The Policy Revolution, 1945-1965
Between the enactment of the State Care Act and the passsage of the CMHSA, the government of New York State was almost exclusively responsible for the care of the mentally ill. However, a number of important changes took place during this sixty-year period. During the first decades of the twentieth-century, a growing number of Progressive-era psychiatrists were no longer content to see themselves as state hospital-based purveyors of custodial care and began envisioning a broader role for themselves. Rejecting the nineteenth-century belief that mental illness was biologically based and typically incurable and that psychiatrists' chief responsibility was to furnish humane custodial care, they sought to reestablish psychiatry's ties to the medical profession and adopt its therapeutic orientation. They also sought to bring their expertise to bear upon a broad array of social problems such as alcoholism and venereal disease. Seeing these ills as manifestations of mental disorder, they asserted that safeguarding individual and social mental hygiene would ultimately eradicate these vexing problems. The psychiatrists drawn to the mental hygiene movement, which was spearheaded by the Manhattan-based National Committee for Mental Hygiene (NCMH), were convinced that mental illness had a hereditary component and had little faith in their power to cure it once it had developed. At the same time, they were confident that those predisposed to develop mental disorders could remain healthy if they learned how to respond appropriately to their environment; as a result, champions of mental hygiene believed that teaching adults and, in particular, children how to negotiate adverse personal and social circumstances could help to prevent many (generally less serious) forms of mental illness. The psychiatrists who gravitated toward the movement were also confident in their ability to work in concert with social workers, psychologists, occupational therapists, and other professionals who could help to improve people's mental adjustment; however, by the 1930's many of them felt that these other professionals were challenging their authority and expertise.
The activities of those drawn to the mental hygiene movement were varied. The leaders of the NCMH and other mental hygiene organizations were like other Progressive-era reformers in that they were convinced that scientific study of social problems would highlight potential remedies and force policymakers and the public to take action. As a result, these groups sponsored a number of local studies of mental illness and treatment options; however, their firm belief that mental illness was preventable often overcame their objectivity. They also undertook an ambitious and remarkably successful effort to convince social workers, parent-education groups, and teachers that children were vulnerable to mental illness and that intellectual accomplishment should not come at the expense of personality development. In addition, mental-hygiene organizations spurred the creation of a number of community-based mental health programs, which were sponsored by Community Chest groups, private foundations such as the Rockefeller Foundation, the Laura Spellman Rockefeller Memorial Fund, the Milbank Memorial Fund and the Commonwealth Fund, the State Charities Aid Association, medical schools, and, in some urban areas, city governments. Information about specific programs is scant, but they existed in Albany and the New York City and it is probable that child guidance clinics and other mental hygiene initiatives took shape in other cities.
Adherents of the mental hygiene movement also sought to alter public policy, and their success in gaining the attention of New York State's legislators is evident in the name given a state agency created in 1926: the Department of Mental Hygiene (DMH). The responsibilities of the DMH as it was first constituted were very modest: the agency was to "visit and inspect all institutions, either public or private, used for the care and treatment of" people who were mentally ill, epileptic, or mentally retarded. However, in the following year the state's new Mental Hygiene Law gave the agency the responsibilities and overall structure that it would have for the next fifty years. It made the DMH responsible for the administration of all state-owned institutions caring for those with mental disorders and for insuring that all mentally ill, developmentally disabled, and epileptic New Yorkers received appropriate care. One provision of the Mental Hygiene Law further testified to the influence of the mental hygiene movement upon state policy: it mandated the creation of a DMH Division of Prevention, which was to monitor "psychiatric field work [and] after care and community supervision" of individuals discharged from state hospitals and perform other activities needed to avert the development of mental disorders.
At the same time as psychiatric champions sought to expand their professional influence beyond the grounds of state mental hospitals, psychiatric activities within these institutions were changing substantially. The years between the First and Second World Wars witnessed the development of new therapies that initially seemed quite promising: fever therapy, which was developed during the 1920's, the surgical procedure known as prefrontal lobotomy, which emerged a decade later and seemed to promise an end to uncontrollable violence and a cure for at least some patients who were not helped by other therapies, insulin and metrazol shock therapies, which also came into use in the 1930's, and electro-convulsive treatment, which was used in the United States from the early 1940's onward and replaced insulin and metrazol as the shock treatment of choice. Psychiatrists were often extremely ambivalent about these therapies, which were drastic and poorly understood. Shock and surgical treatments sometimes produced modest or pronounced improvements, but even their leading proponents did not understand how or why they worked. This uncertainty aside, the aggressive therapeutic stance that underlay these therapies was a manifestation of psychiatrists' desire to prove themselves to be competent physicians.
