community activism and community mental health: a chimera of the sixties, a view from the eighties

Journal of Community Psychology Volume 16, July 1988

Community Activism and Community Mental Health: A Chimera of the Sixties, a View from the Eighties

Stanley S. Robin Morton 0. Wagenfeld

Western Michigan University

The conclusion that the decline of community mental health is primarily a result of the current political, social, and fiscal environment is examined in this paper. Following an analysis of the community mental health movement, its ideology and origins, data from several studies are cited to support the thesis that community mental health ideology was not internalized by community mental health center directors and workers, as demonstrated in their attitudes or role behaviors. The data are supported by analysis of the division of time and effort in the activities of community mental health centers during the 1970s. Since these data were gathered at the height of the community mental health movement, the current state of the movement is interpreted in part as a reflection of the basic lack of ideological and role commitment to it on the part of staff in community mental health centers. These observations are discussed in the context of community mental health as an incomplete social movement.

President Kennedy’s now famous call for a “bold new approach” to the care and treatment of the mentally ill and the passage of the Community Mental Health Centers Act (PL 88-164) in 1963 were designed to usher in a new era of mental health care and service delivery (Wagenfeld & Jacobs, 1982). For a number of years, journalistic ex- posCs detailed the deplorable and often inhumane conditions that existed in public mental hospitals. Particularly in the post-World War I1 period, there was increasing scientific evidence of both the high prevalence of untreated mental disorder in the community and the inequities in the mental health care delivery system. Adequate care from private practitioners and adequate facilities had been the privilege of the urban and the a u e n t . Ironically, those in the lower classes and residents of the inner city and rural areas, with high rates of psychological disorder, either received no care or were shipped off to remote, isolated state mental hospitals that were increasingly depicted as “snake pits” or “human warehouses .”

To remedy this, the Community Mental Health Centers Act provided for the establishment of a national network of community-based facilities intended to bring adequate care to all. The avowed aim was community-based treatment, as an alternative to what was seen as incarceration in the state hospitals. In addition to community-based treatment, President Kennedy’s message also made reference to the need for the prevention of disorder. It was argued that the ubiquity of disorder made even the most am- bitious treatment program inadequate to the task. Something had to be done to reduce the incidence of mental disorder.

This is a revision of a paper presented to the Society for the Study of Social Problems at the annual meeting in San Francisco in 1982. Special thanks are due to Bernard Bloom and Howard Parad for data made available to us.

For further information, contact Morton 0. Wagenfeld, Department of Sociology, Western Michigan University, Kalamazoo, MI 49008.

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The original Community Mental Health Centers Act (PL 88-164) and subsequent regulations [Sec 54.203(a)] provided the mechanisms for this through mandated consultation and education-one of the five original essential services. Programs of consultation with community caregivers and mental health education would help to prevent mental disorder. A number of leaders in mental health, largely academicians and theoreticians, saw this legislation as providing the opportunity for the mental health disciplines to exercise an enormous potential for positive social change. Community mental health centers (CMHCs) and community mental health staff would, in addition to treating those already disordered, prevent mental illness in much the same way as public health workers had eradicated many infectious diseases in the United States in the nineteenth century. Poverty, injustice, and racism were seen not only as evils in themselves but also as causes of disorder. Through consultation with community leaders and through mental health education, salutary change would be brought about (Levine, 1981; Mer- win & Ochberg, 1983; Wagenfeld & Jacobs, 1982). In addition, calls were frequently and eloquently sounded for those in the newly created community mental health centers to meet those new challenges and to assume the additional functions of social activists or agents of social change (Caplan, 1964; Dumont, 1968; Peck, Kaplan, & Roman, 1966). These exhortations fit in well with the prevailing reformist and ameliorative zeitgeist of the 1960s.

It would be inadequate and misleading to assert that community mental health was simply a creation of the optimism of the sixties. It arose from the convergence of a series of developments within the mental health field, advances in psychopharmacology, and a high level of economic prosperity. These forces combined to make possible the launch- ing of a major federal initiative in the community-based care of the mentally ill (Bloom, 1975; Levine, 1981; Musto, 1975; Snow & Newton, 1976; Wagenfeld, Lemkau, & Justice, 1982; Wagenfeld & Robin, 1980; Wagenfeld, Robin, & Jones, 1974).

