Measuring Agency Investment in Community Mental Health Stephen Z. Cohen, Ph.D.* William J. Reid, D.S.W. Lawrence K. Berg, Ph.D.
ABSTRACT: This paper reports a study of the extent to which essential elenzents of community mental health are part of mental health agencies' practices. A sample of 263 social workers reported on the nature of programming and services of 19 nzental health facilities ranging front city and state community nzental health centers to inpatient psychiatric hospitals. All agencies were found to be engaged primarily in diagnosis and treatment, and such community mental health components as primary prevention, coordination, continuity of care, and use of comnzunity boards were virtually nonexistent. Possible explanations and implications of these findings are discussed.
C o m m u n i t y mental health, psychiatry's great " t h i r d revo l u t i o n , " for a long time has b e e n primarily a set of idealized formulations in the heads of contributors to professional journals a b o u t h o w the mentally ill should be served. In recent years, h o w e v e r , m a n y c o m p o n e n t s of this highly complex, m u l t i d i m e n s i o n a l set of ideas have b e c o m e o p e r a t i o n a l i z e d into the programs and practices of i n d i v i d u a l agencies and the mental health systems of state and local g o v e r n m e n t s . Pressure to m o v e in this direction has come from (1) federal legislation w h i c h has given substantial s u p p o r t to d e v e l o p m e n t of c o m m u n i t y mental health centers and programs; (2) increased public concern o v e r failure of the existing a p p r o a c h e s and greater public i n v o l v e m e n t in decision m a k i n g regarding provision of health and welfare services in general; and (3) m o v e m e n t w i t h i n the helping professions from concern a b o u t professional elitism, ineffectiveness, and exclusionary practices t o w a r d actions that w o u l d i m p r o v e the quality of care and treatment. It is not u n c o m m o n for practical application to lag far b e h i n d theory. Yet the ultimate merit of any t h e o r y rests on an assessment of the realization of its operations. The purpose of this p a p e r is to r e p o r t findings of a study, a portion of w h i c h was d e s i g n e d to m e a s u r e the extent to w h i c h c o m m u n i t y mental health concepts have b e c o m e incorporated into actual agency practice. In addition, the s t u d y design included an e x a m i n a t i o n of the specific practices of social workers in settings c o m m i t t e d to the practice of c o m m u nity mental health as well as in agencies and hospitals e n g a g e d in a more tra-
* Dr. Cohen is Associate Professor at the Jane Addams School of Social Work, University off Illinois, Chicago Circle, Box 4348, Chicago, Illinois 60680. Dr. Reid is a George Herbert Jones Professor of Social Work at the School of Social Service Administration. Dr. Berg is Assistant Professor at the School of Social Work and Community Planning, the University of Maryland at Baltimore. The paper is based on a project supported by grants from the National Institute of Mental Health (USPHS 5-TO 1 MH 12008) and the U.S. Department of Health, Education, and Welfare (SRS-98-P-O0500/5). Community Mental Health Journal, VoL 11 (3), 1975
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ditional a p p r o a c h to service. Details of this s t u d y have been reported elsewhere (Berg, Reid, & C o h e n , 1972). C O M M U N I T Y MENTAL H E A L T H THEORY The C o m m u n i t y Mental Health Centers Act (U.S. Congress, Senate, 1963) p r o v i d e d guidelines on those elements that s h o u l d be .included in c o m m u n i t y mental health programs. These included the n o w f a m o u s five essential services: (1) inpatient services, (2) o u t p a t i e n t services, (3) partial hospitalization, (4) e m e r g e n c y service, and (5) consultation and education. These guidelines anticipated that an additional five services--(a) diagnostic service, (b) rehabilitation, (c) precare, (d) aftercare, and (e) training, research, and e v a l u a t i o n - - w o u l d b e c o m e part of a c o m p r e h e n s i v e comm u n i t y mental health center program. A d d i t i o n a l criteria are listed in federal regulations as c o n d i t i o n s for comm u n i t y mental health grants (Glasscote, Sussex, C u m m i n g , & Smith, 1969). A c o m m u n i t y mental health center m u s t p r o v i d e services to a specific geographic or c a t c h m e n t area. It m u s t make p r o g r a m s available to p e r s o n s of all ages but w i t h special attention to children and p e r s o n s over 65 years of age. Qualified n o n p s y c h i a t r i c p h y s i c i a n s must be included a m o n g those providing treatment and follow-up care to patients. Services m u s t be available for all diagnostic categories; that is, a c o m p r e h e n s i v e array of services for all types of mental illness m u s t be provided. Finally, services m u s t be o r g a n i z e d to direct patients to services as n e e d e d , thus i n s u r i n g c o n t i n u i t y of care. The federal g o v e r n m e n t does not attempt to regulate p r o g r a m philosophies. The p r o v i s i o n of specific services is in itself a sufficient prec o n d i t i o n for receiving grants. The a p p r o a c h or p h i l o s o p h y that m a y u n d e r lie those services is left to the discretion of the particular agency. A l t h o u g h there is still a wide difference of o p i n i o n r e g a r d i n g what, precisely, constitutes a c o m m u n i t y mental health approach, a review of the literature in the field reveals recurring general principles (Baker & Schulberg, 1967; Bellak, 1964; Bellak & Barton, 1969; B i n d m a n & Spiegel, 1969; Caplan, 1964; Lamb, 1969)
1. Community mental health is an outgrowth of public health and should make adequate use of public health principles in meeting the mental health needs of a community. 2. There should be active involvement of community residents and other agencies in programs, as well as the direct involvement of various nonprofessionals and professionals other than psychiatrists, in the care of the mentally ill. 3. High priority should be given to indirect, preventive services provided to organizations and individuals who are directly in touch with community residents. 4. Treatment and rehabilitation of high-risk populations and "unattractive patients" should be given priority. 5. Treatment should at all times be guided by a commitment to "minimal intervention." 6. There should be a continuous recognition of the significance of social, economic, and cultural factors, as well as the intrapsychic determinants of human behavior, and when necessary these factors should be taken into account in developing intervention programs.
