Community Mental Health Journal
Volume2, Number4, Winter, 1966
PROBLEMS
ASSOCIATED
MENTAL
HEALTH
WITH
COMMUNITY
PROGRAMS
ARTHUR J. BINDMAN, PH.D., M.P.H.*
mental h e a l t h programs have had the same emphasis, t h e same goals, or even similar problems with which to contend. In general, these programs have depended u p o n state agencies for financial stimulation a n d support, standards of practice, and o t h e r consultative and training functions. T h e method of support and the degree to which these agencies have participated in local programming appear to be crucial variables in the assessment of program growth and effectivehess, as well as in tackling the c o m m u n i t i e s ' m e n t a l health problems.
Community mental health programs vary in relation to their types of administrative and fiscal policy and structure. Discontinuity of services may increase due to proliferation of community-based programs, and community mental health personnel must be trained to deal with many needs and new programs. There will also be conflicts over individual professional interests versus community needs. Problems of staff recruitment will increase and concerted efforts are necessary to increase inservice education in order to reshape professional roles. Psychologists in particular are interested in new developments in "community psychology" as a means of contributing to these efforts.
PROGRAMSTRUCTURE
I n r e c e n t years c o m m u n i t y mental h e a l t h programs have been growing rapidly, spurred on by the changing interests of practitioners, the greater involvement of c o m m u n i t y members, initiation t h r o u g h legislative mandates, and the outpouring of increased financial support. Few c o m m u n i t y
A major t r e n d of financial s u p p o r t and control appears to be that in which state d e p a r t m e n t s of mental or public h e a l t h receive a legislative m a n d a t e and finances to work on a matching-fund basis with comm u n i t i e s t h r o u g h local m u n i c i p a l boards. A n o t h e r approach is that of local partnership with the state (Hallock & Vanghan,
* Dr. Bindman, a clinical psychologist, is Director of Psychological Services, Massachusetts Department of Mental Health, Boston. This article is based on a paper presented in a symposium on ~'Contributions of Psychologists to Community Mental Health Programs" at the American Psychological Association Convention, Chicago, 1965. 333
334
THE COMMUNITYMENTAL HEALTHJOURNAL
1956). Local mental health associations provide private support for a mental health center while the state provides personnel, consultation, and training programs. Bind. man and Klebanoff (1960) have discussed the relative merits of these approaches. Specific legislation and matching-fund financing would appear to be a means for rapid program development. The issue of state control can be minimized if matchingfund programs set their goals, know the limits of their budgets as defined clearly by legislation, and also maintain high standards for personnel and programming. A good civil service or merit system from which standards stem can help. On the other hand, matching-fund programs do have certain weaknesses. They do not necessarily have popular interest and support unless the community is involved. Also, localities feel that the state '~calls the tune," resulting in feelings of dependency and attendant hostility. In the local partnership program, there are other weaknesses to overcome. Where the state department does not play such a central and powerful role, a vacuum of sorts is left, which gets filled by the conflicting interests and goals of various groups. Where local funds and interests are solicited in order to provide for greater local autonomy and for participation and flexibility in program planning, the result can be the channelization of energies in many directions. For example, some communities may become overinvolved with the development of their local mental health associa. tion which is tied in with the state mental health association's program. Although the community may need a variety of basic community mental health services, most of its energy may be siphoned into secondary functions under the direction of the state mental health association, with little attention to the development of more basic services. Other communities may spend a major portion of their time in such areas as fundraising to the detriment of self-surveys, self-education, and sound program planning. In many instances the official state mental health agency must play a delicate and subtle consultative and community organ-
ization role, which helps these communities achieve useful and realistic goals. The state mental health agency should not be strictly supervisory and inspection oriented, but rather a consultant and partner. However, the state agency cannot be completely non. directive in its approach. Communities do need technical assistance and direction. Bindman and Klebanoff (1960) point out that "more than one community has later complained that excessive permissiveness resulted only in anxiety and frustration because they were not in possession of a sufficient degree of technical information upon which t o base their own conclusions or direct themselves knowledgeably." There is a third approach, which is used by Connecticut. This combines the matching-fund and local partnership methods but seems to result in more local autonomy as the long-term goal. The state supplies seed money and personnel to start a program once a local community has organized itself to support the program in part. The community takes