It would also be misleading to imply that there was not considerable controversy about community mental health and dissent from these proffered activist roles. A leading psychiatrist regarded activism as a “flight from the patient ,” while others dismissed it as a new “psychiatric bandwagon” (Burrows, 1969; Dunham, 1967).

Beginning with the early 1970s, articles assessing the impact and direction of community mental health- particularly its activist element - began to appear. Generally, the theme and content of these efforts was captured in the title of an article by David Musto, “Whatever Happened to Community Mental Health?” (Arnhoff, 1975; Musto, 1975; Robin & Wagenfeld, 1976; Snow & Newton, 1976). Basically, two positions were evident. The first was critical of the conceptual basis of activism and asserted that community mental health had lost a good deal of its original purpose and an opportunity for maximal impact in its pursuit of the chimera of activism. As Zusman and Lamb (1977) have noted,

In our view, there has not been a failure of community mental health, per se, but rather a failure to focus on the basic mission of community mental health. Only limited aspects of the original conception have been implemented, while the interest of most workers has gone off in other directions. . . . Community mental health has tended to focus on treating the “healthy but unhappy.” Considering the amount of manpower and funding available, an inordinate amount of effort and publicity has been put into primary prevention and social and political activism rather than direct service. (p. 889)

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The second position also argued that community mental health had failed - but for a very different reason. In this view, activism was not a perturbation from the movement’s main course, but its raison d’Ctre. Community mental health failed because it did not fulfill its promise of social change, reform, and social activism. The basis for this failure was generally ascribed to the persistence of the “medical model,” which was viewed as too narrow and antithetical to community involvement and activism (Chu & Trotter, 1973; Rumer, 1980).

It seems clear that community mental health- as it was envisaged in the sixties and early seventies- is gone. The easy conclusion about its apparent demise is that it was a victim of a radically altered social and political environment. With the repeal of the Mental Health Systems Act enacted during the Carter Administration and the instituting of the Alcohol, Drug, and Mental Health (ADM) block grant to the states, categorical federal support for establishing and maintaining community mental health centers, along with a good part of related NIMH activity, is at an end (Wagenfeld & Jacobs, 1982). Whatever uniformity may have previously existed with respect to service delivery philosophy, priorities, and mandated services as a result of federal leadership has vir- tually ended. It seems likely that existing community mental health centers will now function under the control of a variety of state and local agencies, whose vision of mental health services may be uncertain and inconsistent, if not actually antithetical to some of the fundamental concepts of community mental health.

The fiscal restraint on community mental health services is not an isolated phenomenon but is part of a broader context - a new vision of the role of the federal government. This new view specifically disavows the notion of the government as an agent of social change in an attempt to ameliorate the social conditions of the poor, minorities, and the disadvantaged. In this new climate, much of the ideology of community mental health- as it developed in the 1960s-is anathema.

The thesis of this article, however, is that the diminution of community mental health is not solely the result of current fiscal policies and conservative philosophies but that it must be seen as residing also in some of the structural and ideological bases of the movement. Even in the face of current conditions and dominant political philosophy, community mental health centers and the service delivery philosophy they were intended to encompass might have been preserved in part if the ideology and consequent professional behavior had been more firmly rooted in the minds and practices of community mental health workers, In other words, we will argue that the current federal administration put to death something that never really existed.

In order to examine this thesis, we will review and bring together some of our prior research (cited below) and supplement these data with findings from parallel research (Bloom and Parad, 1977a, 1977b). These data are useful in examining this thesis, though they were developed for other purposes. This secondary analysis proceeds after a brief discussion of the methods used to conduct the research.

Methods and Findings Community mental health workers were defined as professional and paraprofes-

sional staff employed by community mental health centers. Community mental health centers were categorized and chosen for this research on the basis of three catchment area and three organizational characteristics: organizational complexity (number of con- stituent agencies), auspices (nature of the recipient of the staffing or construction grant),


locus of accountability (proximity of source of control), the geographic complexity (inner city, rural, etc.), ethnicity (percent White), and socioeconomic status (federal designa- tion as “poverty” or “non-poverty”). Twenty community mental health centers were chosen to represent the combination of these catchment areas (geographic area served by the community mental health center) and organizational variables as they were found in the universe of operating centers during the seventies. The sample of centers also represented all geographic areas of the United States.

Questionnaires were developed and mailed to all appropriate staff. Staff were identified by name and professional affiliation on rosters submitted by center directors. Usable questionnaires were returned by 55.8% of all staff. Staff returning questionnaires were similar in disciplinary distribution to the population of community mental health workers sampled.