As important as these therapeutic innovations were, they were not the only developments shaping psychiatrists' attitudes about state mental institutions. A number of phenomena taking place outside of the mental health field posed great difficulties for state hospital administrators and grave problems for their patients. The economic hardships of the Great Depression resulted in pervasive overcrowding, staff shortages, and deterioration of facilities' physical plants. These problems worsened throughout the Second World War, which siphoned resources and personnel away from state hospitals and other institutions serving the civilian population. After the war ended, this constellation of problems gave rise to a concerted professional and public campaign for improvement of hospital conditions. Reformers had long been critical of the level of care furnished in most state mental hospitals, but after the end of the Second World War their condemnation of state institutions became increasingly vocal. Albert Deutsch, author of the classic postwar polemic, The Shame of the States, and other reformers who penned exposÚs of institutional conditions began calling not only for dramatic improvements in hospital conditions but a fundamental reevaluation of the role of state facilities in the care and treatment of the mentally ill. Their writings, which almost uniformly depicted state hospitals as dens of great and pointless suffering, to this day exert lingering influence upon popular and scholarly conceptions of mental institutions.
Postwar lay reformers were not alone in questioning the existence of state mental hospitals. Psychiatrists themselves called for nothing less than a revolutionary change in the treatment of the mentally ill. The profession's prewar efforts to broaden its responsibilities and loosen its ties to state institutions came to full fruition as a growing number of its practitioners began denouncing mental hospitals. Psychiatrists who had treated military personnel suffering from combat-related mental illness found that this patient cohort responded best to immediate, short-term care furnished outside of the asylum environment. In addition, many of them shared the public's shock and revulsion at the dilapidation and overcrowding that existed in many state facilities. The combination of wartime therapeutic successes and disgust at existing institutional conditions led a growing number of psychiatrists to see traditional mental hospitals as inherently detrimental to patients. Convinced that the mental illnesses found in the civilian population were essentially identical to those suffered by military personnel and that state institutions were impeding effective treatment, they began stressing the environmental dimensions of mental disease and the efficacy of outpatient-based therapy and preventative care.
The psychiatric professions postwar shift toward environmental models of mental illness should not be exaggerated. Some practitioners remained convinced that mental disorders were biological in origin or that they were largely incurable, and the American Psychiatric Association (APA) and other psychiatric professional organizations endured bitter battles over theories of etiology, personality formation, behavioral motivation, and treatment models during the late 1940's and 1950's. Furthermore, even die-hard environmentalists embraced Thorazine and other new psychiatric drugs that appeared in the mid-1950's and shared the profession's belief that these new medicines would facilitate outpatient treatment. Nonetheless, those dissatisfied with the traditional inpatient hospital and somatic theories about the etiology of mental illness were very much in the ascendant, and their influence is manifest in post-war legislative developments. Even before the end of the Second World War, reform-oriented mental health professionals such as Robert Felix, the head of the Public Health Service's Division of Mental Hygiene, began lobbying for federal funding of treatment of and research concerning mental illness. The efforts of Felix and others gave impetus to the 1946 National Mental Health Act (NMHA), which sanctioned the disbursement of funds to researchers studying the etiology and treatment of mental illness, to institutions educating mental health professionals, and to states desiring to establish or maintain local mental health programs. The NMHA also provided for the establishment of a new division of the National Institute of Health, the National Institute for Mental Health (NIMH), which would be responsible for evaluating grant applications and monitoring funded projects; the NIMH was formally established in 1949, and Robert Felix served as its head from 1949-64. The Hill-Burton Act, also passed in 1946, provided funds for construction of mental hospitals and psychiatric wings in general hospitals and thus further increased federal involvement in mental health care.