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7. Short-term hospitalization in small hospitals should be made available when needed; the large state hospital, providing custodial care, should be phased out. 8. There should be ongoing research as well as systematic evaluation of program effectiveness. 9. There should be a commitment to the use of local community boards or other indigenous structures in identifying problems and developing programs. These u n d e r l y i n g principles, t o g e t h e r w i t h the services a n d criteria listed as a p r e c o n d i t i o n for federal grants, constitute the d e f i n i t i o n of the c o m m u nity m e n t a l health a p p r o a c h u s e d in the study. THE SAMPLE OF A G E N C I E S The s t u d y was d e s i g n e d to e x a m i n e role p e r f o r m a n c e a n d role p r o b l e m s of social w o r k e r s in o r g a n i z a t i o n s a n d agencies w i t h v a r y i n g d e g r e e s of e m p h a s i s on c o m m u n i t y m e n t a l health p r o g r a m s . Three o r g a n i z a tions s e r v i n g the m e t r o p o l i t a n area of Chicago a n d one in N e w York City p r o v i d e d the 19 separate facilities that ' c o n s t i t u t e d the s a m p l e of agencies. Of these, 16 w e r e s u b u n i t s of the Illinois D e p a r t m e n t of Mental Health, of w h i c h 13 w e r e s u b r e g i o n facilities s e r v i n g p o p u l a t i o n s of 75,000 to 200,000 p e r s o n s in the Chicago m e t r o p o l i t a n area. T h e s e s u b r e g i o n facilities h a d b e e n o p e r a t i n g for 4 years u n d e r d e p a r t m e n t g u i d e l i n e s that s u p p o r t e d or r e q u i r e d such c o m m u n i t y m e n t a l health c o m p o n e n t s as c o m m i t m e n t to a defined p o p u l a t i o n , c o m p r e h e n s i v e c o n t i n u i t y of care, c o m m u n i t y involvem e n t , a n d priority to h i g h - r i s k groups. Because of these factors, these facilities offered an o p p o r t u n i t y to s t u d y the n a t u r e of c o m m u n i t y m e n t a l health practice in a large u r b a n area. The r e m a i n i n g three units of the Illinois D e p a r t m e n t of Mental H e a l t h w e r e the R e a d - C h i c a g o State Mental H e a l t h Center, the M a n t e n o State Hospital, a n d the Illinois State Psychiatric Institute. Because these are agencies w h o s e p r i m a r y f u n c t i o n is service to psychiatric inpatients, little o r i e n t a t i o n to c o m m u n i t y m e n t a l health ideolo g y or practice w a s expected. T h e i r inclusion p r o v i d e d m o r e traditional m e n tal health practice a p p r o a c h e s against w h i c h selected features of c o m m u n i t y m e n t a l health practice could be c o m p a r e d . The Chicago Board of H e a l t h o p e r a t e s 15 m e n t a l health clinics, each of w h i c h is r e s p o n s i b l e for a particular c a t c h m e n t area; all are also k n o w n to be o r i e n t e d to a c o m m u n i t y m e n t a l health a p p r o a c h . The small n u m b e r of res p o n d e n t s w i t h i n each clinic r e q u i r e d that all 15 Board of H e a l t h clinics be treated as a single agency. It was a n t i c i p a t e d that this a g e n c y w o u l d d e m onstrate h i g h c o m m i t m e n t to a c o m m u n i t y m e n t a l health a p p r o a c h . Michael Reese, a general hospital in Chicago w i t h a s u b s t a n t i a l psychiatric i n p a t i e n t a n d o u t p a t i e n t p r o g r a m , a n d Hillside Hospital, a v o l u n t a r y psychiatric hospital in N e w York City, b e c a m e the final two m e m b e r s of the a g e n c y s a m p l e p r o v i d i n g a d d i t i o n a l contrast w i t h a n o n - c o m m u n i t y m e n t a l health service. It w a s felt that the 19 agencies offered a r a n g e f r o m h i g h to low o r i e n t a t i o n to c o m m u n i t y m e n t a l health a n d w o u l d allow c o m p a r a t i v e analysis of overall p r o g r a m focus, social w o r k e r characteristics, social w o r k roles, and role p r o b l e m s . A l t h o u g h the s a m p l e of agencies w a s limited p r i m a r ily to Chicago, we w e r e r e a s o n a b l y c o n f i d e n t that o u r selection c o n t a i n e d
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most major facilities in Chicago with c o m m u n i t y mental health programs. Thus the s t u d y p r o v i d e s a profile of c o m m u n i t y mental health programs in a principal American city. THE SAMPLE OF SOCIAL WORKERS The 19 agencies p r o v i d e d the names of 377 social workers w i t h and w i t h o u t a master's degree in social work. Q u e s t i o n n a i r e s were sent d u r i n g the spring of 1971; 263 (70%) were returned. Of these, 189 (72%) held a master of social work degree and 74 (28%) were persons w i t h a college degree (other than M.S.W.) w h o s e job title or function was "social w o r k e r . " This sample of social workers p r o v i d e d , t h r o u g h a self-administered instrument, the s t u d y data that included: (1) biographical data, (2) a m o u n t of time workers spent in selected work activities, (3) p r o g r a m focuses of the e m p l o y i n g agencies, (4) w o r k e r perception of role problems, (5) c o m m u n i t y mental health ideology, (6) p e r c e p t i o n of value of graduate social work education for work roles, (7) a m o u n t of interaction w i t h other professionals, (8) extent of organizational b o u n d a r y - s p a n n i n g activity, (9) types of programs offered to " h i g h - r i s k " clients, and (10) perceptions of agency effectiveness. The social w o r k r e s p o n d e n t s , therefore, were informants not only about themselves and their o w n practice, but about the nature of the c o m m u n i t y mental health programs of their agencies. C O M M U N I T Y MENTAL H E A L T H PROGRAM ORIENTATION A major p u r p o s e of the s t u d y was to examine factors that differentiate agencies w i t h h i g h and low orientation to c o m m u n i t y mental health programs. To do this it became necessary to develop a m e t h o d for det e r m i n i n g the degree of orientation to c o m m u n i t y mental health in each agency's program. The c o m p o n e n t s of the d e f i n i t i o n of c o m m u n i t y mental health p r e s e n t e d above were used as the basis for the C o m m u n i t y Mental Health Program A s s e s s m e n t Scale (COMPASS), a list of 25 specific p r o g r a m elements. Each r e s p o n d e n t was asked to indicate w h e t h e r or not any program element oriented t o w a r d c o m m u n i t y mental health was present in the agency. Since not all social workers perceived all aspects of a complex agency in the same way, a c o m m u n i t y mental health p r o g r a m element was pres u m e d to exist if there was a g r e e m e n t a m o n g more than 50% of the respondents. In actuality the level of a g r e e m e n t was m u c h higher; the m e a n rate of a g r e e m e n t over all facilities was 80%. Thus social workers in a given facility t e n d e d to be in accord as to w h e t h e r or not the facility possessed a particular c o m m u n i t y mental health p r o g r a m element. A m e d i a n of 11 social workers reported from each facility. The n u m b e r of c o m m u n i t y mental health p r o g r a m elements r e p o r t e d for each facility was c o m p u t e d . The highest ranking agency r e p o r t e d only 13 of the 25 possible program elements. All other agencies s h o w e d the presence of less than one-half of the n u m b e r of m a x i m u m c o m p o n e n t s of a p r o g r a m oriented to c o m m u n i t y mental health. W h a t had b e e n i n t e n d e d to be a ranking that w o u l d allow c o m p a r i s o n b e t w e e n " h i g h " c o m m u n i t y mental health and " l o w " c o m m u n i t y mental health agencies became, rather, a c o m p a r i s o n
Stephen Z. Cohen, William J. Reid and Lawrence K. Berg
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between moderate and low orientation to community mental health. In subsequent analyses 8 agencies with eight or more program elements were considered to have a greater community mental health program orientation and the 11 agencies with fewer than eight com m uni t y mental health program elements were considered to have a lesser com m uni t y mental health orientation. This classification of the agencies based on the study data accorded generally with our prior expectations concerning their relative emphasis. The Chicago Board of Health (the top-ranked agency) and six regional units of the Illinois State Department of Mental Health fell in the group with greater community mental health orientation. The group showing less such orientation was made up of the remaining regional units of the Illinois Department of Mental Health and agencies selected because of their reputed lack of commu n ity mental health programming. The list of program elements used in the COMPASS was highly diverse and the rank order does not reflect the extent of difference among the agencies. One agency might emphasize the use of paraprofessionals, the involvement of local co mm uni t y agencies, short-term treatment, and consultation programs, whereas another center's program might reflect emphasis on mental health education, work with natural c omm uni t y groups, use of local community boards, and continuity of care. The two agencies would receive identical scores on the community mental health program scale, yet be very different in the character of their program. It should also be noted that an agency with a variety of community mental health programs (even t hough each might be " th i n" ) would score higher than an agency with fewer but more extensive programs in community mental health. Table 1 shows the percentage of "greater" and "lesser" c o m m u n i t y mental health oriented agencies reporting the presence of the 25 program elements. TABLE 1
Presence of Each Program Element, by Azency Program Orientation Percentage of Agencies Reporting Presence of Program Element
Greater CMH n = 8
Program Element
i.
