planning and the environment of a community mental health center

FRANK BAKER, Ph.D.

Planning and the Environment of a

Community Mental Health Center

"In community mental health confers with poorly developed planning units . . . the director may find himself in a state of ~ntermittent crisis attemptin.g to meet one unanticipated e~'~vironmental problem after another. Such a reactive stance to environmental events makes it difficult to be proactive in developing i~novative programs, s~nce organizatianal resources are quickly captured by makeshift attempts to deal with a series of emergencies."

A hypothetical case study illustrates how easy it is to fall into this trap eve~ after elaborate and seemingly in- telligent planning.

II~-TRODUCTION

Acting ~s the director of u community mental health center po,ses a number of dilemmas for the clinician turned executive. I,n the nature of the role, he becomes chief executive of a large organizatioa. Unfortunately, there has been very little discussion ~ the li~terature of the requirements for administering a complex mental hea],th organization, nor of the pro,blems of a mental health prof(~ssio.n, al ~s manager of such an enterprise.

The term "manager" has never had the same currency amoag men, tal health professionals ~s it has had among their counter-

p a r t s heading business enterprises, Levinson and Klerman (1967, 1970) have suggested the hyphenated euphem}sm--"clinician-executive"---~s an alternative, thereby emphasizing the clinical back- ground of the mental health professional and the rela~ed adv.an-

Dr. Baker is head of the Program Research Unit, %he Labora.tory of Community Psychiatry, and assistant plofessor of psychology, Department of Psychiatry, Haxval'd Medical School, 58 Fenwood Road, Boston, Mass. 02115.

Preparation of this paper was supported by NIMH Grant ~MH18382.

9~ PLANNING A. M.ENTAL I~EALTI~I CENTEP~

rages and disadvantages of this earlier career r,ole, but at the same time emphasizing the important aspects of orgaali~ational e~ec'a%ive responsibility. Hirsehowitz (1971) speaks of the role of "c'omm~nity men~,al health leader" and likewise proceeds to discuss the problems of administrative managemen,t for a mental heMth profess4:onal who has a primarily clinical training. Whatever otne finally chooses to call the role, there are tasks and responsibilRies neee.ssary for optimum functioning which require further analysis.

A gemeral theory of management has been evolving in recent years which focuses on the basic administrative processes necessary for the accomplishment of primary organization goals and objectives. Although the managerial process has been described in a number of different ways, there seems to be gen,eral agree- meat th.at four fundamental functions require consideration-- planning, .organizing, controlling, and communicating (Steiner, 1969). The focus of this paper is on the first major function-- planning, which is generally defined as the process by which resources of an organizational system are adapted to changing internal a~d environmental forces.

Ttl~s paper begins with a theoretical discussion whi, ch is then illustrated by a hypothetical ease study of planning and change in a developing eommtmity mental health center. The theoretical approach employed here is that of open systems and draws upon recen, t developments in general systems and modern organization theory. Specifically, this paper focuses on the ways in which viewing a community mental center as an open organizational system operating in a complex, dyammic enviro~lment can provide in, sight into the planning tasks of the executive of a center.

PLA~m~c, AS AX _&Ia~TtTD~" In one .sense, planning is an atti, tude, an orien%ation to the

future, ~sinee it involves defining to,day what one is going to be doing tomorrow. As an attitude, planning is n,o.t unfamiliar to clinieian-e:~eeutives who are at least familiar with planning in regard to treatment of individual patients. What may be unfamiliar and yet of vital importance to the environmental adapta`tioa of t h e center, is a generM acceptance of a planning .as attitude oriented to the heMth of the to`tal ei~terprise.