Federal developments were paralleled by those taking shape at the state level. Although mental health was rarely their top concern, state politicians shared professional and broader public concerns about institutional conditions, and they were also concerned about the cost of caring for the mentally ill. Those in New York State, which had by far the largest number of institutionalized patients, were particularly eager to alter the manner in which care was provided and funded. Community treatment and prevention programs took shape in almost every state during the 1950's, and state funding for such programs rapidly outstripped federal support. In New York, legislation enacted in 1949 created the New York State Mental Health Commission (SMHC) within the DMH. The SMHC, which was to meet annually between 1949-54 and to submit to the legislature a final report outlining its recommendations in February 1954, was charged with creating a master plan for state mental health programs. Components of this master plan were to include, among other things, facilitating the recruitment and training of needed mental health personnel, planning and developing needed in- and outpatient services for children and adults, sponsoring needed research, and coordinating the activities of public and private agencies working in any given community.
The SMHC ultimately concluded that public demand for community-based mental health care was increasing, that such care was in egregiously short supply in every part of the state, that the availability of such care varied widely from one locality to the next, that there was no single local government agency accountable for community mental health programs, and that the efforts of various state agencies to establish programs for populations in need led to local-level confusion. These findings and politicians' ever-present concerns about the escalating cost of supporting the state's mental hospitals, which cared for roughly one-fifth of the nation's 559,000 psychiatric inpatients, helped to propel passage of New York State's Community Mental Health Services Act (CMHSA), the first legislation of its kind in the United States. State politicians who feared that funding community-based services would place further pressure on the state budget were ultimately persuaded to support the act by the mounting expense of inpatient treatment and predictions that state hospital admissions would increase and that community-based care would be cheaper than treatment furnished in state institutions, and psychiatrists assertions that community-based care was more humane and effective.
The CMHSA encouraged but did not compel the governments of counties and of cities of more than 50,000 people to establish community mental health boards (CMHB's); New York City was exempted from these guidelines and instructed to create a single CMHB for all five boroughs. By law, CMHB's were composed of the locality's ranking health and welfare officials and at least two physicians and headed by psychiatrists; other local officials and representatives from community service groups were allowed to sit on them. CMHB's were to assume responsibility for identifying and planning to meet the mental health needs of their communities and administering all locally-based in- and outpatient preventative, treatment, rehabilitation, and educational/consultative programs. In effect, the act gave CMHB's a sweeping mandate but little concrete direction. The CMHSA also sought to induce localities to act by compelling the state to reimburse half of a given CMHB's approved expenditures. The CMHSA capped the reimbursement that a given CMHB could request at $1.00 per capita of the general population it served. Although this figure sounds low, the intent of those who drafted the reimbursement provision was to double the existing level of care in the best-served parts of the state. At the same time, legislators passed a bond act designed to raise $350,000,000 for construction of new state hospital facilities and the planned community mental health centers; the act, which attached mental health construction bonds to an existing bond act designed to provide bonuses to World War II veterans and their families, was subsequently approved by voters.
The move toward community-based and -controlled mental health care was given added momentum by changes in the operations of state mental hospitals. The open hospital movement, which emerged in Great Britain in the late 1940's and early 1950's and, in the wake of British presentations at the 1954 World Association for Mental Health conference in Toronto, began shaping inpatient mental health care in the United States during the mid- to late 1950's. Its adherents believed that state institutions as they then existed infantilized patients and intensified their mental illnesses. They argued that that involuntary commitment and institutional regimentation, no matter how gentle, robbed patients of decision-making abilities and other skills they needed to function in society. They also urged that commitment to mental hospitals be largely voluntary and that hospitals allow patients the greatest possible control over their own movements and behavior; high walls, tight schedules, and security checks were to be replaced by open facilities that allowed patients to choose how and where they would spend their time. Lastly, proponents of the open hospital envisioned a smaller treatment role for the hospital, stressing that institutionalization should be of short duration and that it should become part of an array of in- and outpatient programs designed to allow the mentally ill to return to society as soon as possible. As Gerald Grob notes, their ultimate goal was "to blur the demarcation between . . . hospital and community."