over an increasing portion of the financial support of the program over a period of time. In many respects the federal mental health program will follow a similar pattern, particularly where personnel support is concerned. This raises the serious question for some states of whether they are buying a r162 in a poke." They may feel they will be adding to a much larger budget for mental health in the future if they participate now. There does not appear to be any ideal solution. Matching-fund programs do provide a high level of funding but with accompanying central control. Partnership programs are weak financially but may have more local autonomy and creativity. The seed-money approach may serve to start a program provided there is the right mixture of state and local control, but funds may run out before ample local support is forthcoming, or this method may be unacceptable to some states. PROGRAM CONTINUITYAND DEVELOPMENT
Regardless of the type of community mental health support, there appear to be many obstacles to continuity of treatment,
ARTHUR J. BINDMAN often related to patterns of agency cooperation and structure. This discontinuity may actually be increasing due to a proliferation of new types of programs supported by Federal agencies other than those from the mental health sphere. For example, funds from the Office of Economic Opportunity have resulted in programs such as Head Start, multiservice center, special job training and school programs, all of which should have relationships with the mental health field. In many instances the mental health ~r concerned with its own plans for the future, as well as with continuous demands from myriads of patients, has often moved slowly in developing interagency relationships and cooperation. Planners and administrators at the highest levels must make a conscious effort to coordinate the development of all social welfare programs at the community level or be faced with increasing breakdown in communication, referral, and services for patients. If an agency has followed a classical pattern of waiting for the patient to appear on its doorstep and then treating his problems, regardless of the patient's social and environmental needs, this will only enhance the patient's alienation from that agency. A productive community mental health program must be aware of the range of sociopsychological-political problems in its community, must be sensitive to the needs of its clientele, and must utilize community organization, public relations, and even political science techniques in order not only to increase its effectiveness but to reduce the communication and interagency blocks that so frequently harm people. How many of us have seen agencies that call themselves community mental health centers yet practice a type of semi-isolated, pick-and-choose approach, not dealing with the deep-seated problems of their community, and not really relating to the other health, education, and welfare agencies? It is all too frequent; patients and communities suffer from this approach. COMPETENCE Psychologists and social workers can play a major part in breaking down barriers, in-
335
creasing communication, and interrelating the functions of various agencies. Many of these nonmedical professionals have begun to participate in the administration of community mental health programs, and it is to be hoped that this bodes well for the future. Unless the administration of these programs is based upon competence, rather than upon the idea that medical direction is the only way through which these programs can function, there will continue to be, not only weaknesses in program operations, but difficulties in obtaining competent personnel. Nonmedical personnel will continue to desert these programs for university, industrial, or private practice settings. The Senate Committee on Labor and Public Welfare Report No. 366 (1965) on the Community Mental Health Centers Staffing Bill has spelled out the r162 intent," namely, that r162 overall leadership of a community mental health center program may be carried out by any one of the major mental health professions. Many professions have vital roles to play in the prevention, treatment and rehabilitation of patients with mental illnesses." Not only is the type of overall state administration or mental health leadership a problem for patient care, but the philosophy of program management is one of the greatest problems. The same Senate Report No. 366 calls for the coordination of the community mental health center program with all relevant federal programs to avoid duplication, such as with school guidance and counseling, housing programs, poverty programs, and welfare programs. Too many programs have difficulty in relating adult and child services together, or mental illness and mental retardation programs, let alone relating to the more esoteric programs, such as housing. Mental health professionals frequently reject areas of responsibility to which they could and should contribute. For example, many administrators have been faced for years with the problem of ~r mental retardation concerns to mental health agencies. It has taken much interpretation, inservice education, promulgation of program goals, and state regulations, but some mental health professionals
336
THE COMMUNITYMENTALHEALTHJOURNAL
