Program Change Through Mental Health Planning Franklin B. Fogelson, LL.B., Ph.D. Harold W. Demone, Jr., Ph.D.
ABSTRACT: Planning for innovative program change is examined through references to selected experiences of the Massachusetts Mental Health Planning Project. The planning field was extremely complex and populated by a vast array of divergent forces. In the absence of an organization accepted as a neutral sanctioning body, the planning organism itself must develop some autonomy and positive sanction. It must develop credibility as a legitimate change system. Conscious mechanisms must be developed to insure interaction. Stressed factors are: open communication, two-way participation, flexibility and clear objectives. Dissent to recommendations may be nondirected, or aimed at specific elements of the innovative change. Strategies of neutralization of conflict are necessary. The planning body must engage in a series of ever-changing flexibIe coalitions.
The last decade has been an era of planning in the fields of health and welfare. It has also been an era of innovative program change. Although innovation and planning are often part of the same endeavor, they are not necessarily synonymous either in intent or product. Planning may legitimately have as its objective the reordering or redistribution of resources or services toward a greater degree of efficiency, equity, or coordination than had previously been achieved. Implicit in the concept of innovative program change on a large scale, however, is that although a sufficient objective of planning is efficiency and equity, a necessary objective of innovation is the introduction of new or substantially altered programs. Planning as a professional art may be carried out without innovational motives. However, innovation as a conscious effort should not be attempted without a planning component as an integral part of the process. (Planning Dr. Fogelson is Director of Field Work, Laboratory of Community Psychiatry, Department of Psychiatry, Harvard Medical School, 58 Fenwood Road, Boston, Mass. o21z 5. He was formerly Associate Director, Massachusetts Mental Health Planning Project. Dr. Demone is Executive Director, United Community Services of Metropolitan Boston, 14 Somerset St., Boston, Mass.; and Assistant Clinical Professor of Social Welfare, Laboratory of Community Psychiatry, Department of Psychiatry, Harvard Medical School. He was formerly Director, Massachusetts Mental Health Planning Project and Massachusetts Menta~ Retardation Planning Project. An earlier version of this paper was read at the Northeastern Regional Institute of the National Association of Social Workers, Boston, March z, z967. Community Mental Health Journal, Vol. 5 (1), 1969
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Community Mental Health Journal
is obviously viewed as a progressive process. It is equally possible to plan to go backwards.) A dramatic example of innovation through planning may be found in the state-wide two-year Mental Health Planning Projects conducted throughout the country from July, ~963 through June, "r965. BACKGROUND Although certain of the activities of this endeavor have been reported in the literature (Fogelson, 5964; Demone, 5965, 5966; Demone, McGrath & Spivack, 5968; Spivack & Demone, 5968; Schulberg & Demone, 5966; Schulberg, 5966; Schulberg & Wechsler, 5967) it will be helpful to place the project in a historical perspective. The Massachusetts Mental Health Planning Project was one of 53 twoyear, state-wide District of Columbia and territorial comprehensive planning efforts funded by an annual $4.2 million grant from the National Institute of Mental Health. Although considerable latitude was given to the states, it was made dear in the invitation for proposals that the states' responsibility in this mutual venture included planning toward a comprehensive community mental health program for the entire state (NIMH Digest, 5963). The planning grants were but a link in a chain of increasing Federal commitment to the concept of mental health programs located in and developed as an integral part of the communities they served. Less than a decade after the establishment of the National Institute of Mental Health (NIMH), in 5946, the Congress enacted the Mental Health Study Act of "r955, which directed the Joint Commission on Mental Illness and Health to study existing resources and make recommendations for combatting mental illness. The commission's Report to Congress published in 5965 under the title Action for Mental Health, elicited a spirited response. In 5965, the Surgeon General's Ad Hoc Committee on Planning Mental Health Facilities recommended "that the governor of each state consider taking whatever steps are necessary to stimulate the development of a plan for mental health facilities" (U.S. Department of Health, Education, and Welfare, 5963). The following year both the Conference of State and Territorial Mental Health Authorities and the National Governors Conference went on record as strongly recommending the allocation of Federal funds to make feasible the development of state-wide planning efforts with the aim of implementing the developing community mental health concept. Responding in part to the urging of these prominent groups and in part to his own personal concern for the plight of the mentally ill, in February of 5963 the late President Kennedy issued his now famous mental health message to Congress. In this message he called for a "wholly new emphasis and approach to care for the mentally ill" in which treatment would be offered "in their own communities," and in which emphasis would be on quickly returning the mentally ill to a useful place in society. The Federal guidelines which followed very specifically called for active community and professional participation in a
Franklin B. Fogelson and Harold W. Demone, Jr.
5
planning effort directed toward community-based programs in contrast to the classical custodial institutional model. MASSACHUSETTS COMMITMENT TO COMMUNITY PROGRAMS It would, of course, be inaccurate to suggest that any movement in the direction of community mental health programs was a journey into virgin territory. In a number of states, mental health programs of a community nature had been in operation for many years. For the most part, however, these programs constituted appendages to the main body of mental health treatment programs, as measured by the proportions of funds expended for community programs in contrast to hospital programs. Massachusetts, due to the inspired leadership of such individuals as Dr. Harry C. Solomon and Dr. Jack Ewalt, has progressed well along the road toward the development of mental health programs, primarily child guidance clinics, in which the community plays an active role. Dr. Solomon, during the period of the Mental Health Planning Project, was the Commissioner of Mental Health for the Commonwealth of Massachusetts, and was previously superintendent of the Massachusetts Mental Health Center, considered by many to be a prototype of the community mental health center. Dr. Ewalt is currently superintendent of the Massachusetts Mental Health Center. A former Commissioner of Mental Health for Massachusetts, he directed the previously mentioned national study of the Joint Commission on Mental Illness and Mental Health. Other significant Massachusetts community mental health innovators induded Dr. Erich Lindemann and Dr. Gerald Caplan, both of Harvard. Nevertheless, as measured by expenditures, the bulk of the mental health programs in the state and in the nation operated with nominal community participation and in settings which were psychologically (if no longer physically) isolated from the community. By accepting funds to plan for the development of a comprehensive system of community mental health programs, the states were making an implicit commitment to major program change. COMPREHENSIVE APPROACH TO COMPREHENSIVE PLANNING Herman Field (2965) suggests that a basic characteristic of the planning method is a holistic or gestalt view. When one plans for as extensive an entity as an entire state, the delineation of the components of the field is itself a comprehensive task. The system is an interacting complex of socioeconomic, political, professional, technical, bureaucratic, and other considerations. In this paper, examination will be limited to certain selected principles underlying the efforts of the Massachusetts Mental Health Planning Project as it attempted to both sharpen the direction of change and to accelerate its process. Some of the other dimensions are described in the references cited earlier.