New York State mental health officials and professionals found the open hospital concept highly attractive. In 1957, DMH Commissioner Paul H. Hoch sent six state mental hospital administrators to Britain to study open facilities. All six became adherents of the concept, and by late 1959, seventy percent of the patients at the Central Islip State Hospital, eighty percent of those at the Brooklyn State Hospital, and ninety percent of those at the Hudson River and Middletown State Hospitals resided in open wards. Hoch and other New York State professionals who advocated the creation of open hospitals were aided by the New York City-based Milbank Memorial Fund, which had since 1922 provided money for public health projects and studies in New York State and had become interested in mental health issues during the 1930's. The fund financed the 1957 hospital administrators' tour of British facilities and held annual conferences at which American, Canadian, and British mental health professionals detailed their efforts to create effective prevention, treatment, and rehabilitation projects. In turn, high-ranking New York State mental health officials helped guide the funds activities: Commissioner Hoch and Hudson River State Hospital head Dr. Robert C. Hunt sat on its Technical Board.
New York State advocates of the open hospital identified several obstacles that stood in their way. They felt that the courts were overly concerned about the possibility that lowering the number of involuntary commitments might increase the crime rate, and they believed that the general public's lack of knowledge about the nature of mental illness was impeding progress. They also perceived another hurdle specific to New York State: the 1890 State Care Act, which made treatment of the mentally ill the exclusive responsibility of the state. In 1957, Robert Hunt charged that:
"The state [had] . . . in effect established a system that allows everyone else to be irresponsible. Local government, general hospitals, practicing physicians, individual citizens, and patients long since abdicated to the state all responsibility for caring for their fellow man when he becomes mentally ill. In New York State local officials can . . . dispose of a problem case with no cost whatever [sic] to any local agency or to the family. They may actually make a profit by removing a name from the welfare rolls."
Not all advocates of community mental health care believed that local politicians were obsessively stingy. However, Hunt's argument continually resurfaced in subsequent decades. In 1965, the New York State Planning Committee on Mental Disorders, which was composed of state officials, mental health professionals, CMHB members, and representatives from interested private groups, argued that "choice of treatment facility should be based on the needs of the patient" and implied that ending "exclusive State fiscal responsibility for State hospital care" would result in more appropriate treatment. In 1976, the Assembly Joint Committee to Study the Department of Mental Hygiene noted that "the presence of a State facility in a county [could] inhibit the development of local programs because it [was] easier and less costly for the locality to use the State facility."
Not surprisingly, the enthusiasm of Hoch, Hunt, and other New York State mental health professionals for community health care programs far exceeded the rate of program development. Community-based programs took shape gradually and CMHB personnel benefited from the creation in 1956 of the Association of Community Mental Health Boards (ACMHB), which from 1957 onward sponsored annual conferences intended to allow CMHB members to share their experiences. However, progress did not occur at the speed that reformers wanted. Stanley Davies, who in 1959 conducted a study of CMHB's for the New York Association for Mental Health, underscored the slow rate of change. Davies visited thirty of the thirty-one counties that had CMHB's or community mental health programs in place in late 1959, and found that there were 171 outpatient mental health clinics in operation (seventy-nine of which were in New York City), general psychiatric wards in eighteen hospitals, thirty-six consultative and educational programs, and four rehabilitation programs. The sole responsibility of the CMHB's in the thirteen rural counties, which he defined as those that had less than 200,000 inhabitants, was the administration of all-purpose part- or full-time clinics; in six of these counties, these clinics did not exist prior to the formation of the county CMHB.
In explaining why the pace of change was so slow, Davies pointed to a number of issues. Funding was a persistent problem, and CMHB's that operated in rural areas often found it particularly difficult to secure adequate funds. Rural CMHB's also found it hard to induce qualified psychiatrists, psychologists, social workers, and other needed personnel to move away from cities. In addition, those that were established in counties without existing social-welfare and child-services agencies were besieged by people with needs and problems that fell outside of the CMHB's legal mandate. Urban-area CMHB's, which typically inherited control of programs that were already in existence and worked with voluntary organizations seeking state reimbursement, encountered a different set of problems. Local governments that had financed community initiatives and voluntary mental-health programs were eager to secure state funds, and urban CMHB's were beset by reimbursement demands as soon as they were formed. These demands and the administrative functions that these CMHB's were forced to perform almost immediately after they came into existence often consumed all of their time and resources, and they were unable to fulfil the planning component of their mission. In addition, CMHB's that assumed control over or, as was more common, established service contracts with existing programs sometimes found that program personnel saw them as usurpers. The CMHB governing community health programs in New York City, which furnished the highest level of local services in New York State, encountered particular difficulties. Demand for reimbursement was such that the citys CMHB quickly reached the maximum established by the CMHSA and could not establish any other programs.
