Mental Health Besieged, 1965-1977
From the mid-1960's onward, the problems associated with the slow development of community mental health centers, the inherent shortcomings of the centers themselves, and excessively optimistic discharge policies became increasingly apparent. Politicians and the general public were increasingly critical of the the poorly planned revolution in mental health treatment and policy. However, this criticism had little immediate effect: even as the flaws inherent in the nations developing mental health policy became too great to ignore, the commitment of state and federal policymakers to community mental health and dramatic reduction in state inpatient censuses intensified. At the same time, societys opinions about mental health and psychiatry changed dramatically as a result of the intense cultural, political, and social ferment that characterized the latter half of the 1960s and early 1970s. People on opposite ends of the political spectrum denounced the very concept of mental health. Psychiatrists, who had formerly been seen as compassionate experts, were instead frequently denounced as ruthless oppressors bent on singling out and crushing the individuality of those who rejected the dominant values of society.
The mental health professions were both instigators and victims of these upheavals. Some psychologists, social workers, and environmentally-oriented psychiatrists were sympathetic to Lyndon Johnsons social welfare initiatives and made commitment to social activism a key component of their professional identities: if mental illness were caused by poor social conditions, then combating racism, poverty, and other social ills was a logical and necessary part of mental health work. Members of the Group for the Advancement of Psychiatry, a liberal professional organization formed in the late 1940s by William Menninger and other sociodynamic psychiatrists, had since the early 1950s advocated psychiatric involvement in social reform causes. During the late 1960s, a growing number of those working in the field embraced the reform-oriented ethos of what Gerald Grob terms "community psychiatry." A smaller number went even further and pronounced themselves champions of the overthrow of capitalism and technocracy.
The pronouncements of the Group for the Advancement of Psychiatry and proponents of community psychiatry focused unwelcome attention upon the profession as a whole. Extremist right-wing organizations had long denounced mental health programs as covert attempts to facilitate the spread of Soviet communism, and their attacks increased as psychiatrists and others voiced their support for the civil rights and anti-war movements, anti-poverty programs, and other causes. By the late 1960s and early 1970s, mainstream conservatives, who were increasingly convinced that the mental health field was composed almost exclusively of their political enemies, were also suspicious of psychiatry. President Richard Nixon sought to eviscerate the CMHCCA and other federal supports for mental health care on the grounds that they had been intended only as pilot measures; however, his efforts to dismantle federal mental health policy were foiled by the courts.
Contrary to the accusations made by reactionaries and conservatives, the majority of psychiatrists refused to embrace social activism. A growing number of those within the profession remained convinced that mental illness was a neurobiological disorder; from the late 1960's onward, psychiatrists have abandoned sociodynamic theories and placed increasing emphasis the somatic dimensions of mental disorder. Others were supporters of the civil rights movement and other liberal goals but were firmly convinced that citing their credentials when supporting political causes was unprofessional. The activists within the profession were a small group. Outside of the profession, however, the influence of this group far exceeded their numbers. This phenomenon is perhaps most evident in the popularity of one of its subgroups: leftist and libertarian practitioners who sought to strip their own profession of its legitimacy. R.D. Laing, a left-wing Scottish practitioner who was an active member of Britain's Campaign for Nuclear Disarmament, asserted that schizophrenia and other serious mental illnesses were in fact logical responses to a society that had become delusional and self-destructive and that defining a person as mentally ill was a means of maintaining the hegemony of the existing order. Laing's ideas were in many respects an outgrowth of the environmental theories of mental illness that had emerged in the immediate postwar period; he simply carried the belief that mental illness was influenced by social conditions to an unprecedented extreme. The work of Thomas Szasz, a Hungarian-born professor at the SUNY Upstate Medical Center at Syracuse University, also won widespread acceptance. A libertarian who believed that psychiatry was nothing more than a covert means of extending the power of the state over its citizens, Szasz argued that mental illness did not exist; those suffering from "mental illness" were in fact abdicating their responsibility to make moral choices.