Community mental health ideology was measured by the 38-item, highly reliable (Cronbach alpha reliability of .94) Baker-Schuiberg Community Mental Health Ideology Scale (Baker 8z Schulberg, 1967). The variables of age, years at center, education, percent of time spent in direct services, and percent of time spent in indirect services were reported by the respondents.

Community mental health center role activism was measured by workers’ responses to a set of 18 community mental health vignettes illustrative of “typical” community situations they might encounter. For each vignette, the worker was asked to indicate which of a series of four role behaviors he/she felt the community mental health center expected of him/her. Each set of substantive responses comprised a range of behaviors ranked from 1 (least activist) to 4 (most activist). Activism was seen as the willingness to change the community or social structure as a solution to the mental health problem presented in the vignettes. The sum of the scores over the 18 vignettes served as the activism score.

Personal/professional role activism was measured in exactly the same fashion, ex- cept that the respondent was asked to select a response on the basis of hidher personal and professional preference.

Reliability assessments for both the vignettes and the response categories were made by a panel of judges (social work faculty and practitioners and sociologists), and satisfac- tory levels of reliability (> .90) were obtained.

Workers were also asked to indicate the proportion of time spent in direct and indirect service and other center activities as a way of gauging both their own and their centers’ commitment to community activities as opposed to traditional in-wall professional activities.

In addition to analysis of worker responses, we interviewed the directors of the community mental health centers in our sample. In some critical ways, the embodiment of community mental health ideology can be assessed through the perspective of this group. Although the directors were not the ideologists of the community mental health movement in the same way as academic psychiatrists, they could serve as transmitters of this ideology to their centers and workers. At the very least, they could be seen as setting the tone of their organization and strongly influencing the expectations, rewards, and punishments devolving upon center workers in the pursuit of their professional duties.

The transcripts of these interviews were analyzed (Wacks, Miller, Robin, & Wagenfeld, 1975), and, beyond a modest and carefully qualified agreement about social

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activism, there was little consensus among directors about the basic tenets of community mental health. There was disagreement about its ideology and the application of this ideology to their centers; i.e., etiology of mental illness, alteration of social structure, definition of catchment area mental health problems in social terms, and center participation in social change efforts. Table 1 details the positions of the center directors. More significant than the diversity of opinion on the specific items, however, is the fact that analysis of director interviews failed to yield any coherent ideology. No common patterns of beliefs, as one might expect if community mental health ideology were uniformly endorsed, could be found among the directors.

Table 1 Directors’ Views of Community Mental Health Ideology Elements*

Responses Social Psychiatric Mixed

Mental health etiology Characteristics of catchment

area mental health problems

12 5 3

8 9 3

Responses Yes No

Center involvement in social change activity desirable 11 9

Responses Yes extensively Yes limitedly No

Center involvement in community activity 8 6 6

*Detailed description of methods available from authors.

Not only did our analysis reveal that directors were not strong endorsers of the values and goals of the community mental health movement but also that they did not provide clear influence on the beliefs of their staffs, as measured by staff endorsement of the ideology of community mental health. The Baker-Schulberg Community Mental Health Ideology Scale consists of five conceptual dimensions: continuity of care, population focus, primary prevention, social treatment goals, and total community involvement. Baker and Schulberg tested their scale on professional groups at a state mental hospital. They, and later Howard and Baker (1971), found higher levels of community mental health ideology endorsement among graduate students in psychiatric nursing programs than among staff in the state hospital study. Early studies by Langston (1970) and Poovathumkal(l973) found the same low level of community mental health ideology scores among equivalent disciplinary groups employed in community mental health centers. The same patterns prevailed when data from the workers at the 20 community mental health centers were gathered by us as the community mental health movement was reaching its apex. While there were interorganizational and interprofessional varia- tions, we concluded that community mental health centers are not bastions of community mental health ideology (Robin & Wagenfeld, 1976; Wagenfeld, Robin, & Jones, 1974).

Ninety-six percent of the community mental health workers in our sample of centers scored in the third and fourth quartiles of the Baker-Schulberg community mental health


ideology range, indicating a marked endorsement of the ideology. These scores are, however, relatively modest when compared to the mean scores of the nine criterion groups used by Baker and Schulberg (1967) in the initial development of the scale - groups not composed of staff members of community mental health centers.