still reject this need for cooperation. Our relationships between mental health and the official rehabilitation agency, mental health and employment security, or mental health and education are still not smooth. Relationships between state mental health agencies and private agencies still leave something to be desired, with the latter often "choosing" special patients and leaving the poor ones for the former. None of these problems will be solved in some Utopia of the future, but we must be aware of them, plan for their reduction, and train personnel to deal with them in a more conscious and conscientious manner. PROGRAM EMPHASIS Where should a community mental health program concentrate its efforts? Should it emphasize early diagnosis and intensive treatment? Should it aim toward prevention of mental health problems by methods of intervention, consultation, pro. motion, and education? What about such areas as training, research, community organization, and rehabilitation and follow-up of returning mental patients? We should face facts: community mental health programs cannot do a good job in all areas unless the size of the patient population is limited, staff is greatly enlarged and well trained, and there is continued emphasis on new methods of handling mental health problems in an efficient manner. Primary and secondary preventive techniques, such as working with maternal and child health agencies, controlling environmental haz. ards, enhancing family life, particularly for children who would be severely deprived, working with geriatric problems, and even working with nutritionists should become some of the major points of attack (Gruen. berg, 1957). However, every community mental health program must establish priorities. Often these priorities stem from long.standing interests, based upon earlier training and direction, without a basis upon a particular community's needs. TRAINING AND STAFF RECRUITMENT The influx of large sums of money into community mental health programs has had
some influence upon better salaries for recruitment of professional personnel. However, the recruitment problem is far from solved. There is only a limited "barrel" from which to draw potential workers. A community mental health program will rise or fall on its ability to recruit able personnel. If recruitment techniques draw in only the "discontented," the individual looking for an "easy berth," the professional with weak training in basic aspects of diagnosis and treatment, or personnel who cannot flexibly adapt to new roles within the mental health setting or in the community, such a program is doomed to severe problems and even failure. Recruitment should aim toward obtaining welltrained individuals who are secure in their professional roles but flexible enough to seek new methods and new functions for themselves and those with whom they work. Creativity, originality, and an emphasis upon breadth and scope of knowledge would appear to be essentials in order to obtain the type of persons who enhance programs. Too frequently we are hampered by those who are easily threatened, who zealously guard their professional role, who rigidify and codify each action in such a way as to hamstring any new innovations that make for better programming. A major tool for development and continued growth is an inservice training program. This program, utilizing both state-level staff members, university and other consultants, as well as special workshops and institutes, can serve as the key for stimulating, directing, and maintaining the interest and morale of community mental health workers. For example, the Massachusetts community mental health program has continually maintained an inservice training program in which all personnel gained not only a background in public health aspects of mental health but also in such specific techniques as mental health consultation and administration of community mental health programs (Bindman& Klebanoff, 1960; Caplan, 1963; Bindman, 1964a,b). As these training programs have waxed and waned over the years, one could almost make a direct correlation to staff turnover, morale, and ade-
ARTHUR J. BINDMAN quate goal-orientation of the program. Not only have schools of public health and medical schools begun to show more interest in community mental health training, but we have also begun to see some enlargement of the scope of training in the basic professions of psychiatry, psychology, and social work. These training programs must be related to ongoing community mental health activities, so that both trainees and workers can participate in new develop. ments and so that there is a possibility for interchange between university and service personnel. ROLE DEFINITIONS AND FUNCTIONS An example of the problem of role definition in community mental health is the one faced by psychologists. The question of emphasis on specific roles and functions is so blurred that it is no small wonder that clinical psychology, in particular, is split into a factionalistic, almost nihilistic selfappraisal. Some wish to stress the role of the scientist and others the practitioner; some emphasize preventive work with children, while others emphasize work with other age groups; and some wish to provide classical therapy and testing, while others wish to try new programs and lead in their administration. In all of these areas the psychologist is often ill at ease, knowing that he can provide certain high-level services in keeping with his training and experience, yet often blocked by his classical graduate training or by rigid administrative methods in which he plays a secondary role or provides only a portion of his knowledge. Psy, chiatry has begun to develop a number of programs to train young psychiatrists in community mental health methods, but psychology is still behind in this regard. On the other hand, what can psychologists in. troduce in their training programs to achieve a distinctive role and function? If they stress community organization, they threaten the social workers; if they stress psychotherapy, they threaten the psychiatrists; if school mental health programs are stressed, they threaten the increasing number of school guidance and counseling workers; an increasing amount of research