The writings of scholars outside of the psychiatric profession gave added force to the assault on psychiatric legitimacy, and their influence is to this day evident within a number of academic disciplines. In 1965, the English translation of French philosopher Michel Foucault's Madness and Civilization first appeared. Foucault argued that the altruism that had been associated with psychiatry since the eighteenth century was a facade: psychiatrists were not humane helpers of the mentally ill but coercive figures seeking to force asylum inmates to internalize the moral discipline of bourgeois society. In later writings, Foucault elaborated upon these ideas. Taken together, his writings constitute a history of Western civilization that stresses the shift away from external feudal constrictions on behavior toward modern efforts to induce individuals to internalize the values of the modern state and police their own thoughts and actions. He asserted that the function of insane asylums and prisons is to compel the compliance of those who resist integration into the state's moral and behavioral regime. Foucault's assessment of the inner meaning of madness and other forms of social deviance to this day carries immense weight in the social science and humanities; although Foucault's popularity has waned in Europe and North America, scholars remain divided as to the accuracy and value of his work, his ideas continue to guide many sociologists, historians, and policy analysts.
A number of sociologists working independently of Foucault also stressed the coercive dimensions of mental health diagnosis and treatment. Earving Goffman's Asylums, which was published in 1961, extended Bruno Bettelheim's arguments about the devastating impact of Nazi concentration camps upon the human psyche to mental hospitals. Goffman asserts that the two were alike in that they were "total institutions" that isolated inmates from society, strictly regulated their behavior, and stripped them of all sense of individuality and dignity. In this respect his arguments differ little from those advanced by Paul Hoch, Robert Hunt, and other psychiatric champions of the open hospital movement and community-based mental health care. However, Goffman also had a jaundiced view of psychiatry and its undergirding assumptions. He concluded that the real function of mental hospitals was to sustain the psychiatric profession and its belief in the medical model of diagnosis and treatment: "to get out of the hospital, or to ease their life within it, they [patients] must show acceptance of the place accorded them, and the place accorded to them is to support the occupational role of those who appear to force this bargain."
Other sociologists argued that psychiatry was concerned less about insuring the continued existence of their own profession than about enforcing social order. Sociologists had long been sensitive to the ways in which societies defined and stigmatized aberrant behavior, but in the turbulent political and social climate of the 1960's the study of deviancy became explicitly political. A growing number of them turned their attention to the study of social deviance and found signs of authoritarian social control everywhere they looked. Thomas Scheff and other scholars asserted that psychiatric diagnoses such as schizophrenia were little more than labels attached to those who refused to conform to dominant societal values; in turn, those labeled as deviant came to see themselves as such and became even more insistent upon acting abnormally.
The arguments of Laing, Szasz, Goffman, Scheff, and others critical of psychiatry and mental institutions gained wide currency from the mid-1960's onward, and their impact upon popular culture is readily evident. During the 1950's, books and films had generally depicted psychiatrists as humane and competent professionals, but from the early 1960's onward writers and filmmakers took a much harsher view of them. Acclaimed novels such as One Flew Over the Cuckoo's Nest (1962) and A Fine Madness (1964), documentaries such as The Titicut Follies (1967) and fictional films such as Diary of a Mad Housewife (1970) and the highly regarded motion-picture version of One Flew Over the Cuckoo's Nest (1975) framed them as malevolent and dictatorial. The press, which had long played an important role in creating public concern about conditions within mental institutions, also became increasingly assertive in challenging the authority and expertise of state hospital administrators and other members of the psychiatric profession.