FRANK BAKER~ PH.D. 97

Planza~ng without Plans As a eogni%ive process of thinking through what i,s desired and

how it will be achieved, planning is '% basic organic function of management" (Steiner, ]969). In another sense, phmning is a so ci,al process with which the staff of mental health ,organizatioa, s are quite familiar. A group of the center's professional staft m a y meet over an extended period of time on a regular basis to discuss some problem such as how to staff a service which is short of manpower, or how to get patients back into the cmmnunity, and so on. There may or nmy not be a tangible product of this group in the form of a written or oral commitment to a specific course of future action. Often one gets the impression that while such a social process may have benefits related to building morale, a sense of group identity, the feeling of i~dividual participatlon in decision-making, and other such pay.o,ffs--that once having gone through the process, management a~d staff co~clude they have discharged their responsibilities even though no concrete plans have r~sulted, This is pl~anning without plan,s.

Plans without Planning Mental health professionals are also familiar with plans, par-

ticu}arly written plans, which have been produced without ade- qt~ately involving tho,se organizafior~al members who are con- corned and knowledgable about the subject of the planning. In the ease of this other extreme type of planning in which the important s~bsystems and role actors have not been ~dequately involved in the development of the plan, the result is likely to be sterile and unproductive. Planning as a process has important functions in building the consensus, acceptance, and support ~eces- sary for trar~slation of a plan ir~to ~ction. M~st human service o rgar~izations have their share of c(~stly paper pla~s gathering dust o~ the shelf which, while they might or might not have been in, tended t~o guide acHon, were produced i~ the :absence of ,suffi- c:ient planning process to allow successful implementation.

I f the management of a community mental health een, ter is not m'mdful of the difference between planning and plans, an in- effective form of planning may be established which invites d~s- satisfaeti~o~. A one~shot, single time-slice, static plan cannot deal wi~h r Hnuous planning problems. This is not to say that plans should be changed every day, but rather that thought about plan-

9~ PLANNING A Z~E~NTAL I-s CENTER

ning should be ccmtinuous and plans must be updated in the light of changing co,nditions.

Ad Hoc versus Comprehensive Planning Much mental health planning is ad hoc, i.e., a ~spe,cific problem

is recognized and an attempt is made to solve that li~uited problem. The primary deficiency in this type of pla,nning is that de- cis~o,ns are made in isolation. Recog,n,ition of the sho~tco~mings of ad hoc categorical planning of ,service delivery is basic to the comprehensive community mental health approach, and yet in tr~5,ng to establish workable comprehensive commun~r programs, actio,n too often continues to be guided by a ,non-comprehensive approach.

Such an ad hoc appro.ach to planning has many obvious short- comings. For example, de~sions guided by ad hoc planning can seric~usly ,narrow the choices available for future a ctio,n. A simple illustration is that of the architeoture of the buildings that house a community mental health center. In recogniti, o,n of the "co,n- crete" constraints imposed upcm mental ho.spitals built to ac- c~mmo,date the t e~h,nology ,and ideology of an earlier time, it ~s being recommended that the ,new men~al health fa,cili~e~s be planned a,nd built with movable inter,nal walls designed t.o a~commo- date the technology and professional attitudes of the future (Mc- Kinley & Foley, 1967).

Co~nprehe,nsiveness n o~ only involves concern for accommoda- tio,n to future change, bu~ also includes reeognitivn of the inter- depende~tce of parts of a community me,ntal health program. Rec- ogn~itio,n of the need to co,ns.ider the totali~ty of parts of a me,nta[ health program in interact~o,n with each other leads one to ,analyze such a program as a system.

~IuIvs SERVICE ORGANIZAT~[ONS AS OPEN SYSTEMS

Systems co,ncepts are ~aining increasingly wide acceptance in the design, evaluati,on and planning .of human service organizations. Some system appro.ach~s analyze c(~mplex organizations as relatively closed systems while other approaches treat such systems as relatively open to e,nv[ro,nmental influence (For rester, 1969; Sheldon, Baker & McLaughli~, 1970).

Early systems theory was concerned w~th .the analysis of inter~al pr,o,cesses in organisms, or organizatio,ns, and involved

~P~A~K BAKF.,R~ PH.D. 99

establishing relationships between parts and the whole using a closed-systems approach. Systems a~,alysis based an open-sys-

tems theory attempts to relate the whole organ.ization t,o elements in its environment, as contrasted to systems analys~s approaches which assame a closed system or~aniza~anal model fo,r coave- nience of approach. Systems analysis b~sed on closed systems models has been very useful "m des iga.~ng cer ta~ military und indu~str~al ,systems, but such an approach introduces di, st ort~ans which are of particular concern in health and welfare organizations where openness to the environment ~s highly valued.