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Community Mental Health Journal
IDENTIFICATION AS AN AUTONOMOUS ENTITY Inherent in the type of planning discussed here is the vast array of competing forces likely to be affected. Many will have a strong vested interest in preserving a portion of the status quo, e.g. a voluntary mental health group may be committed to the concept of a coordinated statewide program in community mental health. They may, however, have strong reservations about surrendering any of their perceived domain over local mental health programs. Similarly, the state mental health authority (official state agency) may enthusiastically engage in interdepartmental planning for a particular target population (for instance, the retarded or the criminally insane) as long as such planning does not dearly lead to the diminution of the departmental budget or authority or to the imposition of unwanted responsibilities. The legislative leadership may appreciate the value of developing flexible intervention programs but resist granting to community units the fiscal freedom necessary for such flexibility. It must be understood that problems of the type noted may be symptomatic of long-standing positions, or merely pertinent manifestations of recurring issues independent of mental health. In any case, they represent the realities facing all planners. Where they represent manifest or latent conflict between competing parties, they not only limit the planners' freedom but impair the establishment of needed relationships with influential competing camps within the system toward which the innovative effort is being directed. Two steps to effective planning are: the need to acquire an intensive understanding of the inner workings of the system and, lacking power, the need to proceed under the umbrella of positive sanction. These factors are closely related. In seeking to bring about major change within a system as large as that in Massachusetts, a vast amount of technical and political information, often of an historical nature, is needed. Most cannot be found in written reports or even through sophisticated interviewing techniques. Often the sense of this information can only be achieved through deep immersion in the workings of all aspects of the system, e.g. the problems of the Department of Mental Health in delivering services and working with the legislature, the problems of the state-wide voluntary mental health association in securing adequate financing and in their relationships with their constituent agencies, the difficulties of the medical society (and other professional groups as well) as they sought to frame an appropriate response to changes, some of which were perceived as threatening. Such intelligence can often only be obtained either through actual involvement in the problem-solving process or through the confidence of those who view the planners as collaborative fellow-actors. The need for positive sanction goes not only to information gathering but to conceptualization of the direction of planned change and the implementation of plans as well. Unless sanction to alter the status quo comes from a wide range of actors both within and outside the system, effective innovation seems doomed to failure.
Franklin B. Fogelson and Harold W. Demone, Jr.
7
The course chosen by the Planning Project director was organizational autonomy rooted within but not of the system. The Department of Mental Health contracted with The Medical Foundation, Inc., a Boston-based voluntary noncategorical health agency receiving support from United Funds, to do the planning. The foundation later received similar contracts in mental retardation and rehabilitation. The executive director of the foundation also served as director of the Planning Project. The objective was to obtain a maximum of systemic sanction, access to "inside" information, freedom to improvise, and expectation of a mutual effort toward implementation. The Commissioner of Mental Health, however, retained veto power over the selection of the planning staff and was chairman of the Planning Project Advisory Council. Key departmental persons also served on the council and the various task forces. Department of Mental Health leaders regularly attended and participated in project staff and strategy meetings, and several project members did the same with the department. A staff member of the project religiously attended the meetings of the State Hospital superintendents. The project organized an interdepartmental meeting of commissioners and often staff members served as trouble-shooters for the department in its relationship with other government departments, voluntary agencies, and the public at large. Thus a serious effort was made to be a part of the department but not its creature, to be free enough to communicate effectively with departmental critics, and to be sufficiently linked to be appropriately informed. Attempts were made to involve key state legislators in the planning process. Although more than 3o were formal participants, these efforts were only partially successful. This may have been in part because the legislature saw this as a project funded through the executive branch. As such, the project was no doubt viewed with some suspicion and as a potential adversary. Additionally, the Massachusetts legislature, unlike any other in the country, must respond to free petition by both public hearings and a formal vote. Consequently they are almost always actively engaged in the legislative process, leaving little free time for voluntary activities. More success was had with the executive department (the product would eventually be theirs), even with a change in administration and political party midway in the project's life. Not only were high executive officials of the Commonwealth actively involved in planning, but staff professionals were used by both governors as consultants and "idea" men, i.e. the mental health and retardation components of both governors' annual messages to the legislature were the product of collaboration between the governors' staffs and Planning Project personnel. Equally complex was the establishment of an effective relationship with the nongovernmental portions of the mental health system. In addition to the inclusion of leaders from the various agency and professional associations as integral partners of the planning process, a regular system of feedback was employed. This included not only the formal exchange of ideas at
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Community Mental Health Journal
both regular and specially called meetings, but also an exchange through many informal networks. To illustrate these processes, special reference will be made to the State Medical Society and the state-wide voluntary mental health association. The Massachusetts Medical Society, following the lead of the American Medical Association, initially adopted a somewhat "wait and see" attitude toward our planning efforts. Of course, within the society the spectrum of opinion ran from those who opposed the project's goals (e.g., opposed to nonmedical participation in health matters, opposed to government, opposed to mental health, opposed to psychiatry, opposed to dynamic psychiatry, opposed to planning, and opposed to the concept of community mental health as an effective psychiatric tool), to those who wholly supported the goals. The project's response to the medical society, as to all groups, was one of conciliatory firmness. Participation of all segments of medical and other professional opinion was sought, although it was made clear that domination by any single group was in the interests of neither the medical nor nonmedical actors in the mental health system, the public or the prospective patients. Suggestions for names of task force leaders and members were sought from and reviewed with the medical society leadership. The project remained open to all suggestions regarding the most appropriate approaches to mental health, but made clear to the president and Mental Health Committee that it felt that domination by any professional or special interest group of the Advisory Council and task forces would be inimical to true comprehensive planning. (The support of the society president at this time was most important.) By the same token, it was made clear that there was appreciation of the special role and interest of the medical profession and that these views would be significantly represented in the decision-making process. Particular attention was given to the mental health committee of the society and, in a precedent-breaking move, they invited the project director (not a physician), following his introduction by the Commissioner of Mental Health, to sit in on their regular meetings during the course of the project. The project also conducted joint surveys with several psychiatric and nonpsychiatric medical specialty groups in order to delineate the nature of the mental health components of their private practice. The results of the surveys were shared with the groups involved (Schulberg, 5966 ). With continuing communication, any possibility of adversary relationship between the society and the project was alleviated. This was of particular importance since relations between the state mental health authority and the society were strained. Although areas of disagreement continued through the planning effort, avenues for accommodation were always kept open. Most important was that the great majority of the society leadership accepted the project as neither the captive of the department, nor as members of an anti-medical intrigue. Another group with whom it was imperative the project relate was the state voluntary mental health association. They were long at odds with the
Franklin B. Fogelson and Harold W. Demone, Jr.