337
is being done by psychiatry, and this too becomes an area of conflict. As the new comprehensive mental health centers are being planned and built, the psychologist must definitely redefine and reshape his role. There is no specific answer at present, but perhaps a trend can be noted. Several years ago one could fairly readily define the clinical psychologist's functions in a number of key areas, such as diagnosis, psychotherapy, research, training, consultation, and administration (Bindman, et al., 1961). More recently McCullough (1962) emphasized the need for state-employed psychologists to be knowledgeable about such diverse fields as (1) community organization and group dynamics; (2) psychological aspects of rehabilitation methods; (3) research and evaluation of mass treatment, milieu therapy, and other large.scale procedures; (4) consultative skills and program planning and development; (5) administration; (6) communication and interdisciplinary relationships; and (7) agency structure. A recent conference on the education of psychologists for community mental health (Bennett, et. al., 1966) stressed the need for so-called "community psychologists." Community mental health practice and clinical psychology were both seen as sub. specialties and as separate from community psychology. The community psychologist was primarily seen as a "participant-conceptualizer," i.e., involved in and stimulating community processes, as well as conceptualizing these processes within a psychological-sociological framework. This is indeed a broad canvas on which psychology can paint its picture and includes functions and roles in large-scale research, program and administrative consultation, dynamics of social change, communication problems, administration, social system analysis and action, preventive intervention, direction and utilization of natural human resources, conflict resolution, intergroup relations, and community organization and dynamics. Lest one think that psychology is becoming escapist or megalomanic, it should be noted that many of these areas of interest are now the concern of psychologists. Further era-
338
THE COMMUNITYMENTAL HEALTH JOURNAL
phasis through new specialized training programs, utilization of different practicum and internship settings, combined with an interdisciplinary faculty and student body, could provide a cadre of psychologists who could begin really to understand and deal with major sociopsychological issues of our society instead of merely acting like "junior psychiatrists." This does not imply that all clinical psychologists should immediately shift from what they are now doing and become community psychologists. Many psychologists are now providing important and useful services in our present mental health programs. A shift in attitude and emphasis combining a more sociological, public health orientation with present clinical skills may be the base for even further gains in assisting client populations. The use of inservice education and postdoctoral specialty programs may be the final means for achieving a major change in the psychologist's functioning in the community. Psychologists practicing in the community desperately need this transfusion of attitude and orientation. Unless this can begin to take place within the next few years, psychologists can expect to feel even greater dissatisfaction in their roles as they participate in a comprehensive community mental health program that operates on a fairly restricted and narrow model. This paper has attempted to trace some of the problems the professional faces as he enters the new era of comprehensive community mental health services. Some of the
issues and problems are in the province of administrative policy and structure with their attendant lags, as far as change is concerned. Other issues are still within the grasp of the various mental health professionals, and they must initiate a process of self-development and change to meet community needs. REFERENCES BENNETT,C. C., et. al. Community Psychology: a report of the Boston Conference on the education of" psychologists for community mental health. Boston: Boston University and So. Shore Mental Hlth. Center, 1966. BIND~AN,A. J. Bibliography on consultation. Boston Univ. ]. Ed., 1964a, 146, 56-60. BINDMAN,A. J. The psychologist as a mental health consultant. ]. psychiat. Nursing, 1964b, 2, 367380. BINDMAN,A. J., GILBERT,R. R., NEIBERG,N. A., & HAUGHEY,D. W. The psychologist's function on a state level. Merit. Hosp., 1961, 12, 6-9. BINDMAN,A.J., & KLEBANOFF,L. B. Administrative problems in establishing a community mental health program. Amer. J. Orthopsychiat. 1960, 30, 696-711. CAPLAN, G. Types of mental health consultation. Amer. J. Orthopsychiat., 1963, 33, 470-481. GRUENBERC,E. M. Applications of control methods to mental illness. Amer. J. Pub. Hlth, 1957, 47, 944-952. HALLOCK, A. K., & VAUGHAN,W. T. Community organization--a dynamic component of community mental health practice. Amer. J. Ortho. psychiat., 1956, 30, 696-711. McCuLLOUGH, i . W. State perspectives for psychological services. In Manpower and psychology. Trenton, N.J.: N.J. Dept. Institutions and Agencies, 1962. Pp. 14-24. SENATECOMMITTEEONLABORANDPUBLICWELFARE.
Report 366. Amer.psychol. Ass., Div. 13 Newsltr, 1965, 2, 9.
