1. Deinstitutionalization Rachel Ahrenholtz

2. Care of the Mentally Ill • Since 1766 care of the mentally ill was exclusive responsibility of state and local government • 1890 New York passed legislation that placed mentally ill into hospitals • Prior to 1945 only one attempt to transfer state responsibility to the Federal Government

3. Robert Felix The Man with the Plan • Born May 29, 1904 • Grew up in Downs, Kansas (1,427 people) • Came from a family of doctors • Education • University of Colorado School of Medicine • Masters degree from Johns Hopkins University, School of Public Health in Baltimore - where he wrote his “plan” in 1941 • Psychiatric training under Dr. Franklin Ebaugh • Colorado Psychopathic Hospital

4. Felix’s Work • Worked for the United States Public Health Services • Federal prison in Springfield, Missouri • Federal Narcotics Treatment Center in Lexington, Kentucky • Coast Guard Academy in New London, Connecticut • Well known for his expertise in treating alcoholism and drug addiction • 1944 become Chief of the Mental Hygiene Division of the Public Health Services

5. The National Plan • Felix 1945 Masters degree thesis • Called for the involvement of the Federal Government in a wide range of mental illness related activities • By creating two programs • Community mental health clinics • Modification of the environment to prevent future cases of mental illness

6. The Clinics • Treatment for • “the non-psychotic and pre-psychotic patients… • Early detection and prevention • Schools, courts, and welfare department • Felix was enamored with the ideas of Sigmund • One out-patient mental health clinic for every 100,000 people • “Treatment or psychological counseling for patients not in need of hospitalization and, most significant, for patients in the early stage of illness, when the prospect of cure is greatest”

7. Modification • Modification of social and culture environment to prevent future psychiatric problems • In line with Margaret Mead • Clinics should correct such factors • Concerned with more than the psychoses and hospitalized mental illness…. • Research towards social

8. Why we needed a Plan? • Postwar years - end of World War II • Confronted the nation with two facts: • Serious mental illnesses where much more prevalent • Conditions in state mental hospitals were appalling • Military draft: • 18% rejected for mental illness • 14% for mental retardation • 5% because of neurological diseases • All discharged for disability was a total of 38%

9. Why the Plan? (continued) • Conditions of mental hospitals: • Came to light when Mennonites and Quakers were assigned to alternative duty during the war • 1943 they began publishing their findings • Hospitals were: • Understaffed greatly - up to half were drafted for the war • Grossly overcrowded- 150,151 in 1903 to 423,445 in 1940 • This sparked congress to take action and thus the creation of the National Neuropsychiatric Institute in 1945

10. National Neuropsychiatric Institute • Purpose was to provide more effective methods of prevention, diagnosis, and treatment for such disorders and for other purposes • Comparison was made to the Manhattan Project • Felix wrote a bill and persuaded Representative Percy Priest, Chairman of the Labor and Public Welfare Committee to introduce it

11. National Neuropsychiatric Institute (continued) • First time the Federal Government would take on the fiscal role in clinical care of individuals with mental illness. • Once passed the name was changed to National Institute of Mental Health (NIMH) • Harry Truman signed it on July 3, 1946 • Only a few objections came • Senator Robert A Taft and Representative Clarence J. Brown

12. Federalization • By 1948 Felix awarded $2.1 million ($22 million) to 45 states to develop or expand community mental health services • The money was for the establishment and maintenance Note!- Nothing to improve state mental hospitals

13. Who helped • Jack Ewalt • Small town in Kansas • Attended University of Colorado and trained with Dr. Franklin Ebaugh • He wanted federal to provide total financing cost of services for the mental ill • William Menninger • Also from Kansas • Founded Menninger Clinic • Knew Felix from childhood • Believed psychiatric were obligated to participate in community affairs in order to apply their knowledge to problems

14. Who helped (continued) • Francis Branceland • From Philadelphia • Studied psychoanalysis with Carl Jung in Switzerland • Causes of mental illness laid in the interpersonal relationships • Mike Gorman • Son of Irish immigrants • Graduated top of his class from New York university in 1934 • Public relations for the Tinker Air Force Base in 1942 • Worked at daily Oklahoman sent to investigate the state hospital, and book ‘Oklahoma attacks its snake pits’ • Was hired by Mary Lasker to lobby in Washington • Become one of the most effective lobbyists the national capital has ever seen