Many of the same findings are seen in the work of Bloom and Parad (1977a), survey- ing staff in 55 community mental health centers in 13 western states. Using a scale developed through a cluster analysis of the Baker and Schulberg instrument and the Gottesfeld Critical Issues Test (Gottesfeld, 1974), they found two discernible clusters relevant to our concerns. The community development orientation cluster and the traditional remedial cluster were found to be inversely associated. Among community mental health center workers, scores on the traditional remedial cluster were higher than those on the community development orientation cluster.

Even more salient than the ideological endorsement is the extent to which expected behaviors (roles) of workers include specific enactments of the community mental health ideology concept. Our findings show the defined roles of workers as members of the community mental health centers (Community Mental Health Role Activism Scale) to be lacking in social activism components (Robin 8z Wagenfeld, 1976). The maximum scored value was 69 in a possible range of 18-90, the mean being just into the second quartile of the range, with a small standard deviation of 8.6. The more hypothetical personal/professional role, freed in our study from organizational constraint, was somewhat higher -a mean of 44.3, about midway in the second quartile of the possible range, with a standard deviation of 9.2-but did not contain a strong social activism component.

Community mental health ideology was not evenly distributed among the various disciplines comprising the community mental health centers’ staffs. Significant differences in levels of endorsement were found by us (Wagenfeld et al., 1974) and by Bloom and Parad (1977b). In each study, it was psychiatrists and other physicians and nurses who least endorsed community mental health ideology or community development and who endorsed traditional remedial and conservative professional clusters at the highest levels. Physicians with the highest general status and strongest attachment to the medical mode1 are the least enthusiastic advocates of community mental health. As noted,

[allthough psychiatrists have been instrumental in developing this ideology of community mental health, they are not the leaders in applying it within community mental health centers. Compared to their co-workers they can be seen as a conservatiz- ing influence. . . . To the extent that the community mental health movement demands attention to the community origins of mental illness, primary prevention and responsibility for the mental health of an entire catchment area, then the ideological stance of psychiatrists is nonsupportive. . . . [Gliven the high status of psychiatrists, it seems unlikely that community mental health will progress as its advocates hope without stronger support from psychiatrists. (Robin & Wagenfeld,

This pattern remains intact when the roles of community mental health center workers are investigated (Wagenfeld & Robin, 1980; Wagenfeld et al., 1974). Although there are no significant differences among disciplines for the community mental health center roles, psychiatrists and nurses have the lowest levels of social activism in personal/professional roles.

If workers of the highest status cast doubt on the reality of community mental health in community mental health centers, then we are also informed in a special way by the

1977, pp. 39-40)


data gathered on paraprofessionals in community mental health centers (Wagenfeld et al., 1974), who endorse community mental health ideology at a level significantly higher than psychiatrists (p < .05) but at levels significantly lower than social workers and psychologists (p < .05). In personal/professional role specification they include social activism at the same level as nurses, psychologists, and social workers but at a higher level than psychiatrists. They show no sign of being co-opted; their role definition does not change with greater time at the community mental health center. However, their social activism level increases with greater education. “Those paraprofessionals, whose education makes them least like the indigenous populations from which they were presumably drawn, define the personal/professional role with greater activism” (Riley, Wagenfeld, & Robin, 1981). The analysis of the community mental health center paraprofessional, therefore, provides a simultaneous insight into both the ideological proclivities of community mental health center workers and those of the indigenous populations to be served by the community mental health centers. In both instances, within and outside of the community mental health center, support for community change as a vehicle for primary prevention seemed to fall short of that espoused by community mental health’s leaders.

The most direct way of assessing the extent to which the ideals and practices of community mental health exist in community mental health centers would be the direct observation of the professional activities of the center staffs. Failing the opportunity to observe behavior, self-reporting of workers’ professional activities and the reporting of staff assignment to center duties provide a useful indication.

In our study of the nationwide sample of community mental health centers, only 17% of respondents were based in indirect service components. In fact, if we examine the proportion of staff reportedly assigned to tasks most directly reflective of community mental health ideology (community organization), the proportion drops to 7%. (The remainder of the 17% report involvement in consultation and education.)