Some effort
2.
Consultation
to work with natural to co~nunity
75.0
0.0
75.0
. . i00.0
36.4
63.6
62.5
0,0
62.5
I00.0
54.5
45.5
87.5
45.5
42.0
.
75.0
36.4
38.6
most . . .
100.0
72.7
27.3
caretakers
3.
Mental
4.
Use of alternative services to prevent hospitalization . . . . . . . . . . . . .
5.
Helping other organizations mental health resources
6.
7.
health
groups
information
to the public.
develop
Use of local community
persons
roles
.
.
.
.
.
De-emphasizing of the time .
.
.
.
.
.
long-term . . . . . .
.
L~sser CMH Per cent n = 11 Difference
.
.
in helping .
.
treatment . . . . .
.
.
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TABLE 1 (Continued) Percentage of A g e n c i e s R e p o r t i n g Presence of P r o g r a m Element
Greater CMH n = 8
P r o g r a m Element
Lesser CMB Per cent n = ii Difference
8.
C o n t i n u i n g evaluative research . . . . . .
62.5
36.4
26.1
9.
R e s p o n s i b i l i t y for the c o o r d i n a t i o n of mental health services in c o m m u n i t y . . . 25.0
0.0
25.0
75,0
54.5
20.5
. . .i00.0
81.8
18.2
10.
R e s p o n s i b i l i t y for patients w h o are not in active treatment . . . . . . . . . . .
11.
Responsiblity
12.
Use of cowcnunity p o l i c y boards for some programs . . . . . . . . . . . . . . . . .
25,0
9.1
15.9
13,
Service to people e x p e r i e n c i n g life difficulty who are not m e n t a l l y i11 . . . . .
50.0
36.4
13.6
14.
In-service training and consultation to c o m m u n i t y people as a major effort . . .
12.5
0.0
12,5
15.
C o n t i n u i n g in treatment plan of patients referred to other a g e n c i e s . . . . . . .
12.5
0.0
12.5
Use of short-term treatment most of the time . . . . . . . . . . . . . . . . . .
37.5
36.4
i.I
16.
for a geographic area
17.
D e - e m p h a s i z i n g m u c h use of staff time for diagnosis and treatment . . . . . . .
0.0
0.0
0.0
18.
E m p h a s i z i n g reaching out rather than service to identified patients . . . . .
0.0
0.0
0.0
19.
M u c h use of local c o m m u n i t y persons in helping roles . . . . . . . . . . . . . .
0.0
0.0
0.0
20,
M u c h use of staff time in d e a l i n g with p r e v e n t i o n of mental illness . . . . . . .
0.0
0.0
0,0
21.
M u c h staff time is spent in c o n s u l t a t i o n to co~r caretakers . . . . . . . . .
0.0
0.0
0,0
22.
Use of cormnunity boards in most of the important policy d e c i s i o n s . . . . . . .
0.0
0.0
0.0
23.
M a j o r effort in w o r k i n g w i t h natural groups . . . . . . . . . . . . . . . . .
0.0
0.0
0.0
24.
C o n t i n u i n g research into needs of community . . . . . . . . . . . . . . . . .
12.5
18.2
- 5.7
25.
I n v o l v i n g the referring agency in treatment plans . . . . . . . . . . . . . . .
0.0
9.1
- 9.1
The larger the item's "percent difference," the better is its ability to discriminate b e t w e e n agencies w i t h greater and lesser c o m m u n i t y mental health orientation. The factors that seem to d i s t i n g u i s h the agencies oriented toward comm u n i t y mental health from agencies w i t h a different orientation are (1) greater use of staff time to work w i t h natural groups in the c o m m u n i t y , (2) use of staff time to provide consultation to c o m m u n i t y caretakers, (3) use of staff time to provide mental health information to the public, (4) use of alternative services to prevent hospitalization, (5) use of staff time to help c o m m u n i t y
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organizations develop mental health resources, and (6) use of local community residents in helping roles. Although it is interesting to see what the higher ranking agencies do that gives them a greater com m uni t y mental health orientation, the absence of several components is particularly noteworthy. None of the agencies reported that their programs focused more on reaching out to potential clients than on offering services to identified patients. None of the agencies indicated that much of the staff's time is spent in dealing with prevention (socioeconomic causes of mental illness). All agencies reported that much staff time was spent in diagnosis and treatment of clients and patients. Only one agency reported that it remained involved in the treatment of a patient after he was referred elsewhere, and only one agency involved a referring organization in its treatment planning. Continuity of care as defined by ongoing involvement of referrers and referred was virtually nonexistent in the sample. ACTIVITIES OF THE SOCIAL WORKERS It might be tempting to conclude that the reporting by substantial proportions of the "greater" c o m m u n i t y mental health oriented agencies of the presence of work with natural groups, consultation, provision of mental health information, and so on (Table 1, Items 1-6) suggests a high degree of agency activity in carrying out these programs. One indication of the importance of some agency programs over others is the amount of staff time allotted. Although members of various other professional and nonprofessional groups may take on particular agency functions, we assumed that the activities of social workers provided a valid index of agency programmatic priorities. The social worker respondents reported the n u m b e r of hours they devoted to each of 27 specific practice activities during the week immediately prior to completing the questionnaire. The n u m b e r of hours was converted to a proportion of the workers' total reported work time. A mean percentage of reported time spent in each activity was computed for both the workers in the agencies that were more oriented to c o m m u n i t y mental health and for those in the less oriented agencies. The results for the 184 workers with master's degrees in social work are summarized in Table 2. The activities of social workers without master's degrees showed little variation between the two types of agencies. Less than 20% of the time of social workers in the "greater" com m uni t y mental health agencies is devoted to com muni t y activities, such as work with natural community groups, consultation to other organizations, interagency planning and coordination, mental health education, and so on, and less than 5% of the "lesser" agencies' social workers' time is spent in these commu n ity activities. The largest proportion of social work time (47% and 61%) is spent in diagnostic and treatment activities, and both groupings of agencies required approximately equal (37%) social worker time in supervision and administrative activities. The social worker activities that were identified as being associated with a
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TABLE 2 Distribution of Hours per Week for MSWs by Activity and Agency Program Orientation Mean Percent Hours Per Week
Workers in Greater CM~ Agencies
Diagnosis and Treatment Community Activities Supervision and Training Administration, Research, and Other
*Differences are significant, p , . O l percents of time as scores.