However, the effects of the assault upon psychiatry and mental health were most evident within the reform and radical movements that flourished during the latter half of the 1960's. Many of those drawn into these movements readily embraced Laing and Scheff, who were openly sympathetic to leftist causes; the work of Szasz, who never hid his contempt for the New Left, also captivated them. To many drawn into the nascent youth subculture, psychiatry and mental hospitals were little more than an effort to force teenagers and young adults to accept the achievement- and acquisition-oriented ethos of consumer capitalism. However, not all of these activist young people were willing to discard the concept of mental health entirely. In cities across the United States, they established alternative services that sought to cast aside the traditional hierarchical relationship between caregiver and client and treat young people's drug use, sexual behavior and emotional distress with sympathetic concern. Some of these programs were started by altruistic laypeople, others by young psychologists and social workers dissatisfied with existing institutions and programs, and still others through the cooperative efforts of lay and professional people. These activists often contended not only with the hostility of established mental health providers but with the distrust of young people and political radicals, who often suspected them of being police informants or covert supporters of "the Establishment." In addition, they often experienced considerable internal conflict: the pressures associated with commitment to a precarious venture, their ambivalent relationships with both the larger society and the youth subculture, and their attempts to improvise more egalitarian and emotionally honest ways of living sometimes led them to turn upon one another. Many of these programs, which almost always placed far greater emphasis upon resolution of emotional difficulties than upon treatment of serious mental illness, perished shortly after they were started, but others were eventually incorporated into existing networks of community mental health and welfare services.
The hostile attitude of leftist radicals toward the profession of psychiatry and institutionalization was echoed by adherents of the other social movements that emerged during the late 1960's and early 1970's. The resurgent feminist movement was sharply critical of the ways in which mental health providers treated women. In the highly influential The Feminine Mystique, Betty Friedan sharply criticized psychiatrists who tried to treat what she called "the problem with no name" with tranquilizers and psychotherapy; Friedan, whose arguments centered upon educated middle-class homemakers, argued that the "problem" was little more than a frustrated yearning for challenging work. Friedan believed that psychiatrists were acting out of ignorance, but other feminists asserted that mental health professionals were knowingly coercive. Writers such as Phyllis Chesler and psychologist Naomi Weisstein asserted that psychiatrists had long sought to force women to accept their subordination and punished women who were aggressive, uncooperative, or sexually unorthodox. At roughly the same time, those involved in the nascent gay rights movement launched stinging assaults on the abuses that the profession, which until 1973 defined homosexuality as a form of mental illness, had inflicted upon gay men and lesbians. Attitudes toward mental health within these movements varied in ways similar to that seen within the youth subculture as a whole: some feminists and gay activists denounced the very concept of mental health as a political weapon, while others sought to create mental health programs that would support women and gay people as they struggled to overcome their internal and external oppression.
Former mental patients also began denouncing psychiatrists and mental institutions. Former patients had in previous decades organized on their own behalf: Clifford Beers, who had been institutionalized in private and state facilities for a short period of time, was the driving force behind the creation of the NCMH, and groups of former patients started self-help programs such as the Manhattan-based Fountain House program. However, the ex-patient movement of the 1960s was notable for its sweeping attacks upon the legitimacy of psychiatry and the very concept of mental illness. Groups such as New York City's Mental Patients Liberation Project and publications such as the Madness Network News declared that psychiatry was a bulwark of the established social order and mental institutions were inhumane. Those active in the movement sponsored numerous demonstrations, boycotts, and sit-ins (including a month-long occupation of the offices of California governor Jerry Brown) in an effort to draw attention to their cause. Politically active former patients were aided by mental health professionals sympathetic to their cause. In 1973, radical therapists and former patients held the first annual North American Conference on Human Rights and Psychiatric Oppression, and the group sponsored annual meetings well into the 1980's. However, tensions between the therapists and former patients eventually became too great to surmount and many patient liberation groups ultimately broke with their supporters in the mental health professions.
