as 1972, an internal NIMH report that I coauthored as an NIMH employee documented egregious abuse at several centers, including an estimate of the funds the centers should be required to repay to the federal government for being out of compliance. The report concluded:

The main point of this report is not how ineffective these particular Centers are, but that because of the present system of non-accountability
all Centers could be this ineffective
. Those Centers which are doing a better job are doing so because of their leadership, not because NIMH has required them to do so. The lack of accountability of the Centers means that all Centers, no matter what they are doing, continue to receive public money from NIMH. If a Center is not doing what it said it would, NIMH is not really interested in knowing. This is the heart of the problem—the slow, sad steps which lead to a minuet of mutual deception.

In fact, no funds were recovered from the out-of-compliance centers until 1982, when a new employee, Paul Curtis, assumed responsibility for monitoring CMHC funds and initiated legal action against 10 centers. Although he recovered $3.8 million ($8.6 million in 2010 dollars), Curtis said he “met with very determined resistance from the NIMH. . . . I was actively discouraged from seeking recoveries.” After Curtis retired in 1986, all efforts to recover federal funds ceased. NIMH viewed its role as giving away federal money, not monitoring how it was being spent.
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The CMHC program survived the early 1970s for only two reasons: Nixon’s other problems and the Democratic Congress. Nixon’s problems began in November 1969 with the largest antiwar rally in American history. This was followed by the My Lai massacre and the sending of U. S. troops into Cambodia; by this time, the Vietnam War had become Nixon’s war. In 1972, five Republican operatives were arrested while breaking into the Democratic National Headquarters in the Watergate. In what would become a political soap opera, this was followed by Vice President Spiro Agnew’s resignation after being charged with income tax evasion; the firing of Special Prosecutor Archibald Cox; the resignation of Attorney General Elliot Richardson; the indictment of seven White House aides for obstructing the Watergate investigation; and finally, on August 8, 1974, the resignation of Nixon himself. Although Nixon disliked psychiatrists and the community mental health program, his ongoing personal crises precluded giving sustained attention to these issues.

In Congress, both the House and Senate were solidly Democratic throughout the 1960s and 1970s. Nixon was unpopular, so whatever he recommended, Congress often did the
opposite. All NIMH had to do to keep the CMHC program going was to remind Congress that the program was Jack Kennedy’s legacy and that Nixon opposed it; this combination virtually guaranteed congressional approval. Presidents Nixon and Ford could veto CMHC appropriation bills all they wanted; Congress simply overrode the vetoes.

Even in Congress, however, increasing questions were being raised about the effectiveness of the CMHC program. By the mid-1970s, homeless mentally ill persons were becoming more obvious in the nation’s cities, and people began asking why. In 1974 the General Accounting Office published a highly critical report on CMHCs, and in late 1974 and 1975 congressional hearings were held. The outcome reaffirmed the support of Congress for the program but also mandated seven more services to be added to the original five: screening of patients prior to admission to state hospitals; follow-up care for those released from the hospitals; development of transitional living facilities for released patients; and specialized services for children, the elderly, drug abusers, and alcohol abusers. Because the CMHC program was failing abjectly to deliver its original five mandated services, adding seven more was a feat of illogic remarkable even by Washington standards. Saul Feldman described the 1975 CMHC amendments as “a good example of . . . overpromise and self-defeating behavior”:

Whatever short-term political advantage the Amendments may have served is of little consequence compared with the frustration and disillusionment already becoming visible. . . . It seems clear that community mental health centers cannot now and will not in the near future be able to do what the legislature requires, that failure is inevitable, and that the cost of this failure may be severe.
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A MERCIFUL DEATH

The election of Jimmy Carter as president in November 1976 provided the CMHC program with a temporary reprieve, even if it was by then on life support. Rosalynn Carter had a special interest in mental health issues, and one of the president’s first official acts was to sign an executive order creating a President’s Commission on Mental Health. Thirty-five task panels met over the following year and in April 1978 the commission delivered a 2,139-page report with 117 recommendations.

Like the Joint Commission on Mental Illness and Health two decades earlier, the Carter Commission report included something for everyone. Two of the 35 task panels assessed services for people with severe psychiatric disorders: “Community Mental Health Centers Assessment” and “Deinstitutionalization, Rehabilitation, and Long-Term Care.” The other 33 task panels covered everything from “Rural Mental Health” and “Migrant and Seasonal Farmworkers” to “Americans of Euro-Ethnic Origin” and “Arts in Therapy and Environment.” The CMHC panel acknowledged that the program had failed in many
ways but attributed the failure to the fact that “previous administrations had sought to end the program” and to “a failure of Federal oversight, technical assistance, evaluation and leadership.” Incredibly, the task panel even concluded that “to criticize the centers themselves for many (but not all) of their failings is to ‘blame the victim!’ “
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Despite its criticism of past federal leadership, the Carter Commission’s recommendations focused mostly on creating new federal mental health programs and making federal support permanent. The commission proposed the funding of additional CMHCs and even included a new federal grant program to prevent mental illness by reducing “societal stresses produced by racism, poverty, sexism, ageism and urban blight.” Most remarkable, however, was its recommendation that “states receiving Federal funds for the care of the chronically mentally disabled must, in conjunction with local authorities, designate an agency in each geographic area to assume responsibility for ensuring that every chronically mentally disabled person’s needs are adequately met.” This, of course, was what the CMHC program should have been doing all along. It was as if the CMHCs did not even exist.
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Even as the Carter Commission was deliberating, evidence continued to accumulate that the CMHC program was failing to provide care for the masses of patients being discharged from state hospitals. Increasingly, psychiatric leaders publicly repudiated the program. One called it a “sham”: