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THE MENTAL HEALTH
OF URBAN AMERICA

The Urban Programs of
The National Institute
of Mental Health

Prepared by:

Program Analysis and Evaluation Branch
Office of Program Planning and Evaluation

National Institute of Mental Health
Chevy Chase, Maryland 20015

US. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
{BPublic Health Service, r: s. W" fl WAT/£1
Health Services and Mental Health Administration

April 1969

 

For sale by the Superintendent of Documents, U.S. Government Printing Olfice
Washington, DC. 20402 - Price $1

PUBLIC HEALTH SERVICE PUBLICATION
NO. 1906

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A}; 1/

PUBLIC
HEALTH
llBRARY

FOREWORD

Throughout history, the urban environment has been the setting for
many of man’s greatest achievements, but also for many of his most
lacerating problems. Today, as in ancient times, American cities are the
center of much that is healthy and ennobling in life; at the same time,
however, they are the hub of too much that is sick and self-destructive.
Commerce and industry have flourished in the American city along
with poverty and unemployment; creativity and culture have been
nurtured, but so, too, have ignorance and intellectual and cultural
deprivation. At the same time that advances in health research and
services have lengthened and enriched the lives of millions of Ameri-
cans, many others in metropolitan areas have become the specially
vulnerable victims of mental illness, and of social pathology evidenced
by such problems as drug abuse, delinquency, and violence.

The concern of the National Institute of Mental Health with urban
life springs from its mission not only to solve problems of mental and
emotional illness, but to promote those positive features of life-—
intellectual, emotional, social—that are the true anchors of mental
health. Thus, for example, the Institute’s concern is not only with
salvaging the untreated schizophrenic from a life of chronic deteriora-
tion but also with advancing the intellectual and psychological po-
tential of the child whose normal development is being stunted by
a life of trauma and deprivation. It is not only to save the life of
the depressed and suicidal college student, lost in the anonymity of
the city, but also to give meaning and purpose to the declining years
of the senior citizen. Advances in the treatment and preVention of
psychoses, or delinquency, or drug abuse, or violence, must be matched
by advances in our capacity to promote the mental health of all our
urban citizens.

The Institute’s activities in the field of urban mental health cannot
be exhaustively described in a single report for they range over a varied
array of programs—_from basic behavioral science research to the
construction and stafl‘ing of new mental health facilities, from the
development and demonstration of service programs to the establish-
ment of a creative liaison with State and local agencies across the

788 iii

Nation, from the production of manpower to meet urban mental
health needs to programs of education and prevention aimed at the
urban resident himself. Despite their diversity, however, the examples
of the Institute’s programs and projects cited here will provide the
reader with an overview of the aims and efforts of NIMH as it deals
with the complex mental health problems of our cities.

No one agency can entirely meet the challenge posed by contempo-
rary urban problems; needed is the collaborative effort of all those
concerned with the urban environment and the well-being of its citi-
zens. In such an enterprise, NIMH often carries a special responsibil-
ity—of testing assumptions, of exposing basic facts, of advancing in-
novative ideas, of supporting and evaluating promising approaches.
It is hoped that this report, by communicating the results of current
activities, will provide a link in the broad collaborative endeavor nec-
essary to improve the quality of America’s urban life.

This report was prepared by the Institute’s Program Aanlysis and
Evaluation Branch, directed by Dr. Julius Segal, collaborating with
those segments of NIMH whose specific programs are described
throughout.

STANLEY F. YOLLEs, M.D.,
Assistant Surgeon General,
Director, National Institute of Mental Health.

iv

CONTENTS

Page
FOREWORD ..................... iii
INTRODUCTION ................... 1
Urban America and Its Citizens .......... 1
Scope of the Problem ............... 2
Organization of the Report ............ 4
References .................... 5
STUDIES OF URBAN LIFE AND MENTAL HEALTH. 7
Introduction ................... 7
Poverty and Mental Illiness ............ 7
Attitudes of the Poor ............... 9
Effects of Cultural Deprivation .......... 10
Family Stability and Disintegration ........ 17
Effects of Crowding ................ 18
Effects of Migration ............... 21
Effects of Urban Renewal ............. 23
Studies of Housing Projects ............ 24
The Dynamics of Prejudice ............ 25
Battered Children ................. 28
SPECIAL MENTAL HEALTH PROBLEMS OF URBAN
LIFE ........................ 31
CRIME AND DELINQUENCY .............. 31
Patterns and Trends ............... 31
Family Patterns and Delinquency .......... 32
Learning How to Prevent and Treat Delinquency . . 33
Improving Institutional Treatment ......... 38
Community Treatment .............. 40
Improving the Probation Process .......... 42
Projects for Prevention .............. 42
The Violent Offender ............... 45
Training People to Cope With Delinquency ..... 47
MAss VIOLENCE .................. 48
A Historical Perspective .............. 48
Rioting: Causes and Phases ............ 48
Preventing Riots: Some Fundamental Needs ..... 52
Where More Information Is Needed ........ 53
Other Research—Under Way or Planned ...... 54
Helping to Make Better Policemen . .- ....... 57

DRUG ABUSE ......................

Drugs as an Urban Problem ............
NARA: The Institute Directs a Vast New Treatment
Program ....................
Other Treatment and Prevention Projects ......
For Better Information on the Drug Problem
Research Programs ................
Environmental Factors ..............
Prescription Drugs ................
Training and Education ..............

BRINGING MENTAL HEALTH SERVICES TO THE

COMMUNITY ...................

Introduction ......... ' ..........
The Development of Centers ............
Mental Health Centers: Accessibility ........
Making Services Relevant to the Community’s Needs .
A Demonstration in Helping Residents of a Slum . . .
Other Examples of Community Mental Health Centers.
Consulting and Educating .............
Neighborhood Service Programs and Health Centers .
Rehabilitation Work ...............
Improving State Hospital Services .........
Mobilizing City Residents Themselves ........
Mental Health Protection for Workers. . . . . . ; .
Services for Older People .............

SUPPLYING THE MANPOWER ...........

vi

Introduction ...................
Training Professional Manpower:
In Psychiatry ................
In Psychology ................
In Other Social Sciences ............
In Social Work ................
In Nursing .................
Experimental and Special Training Projects .....
Continuing Education ...............
Research Fellowships ...............
Training People From the Neighborhood as Mental
Health Workers ................
Some of the Values of the Indigenous Aide ......
Samples of Training Programs ...........
The Pilot Program of Baker’s Dozen ........
New Techniques: Protests, Advertising, and the Tele-
phone .....................
Some Projects in the Planning» Stage ........

Page

58
58

60
64
65
67
68
69
70

73
73
74
75
78
80
82
83
84
85
87
88
89
93
97
97

98
98
99
100
101
102
103
104

104
105
107
109

111
113

THE FUTURE OF URBAN AMERICA .........
Social Planning .................
Intergovernmental Cooperation ..........
Enlisting Those Who Can Help ..........
Bold Research, Better Information, and Sound Evalua-

tion ......................

REFERENCES ....................

ACKNOWLEDGMENTS ................

Page
115
116
117
118

119
121
140

 

Men come together in cities in order
to live. They remain together in order

to live the good ltfe.
~Ari5totle

INTRODUCTION

Urban America and Its Citizens

Between 1950 and 1960 the urban population of the United States
more than doubled. Today seven out of ten of us—14:0 million in all—
live in urban areas; Barring catastrophic events or unforeseen changes
in birth rates and living patterns, the end of the century will find 285
million of us, or 80 percent, living in America’s metropolitan centers.

Cities have always been seen as centers of much that is good, or
makes for good, in life: culture, commerce, business, industry, health
facilities, the propagation and exchange of ideas, religion, education,
recreation. Each year half a million Americans leave the countryside
hoping to find a better life in the city—a good job, a decent home, and,
no doubt, some of the excitement and stimulation associated with
city living. But as migrants pour into the cities, often with little
money, only a few years of school, and no training for urban jobs,
their problems are compounded. J ammed into slums and—if they
are members of minority groups—frequently discriminated against
for jobs and housing, the newly arrived urban poor join their brethren
in straining the municipal welfare, educational, medical, and police
systems to the breaking point.

In spite of the persistent attempts at desegregation over the past
decade—in schools, hospitals, transportation, restaurants, hotels, and
housing—the pattern of today’s urban growth is producing a generally
segregated society: the inner cities steadily become more Negro, the
urban fringes remain almost entirely white:

0 From 1950 to 1966, more than 85 percent of the increase in
the population of Negro Americans occurred in the cities, as
against less than 3 percent of the increase in the number of white
Americans. Since 1960, the number of white people in the cities

has actually declined by 1.3 million. During the same period, more
than 75 percent of the increase in the white population took place

1

in the suburbs, as compared to 12 percent of the increase in the
lltxlegro population. Only 4 percent of the suburban population is
egro.

0 The larger the city involved, the faster the Negro population
is dgrowing and the greater the percentage of Negroes. Negroes
to ay comprise 20 percent of the City population, compared to 12
percent in 1950; they comprise 26 percent of the population in
cities with more than a million people. Today, one—third of all
American Negroes are living in our 12 largest cities.

The mental health problems occasioned by urban life cannot, of
course, be defined or understood in terms of a single variable—whether
race, or economics, or housing, or education. There are no simple an-
swers to the pervasive challenges posed to American society by the
urban condition. The problems raised are both urgent and obscure,
acute and chronic, and they are reflected in virtually every aspect of

human behavior.

Scope of the Problem

The problems of urban populations—particularly of the poor and
culturally disadvantaged among them—constitute in their almost in-
finite variety a challenge of the highest priority for those concerned
with the mental health of the Nation. The disproportionately high
incidence of mental illness, delinquency, crime, drug abuse, violence,
‘ and other social problems is testimony to the need for wise and com-
passionate attention to the people of the cities and their environment.
The residents of America’s inner cities—our crowded, shabby, and
neglected neighborhoods—have become the core of the urban problem.
Though the prosperous may live only a short distance physically from
their “neighbors” of the inner city, the latter are truly a remote and
disadvantaged group with respect to vital health and social services.

A growing body of data demonstrates that mental health is most
likely to suffer when the environment is marked by the poverty and
hopelessness so often found in our worst neighborhoods. For example,
a child of parents at the bottom of the socioeconomic scale who comes
into the world with the same basic intellect as a child of parents at
the top is less likely, for lack of stimulation and opportunity, to de-
velop it. Moreover, poverty often interferes with the development not
only of intelligence but also of a healthy personality. There is evi-
dence, too, of an association between poverty on the one hand and, on
the other, ignorance and distrust of democratic ideals and institutions.
Violence, too, breeds in an atmosphere of deprivation and despair (I) .

The effects of deprivation cannot be remedied alone by better hous-
ing, access to more and better jobs, improvements in the welfare system,
or an end to discriminatory practices. Research has shown that pro-
longed deprivation afi'ects the emotions, the thinking, and the will: it

2

gets into the very bones. People who are trapped in the culture of
poverty are not likely to be changed merely by the acquisition of
money, one investigator points out; many factors other than economic
must be taken into account. Those who seem to have little ability or
promise, even in their own eyes, often demonstrate unsuspected talent
when they are both motivated to learn and given the opportunity to
learn (2). Evidently hope, though it may be exceedingly difficult to
instill, acts like a wonder drug.

Hospitalization rates for mental illness rise with the confluence of
poverty, unemployment, undereducation, substandard housing, dis-
crimination, and other social ills so characteristic of urban slum and
ghetto areas. For example, studies by the Institute’s Biometry Branch
show that in Baltimore the hospital admission rate for schizophrenia
is about twice as high as that in other parts of Maryland. Whereas an
estimated 2 percent of the Nation’s population is afliicted by major
mental illness, estimates for concentrated urban populations run as
high as 10 percent. Rises in crime rates, drug abuse, alcoholism, and
family disintegration are all associated with urban growth. The rate
of suicide among Negroes, which has generally been very low compared
with that among whites, has increased with their migration into metro-
politan areas.

A Welfare Administration study showed that the blighted areas of
Sacramento, Calif, comprised only 8 percent of that city’s total land
and 20 percent of its population. These citizens paid only 12 percent
of the city’s taxes. However, they took 25 percent of the city’s budget
for fire protection, 50 percent of its budget for health services, and
51 percent of its budget for police protection. They accounted for 26
percent of the city’s fires, 36 percent of its juvenile delinquency, 42
percent of the crimes committed by adults, and 76 percent of the tuber-
culosis cases. In other cities, the same study shows, areas of urban
blight, as compared to good housing areas, occasion the following per
capita costs: police charges, 2.5 times more; ambulance runs, almost
twice as many; fire calls, almost twice as many; visiting nurse calls,
four times more; other health services, 2.2 times more; welfare serv-
ices, 14 times more (3) .

Unfortunately, many of the public programs undertaken to alleviate
the urban crisis—urban renewal, public housing, highway construc-
tion, welfare programs, industrial decentralization—produce disloca-
tion and the need for further adjustment. Furthermore, the people
most affected are often the least prepared to cope with the stress
incurred.

Some notion of the extent of mental health problems found in a city
can be suggested by considering a hypothetical American community
of 500,000 persons. The mental health problems of these residents cited
below are a statistical average; that is, the figures were established

3

by considering the data for the country as a whole. Actually, then,
a description of the ills of this “average” community understates the
urban condition because the incidence of mental illness and social prob-
lems runs higher in the cities than in the country as a whole. But the
following figures do indicate rather vividly the variety of mental
health concerns afilicting a community numbering 500,000 residents:

0 Nearly 10,000 children—over 7 percent illegitimate—will
be born into the community during the year. At least 2,000 will
require some form of mental health service during their lifetime,
40 percent in mental hospitals.

04 More than 99,000 adolescents and adults in the community
have no more than an eighth grade education; among the children
in high school, 6 percent will drop out next year.

0 Of the 4,000 draftees screened last year for military duty,
1,485—nearly 40 percent—were rejected, a third of these because
they were mentally or emotionally unfit.

0 Each year, within the community, over 6,600 serious crimes—
an average of 19 a day—are handled by the police. The crimes
include 26 murders, 56 rapes, 528 assaults, 1,240 auto thefts, and
2,996 burglaries. Nearly 3,300 youngsters 10—17 years of age are
brought before the juvenile courts annually.

0 During the last year, nearly 500 residents attempted suicide,
and 66 succeeded.

0 Also during the last year, nearly 2,700 persons were admitted
to inpatient psychiatric facilities.

0 Living in this “average” community are 1,980 schizophrenics,
thousands of people suffering from depression, nearly 13,000 alco-
holics, 9,900 homosexuals, 165 narcotic addicts, and 1,300 mentally
ill children.

The challenges posed by this hypothetical average community are

varied and serious. In our densely populated urban areas, the prob-
lems—and the mental health needs—are intensified.

Organization of the Report

The varied NIMH programs in urban mental health can be viewed
along a number of alternative dimensions, and thus a variety of
organizational schemes or outlines might have been used in this report.
It might have been possible, for example, to divide the report into
segments dealing in turn with major aspects of urban life—economic,
educational, social—and to describe the activities of NIMH that relate
to each. Or, emphasis might have been placed on the organizational
framework of NIMH, with indications of how each division of the
Institute and its special centers of activity contribute to the urban
mental health program.

None of the above alternatives, however, would have fully accom—
plished the major purpose of this report—which is to describe how all

4

elements of NIMH converge on the goal of improving the quality of
life for America’s urban populations. It is for this reason that the
report emphasizes how the interacting contributions of research, train-
in g, and service programs merge in the solution of urban mental health
problems. Reflected here is a recognition that if we are to enhance the
mental health of the city dweller, we must utilize all of the resources
of the Institute—from the most basic re-seach to the most practical
community action programs.

The four major chapters of this report contain examples of Insti-
tute activities which, although overlapping, emphasize different
aspects of the problem:

0 The first, drawing mainly from research programs, describes
in some detail what is being learned about the nature and causes
of urban mental health problems. Across the country and in its
own laboratories, NIMH supports researchers who are working
on such important questions as: Why do poor people stay longer
than others in mental hospitals? How can urban renewal be ac-
complished without endangering the emotional well-being of
those uprooted by it? What background influences, if any, dis-
tinguish those poor people who finish school, get jobs, and enjoy
at least a measure of success from those who do not? What are
the most efiective ways of helping children realize their intel-
lectual potential and equip themselves to break the cycle of pov—
erty, apathy, despair, and continued poverty which tends to persist
in one generation after another? What mental health services are
most needed by the Americans of our slums and ghettos and how
can they be provided most effectively ?

0 Next, a chapter discusses NIMH activities in connection with
three major problems closely associated with urban life: crime and
delinquency, Violence, and drug abuse.

0 Two chapters then describe how Institute-sponsored projects
and programs are serving the mental health needs of the city—-
first, ‘by offering direct services through community mental health
centers and a Wlde variety of demonstration projects; and, second,
through training programs designed to increase the numbers of
mental health workers, including nonprofessionals, with the abil-
ity to handle the diverse mental health needs of our urban citizens.

0 Finally, a closing chapter discusses the importance of lan-
ning and evaluation in the urban mental health field, re ated
efforts by the Institute and other agencies, and the nature of
problems still to be resolved.

R eferences

It should be kept in mind that this report is in no sense exhaustive
in its survey of the Institute’s urban program. Nor should the reader
conclude that the references to specific projects included here neces-
sarily encompass all of the most significant work in a given area. The
intention is simply to provide the flavor of the complex and varied
efl'ort—some of it in its very early stages—directed toward main-

5

taining and improving urban mental health; the specific works cited
should be regarded, therefore, only as examples of many comparable
projects and programs. Further, in a report of limited length covering
such varied activities, it has not been possible to present the many
potential ramifications of each effort cited. The reader should also be
aware that the inclusion of a particular study under a given heading
is often arbitrary, since a project is often equally relevant to two or
more areas of major efl'ort.

References at the close of the report identify the directors of N IMH-
supported projects, the titles of their sdudies and programs, and the
institutions at which the work reported here was done.

Whoever would change men must

change the condition of their lives.
——Theodor Herzl

STUDIES OF
URBAN LIFE AND
MENTAL HEALTH

Introduction

This chapter focuses primarily on NIMH research programs de-
signed to identify in concrete terms the nature of the impact of the
urban environment on mental health. Included, for example, are find-
ings describing the association between poverty and mental illness,
and the efl’ects of migration and urban renewal. Discussed here are
data identifying the pernicious results—often a lifetime—of cultural
deprivation, and some of the work being done to prevent and offset
them. Reported, too, are studies dealing with family and indi-
vidual attitudes and their influence on mental health. Much of the work
described here is derived from the efforts of behavioral scientists de-
voted to bridging the gap between the world of research and the practi-
cal realities involved in improving the lives of our inner—city residents.

Poverty and Mental Illness

Between 1959 and 1966, the number of persons counted as poor in
the United States dropped more than 9 million. In the latter year,
nevertheless, 30 million persons, or 15 percent of the population, were
living in poverty, the majority of them in cities. Their households had
insuflEicient income to cover even the barest necessities. (The measure
is the poverty index of the Social Security Administration, a standard
adjusted for such factors as size of family. In the case of nonfarm
households, for example, poverty thresholds range from an annual
income of $1,595 for a single woman living alone to $5,440 for a family
of seven or more.)

7

Compared with the general population, the poor include dispro-
portionately more nonwhite—usually Negro—families, families with
no man at the head, families with many children, and old people.
Thirty-five percent of the nonwhite families are below the poverty
level as compared to 10 percent of the white families (.4) .

The saddest, most ominous figures deal with children. In 1966, one
out of every six children under the age of 18 was growing up in a fam-
ily whose income was below the poverty line. About 1 million of the
youngsters receiving assistance under the Aid to Families with De—
pendent ‘Children Program—or one out of every three children in this
group—have severe emotional problems that need psychiatric
attention.

Studies by Institute-supported investigators have helped document
the association between poverty and mental illness. One project—
stafi'ed by a team of psychiatrists, psychologists, sociologists, anthro-
pologists, and statisticians—was the first to attempt an exhaustive
epidemiological analysis of a highly complex and densely populated
urban area (5). The investigators used psychiatric screening inter-
views to study the mental health of a large sample of adults residing
in a 190—block area in Manhattan. In addition, a census was made of
those residents being treated for mental or emotional disorders. Per-
sons in the lower socioeconomic levels were found to have both a higher
incidence of mental illness and a lower rate of treatment.

An epidemiologic study in Baltimore confirms that high rates of
mental illness tend to be associated with low socioeconomic levels (6) .
Diagnoses of schizophrenic reactions, alcoholism, mental retardation,
and brain syndromes were particularly associated with these levels.
However, two census tracts in Baltimore ranked in the highest quar-
tiles both for median family income and for total psychiatric admis-
sion rates, and two census tracts ranked in the lowest quartile on both
measures. Although the data require further study, the findings serve
as a remainder that socioeconomic level is only one of many factors in-
fluencing mental illness rates.

One research team has followed up the mental patients studied in
New Haven in the 1950’s in a classic analysis of social environment and
mental illness (’7). The original study found that while members of all
social classes in the New Haven community were victims of mental
illness, the predominant type of illness differed from class to class;
the incidence of schizophrenia, for example, was much higher in the
lower classes, while affective disorders and neuroses occurred more
frequently in the upper classes. Moreover, lower-class families dis—
played negative attitudes toward those with mental illness and toward
psychiatric treatment.

In the followup study the investigators again found social position
exerting a striking influence: the higher the social class, the greater

the percentage of patients—no matter what the diagnosis—that had
been discharged from hospital care. Some of the reasons for that dif-
ference have been uncovered by a study of patients who were being
treated for schizophrenia in 1950 and who, 10 years later, were living
in the community. The lower the social status of the former patient,
it develops, the better his mental health—as indicated by a screening
device based on psychiatric symptoms—but the poorer his occupa-
tional and general social adjustment. Patients from the lower social
levels, the investigators explain, had to be quite healthy before their
families would accept them from the hospital. No matter how healthy
they were, however, they generally found themselves extremely isolated
socially—in part because of the stigma attached to hospitalization for
mental illness and in part because their families, harassed by economic
and childcare problems while the husband or wife was under treat-
ment, often had withdrawn from social contacts. On the other hand,
many of the middle-class and upper-class patients were still compara-
tively disturbed when they left the hospital. But their families and
associates, having a greater understanding of mental illness, welcomed
them back and, in fact, went out of their way to help them return to
the mainstream of activities.

The investigators believe that the study points clearly to a major
need: many more mental health facilities for persons at the lower
socioeconomic levels, and facilities that will offer not merely treat-
ment in the traditional sense of weekly therapy sessions, but also a
variety of other services. Former patients from the upper classes
already have strong resources—in particular, their families, friends,
and business and professional associates. Patients from the lower
classes, however, have only weak resources. With additional facilities,
a much larger proportion of these patients could be discharged from
mental hospitals, the investigators point out, and then given the
emotional support needed for successful adjustment in the community.
This is one of the major aims of the Institute’s community mental
health programs.

Attitudes of the Poor

A number of studies are examining the attitudes and values of poor
people in order to describe those factors—in addition to economic—
that should be considered if urban mental health problems are to be
attacked most effectively.

A study of 3,100 men from all occupational levels conducted by the
Institute’s own social science laboratories shows that the actual effects
on attitude and behavior of social and economic class are even more
pervasive than we have suspected (8). To be a member of the lower
class, to be poor, is often to suffer a hopeless self-image and a bleak and
barren view of the future; to expect little of yourself and even less of

9

335—«1 19—69—2

your children; and to bear toward one’s self—and sometimes toward
the world outside—the seeds of hate and aggression. The men studied
are likely to see themselves as incompetent and other people as untrust-
worthy. Their highest aspiration is often just to stay out of trouble.
At the same time, they are much more authoritarian in their outlook:
the more'they must bend to external pressure, apparently, the greater
their need to impose pressure on others.

Negro men who meet regularly on the street in front of a particular
shop in a slum area, another investigator finds, have many of the same
goals and values as the larger or middle-class society (.9) . But the street
corner man fails to achieve these goals and then tries, as best he can,
to conceal his failure from others and even from himself. Of the two
dozen men in this study, all are either unskilled workers or unem-
ployed. Some hold two or three jobs to hold their families together. A
minority don’t work and don’t want to work. Even the majority who
do work have little expectation that the kinds of jobs they can get will
lead to better things. Self—esteem must be bolstered in other ways.
Marriage is considered superior to other kinds of relationships with
women, but these men feel that it rarely succeeds. Many ascribe their
failure in marriage to such “manly flaws” as too much appetite for
drink, sex, or independence. Economic failure or fear of economic
failure scars most of the men. In another study, members of Negro
delinquent gangs were also found to express goals much like those
motivating middle—class persons, but these youngsters had been badly
prepared to take approved, realistic action to meet their goals (10).

A participant observer who lived in a predominantly Negro housing
project found that the residents wanted not only better food, shelter,
clothing, and education but also more stable family unions (.9). Other
investigators, studying social problems in a similar setting, seek infor—
mation on a number of important subjects, among them: family
dynamics, in particular how order is maintained and how family
behavior influences a growing person’s participation in school and
other community activities; the norms, values, and dangers of the
social interaction that commonly occur “on the street” in lower class
areas; the drinking behavior of lower class adults, particularly of
women; the techniques people use to try to solve their problems—to
look for credit, for example, to seek medical care, to hunt for a job—
and the significance of religious experience (11) . A clear understand-
ing of the role of such factors will help provide the basis for more
rational and effective mental health service programs.

Efiects of Cultural Deprivation

An authority on infant and child mental health estimates that more
than half of the children in urban slums have learning problems,
which include reading deficiencies, inability to grasp abstract ideas or

10

symbols, too little curiosity, and difficulty in retaining concepts (12).
Two of the major causes of such problems, he reports, are brain dam-
age (suffered during the months before birth or soon after birth) and
environmental difficulties. Both of these conditions are more prevalent
in the crowded, impoverished areas of our cities.

Poor prenatal care and a deficient diet during pregnancy are rela-
tively common in mothers at the lowest socioeconomic levels and are
among the many factors increasing the chance of a brain-damaged
infant (13). If a child has an inherent difficulty, such as brain dam-
age or a poor genetic endowment, life in an urban slum tends to
magnify the resulting problem in learning. And if he has no biological
difficulty, his learning capacity may nevertheless be permanently
limited by environmental factors that can be described as cultural
deprivation.

When children are very young, regardless of social or racial origin,
one group will perform much the same as another on developmental
tests. Beginning somewhere between 18 months and 2 years, however,
the curve representing the performance of children from the lowest
socioeconomic level begins to drop, and from then on these children as
a group score significantly lower than other children on measures of
ability and achievement. One Institute-supported research team has
been following the same group of people long enough to find that the
lowered IQ average persists through at least the age of 18 (14). Pre-
sumably it continues.

During a critical period early in life, evidently something happens—
or fails to happen—which stunts the intellectual development of dis-
advantaged children. They enter school with an intellectual handicap
that prevents them for taking full advantage of what the school—the
usual school, that is, planned with little thought for underprepared
pupils—has to offer. These children often have not been properly
stimulated. Infants, if they are to develop at a normal rate, need to
be caressed and loved; they need interesting things to look at and
interesting objects to grab for; as they grow, they need opportunities—
and encouragement—t0 explore, to play with blocks and other mate—
rials, to look at pictures, to use crayons, to be read and talked to (15) .

Institute-supported basic research has shown that the stimulated
infant, whether human or animal, progresses more rapidly than his
unstimulated counterpart (16') . Of more immediate importance, work
at N IMH and by its grantees demonstrates that the intellectual handi-
cap often seen in the disadvantaged child can very likely be prevented
or corrected by providing him with the stimulation he doesn’t receive
at home. Problems in emotional well-being as well as in intellectual
achievement can be lessened or prevented if children and parents are
reached early enough.

Unless the educational system is prepared to prevent or to overcome

11

handicaps of deprived children, a cycle of deterioration and failure
may be set in motion. One authority cites findings about the achieve-
ment levels of pupils in the whole of New York City as compared to
the levels of pupils in one section of the city, Harlem (17). In the third
grade, the Harlem pupils are 1 year behind; in the eighth grade, 21/2
years behind. As for IQ, the Harlem children in the eighth grade
score lower than they did in the third. And when a black ghetto young—
ster graduates from high school, he has a smaller chance of finding
a job than a white youngster who has failed to graduate (18) .

One research team studying life in a large public housing develop-
ment, occupied mainly by Negroes, finds evidence that when the chil-
dren enter school, they may be quite capable of doing well (11) . How-
ever, a number of factors—including the home environment, inade-
quate teaching methods, and the attitude of the teacher—interact to
bring about a disinterest in, and alienation from, the school. “Ne-
gro children enter the school system disadvantaged in every way,”
reports another group of investigators, whose main interest is the
causes of civil disorders. “Middle-class families prepare their children
for school, for there is both time and money. Because the lower-class
Negro mother does not have the time or sometimes even the strength,
the early learning of the disadvantaged child is often grossly neglect-
ed, resulting in deficits in the use of and understanding of formal
language and abstract thinking. When he enters the school system,
he finds what would seem to him to be an inflexible bureaucracy or-
ganized around certain assumptions as to the kind of readiness and
ability to learn of the underclass child. The ensuing clash between
the child and the system produces a repeated cycle of failure, humilia—
tion, apathy, defeat, and a growing reactive defiance. The inadequacy
of inner city schools contributes to the cycle together with the resigna-
tion and low-achievement expectancies of some teachers. Education
has always been the vehicle for upward mobility in America, and
if the lower-class Negro child cannot compete in our educational sys-
tem, he certainly cannot compete as an adult for skilled jobs and
economic security (19).

However, a number of demonstrations indicate that permanent
intellectual impairment can be prevented in many cases by activities,
varying in scope and content, providing essential stimulation. In one
NIMH study, for example, 30 children from poor families were “tu-
tored” 1 hour a day, 5 days a week, between their 15th and 36th
months (20) . The “tutoring” included songs, stories, and verbal games.
The IQ of these children rose from 90 to 106, while those of a control
group remained constant at 90. Moreover, the stimulated children
were ahead of the others in verbal and perceptual development and
also in such traits as perserverance and attentiveness.

In another project, a group of 42 children, mostly Negro and Puerto

12

Rican, from an East Harlem slum area participated in a program of
group meetings that attempted to improve the child’s self—image and
sense of mastery of his fate as well as to provide intellectual stimu-
lation. The children were of average or superior intelligence. Com-
pared with a control group after 2 years, the children in the program
showed a marked increase in reading ability, which is a key factor in
educational achievement (21) .

One investigator invited lower-class mothers of nursery school chil-
dren to observe the work of the teachers—women who were enthusi-
astic about their jobs and who regularly spent time conversing with
the children and stimulating their interest (22) . Evidently the mothers
carried the techniques home and used them, for the test performance
' of their younger children—not yet in nursery school—improved sig-
nificantly. Moreover, the mothers somehow must have communicated
the techniques to the neighbors, for the performances of the neigh-
bors’ children improved, too. Families in another t0wn 40 miles away
were used as a control group; their children showed no gains. In a
new project aimed at breaking the cycle of educational poverty in
lower socieconomic communities, educators are setting up backyard
play centers for 2-year-olds and providing special instruction for
their mothers.