Davies also discovered that the availability of care continued to vary widely from one part of the state to the next, and he identified another difficulty stemming from the provisions of the CMHSA: localities that did not wish to establish a CMHB were under no obligation to do so, and a number of counties, almost all of which were rural, had witnessed failed attempts at persuading county officials and the broader public that community-based mental health services were needed. Stressing that the solution to this problem lay in the education of citizens and local politicians, Davies did not argue that communities should be compelled to create CMHB's or to allocate funds for community programs. However, in highlighting the role of citizen resistance in retarding the creation community programs he identified a problem that in future decades would continue to bedevil advocates of locally-based prevention, treatment, and rehabilitation: the public's ongoing ignorance about mental illness and persistent preference for segregation of the mentally ill in isolated institutions.
Davies did not explicitly single out one other factor that helped to retard the development of community mental-health programs: the imprecision of the CMHSA as to priorities and target clienteles. Responsibility for making such assessments was placed in the hands of individual CMHBs with the laudable intent of allowing each community to create programs and policies that best met its unique circumstances and needs. However, assigning primary responsibility for effecting radical changes in mental health policy to inexperienced local organizations virtually guaranteed that progress would be slow. State officials became increasingly aware that CMHB's were in need of guidance, and in 1959 the DMH created ten Regional Mental Health Advisory Committees (RMHAC's) that were charged with helping CMHB's plan, implement, and administer programs. In 1962, the DMH created the positions of Associate Commissioner for Community Services and Assistant Commissioner for Community Services in an effort to facilitate the development of local programs. In 1965, it underwent a structural reorganization that made the newly created Division of Local Services one of its three main operating divisions.
The lack of coordination between state and local efforts nonetheless persisted. The obstacles encountered by CMHB's and their champions within the DMH were many and their origins complex. The difficulty of coordinating local and state initiatives and creating a comprehensive array of in- and outpatient services was the subject of the 1961 annual conference of the Milbank Memorial Fund. At the conference, future Commissioner of Mental Hygiene Dr. Lawrence R. Kolb argued that research- oriented and teaching hospitals, long noted for furnishing high levels of care to the mentally ill, could nonetheless act in ways that were counterproductive. Their admissions policies were guided in part by the need for exemplary teaching and research cases, and as a result some patients who were in great need of care were turned away. Such policies often resulted in a poor fit between the hospital and community it served and also served students and researchers poorly: those exposed only to these carefully selected cases failed to grasp the actual distribution of mental illness within communities or to appreciate the role of community-based programs in aiding the mentally ill. Others present at the conference highlighted the persistence of staffing shortages, localities' reluctance to fund programs, and the dearth of rehabilitative programs designed to ease the return from the mental hospital to society.
Despite these difficulties in implementation, the New York State CMHSA anticipated developments taking place in other states. California, New Jersey, and Minnesota passed similar laws in 1957, and mental health authorities in other states began implementing similar programs without benefit of legislative mandate. New York States new mental health policy also set the course changes that took place on the federal level. In the early 1950s interested members of Congress, federal officials working within the NIMH and the Department of Health, Education, and Welfare (HEW), and mental health professionals active in the APA and the American Medical Association (AMA) agreed that the federal government should take a more active role in financing and directing mental health care. In 1955, they established the Joint Commission on Mental Illness and Health (JCMIH), which was sponsored by APA and AMA but supported in part by federal funds. The JCMIH issued its final report, entitled Action for Mental Health, in 1961. Action for Mental Health outlined a comprehensive plan that called for federal support for construction and staffing of community mental health centers. Neither the AMA nor the APA unconditionally accepted the recommendations of the JCMIH, which nonetheless guided the development of federal mental health policy. In 1963, the Community Mental Health Centers Construction Act (CMHCCA), which authorized funds to help defray the costs of constructing (but not staffing) local clinics, was enacted; federal support for staffing, which was administered by HEW, was passed in August 1965. The CMHCCA also established federal funding for the care and training of the mentally retarded and developmentally disabled, whose circumstances were of particular concern to President John F. Kennedy, other members of the Kennedy family, and a growing number of citizen advocates. However, the CMHCCA, which constituted a radical break from previous national mental health policy in both the kind of facilities it supported and the degree of direct federal involvement that it represented, did not clearly define the functions and target clientele of the community centers or their relationship to other local health-care institutions. In its imprecision, it strongly resembled New York State's CMHSA.