15. Perfect time for Action for Mental Health • 1953 Korea War gave way to the Cold War • This created a belief that federal could fix any and all problems • Perfect time for the next phrase 1954 • Call for study current conditions and develop a national mental health program. • This lead to legislation creating a commission by Senator Hill and JFK • The Commission of Mental Illness and Health passed without a single dissenting vote

16. Mental Illness and Health Commission • Congress appointed Felix to set up the commission • Felix appointed Ewalt as director • Braneland and Gorman as commission members • Mission - to lay ground work and gather support • Success • 1950- 1955 NIMH budgets increased from $9.2 million to $14.0 million • 1955-1960 the budget increased from $14.0 million to $67.5 million ($711 million)

17. The Outcome of the Commission • It was sufficiently ambiguous to allow groups to read what they wished • Included a call for more federal money for research and training • Also three key recommendations • Mental hospitals were “bankrupt beyond repair” • Future psychiatric services should be coordinated by community mental health centers. 1 center for 50,000 population • Massive financial participation by Federal Government in the care of mental patients

18. Unexpected Solution • During 1955 the miracle drug - Chlorpromazine “Thorazine” • William Winkelman a psychiatrist in Philadelphia reported 142 patients with varying diagnoses made remarkable strives • Mental hospitals were still thought of as “bankrupted” • Between 1946 - 1955, 17 states decreased the census • In 1955 with 558,922 patients and in 1956 7,532 fewer

19. Release of the Commission Report • Early 1959 the report was ready to be released • At this time Dwight Eisenhower was in office • 1960 elections JFK won • Released the report before he was even sworn in • The Kennedy family awaited the opportunity to raise awareness for mental retardation

20. Kennedy agenda • Mental retardation - ‘was the closest to Kennedy’s heart” • 1962 Rosemary was public knowledge and the efforts to promote research was underway • Kennedy first claim on the administration attention was mental retardation not mental illness

21. Small Hiccup • In 1961 Felix was ready to roll out his plan but there was a small catch • Eunice pushed for the mental retardation thus forming the President’s planal on mental retardation • Started in October 1961 • Included 27 members • Create a plan to combat mental retardation within 1 year • In October 1962 issued a 200 page report with 95 recommendations • Felix and others were upset • Joint legislation was the only option

22. Discussion Question • What is your option on the mental illness and the mental retardation commissions and acts being separated or should they have been combined?

23. Finally Felix Plan • Without a Kennedy leading the way a committee was formed • Felix, Brown and Yolles were the only mental health professional on the committee • The committee was to make decisions on funding, centers, and staff • Federal initiative that would eliminate the state mental hospitals • This was a fatal flaw

24. The Details • Creation of community clinics were underway • Federal funds • Cover some of the cost of construction • Staffing for the first 4 years - failed to pass • Control of the centers - bypass state • By late 1962 with Kennedy and the democrats with majority in the House and Senate • Plan yearly cost was $850 million ($7 billion) • October 31, 1963 it passed

25. Life of the Federal Program • It was seen as a repudiation of Kennedy and all he stood for • President Lyndon Johnson fully supported the plan • After 1964 elections Johnson fully incorporated program into his great society legislative agenda • NIMH jumped at the opportunity to reintroduce the piece that failed to pass originally - federal funds for staffing • Shortly after it passed Felix retired naming Yolles Director of the NIMH and Brown become the first Program Director for CMHC

26. Community Mental Health Centers (CMHC) • First federal community mental health center opened in 1966 • All together 789 centers would be funded in the following 13 years • This totaled to 2.7 billion ($21.2 billion) in federal out payment • Most centers received both funding on condition of 20 year service • Centers had to provide: • Inpatient beds, partial hospitalization beds, 24 hour emergency evaluations, outpatient services, and consultation / education. • Along with community outreach to prevent mental illness • No where did it say anything about state mental health hospitals

27. Preventing Mental Illness • Yolles carried Felix's program to the extremes • Encouraged centers to focus resources on social problems for prevention • Between 1970 - 1972 the top priority was prevention but only 3-4% of staff’s time was spent on prevention • Front line workers saw how ridiculous and impossible this task was