In another project, Negro children from culturally deprived back-
grounds at-tended special summer preschool classes, where they were
encouraged to express themselves verbally and through play materials,
and were rewarded for achievements. The mothers usually worked
during the day; and in close to half the homes the father was absent.
The children had never been encouraged to talk, explore, or be crea-
tive; they had had no books, blocks, or drawing materials. Children
who attended the special classes for three summers gained an average
of 9 points on IQ tests, while those who attended for two summers
gained 5 points. Children in a control group lost 5 to 7 points during
the same period (23).

In Washington, D.C., an Institute-supported project has been send-
ing a team of Specialists to a low socioeconomic neighborhood to pro-
vide a well-rounded program of services to poor families. Brought
directly to the home, this program begins with health care and counsel-
ing for expectant mothers. Then it provides health care for the chil-
dren and seeks to improve child-rearing practices, mother-child
relationships, and environmental conditions. Mothers are taught to
provide appropriate stimulation so that the intellectual potential of
their children will be maintained and enhanced.

To help children fulfill their potential and escape the poverty cycle,
a wide-ranging project has these highly important immediate aims:

1. to develop effective methods of group care of children through
small—group mothering situations in residential and day-care

13

units, and effective hospital nursery care of infants who remain
there for long periods before placement

2. to use a child-rearing demonstration project to teach more
appropriate child-rearlng patterns to families ’

. to develop better methods for adoption agencies to function
. to train infant and child-care workers and neighborhood aides

. to improve methods of assessing the individual differences and
needs of infants and to develop ways of meeting these needs in
vulnerable infants

6. to study means of channeling aggression in children raised
under varying circumstances

7. to note the effects on children of growing up with weak or
absent fathers (24)

Many other programs to help underprivileged children surmount
the circumstances of their environment—and to demonstrate that they
can be helped to do so—are under way. On New York’s lower East Side,
160 second-graders with severe learning difficulties are participating
in special after-hour programs of educational games, crafts, and other
* activities related to the development of academic skills (25). In San
Antonio, Tex., a program is directed toward impoverished Mexican-
American families, the purpose being to help prepare preschoolers
through work with them and their mothers, to adjust more readily
to school life in an alien culture while preserving their own culture
(26‘). After 2 years, the average IQ of pre-schoolers, as measured by
the Peabody Picture Vocabulary Test, jumped from 91 to 116. In
Chicago, 12 elementary schools in the Woodlawn areas, predominantly
' Negro, are collaborating with community leaders to solve some of the
problems experienced by first-graders as they try to adapt to school
(27). Under one part of this program, maladapted youngsters meet
each week with their teacher and a psychiatrist. In Los Angeles, the
Campfire Girls are working with culturally deprived girls in the
second and third grades who are not doing well in school and are
having difficulty in getting along with other children and with adults
(28).

In the Hill District of Pittsburgh, representative of Negro ghettos,
an investigator is specifically concerned with the twin problems of
low self-esteem and low levels of aspiration among indigent Negro
children (2.9). The project has three aspects: school programs, interest-
activity programs, and an evaluation. The goal is to mitigate the
effects of poverty and the restrictive social system on ghetto children.

Another team is studying the manifestations and causes of anti-
social behavior at its very beginnings in the early childhood years
(30). The researchers are investigating hypotheses concerning the
causes of such behavior in terms of developmental history, family his-
tory, parental attitudes and parent-child relationships. They also hope
to determine what personality or characteristics of a delinquent teen-

01960

14

ager can be identified in the very young antisocial child. A more
broadly based 5-year demonstration project (31) seeks to identify the
variables within the child, home, school, and community related to
the child’s ability to adapt successfully and to cope with the stress
of school entry and the early school years. These researchers will also
study various methods of intervention by mental health personnel to
help the child, home, school, and community make use of stressful
situations as a means of increasing adaptive skills.

V Still another long-range study is concerned with the psychological
and social origins of achievement motivation and achievement values—
the “achievement syndrome”——and how such factors influence and are
linfluenced by the culture and functioning of social groups (32). Re-
sults to date, obtained from studies in Connecticut and Brazil, indicate
that the striving, achievement—oriented person is less characteristic of
Brazil than of the United States, and the investigator suggests the
possibility that the relative infrequency of this personality type may
be related to the slow development of the Brazilian economy.

The results of the projects completed or under way have led to
the development of plans for a major new program to help overcome
the social and educational handicaps of preschool children in dis-
advantaged areas. Needed are large-scale demonstration projects estab-
lished in a number of communities—from 20 to 30—throughout the
country. No two projects would be exactly alike, for each would be
influenced by local community leaders, with a key role in planning,
developing, and staffing the project. Working with them to develop
and evaluate programs would be community agencies and nearby
universities. In some projects the children would come to community
centers; in others, visitors would go into selected homes to work with
children individually. Where there was a high incidence of identified
emotional disorders, special programs to care for the disturbed chil-
dren would be developed. Education and counseling about the de-
velopmental problems of young children, under the plans, would be
available to parents in all the projects. Mothers and, in many cases,
their older children would be trained as helping agents.

The Institute’s proposed program for very young children, which
is related to a much larger program of day-care services to be develOped
by the Children’s Bureau, would provide not only needed services
but also a means of developing and testing more effective methods
of strengthening the ability of underprivileged children and their
families to overcome their handicaps and cope with life successfully.
Hopefully the project would also lead to new and fruitful relationships
between underprivileged communities and nearby academic institu-
tions.

\Other projects, too, seek to strengthen the emotional health both
of parents and of children, who will eventually become parents and,

15

willy—nilly, influence the emotional health of their own children. To
help resolve the severe emotional and social stress commonly under-
gone by the Puerto Rican family in New York City, a number of orga-
nizations, professional persons, and neighborhood leaders have been
working together in an Institute—supported project that has provided
a work program for adolescents, a reading development program for
young street-children, a club for the young, and a credit union serving
several hundred adults (33) . _

In Denver, the Institute supports a project, in a neighborhood
threatened with blight, that emphasizes the development of a com-
munity association for dealing with and preventing such problems as
dropping out of school, dependency, family breakdowns, alcoholism,
and crime and delinquency (34). Berkeley, Calif, has a “workreation
program” that offers jobs and recreation to youngsters from 14 through
17. Financed in part by the Institute, it is sponsored by the schools,
the recreation and parks department, the library, and the local office
of the State Employment Service. It is intended to meet the problem—
common especially among the poor—of the lack of job opportunities
for untrained young people during the summer and, particularly in
the case of dropouts, the year around. If a young person cannot get a
job, the directors of the program point out, how can he develop one
of the essentials of a satisfying life—a sense of responsibility for what—
ever work is engaging him (35 ) '4

A Knoxville, Tenn., program, designed to improve the study and
social habits of high-achieving Negro high school students from sub-
standard schools, is preparing these students to compete in college
on a more even footing with students from better schools (36). Most
of the students participating in the 6-week summer program are re—
ported to show statistically significant improvement, and much of
this improvement is maintained. Of the 159 students who have attended
recent sessions, 133 are now in college. In the program, almost every
minute of the student’s day is planned to meet his needs. Mathematics,
English, and reading classes are held daily and a library study period
5 nights a week. Counseling, individual study, and arts and crafts
sessions are each held 2 hours once a week. Time is also allotted
for athletic, social, and cultural activities. The project is sponsored
by the Educational Counseling Service of the Board of National Mis-
sions of the United Presbyterian Church, with NIMH and Yale Uni-
versity Child Study Center supporting evaluation of the program
(36).

Research findings have little value, of course, unless they reach
the people who can put them to work. Under one Institute grant, in-
vestigators studied the child-rearing practices of low-income families
and provided a number of findings considered valuable in understand-
ing such families and in helping them sidestep or overcome a variety

16

of difficulties (37). Now the investigators are devising ways—includ-
ing the use of television, radio, workshops, lectures, and professional
papers—to get their information quickly and effectively into the main-
stream of policymaking and practice by local health, welfare, and ed-
ucational authorities.

Family Stability and Disintegration

Unless children have the opportunity to identify with strong, healthy
personalities, they are likely to encounter serious emotional difliculties
as they grow up. A study of 48 diverse societies indicates a high fre-
quency of crime in those societies where boys have only a limited
opportunity to form identifications with their fathers (38). A study
in this country found a correlation between adolescent misbehavior
and absence of the father (3.9).

One theory suggests that when the father is absent or weak, delin-
quency may grow out of “defensive masculinity” or “compulsive mas-
culine behavior,” meaning an attempt by teenage boys to counteract
their early strong identification with their mothers. Supporting evi-
dence comes from a recent study of the Black Caribs of British Hon-
duras, which found that boys who had grown up in households Without
adult males had reputations as brave men, used profanity frequently,
and drank heavily (40). Some investigators believe that boys in
woman-dominated households tend later on to shun everything they
consider feminine, including books and school.

Since the absent or weak father is characteristic of many Negro

families, one investigator is studying how the matriarchal structure
is established and maintained. Preliminary findings indicate that
among working-class Negroes, girls are exposed to greater warmth, less
authoritarianism, and higher standards of excellence than boys (1,1).
In marriage, then, the woman generally has higher aspirations than
her husband, and he is either unable or unwilling, or both, to meet her
expectations. Their relationship is eroded by the woman’s dissatisfac-
tion and by damage to the man’s self-concept. The matriarchy con-
tinues. And if the father has no job, the son is likely not to be strongly
motivated to try to get one for himself (11 ) .
- Other research along the same general line is concerned with the
relationship between male employment and family stability (11) ; the
behavior patterns of males who don’t get jobs, concepts of manhood
among Negro males, and the effect of these concepts upon the life of
the individual and his family (42) ; and the effect of public housing
as compared to private on the attitudes and interests of the adolescent
girl, and factors influencing the rate of illegitimate motherhood among
these girls (11 ) .

17

Efiects of Crowding

The prevalence of mental health problems in the poverty-stricken
areas of cities, many investigators believe, can be attributed in part
to the simple fact of overcrowding. When a three-room apartment
has to serve as home for half a dozen people, when children have to
sleep in the same bedroom and sometimes the same bed as their parents,
when hallways and stairs are in almost constant and noisy use, and
when a person can escape his crowded home only by going into the
crowded streets, it is hard to believe that the mind and the emotions
or the physical health go unscathed. I

“City dwellers at any income level,” writes a family life specialist,
“are uncomfortably aware of external crowding—on bus and subway
and on the highways, lunch hour in the cafeteria, and the first hot day
of summer in the public park. But poor families are especially affected.
They live with what the core city holds for them, while others buy
space through travel or otherwise. . . . It appears that crowding in
external space has negative consequences in illness, in relationships
between people, and in general irritability (43) .”

Although there is as yet very little scientific evidence linking crowd-
ing itself to pathological conditions in man, it is well documented
among animals. In a now famous study, an Institute investigator
followed the progress of Norway rats placed in a large enclosure with
built-in apartments for nesting, and allowed to breed freely. They were
protected from disease and predators and given all the food and water
they could consume. If everything went well, the original colony of
this rat paradise should have grown to about 5,000. After 2 years,
however, the enclosure held only 150 rats, and the number never rose,
the chief immediate reason being an infant mortality rate running
from 80 to 96 percent (44) .

What had gone wrong? As the original inhabitants bred and bore
young, a few dominant males staked out spacious quarters that they
defended for themselves and their mates. The rest of the'rats ate,
slept, and socialized in a crowded, confused mass. And, like city people
jamming certain restaurants, they milled around one food station al-
though there were several others just like it. Observers noticed that
some of the males were homosexual and others totally withdrawn; a.
few others had become vicious, even cannibalistic. Females in the
crowded area became unable to bear litters. Many resorbed full-term
fetuses. Those that did bear litters were too distracted to end them.
The pressures of group living had turned paradise into bedlam.

Deleterious effects of crowding, or social pressure, have often been
observed under natural conditions as well. Japanese deer, left to breed
on an island off the Maryland coast, grew to a herd of about 300; then,
within a few months, 200 died. Autopsies showed that they were dead
neither of malnutrition nor epidemic disease. Many of the dead animals

18

did have enlarged adrenal glands and signs of chronic kidney illness,
and experiments since then have indicated that both of these condi—
tions can rise as the result of stress and social pressure. In Pennsyl-
vania, a colony of 10,000 woodchucks was found to be suddenly
declining in numbers at a time when food was plentiful. Autopsies
showed kidney ailments like those found in the Japanese deer.

In a forest near Krakow, Poland, scientists over a long period studied
a nation of tiny rodents called voles. The animals would greatly in—
crease in numbers and then almost die out. A shortage of food caused
by the vastly increased population has been the usual explanation for
such phenomena. But the Polish scientists found that when the voles
suddenly began dying off, they were consuming less than one-fifth of
the readily available food supply.

The lemming, an Arctic rodent, is famous for its population explo-
sions, followed by a nervous, reckless migration that ends, according
to legend, when the animals throw themselves into the sea. But some
years ago a Swedish scientist found that the lemmings in the crowded
area he was watching did not migrate; they went through a period of
tension or hysteria and then began dying on the spot, in holes or other
shelters, for reasons not explained. Similar observations have been
made in Alaska and elsewhere.

As living conditions become crowded, recent laboratory studies have
found actual physiological changes take place. These include an in-
crease in the level of epinephrine, or adrenalin, and a concomitant
decrease in the level of its immediate precursor, norepinephrine.
(Because a high concentration of norepinephrine is found in those
portions of the brain associated with the control of excitability and
aggressive behavior, it has been suggested that this neurohormone
influences emotional states.) Other changes include an increase in the
weight of the adrenal glands, which secrete adrenalin and other
hormones that help the body handle stress. If the stress is long—con—
tinued, the glands may become abnormally large in their effort to meet
the needs. Some investigators believe that chronic kidney disease like
that seen in the deer and the woodchucks is a sign that the stress has
become intolerable.

An Institute-supported investigator reports that once a colony of
prairie deer mice has reached the “growth cessation level,” or the point
at which the animals stop increasing in number, the adrenal glands of
the members are heavier than normal and the reproductive organs
lighter (45) . Almost all the females born as the colony approaches this
level fail to reproduce.

Other investigators have found that when births do occur among
mice raised in crowded cages, the offspring are often malformed. Even
when pregnant females are removed to cages of their own, the young

,

19

seem to be affected by the stress suffered by their mothers: they grow
slowly and, when they mate, produce stunted offspring.

As further evidence that crowding produces stress, an experimenter
added a small amount of a tranquilizer to the drinking water of a
mouse colony that had reached its growth limit at 60 members. The
colony began reproducing again and more than tripled in size. The
tranquilized mice had adrenals of normal size. In short, there is
abundant evidence that among animals, at least, crowded living condi-
tions and their immediate consequence, a greatly increased level of
interaction with other members of the population, impose a stress that
can lead to abnormal behavior, reproductive failure, sickness, and
even death.