Civil libertarians were also influenced by the popularity of Laing, Szasz, and Scheff, and as a result began paying closer attention to the practices of mental health professionals. Organizations such as the American Civil Liberties Union and the American Bar Association had in past years devoted increasing attention to the legal issues raised by commitment procedures, but their efforts were limited largely to outlining the law as it then existed and recommending limited changes. As Gerald Grob asserts, these efforts nonetheless had the effect of drawing attention to patient rights and implying that these rights were being violated. This perception was heightened by the proceedings of the Senate Judiciary Committee's Subcommittee on Constitutional Rights, which in 1961 began investigating commitment procedures in the District of Columbia even though there was little evidence that abuses existed; the subcommittee was chaired by Sam Earvin, a Southerner who may have wanted to look tough on civil rights without having to contend with racial issues. New York State and a number of other states responded to initiative such as these by reforming their commitment laws. New York State's new commitment law, which passed in April 1964 and went into effect the following September, greatly reduced the state's reliance upon courtroom commitment hearings, which were widely regarded as humiliating public ordeals. The law also mandated that every involuntary commitment decisions be subject to periodic review and created the Mental Health Information Service, an advocacy and legal advisory service for patients and their families. In 1967, California went even further, enacting legislation that prohibited those who were neither dangerous nor gravely ill from being involuntarily committed for more than seventeen days.
These changes were not sufficient to prevent judicial scrutiny of institutionalization. By the late 1960's and early 1970's, lower federal and state courts, which had traditionally been content to leave mental health policy to psychiatrists, became increasingly willing to intervene when it seemed that patients' civil liberties were being violated. In 1966, Judge David Bazelon of the District of Columbia Circuit Court of Appeals issued a ruling, Rouse v. Cameron, that set the law on a collision course with state commitment procedures. Bazelon asserted that individuals sent to mental hospitals by criminal courts had a right to therapeutic treatment and that denial of such treatment constituted cruel and unusual punishment, denial of due process, and violation of equal protection of the law. Later that year, Bazelon issued another ruling that established patients' right to treatment in the least restrictive setting suited to their condition. Two years later, the Massachusetts Supreme Court followed Bazelon's line of argument and ruled that patients who had been sent to mental hospitals after being deemed incompetent to stand trial for criminal offenses had a right to expect treatment. In New York State, the Court of Claims ruled in 1968 that a man who had been held in Matteawan State Hospital for more than fourteen years because he had allegedly violated his parole had been treated unjustly and awarded him some $300,000 in damages. In the years that followed, many other state and federal courts ruled that some commitment practices violated the Eighth and Fourteenth Amendments. This trend culminated in the U.S. Supreme Court's 1975 decision in O'Connor v. Donaldson. The court did not find that mental patients had a right to treatment, but it unequivocally stated that people who were not dangerous to themselves or others and who were capable of living independently or with assistance from willing family and friends could not be institutionalized against their will. In addition, a number of lower court rulings, including New York City Health and Hospitals Corporation v. Stein, afforded mental patients the right to refuse treatment if they so chose.
In the wake of these decisions, public-interest lawyers, who had during the 1960's begun working with African-Americans, Latinos, women, and other groups traditionally ill-served by the law, started to defend the rights of the mentally ill and the developmentally disabled. In New York State, the New York Civil Liberties Union (NYCLU) initiated a new campaign upon behalf of mental patients. Led by David Ennis, who had little prior knowledge about the inner workings of the mental health system apart from reading of the works of Thomas Szasz, the campaign was also supported by Brooklyn lawyer Morton Birnbaum, the author of a 1960 American Bar Association Journal article that had heavily influenced David Bazelon. The NYCLU initiated New York State Association for Retarded Children v. Rockefeller, the landmark case more popularly known as Willowbrook. Although the court's 1973 ruling stopped short of asserting that people in New York State facilities for the mentally ill, the mentally retarded, and the developmentally disabled had a right to treatment, it found that overcrowding at the Willowbrook State Hospital, a facility for the mentally retarded and the developmentally disabled, violated patients' right to protection from harm and ultimately handed down a consent decree that mandated that all Willowbrook patients were to be placed in community residences. The Willowbrook case gave added impetus to the discharge of patients from state facilities: at least some DMH and other state health officials were afraid that state hospital administrators might eventually have to contend with a Willowbrook-type ruling. In response to this fear, the department may have assigned discharge quotas to administrators of state mental hospitals in an effort to reduce the inpatient census and avert unfavorable legal rulings.