9
Department of Mental Health policy to establish "mental health associations" as community partners in the child guidance clinic system. It was possible that they would perceive the project as a further governmental incursion into their domain. Given their understanding and expertise in the system and the constituency of citizen leaders they represented, the active opposition resulting from such a perception could have been very harmful to the planning effort. A new executive director from out of state arrived to assume leadership of the association at about the time the project began. Among his problems were familiarizing himself with the complexities of the state system and at the same time coping with internal dissension from the lay leadership of several of the constituent local agencies over the issue of their providing direct mental health services counter to national and state mental health association policy. The project staff immediately made available to the new executive as much information as it could regarding the state and its mental health system. Again suggestions were solicited for task force and advisory council membership and selections were reviewed with the leadership of the association. Many of those on task forces were, together with other qualifications, in some way identified with mental health associations. They included those who were in opposition to the state association's leadership and often the project provided the most neutral forum in which the opposing groups could meet. The project by its long-range program orientation also provided topics for discussion between the Department of Mental Health and the local associations which were less inflammatory than those which had dominated many previous communications. In providing this forum, the project pointedly adopted a neutral stance and in so doing helped to establish its identity independent of either the state department or the voluntary association. One of the basic points of conflict which eventually emerged in the project was the appropriate role and degree of control which citizen volunteers were to have in connection with new programs. As might be anticipated, the Department of Mental Health and the voluntary association sometimes found themselves at opposite ends of the continuum. In the often hard-hitting conflict that followed, the independent role of the project, which was accepted by both partisans, made it possible to work through compromises which were at least reasonably acceptable to most of those concerned. FLEXIBILITY OF COALITIONS The second basic principle adhered to was that coalitions and alliances formed at various stages of the planning process were necessarily flexible and subject to change. It was assumed that as the nature of the innovations became more specific, allies would become more discriminating in their support, e.g. as the likelihood of recommendations for optional selected nonmedical administration became apparent (made by a task force with a physician chairman and a majority of physician members), the anti-
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Community Mental Health Journal
project voices within the medical society became more prominant; as the project's middle-of-the-road position on citizen control emerged, so did opposition within the state and local voluntary mental health association (and also from the state hospital superintendents, but for opposite reasons). Again what emerged was the obvious fact, consensus-seeking had substantial limits, unanimous approval of the innovations sought was impossible to achieve. While vigorously seeking consensus, expression of dissent was sanctioned throughout the process, and the project published dissenting opinions in many task force reports and in the final project report itself. The combination of strategies, consensus-seeking within limits, and sanctioned, formalized dissent led to an effort to delineate the nature of opposition to specifics so that objection to one segment of the recommendations need not be inconsistent with general support of the plan. A prime example of this approach was seen in the project's relationships with the Massachusetts Association for Mental Health. As has been mentioned earlier, the question of citizen control of programs proved to be a key point of dissension. The consistent position of the association was that both fiscal and program control should be vested in local citizen community mental health boards. The Task Force on Administration on legal, practical, political, historical, and philosophical grounds proceeded from the position that such control had to be selectively exercised and limited. In many meetings, at all levels, the position of the project was argued and attempts were made to convince both lay and professional people in the association that their concept was not valid for Massachusetts. The result was that this series of issues was separated from the many other agreed-upon issues. The difference was not allowed to become divisive. The broad commitment of the association to innovation in mental health was thus preserved. The association continued vigorously to put forth its position not only within the project and its own group but among key legislative leaders. Things came to a head when, shortly before the final report was to be issued, a leading Boston newspaper brought the issue before the public with a frontpage headlined article which indicated that the report would call for a centralized Department of Mental Health with only token representation by citizen volunteers in the community mental health program. This, of course, did not accurately reflect the tenor of the project's recommendations, nor was this the association's true appraisal of them, but was a reflection rather of the art of writing page one headlines. Nevertheless, by bringing the question into the public domain in such a way as to suggest that the differences between the project's report and the association's position were qualitative rather than quantitative, the success of the whole could have been in jeopardy. When this possibility was discussed with the association leadership, they quickly agreed and threw themselves wholeheartedly behind the project report, contenting themselves with a pro forma dissent to a few minor points. When legislation based on this report was being considered, they continued
Franklin B. Fogelson and Harold W. Demone, Jr.