But what is crowding? What constitutes social pressure? We have

answers for certain species of animals under certain conditions. (For
example, when the deer began dying off on James Island, Md., the
herd’s living space had shrunk to an average of 1 acre per member.)
We have no answers for man. We know only that the highest inci-
dences of aberrant behavior—including crime and delinquency, drug
abuse, and illegitimacy—and of other social and mental health prob-
lems occur where human beings are most closely packed. Basic infor-
mation sufficient to establish human levels of tolerance for crowding
is being sought both by the Institute and by other agencies of the De-
partment of Health, Education, and Welfare.
" It is not only crowding, of course, that causes stress but also most
other conditions associated with the lives of the urban poor. The bodily
and behavioral changes that occur in response to moderate degrees of
stress have been studied fairly extensively in recent years, but little
is known of the effects of severe, prolonged environmental stress on
those who survive it, and on the individual’s capacity to adapt to stress
in the future (46'). Knowledge gained from research in this area may
be of sociological as well as biological significance.

The need to lay claim to and organize territory and to maintain
a pattern of distances from one’s fellowmen, one Institute-supported
investigator believes, may prove to be just as basic as the needs for
food, sex, and approval (4’7). As one example of the importance of
adequate living space, he points to observations made a few years ago
in a large mental hOSpital. When patients in a crowded ward were
moved to a more nearly adequate setting, their behavior improved
dramatically.

The same investigator also believes that each ethnic group prescribes
unconsciously the physical distances to be maintained in conducting
various kinds of interactions with other people. Unless these distances
are known and taken into account, the investigator believes, two persons
from different ethnic groups encountering each other face to face may
find themselves alienated. To determine the patterns of spatial rela-

20

tionships, the project is photographing Negroes, Puerto Ricans,
Japanese, and middle-class Americans of North European heritage
as they encounter members of their own groups and members of other
groups.

As part of the Institute’s activities in the development of community
mental health facilities, a number of studies dealing not only with the
treatment program but also with the architectural design of mental
health centers have been initiated. The purpose here is to identify the
most health-inducive ways to design community mental health centers.

E fleets of Migration

One research team has begun studying a number of families who
have migrated from Puerto Rico to New York City. It is trying to
find how they differ from their relatives who have stayed at home and
how the first generation in New York differs from the second (48).
It is also investigating the similarities and differences among poor
Puerto Rican, poor Negro, and poor white families. And it hopes to
learn, as does an investigator in Denver, why some Spanish-speaking
migrants are successful in a big city while others are not (4.9). By
providing information on the specific problems of the poor, how these
may differ between cultures and even within a culture, and why migra-
tion proves beneficial in some cases but not in others, such studies will
help bring about more effective services.

There is already evidence that migration can have a deleterious
effect on mental health, possibly by aggravating existing trouble. A
study conducted in New York, California, and Ohio (50) finds that
the rate of first admissions to mental hospitals for immigrants—de-
fined as persons who moved to the State during the preceding 5-year
period—is considerably higher than for nonmigrants. The rate is
higher for Negro migrants than for whites, but as Negroes go up the
socioeconomic ladder, their hospital admission rates decline. Negroes
who had migrated to northern cities, an earlier study showed, were
more heavily represented in first admission statistics than their num-
bers warranted. An epidemiological survey of first admissions to men-
tal hospitals among northern native and migrant Negroes in New
York State is now under way (51) .

An investigator who studied a sample of male suicides in Los
Angeles found that the men tended to have two equally important
problems: a failure or a perceived failure in their work role, and the
absence of a satisfying family life. In New Orleans, on the other hand,
work-role failure was far more common than family trouble. As a
probable explanation of the difference, the investigator found that
virtually all the Los Angeles men had come from out-of-state and
presumably had had difficulty, therefore, in establishing and main-

21

taining social relationships (52) . Almost all the New Orleans men had
been born in or near the city. All the New Orleans cases and almost
all the Los Angeles cases were white. Among New Orleans Negroes
who committed suicide, the most common factor was trouble with
authority, the police in particular.

American Indians are often migrants, too. One study has been con-
cemed largely with those who have relocated in the San Francisco
Bay region since the early 1950’s under Government sponsorship (53).
Among the factors mitigating against the successful integration of
American Indian men into urban-industrial society are: failure to
finish high school, lack of training for a skilled labor or white—collar
job, lack of previous successful experience—as in military service or
a non-Indian school away from home—outside of the Indian environ-
ment, problems at home before relocation, resentment about the way
the tribe has been treated, and absence in the urban area of a source of
close emotional support, such as relatives.

Another project is concerned with Navahos: those who migrated
to Denver, those who stayed on the reservation, and those who re‘
turned (54). A few tentative findings show that even successful mi—
grants return regularly and frequently to the reservation, a pattern
also found in Appalachian urban migrants. Men who come to Denver
accompanied by their wives are much more likely to remain and adjust
successfully than those who come alone. Unlike many Appalachian
urban migrants, the Navahos do not form organized ethnic social
groups in Denver and do not live together in a neighborhood.

There is a different type of migrant—one who makes impulsive and
often desperate moves from city to city, or in some cases within the
city. The Travelers Aid Society of Philadelphia calls such migrants
“people in flight.” As individuals or families they have made at least
one unplanned move during the past 5 years, and usually they have
made many moves, so that fleeing has become a pattern. Working under
an NIMH grant, the Society finds that such persons often have run
from trouble with the law, family problems, bad debts, and sexual en-
tanglements (55). Occasionally they are trying to escape unpleasant
hallucinations. Flight is a symptom of pathology, the degree of which
is usually underestimated, the investigators believe. The information
provided by the client is generally unreliable. Many clients turn out
to have chronic or borderline schizophrenia. If these people are to be
helped, the agency usually has to get in touch with family members
and with organizations, generally out of State. The Society found
that its efforts to be effective were seriously hampered because it could
not offer sheltered and supervised emergency lodging.

22

Efiects of Urban Renewal

When a working-class community is wiped out by a redevelopment
project, many of the people who lived there grieve as deeply as they
would over the death of a husband or a wife. Their sense of loss per-
sists in some cases for at least 2 years and can threaten emotional
health and social functioning. These findings of an NIMH-supported
study of the people who used to live in a slum area, Boston’s’West
End, suggest that urban renewal can actually lead to deterioration in
the lives of many of the relocated families unless carefully planned
from the start with the participation of the families who are being
affected (56). This study is providing details about the factors facili-
tating or impeding adaptation to the urban renewal crisis.

Poor people in the city, one authority points out, tend to be block
dwellers. They do not feel at home outside their neighborhood. Ten
blocks away, or 20, is term incognita. To some slum dwellers, their
slum offers compensations—such as security, warmth, a sense of be-
longing. “The block dweller will have some difficulty in finding a job,”
writes this authority, “let alone mastering the complex resources that
determine how well he can be trained and serve his health and other
needs. But one does not convert a block dweller by moving him. His
orientation is a product of his background; moving him simply sweeps
away the security he knows. . . . Poor people take a special View of
city space, preferring the familiar, the intimate, and the territorial to
the challenging, the open, and the selective. Where change now takes
place, poor people’s space, ‘village’ space, is being wiped out. We could
not make a city into a village if we wished it. But neither should we
erase the village entirely. In planning cities, room has to be found
for village space—whether rehabilitated or built anew—to provide a
firm base from which, in time, presumably poor families or their chil-
dren will move on.” Disorganizing change, this authority notes, has
a bad effect on almost any kind of family. But it “reinforces” those
patterns of poor people that keep them poor. Apathy, orientation to
the present, and a sense of helplessness are the attitudes that poor peo-
ple’s experiences have tended to produce. Such attitudes will only
be hardened when people are caught up in a change they neither
choose nor understand and which does not seem constructive to
them (43).

Another Boston study concerned with minimizing the hazards and“
maximizing the opportunities resulting from urban renewal is com-
paring the effectiveness of several relocation systems (57). The sub-
jects are 3,500 families to be relocated in the city’s South End. Some
of these will receive the usual services of the Boston Redevelopment
Authority, which include evaluation of needs, social planning, and
financial assistance. Other families will receive, in addition, direct
mental health services~—by psychiatrists, psychologists, and social

23

workers—intended to ease the strain of relocation. Still other families,
forced to move because building codes are being enforced, will receive
no special services—the normal procedure in such cases. All families
will be reevaluated a year after they have moved to determine how
relocation has affected them and whether or not the kind of relocation
service offered made any difference.

Skid rows, too, are affected by urban renewal. One project is study-
ing what happens to relocated skid row men and how measures in-
tended to prevent the formation of new skid rows are working out
(58). Another project is analyzing the process through which men
become homeless—that is, end up on skid row or its relocated substi-
tute (5.9). The number of homeless men in the cities of America seems
to be dwindling. The population of the Bowery, in New York City,
declined more than 50 percent between 1949 and 1966, and authorities
in 24 out of 28 other American cities agree that their local skid row
populations are decreasing (54).

Studies of Housing Projects

Interviews with a random sample of families living in a large all-
Negro housing project in the midwest produced evidence of the stress
that marks the lives of such families (11). In general, they are uncer-
tain of income and feel highly vulnerable to the opinion held of them
by welfare workers. Only the men who are employed retain a sense of
self-esteem. The women on public assistance and the men whose fami- .
lies receive public assistance all feel very negatively about themselves.
The families feel that their high—rise apartment has many dangers,
including large open windows, dark halls, and unsafe elevators.
Mothers feel imprisoned in their own apartments. Children sent to
the store often have their money taken by older children. Tenants do
not feel they have enough police protection from either project or city
police.

The tenants’ preoccupation with problems of subsistence influences
their feelings about almost every issue. Interpersonal relations are
guarded in part, at least, by the awareness that the other fellow may
someday need help and become an emotional and financial drain.
Family relationships are important even though most of these people
had'left many close relatives behind in the deep South. Most residents
feel a sense of responsibility toward their parents. Faithfulness in
marriage is expected; there is more tolerance toward men who are
unfaithful than toward women. Premarital pregnancy is not of great
‘ concern.

The investigators note that these people “privatize” their lives
because they have learned that to share problems and information may
produce greater difficulty than benefit. The life situation of the

24

average Negro lower-class public housing occupant embraces few
permanent alliances that are not subject to competing demands when
one’s survival is at stake. Then the resourceful person musters all of
his or her assets, which may include information about someone else’s
behavior, finances, or husband.

Another example of the feeling of helplessness of most of these
residents is the common answer given to the question of what they
would do if their public assistance money were dropped. Almost. all
answered, “I’d try to get a job.” Reflecting the results of past attempts
to get work, there were no assertions that “I’ll get a job.” Some com-
mented that next they would beg or steal. All residents feel trouble is
omnipresent. Most feel that the community has little concern about
their problems, except those of children’s health; the residents do
know of clinics for child care and dental work.

The children are given family responsibility early. Regardless of
the number of children in a family, the parents tend to describe them
very individually. Most parents have high aspirations for their chil-
dren but at the same time feel that many will drop out before finish—
ing high school. Most parents fear pregnancy will occur when a daugh-
ter reaches 16. The vast majority of parents, nevertheless, say they
are satisfied with the way their children have grown up. i

In every area, these Negro families express an expectation of frus—
tration, trouble, and lack of assistance. Most people have few friends
and very few long-term relationships. Most feel that difficulties should
be dealt with privately or with the help of friends and relatives.
Where churches or neighborhood organizations have become a part of
the daily life, they, too, are utilized.

This same multifaceted study of public housing (11) is showing
that the “street life” contains many factors in opposition to those con-
ducive to having a steady job. It also finds evidence that men who do
not work serve as poor models for young people.

The Dynamics of Prejudice

Despite advances in the reduction of prejudice in American society,
its role continues to be a potent one in shaping the attitudes and
behavior of many Americans. By most criteria, sound mental health
can hardly flourish in the presence of prejudice—of irrational hate
and hostility. The Institute supports a number of investigations to
add to what is already known about how attitudes are formed and
changed: the prejudice of the white against the black, of the black
against the white, and of one religious or ethnic group against another.

Much valuable information on the play of forces making for stable
integrated neighborhoods is expected to come from a national survey
of persons living in privately owned dwelling units in racially inte—
grated areas (60). Special concerns include the relationship between

‘ 25
335—119—69—~——3

verbal attitudes on integration and actual behavior; satisfactions and
tensions developed among those living in integrated neighborhoods;
the major factors influencing a family’s decision to move into, or
remain in, a newly integrated area; and a description of the physical
characteristics of housing in successfully integrated areas. Analysis
of the data will center on identifying characteristics of neighborhoods
with stable integration, characteristics of families moving into inte—
grated areas, and the psychological correlates of living in such areas.

A white person strongly prejudiced against Negroes has, of course,
a very low expectation about how things will turn outif Negroes and
whites interact. One investigator finds, however, that this negative
attitude can be neutralized if the prejudiced white has a suflicient num-
ber of positive experiences relating to Negro strangers (61). The
investigator is trying to determine as specifically as possible the con-
ditions under which such neutralization occurs.

In a study of anger and aggression, one set of experiments is con-
cerned with the modification of aggression in lower-class Negro
adolescents who easily express hostile feelings (6‘2) . The investigator
is testing the hypothesis that after exposure to an anger-arousing
situation, the adolescents will show more aggression than usual in
reacting to opinions expressed by a White person. The effect of telling
the youngsters that the white person was active in civil rights protests
will be measured. Finally, the investigator will evaluate the effective-
ness of various methods for modifying aggressive behavior in the"
Negro young people who manifested aggression against whites.

Another investigator is studying interpersonal trust and the psycho-
logical factors related to it. Trust is defined as a generalized expect-
ancy that what other people say regarding their future behavior can
be relied upon. Following the development of individual measures
and criterion situations, studies will be made of related personality
characteristics, sociological and demographic characteristics, and situfi
ational influences on trusting behavior. One study, for example, will

explore the characteristics of those social agents who are trusted more / '

than usual. This research on interpersonal trust is considered of crucial
importance for many problems ranging from simple person—to-person
interactions, whether the persons are of the sanfe or different races,
to negotiations between nations (6‘3).

Attitudes of older adults toward Negroes will be assessed both
before and after a year of active participation in a racially integrated
Senior Citizens Center, and will be compared with those of control
groups who participate in comparable activities in nonintegrated
groups. Four aspects of attitudes will be measured: feelings, self-
reported behavior, projected behavior, and observed behavior. The
experiment will be repeated four times to learn if the attitudes are

26

3"-

changing for reasons other than the participation in integrated
programs (64) .

With Institute support, a cross-cultural nursery school is being
evaluated as an instrument for promoting mental health in a commu—
nity that is being subjected to the stresses of redevelopment. The com-
munity is composed of three distinct housing patterns: middle-income
cooperative apartments, low-cost public housing, and ghetto housing.
Three nursery schools are proposed, each composed of 20 children and
their families from all three of the housing patterns. Children are to
enter a school between 2.3 and 2.6 years of age and remain 3 years.
Parents are to be closely related to the school as aides and learners.
The project expects to assess the effects of the cross—cultural nursery
schools by studying: (1) behavioral changes in the children—includ-
ing basic trust, autonomy, initiative, cognitive development, and social
competence; (2) behavioral changes in the families—including social
competence, adaptability, and intergroup acceptance; and (3) changes
in the families’ utilization of community resources and participation
in community activities, particularly as these relate to cross—cultural
involvement (65).

Another project studies behavioral change resulting from social in-
fluence in both experimentally produced and natural situations. The
investigator is interested in the quality, depth, and durability of
changes and of resistance to change. Work so far suggests that the
accuracy with which a person receives and perceives a message depends
in part upon the Communicator’s prestige and personality. The in-

" ‘vestigator also proposes to study attitude change under circumstances
.where intergroup conflict stems from the self—perpetuating nature of

hostile attitudes. The purpose is to find ways of reducing the conflict
so that the groups Will be open to new information about one another
despite their negative preconceptions (66). The experimenter will

, attempt to induce changes.