Volume2, Number4, Winter, 1966
PROBLEMS
ASSOCIATED
MENTAL
HEALTH
WITH
COMMUNITY
PROGRAMS
ARTHUR J. BINDMAN, PH.D., M.P.H.*
mental h e a l t h programs have had the same emphasis, t h e same goals, or even similar problems with which to contend. In general, these programs have depended u p o n state agencies for financial stimulation a n d support, standards of practice, and o t h e r consultative and training functions. T h e method of support and the degree to which these agencies have participated in local programming appear to be crucial variables in the assessment of program growth and effectivehess, as well as in tackling the c o m m u n i t i e s ' m e n t a l health problems.
Community mental health programs vary in relation to their types of administrative and fiscal policy and structure. Discontinuity of services may increase due to proliferation of community-based programs, and community mental health personnel must be trained to deal with many needs and new programs. There will also be conflicts over individual professional interests versus community needs. Problems of staff recruitment will increase and concerted efforts are necessary to increase inservice education in order to reshape professional roles. Psychologists in particular are interested in new developments in "community psychology" as a means of contributing to these efforts.
PROGRAMSTRUCTURE
I n r e c e n t years c o m m u n i t y mental h e a l t h programs have been growing rapidly, spurred on by the changing interests of practitioners, the greater involvement of c o m m u n i t y members, initiation t h r o u g h legislative mandates, and the outpouring of increased financial support. Few c o m m u n i t y
A major t r e n d of financial s u p p o r t and control appears to be that in which state d e p a r t m e n t s of mental or public h e a l t h receive a legislative m a n d a t e and finances to work on a matching-fund basis with comm u n i t i e s t h r o u g h local m u n i c i p a l boards. A n o t h e r approach is that of local partnership with the state (Hallock & Vanghan,
* Dr. Bindman, a clinical psychologist, is Director of Psychological Services, Massachusetts Department of Mental Health, Boston. This article is based on a paper presented in a symposium on ~'Contributions of Psychologists to Community Mental Health Programs" at the American Psychological Association Convention, Chicago, 1965. 333
334
THE COMMUNITYMENTAL HEALTHJOURNAL
1956). Local mental health associations provide private support for a mental health center while the state provides personnel, consultation, and training programs. Bind. man and Klebanoff (1960) have discussed the relative merits of these approaches. Specific legislation and matching-fund financing would appear to be a means for rapid program development. The issue of state control can be minimized if matchingfund programs set their goals, know the limits of their budgets as defined clearly by legislation, and also maintain high standards for personnel and programming. A good civil service or merit system from which standards stem can help. On the other hand, matching-fund programs do have certain weaknesses. They do not necessarily have popular interest and support unless the community is involved. Also, localities feel that the state '~calls the tune," resulting in feelings of dependency and attendant hostility. In the local partnership program, there are other weaknesses to overcome. Where the state department does not play such a central and powerful role, a vacuum of sorts is left, which gets filled by the conflicting interests and goals of various groups. Where local funds and interests are solicited in order to provide for greater local autonomy and for participation and flexibility in program planning, the result can be the channelization of energies in many directions. For example, some communities may become overinvolved with the development of their local mental health associa. tion which is tied in with the state mental health association's program. Although the community may need a variety of basic community mental health services, most of its energy may be siphoned into secondary functions under the direction of the state mental health association, with little attention to the development of more basic services. Other communities may spend a major portion of their time in such areas as fundraising to the detriment of self-surveys, self-education, and sound program planning. In many instances the official state mental health agency must play a delicate and subtle consultative and community organ-
ization role, which helps these communities achieve useful and realistic goals. The state mental health agency should not be strictly supervisory and inspection oriented, but rather a consultant and partner. However, the state agency cannot be completely non. directive in its approach. Communities do need technical assistance and direction. Bindman and Klebanoff (1960) point out that "more than one community has later complained that excessive permissiveness resulted only in anxiety and frustration because they were not in possession of a sufficient degree of technical information upon which t o base their own conclusions or direct themselves knowledgeably." There is a third approach, which is used by Connecticut. This combines the matching-fund and local partnership methods but seems to result in more local autonomy as the long-term goal. The state supplies seed money and personnel to start a program once a local community has organized itself to support the program in part. The community takes over an increasing portion