28. Times Check in • All this was happening during: • 1963 Martian Luther King Jr. was arrested • 1968 he was assassinated • Overall a continuous series of racial confrontations rocked the nation • Anti-war demonstrations

29. The Nation Needed Help • Yolles and NIMH believed the nation as a whole needed to be healed Whole cities become patients • Leonard Duhl Psychiatrists should be change agents involved in community politics • Matthew Dumont Psychiatrists should play a prominent role • The NIMH view themselves as important players in the war on racism and poverty and greatly funded CMHC in poverty areas to fight this • By 1969 NIMH abandoned the treatment of mental illness as its primary mission in favor of prompting mental health

30. Court Rulings • In 1966 a 60 year old woman was found wandering • Also 1966 Mr. Rouse - treatment or released • In 1965 Medicare and Medicaid • By 1970 - 270 centers were operational • They were failing • Suggestion of moving funds • Yolles was fired

31. New Leadership • In 1970 Bertram Brown took over as Director of the NIMH • Shortly after taking over Nixon came a knocking • Brown went behind Nixon to Congress • Between 1969 and 1973- 2.9 million ($17 million)was mandated to evaluate patient care - found lack of accountability • 1982 some funds were recovered

32. The Death of the Program • Nixon disliked the program • Liked psychiatry with communism • This was reinforced by the NIMH • Mental state hospitals exit • By 1979 only 170,619 were left • Between 1970-1973 12 state hospitals closed • The CMHC remained open despite Nixon • 1976 548 in business and 200 more funded but not operational yet • Only 3.6% to 6.5% of discharged patients were CMHC patients

33. Time Check again • 1969 the biggest anti-war rally in America • Followed by My Lai Massacre and sending US troops into Cambodia • Vietnam War was now Nixon's war • The Watergate scandal in 1972 • Vice President Sprio Agnew’s resignation after tax evasion • August 8, 1974 the resignation of Nixon

34. Who was CMHC Seeing? • Social maladjustment or no mental disorder – 22% • Neuroses and personality disorders – 21% • Childhood disorders, mostly behavioral – 13% • Depressive disorders – 13% • Substance abuse – 10% • Schizophrenia – 10% • A catch all “all other diagnoses” was the rest • Out of the 789 only a few provided significant care for discharged patients

35. What CMIC Was Really Doing? • Almost all of the centers were not delivering the 5 essential services • Many took construction funding and used them for other purposes • 16 year study published in 1976 found no relationship between opening centers and change in state mental hospital resident rates

36. New Program - The CSP • 1976 Jimmy Cater was elected President's Commission on Mental Health • Instead of fixing CMHC the community support program (CSP) was started • Funded 3.5 million ($15.7 million) • Brown was fired in 1977

37. Additional Court Cases • 1971 Wyatt vs. Stickney • 1975 O'Connor vs. Donaldson • 1972 Lessard vs. Schmidt • During the 1970s - supplemental security income

38. Final Movement • Carter signed the Mental Health System Act • In 1980 Ronald Reagan defeated Jimmy Carter and Republications took control of Senate • The Republications killed the Act • By 1981 the CMHC movement was finally done • By then states had washed their hands

39. What Happened After? • In 1974 no local or state had responsibility for discharged patients • In 1977 responsibility was unclear and fragmented • In 1978 no agency at any level had been clearly charged with responsibility • By 1981 no coordinated program for aftercare existed

40. Deinstitutionalization • Effectively deinstitutionalized individuals was 650,000 • Deinstitutionalization was not a mistake, the failure of providing follow-up care was Because of medication it was both logical and humane to release • Some people did ok • Many became homeless and imprisoned

41. After • Population of mental ill • 120,000 still hospitalized • 381,000 were in nursing homes • Between 175,000- 300,000 were living in board-care homes • 125,000- 300,000 thought to be homeless • 1990 the last release of the hospitals • 1998 in San Francisco – homeless mentally ill was 6,000 • This lead to the criminalization

42. Discussion Questions • Would you want the ability to commit a family member into a treatment facility? • Where do you think the centers went wrong?