11
in this vein. (An important feature of the Massachusetts effort is that legislation was a major goal. This is not to imply that successful planning need be equated with legislation, but that legislation may sometimes be necessary.) Both in their active lobbying and testimony before several legislative communities, they enthusiastically supported the bill. They indicated that, while they felt the citizen participation sections were weak and should be reconsidered in future years, the bill itself was valid and deserved support. Even when the legislature further cut the authority of citizen boards, the association remained firmly behind the bill. The superordinate goal to improve the quality of mental health services through a community mental health program--won out over jurisdictional issues. A somewhat different situation prevailed in connection with the medical society. As previously mentioned, there was general reservation among some physicians about the role of nonmedical agents in the projected community program. Concern was also felt over the role of government as a competitor in a field which was perceived as the property of the private practitioner. These concerns and questions were not voiced in the context of active opposition to the project, but rather in a wait and see attitude which allowed for full cooperation with the planning effort (although with far less commitment as to outcome than was found in the association). Within the society, however, there was a small group who had strong feelings about these issues and who opposed the underlying concepts of community mental health. For a variety of reasons this group, prior to the beginning of the project, had been constituted as the official spokesman for the society in questions of mental health. From this position of strength they would be in a position to persuade the society to place itself on record as being opposed to the planning effort. Such an eventuality was viewed as a real possibility and one which could have been a mortal blow to the likelihood of a successful outcome for the project. It became a task of the project staff to establish mechanisms leading to a coalition with the medical society. The project staff actively reached out to the mental health committee of the medical society and actively involved them in the planning process. Their most articulate spokesman, along with the president of the medical society, served on the Advisory Council. In addition, many other physicians were also on the council. Other members of the committee and many more not on the committee participated as task force members. It is important to recognize that what went on was something more than a pro forma cooptation of a difficult group. They were truly part of the project, their views were considered and made a real impact in shaping the direction of the final recommendation of the project as a whole. The relationship was not an easy one, and basic value differences often led to stormy sessions. However, these disagreements were played out within the context of a coalition which sought to develop a worthwhile report. At no time was it presumed that this group would permanently ally itself to the project and actively support, uncritically, implementation of the final project report in all of its details.
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Community Mental Health Journal
However, the legitimation given to this group within the project made it possible for the medical society to move from a neutral to a cooperative role. It is interesting that although the leader of the dissident group filed a forceful dissent to a few of the 570 project recommendations, the medical society did not take a formal stand in opposition. Although members of this group testified against selected features of the Mental Health Bill before the legislature, they supported its major elements. In fact, the majority of physicians taking a public position supported the general recommendations and the proposed legislation. By way of epilogue, clear testimony as to the fragility of alliances appeared in the form of a letter to the editor to all Boston papers shortly after the passage of the Community Mental Health-Retardation Act, which closely paralleled the project's recommendations. In it the leader of the dissident group decried the bill passed in concept, in content and in particular because the medical profession was not involved in its development. FLEXIBILITY OF INTERVENTIVE STANCES The final underlying principle which will be examined here is the nature of the intervening stance played by the planner. The conceptualization of the stance taken by planners in itself merits a more complete explanation in a separate paper. For that reason it will be touched upon here only briefly. The literature abounds with thoughtful analyses and conceptualizations in this field of interest. Particularly noteworthy has been the work of Roland Warren (:t965) and Robert Morris and Martin Rein (I963). The planner must have a dear understanding of the substance of the change he seeks to achieve. He must also avoid becoming the victim of his own rigidity as to the form of the change. The willingness to compromise, to assess and evaluate the realistic limits of the change which can be effected, is basic. For example, it was clear that a large measure of fiscal flexibility would be valuable in developing viable community programs. However, an assessment of the political situation in the Commonwealth made it clear that such a request to the legislature might result in the sabotaging of the entire program. Accordingly, the Planning Project Report called for very circumscribed fiscal independence (a simplified budget transfer procedure) which, although it did represent movement in the right direction, was far short of the ideal. However, this was a recommendation which had a reasonable chance of being implemented. (In fact, this measure remained in the bill until just before passage, when it was eliminated by the Ways and Means Committee.) Finally, the planner must see himself within a historical perspective. There is a tendency to equate innovation with dramatic change. Occasionally such a breakthrough can be made, but more often innovation is accomplished in modest steps. It is a continuing process, but one in which successful implementation of only partly realized goals for change may have a major effect upon the system bearing the impact.
Franklin B. Fogelson and Harold W. Demone, Jr.
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REFERENCES Demone, H. W., Jr. The limits of rationality in planning. Community Mental Health Journal, i965, I, 375-38I. Demone, H. W., Jr. Massachusetts--a prototype for mental health planning. Psychiatric Opinion, I966 , 3, I25-32. Demone, H. W., Jr., McGrath, M., & Spivack, M. Decision-making issues in the development of community mental health centers, 1968. Field, H. Organizing the planning process. Annals of the New York Academy of Science, September, i965, p. 67I. Fogelson, F. B. Statewide planning in mental health: an early report. Social Work, October, I964, 26-33. Morris, R., & Rein, M. Emerging patterns in community planning. Social, Work Practice, 9963. New York: Columbia University Press, 1963. Schulberg, H. C. Private practice and community mental health. Hospital and Community Psychiatry, I966 , I7, 363-366. Schulberg, H. C., & Demone, H. W., Jr. The impact of mental health planning. Psychiatry Digest, January, 2966, 27, 33-41 . Schulberg, H. C., & Wechsler, H. The uses and misuses of data in assessing mental health needs. Community Mental Health Journal, ~967, 3, 4, 389-395 9 Spivack, M., & Demone, H. W., Jr. Mental Health Facilities: A Model for Physical Planning, I968. United States Public Health Service, National Institute of Mental Health. Digest, State Mental Health Planning Grant Proposals, I913. United States Public Health Service. Planning Facilities for Mental Health Services. Washington, D.C.: Department of Health, Education, and Welfare, January, 296I, p. 3. Warren, R. L. Types of purposive social change at the community level. Papers in Social Welfare, No. I i , 2965. Waltham, Massachusetts: Brandeis University.