Other factors hastened the decline in hospital populations in New York State and other states. New federal programs made it possible for increasing numbers of mentally ill people who were incapable of supporting themselves to live independently or to be housed in other institutions. Medicaid and Medicare, which resulted in the transfer of large numbers of the aged mentally ill to nursing homes from the mid-1960's onward, were expanded in 1966 to subsidize alternative forms of care for the mentally ill. At the same time, other new Social Security programs were created: Old Age Assistance, Aid to the Permanently and Totally Disabled (ATPD), and Old Age and Survivor Insurance. The states took advantage of these programs, which made matching funds available to them, and discharged increasing numbers of patients from state facilities. Deinstitutionalization accelerated even further in the wake of the 1972 legislation that created two new Social Security programs, Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI). SSI and SSDI were designed to guarantee the mentally and physically disabled a minimum income and to remove the stigma long associated with relief payments; by placing them under the umbrella of Social Security, policymakers hoped that these programs would be regarded as entitlements and thus preserve the dignity of recipients. States, which were concerned less with safeguarding the self-worth of the indigent disabled than with shifting the cost of caring for the disabled to the federal government, rushed to secure SSI and SSDI dollars. All of those receiving APTD benefits before 31 December 1973 were guaranteed SSI benefits, and the states responded by enrolling as many of the seriously mentally ill as they could. In addition, SSI's status as an entitlement meant that the application process could begin before a patient was discharged from a state institution, and hospital personnel often took an active part in helping patients secure SSI benefits.
However, SSI, which gradually superseded APTD and was funded wholly by the federal government, had unanticipated and profound effects upon the treatment of the mentally ill. Ann Braden Johnson notes that the SSI program's emphasis upon the rights and dignity of recipients prevented it from mandating that they seek treatment. In addition, those living in publicly-owned halfway houses designed to ease the transition from the institution to society were not eligible for SSI. Patients who had no desire to continue treatment were not forced to do so, and those who did want to do so at times found it difficult to obtain care. As a result of this combination of program requirements and treatment scarcity, many former state mental patients who received SSI ended up living in nursing homes, single-room occupancy hotels (SRO's), or in the nursing homes and private proprietary homes for adults (PPHA's) that sprang up like mushrooms in the wake of the program's creation. This phenomenon may best be described as reinstitutionalization: life in many PPHA's and nursing homes is every bit as regimented and stultifying as life in the state hospital back wards. Television and print journalists who no longer find the state hospitals rich sources of scandal have not been disappointed by these institutions, some (but not all) of which are characterized by listless and overmedicated residents deprived of all recreation other than television, overworked and sometimes abusive staffers, and administrative corruption.
Mental health care in New York State was also affected by a number of less predictable national developments. The economic stagnation and inflation of the 1970's affected almost every aspect of New York State government, and the DMH encountered its share of cost-cutting initiatives and efforts to ensure its fiscal responsibility. Policymakers' concerns about squandering of resources were almost invariably wedded to criticism of the failures of community mental health programs, which politicians and advocacy organizations saw as inadequate, lacking oversight, and resistant to citizen involvement. The DMH, which remained generally optimistic about the possibility of treating most mental illnesses in community-based outpatient settings, tried to respond to these concerns. In 1973, it created the Office of Citizen Participation in an effort to facilitate public involvement in the creation of community mental health programs, and in 1974 established a citizen advisory council charged with drafting recommendations for mental health, mental retardation, and substance abuse treatment. During its 1975 reorganization, it created a new office dedicated to oversight of expenditures and gave greater power to its Office of Evaluation and Inspection.