of the financial support of the program over a period of time. In many respects the federal mental health program will follow a similar pattern, particularly where personnel support is concerned. This raises the serious question for some states of whether they are buying a r162 in a poke." They may feel they will be adding to a much larger budget for mental health in the future if they participate now. There does not appear to be any ideal solution. Matching-fund programs do provide a high level of funding but with accompanying central control. Partnership programs are weak financially but may have more local autonomy and creativity. The seed-money approach may serve to start a program provided there is the right mixture of state and local control, but funds may run out before ample local support is forthcoming, or this method may be unacceptable to some states. PROGRAM CONTINUITYAND DEVELOPMENT
Regardless of the type of community mental health support, there appear to be many obstacles to continuity of treatment,
ARTHUR J. BINDMAN often related to patterns of agency cooperation and structure. This discontinuity may actually be increasing due to a proliferation of new types of programs supported by Federal agencies other than those from the mental health sphere. For example, funds from the Office of Economic Opportunity have resulted in programs such as Head Start, multiservice center, special job training and school programs, all of which should have relationships with the mental health field. In many instances the mental health ~r concerned with its own plans for the future, as well as with continuous demands from myriads of patients, has often moved slowly in developing interagency relationships and cooperation. Planners and administrators at the highest levels must make a conscious effort to coordinate the development of all social welfare programs at the community level or be faced with increasing breakdown in communication, referral, and services for patients. If an agency has followed a classical pattern of waiting for the patient to appear on its doorstep and then treating his problems, regardless of the patient's social and environmental needs, this will only enhance the patient's alienation from that agency. A productive community mental health program must be aware of the range of sociopsychological-political problems in its community, must be sensitive to the needs of its clientele, and must utilize community organization, public relations, and even political science techniques in order not only to increase its effectiveness but to reduce the communication and interagency blocks that so frequently harm people. How many of us have seen agencies that call themselves community mental health centers yet practice a type of semi-isolated, pick-and-choose approach, not dealing with the deep-seated problems of their community, and not really relating to the other health, education, and welfare agencies? It is all too frequent; patients and communities suffer from this approach. COMPETENCE Psychologists and social workers can play a major part in breaking down barriers, in-
335
creasing communication, and interrelating the functions of various agencies. Many of these nonmedical professionals have begun to participate in the administration of community mental health programs, and it is to be hoped that this bodes well for the future. Unless the administration of these programs is based upon competence, rather than upon the idea that medical direction is the only way through which these programs can function, there will continue to be, not only weaknesses in program operations, but difficulties in obtaining competent personnel. Nonmedical personnel will continue to desert these programs for university, industrial, or private practice settings. The Senate Committee on Labor and Public Welfare Report No. 366 (1965) on the Community Mental Health Centers Staffing Bill has spelled out the r162 intent," namely, that r162 overall leadership of a community mental health center program may be carried out by any one of the major mental health professions. Many professions have vital roles to play in the prevention, treatment and rehabilitation of patients with mental illnesses." Not only is the type of overall state administration or mental health leadership a problem for patient care, but the philosophy of program management is one of the greatest problems. The same Senate Report No. 366 calls for the coordination of the community mental health center program with all relevant federal programs to avoid duplication, such as with school guidance and counseling, housing programs, poverty programs, and welfare programs. Too many programs have difficulty in relating adult and child services together, or mental illness and mental retardation programs, let alone relating to the more esoteric programs, such as housing. Mental health professionals frequently reject areas of responsibility to which they could and should contribute. For example, many administrators have been faced for years with the problem of ~r mental retardation concerns to mental health agencies. It has taken much interpretation, inservice education, promulgation of program goals, and state regulations, but some mental health professionals
336
THE COMMUNITYMENTALHEALTHJOURNAL