The CMHCCA reinforced New York State's move toward community-based provision of mental health care. Under its provisions, funds were made available for every state that devised plans for community mental health programs and facility construction, designated an agency to execute them, and appointed a broadly representative advisory council to guide state policy. In New York State, DMH Commissioner Paul Hoch applied for a planning grant from the NIMH and after approval of his request in May 1963 appointed a Planning Committee on Mental Disorders (PCMD) composed of DMH and other state officials, CMHB members, representatives of professional organizations, and leaders of voluntary advocacy groups. Hoch also ordered all of the RMHAC's to appoint regional planning committees that would report to the PCMD. In order to take full advantage of the federal funds that the CMHCCA made available, in summer 1964 Governor Nelson Rockefeller made the DMH solely responsible for meeting the needs of New York States mentally retarded and developmentally disabled citizens. As a result, Commissioner Hoch created a Mental Retardation Section within the PCMD and urged all of the RMHAC's to appoint developmental-disability experts to the regional committees. New York State was one of the first to receive CMHCCA funds, and as of 1966 it had gotten $6,600,000 for construction of community centers and another $1,500,000 for construction of facilities for the mentally disabled.
However, New York State's increasing expenditures upon mental health center construction and staffing were not propelled solely by the availability of federal funds. Elected officials buoyed by the booming economy and promises that community mental health care initiatives would in the long run save money created a number of new funding initiatives. In April 1963, roughly six months before the CMHCCA became law, legislation established the New York State Mental Hygiene Facilities Improvement Corporation (MHFIC), a public-benefit corporation run by the DMH commissioner and two trustees appointed by the governor. The MHFIC, which began its work in January 1964, was empowered to plan, undertake, and direct construction and rehabilitation of facilities for the mentally ill, the mentally retarded, and the developmentally disabled, and it was given control over all local, state, and federal monies intended for these purposes. The MHFIC could also purchase or lease real estate and buildings needed for the creation, expansion, or renovation of mental health facilities. At the same time, the Housing Finance Authority (HFA), which had been established to promote the construction of affordable housing, was given the power to furnish loans for the construction of schools and hospitals; as of 1966, the HFA had loaned $600,000,000 for mental health facility construction. The same piece of legislation also created the Mental Health Services Fund, which was financed out of the surplus monies that the MHFIC returned to the state comptroller at the end of the year and helped to support personnel training and research activities.
In the wake of the CMHCCA's passage, New York State devoted even more funds to facility construction. In early 1965, Governor Nelson Rockefeller announced plans for a mammoth construction initiative. Five hospitals designed to replace outdated facilities, twelve hospitals exclusively for children, and eight state schools for the developmentally disabled were planned; in the following year, work began upon four of the hospitals and nine new rehabilitation wings at existing facilities. In 1965, new state legislation enabled local governments to seek state reimbursement of up to one-third of the capital costs and one-half of the operating costs incurred by community mental health centers and psychiatric wings within public hospitals; this legislation also raised the expenditure ceiling for community mental health programs, which had been raised to $1.20 per capita in 1960, to $1.40 per capita and waived this limit for communities that met certain qualifications. However, the legislative developments of 1963 and 1965 should not be seen as signs that state government was consciously seeking to micro-manage community-based mental health care. State expenditures for construction, equipment, and training certainly increased, but policymakers were convinced that the programs housed within state-financed buildings should be controlled largely by local authorities. A pamphlet sent to local officials during the latter half of the 1960's stressed that even though the MHFIC would design, construct, and equip facilities and the HFA would finance construction, municipalities would be responsible for their maintenance and operation; after the bonds that had financed construction were retired, localities would also assume ownership of the facilities that the HFA and the MHFIC had built.