Workers in Lesser CMH Agencies
N = 62
N = 122
46.60 18.54 12.48 22.58
60.45 4.90 14.12 19.71
(t-test).
Difference
13.85" 13.64" 1.64 2.87
treating the workers'
community mental health approach included not only the community activities mentioned above but also crisis intervention, or conducting interviews in planned short-term treatment (a subelement of diagnosis and treatment), and supervision, or conducting in-service training for mental health workers below the B.A. level (a subelement of supervision and training). Thus the total percent of time social workers devote to all community mental health activities is 28% for workers in the "greater" community mental health agencies and 11% for those in the "lesser" community mental health facilities. For all specific community mental health activities, except crisis-intervention-short-term treatment, the differences between the "greater" and "lesser" agencies were significant (p < .05 t test). The finding that workers in the "greater" community mental health settings spent significantly more time in community-oriented activities than their "lesser" community mental health counterparts is consistent with the original division determined by the Community Mental Health Program Assessment Scale (COMPASS). The investment of an agency in community mental health was initially measured by tabulating the presence of specific programmatic activities. The validity of this method of assessment is supported by the additional finding that workers' self-reporting of their own activities follows the same pattern; that is, workers in agencies determined by the COMPASS to have greater involvement in community mental health programming were, themselves, more actively engaged in community mental health activity, though at most, only 28% of their total work time. DISCUSSION The meaning of these data is much like the proverbial glass of water that is either half full or half empty depending on the observer's state of mind. One could certainly conclude that the study demonstrates that within a few short years community-based mental health facilities have placed many important community mental health concepts in operation. Taking responsibility for service to a catchment area, moving away from longterm treatment, seeking alternatives to hospitalization, and providing consul-
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tation to c o m m u n i t y caretakers are a m o n g the p r o g r a m c o m p o n e n t s r e p o r t e d b y all the facilities with greater c o m m u n i t y mental health orientation and even b y m a n y of the lesser-oriented ones. The m o r e traditional hospital programs also give e v i d e n c e of i m p l e m e n t a t i o n of selected c o m p o n e n t s of c o m m u n i t y mental health. Surely this suggests that the glass m a y be at least half full. O n the other h a n d the findings indicate that only selected features of c o m m u n i t y mental health seem to be present in the programs sampled and e v e n these receive limited agency resources. All but one of the " g r e a t e r " c o m m u n i t y mental health agencies report less than half the possible comm u n i t y mental health p r o g r a m c o m p o n e n t s . More t h a n 80% of w o r k e r time in these agencies is d e v o t e d to treatment, supervision, and administration; only two of t h e m make use of b o a r d s m a d e u p of persons from the c o m m u nity to guide their policies. Primary p r e v e n t i o n , c o n t i n u i t y of care, coordination of mental health services are either n o n e x i s t e n t or are present only in isolated instances. The data suggest that nearly all facilities in the sample have accepted responsibility for m e e t i n g the mental health n e e d s of all persons in a specific geographic area. This carries w i t h it an a p p a r e n t c o m m i t m e n t to provide t r e a t m e n t to psychiatric casualties; the agencies and their workers are e n gaged, essentially, in that activity. Such an i n t e r p r e t a t i o n of the c o m m i t m e n t to the p o p u l a t i o n may, in fact, retard the d e v e l o p m e n t of o t h e r i m p o r t a n t c o m p o n e n t s of c o m m u n i t y mental health. If the agency assigns its staff to t r e a t m e n t and treatment-related s u p e r v i s i o n and administration, there seems to be no one left to do the c o m m u n i t y planning, organizing, coordinating, educating, and other essentials of c o m m u n i t y mental health. The training experiences of workers m a y influence the selection of priorities b y agencies. Nearly 80% of the workers in this sample w h o held a master's degree in social work had specialized in casework. It m a y be that workers tend to do that w h i c h they have b e e n trained to do. If more c o m m u n i t y - o r i e n t e d mental health activities are to take place, agencies m a y n e e d to e m p l o y more persons r e a d y to carry out such functions, and professional e d u c a t i o n will n e e d to adapt to these c h a n g i n g expectations. A m o n g the agencies in this sample were the major state and m u n i c i p a l mental health d e p a r t m e n t s serving a large m e t r o p o l i t a n c o m m u n i t y and p u b licly c o m m i t t e d to such c o m m u n i t y mental health concepts as p r e v e n t i o n , c o n t i n u i t y of care, c o m m u n i t y participation, and c o o r d i n a t i o n of services. The fact that only small portions of w o r k e r time are u s e d to i m p l e m e n t these c o m m u n i t y mental health concepts in a few isolated settings suggests the " t h i r d r e v o l u t i o n " is still a long w a y off. REFERENCES Baker, F., & Schulberg, C. The development of a community mental health ideology scale. Community Mental Health Journal, 1967, 3,216-25. BeUak, L. Handbook of community psychiatry and community mental health. New York: Grune & Stratton, 1964. Bellak, L., & Barten, H. (Eds.). Progress in community mental health (Vol. 1). New York: Grune & Stratton, 1969. Berg, L. K., Reid, W. l., & Cohen, S. Z. Social workers in community mental health. Chicago: School of Social Service Administration, University of Chicago, 1972.
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Bindman, A. J., & Spiegel, A. D. (Eds.). Perspectives in community mental health. Chicago: A1dine, 1969. Caplan, G. Principles of preventive psychiatry. New York: Basic Books, 1964. Glasscote, R. M., Sussex, J. N., Curnming, E., & Smith, L. H. The community mental health center: An interim appraisal. Washington, D.C.: The Joint Information Service of the American Psychiatric Association and the National Association for Mental Health, 1969. Lamb, H. R., Heath, D., & Downing, J. J. (Eds.). Handbook qf community nzental health practice. San Francisco: Jossey-Bass, 1969. U.S. Congress, Senate. The Community Mental Health Centers Act of 1963. S.1576, Title 1I, 88th Cong., 1st sess., 1963.