still reject this need for cooperation. Our relationships between mental health and the official rehabilitation agency, mental health and employment security, or mental health and education are still not smooth. Relationships between state mental health agencies and private agencies still leave something to be desired, with the latter often "choosing" special patients and leaving the poor ones for the former. None of these problems will be solved in some Utopia of the future, but we must be aware of them, plan for their reduction, and train personnel to deal with them in a more conscious and conscientious manner. PROGRAM EMPHASIS Where should a community mental health program concentrate its efforts? Should it emphasize early diagnosis and intensive treatment? Should it aim toward prevention of mental health problems by methods of intervention, consultation, pro. motion, and education? What about such areas as training, research, community organization, and rehabilitation and follow-up of returning mental patients? We should face facts: community mental health programs cannot do a good job in all areas unless the size of the patient population is limited, staff is greatly enlarged and well trained, and there is continued emphasis on new methods of handling mental health problems in an efficient manner. Primary and secondary preventive techniques, such as working with maternal and child health agencies, controlling environmental haz. ards, enhancing family life, particularly for children who would be severely deprived, working with geriatric problems, and even working with nutritionists should become some of the major points of attack (Gruen. berg, 1957). However, every community mental health program must establish priorities. Often these priorities stem from long.standing interests, based upon earlier training and direction, without a basis upon a particular community's needs. TRAINING AND STAFF RECRUITMENT The influx of large sums of money into community mental health programs has had
some influence upon better salaries for recruitment of professional personnel. However, the recruitment problem is far from solved. There is only a limited "barrel" from which to draw potential workers. A community mental health program will rise or fall on its ability to recruit able personnel. If recruitment techniques draw in only the "discontented," the individual looking for an "easy berth," the professional with weak training in basic aspects of diagnosis and treatment, or personnel who cannot flexibly adapt to new roles within the mental health setting or in the community, such a program is doomed to severe problems and even failure. Recruitment should aim toward obtaining welltrained individuals who are secure in their professional roles but flexible enough to seek new methods and new functions for themselves and those with whom they work. Creativity, originality, and an emphasis upon breadth and scope of knowledge would appear to be essentials in order to obtain the type of persons who enhance programs. Too frequently we are hampered by those who are easily threatened, who zealously guard their professional role, who rigidify and codify each action in such a way as to hamstring any new innovations that make for better programming. A major tool for development and continued growth is an inservice training program. This program, utilizing both state-level staff members, university and other consultants, as well as special workshops and institutes, can serve as the key for stimulating, directing, and maintaining the interest and morale of community mental health workers. For example, the Massachusetts community mental health program has continually maintained an inservice training program in which all personnel gained not only a background in public health aspects of mental health but also in such specific techniques as mental health consultation and administration of community mental health programs (Bindman& Klebanoff, 1960; Caplan, 1963; Bindman, 1964a,b). As these training programs have waxed and waned over the years, one could almost make a direct correlation to staff turnover, morale, and ade-
ARTHUR J. BINDMAN quate goal-orientation of the program. Not only have schools of public health and medical schools begun to show more interest in community mental health training, but we have also begun to see some enlargement of the scope of training in the basic professions of psychiatry, psychology, and social work. These training programs must be related to ongoing community mental health activities, so that both trainees and workers can participate in new develop. ments and so that there is a possibility for interchange between university and service personnel. ROLE DEFINITIONS AND FUNCTIONS An example of the problem of role definition in community mental health is the one faced by psychologists. The question of emphasis on specific roles and functions is so blurred that it is no small wonder that clinical psychology, in particular, is split into a factionalistic, almost nihilistic selfappraisal. Some wish to stress the role of the scientist and others the practitioner; some emphasize preventive work with children, while others emphasize work with other age groups; and some wish to provide classical therapy and testing, while others wish to try new programs and lead in their administration. In all of these areas the psychologist is often ill at ease, knowing that he can provide certain high-level services in keeping with his training and experience, yet often blocked by his classical graduate training or by rigid administrative methods in which he plays a secondary role or provides only a portion of his knowledge. Psy, chiatry has begun to develop a number of programs to train young psychiatrists in community mental health methods, but psychology is still behind in this regard. On the other hand, what can psychologists in. troduce in their training programs to achieve a distinctive role and function? If they stress community organization, they threaten the social workers; if they stress psychotherapy, they threaten the psychiatrists; if school mental health programs are stressed, they threaten the increasing number of school guidance and counseling workers; an increasing amount of research