Another investigator, considering patterns of friendship among
various groups in Detroit, finds that the friendship network 1s likely
to be interlocking, or closed, in the case of Jews and Catholics and
also in the case of the Polish and Irish, who are predominantly
Catholic (67). Among Protestants, the network friendship is more
likely to be radial, or open, as it is in general among people who have

.moved upward socially and economically. Strong evidence supports

the conclusion that interlocking friendship networks are more likely
than the radial to be composed of people of the same ethnic origin,
educational attainment, and political party preferences. They are
likely to come from the same neighborhood and to see each other more
often, both in somebody’s home and at work. Men in such networks
are likely to have lower intellectual capacity than men in radial
friendship networks and to prefer relatively secure occupations. Their

27

9

political preferences are likely to be more stable from generation to
generation and more crystallized, suggesting that open-mindedness is
associated With open friendship structures while closed-mindedness
is related to closed, or interlocking, friendship structures.

Research conducted in a Mexican slum in a large American city
concerns the type of social change related to the upward socio-eco-
nomic mobility of individuals and small groups and trying to estab-
lish what happens to a person’s view of the world and himself, with
attention to both natural and supernatural factors, as he adapts to
new urban norms (68).

Battered Children

Children who have been physically abused by their parents are not
solely an urban problem, but they are more likely to come to public at-
tention in cities, and they are most often treated there. Also, many of
the problems characteristic of slum areas are the same problems that
contribute to the family strain and disorganization playing a major
part in child abuse (69) .

An investigator, who has studied 50 battered children and their
families, sums up her finding this way:

Out of our work has come the firm conviction that child abuse
is almost inevitably associated with an accumulation of stresses
on the family. Such stresses can be easily identified in the lower-
class portion of the population. They include inadequate educa-
tion, scarce job opportunities, unrellable income, poor housing,
and the inability to save or plan for emergencies. There is likely
to be quarreling, or separation, desertion, or divorce. The most
common kind of stress in our abusive families was the birth of
several children close together, often less than 1 year apart.

The families were socially isolated, too. The parents tended to have
few connections with groups like the PTA, the union, the church. Fre—
quently they were alienated from other family members and had few
close friends.

Prematurity, which is often unusually high in slum areas, also ap-
pears to be associated with child abuse. One investigation found that
almost a third of the abused children in the study had been born pre-
maturely. Among whites in the United States, 7 percent of births are
premature; among nonwhites, 12 percent. Some authorities speculate
that prematurity in the cases of abused children, when it occurs in the
absence of medical or obstetrical complications, may represent rejec-
tion of the child even before his birth (6‘0). Whatever its cause, a
premature birth is an emergency, even a crisis, that compounds for a
family the usual problems associated with the birth of a child.

Child abuse, the studies show, is rarely deliberate. Usually the
parents are overwhelmed by the pressures of life and are, in fact,

28

emotionally disturbed. The abuse may begin as an expression of rage
or an attempt at punishment and then become increasingly serious.
Rarely, too, is only one parent truly responsible; the other parent al—
most always knows about and tolerates the abuse.

The investigators believe that child abuse should be distinguished
from the ordinary types of assault cases: that the goal of any legal
measures should be protection of children rather than punishment of
parents. Many people such as teachers, social workers, doctors, and
public health nurses, it is reasoned, may suspect or know very early
that a child is being mistreated and will be more Willing to report the
case if assured that the law’s chief concern will be with safeguarding
the child. Treatment of the parents, it is generally agreed, ought to be
a major part of that concern.

29

 

The Human Problems of the City Are
Staggering . . . for the Problems We
Are Dealing With Are Stubborn,
Entrenched and Slow to Yield.

—-Lyndon Baint: johnson

SPECIAL MENTAL
HEALTH PROBLEMS
OF URBAN LIFE

Introduction

Every problem of mental health seen in our cities appears also in our
suburbs, our towns, our villages, and our countryside. However, three
grievous problems are especially prevalent in our cities, and particu-
larly in our larger cities. They are crime and delinquency, mass vio-
lence, and drug abuse. This chapter describes some of the Institute’s
findings about these three problems, and What it is doing to supply
the information and the services necessary to prevent and contain
them.

Crime and Delinquency

Patterns and Trends

Antisocial behavior, ranging from truancy and petty thievery to
multiple homicide, is a major problem in our society. Its monetary
cost to the Nation—including the cost of law enforcement, adminis-
tration of justice, and correctional efforts—has beenestimated at more
than $20 billion a year. The mental health costs, which defy measure—
ment in terms of dollars and cents, affect countless innocent people.

Crime rates are highest in the big cities. Twenty-six cities containing
less than 18 percent of the total population account for more than _
half of all reported serious crimes against the person and more than

31

30 percent of all reported serious property crimes. One of every three
robberies and nearly one of every five rapes occurs in cities of more
than 1 million. The average rate in these cities for most serious crimes
is about twice as great (and often more) as in the suburbs or rural
areas. With a few exceptions, average rates increase with the size of
the city. Suburban rates are closest to those of the smaller cities.

The common serious crimes—murder, rape, robbery, aggravated
assault, and burglary—occur most often in the slums of large cities.
Studies of the conditions of life most commonly associated with high
crime rates have been conducted for well over a century in Europe and
for many years in the United States. The findings have been remark-
ably consistent. Burglary, robbery, and serious assaults occur in areas
characterized by low income, high population density, physical de-
terioriation, overcrowded and substandard housing, low rates of home
ownership or single-family dwellings, concentrations of ethnic minori-
ties, broken homes, working mothers, low levels of education and vo-
cational skill, high unemployment, high proportions of single males,
and high rates of tuberculosis and infant mortality.

“There have always been slums in the cities,” observed the Presi-
dent’s Commission on Law Enforcement and Administration of J us-
tice, “and they have always been places where there was the most
crime. What has made this condition even more menacing in recent
years is that the slums, with all their squalor and turbulence, have
more and more become ghettos, neighborhoods in which racial minori-
ties are sequestered with little chance of escape. People who, though
declared by the law to be equal, are prevented by society from im-
proving their circumstances, even when they have the ability and
the desire to do so, are people with extraordinary strains on their
respect for the law and society.”

Crime rates in American cities tend to be highest in the city center
and to decrease in relationship to distance from the center. Beyond
city boundaries, however, there is a clustering of offenses and offenders
in satellite areas that are developing some of the characteristics of
the central city, including a population marked by its low economic
status and high proportion of broken homes.

For as long as crime statistics of any kind have been compiled, they
have shown that males between the ages of 15 and 24 are the most
crime-prone group in the population. In recent years, as the result
of the “baby boom” that took place after World War II, this group
has been growing faster than any other.

Family Patterns and Delinquency

Delinquents tend to come from backgrounds of social and economic
deprivation. Many have only one parent at home. Many have an un-
usually large number of brothers and sisters. The youngsters who

32

become delinquent tend to have done badly in school; many have
dropped a class or two behind their fellows or dropped out of school
entirely.

Investigators studying the causes of antisocial behavior have been
especially interested in the attitudes, child-rearing practices, and com-
position of families in the run-down neighborhoods of large cities,
where the proportion of delinquent youngsters reaches several times
the national average. Studies suggest that the parents in such areas,
and even the delinquents themselves, tend to have a surprisingly strong
desire to abide by middle-class family and moral values but are frus-
trated by the circumstances in which they find themselves (.9, 10).

Among the factors that destroy proper parental functioning and
help make for delinquent behavior by children, one study points to
the high rate of unemployment among males in disadvantaged neigh—
borhoods. Continued joblessness can lead in one way or another——
through antisocial behavior by the husband, for example, or through
disparagement of the husband by his wife—to rupture of the family
or to a fatal weakening of the man’s place in the family. Of primary
importance in keeping a boy out of trouble and enabling him as an
adult to have a stable marriage, a study of the lives of Negro men
suggests, is the presence of his father in the home while the boy is
growing up (9).

The theory that crime and delinquency are associated with the fail-
ure to give a boy adequate opportunity to identify with his father has
been supported by studies of a number of other societies (36, 38). For
family stability, the father evidently must not only be present but
also take an active part in family management. Investigators studied
a number of families having a child from 6 to 10 years of age who
had been referred to a psychiatric clinic for such activity as persistent
firesetting, wanton destruction of property, and attacks upon people.
The fathers of the antisocial boys seemed to be passive individuals
both in child-rearing and in family affairs in general; and they ap-
peared to gain vicarious satisfaction from their sons’ misbehavior,
interpreting it as proof of desirable masculine Self-assertion (7’0).

Learning How To Prevent and Treat Delinquency

A variety of studies suggest that the problem of crime and delin-
quency can be dealt with most effectively by dealing with the condi-
tions giving rise to it. Members of delinquent gangs, one Institute-
supported study found, suffer from social disabilities that presumably
had their roots in early family life (10). As a consequence of such
disabilities, the boys studied are relatively ignorant of how, for ex-
ample, to dress for a given occasion, or to eat in public, or to carry on a
polite conversation. When they entered school, they lacked the skills
needed to meet new situations. Consequently they were handicapped

33

in getting along with their teachers and classmates and in learning.
Their school experiences, in turn, made them additionally handicapped
for work and other conventional activities. These boys drifted into
gang membership, the investigators believe, in an effort to meet the
universal need for relationships with other people. And they became
involved in delinquency as a way of achieving and maintaining within
the gang What their social disabilities prevented them from achieving
outside of it—status. No gang boy expects the gang membership phase
of his career to last forever; the trouble is that involvement in gang life
hampers the achievement of values held by the boys with respect to
future phases of life (10) .

Evidence that the roots of delinquency often lie in the home has
been found also in a study of delinquents from families at upper socio-
economic levels. The delinquents studied were described as “socio—
paths,” or persons with a “character disorder,” meaning that they
did not seem to be troubled by their antisocial behavior. In general,
the boys had come to the attention of some public agency for auto
theft, stealing from stores, or assault; the girls, for sexual delinquency.
From preliminary observations, the parents in these well-to-do fami-
lies seemed to be marked by an unawareness of what the child had been
up to; a willingness to accept delinquent behavior until some agent of
society stepped in; and, in many cases, a concern with appearances
rather than with social and ethical values (71).

A study of adolescents in several communities of Los Angeles
pointed to the existence of an adolescent subculture whose members,
described by the investigators as “insiders,” cut across class lines and
were found in every neighborhood. From 80 to 90 percent of the delin-
quent youth in a community, the investigators believe, are “insiders,”
subscribing to a way of life and values that are poorly understood by
their elders (7’2) .

In a lower class, predominantly white district of Boston, crime was
found to be both more prevalent and more serious among the delin-
quent gangs at the lowest social level, and these gangs responded less
well than others to measures intended to reduce delinquency (7’3) . The
investigator suggests that at the lowest social level, antisocial behavior
is more central to the culture. Another investigator is following up
former gang members to learn how they have adjusted as young adults
in matters of work, family and social life, and relationship with the
law. The results will give us more information on how gang member-
ship, generally limited to youngsters from underprivileged families,
affects later life (74).

It is not poverty itself that may turn a boy toward delinquency,
an investigator believes, but a hopeless attitude toward the future
(75) . And the boy’s perception of the future as hopeful or hopeless will
be determined in part by how he does in school. Hence the nature of

34

the educational system is important. The inference from such studies
is that early child-care programs, demonstrated as valuable by other In-
stitute—supported research, may lead not only to better intellectual and
emotional functioning but also to a lowered rate of delinquency and
crime among deprived groups.

A number of research teams are trying to answer such basic questions
as where and under what circumstances criminal or delinquent be-
havior occurs and who participates in it, for what reasons, and how
frequently. One investigation, for example, seeks to determine the
incidence, frequency, and type of delinquent acts committed by a
group of 10,000 boys in a large metropolitan area. All the boys were
born in 1945, entered schools in the area under study before the age
of 10, and remained in that area through their 18th birthday. The in—
vestigators are determining how delinquency evolved by age and the
severity of offenses, and they are comparing the delinquents with
nondelinquents in respect to such variables as school history, intelli-
gence, race, and residential area. Preliminary findings indicate that
approximately one-third of the boys are listed oflicially as having
committed delinquent acts, though a number of the violations were
very minor (76’).

Another investigator has begun to ’measure delinquent activity— '
both detected and undetected by the law—among a representative
sample of American boys and girls ranging in age from 13 to 16 years.
His purpose is to obtain information about the nature of the delinquent
acts, the circumstances under which they took place, and the economic
and cultural background of the youngsters committing them (77).
In still another survey of several thousand adolescents, the investiga-
tors are using school records in an attempt to establish a relationship
between such factors as personality traits, achievement test scores, and
home background on the one hand and, on the other, various forms of
maladjustment that appear later, including juvenile delinquency,
motor vehicle violations and accidents, and emotional disorders (78) .

A long—term study of Negro boys seeks to learn how other factors in
early life, including performance in elementary school, presence or
absence of the father, and occupation of the guardian, influence a
youngster’s later education, work, married life, and respect for the
law (7.9). One highly important result of such studies, it is expected,
will be information about those points where intervention will most
effectively prevent further or more serious delinquency.

One Negro mother, interviewed by a psychiatrist about her family,
suggests some of the complex variables that must be considered in
understanding the roots of delinquency:

They say we’ re lazy and we don’t pay much attention to the
law, and sure enough I have two boys to prove it and one to dis-

prove it, so it’s two to one against us in this family. But I’d like to
tell people why I think my two boys went bad.

35

I preached and hollered at all three the same. Those older boys
were good boys just like the little one, and I remember when they
wanted to study and be somebody, just like him. But they never
had a chance. They were born too soon .

They went to school until it didn’t make any sense to stay there,
because we had no money and they thought they should try to get
jobs. So they left school and tried. They tried and tried and there
wasn’t anything for them.

I wonder, do people who never have to worry about work know
what happens to you when you keep on knocking your head on a
stone wall and there’s still no work? I’ll tell you what, your head
bleeds, and you get tired; you get so tired that you give up. Then
you have all those hours and whatever you can figure out to do
with them . .

. . . Now, it’s all right if you’re an older woman like me and
you have children; you keep busy with them. But if you’re a man,
you don’t have kids to occupy you. So what can you do? I’ll tell
you what happens, you just fold up and die.

That’s what drugs and liquor mean. They mean you’ve died. I
mean you’ve hung up on the world, because you keep on calling
and there just ain’t no answer on the other end of the line. 4

I watched my boys go bad like milk you know is standing too
long; there’s no use for it, so it gets sour . . . . Now, at least one is
going to be OK. And I’ll tell you, it’s because hewas born at the
right time. I know it in my bones that he would have turned out
just like the others except for what’s happening now, With the
integration and all that. He got chosen to go to a white school be-
cause he was a quiet boy, and it gave him a real chance, and now
he’s got that scholarship to college. ‘

We all know he’s going to be fine. And you know what he Says to -
his brothers? He says he’s glad it happened to him, but he feels
bad because peOple think he’s so spec1al; but the truth is he was
given a chance and his brothers weren’t, so he feels dishonest some-
times. But I tell him, it’s not you who are dishonest, Son, it’s the
world, and they are finally coming around to know it, so we should
all thank God for that (80).

The so-called typological approach to the treatment and control of
delinquency is being taken by another group of Institute-supported
studies. In such an approach, the investigators seek to learn what kinds
of treatment programs, in what kinds of settings, administered by
what kinds of treatment agents are most effective with different kinds '
of delinquents (48) .

For a better understanding of the personality forces associated with
adolescent misbehavior, an investigator and his associates have de- ‘
veloped a self—report questionnaire that discriminates between delin-
quents and nondelinquents (81). The investigators believe that it and
other instruments they have developed and tested—checklists for
analyzing the case histories of delinquents and for rating the behavior
of delinquents in institutions—can be useful in determining the cause,
prognosis, and most effective treatment of delinquency.