ABSTRACT: This paper reports a study of the extent to which essential elenzents of community mental health are part of mental health agencies' practices. A sample of 263 social workers reported on the nature of programming and services of 19 nzental health facilities ranging front city and state community nzental health centers to inpatient psychiatric hospitals. All agencies were found to be engaged primarily in diagnosis and treatment, and such community mental health components as primary prevention, coordination, continuity of care, and use of comnzunity boards were virtually nonexistent. Possible explanations and implications of these findings are discussed.
C o m m u n i t y mental health, psychiatry's great " t h i r d revo l u t i o n , " for a long time has b e e n primarily a set of idealized formulations in the heads of contributors to professional journals a b o u t h o w the mentally ill should be served. In recent years, h o w e v e r , m a n y c o m p o n e n t s of this highly complex, m u l t i d i m e n s i o n a l set of ideas have b e c o m e o p e r a t i o n a l i z e d into the programs and practices of i n d i v i d u a l agencies and the mental health systems of state and local g o v e r n m e n t s . Pressure to m o v e in this direction has come from (1) federal legislation w h i c h has given substantial s u p p o r t to d e v e l o p m e n t of c o m m u n i t y mental health centers and programs; (2) increased public concern o v e r failure of the existing a p p r o a c h e s and greater public i n v o l v e m e n t in decision m a k i n g regarding provision of health and welfare services in general; and (3) m o v e m e n t w i t h i n the helping professions from concern a b o u t professional elitism, ineffectiveness, and exclusionary practices t o w a r d actions that w o u l d i m p r o v e the quality of care and treatment. It is not u n c o m m o n for practical application to lag far b e h i n d theory. Yet the ultimate merit of any t h e o r y rests on an assessment of the realization of its operations. The purpose of this p a p e r is to r e p o r t findings of a study, a portion of w h i c h was d e s i g n e d to m e a s u r e the extent to w h i c h c o m m u n i t y mental health concepts have b e c o m e incorporated into actual agency practice. In addition, the s t u d y design included an e x a m i n a t i o n of the specific practices of social workers in settings c o m m i t t e d to the practice of c o m m u nity mental health as well as in agencies and hospitals e n g a g e d in a more tra-
* Dr. Cohen is Associate Professor at the Jane Addams School of Social Work, University off Illinois, Chicago Circle, Box 4348, Chicago, Illinois 60680. Dr. Reid is a George Herbert Jones Professor of Social Work at the School of Social Service Administration. Dr. Berg is Assistant Professor at the School of Social Work and Community Planning, the University of Maryland at Baltimore. The paper is based on a project supported by grants from the National Institute of Mental Health (USPHS 5-TO 1 MH 12008) and the U.S. Department of Health, Education, and Welfare (SRS-98-P-O0500/5). Community Mental Health Journal, VoL 11 (3), 1975
239
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ditional a p p r o a c h to service. Details of this s t u d y have been reported elsewhere (Berg, Reid, & C o h e n , 1972). C O M M U N I T Y MENTAL H E A L T H THEORY The C o m m u n i t y Mental Health Centers Act (U.S. Congress, Senate, 1963) p r o v i d e d guidelines on those elements that s h o u l d be .included in c o m m u n i t y mental health programs. These included the n o w f a m o u s five essential services: (1) inpatient services, (2) o u t p a t i e n t services, (3) partial hospitalization, (4) e m e r g e n c y service, and (5) consultation and education. These guidelines anticipated that an additional five services--(a) diagnostic service, (b) rehabilitation, (c) precare, (d) aftercare, and (e) training, research, and e v a l u a t i o n - - w o u l d b e c o m e part of a c o m p r e h e n s i v e comm u n i t y mental health center program. A d d i t i o n a l criteria are listed in federal regulations as c o n d i t i o n s for comm u n i t y mental health grants (Glasscote, Sussex, C u m m i n g , & Smith, 1969). A c o m m u n i t y mental health center m u s t p r o v i d e services to a specific geographic or c a t c h m e n t area. It m u s t make p r o g r a m s available to p e r s o n s of all ages but w i t h special attention to children and p e r s o n s over 65 years of age. Qualified n o n p s y c h i a t r i c p h y s i c i a n s must be included a m o n g those providing treatment and follow-up care to patients. Services m u s t be available for all diagnostic categories; that is, a c o m p r e h e n s i v e array of services for all types of mental illness m u s t be provided. Finally, services m u s t be o r g a n i z e d to direct patients to services as n e e d e d , thus i n s u r i n g c o n t i n u i t y of care. The federal g o v e r n m e n t does not attempt to regulate p r o g r a m philosophies. The p r o v i s i o n of specific services is in itself a sufficient prec o n d i t i o n for receiving grants. The a p p r o a c h or p h i l o s o p h y that m a y u n d e r lie those services is left to the discretion of the particular agency. A l t h o u g h there is still a wide difference of o p i n i o n r e g a r d i n g what, precisely, constitutes a c o m m u n i t y mental health approach, a review of the literature in the field reveals recurring general principles (Baker & Schulberg, 1967; Bellak, 1964; Bellak & Barton, 1969; B i n d m a n & Spiegel, 1969; Caplan, 1964; Lamb, 1969)
1. Community mental health is an outgrowth of public health and should make adequate use of public health principles in meeting the mental health needs of a community. 2. There should be active involvement of community residents and other agencies in programs, as well as the direct involvement of various nonprofessionals and professionals other than psychiatrists, in the care of the mentally ill. 3. High priority should be given to indirect, preventive services provided to organizations and individuals who are directly in touch with community residents. 4. Treatment and rehabilitation of high-risk populations and "unattractive patients" should be given priority. 5. Treatment should at all times be guided by a commitment to "minimal intervention." 6. There should be a continuous recognition of the significance of social, economic, and cultural factors, as well as the intrapsychic determinants of human behavior, and when necessary these factors should be taken into account in developing intervention programs.