In a five-year study of the multiple in~eraet'mg variables affect- ing the growth of a state mental hospital into a community me~,~al health center, the author employed a model of the commanity mental health center organiza~tian as an open system (Baker, 1969). Canceptualized as an open system, an organization is defined ~s a bounded interacting set of sl~bsystems (e.g., ro~les, teams, and departments) engaging in an input-output commerce with an external environment in the proces.sing of pe,o,ple, information, mo~ey and material resources. Based oll general systems theory (Bertatanffy, 1963; Miller, 1965), this view of organi~atio~s as open systems emphasizes the importance of characterizing the enviro~m,en~ts within which systems must adapt to survive and develop.

CAUSAL TEXTURE OF ]:H~ CE~-2'ER~S Ek~VIRO~h{ENT

A major problem in planning and managing oTgunizati~mal change is that the enviranmen~l contexts in which most eo,ntem- porary organizations exist are themselves undergoing c~ange at an in~ce~s~ing rate in the direction of increa~sing complexity. I t is only recently that theorists concerned with open systems have attempted to characterize the environments in which o rganiza- ti.o~al systems must adapt to ~urvive and develop.

Communs mental health centers, along w~th other human service orgav:iza~tio~s, can be canceptualized as operating under a variety of differing environmental conditions. Emery and Trist (1965) have referred to these conditions as differences in the cat~sal texture of the enviranment, and they have performed an importanr ser~ce by classifying a number of types o.f envirwn- merits. Emery and Trist conceptualize a continuum on which environmental causal texture differs in the degree of u~certain~y and

]00 PLANI~ING A l~[ENTAL HEALTH CENTER

in the degree of interdependence exhibited among the parts or regions of the environment. According to this co~ltinuum, society can be seen as moving from a time in which candition, s were relatively placid and certain to an era in which organizations must operate in "turbuleaW' environments. The turbulence results not simply from the increased interaction of identit}~ble component systems, but from the complexity a~d Inulfiple character of the causM interconnectioa~s of the environmental field itself.

I t is be,coming increasingly apparen,t that, like other human service organizations, community Inental heMth centers retest operate in enviro,Imlents characterized by turbulence. The environmental turbulence ~s being increased by the expansion of science and technology, by ehanges in societal values, by changes hi professions, and notably by the growing aspira~o.Im of people throughout the society to control rather than to be victim,s ,of their surrotmdings.

In order to survive and mMntain some degree ,o~ autonomy of acti~)n in a "turbulent" environment, a ceI,~ter must fulfill a number of irnportan.t fua~etions. I t must deal with the external environment in such a way that it can acquire and ma~ltain sufficient levels of necessary resources. A community mental health ce~fer must also adapt to the environment it,self. Thus, a~ times a cen~er as ,a total system will take a reactive stance with regard to the environm, eld, responding to task demands generated from w~thout. At o,ther times the organization will take a p roaetive stance i~ response to internally generated demands for more resources and will initiate activity which attempts to modify environmental cen- di• ~so ~s to improve the organization's overM1 position with re~ard to resource acquis}t~o~.

SHORT-RANGE A~D LO~G-RAI~GE PLAN-~II~G

In a stable environment and with small, relatively tm, complloa~ted operations, a mental health organization can carry out plmming with relative ease and employ a primarily short-range viewpoint. In a complex, dynami, c environment, ,such as tha~ faced by m(~st community mental health centers, and with the more complicated range of service operation, s required by the comprehen~sive man- date o f a center, planning must take a longer-range viewpohat. At the same timae, the accelerated roles and complexity o,f flateractive efforts in a turbu]ent interorganization,al field makes the span of

:PRANK BAXER~ PH.D. 101

prediction necessary fo.r long-range plazm,ing more d~tticult and hazardous.