36

The questionnaire comprises three sets of items, each measuring
an independent personality factor or dimension. One factor, labeled
“psychopathic delinquency,” apparently reflects tough, amoral, rebel-
lious qualities coupled with impulsivity, a conspicuous distrust of
authority, and a freedom from family ties. Among the true-false items
used to measure this factor are: “In this world you’re a fool if you
trust other people”; “You gotta fight to get what’s coming to you”;
“The worst thing a person can do is get caught.” Another personality
dimension associated with delinquency is described as “neurotic delin-
quency.” Like the first one, this too, reflects impulsive and aggressive
tendencies, the researchers report, but here they are accompanied by
tension, guilt, remorse, and depression. The third factor is labeled
“delinquent background” or “subcultural delinquency.” It seems to
mirror attitudes occurring among delinquents in whom personality
maladjustment is not clearly evident. Sample items: “Most boys stay
in school because the law says they have to”; “Sometimes I have stolen
things that I didn’t really want”; “My folks usually blame bad com-
pany for the trouble I get into.”

The questionnaire and the other instruments are now being used to
study boys in a Federal training school. The immediate goal is to see
whether or not there is a relationship between a boy’s score on a given
personality dimension and how well he progresses in the institution
and on parole. If there is, as the investigators expect, it should be
possible to design rehabilitative programs that take into account the
' ' different kinds of delinquent personalities that must be treated.

Meanwhile, a variety of new community approaches are suggested.
For example, a pilot program of comprehensive care for emotionally
disturbed children, committed by the courts for rehabilitation treat-
ment, has been established in a resident children’s home that functions
as a diagnostic reception center. Treatment includes correctional case-
work counseling, mental health diagnostic study and treatment, clinical
consultations with psychiatric teams of Statemental hospitals, and
psychiatric evaluation of prospective foster homes(8§2). In Seattle,
Wash., an agency is comparing the effectiveness of three different
approaches to helping antisocial youngsters: (l) sending a so-called
detached worker into the street to work, with gang members in their
own environment; (2) bringing the entire gang into the agency
for treatment; and (3) offering group treatment for certain mem-
bers (83).“find, as one more example, in San Antonio, Tex., a demon-
stration project is showing to what extent the involvement of a com-
munity center with Mexican-American gangs can direct their be-
havior in socially acceptable directions and to what extent, also, the
community center’s program can prevent the younger boys from
moving into existing gangs or forming new ones (84).

37

Improving Institutional Treatment

One of the most promising recent developments in the institutional
care of delinquents and criminals has been the demonstration that
even inmates who perceive themselves as “sure losers” can be moti-
vated to take part in a self-instructional program. In one institution
such a program has enabled 16 men with only an eighth grade educa-
tion to complete high school and be accepted into college. More than
600 inmates have received prevocational training, and of the approxi-
mately 400 who have been released, the majority now have jobs with
some 160 employers. The recidivism rate is markedly lower among
‘these eX-convicts. Based on the experimental work supported by
NIMH, which is continuing, major projects have been undertaken
at this institution with the support of the Department of Labor and
the Vocational Rehabilitation Administration. More than 90 percent
of the inmates are now engaged in some sort of educational activity.
The program could well become a model for use elsewhere (85).

Another project designed to rehabiltate offenders by providing
training in the institution for employment on release is directing
inmates into careers in the field of crime prevention. The project,
which emphasizes self-understanding and social development, is part
of a growing trend to involve persons with problems in the solution of
those problems. Upon parole, the offenders are assigned to work with
research and action groups in crime and delinquency prevention pro-
grams. Eighteen men have been involved in a training program
lasting 4 months. Their relationships with other people improved
almost immediately but, as might have been expected, new values
and a sense of commitment were often slow to develop, and some
trainees needed varying amounts of on—the-job support (86’). Those
' who benefited most were individuals from severely deprived back-
grounds; white middle-class offenders with a relatively good educa-
tion were the least likely to make use of the new opportunities.

Treatment of young delinquent boys from the most socially de-
prived groups presents a serious challenge to mental health practice.
The task of rehabilitaing the child and his family becomes more
formidable when court intervention removes the child from the family
and thus reinforces the parents’ feeling that there is no link between
parental behavior and the child’s problems. A study at a residential
treatment center serving such youngsters—from 8 to 14 years old,
seriously disturbed, and expressing their conflicts and hostilities in
antisocial behavior—has come up with hopeful answers (87).

The youngsters treated at this Center, many of them Negro or Puerto
Rican, come from large families at a low socioeconomic level. The re-
search team postulated that in such families there is a relinquishing
of the executive guidance function by the parents. In its place a sib-
ling subsystem with its own values, opposing those of the parents,

38

develops. This situation was assumed to be of crucial importance in
a child’s failure to develop adequate internal controls.

The investigators attempted to reverse that pattern by treating
not only the individual but also the siblings as a subgroup and the
family as a whole. And this type of family therapy was found to
reduce considerably the period of time an antisocial child spends in
residence. Contrary to expectations, the study found that these “hard
core” families were intensely interested in the treatment offered. All
but one of the experimental families completed the 30-sessi0n treat-
ment, and there were very few broken appointments.

The investigators believe that the removal of disturbed children
from their homes could be reduced by approximately 30 percent if
such family therapy were available, on an outpatient basis, at an
earlier stage. The agency is now moving to add a family outpatient
clinic and a day-treatment center so that fewer children will have
to be taken from their families and treated in an institution.

Several other NIMH—financed studies are designed to show how the
deviant subculture often existing among inmates can be overcome.
In one of these a correctional institution is using group counseling
in the hope that the offenders will 'be less likely to endorsethe “inmate
code,” will gain a more accurate perception of staff views, and will be
less likely, after release, to get into trouble again (88).

Investigators in another correctional institution are studying the
behavior of .boys in three differently managed cottages. The first
cottage is headed by an educator who stresses stable, orderly routines;
the second, by an “old-line” nonprofessional who also is concerned
with orderly routines but who has developed a more easygoing rela-
tionship with the boys based upon the implicit agreement that the
cottage have “no trouble”; the third, by a professional social group
worker who gives his boys more autonomy. The greatest success in
supplanting deviant values has occurred in the third unit. The investi-
gators believe that their findings will lead to the development of more
effective residential treatment centers (89) . '

In a different approach, another investigator is studying the effect
of dividing institutionalized delinquents into several groups on the
basis of their maturity in interpersonal relationships, assigning each
group to a separate living unit, and giving each group the treatment
considered more appropriate (48) . If the project is successful, it would
be an important step toward closing the gap between a hypothetically
ideal program in which treatment would be individually prescribed
and the present system in most correctional institutions, in which
little consideration is given to individual needs.

A study of girls committed to State institutions for delinquents has
led to a better understanding of these troubled young people and to
suggested changes in treatment. Many such girls have had a long

39

series of brutal experiences: They have been exposed repeatedly to
emotional trauma without intervening periods of sufficient gratifica-
tion to enable them to recuperate, and without enough rewarding emo-
tional experiences to counteract the recurrent trauma. If this sequence
continues long enough, an immunity to stress develops, human involve-
ment is warded off, and anxiety appears to have vanished. Such
youngsters are especially difficult to reach‘ in treatment.

Three steps in treatment are suggested: Focusing on and strengthen—
ing the healthy aspects of personality, providing individual therapy on
a supportive level, and supplying individual and group treatment that
examines the individual’s reactions to stress and tries to provide
insight. At this point, increasing demands from the educational and
living situations can be introduced. The investigator found that pro-
grams for institutionalized girls in her State were particularly weak
in vocational and educational guidance, which these youngsters needed
and wanted. Action is under way to make some of the reforms sug-
gested by this study (90) .

Other investigators are establishing an intensive treatment unit for
“sexual psychopaths.” The program emphasizes group work, patient
government, recreational activities, education and vocational services,
and therapeutic milieu. An attendant-counselor, working under pro-
fessional supervision, is assigned to each patient. Families of patients
are encouraged to participate in the treatment program from the point
of admission through discharge. When patients are paroled, sponsors
will report monthly about their behavior. Psychological tests, rating
scales, and behavioral indices will be used to evaluate their progress
during both hospitalization and parole. The project should increase
our understanding of sexual deviation and lead to more efi'ective meth-
ods of prevention and treatment (91).

Little is known about the actual criteria, other than legal ones, which
affect the disposition of delinquency cases; but it has been observed
that the courts tend to deal more severely with persons from minority
racial groups and from lower socioeconomic backgrounds. The cases
of about 1,000 delinquents will be studied through case workers’ re—
ports, which include the worker’s perception of the delinquent, his
recommendation to the court, and the final disposition of the case (.92).
Ultimately this investigation will lead to a more extensive inquiry,
involving agencies such as police departments and mental health
boards, to determine the criteria used by various agencies and how
the decisions affect the individuals processed.

Community Treatment

With two-thirds of the total corrections’ caseload under probation
or parole supervision at any given time, the central question is no
longer whether to handle offenders in the community but how to do so

40

safely and successfully. While it is necessary to confine dangerous
offenders in order to protect the community, recent studies have demon-
strated that intensive community treatment is an economical and
desirable alternative to incarceration.

In one of the most influential of these studies, approximately 600
first-offenders from 13 to 18 years of age convicted of nonviolent crimes
were referred to the California Youth Authority. The youngsters were
split randomly into two equal groups. Those in one group were assigned
to an intensive community treatment program; those in the other
group, to the regular correctional institution program.

For the community-based group a typological approach to treat-
ment was used. The young offenders were placed in one of three major
groups according to their degree of social maturity—low, middle, or
high. The very immature, somewhat infantile clients received a great
deal of support and guidance; the middle-maturity subjects, who were
guided more by the power of authority than by a sense of right or
wrong, received firm and consistent management; high—maturity sub—
jects received treatment intended mainly to help them understand
themselves.

The main idea behind the program is that maintaining an offender
in the community makes him more amenable to accepting help than
does banishing him from and then trying to integrate him back into
the community. Each community treatment team is staffed by seven
parole agents, six male and one female. Each agent handles 10 to 12
cases and sees each offender from two to five times a week, sometimes
devoting all day to one youth. Although not yet completed, the pro-
gram has received national attention as an outstanding example of a
promising approach to the treatment and rehabilitation of delinquents.
A followup after 6 years shows that this intensive community treat—
ment has been markedly more successful and has cost much less than
institutionalization. Reports indicate that only 28 percent of the com—
munity-based group have been subject to parole revocation as against
52 percent of those discharged from institutions. Savings in costs
of constructing new correctional institutions have amounted to $8
million (.93).

Also concerned with the potentialities of treatment within the com—
munity is a study of young male felons who have been referred for
pie—sentence investigation. These are classified into three groups on
the basis of probation success probabilities and then randomly
assigned to an experimental or a control group. The groups differ in
regard to the frequency of worker—client contact, the theoretical
orientation of the caseworkers, and the availability of psychiatric
consultation (94).

41

335—119—69—4

Improving the Probation Process

Another major effort in the battle to control delinquency is pro—
viding information that will enable communities to improve the pro-
bation process. Work in California points to great variation in the
amount and nature of the treatment received by delinquent youngsters
who are wards of the court (.95). Some are never seen by their proba-
tion oflicers after the court experience; many are seen on the average
of once a month; others are given extended interviews once a week.
Many, though not all, youngsters who are in trouble end up being
labeled as delinquent, or wards of the court, and such labeling is
believed by some authorities to affect adversely the way the youngster
behaves toward others and the way others behave toward him. Several
investigators are now trying to evaluate the various probation prac-
tices and also the effect of labeling. The criterion is whether the
youngster receiving a certain kind and amount of supervision or treat-
ment, or none at all, and bearing or not bearing a label, engages in
«further deviant behavior (.95). The hope is that these studies will
shed light on the particular procedures most effective with youngsters
from particular backgrounds and that supervision procedures can be
modified accordingly. The findings would then also be of use in train-
ing recruits as probation oflicers.

One study of the effects of variation in the intensity with which
probation officers supervise offenders led to a surprising finding. The
degree of supervision seemed to make little difference in the rate of
violation by parole groups formed of members chosen at random.
As one result, experimenters have begun to place all the likely failures
by themselves, in small groups, with the hope that parole officers
faced with lighter caseloads of similar persons, even though all are
considered difficult, will be able to find better ways to help (.96) .

Another investigator has been making a 3-year followup of juve-
nile and young adult delinquents who have just been-paroled from an
institution. The effort here is to record the general sequence of events,
after parole, as an aid to understanding the process by which offenders
return to or depart from their previous delinquent activities. The
investigator hypothesizes that rehabilitation will accompany shifts in
companions and in group activities. (97')

Projects for Prevention

Though more information is needed—and is being sought in such
studies as those reported upon earlier about how to identify and
handle potential delinquents and how most effectively to treat actual
delinquents—the Institute already supports a number of attempts to
intervene in the environmental conditions known to be associated with
crime. The goal is to lessen the social and psychological disabilities

42

too frequently present in youngsters from our poorest neighborhoods
and too frequently, through the process of cultural inheritance, passed
on by them to their children.

One effort embraces a number of related programs to provide better
opportunities for the residents, particularly the youngsters, of a
socioeconomically poor neighborhood and to help the community
develop the ability to cope with its problems (.98). Several other pro-
grams—one, for example, that provides elementary school children
with home tutoring by high school students—are aimed at improving
a young person’s capacity to benefit from schooling. Others try to
improve the skills and attitudes needed for successful employment.
Some programs provide services of various types to troubled families;
others, to troubled individuals. One encourages teenagers to turn from
apathy or unproductive anger and to act collectively and construc—
tively against racial discrimination, housing violations, and other
injustices. Drama groups, coffee houses, and other groups have been
organized. For teachers and social workers in this deprived area,
professional education groups were organized to provide special train-
ing experiences. Technical assistance and building repair programs
were begun. The trainees learned how to do many jobs such as brick—
laying, plastering, and installation of wall covering.

Studies of delinquent gangs in Chicago and Boston have indicated
the value of the so-called detached worker—a mature, educated, and
interested person, employed by a community agency, who “hangs
around” with gang members and tries to help them with their prob-
lems. In both studies, the workers eventually were accepted by the
gang members, served as counsellors and advisers, and, among other
services, gained access for gang members to a wide variety of legiti-
mate intitutions and organizations such as business firms, athletic
leagues, guidance services, and health facilities. The investigators hope
that if a boy can become interested in employment, perhaps he can
also become interested in going back to school or in getting some kind
of additional training. And if the road can be cleared to steady employ-
ment for one boy, perhaps he can become a channel through which to
reach other boys. Possibly the most powerful influence against delin-
quency, suggests one of the investigators, is the opportunity for a
youngster to step into a job as soon as he leaves school (.9, 61;).

The effectiveness of one NIMH—supported program for rehabilitat-
ing disturbed, delinquent adolescents can be summed up in the words
of one of the participants: “When you are working you get satis-
faction out of it.” This boy and others like him were not getting satis-
faction from their school life and their behavior showed it. Many had
arrest records and were disruptive in school. All were doing poorly in
their academic work. These were the youths, age 14 to 16, that the
work-therapy program for adolescent delinquents at the Jewish Voca-

43

tional Service in Milwaukee, Wis, was designed to reach. During the
five years of the N IMH-supported project, from 1962 to 1967, more
than 350 youths participated (99).