Being aware, however, that even those working in other center components may be involved in “indirect” community activities and that some of those assigned to community components of their centers may perform “direct” services, we queried workers about the proportions of their time spent in direct and indirect services. All categories of respondents (psychiatrists, psychologists, social workers, nurses, and paraprofessionals) reported far greater proportions of time spent in direct than in indirect services. About one-quarter reported that 0-25% of their time was spent in direct services, another 25% reported 26-509’0 direct service time, 25% reported 51-75% of their time, and a quarter reported 76-100% of their time to be spent in direct service. Almost 90% provided some direct service to patients and clients. In contrast, 50% of the workers spent 10% or less of their time in indirect services. Only 28% of the staff spent one-quarter or more of their time in community-based enterprises, whereas a majority of the staff (75%) spent one-quarter or more of their time in direct services. Not surprisingly, the differential involvement of staff in direct and indirect services is positively related to their perception of the appropriate activism in their personal/professional role and to the endorsement of community mental health ideology (Wagenfeld & Robin, 1980).

These observations are buttressed by more recent data about reported activities of community mental health center staff presented by Bloom and Parad (1977a). Gather- ing data from 1,500 community mental health center staff members at 55 centers in the western United States, they found that community activities duties accounted for a mean


7 hours per week, constituting the smallest amount of time invested in any major category of activity. Further, psychologists, social workers, nurses, and especially psychiatrists (who averaged less than 4 hours a week in these activities) spent the least time in community mental health activities. They conclude, “ . . . activities of center staff seem generally similar to what is commonly thought to have been how mental health professionals spent their time before the advent of. the community mental health movement.”

The finding that community mental health center staff spend most of their time delivering direct patient services is not surprising for several practical reasons. First, in spite of the rhetoric espousing activism and prevention, four of the five mandated services in the original community mental health legislation were direct: inpatient, out- patient, emergency, and partial hospitalization. In other words, if one were to assign equal weight to all service modalities (an unrealistic assumption), then indirect services would account for -at most - one-fifth of a community mental health center’s activities. Although the “glamour” of social and community activism and the appeal of assuming new and more visible roles may have given the activity a disproportionate share of attention in the media, among mental health professionals, and in the expectations of social movement activists, reimbursement for these community activities was infrequent, so there were few fiscal incentives. Beyond fiscal considerations, the paucity of change- oriented community activity was probably related to a political dimension; change in institutional arrangements frequently involves conflict with existing power structures. Additionally, the view of our respondents that such activity was largely outside the pur- view of community mental health may have been buttressed by the well-publicized failures of and the acrimonious conflict generated by such community-oriented programs as the Lincoln Hospital program in New York City and the Temple University community mental health center in Philadelphia.

Discussion The burden of our argument and data has been that the activist, community-

oriented, socially ameliorative community mental health concept envisioned by many of its founders never really existed - at least in the beliefs and day-to-day activities of community mental health center staff. While there were significant interprofessional differences in activism and ideological endorsement, the absolute levels of support were relatively and uniformly modest. Further, there was little time devoted to these community activities.

In his 1971 book Panzetta used the felicitous phrase “psychiatric chutzpah” to describe the calls for broad-scope activism in community mental health. In a related way, Dinitz and Beran (1971) referred to community mental health as a “boundaryless” and “boundary-busting” system. In the few instances in which community mental health centers attempted wide-scale changes in the social structure, they were highly publicized and singularly unsuccessful (e.g., Lincoln Hospital community mental health center in New York and Temple University community mental health center in Philadelphia). These programs were under the leadership of psychiatrists who were theoreticians and intellectual leaders in the early years of community mental health. They were not wide- ly emulated.

To some extent, the overly optimistic and enthusiastic claims of the academicians and theoreticians became institutionalized by the Congress. Successive amendments to the original legislation (PL 88-164) resulted in a considerably expanded and altered pro-

COMMUNITY ACTIVISM 28 1

gram. From the original five essential services mandated in 1963, the scope of community mental health grew until, in 1975, community mental health centers were required to provide 12 services, including services for children and the elderly, screening, and treatment for drug and alcohol abusers. Scarcely a community mental health center in the country was in compliance with these regulations. In the words of one NIMH official, community mental health had become like a dinosaur, unable to support its own weight. These new service requirements also helped to move community mental health centers away from activism into more traditional, clinical concerns (Wagenfeld & Jacobs, 1982). We do not suggest that activism was solely a product of some of its architects’ imagina- tion. For example, as we have pointed out elsewhere, other research has shown that rural community mental health centers as a group have more nearly approached the ideal of the community-oriented multiservice agency envisaged by the community mental health concept (Jones, Robin, & Wagenfeld, 1974; Wagenfeld et al., 1974). However, the hazards of these activities have become evident; these centers seem to be suffering disproportionately in the current retrenchment (Hargrove & Melton, in review; Mermel- stein & Sundet, 1986).