337
is being done by psychiatry, and this too becomes an area of conflict. As the new comprehensive mental health centers are being planned and built, the psychologist must definitely redefine and reshape his role. There is no specific answer at present, but perhaps a trend can be noted. Several years ago one could fairly readily define the clinical psychologist's functions in a number of key areas, such as diagnosis, psychotherapy, research, training, consultation, and administration (Bindman, et al., 1961). More recently McCullough (1962) emphasized the need for state-employed psychologists to be knowledgeable about such diverse fields as (1) community organization and group dynamics; (2) psychological aspects of rehabilitation methods; (3) research and evaluation of mass treatment, milieu therapy, and other large.scale procedures; (4) consultative skills and program planning and development; (5) administration; (6) communication and interdisciplinary relationships; and (7) agency structure. A recent conference on the education of psychologists for community mental health (Bennett, et. al., 1966) stressed the need for so-called "community psychologists." Community mental health practice and clinical psychology were both seen as sub. specialties and as separate from community psychology. The community psychologist was primarily seen as a "participant-conceptualizer," i.e., involved in and stimulating community processes, as well as conceptualizing these processes within a psychological-sociological framework. This is indeed a broad canvas on which psychology can paint its picture and includes functions and roles in large-scale research, program and administrative consultation, dynamics of social change, communication problems, administration, social system analysis and action, preventive intervention, direction and utilization of natural human resources, conflict resolution, intergroup relations, and community organization and dynamics. Lest one think that psychology is becoming escapist or megalomanic, it should be noted that many of these areas of interest are now the concern of psychologists. Further era-
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phasis through new specialized training programs, utilization of different practicum and internship settings, combined with an interdisciplinary faculty and student body, could provide a cadre of psychologists who could begin really to understand and deal with major sociopsychological issues of our society instead of merely acting like "junior psychiatrists." This does not imply that all clinical psychologists should immediately shift from what they are now doing and become community psychologists. Many psychologists are now providing important and useful services in our present mental health programs. A shift in attitude and emphasis combining a more sociological, public health orientation with present clinical skills may be the base for even further gains in assisting client populations. The use of inservice education and postdoctoral specialty programs may be the final means for achieving a major change in the psychologist's functioning in the community. Psychologists practicing in the community desperately need this transfusion of attitude and orientation. Unless this can begin to take place within the next few years, psychologists can expect to feel even greater dissatisfaction in their roles as they participate in a comprehensive community mental health program that operates on a fairly restricted and narrow model. This paper has attempted to trace some of the problems the professional faces as he enters the new era of comprehensive community mental health services. Some of the
issues and problems are in the province of administrative policy and structure with their attendant lags, as far as change is concerned. Other issues are still within the grasp of the various mental health professionals, and they must initiate a process of self-development and change to meet community needs. REFERENCES BENNETT,C. C., et. al. Community Psychology: a report of the Boston Conference on the education of" psychologists for community mental health. Boston: Boston University and So. Shore Mental Hlth. Center, 1966. BIND~AN,A. J. Bibliography on consultation. Boston Univ. ]. Ed., 1964a, 146, 56-60. BINDMAN,A. J. The psychologist as a mental health consultant. ]. psychiat. Nursing, 1964b, 2, 367380. BINDMAN,A. J., GILBERT,R. R., NEIBERG,N. A., & HAUGHEY,D. W. The psychologist's function on a state level. Merit. Hosp., 1961, 12, 6-9. BINDMAN,A.J., & KLEBANOFF,L. B. Administrative problems in establishing a community mental health program. Amer. J. Orthopsychiat. 1960, 30, 696-711. CAPLAN, G. Types of mental health consultation. Amer. J. Orthopsychiat., 1963, 33, 470-481. GRUENBERC,E. M. Applications of control methods to mental illness. Amer. J. Pub. Hlth, 1957, 47, 944-952. HALLOCK, A. K., & VAUGHAN,W. T. Community organization--a dynamic component of community mental health practice. Amer. J. Ortho. psychiat., 1956, 30, 696-711. McCuLLOUGH, i . W. State perspectives for psychological services. In Manpower and psychology. Trenton, N.J.: N.J. Dept. Institutions and Agencies, 1962. Pp. 14-24. SENATECOMMITTEEONLABORANDPUBLICWELFARE.
Report 366. Amer.psychol. Ass., Div. 13 Newsltr, 1965, 2, 9.