ABSTRACT: Planning for innovative program change is examined through references to selected experiences of the Massachusetts Mental Health Planning Project. The planning field was extremely complex and populated by a vast array of divergent forces. In the absence of an organization accepted as a neutral sanctioning body, the planning organism itself must develop some autonomy and positive sanction. It must develop credibility as a legitimate change system. Conscious mechanisms must be developed to insure interaction. Stressed factors are: open communication, two-way participation, flexibility and clear objectives. Dissent to recommendations may be nondirected, or aimed at specific elements of the innovative change. Strategies of neutralization of conflict are necessary. The planning body must engage in a series of ever-changing flexibIe coalitions.
The last decade has been an era of planning in the fields of health and welfare. It has also been an era of innovative program change. Although innovation and planning are often part of the same endeavor, they are not necessarily synonymous either in intent or product. Planning may legitimately have as its objective the reordering or redistribution of resources or services toward a greater degree of efficiency, equity, or coordination than had previously been achieved. Implicit in the concept of innovative program change on a large scale, however, is that although a sufficient objective of planning is efficiency and equity, a necessary objective of innovation is the introduction of new or substantially altered programs. Planning as a professional art may be carried out without innovational motives. However, innovation as a conscious effort should not be attempted without a planning component as an integral part of the process. (Planning Dr. Fogelson is Director of Field Work, Laboratory of Community Psychiatry, Department of Psychiatry, Harvard Medical School, 58 Fenwood Road, Boston, Mass. o21z 5. He was formerly Associate Director, Massachusetts Mental Health Planning Project. Dr. Demone is Executive Director, United Community Services of Metropolitan Boston, 14 Somerset St., Boston, Mass.; and Assistant Clinical Professor of Social Welfare, Laboratory of Community Psychiatry, Department of Psychiatry, Harvard Medical School. He was formerly Director, Massachusetts Mental Health Planning Project and Massachusetts Menta~ Retardation Planning Project. An earlier version of this paper was read at the Northeastern Regional Institute of the National Association of Social Workers, Boston, March z, z967. Community Mental Health Journal, Vol. 5 (1), 1969
4
Community Mental Health Journal
is obviously viewed as a progressive process. It is equally possible to plan to go backwards.) A dramatic example of innovation through planning may be found in the state-wide two-year Mental Health Planning Projects conducted throughout the country from July, ~963 through June, "r965. BACKGROUND Although certain of the activities of this endeavor have been reported in the literature (Fogelson, 5964; Demone, 5965, 5966; Demone, McGrath & Spivack, 5968; Spivack & Demone, 5968; Schulberg & Demone, 5966; Schulberg, 5966; Schulberg & Wechsler, 5967) it will be helpful to place the project in a historical perspective. The Massachusetts Mental Health Planning Project was one of 53 twoyear, state-wide District of Columbia and territorial comprehensive planning efforts funded by an annual $4.2 million grant from the National Institute of Mental Health. Although considerable latitude was given to the states, it was made dear in the invitation for proposals that the states' responsibility in this mutual venture included planning toward a comprehensive community mental health program for the entire state (NIMH Digest, 5963). The planning grants were but a link in a chain of increasing Federal commitment to the concept of mental health programs located in and developed as an integral part of the communities they served. Less than a decade after the establishment of the National Institute of Mental Health (NIMH), in 5946, the Congress enacted the Mental Health Study Act of "r955, which directed the Joint Commission on Mental Illness and Health to study existing resources and make recommendations for combatting mental illness. The commission's Report to Congress published in 5965 under the title Action for Mental Health, elicited a spirited response. In 5965, the Surgeon General's Ad Hoc Committee on Planning Mental Health Facilities recommended "that the governor of each state consider taking whatever steps are necessary to stimulate the development of a plan for mental health facilities" (U.S. Department of Health, Education, and Welfare, 5963). The following year both the Conference of State and Territorial Mental Health Authorities and the National Governors Conference went on record as strongly recommending the allocation of Federal funds to make feasible the development of state-wide planning efforts with the aim of implementing the developing community mental health concept. Responding in part to the urging of these prominent groups and in part to his own personal concern for the plight of the mentally ill, in February of 5963 the late President Kennedy issued his now famous mental health message to Congress. In this message he called for a "wholly new emphasis and approach to care for the mentally ill" in which treatment would be offered "in their own communities," and in which emphasis would be on quickly returning the mentally ill to a useful place in society. The Federal guidelines which followed very specifically called for active community and professional participation in a
Franklin B. Fogelson and Harold W. Demone, Jr.
5
planning effort directed toward community-based programs in contrast to the classical custodial institutional model. MASSACHUSETTS COMMITMENT TO COMMUNITY PROGRAMS It would, of course, be inaccurate to suggest that any movement in the direction of community mental health programs was a journey into virgin territory. In a number of states, mental health programs of a community nature had been in operation for many years. For the most part, however, these programs constituted appendages to the main body of mental health treatment programs, as measured by the proportions of funds expended for community programs in contrast to hospital programs. Massachusetts, due to the inspired leadership of such individuals as Dr. Harry C. Solomon and Dr. Jack Ewalt, has progressed well along the road toward the development of mental health programs, primarily child guidance clinics, in which the community plays an active role. Dr. Solomon, during the period of the Mental Health Planning Project, was the Commissioner of Mental Health for the Commonwealth of Massachusetts, and was previously superintendent of the Massachusetts Mental Health Center, considered by many to be a prototype of the community mental health center. Dr. Ewalt is currently superintendent of the Massachusetts Mental Health Center. A former Commissioner of Mental Health for Massachusetts, he directed the previously mentioned national study of the Joint Commission on Mental Illness and Mental Health. Other significant Massachusetts community mental health innovators induded Dr. Erich Lindemann and Dr. Gerald Caplan, both of Harvard. Nevertheless, as measured by expenditures, the bulk of the mental health programs in the state and in the nation operated with nominal community participation and in settings which were psychologically (if no longer physically) isolated from the community. By accepting funds to plan for the development of a comprehensive system of community mental health programs, the states were making an implicit commitment to major program change. COMPREHENSIVE APPROACH TO COMPREHENSIVE PLANNING Herman Field (2965) suggests that a basic characteristic of the planning method is a holistic or gestalt view. When one plans for as extensive an entity as an entire state, the delineation of the components of the field is itself a comprehensive task. The system is an interacting complex of socioeconomic, political, professional, technical, bureaucratic, and other considerations. In this paper, examination will be limited to certain selected principles underlying the efforts of the Massachusetts Mental Health Planning Project as it attempted to both sharpen the direction of change and to accelerate its process. Some of the other dimensions are described in the references cited earlier.