How does one place these findings in perspective? At several points, we have used the term “movement” to describe community mental health . For many years, the area of social movements has been a fertile field for study by sociologists, social psychologists, historians, and political scientists. A number of theoretical perspectives have been ad- vanced. Although these perspectives differ in many respects, most traditional approaches share a common view that advocates of broad cultural themes stressing change, reform, unrest, etc. often coalesce into organizations (movements) designed to bring them to fruition. These social movements are seen as progressing through stages or phases and can be characterized by particular kinds of leadership, membership, and an ideology (e.g., Killian & Turner, 1957; Smelser, 1962).

The concept of “ideology,” an essential component of social movements, is particularly useful here. Ideologies function “ . . . to render otherwise incomprehensible situations meaningful, to so construe them as to make it possible to act purposefully within them” (Marx, 1969). Put another way, they represent shared cultural meanings that enable purposeful social action in the face of uncertainty. Although originally applied to political phenomena, the analysis of ideologies has been applied more recently to professional or scientific arenas. The significance of ideologies is inversely related to the extent to which the content of the field and the problems facing its practitioners have been completely understood. With the achievement of complete understanding, competing ideologies are replaced by achievement of principles and programs of action or procedures for dealing with situations (paradigms) (Marx, 1969). Additionally, Marx suggested that these criteria apply to fields that are likely to generate ideologies: (1) newness or rapid expansion; (2) a premium on a particularistic, subjective, or intuitive approach to the application of knowledge; and (3) a moral or ethical aura surrounding the subject matter. Because of the paucity of knowledge concerning the etiology of mental disorder, the mental health field has been a fertile ground for the proliferation of ideologies. The ideology of community mental health is but the latest one. Just as the ideology of institutional care developed in the nineteenth century to fuel the movement toward developing state hospitals as a humane alternative to the appalling conditions that existed at the local level, the community mental health ideology was articulated as a reaction to the perception that the traditional mental health care delivery system


had failed. If, as we have argued, ideologies represent shared cultural meanings that enable purposeful social action in the face of uncertainty, then it is clear that this guide for action failed to capture the hearts and minds of the staff at community mental health centers.

A more recent perspective on social movements -resource mobilization- brings additional insight into our findings. Unlike earlier models, which emphasized the primacy of tension and dissatisfaction with the existing order as reasons for the development of social movements, resource mobilization asserts that these tensions, although ubi- quitous, are secondary. From this perspective, social movements are created by “movement entrepreneurs” (Jenkins, 1983; McCarthy & Zald, 1973, 1977). These entrepreneurs are motivated by incentives of career opportunities, and those mobilized and persuaded to provide resources (time, influence, money, communication networks, etc.) are elites who perceive gain, potential, or tender resources for the general good as “conscious constituents .” Large-scale institutional social movements are best mobilized through “bloc recruitment” of preexisting groups and emphasizing gains to these groups through their participation in social movement activity and success. For these entrepreneurs, the definition of grievances will expand to meet the available funds and support personnel (Oberschall, 1973; Snow, Zurcher, & Ekland-Olson, 1980). The importance of the ap- peals of the entrepreneurs to their potential constituents for successful movements has been supported in recent works (Moore, 1978; Useem, 1980; Walsh, 1981).

As we have noted, the entrepreneurs (or leaders) in the instance of community mental health were primarily theoreticians and academic psychiatrists. Although it would be simplistic to suggest that career enhancement was not an incentive, the history of mental health in the post-World War I1 years suggests that the community mental health movement represented an opportunity to advance the position or status of psychiatry in a broader sense. Under the hegemony of psychiatry, the other mental health disciplines would be mobilized to help build a mentally healthy society.

The enabling legislation and the early organizational successes of the community mental health movement have to be viewed against the backdrop of the temper of the times and some inflated claims about mental health’s efficacy (Leighton, 1982; Levine, 1981; Wagenfeld & Jacobs, 1982)-the ability of the mental health disciplines, under the leadership of psychiatry, to prevent as well as treat mental disorder. The early successes provided the appearance of social movement success. The mobilization of the community mental health social movement, however, required more than the successful establishment of a structure from which these activities could proceed. It required the initial organization, recruitment, commitment, and resources of several key elites: center staff, politicians, sectors of the general publics at the sites of the social change, and the disciplines producing mental health professionals.