State policymakers sought to resolve other problems that beset the agency. In 1973, the state sought to improve community services and ensure adequate care for the severely mentally ill who had been discharged from state institutions by passing the Unified Services Act in 1973. The Unified Services Act, which had the backing of the DMH, strongly encouraged CMHB's to devise plans for the treatment of the mentally ill living that tied local services to those provided by the state. Unified services plans had to coordinate state and local programs and to ensure that "all population groups [were] covered, that there [was] coordination and cooperation among local providers of services, . . . and that there [was] continuity of care among all providers of services." Localities were not compelled to devise unified services plans, but those that chose not to still had to create comprehensive local plans; communities that failed to draft approved unified or local service plans that were acceptable to the DMH would not receive state support. In an effort to induce local governments to create unified services plans, state funding to localities that had such plans approved increased according to a complicated population-based formula. In order to make it easier for CMHB's to devise unified services plans, the DMH created eight regional offices designed to support and guide them. In the following year, the DMH gave the directors of these regional offices sole responsibility for oversight of all local and state mental health programs in their jurisdictions in an effort to improve the fit between state and local programs.
However, local governments were hesitant to devise unified services plans. In the three years following the passage of the Unified Services Act, only the counties of Rensselaer, Rockland, Westchester, and Warren and Washington (which put forth one plan for both counties) put forth plans that the state approved. Niagara County also drew up a plan, but the DMH refused to accept it on the grounds that county officials could not secure the cooperation of one of its largest providers. In February 1976, Governor Hugh Carey placed an eighteen-month moratorium on acceptance of unified services plans and charged the DMH with determining why localities were so slow to respond to the Unified Services Act. DMH Commissioner Lawrence Kolb allotted this investigation to a task force charged with improving mental health services. The task force found that localities were confused by the complex and multi-tiered funding provisions built into the act and intimidated by the prospect of having to coordinate the activities of many different (and sometimes uncooperative) agencies and programs. The permanency of unified services plans, which local authorities regarded as experimental and unprecedented, also gave them; once a locality had put forth an acceptable unified services plan, it did not have the choice of retreating and creating a local services plan if the unified plan proved unsuccessful. Most importantly, local governments were daunted by the prospect of having to increase expenditures for mental health care. Local officials who successfully waded through the Unified Services Act's complex funding formula often realized that a unified services plan would force them to spend more money than they would under a local services plan. As it was, the New York City and Erie and Onondaga counties and other local authorities were reducing mental health expenditures as a result of the economy's downturn. As a result of these problems, the Unified Services Act never produced the results desired by policymakers or the DMH.
Lawmakers, not satisfied with the DMHs efforts to remedy the problems associated with community-based mental health services and state hospital discharge policies, also enacted several pieces of legislation intended to remedy the DMH's shortcomings. From 1975 onward, the department was compelled to take into account the extent to which "consumers, consumer groups, voluntary agencies, and other providers of services" had participated in the development of a given unified services plan when judging whether to approve it. In the following year, the state ordered the DMH to devise a comprehensive plan for the "consolidation [and] realignment of patient care functions" that would simultaneously ensure that patients were receiving adequate care and that resources were not being used inappropriately; the possibility of closing some state hospital facilities was specifically mentioned. At the same time, New York State assumed greater responsibility for the care of the severely mentally ill. In 1974, it passed legislation mandating that all of the costs associated with furnishing aftercare to people who had been patients in state hospitals between 1 January 1969 and 31 December 1973 were to be paid by the state. Another new law made New York State temporarily responsible for paying all public and medical assistance costs incurred by discharged patients who had been institutionalized for at least five years; however, the state's responsibility for costs incurred by a given patient ended after he or she had lived outside of state institutions for five years.
The state's targeting of funds for community care, which was reinforced by the DMH's conscious decision to steer funds away from state hospitals and toward local programs in an effort to discourage use of state facilities, may have resulted in a decline in the quality of care found in state institutions. In 1975, the DMH endured the very public humiliation of having the Creedmoor and Pilgrim Psychiatric Centers stripped of their accreditation. The department was acutely aware that loss of accreditation meant that patients in these facilities were no longer eligible for Medicare and Medicaid reimbursements and publicly proclaimed the need for state facilities to meet accepted standards, but continued to divert funds toward outpatient care, which was still widely regarded as less expensive and more humane than care furnished in state hospitals; the inpatient facilities that were best funded were recently constructed ones that were explicitly designed to fit into the community-centered treatment model. In 1977, the DMH further proved that it was committed to moving patients out of state facilities: in response to the planning mandate of the previous year, it proposed closing the Marcy and Northeast Nassau Psychiatric Centers and merging the three facilities situated on New York City's Ward's Island. It also held out the possibility of closing other facilities, arguing that some should be closed because they were no longer housing significant numbers of patients and others because localities were overutilizing them.