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Community Mental Health Journal
IDENTIFICATION AS AN AUTONOMOUS ENTITY Inherent in the type of planning discussed here is the vast array of competing forces likely to be affected. Many will have a strong vested interest in preserving a portion of the status quo, e.g. a voluntary mental health group may be committed to the concept of a coordinated statewide program in community mental health. They may, however, have strong reservations about surrendering any of their perceived domain over local mental health programs. Similarly, the state mental health authority (official state agency) may enthusiastically engage in interdepartmental planning for a particular target population (for instance, the retarded or the criminally insane) as long as such planning does not dearly lead to the diminution of the departmental budget or authority or to the imposition of unwanted responsibilities. The legislative leadership may appreciate the value of developing flexible intervention programs but resist granting to community units the fiscal freedom necessary for such flexibility. It must be understood that problems of the type noted may be symptomatic of long-standing positions, or merely pertinent manifestations of recurring issues independent of mental health. In any case, they represent the realities facing all planners. Where they represent manifest or latent conflict between competing parties, they not only limit the planners' freedom but impair the establishment of needed relationships with influential competing camps within the system toward which the innovative effort is being directed. Two steps to effective planning are: the need to acquire an intensive understanding of the inner workings of the system and, lacking power, the need to proceed under the umbrella of positive sanction. These factors are closely related. In seeking to bring about major change within a system as large as that in Massachusetts, a vast amount of technical and political information, often of an historical nature, is needed. Most cannot be found in written reports or even through sophisticated interviewing techniques. Often the sense of this information can only be achieved through deep immersion in the workings of all aspects of the system, e.g. the problems of the Department of Mental Health in delivering services and working with the legislature, the problems of the state-wide voluntary mental health association in securing adequate financing and in their relationships with their constituent agencies, the difficulties of the medical society (and other professional groups as well) as they sought to frame an appropriate response to changes, some of which were perceived as threatening. Such intelligence can often only be obtained either through actual involvement in the problem-solving process or through the confidence of those who view the planners as collaborative fellow-actors. The need for positive sanction goes not only to information gathering but to conceptualization of the direction of planned change and the implementation of plans as well. Unless sanction to alter the status quo comes from a wide range of actors both within and outside the system, effective innovation seems doomed to failure.
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The course chosen by the Planning Project director was organizational autonomy rooted within but not of the system. The Department of Mental Health contracted with The Medical Foundation, Inc., a Boston-based voluntary noncategorical health agency receiving support from United Funds, to do the planning. The foundation later received similar contracts in mental retardation and rehabilitation. The executive director of the foundation also served as director of the Planning Project. The objective was to obtain a maximum of systemic sanction, access to "inside" information, freedom to improvise, and expectation of a mutual effort toward implementation. The Commissioner of Mental Health, however, retained veto power over the selection of the planning staff and was chairman of the Planning Project Advisory Council. Key departmental persons also served on the council and the various task forces. Department of Mental Health leaders regularly attended and participated in project staff and strategy meetings, and several project members did the same with the department. A staff member of the project religiously attended the meetings of the State Hospital superintendents. The project organized an interdepartmental meeting of commissioners and often staff members served as trouble-shooters for the department in its relationship with other government departments, voluntary agencies, and the public at large. Thus a serious effort was made to be a part of the department but not its creature, to be free enough to communicate effectively with departmental critics, and to be sufficiently linked to be appropriately informed. Attempts were made to involve key state legislators in the planning process. Although more than 3o were formal participants, these efforts were only partially successful. This may have been in part because the legislature saw this as a project funded through the executive branch. As such, the project was no doubt viewed with some suspicion and as a potential adversary. Additionally, the Massachusetts legislature, unlike any other in the country, must respond to free petition by both public hearings and a formal vote. Consequently they are almost always actively engaged in the legislative process, leaving little free time for voluntary activities. More success was had with the executive department (the product would eventually be theirs), even with a change in administration and political party midway in the project's life. Not only were high executive officials of the Commonwealth actively involved in planning, but staff professionals were used by both governors as consultants and "idea" men, i.e. the mental health and retardation components of both governors' annual messages to the legislature were the product of collaboration between the governors' staffs and Planning Project personnel. Equally complex was the establishment of an effective relationship with the nongovernmental portions of the mental health system. In addition to the inclusion of leaders from the various agency and professional associations as integral partners of the planning process, a regular system of feedback was employed. This included not only the formal exchange of ideas at
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Community Mental Health Journal
both regular and specially called meetings, but also an exchange through many informal networks. To illustrate these processes, special reference will be made to the State Medical Society and the state-wide voluntary mental health association. The Massachusetts Medical Society, following the lead of the American Medical Association, initially adopted a somewhat "wait and see" attitude toward our planning efforts. Of course, within the society the spectrum of opinion ran from those who opposed the project's goals (e.g., opposed to nonmedical participation in health matters, opposed to government, opposed to mental health, opposed to psychiatry, opposed to dynamic psychiatry, opposed to planning, and opposed to the concept of community mental health as an effective psychiatric tool), to those who wholly supported the goals. The project's response to the medical society, as to all groups, was one of conciliatory firmness. Participation of all segments of medical and other professional opinion was sought, although it was made clear that domination by any single group was in the interests of neither the medical nor nonmedical actors in the mental health system, the public or the prospective patients. Suggestions for names of task force leaders and members were sought from and reviewed with the medical society leadership. The project remained open to all suggestions regarding the most appropriate approaches to mental health, but made clear to the president and Mental Health Committee that it felt that domination by any professional or special interest group of the Advisory Council and task forces would be inimical to true comprehensive planning. (The support of the society president at this time was most important.) By the same token, it was made clear that there was appreciation of the special role and interest of the medical profession and that these views would be significantly represented in the decision-making process. Particular attention was given to the mental health committee of the society and, in a precedent-breaking move, they invited the project director (not a physician), following his introduction by the Commissioner of Mental Health, to sit in on their regular meetings during the course of the project. The project also conducted joint surveys with several psychiatric and nonpsychiatric medical specialty groups in order to delineate the nature of the mental health components of their private practice. The results of the surveys were shared with the groups involved (Schulberg, 5966 ). With continuing communication, any possibility of adversary relationship between the society and the project was alleviated. This was of particular importance since relations between the state mental health authority and the society were strained. Although areas of disagreement continued through the planning effort, avenues for accommodation were always kept open. Most important was that the great majority of the society leadership accepted the project as neither the captive of the department, nor as members of an anti-medical intrigue. Another group with whom it was imperative the project relate was the state voluntary mental health association. They were long at odds with the
Franklin B. Fogelson and Harold W. Demone, Jr.