In a dyn.amic, uncer.tain environment, a community m.entM health 'een4~er must be flexibly adaptive and must b,e able to develop sh~ort-range plan's that act as a guide for implemem.ting operating tactics. However, at an institutional level these sho,rt- range plan, s must be related to long-range p]an,s which requires setting goals aad developing strategies for the achievement .of these goals .

The I, nside-O~# a~.~d Outside-I~t, Approaches Two busic types of strategic planning approaches can be de-

lineated (Ewing, 1.96~). In the inside-out approach the manager begins with the abilities, ap.tAtudes, and desires of the members of the organization and then looks to the outside environment for opporhmities to utilize the organizati~on's special strengths and to satisfy its particular needs. This approach le,ads management to search in limited ar,e~s of the environment for goals and needs to meet.

In con, tra st, the other pure type of planning, the outside-in appro,ach, begin,s with a survey of the environment. Such an environmental survey ~equires not only .an assessment of present external conditions but also an attempt to forecast future enviro,n- men4al static. Based on this analysis of the outside, the executive then examines the inside of the organization fo.r s~.rengths and weaknes,ses in determining which of the opportunities oT needs in the enviroament to t ry and meet. Since this type of planning begins with external .con,dition,s and turns next to in~ernal cap,a-- cities and desires, it leads t,o different priorities in ~h.e p~o,ce,ss of information-~athering. Information about the in,ternal enviroa~- merit rather than being a starting point, setfs the scope and direeti~on .of ,s~rategic ,analysis, becomes in, stead a kind of eon- straLn~ ,o,r limiting factor on ptanning in response to environ: men'~al demands and oppo,rtuuities.

In community mental health centers with po,o.r]y developed plam~Ng units, the absence of environmental fo,recasting capa- biligies places the organization in a reactive stance t'o changes in extern,al condiSoas. Thus {be director of a center may find himself .in a s:~te of intermittent cri.si:s attempting to meet o,~e un- a~cipa~,ed .envir~onmental problem af~ter ,another. Such a r,e-

102 PLANNIIgG A 2r HEALTH CEI~TER

active s~ance to environmental events makes it difficult to he proactive in developing innovative programs, since organizational resources are quickly captured by makes~hift attempts to deal with a ser~es of emergencies. Examples of .such crises include: voci- ferous demands and demonstrations by black militan,t gro.ups who feel the community mental health een~er is not adequately meei- ing the n, eeds of blacks and has n, ot evidenced concern for the special problems of this popul~atio,n; cuts by the state legislature in appropriations for the slate men(tal health b~dge~ including needed funds for community mental health center ,operations ; eth. nic suecession and other changes in the demograpt~c character- isties of the population living in the catchment area served by the center, and sv on. Such environmental changes could be a n t i , pared by a commitment of staff resources to the surveying, forecasting and aamlyzing of the external enviro,nment.

This do~es n,ot deny the necessity for monitoring changes in the inter~al enwironment as well, since w~ttmut adequate information on processes within the organization, unanticipated internal crises are likely to occur. Thus an administrator, like Janus the an~ent Roman god of gates and beginnin.gs, must present two opposite faces~one turned to the outside of his organization while the other i~ace l(~oks to the in'side of k~s so.c}al system.

MANAGEMENT AS A SUBSYSTEI~

If community men,tel health center admir~istration is treated as an individualistic endeavor, this requireInent of loo~ng in tw.o direc~on.s at ,once is an impo~ssi, ble ~ask. Effective mazmgement of a large organization calls for a dif%rentiated managing subsystem made up of individuals occupying roles in a line relationship to the 4irector as well as to those in a "ftmetiv~al" or s~aff relationship. For example, Hodgson et el. (1965) describe the "executive role co~stellati.an" comprised of s:evel~al key figures in a mental health organization who play a eentrral rote in to~p management de~sion-making.