Stephen Z. Cohen, William J. Reid and Lawrence K. Berg
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7. Short-term hospitalization in small hospitals should be made available when needed; the large state hospital, providing custodial care, should be phased out. 8. There should be ongoing research as well as systematic evaluation of program effectiveness. 9. There should be a commitment to the use of local community boards or other indigenous structures in identifying problems and developing programs. These u n d e r l y i n g principles, t o g e t h e r w i t h the services a n d criteria listed as a p r e c o n d i t i o n for federal grants, constitute the d e f i n i t i o n of the c o m m u nity m e n t a l health a p p r o a c h u s e d in the study. THE SAMPLE OF A G E N C I E S The s t u d y was d e s i g n e d to e x a m i n e role p e r f o r m a n c e a n d role p r o b l e m s of social w o r k e r s in o r g a n i z a t i o n s a n d agencies w i t h v a r y i n g d e g r e e s of e m p h a s i s on c o m m u n i t y m e n t a l health p r o g r a m s . Three o r g a n i z a tions s e r v i n g the m e t r o p o l i t a n area of Chicago a n d one in N e w York City p r o v i d e d the 19 separate facilities that ' c o n s t i t u t e d the s a m p l e of agencies. Of these, 16 w e r e s u b u n i t s of the Illinois D e p a r t m e n t of Mental Health, of w h i c h 13 w e r e s u b r e g i o n facilities s e r v i n g p o p u l a t i o n s of 75,000 to 200,000 p e r s o n s in the Chicago m e t r o p o l i t a n area. T h e s e s u b r e g i o n facilities h a d b e e n o p e r a t i n g for 4 years u n d e r d e p a r t m e n t g u i d e l i n e s that s u p p o r t e d or r e q u i r e d such c o m m u n i t y m e n t a l health c o m p o n e n t s as c o m m i t m e n t to a defined p o p u l a t i o n , c o m p r e h e n s i v e c o n t i n u i t y of care, c o m m u n i t y involvem e n t , a n d priority to h i g h - r i s k groups. Because of these factors, these facilities offered an o p p o r t u n i t y to s t u d y the n a t u r e of c o m m u n i t y m e n t a l health practice in a large u r b a n area. The r e m a i n i n g three units of the Illinois D e p a r t m e n t of Mental H e a l t h w e r e the R e a d - C h i c a g o State Mental H e a l t h Center, the M a n t e n o State Hospital, a n d the Illinois State Psychiatric Institute. Because these are agencies w h o s e p r i m a r y f u n c t i o n is service to psychiatric inpatients, little o r i e n t a t i o n to c o m m u n i t y m e n t a l health ideolo g y or practice w a s expected. T h e i r inclusion p r o v i d e d m o r e traditional m e n tal health practice a p p r o a c h e s against w h i c h selected features of c o m m u n i t y m e n t a l health practice could be c o m p a r e d . The Chicago Board of H e a l t h o p e r a t e s 15 m e n t a l health clinics, each of w h i c h is r e s p o n s i b l e for a particular c a t c h m e n t area; all are also k n o w n to be o r i e n t e d to a c o m m u n i t y m e n t a l health a p p r o a c h . The small n u m b e r of res p o n d e n t s w i t h i n each clinic r e q u i r e d that all 15 Board of H e a l t h clinics be treated as a single agency. It was a n t i c i p a t e d that this a g e n c y w o u l d d e m onstrate h i g h c o m m i t m e n t to a c o m m u n i t y m e n t a l health a p p r o a c h . Michael Reese, a general hospital in Chicago w i t h a s u b s t a n t i a l psychiatric i n p a t i e n t a n d o u t p a t i e n t p r o g r a m , a n d Hillside Hospital, a v o l u n t a r y psychiatric hospital in N e w York City, b e c a m e the final two m e m b e r s of the a g e n c y s a m p l e p r o v i d i n g a d d i t i o n a l contrast w i t h a n o n - c o m m u n i t y m e n t a l health service. It w a s felt that the 19 agencies offered a r a n g e f r o m h i g h to low o r i e n t a t i o n to c o m m u n i t y m e n t a l health a n d w o u l d allow c o m p a r a t i v e analysis of overall p r o g r a m focus, social w o r k e r characteristics, social w o r k roles, and role p r o b l e m s . A l t h o u g h the s a m p l e of agencies w a s limited p r i m a r ily to Chicago, we w e r e r e a s o n a b l y c o n f i d e n t that o u r selection c o n t a i n e d
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most major facilities in Chicago with c o m m u n i t y mental health programs. Thus the s t u d y p r o v i d e s a profile of c o m m u n i t y mental health programs in a principal American city. THE SAMPLE OF SOCIAL WORKERS The 19 agencies p r o v i d e d the names of 377 social workers w i t h and w i t h o u t a master's degree in social work. Q u e s t i o n n a i r e s were sent d u r i n g the spring of 1971; 263 (70%) were returned. Of these, 189 (72%) held a master of social work degree and 74 (28%) were persons w i t h a college degree (other than M.S.W.) w h o s e job title or function was "social w o r k e r . " This sample of social workers p r o v i d e d , t h r o u g h a self-administered instrument, the s t u d y data that included: (1) biographical data, (2) a m o u n t of time workers spent in selected work activities, (3) p r o g r a m focuses of the e m p l o y i n g agencies, (4) w o r k e r perception of role problems, (5) c o m m u n i t y mental health ideology, (6) p e r c e p t i o n of value of graduate social work education for work roles, (7) a m o u n t of interaction w i t h other professionals, (8) extent of organizational b o u n d a r y - s p a n n i n g activity, (9) types of programs offered to " h i g h - r i s k " clients, and (10) perceptions of agency effectiveness. The social w o r k r e s p o n d e n t s , therefore, were informants not only about themselves and their o w n practice, but about the nature of the c o m m u n i t y mental health programs of their agencies. C O M M U N I T Y MENTAL H E A L T H PROGRAM ORIENTATION A major p u r p o s e of the s t u d y was to examine factors that differentiate agencies w i t h h i g h and low orientation to c o m m u n i t y mental health programs. To do this it became necessary to develop a m e t h o d for det e r m i n i n g the degree of orientation to c o m m u n i t y mental health in each agency's program. The c o m p o n e n t s of the d e f i n i t i o n of c o m m u n i t y mental health p r e s e n t e d above were used as the basis for the C o m m u n i t y Mental Health Program A s s e s s m e n t Scale (COMPASS), a list of 25 specific p r o g r a m elements. Each r e s p o n d e n t was asked to indicate w h e t h e r or not any program element oriented t o w a r d c o m m u n i t y mental health was present in the agency. Since not all social workers perceived all aspects of a complex agency in the same way, a c o m m u n i t y mental health p r o g r a m element was pres u m e d to exist if there was a g r e e m e n t a m o n g more than 50% of the respondents. In actuality the level of a g r e e m e n t was m u c h higher; the m e a n rate of a g r e e m e n t over all facilities was 80%. Thus social workers in a given facility t e n d e d to be in accord as to w h e t h e r or not the facility possessed a particular c o m m u n i t y mental health p r o g r a m element. A m e d i a n of 11 social workers reported from each facility. The n u m b e r of c o m m u n i t y mental health p r o g r a m elements r e p o r t e d for each facility was c o m p u t e d . The highest ranking agency r e p o r t e d only 13 of the 25 possible program elements. All other agencies s h o w e d the presence of less than one-half of the n u m b e r of m a x i m u m c o m p o n e n t s of a p r o g r a m oriented to c o m m u n i t y mental health. W h a t had b e e n i n t e n d e d to be a ranking that w o u l d allow c o m p a r i s o n b e t w e e n " h i g h " c o m m u n i t y mental health and " l o w " c o m m u n i t y mental health agencies became, rather, a c o m p a r i s o n
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between moderate and low orientation to community mental health. In subsequent analyses 8 agencies with eight or more program elements were considered to have a greater community mental health program orientation and the 11 agencies with fewer than eight com m uni t y mental health program elements were considered to have a lesser com m uni t y mental health orientation. This classification of the agencies based on the study data accorded generally with our prior expectations concerning their relative emphasis. The Chicago Board of Health (the top-ranked agency) and six regional units of the Illinois State Department of Mental Health fell in the group with greater community mental health orientation. The group showing less such orientation was made up of the remaining regional units of the Illinois Department of Mental Health and agencies selected because of their reputed lack of commu n ity mental health programming. The list of program elements used in the COMPASS was highly diverse and the rank order does not reflect the extent of difference among the agencies. One agency might emphasize the use of paraprofessionals, the involvement of local co mm uni t y agencies, short-term treatment, and consultation programs, whereas another center's program might reflect emphasis on mental health education, work with natural c omm uni t y groups, use of local community boards, and continuity of care. The two agencies would receive identical scores on the community mental health program scale, yet be very different in the character of their program. It should also be noted that an agency with a variety of community mental health programs (even t hough each might be " th i n" ) would score higher than an agency with fewer but more extensive programs in community mental health. Table 1 shows the percentage of "greater" and "lesser" c o m m u n i t y mental health oriented agencies reporting the presence of the 25 program elements. TABLE 1
Presence of Each Program Element, by Azency Program Orientation Percentage of Agencies Reporting Presence of Program Element
Greater CMH n = 8
Program Element
i.