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Department of Mental Health policy to establish "mental health associations" as community partners in the child guidance clinic system. It was possible that they would perceive the project as a further governmental incursion into their domain. Given their understanding and expertise in the system and the constituency of citizen leaders they represented, the active opposition resulting from such a perception could have been very harmful to the planning effort. A new executive director from out of state arrived to assume leadership of the association at about the time the project began. Among his problems were familiarizing himself with the complexities of the state system and at the same time coping with internal dissension from the lay leadership of several of the constituent local agencies over the issue of their providing direct mental health services counter to national and state mental health association policy. The project staff immediately made available to the new executive as much information as it could regarding the state and its mental health system. Again suggestions were solicited for task force and advisory council membership and selections were reviewed with the leadership of the association. Many of those on task forces were, together with other qualifications, in some way identified with mental health associations. They included those who were in opposition to the state association's leadership and often the project provided the most neutral forum in which the opposing groups could meet. The project by its long-range program orientation also provided topics for discussion between the Department of Mental Health and the local associations which were less inflammatory than those which had dominated many previous communications. In providing this forum, the project pointedly adopted a neutral stance and in so doing helped to establish its identity independent of either the state department or the voluntary association. One of the basic points of conflict which eventually emerged in the project was the appropriate role and degree of control which citizen volunteers were to have in connection with new programs. As might be anticipated, the Department of Mental Health and the voluntary association sometimes found themselves at opposite ends of the continuum. In the often hard-hitting conflict that followed, the independent role of the project, which was accepted by both partisans, made it possible to work through compromises which were at least reasonably acceptable to most of those concerned. FLEXIBILITY OF COALITIONS The second basic principle adhered to was that coalitions and alliances formed at various stages of the planning process were necessarily flexible and subject to change. It was assumed that as the nature of the innovations became more specific, allies would become more discriminating in their support, e.g. as the likelihood of recommendations for optional selected nonmedical administration became apparent (made by a task force with a physician chairman and a majority of physician members), the anti-
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Community Mental Health Journal
project voices within the medical society became more prominant; as the project's middle-of-the-road position on citizen control emerged, so did opposition within the state and local voluntary mental health association (and also from the state hospital superintendents, but for opposite reasons). Again what emerged was the obvious fact, consensus-seeking had substantial limits, unanimous approval of the innovations sought was impossible to achieve. While vigorously seeking consensus, expression of dissent was sanctioned throughout the process, and the project published dissenting opinions in many task force reports and in the final project report itself. The combination of strategies, consensus-seeking within limits, and sanctioned, formalized dissent led to an effort to delineate the nature of opposition to specifics so that objection to one segment of the recommendations need not be inconsistent with general support of the plan. A prime example of this approach was seen in the project's relationships with the Massachusetts Association for Mental Health. As has been mentioned earlier, the question of citizen control of programs proved to be a key point of dissension. The consistent position of the association was that both fiscal and program control should be vested in local citizen community mental health boards. The Task Force on Administration on legal, practical, political, historical, and philosophical grounds proceeded from the position that such control had to be selectively exercised and limited. In many meetings, at all levels, the position of the project was argued and attempts were made to convince both lay and professional people in the association that their concept was not valid for Massachusetts. The result was that this series of issues was separated from the many other agreed-upon issues. The difference was not allowed to become divisive. The broad commitment of the association to innovation in mental health was thus preserved. The association continued vigorously to put forth its position not only within the project and its own group but among key legislative leaders. Things came to a head when, shortly before the final report was to be issued, a leading Boston newspaper brought the issue before the public with a frontpage headlined article which indicated that the report would call for a centralized Department of Mental Health with only token representation by citizen volunteers in the community mental health program. This, of course, did not accurately reflect the tenor of the project's recommendations, nor was this the association's true appraisal of them, but was a reflection rather of the art of writing page one headlines. Nevertheless, by bringing the question into the public domain in such a way as to suggest that the differences between the project's report and the association's position were qualitative rather than quantitative, the success of the whole could have been in jeopardy. When this possibility was discussed with the association leadership, they quickly agreed and threw themselves wholeheartedly behind the project report, contenting themselves with a pro forma dissent to a few minor points. When legislation based on this report was being considered, they continued