The "executive role consCellatioa" o.f two or three persons ex- ists as a more or less informal group within a larger group of top and middle management. The senior staff who make up the management of a c~)mmunity mental he a~th center are e(~mpos,ed of those individuals occupying key leadership p(~s~t~ons in the center operating units and professional di,sciplines a~d may in-

:FRANK BAKER, P:~.D. 103

elude over a dozen persons (Kle rman & Lev'.mson, 1970). Typical ly a dire.etc~r will create a formal g roup ing such as an Execut ive Committee. Such a g roup m a y be p r imar i ly @dvi~sory or may have some power .of deci~sion-mak~ng.

Al though ~t is clear that center ~dmi~s t ra t i .on i:s u g roup en- deavo,r, this does n, ot automati.cally make it easier to de~l with b(~th in,tern~al ,and external tt~s,k dem,ands. At to,~er leve}s of management the re is Likely to be a g rea te r eo,ncern for t~e in te rna l problems re la ted to specific opera t ing p!~ograms. The mul t ip le and of ten compet ing goals which characterize the ope ra t ing sub- tmi~ of th'e center o rgan.ization m ay act ~t~o " tu rn the he~d" of t ~ s level of man,agement to an ha,side-out appro,ach of planning, to the neg]e,et of an outside-in appro.ach.

CASE EXAMPI~E OF UI~I-DIRECTIONAL PLANNING An example of the results of concern for one type of planning, either

inside-out or outside-in, to the exclusion of the other type con be found in the cent-decent-recentralizafion process that mental health organizations go through. Many mental hospitals over the past two decades have moved to a decentralized structure for a variety of reasons. Responding to different environmental fields of forces, the patterns of decentralized structure have varied across hospitals and within individual hospitals over time.

Some public mental health hospitals have undergone decentralization as part of broad organizational changes intended to transform the mental hospital into a community mental health center. Based on the author's research on a number of such hospitals employing direct observation and interviewing as well as indirect questionnaire surveys, a composite or prototype case example will be presented here for Wllustrative purposes.

Urban State Hospital (USH} had been hampered for some years by a large inpatient population, shortage of trained treatment staff, and an outmoded physical plont. Organizationally, the hospital was divided into a number of departments and services (e.g., medical, nursing, social work, psychology, occupational therapy, etc.). Each department was headed by an individual who had line authority over all the members of his department. For example, all nurses in the organization were directly responsible to the Director of the Nursing Service. Except for those involved in business administration of the hospital, all department heads were respan- sible to the clinical director, who in turn reported to the Superintendent of the hospital.

The majority of professional staff were concentrated in the Reception Building which contained a group of special admission and acute treatment wards. After a time, if patients showed no improvement, they were

!0~ PLAI~I~IIVG A -rv~ENTAL HEALT]:I CENTER

transferred to a group of physically isolated buildings containing sexually segregated chronic wards. Chronic patients in these "back wards" were principally cared for by psychiatric aides and had little contact with the more highly trained professional staff.

The average patient length of stay was quite long. In the 1950~s the use of new drugs and application of milieu therapy helped to get some chronic patients out of the hospital. A "revolving door" policy of patients being released and returning after a short stay in the community developed. When readmitted, patients were not necessarily returned to the same ward but were assigned to the wards on the basis of bed availability at the time.

In the late 1950's and early 1960"s the availability of grants from the Federal Government and private foundations resulted in the development of special demonstration treatment programs. Wards with special program grants were able to hire additional staff. Ward administrators without these special programs complained of the uneven distribution of staff to these "privileged" programs.

Staff of special demonstration treatment programs came into conflict with the heads of professional departments, since the members of a discipline remained responsible to the department head of their discipline. Encouraged to act in a generalist fashion by their program supervisor, staff in a special treatment program took on responsibilities which were not traditional to their discipline, and consequently found themselves in conflict with their department head. Since each department head retained authority in hiring and assignment of staff in his discipline, the program directors found dimculty in recruiting and hiring the staff they wished. For example, nurses in a family care demonstration project and those in a home treatment program took on tasks in the community which brought them into conflict with the Director of Nursing as well as the Director of Social Services; both felt that nurses should not be "doing what social workers do."