Some effort
2.
Consultation
to work with natural to co~nunity
75.0
0.0
75.0
. . i00.0
36.4
63.6
62.5
0,0
62.5
I00.0
54.5
45.5
87.5
45.5
42.0
.
75.0
36.4
38.6
most . . .
100.0
72.7
27.3
caretakers
3.
Mental
4.
Use of alternative services to prevent hospitalization . . . . . . . . . . . . .
5.
Helping other organizations mental health resources
6.
7.
health
groups
information
to the public.
develop
Use of local community
persons
roles
.
.
.
.
.
De-emphasizing of the time .
.
.
.
.
.
long-term . . . . . .
.
L~sser CMH Per cent n = 11 Difference
.
.
in helping .
.
treatment . . . . .
.
.
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TABLE 1 (Continued) Percentage of A g e n c i e s R e p o r t i n g Presence of P r o g r a m Element
Greater CMH n = 8
P r o g r a m Element
Lesser CMB Per cent n = ii Difference
8.
C o n t i n u i n g evaluative research . . . . . .
62.5
36.4
26.1
9.
R e s p o n s i b i l i t y for the c o o r d i n a t i o n of mental health services in c o m m u n i t y . . . 25.0
0.0
25.0
75,0
54.5
20.5
. . .i00.0
81.8
18.2
10.
R e s p o n s i b i l i t y for patients w h o are not in active treatment . . . . . . . . . . .
11.
Responsiblity
12.
Use of cowcnunity p o l i c y boards for some programs . . . . . . . . . . . . . . . . .
25,0
9.1
15.9
13,
Service to people e x p e r i e n c i n g life difficulty who are not m e n t a l l y i11 . . . . .
50.0
36.4
13.6
14.
In-service training and consultation to c o m m u n i t y people as a major effort . . .
12.5
0.0
12,5
15.
C o n t i n u i n g in treatment plan of patients referred to other a g e n c i e s . . . . . . .
12.5
0.0
12.5
Use of short-term treatment most of the time . . . . . . . . . . . . . . . . . .
37.5
36.4
i.I
16.
for a geographic area
17.
D e - e m p h a s i z i n g m u c h use of staff time for diagnosis and treatment . . . . . . .
0.0
0.0
0.0
18.
E m p h a s i z i n g reaching out rather than service to identified patients . . . . .
0.0
0.0
0.0
19.
M u c h use of local c o m m u n i t y persons in helping roles . . . . . . . . . . . . . .
0.0
0.0
0.0
20,
M u c h use of staff time in d e a l i n g with p r e v e n t i o n of mental illness . . . . . . .
0.0
0.0
0,0
21.
M u c h staff time is spent in c o n s u l t a t i o n to co~r caretakers . . . . . . . . .
0.0
0.0
0,0
22.
Use of cormnunity boards in most of the important policy d e c i s i o n s . . . . . . .
0.0
0.0
0.0
23.
M a j o r effort in w o r k i n g w i t h natural groups . . . . . . . . . . . . . . . . .
0.0
0.0
0.0
24.
C o n t i n u i n g research into needs of community . . . . . . . . . . . . . . . . .
12.5
18.2
- 5.7
25.
I n v o l v i n g the referring agency in treatment plans . . . . . . . . . . . . . . .
0.0
9.1
- 9.1
The larger the item's "percent difference," the better is its ability to discriminate b e t w e e n agencies w i t h greater and lesser c o m m u n i t y mental health orientation. The factors that seem to d i s t i n g u i s h the agencies oriented toward comm u n i t y mental health from agencies w i t h a different orientation are (1) greater use of staff time to work w i t h natural groups in the c o m m u n i t y , (2) use of staff time to provide consultation to c o m m u n i t y caretakers, (3) use of staff time to provide mental health information to the public, (4) use of alternative services to prevent hospitalization, (5) use of staff time to help c o m m u n i t y
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organizations develop mental health resources, and (6) use of local community residents in helping roles. Although it is interesting to see what the higher ranking agencies do that gives them a greater com m uni t y mental health orientation, the absence of several components is particularly noteworthy. None of the agencies reported that their programs focused more on reaching out to potential clients than on offering services to identified patients. None of the agencies indicated that much of the staff's time is spent in dealing with prevention (socioeconomic causes of mental illness). All agencies reported that much staff time was spent in diagnosis and treatment of clients and patients. Only one agency reported that it remained involved in the treatment of a patient after he was referred elsewhere, and only one agency involved a referring organization in its treatment planning. Continuity of care as defined by ongoing involvement of referrers and referred was virtually nonexistent in the sample. ACTIVITIES OF THE SOCIAL WORKERS It might be tempting to conclude that the reporting by substantial proportions of the "greater" c o m m u n i t y mental health oriented agencies of the presence of work with natural groups, consultation, provision of mental health information, and so on (Table 1, Items 1-6) suggests a high degree of agency activity in carrying out these programs. One indication of the importance of some agency programs over others is the amount of staff time allotted. Although members of various other professional and nonprofessional groups may take on particular agency functions, we assumed that the activities of social workers provided a valid index of agency programmatic priorities. The social worker respondents reported the n u m b e r of hours they devoted to each of 27 specific practice activities during the week immediately prior to completing the questionnaire. The n u m b e r of hours was converted to a proportion of the workers' total reported work time. A mean percentage of reported time spent in each activity was computed for both the workers in the agencies that were more oriented to c o m m u n i t y mental health and for those in the less oriented agencies. The results for the 184 workers with master's degrees in social work are summarized in Table 2. The activities of social workers without master's degrees showed little variation between the two types of agencies. Less than 20% of the time of social workers in the "greater" com m uni t y mental health agencies is devoted to com muni t y activities, such as work with natural community groups, consultation to other organizations, interagency planning and coordination, mental health education, and so on, and less than 5% of the "lesser" agencies' social workers' time is spent in these commu n ity activities. The largest proportion of social work time (47% and 61%) is spent in diagnostic and treatment activities, and both groupings of agencies required approximately equal (37%) social worker time in supervision and administrative activities. The social worker activities that were identified as being associated with a
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TABLE 2 Distribution of Hours per Week for MSWs by Activity and Agency Program Orientation Mean Percent Hours Per Week
Workers in Greater CM~ Agencies
Diagnosis and Treatment Community Activities Supervision and Training Administration, Research, and Other
*Differences are significant, p , . O l percents of time as scores.