Boys were referred to the program by their school principal on the
basis of delinquent behavior and poor achievement. They attended the
workshop half-day and school half-day during a two-semester school
year. They worked in groups of 20 to 30, collating and packaging mer—
chandise under contract to an outside firm. Initially they were paid
25 cents an hour, but their wages increased as their work improved.
Daily and weekly bonuses were rewards for exceptional production.
Those who misbehaved were not allowed to work.

The project directors believed real work experience in a structured
setting would help delinquent boys develop a better self—image and
relate better to the demands of society. They believed that achievement,
reinforced by actual earnings, would give the boys the recognition
and sense of “adulthood” that they sought. The goal was to make
the boys aware they could be productive in an environment that re—
quired discipline. Counselors were on hand during workshop hours,
and the boys met with them in weekly individual and group sessions.
As one boy said, “I knew there was someone down there I could talk to.”
More than 50 county schools made referrals to the program. Co-
sponsors included a number of community agencies such as the
Metropolitan Crime Commission, United Community Services, and
the Children’s Court—Probation Department. As one measure of the
program’s success, a permanent work-therapy program patterned
after this project has been set up in Milwaukee at the request of the
public schools. '

Another investigator established a vocationally oriented treatment
program for 10 adolescent delinquent boys who had dropped out of
school (100). He then followed these boys and a similar but untreated
group for 3 years. In the treated group, half of the boys went back
to school; in the‘untreated group, none. The boys in the treated group,
but not the others, have shown significant improvement in personality,
respect for the law, and ability to hold jobs.

In a West Coast community, another Institute—supported study has
brought together a number of professional agencies, laymen’s groups,
and youth organizations to consider how best to reduce conditions
associated with, and conducive to, juvenile delinquency and related
problems and how best to increase the effectiveness of the community’s
resources for helping young people (101). The thought behind this
and similar studies is that a community’s resources against delinquency
can be most effective only when they are fully informed about all
phases of the problem and have developed a unified approach to it.

The Violent Ofiender

The old, highly important, and unanswered question of how best
to classify violent offenders is engaging the attention of several in-
vestigators. One seeks’to devise a typology of violence according to
the purpose for which the violent behavior was executed. Essentially,
this investigator is developing a classification framework for violent
acts and for violence-prone individuals. The hypothesis is that persons
engaged in violent behavior can be reliably classified, and therefore
more effectively treated, by isolating the kinds of interpersonal
strategies which give meaning to their behavior. Each violent offender
subtype, it is assumed, has its own consistent strategy which orders
perception, styles of cognitive organization, modes of interpersonal
relationships, and delinquency patterns. More than 300 recurrently
violent individuals from all of the correctional facilities in one State
are being studied. Institutional case record material and individual
depth interviews have been used to gather extensive data on the
factors leading up to the violent incident; feelings before, during, and
after the commission of the act; and the life of the offender at the time
of the act. The results may make it possible to focus preventive atten-
tion on certain kinds of situations that precipitate violence and on the
persons involved (102) .

On the basis of previous research, another investigator believes
that assaultive criminals can be divided into two types, the under-
controlled assaultive type and the chronically overcontrolled as-
saultive type. People of the latter type, he believes, are particularly
likely to commit assaults of homicidal intensity. He is attempting to
develop personality tests that can discriminate between types of
offenders (103).

In other research, violence is being studied as the end product of a
variety of the components of a social situation. Data for 988 violent
acts have been collected through interviews with victims, aggressors,
and spectators, through oflicial crime and arrest reports, through
special interviews of murderers by the Homicide Squad, and through
the records of judicial dispositions. An analysis is being made of
demographic, ecological, and status characteristics of both victim
and aggressor, separately and as they relate to each other (104).

Eight hundred persons imprisoned for crimes of violence were
interviewed by another investigator, as were their victims, with
special attention to the interaction of criminal and victim. Prominent
findings included these: males are victims of violence about four
times as often as women; unmarried, divorced, or separated males
constitute a particularly susceptible group; strangers are more often
victims than friends or relatives (a finding by no means universal, as
will be seen) ; the highest percentages of violent crimes are committed

45

by persons between the ages of 21 and 30. In addition, in a majority
of cases, both the criminal and his victim were found to have low
educational and job levels. Alcohol consumption was seen as an in-
fluence in the case of aggravated assaults; mental illness and drug
abuse did not play a major role in any of the [incidents studied.
Emotional tension and illegal profit were most often cited as causal
factors (105).

Another study of the interpersonal nature of violence assumes that
violence arises out of the relationship between victim and aggressor.
It is further assumed that persons present during the commission of a
violent act also influence the event. Thus, if violent behavior is to be
understood, more than a simple investigation of the criminal himself
is necessary. The project, which is examining 988 killings or assaults,
1,049 victims, and 1,189 aggressors, represents the first attempt to study
violent acts immediately after their occurrence. Results are expected
to reflect the interaction of demographic, ecological, interpersonal,
and other variables in the social situation (104) .

In considering the problem of individual violence, attention must
be placed not solely upon the apex offense of murder or manslaughter
but also on the broad range of assaults and related patterns of behavior
which at times may result in death. Indeed, such patterns of assaults
have been shown often to be the precursors of later criminal homicides.
For example, a thorough study of criminal homicides in one large city
found that about two-thirds of the killers and almost one-half of the
victims of criminal homicides had previous arrest records—many of
these for aggravated assaults (106').

Other studies have suggested that the risk of serious attack from
spouses; family members, friends, or acquaintances is almost twice as
great as it is from strangers. Moreover, injuries inflicted by family
members or acquaintances are likely to be more severe than those in-
flicted by strangers. A study of 52 psychotic murderers who had been
admitted to a State hospital gave particular attention to men who
had killed their wives. Factors believed to be of importance in deter-
mining the homicidal potential of the marital setting (107’) included
repeated threatening use of weapons, alcoholism, expressions of jeal-
ousy, and ideas of infidelity and persecution.

The Institute’s Hospital Improvement Program has been used to
enhance therapeutic and rehabilitative programs in 10 maximum
security hospitals serving mentally disordered offenders. While such
facilities do not deal exclusively, nor even largely, with persons
charged or convicted of criminal homicides, many such persons and
those found not guilty by reason of insanity are housed in such institu-
tions. For example, in one security hospital, almost 20 percent of the
population have been charged with criminal homicides and another 17
percent with serious assaults (108).

46

Awards for improving in-service training facilities for the staff of
maximum security hospitals also have been made by NIMH. Such
awards are of critical importance to these institutions because of the
general paucity of funds and the inadequacy of facilities and staff.

Training People T 0 Cope With Delinquency

Because delinquency is one of the common problems encountered
by mental health personnel working in the crowded neighborhoods
of the urban poor, many of the training programs described in a later
section can be considered in part as programs to improve our ability
to prevent delinquency and to treat delinquents. The Institute also
supports programs aimed directly at that goal.

The Institute for the Study of Crime and Delinquency is training
professional personnel, administrators, graduate students, and others
in a recently developed method for diagnosing and treating delinquents
according to their personality characteristics. This is the so-called
Differential Treatment Model, developed with NIMH support, and its
success has been demonstrated (109). Training methods include
seminars, participation in a treatment program for delinquents, and
individual supervision of diagnostic and treatment activities.

In Minneapolis the University of Minnesota expects to continue
for some years a program to strengthen the juvenile justice system
by improving the teamwork among the agencies and individuals in-
volved—including the police, the courts, and probation personnel——
and showing all of them how to do their own part of the work more
effectively (110); The directors hope to perfect a model training pro-
gram that can be used throughout the country.

Another significant project is a so-called New Careers study, which
represents part of a groWing trend toward involving persons with
social problems in the solution of those problems, and to develop
offenders themselves for work against delinquency and crime. Eighteen
selected offenders were exposed to a training and rehabilitation pro-
gram that placed emphasis on self—understanding and social develop-
ment. Later, upon parole, they were assigned to work with research and
action groups in crime and delinquency prevention programs. The
results are being assessed (86’) .

Through consultation and training services, comprehensive commu-
nity mental health centers are expected to improve considerably a
community’s efforts to handle the problem of delinquency». The Touro
Community Mental Health Center in New Orleans, for example, holds
weekly sessions during which probation officers of the juvenile court
present general or specific problems (11]). The Center’s professional
stafi acquaints them with new developments in the field and provides
psychiatric and social consultation in selected cases. Beyond this, the

47

Center has trained a group of volunteers (from the local chapter of the
National Council of Jewish Women) to perform some of the functions
of probation officers and thus to lighten the court’s overload.

A study dealing with the policeman’s role is discussed later.

Mass Violence

A Historical Perspective

Recent episodes of mass violence in many of our largest cities are
not unrelated to other significant episodes in American history—the
bloody labor riots of the 19th century and even of the 1930’s, the
lynching of Negroes in the South, violent confrontations between immi-
grants and natives and between one group of immigrants and another,
our 19th century involvement in expansionist wars and in a bitter
Civil War, the Boston Tea Party and related incidents, and the Ameri-
can Revolution itself. Violence has indeed been a continuing feature
of American life. As Dr. Martin Luther King said: “Urban riots are a
special form of violence . . . . They are a distorted form of social
protest.”

The Institute is promoting and supporting work to help understand
the roots and dynamics of violence. For example, half a dozen of the
country’s leading behavioral scientists specializing in the problems
raised by urban rioting reported their findings at a 2-day meeting
called by the Institute. These scientists, and a number of other investi-
gators, are supplying important new knowledge to those who have
responsibility for launching meaningful prevention and control
programs.

Rioting: Causes and Phases

One Institute investigator gathered data in six cities before and
during violent episodes and found that disturbances broke out where
a high Negro grievance level had been ignited by a precipitating in-
cident and inflamed by rumors (112). The most frequent complaint
of the Negroes was that local officials were doing too little about inte-
gration. Though white residents often thought outside agitators had
been responsible for the riot, the vast majority of Negroes thought
otherwise.

People in the black ghettos, the investigator reports, believe that
white people try to exploit black people. They feel that only under the
strongest pressure have whites been willing to take steps to enlarge
opportunities for blacks. In the minds of the black population, whites
sanction what the ghetto sees as constant harassment by the police.
Since the belief system plus the accumulative sense of grievance tends

48

to give rise to the question, “How long will you continue to take this?”,
the precipitating incident has the characteristic of a “last straw.”

This investigator likens the recent civil disturbances to the antidraft
riots at the time of the Civil War, when rich people could buy their
way out of the draft but the poor had to serve. “This,” he points out,
“represented'a failure of the application of the egalitarian values of
our country in a fair and just manner . . . . Today, riots in the urban
ghettos are similarly associated with a strong feeling of grievance on
the part of the members of the black community who feel that the
white community has excluded them from the opportunity structure
characteristic of our egalitarian values. Those who say that ‘rioting
does not pay’ fail to take into consideration the fact that the antidraft
riots of 100 years ago and the current riots have both resulted in signif-
icant changes in the administrative and legal systems to correct the
imbalance in the value system.”

The ghetto dwellers, then, had experienced both a “hostile belief sys-

tem” (that whites want to exploit blacks) and a “severe conflict of
values” (that egalitarian values lead to opportunities for all except
blacks). The investigator believes that these two social conditions,
plus a “failure of communication” and a “failure of social control”
generally precede the outbreak of a riot.
, The failure of communication between the aggrieved group and
those in power can be seen in the case of the Civil War antidraft riots
when the dominant political leaders tended to think they were dealing
with “merely irrational troublemakers.” Says the investigator: “To
state the matter in a current idiom, it was not until after the violence
broke out that the leaders ‘got the message’. Similarly today,” he con-
tinues, “there are those who view the ghetto riots as the acts of
troublemakers or as due to the prominent display of violent leaders in
the newpapers and on television. Such people overlook the fact that
a movement finds its leaders and that in the 1850’s during the anti-
Catholiic riots as well as in the 1860’s during the antidraft riots . . .
each protest movement found its characteristic leaders without
difficulty.

“The communication failure today is not due to the existence of
the media but to their failure to provide the white community with
information about the unbelievable frustrations, inequalities, and de-
structiveness in the lives of ghetto dwellers.”

“Failure in social control” cannot reasonably be laid at the feet
of the police force, the investigator feels, because police can do noth-
ing to control conditions leading to the rioting. “By the time the mat—
ter has reached the degree of excitation where police control is needed,
it is almost too late to do anything effective. Nevertheless, compari-
sons of police behavior in a number of different cities have shown that
the initial Outbreak becomes escalated when police display over-con—

49

trol or under-control. If the police . . . look the other way and make
no arrests or fail to intervene, riot participators regard this as an
invitation to misbehave.” If the police respond with needless aggres-
sion, the investigator holds, clubbing every black face on the street
and making unnecessary arrests, or—worse—fatally injuring riot
participants, then the process of escalation is speeded up. Admittedly,
the optimum-«a just, reasonable, firm, yet restrained response—is
diflicult to find. Nevertheless, as police gain more experience in the
control of riots, they find it easier to avoid either extreme.

Given the fdur conditions discussed above, the riot starts with a
precipitating incident—perhaps an unnecessarily brutal arrest or a
killing—that brings people into the streets in a state of agitation and
anger. The same study shows that in most instances the process can
be halted at this point if the mayor or his representative immediately
visits the area, talks to the people, and promises some redress, and
this will be most effective if there is a preconceived plan to avert
violence by communication in the early stages of the precipitating
event. V

In most cases the precipitating event is followed by Phase 2 of the
riot process—a confrontation between the mob and the police—during
which the avoidance of over-control or under-control is of the great-
est importance. In many cases the energies of the participants are
exhausted by this confrontation and nothing further happens. How-
ever, there may be a “keynoting” process, during which a militant
leader or the angriest members of the mob may urge more violent ac-
tion while moderate leaders try to persuade the crowd to disband,
promising that their protest will be delivered to city hall.

If the militant keynoters win out, the riot goes into “the Roman
Holiday” phase. The participants, mainly youths, begin to break
windows, setting the stage for looting. They taunt the police merci-
lessly. However, the investigator points out, the same youngsters who
riot one day will put on white hats and armbands and condluct com-
munity patrols on behalf of the police the next day.

If the police respond to Phase 3 with excessive brutality, and if
maddening stories—true or false—about the victims reach the black
community, increasing numbers of adults take part in the looting,
and firebombs and guns are brought into play. The riot is thus
escalated into Phase 4, during which the police, troopers, and the Na—
tional Guard besiege portions of the black community. Then the rioting
process continues until the contending forces become exhausted.

The investigator, a psychiatrist, believes that the social forces re‘
sponsible for mass violence are more important than individual moti-
vations. Persons disposed toward a certain amount of violence may
well enter the riot process, but locating such persons will not prevent
the process from being stimulated. “Rather a more effective approach

50

to the possibility of preventing repetitions of urban violence in sum-
mer after summer is based upon a correction of the underlying social
disequilibrium.”