A new Superintendent of the hospital was hired in 1963, Committed to community mental health ideology and to the development of the hospital into a community mental health Center, the new executive found that he first had to deal with gaining management control of the huge state hospital as he found it. In an attempt to break the hospital down into units of more manageable size, the Superintendent appointed a committee to study the feasibility of unitizing the hospital. This small ad hoc committee, made up of selected senior psychiatric staff of the hospital, recommended that unitization be implemented and with the Superinten- dent's backing proceeded to make plans for this organizational change. Although plans for unitization were discussed in many forums and the existing Psychiatric Executive Committee reviewed the planning group rec-

FRANK BAKEI~ PI:[.D. ].05

ommendations as they developed, the date and actual form of unitization were decided by the Superintendent in consultation with only the Chairman of the ad hoc Planning Committee. In 1966, after a year's discussion, Urban State Hospital was decentralized into four units.

The planning which guided the initial establishment of the four units primarily emphasized an "inside-out" approach. The considerations given primary emphasis included:

1. The large size of Urban State Hospital had made its administration unwieldy and the Superintendent saw unitization as a way of simplifying administration of the hospital.

2. Unitization offered a more equitable distribution of staff resources.

3. Unitization offered a way of reducing the gap in quality Of care provided acute and chronic patients, since both types of patients would be placed in the same units and physical distance between acute and chronic wards would be decreased.

4. Unitization offered a way to more evenly disperse the patient load among the entire resident staff.

5. Subdividing the hospital into semi-autonomous domains offered the possibility of staff growth and encouraged innovation in patient care.

These intraorganizational factors were certainly crucial to the internal development of the system. However, changes in the environment of the hospital were largely ignored in this planning effort, even though changes were occurring in the state and in the communities adjacent to the hospital which had powerful implications for the organization's activities. In 1965, the state had completed a two-year planning effort which established a state-wide plan for expanded community mental health programs. Ac- cording to the state plan, Urban State Hospital, rather than serving the entire metropolitan area, would be assigned primary responsibility for a more limited catchment area comprised of four areas of the city. Although unitization as initially planned and adopted included a geographic assignment to units, this was tacked on as an afterthought and was more de- termined by considerations of equal distribution of patients than consideration of the nature of the geographic areas and populations to be served.

In addition, planning for unitization did not take into account the ethnic succession which was taking place in that part of its catchment area which was adjacent to the hospital. Blacks were moving out of the inner- city ghetto into this area of the city, replacing an older Jewish population that had previously resided in the area. The unit plan, which had been adopted by the transitional mental hospital, grouped patients according to where they had lived before coming to the hospital. However, in as- sembling the staff for each Unit, there was little consideration given to

106 PLANNING A ]~I[ENTAL I:[EALTI-I CENTER

developing a team with the activities and knowledge necessary to im- plement a program of community contact and community involvement. Thus, the geographic Unit established to treat patients from the community in which ethnic succession was takinig place took little account of this environmental change. As a result, the Unit soon found that its new admissions were primarily black people who had recently moved to their geographic area from the inner-city ghetto. The Unit found itself with a staff who were ill-prepared to provide treatment responsive to the specific needs and problems of this population. Continuity of care was minimal since the staff found it difficult to identify community agencies with which to link after-care and pre.care activities. To add to the problem, the hospital found staff facing an accusation from community groups that it was practicing discrimination, since most blacks entering the hospital were assigned on the basis of residence to the same Unit.

After unitization, as they sought to develop the hospital into a community mental health center, the Superintendent of Urban State Hospital and his executive staff became increasingly aware of these events which were taking place in the hospital's immediate community environment. They also learned of opportunities for affiliation with several universities which, lacking their own inpatient facilities, were seeking to develop relationships with the state hospital to fulfill the inpatient service requirements of their own application for federal mental health center staffing grants.

Responding to these outside conditions, the hospital underwent a re- unitization in which staff and patients were again shifted around. This time the reorganization attempted to take into account the assigned catchment areas, and geographic units were instituted. Specific inpatient beds were assigned to patients coming from the catchment areas of the developing USH-based community mental health center, and contractual arrangements were made for other wards to provide inpatient services to the newly affiliated university-based community mental health centers.