The DMH's efforts to direct more funds away from inpatient care and toward community-based outpatient programs sparked outright opposition from a number of quarters. The public and private organizations that furnished most community-based mental health care in many instances resisted accepting former state hospital patients, who were typically impoverished and unresponsive to psychotherapy. In addition, many providers of community-based care and treatment felt that the state had not adequately informed them of the impending return of large numbers of acutely ill people to society. In the New York City area, local mental health providers who felt that they had been taken by surprise formed the Coalition of Voluntary Mental Health, Mental Retardation, and Alcoholism Agencies in 1972 and lobbied city and state officials in an effort to avoid being saddled with what they saw as unanticipated and unwelcome responsibilities. It is likely that providers of outpatient care working in other parts of New York State publicly resisted the state's efforts to force them to care for the seriously mentally ill or simply furnished just the bare minimum of care needed to remain eligible for state reimbursement. However, their ability to resist was soon reduced by the 1975 federal Mental Health Act, which sought to force community mental health centers receiving federal funds to screen and treat discharged state mental hospital patients.
The DMH and state policymakers encountered even more resistance from the Civil Service Employees' Association (CSEA) and one of its offshoots, the Public Employees' Federation (PEF). The PEF, which represented most of those employed in state hospital facilities, and the CSEA reacted violently to the news that the DMH was contemplating the closure of hospital facilities and loudly protested the privatization of mental health jobs. The CSEA created a highly publicized task force that concluded that the state was "dumping" the acutely ill onto the streets and into substandard PPHA's and that community mental health care providers would never willingly care for the most seriously ill. During the 1978 gubernatorial election, the union ran a brief but devastatingly effective radio and print advertising campaign that accused the state of sacrificing patient welfare in the name of cost-cutting. This campaign, which did little to endear state hospital employees and community-based mental health workers to one another, apparently helped to produce a gubernatorial policy decision that thwarted state and DMH efforts to reduce the role of state facilities in mental health treatment. Shortly after the election, Governor Hugh Carey's chief policy advisor, Robert Morgado, drafted a memorandum that strongly recommended that the staff-patient ratio at state hospitals be increased to roughly 1.0, that hospital officials strive to ensure that all discharges were appropriate, and that employee retraining and transfer programs be implemented. In the wake of Morgado's memorandum, staffing levels apparently increased: an Accountants for the Public Interest study found that in 1981 the staff-patient ratio in state psychiatric facilities, which had been .25 in 1955, had increased to 1.38.
Efforts to reduce the hospital population and create outpatient programs for the seriously mentally ill also provoked increasing opposition from private citizens. Advocates of community-based mental health care had since the 1950's been aware that the public could resist their initiatives, but citizen resistance to the depopulation of state mental hospitals became an increasing concern of policymakers during the 1970's. In part, public resistance may have stemmed from economic conditions: voters who had readily approved local mental health levies in more affluent times were in all likelihood less willing to increase their tax burdens when inflation and unemployment were on the rise. The discharge of large numbers of acutely mentally ill persons also aroused considerable fear about increases in crime and public disorder. Proposals for the creation of community-based residential programs for the mentally ill aroused increasing opposition from homeowners concerned about their physical safety and their property values. In 1976, the Assembly Joint Committee to Study the Department of Mental Hygiene faulted the past practices of the DMH for aggravating public resistance: in previous years, large numbers of ill-equipped patients had been released into communities that were wholly unprepared for their return to society. The combination of fear, anger, and ignorance that greeted community-based efforts to care for the seriously mentally ill remains a serious problem for the state, local and voluntary agencies that support community-based mental health care and treatment.