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in this vein. (An important feature of the Massachusetts effort is that legislation was a major goal. This is not to imply that successful planning need be equated with legislation, but that legislation may sometimes be necessary.) Both in their active lobbying and testimony before several legislative communities, they enthusiastically supported the bill. They indicated that, while they felt the citizen participation sections were weak and should be reconsidered in future years, the bill itself was valid and deserved support. Even when the legislature further cut the authority of citizen boards, the association remained firmly behind the bill. The superordinate goal to improve the quality of mental health services through a community mental health program--won out over jurisdictional issues. A somewhat different situation prevailed in connection with the medical society. As previously mentioned, there was general reservation among some physicians about the role of nonmedical agents in the projected community program. Concern was also felt over the role of government as a competitor in a field which was perceived as the property of the private practitioner. These concerns and questions were not voiced in the context of active opposition to the project, but rather in a wait and see attitude which allowed for full cooperation with the planning effort (although with far less commitment as to outcome than was found in the association). Within the society, however, there was a small group who had strong feelings about these issues and who opposed the underlying concepts of community mental health. For a variety of reasons this group, prior to the beginning of the project, had been constituted as the official spokesman for the society in questions of mental health. From this position of strength they would be in a position to persuade the society to place itself on record as being opposed to the planning effort. Such an eventuality was viewed as a real possibility and one which could have been a mortal blow to the likelihood of a successful outcome for the project. It became a task of the project staff to establish mechanisms leading to a coalition with the medical society. The project staff actively reached out to the mental health committee of the medical society and actively involved them in the planning process. Their most articulate spokesman, along with the president of the medical society, served on the Advisory Council. In addition, many other physicians were also on the council. Other members of the committee and many more not on the committee participated as task force members. It is important to recognize that what went on was something more than a pro forma cooptation of a difficult group. They were truly part of the project, their views were considered and made a real impact in shaping the direction of the final recommendation of the project as a whole. The relationship was not an easy one, and basic value differences often led to stormy sessions. However, these disagreements were played out within the context of a coalition which sought to develop a worthwhile report. At no time was it presumed that this group would permanently ally itself to the project and actively support, uncritically, implementation of the final project report in all of its details.
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Community Mental Health Journal
However, the legitimation given to this group within the project made it possible for the medical society to move from a neutral to a cooperative role. It is interesting that although the leader of the dissident group filed a forceful dissent to a few of the 570 project recommendations, the medical society did not take a formal stand in opposition. Although members of this group testified against selected features of the Mental Health Bill before the legislature, they supported its major elements. In fact, the majority of physicians taking a public position supported the general recommendations and the proposed legislation. By way of epilogue, clear testimony as to the fragility of alliances appeared in the form of a letter to the editor to all Boston papers shortly after the passage of the Community Mental Health-Retardation Act, which closely paralleled the project's recommendations. In it the leader of the dissident group decried the bill passed in concept, in content and in particular because the medical profession was not involved in its development. FLEXIBILITY OF INTERVENTIVE STANCES The final underlying principle which will be examined here is the nature of the intervening stance played by the planner. The conceptualization of the stance taken by planners in itself merits a more complete explanation in a separate paper. For that reason it will be touched upon here only briefly. The literature abounds with thoughtful analyses and conceptualizations in this field of interest. Particularly noteworthy has been the work of Roland Warren (:t965) and Robert Morris and Martin Rein (I963). The planner must have a dear understanding of the substance of the change he seeks to achieve. He must also avoid becoming the victim of his own rigidity as to the form of the change. The willingness to compromise, to assess and evaluate the realistic limits of the change which can be effected, is basic. For example, it was clear that a large measure of fiscal flexibility would be valuable in developing viable community programs. However, an assessment of the political situation in the Commonwealth made it clear that such a request to the legislature might result in the sabotaging of the entire program. Accordingly, the Planning Project Report called for very circumscribed fiscal independence (a simplified budget transfer procedure) which, although it did represent movement in the right direction, was far short of the ideal. However, this was a recommendation which had a reasonable chance of being implemented. (In fact, this measure remained in the bill until just before passage, when it was eliminated by the Ways and Means Committee.) Finally, the planner must see himself within a historical perspective. There is a tendency to equate innovation with dramatic change. Occasionally such a breakthrough can be made, but more often innovation is accomplished in modest steps. It is a continuing process, but one in which successful implementation of only partly realized goals for change may have a major effect upon the system bearing the impact.
Franklin B. Fogelson and Harold W. Demone, Jr.
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REFERENCES Demone, H. W., Jr. The limits of rationality in planning. Community Mental Health Journal, i965, I, 375-38I. Demone, H. W., Jr. Massachusetts--a prototype for mental health planning. Psychiatric Opinion, I966 , 3, I25-32. Demone, H. W., Jr., McGrath, M., & Spivack, M. Decision-making issues in the development of community mental health centers, 1968. Field, H. Organizing the planning process. Annals of the New York Academy of Science, September, i965, p. 67I. Fogelson, F. B. Statewide planning in mental health: an early report. Social Work, October, I964, 26-33. Morris, R., & Rein, M. Emerging patterns in community planning. Social, Work Practice, 9963. New York: Columbia University Press, 1963. Schulberg, H. C. Private practice and community mental health. Hospital and Community Psychiatry, I966 , I7, 363-366. Schulberg, H. C., & Demone, H. W., Jr. The impact of mental health planning. Psychiatry Digest, January, 2966, 27, 33-41 . Schulberg, H. C., & Wechsler, H. The uses and misuses of data in assessing mental health needs. Community Mental Health Journal, ~967, 3, 4, 389-395 9 Spivack, M., & Demone, H. W., Jr. Mental Health Facilities: A Model for Physical Planning, I968. United States Public Health Service, National Institute of Mental Health. Digest, State Mental Health Planning Grant Proposals, I913. United States Public Health Service. Planning Facilities for Mental Health Services. Washington, D.C.: Department of Health, Education, and Welfare, January, 296I, p. 3. Warren, R. L. Types of purposive social change at the community level. Papers in Social Welfare, No. I i , 2965. Waltham, Massachusetts: Brandeis University.