Workers in Lesser CMH Agencies
N = 62
N = 122
46.60 18.54 12.48 22.58
60.45 4.90 14.12 19.71
(t-test).
Difference
13.85" 13.64" 1.64 2.87
treating the workers'
community mental health approach included not only the community activities mentioned above but also crisis intervention, or conducting interviews in planned short-term treatment (a subelement of diagnosis and treatment), and supervision, or conducting in-service training for mental health workers below the B.A. level (a subelement of supervision and training). Thus the total percent of time social workers devote to all community mental health activities is 28% for workers in the "greater" community mental health agencies and 11% for those in the "lesser" community mental health facilities. For all specific community mental health activities, except crisis-intervention-short-term treatment, the differences between the "greater" and "lesser" agencies were significant (p < .05 t test). The finding that workers in the "greater" community mental health settings spent significantly more time in community-oriented activities than their "lesser" community mental health counterparts is consistent with the original division determined by the Community Mental Health Program Assessment Scale (COMPASS). The investment of an agency in community mental health was initially measured by tabulating the presence of specific programmatic activities. The validity of this method of assessment is supported by the additional finding that workers' self-reporting of their own activities follows the same pattern; that is, workers in agencies determined by the COMPASS to have greater involvement in community mental health programming were, themselves, more actively engaged in community mental health activity, though at most, only 28% of their total work time. DISCUSSION The meaning of these data is much like the proverbial glass of water that is either half full or half empty depending on the observer's state of mind. One could certainly conclude that the study demonstrates that within a few short years community-based mental health facilities have placed many important community mental health concepts in operation. Taking responsibility for service to a catchment area, moving away from longterm treatment, seeking alternatives to hospitalization, and providing consul-
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tation to c o m m u n i t y caretakers are a m o n g the p r o g r a m c o m p o n e n t s r e p o r t e d b y all the facilities with greater c o m m u n i t y mental health orientation and even b y m a n y of the lesser-oriented ones. The m o r e traditional hospital programs also give e v i d e n c e of i m p l e m e n t a t i o n of selected c o m p o n e n t s of c o m m u n i t y mental health. Surely this suggests that the glass m a y be at least half full. O n the other h a n d the findings indicate that only selected features of c o m m u n i t y mental health seem to be present in the programs sampled and e v e n these receive limited agency resources. All but one of the " g r e a t e r " c o m m u n i t y mental health agencies report less than half the possible comm u n i t y mental health p r o g r a m c o m p o n e n t s . More t h a n 80% of w o r k e r time in these agencies is d e v o t e d to treatment, supervision, and administration; only two of t h e m make use of b o a r d s m a d e u p of persons from the c o m m u nity to guide their policies. Primary p r e v e n t i o n , c o n t i n u i t y of care, coordination of mental health services are either n o n e x i s t e n t or are present only in isolated instances. The data suggest that nearly all facilities in the sample have accepted responsibility for m e e t i n g the mental health n e e d s of all persons in a specific geographic area. This carries w i t h it an a p p a r e n t c o m m i t m e n t to provide t r e a t m e n t to psychiatric casualties; the agencies and their workers are e n gaged, essentially, in that activity. Such an i n t e r p r e t a t i o n of the c o m m i t m e n t to the p o p u l a t i o n may, in fact, retard the d e v e l o p m e n t of o t h e r i m p o r t a n t c o m p o n e n t s of c o m m u n i t y mental health. If the agency assigns its staff to t r e a t m e n t and treatment-related s u p e r v i s i o n and administration, there seems to be no one left to do the c o m m u n i t y planning, organizing, coordinating, educating, and other essentials of c o m m u n i t y mental health. The training experiences of workers m a y influence the selection of priorities b y agencies. Nearly 80% of the workers in this sample w h o held a master's degree in social work had specialized in casework. It m a y be that workers tend to do that w h i c h they have b e e n trained to do. If more c o m m u n i t y - o r i e n t e d mental health activities are to take place, agencies m a y n e e d to e m p l o y more persons r e a d y to carry out such functions, and professional e d u c a t i o n will n e e d to adapt to these c h a n g i n g expectations. A m o n g the agencies in this sample were the major state and m u n i c i p a l mental health d e p a r t m e n t s serving a large m e t r o p o l i t a n c o m m u n i t y and p u b licly c o m m i t t e d to such c o m m u n i t y mental health concepts as p r e v e n t i o n , c o n t i n u i t y of care, c o m m u n i t y participation, and c o o r d i n a t i o n of services. The fact that only small portions of w o r k e r time are u s e d to i m p l e m e n t these c o m m u n i t y mental health concepts in a few isolated settings suggests the " t h i r d r e v o l u t i o n " is still a long w a y off. REFERENCES Baker, F., & Schulberg, C. The development of a community mental health ideology scale. Community Mental Health Journal, 1967, 3,216-25. BeUak, L. Handbook of community psychiatry and community mental health. New York: Grune & Stratton, 1964. Bellak, L., & Barten, H. (Eds.). Progress in community mental health (Vol. 1). New York: Grune & Stratton, 1969. Berg, L. K., Reid, W. l., & Cohen, S. Z. Social workers in community mental health. Chicago: School of Social Service Administration, University of Chicago, 1972.
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Bindman, A. J., & Spiegel, A. D. (Eds.). Perspectives in community mental health. Chicago: A1dine, 1969. Caplan, G. Principles of preventive psychiatry. New York: Basic Books, 1964. Glasscote, R. M., Sussex, J. N., Curnming, E., & Smith, L. H. The community mental health center: An interim appraisal. Washington, D.C.: The Joint Information Service of the American Psychiatric Association and the National Association for Mental Health, 1969. Lamb, H. R., Heath, D., & Downing, J. J. (Eds.). Handbook qf community nzental health practice. San Francisco: Jossey-Bass, 1969. U.S. Congress, Senate. The Community Mental Health Centers Act of 1963. S.1576, Title 1I, 88th Cong., 1st sess., 1963.