The Department of Mental Hygiene also moved to take advantage of various sources of federal funds that became available as a result of programs created or expanded during the administration of Lyndon Johnson. In 1966, it published a handbook detailing the monies available to state and local mental-health programs through the NIMH and other divisions of HEW, the Department of Labor, and the Office of Economic Opportunity; the guide also outlined federal funding sources for programs serving the developmentally disabled. However, the most significant new federal programs were Medicare, a federally-funded health insurance program for senior citizens, and Medicaid, a health insurance program for the needy jointly financed by the federal, state, and local governments. Both of these programs, which were enacted in 1965, covered some forms of mental health treatment and greatly altered the care given mentally ill persons. The framers of these laws sharply limited Medicare and Medicaid reimbursement for care furnished in state mental hospitals; in keeping with prevailing opinion, they believed that state facilities placed far less emphasis upon treatment than psychiatric wings situated in general hospitals. They also made impoverished mentally ill persons under the age of sixty-five ineligible for Medicaid coverage. These stipulations had unanticipated and dramatic consequences. Mental hospital administrators across the nation began moving the aged mentally ill, who had long constituted a substantial proportion of the institutionalized population, out of state hospitals. Some mentally ill senior citizens were sent to psychiatric facilities attached to general hospitals, but the great majority ended up in nursing homes. New York State was not an exception to this trend, which was often detrimental to those moved out of state facilities and yet beneficial to those who remained within. In subsequent years, the DMH realized that its rush to move mental patients into nursing homes was in some respects ill-considered: by the mid-1970's, nursing home operators who had in the past had negative experiences with former state hospital patients and local social welfare agencies that had no desire to fund any of the costs associated with nursing home care heartily resisted the DMH's efforts to place discharged patients in such facilities.
The unexpected consequences of Medicare and Medicaid regulations were not offset by dramatic successes in the creation of community-based mental health facilities. As of early 1967, one hundred centers across the nation had received CMHCCA funds, forty-seven centers had been granted monies for staffing, and twenty-six centers were receiving federal support for both construction and staffing. The pace of center development fell far short of the projections of CMHCCA proponents, who envisioned the relatively rapid creation of some 2,000 centers nationwide. Gerald Grob argues that the slow growth of community centers at the federal level was in part the result of increased competition for funds within HEW and persistent shortages of qualified mental-health personnel. He also underscores the impact of the escalating conflict in Vietnam, which increasingly occupied the attention of President Johnson and the public at large and drained money from social welfare programs, upon federal mental health expenditures.
Grob also highlights the shortcomings inherent in the centers themselves. Beliefs about etiology and treatment held by the staffers of many centers remained nebulous, ensuring wide variation in the scope and kinds of therapies that the centers offered. Furthermore, centers focused increasing attention and resources upon those who had less serious forms of mental illness. In part, this shift was due to the increasing role that psychologists played in furnishing treatment. Psychologists, who tended to reject somatic explanations of the etiology of mental illness and were relatively uninterested in furnishing care to the most seriously mentally ill, were employed in ever-greater numbers in community centers. Relations between psychiatrists and psychologists had been tense since the 1930's, but in the 1960's psychologists challenges to psychiatry's pre-eminence in the field of mental health at last came to fruition. However, psychologists were not alone in their dislike of treating the acutely mentally ill. Psychiatrists who worked in the centers often saw themselves chiefly as providers of psychotherapy, a therapeutic tool that was resource-intensive and most efficacious when used with educated patients who had relatively minor mental disorders.
Other factors hampered the effectiveness of the centers. Programs designed to help to smooth the transition from institutionalization to life in the larger community often fit poorly with the community center model and were not always eligible for government funding. As a result, these essential components of the new mental health system envisioned by champions of community programs were few and far between. In addition, the CMHCCA's insistence that centers be controlled locally rendered them vulnerable to increasing community demands for services such as substance abuse treatment and counseling designed to help people resolve personal problems. From 1968 onward, federal laws mandating that centers treat substance abuse, a growing public concern, compelled the centers to provide such care. Local control of centers also gave rise to the same problem that New York State experienced in the wake of the CMHSA: lack of coordination between different treatment programs. Lastly, it set the stage for bitter internal struggles that beset many centers as a result of the social, cultural and political upheavals of the late 1960's and early 1970's.