Much needless effort and inconvenience for staff and patients might have been avoided if the outside forces had been taken into account in earlier planning. Even in this second unitization, events in the black community were not considered adequately and those members of the organization who were familiar with these events were not involved in the planning process. Thus another ad hoc short-term plan was developed with the result that the hospital-based community mental health center was forced to undergo a third reorganization at a later time in response to these environmental forces.

~kNALYSIS OF CASE ,ExKIVfPLE

The clin, ieian-executives in the Urban State Hospital ~a, se example, while displaying the necessary future ori, ent~ti~)n, did no,t

:FRANK BAKER~ PH.D. 107

co~dact their plasming operations by e)mmining the ?sotal hospital organizational system in i t s environment. They avoided the trap of' producing a "plan without planning," but did n,ot sufficiently involve the relevant knowledgeable organizational members in their p~anning process. As described, the planning for organdza- fi~o~al cha~ge which was crucial to the development of community mental health center services at the hospital did no,t ,adequately relate ?so this long-range goal. Instead the achninistration conducted a type of ad hoe planning which wgs ini~tially overly concerned with internal system factors to the exclusion of consideration of important changing envir,onmen?sal conditi,o~s.

Although, as indica:ted in this simplified case example, internal and external factors rapidly change and are sys,?semically very complex, and thus very difficult for a mental health admin~strat(~r to deal w~th, there is at least one "moral" which ca~ be draw~ from She story. There are times when it is essential for a mental health administrator to think in terms of the people and facilities of the orgazfizati, on itself; there are other times when it is es,senfial to develop the viewpoint of particular par~s of the environment. Although different "clinician-executives" will prefer varying em- phases, and any one executdve will ta~d to emphasize one viewpoint over another at various times, sotmd strategic planning requi~es that both in~ernal system conditions and extern, al environmental fa,ctors be taken into account by a well-develooed adaptive man~agerial subsystem.

BIBLIOGRAPHY

Baker, P.: An open systems approach to the study o~' mental hospitals in transition. Commun. Mont. ]=I]th. J., 5: 403-412~ 1969.

Bertalanffy, L. : General Systems Theory. George Braziller. New York. 1968. Emery, F. E., and Trist, E. L.: The causal texture of organizational environments.

Human Relations, 18: 21-32, 1965. Ewing, D. E. : The Practice of Planning. Harper and Row. New York. 1968. Forrester, 5. W. : Urban Dynamics. M.I.T. Press. Cambridge, Mass. 1969. Hirschowitz, R. G. : Dilemmas of leadership in community mental health. PSYOHIATI~IC

QUARTEr~L~ ~, ~t5: 102-116~ 1971. Hodgson, R. C.; Levinson, D. ft., and galeznik, A. : The Executive Role Constellation.

An analysls of personality and role relations in management. I)ivlsion of Research. Harvard Business School. Cambridge, Mass. 1965.

Klerman, G. L., and Le~_nson, D. J. : Becoming the Director. In: The Practice of Community Mental Health, pp. 469-493. i4enrv Grunebaum (ed.) Little, Brown. Boston. 1970.

Le~inson, D. J , and lTlerman, G. L.: The cllnlclan-executlve. Psychiatry. 3-15, Feb. 1967.

108 PLAI~*NING A .A~ENTAL HEALTH CENTER

h'~cKinley, David A., and Foley, A. R.: Community mental health center: Metro- suburban-rural situation. In: Architeeture ~or the Community l~ent~l Health Center, pp. 10-25. Coryl LaRue Jones (ed). Mental Health Materials Center. ~ew York. 1967.

Miller, J. G.: Living systems: Structure and process. Behavioral Science, 10: 337- 379, 1965.

Sheldon, A. ; Baker, F., and Me.Laughlin, C.: Systems and Medical Care. I~.I.T. Press. Cambridge, l~ass. ]970.

Stelner, G. A.: Top Management Planning. Collier-Macmillan. London. 1969.

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