The failure of the community mental health movement to make the transition from leadership rhetoric to working staff resource commitment suggests that the benefits of their commitment were not clear either to the entrepreneurs or to their professional constituents. Although it is difficult to know how successful resource mobilization might have been, its absence in the face of the early appearance of success constitutes one possible explanation of the failure of social activism.

Conclusion Current realities and a look into a slightly clouded crystal ball strongly indicate

that there is unlikely to be any future support for social activism. Indeed, all communi-


ty services are in some peril. One of the major reasons, as noted at the beginning of this article, is that the entire nature of the federal health and human services effort has been radically altered by the Omnibus Reconciliation Act of 1981 (PL 97-35). Now services for mental health and drug and alcohol services have been consolidated into a single ADM Block Grant, with funds going directly to the states and with considerably fewer restrictions than was the case with categorical funding.

In addition to this centralization of control, there has been an absolute decline in the dollar amount available for ADM services. Under Block Grants, the tendency has been to channel the scarce resources to the care of the severely ill in community and institutional settings (Ahr & Holcomb, 1985). However real and pressing the needs of the chronically ill, such a climate does not favor the maintenance of community-based services, much less social activism.

There is evidence that the “handwriting on the wall” for activism existed even prior to the advent of Block Grants. In studying “graduate” community mental health centers (those that had completed their period of federal funding), Woy, Wasserman, and Weiner-Pomerantz (1 98 1) identified service utilization patterns associated with the fiscal viability of centers. The fiscally viable centers were those that had moved away from the original model of community mental health and had concentrated instead on revenue- generating direct services. Thus, the temper of the times is very much against the role of government, government-sponsored agencies, or other agencies as initiators and facilitators of social change.

Other factors internal to mental health are also likely to prevent the reemergence of activism. First, as Regier, Goldberg, and Taube (1978) and others have pointed out, a substantial proportion of people with mental disorders are seen in the general medical sector. This, then, can be seen as de facto support for what Ozarin, Scharfstein, and Albert (1979) have referred to as the “mainstreaming” of psychiatry into medicine.

In addition, to use Fink and Weinstein’s (1979) phrase, there has been a “deprofessionalization of community mental health centers” resulting from a lack of a clear sense of the mission, scope, or purpose of community mental health. Was it to be an improved system of service -particularly for the traditionally underserved - or was it to be a medium of social change? One of the consequences of the failure to resolve this problem was a gradual decline in the number of psychiatrists and other professionals in community mental health centers, with a loss in the quality of patient care.

To remedy this problem, community mental health centers have to “return to basics” (Borus, 1978; Winslow, 1979), making activism unlikely. Advances in the past 20 years in diagnosis and psychopharmacology have made the term “mental illness” germane again - hence, the call for traditional medical functions under psychiatric leadership (Kler- man, 1979).

For still another reason a return to activism is unlikely. To some extent, efforts at social activism were predicated on the notion that the poor suffered from a greater prevalence of mental disorder and from a more serious kind. This was largely supported by the research on mental disorder at that time. A large part of the psychiatric epidemiology of the sixties and the seventies used as indices of mental disorder instruments that measured the global concepts of “impairment” or “demoralization.” Recently, however, a “third generation” of field instruments in psychiatric epidemiology has appeared, based on the new nomenclature in DSM-I11 (Regier et al., 1984). These have stressed specific clinical categories and seem less likely to be compatible with global efforts at social amelioration.


It is generally agreed that one of the egregious errors of the community mental health movement was its failure to tend to the needs of the chronic mental patients who had been prematurely deinstitutionalized from state mental hospitals. This has been extensively documented in the professional literature and reinforced by frequent reporting in the mass media (Gruenberg, 1982; Hollister, 1982; Lamb, 1979, 1984; Merwin & Ochberg, 1983; Talbott, 1980). There is strong pressure for direct services to this group. Hence, large-scale community involvement and change, as envisaged in the early years of the community mental health movement and of the sort that we have studied, are clearly not a viable part of this agenda.

Thus the impetus for the social change ideology, which in the past was never realized, is now blunted, if not reversed. The brief, illusory glimmer, in the Carter administration, that mental health through selective social change might be reinvested (or newly invested) in community mental health centers has died. The panegyric for the community in community mental health is a lamentation for the stillborn.

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