The very week of the large-scale riot in Detroit in the summer of
1967, the Institute funded an investigation into its basic causes. In
a preliminary report the investigators say (19) :

The events of last July are painfully remembered, still with
some shocked surprise because Detroit did not anticipate its burn-
ing. The surprise to the community arose from incorrect ideas
about what causes riots and inadequate knowledge of the nature
of revolutions and social disorder. The white community looked
away from the long history of inequalities and the many sources
of unrest and injustice and emphasized the recently more favor-
able and relatively advantageous conditions in Detroit over other
lar e cities. Our city was portrayed by whites as a model city,
an it was emphasized that our mayor was resourceful, innovative,
and responsive to black needs. Large federal grants, it was
pointed out, were allotted to the city for urban renewal, ameliora-
tion of poverty and vocational retraining. There were no inescap-
able ghettos as in Harlem and Watts, and Negroes were living in
widely scattered sections of the city, many in brick, solidly built,
attractive homes. Of course, the white community admitted, there
were slums with tenement housing and absentee landlords, but
the Negro in Detroit was upwardly mobile—he was making it as
in no other American city. -

It is clear now, and should have been clear before the riot, that
these positive programs and relatively favorable conditions were
simply not enough to overcome the fact that life in urban centers
is unacceptable to most Negroes. The programs simply masked
such facts as the persistent unemployment rate among young
people (‘29 percent in the 17—24 age group), that most Negroes
feel they are being misused and exploited by whites and that the
conditions of life in our urban centers do not really vary sub-
stantially from city to city in their fundamental quality. It is
clear now as well that the mere fact that many Negroes are up—
wardly mobile is no guarantee against riots. Indeed it maybe this
very upward striving, rising expectation and hope in a context
of continued frustration, discrimination, and exploitation which
leads to outbursts of such activity.

Those arrested during the Detroit riot were found to be a remarkably
homogeneous group. They were young and predominantly single.
Less than half of the Negroes had lived with their natural fathers
continuously for the first 16 years of their lives; more than a fifth
had never lived with their natural fathers. Only three-fourths had
lived continuously with their mothers. The majority had grown up in
the North. The unemployment rate was high when compared to the
national rate, but 82 percent had jobs, and these jobs paid an average
wage of $115 per week. For the most part, though, the jobs were
unskilled and semi—skilled, and one of the major grievances of Negroes
in the sample studied was their inability to advance vocationally at

51

a rate consistent with their expectations. On the average they had
completed only the 10th grade of school, though 39 percent had grad-
uated from high school and many others were still in high school and
may graduate.

Those arrested were “a strikingly unafliliated group belonging to few
organizations, such as churches, political parties, block clubs or civil
rights organizations. Despite the absence of formal or institutionalized
outlets for militancy, many within the group had a strong black
identification and an easily articulated sense of pride in being
Negroes.”

Poverty, apathy, and hopelessness are not applicable terms for this
group, the investigators report, and are not valid explanations for
civil disorder. “Such a statement,” they say, “does not deny the exist-
ence of poverty, unemployment or apathy in urban ghettos or the
great need for federal programs to relieve the very real anguish which
is endemic there. The homes, the possessions, and the mobility of white
people have been visible to the Negro now as never before through
newspapers, television, and repeated encounters, and he aspires to
those standards. These aspirations for the militant middle class can
be pursued through established organizations within the rules of the
political process. One can speculate that the riot has become the mode
of protest for the unaffiliated but increasingly black-conscious and up-
wardly mobile, lower-class black male no longer fearful of expressing
his aggression. The Detroit arrestee was not a committed and dis—
ciplined revolutionary last summer, but he can be considered as a
candidate for ideological black activism unless he is allowed full entry
into our society and parity with his white brother.” The investiga-
tors’ data indicate that in Detroit the events of 1967 “can best be
understood as part of an emerging black identity and self-esteem in a
generation no longer terrorized by the racism of the South and with
goals which do not stop short of full equality now.”

According to one student of the 1967 riots, the concept of relative
deprivation is important (113). Apparently, participation in and at-
titude toward the riots bear little relationship to the absolute economic
and soCial condition of the individuals but correlate closely with the
sense of relative deprivation. Persons who compare their status to
what, in their judgment, it would have been if they were not black,
are angrier than those whose reference is to other Negroes, or to
their condition in a different place or at an earlier time.

Preventing Riots: Some Fundamental Needs

Because of the rising expectations of Negroes in the ghettos, it is
now more important than ever before to provide better opportunities
for those measures—notably education and employment—that help a
person achieve not only self-respect but also responsibility.

52

Behavioral scientists who have been studying riots and their causes
believe that basic programs for dealing with the problems of the
ghettos probably must include rent supplements, increased Federal
aid to education, the Model Cities program, and massive public works
projects. For those Negroes who now barely manage to keep going,
one principal answer may be guaranteed jobs—guaranteed either by
industry or by government.

The highest priority problem probably is unemployment. The un-
employment rate among some high school graduates is approximately
20 percent, almost as high as the urban rate at the depth of the depres-
sion—and that rate was considered a social catastrophe. Also of great
importance are poor neighborhood conditions and discriminatory prac-
tices. In one city, Negro youths who had gone to the same high school
as white youths, taken the same courses in auto mechanics, and got
the same kind of jobs, were paid from $10 to $15 a week less at the
start and for at least a number of years afterward.

High on the list of goals, too, is the correction of offensive practices
by the police and other social control agents, such as the schools and
the welfare system. In the ghetto, what has been variously called a
sense of restraint, a sense of community, or a moral consensus is very
weak. Some of the tactics the police pursue—field interrogation, for
instance, and stop-and-search maneuvers—undermine that already
weak sense of restraint. One interesting statistic shows that for every
crime committed in the Negro ghetto of a major city (Los Angeles),
twice as many persons are arrested as for every crime committed in
the white communities. This suggests a basic difference in police atti-
tudes toward Negroes and whites. And the numerous arrests—many,
presumably, unjustified—interfere with employability and can have
a devastating psychological effect. Nevertheless, the police in some
cases are simply the scapegoats for inadequacies elsewhere. If the social
control system is adequate with respect to education, jobs, welfare,
and so on, the police clearly have a less difficult job.

Where More Information Is Needed

Although we already know a great deal about the causes of civil dis-
orders and should act on this knowledge, further research is needed
to provide new insights for successfully dealing with the problem of
mass violence in both the immediate and the long-range future. One
need is for detailed information about a greater number of riots.
Study of a representative sample should lead to better information
than is now available on a number of important factors, including
these:

_ 0 The number and characteristics of those participating in a
riot—age, sex, and so on. Something is already known about some
of these pomts, but more information would be helpful. For

53

example, is there anything about those who are most destruc-
tive—the snipers, the arsonists, the looters—that sets them apart
from the rest? In one city, at least, the snipers seem not to have
been militants but marginal people—“survwalists”.

0 The background of disturbances—not the precipitating inci-
dents so much as the earlier relationship between the Negro com-
munity and the authorities.

0 ,How the political situation affects the activities of the mayor
and his administration.

0 The responsiveness of city governments to Negro interest
groups before, during, and after riotous activity.

Related subjects on which more information is needed includes:

0 The handling and prevention of riots. There have been a
number of disturbances that for some reason have not spread. It.
would be tactically useful, though perhaps of little help over the
long run, to learn more about how a potential riot is defused.

0 The effectiveness of human relations commissions, review
boards, and similar organizations. Have they made any dif-
ference? What can be expected of them? What is the effect of
public information programs to promote tolerance and increase
the willingness of unions and employers to open the door to
Negroes?

0 Methods of communicatin with the militants and the
Negroes at the bottom of the socmeconomic scale.

Of greater importance in the long run than study of the specific
matters. so far listed, very probably, is research into social change,
which bears upon urban problems in general as well as upon race
relations in particular.

Other Research—Under Way or Planned

The participation of gang youth both in the Civil Rights movement
and. in the riots of the summer of 1964 is being assessed in eight cities.
Not all of the cities have had riots, but all have large numbers of
adolescents who are members of minority groups, are economically
and socially deprived, feel alienated from the main and legitimate
streams of community life, and are potentially explosive. The investi-
gator found in an earlier study that much of their aggressive activity
was directed against other gangs, frequently of the same background
(114). Now, he hopes to discover whether or not the Civil Rights
movement offered any “healthy opportunity for protest” to these young
people and whether or not the riots offered opportunities so congenial
to the behavior and values of gang youth that the youngsters took an
important part in the rioting. Moreover, the investigator will look at
various social work programs to learn how they did or did not con-
tribute to the participation of urban youth either in the Civil Rights
movement or in the riots, or both.

A grant for one of the most comprehensive research projects in v

54

this field is pending. Under the proposal, the investigator would ana-
lyze the police records of individuals arrested in racial disorders
occurring throughout the country from 1964 through 1967 (115).
From these records he intends to develop a profile of the riot par-
ticipant in terms of such characteristics as age, sex, race, birthplace,
previous arrest record, formal offense, and employment history. By
comparing this profile with that of the residents of Negro ghettos
based upon census data, he hopes to determine which segments of the
Negro community are over- and under—represented in motel/Further-
more, by analyzing the arrest sheets from cities located in different
regions and subjected to rioting in different years and of different
magnitude, he intends to discover whether riot participation has
changed over the past 4 years, whether it differs from city to city or
from region to region, and whether it varies according to the intensity
and duration of the riots.

Riots, another investigator hypothesizes, are simply an intensifica-
tion of previous social disorders within certain areas of the city and
an intensification of behavior previously demonstrated by the indi-
viduals who take part in the riots. He hopes to verify this hypothesis
in one city and to compare his findings with data from other cities
where riots have occurred (115 ). Among the subjects to be considered
are the frustrations and grievances of the rioters and the goals and
responsiveness of government. The outcome, it is hoped, will encourage
a new dialogue between the white and Negro communities and suggest
solutions to problems that led up to the riots.

The August 1965 riot in the Watts area of Los Angeles will be ana-
lyzed in an attempt to develop general principles for explaining riot
behavior from the beginning of the disturbance to the end (116‘) . The
results would be checked against information about a number of com—
parable riots. Watts is also the scene of a study of the relationship
between work alienation on the one hand and racial hostility and social
violence on the other. Alienation is defined as a feeling of powerless-
ness, meaninglessness, normlessness, isolation, and self—estrangement.
The study is concerned with both the sources and consequences of
alienation in work (117) .

The relationship between the community power structure and the
civil rights movement at the community level is being studied to in
crease our understanding of community conflict and social change
(118). Questions being dealt with include these: Are conflicts initiated
from within or without? Can the intensity, duration, and tactics of
conflicts be plotted? How do demographic factors affect the develop-
ment of conflicts? And, how may the differing types of power structure
affect the problems? 7

An analysis of the operations of all organizations playing an im-
portant role in large-scale community crises is pending (119). The

55

research would be carried out primarily by field teams dispatched to
the sites of civil disturbances or other crises.

Because the communication gap between whites and blacks often
makes it exceedingly difficult for white interviewers to get reliable
responses on social and political issues, another project is exploring
how traditional and new research techniques can be most eifectively
adapted to the problems of research in community violence (120). At
the Institute’s request, another investigator is conducting several work-
shops to consider such questions as how to employ Negroes who live
in the ghetto as research personnel, how to overcome the insecurity
such people are likely to have because they are working for the white
establishment, what level of education and talent such persons should
have to qualify as trainees, and how to overcome the tendency of per-
sons with a given orientation—toward militancy, for example—to
elicit data that conforms only to their own notions (121 ). The work-
shops are for persons who are or could become seriously involved in
field research on community violence.

The National Advisory Commission on Civil Disorders saw White
racism as a pervasive phenomenon of American society. To get facts
about racism, white and black, NIMH supports some 20 studies dealing
with minority groups and interracial relations. A number of these were
mentioned earlier, in the section dealing with prejudice.

One new project aims to measure interracial prejudice in one com-
munity as a function of age and race, and of the interaction of age
and race, among whites and Negroes of various ages. The investigator
also aims to determine to what degree and in what manner interracial
prejudice within different age and racial groups is affected by the
phenomenon of periodic racial violence, and to measure the trends
in racial prejudice within this community over a 3—year period (122) .

Another investigator seeks to learn if Negro males have developed
distinctive concepts of manhood, as seems likely in many cases, and if
they have, to learn how these concepts afi'ect behavior on the job, in
the family, at leisure, and in community relations (42). New Negro
groups and leaders, including prominent extremist bodies and those
most alienated from American loyalties—for example, the Black Mus-
lims-—are the subjects of another project.

In some integrated neighborhoods, whites and blacks apparently
get along well; in others, they obviously do not. As noted earlier, the
Institute—trying to learn more about the factors promoting vio-
lence—supports a national survey of persons living in privately owned
dwelling units in such neighborhoods (6'0) . Also underway are a num-
ber of other basic research projects intended to add to our knowledge
of why people get along, or fail to get along, with one another and
of how hostile attitudes and behavior toward a group may be changed
by social influences (124).

56

All the projects noted above are responses to the need to understand
the causes and development of the serious civil disorders of the past
several years. Although the riots themselves may appear to be our
primary domestic difficulty, social scientists generally agree that they
are merely symptoms of deeply rooted social problems. In order to
understand the riots, we must understand the conditions which nurture
and foster them.

Helping To Make Better Policemen

As indicated previously, the role of the policeman in all types of
crime, delinquency, and mass Violence is often crucial. Some of our
urban riots have been precipitated by incidents involving policemen;
others have been prolonged or become unduly violent, partly because
of methods used by the police; in still other cases, activities by the
police and other civic agencies have averted a riot or effectively cooled
it during an early stage. In a policeman’s ordinary, day-to-day activ-
ities there is also evidence he may change for better or worse the
attitude of the individual ghetto resident not only toward authority
but also toward white people in general.

Eiforts to improve a policeman’s ability to handle himself effectively
in an urban civilization, complicated by racial as well as a host of other
problems, are being made by local, State, and Federal agencies that
have no direct association with NIMII but often call on it for consulta-
tion on problems ranging from how to treat a certain delinquent
youngster to how to avert mass violence. In some cities, programs
financed by the Institute offer not only consultation but also training
in understanding individual and group behavior. Further, the Insti-
tute supports research—looking at the way the police themselves View
their ability to cope with the variety of social problems facing them
daily—which may have important implications for shaping the train-
ing and practice of police forces (123). This work is being ccmducted
by The International Association of Chiefs of Police, Inc.

Police training, one of the investigators points out, must have a large
legal and practical “how to do it” core. Though the trainers are often
well versed in the sociological and psychological implications of police
work, they find that sometimes a man cannot use these implications
quickly enough to handle a sudden everyday problem. Often he has
to rely on his concept of his role. In these confusing timeSphow does
the new policeman form his concept of himself as a policeman? How
does his family feel about him in this role? His neighbors? Does the
policeman experience conflict between his work and the various other
functions of his life-as parent, spouse, churchgoer, etc? Do sons of
policemen who become policemen themselves difl'er frOm new police-
men Who have no relatives on the force?

57

335—1‘19—69—6

After years of observation, the investigators have noted that many
young men experience an undesirable change of attitude within their
first few months on the force. It is suggested that police work “does
something” to a young man that eventually results in the deterioration
of his psychological and social relationships with the public. Expo- '
sure to depravity, irresponsibility, resistance to authority, danger, and
especially to the ever-present threat of violence to the officer himself
brings an elevated level of anxiety and a rise in defensive behavior.
The “old timer,” often disillusioned, embittered, and in many ways
overwhelmed, also may have a powerful effect on younger men; a new
man is often asked to take an assignment with an older man who is
more experienced but perhaps less acquainted with some of the newer
concepts of police work.

The investigators hypothesize that new officers will develop self-
pity and some boredom with patrol work. Resentment will build up
gradually as things go wrong. Lack of community and political sup-
port, the investigators feel, seriously afl‘ects policemen. Some police-
men, they believe, are prone to see enforcement techniques as ends
rather than means. Some will abuse their authority out of personality
needs. Some, as time goes by, will become cynical. The patrolman on
the beat may come into conflict with his superiors. There is bitter and
Widespread resentment over recent court decisions because it is felt
that these decisions place policemen in greater jeopardy.

The investigators believe that most policemen are more adept at
dealing with situations for which the procedures are clearly and
rigidly defined. Still, rigid organizational structures may well dis-
courage innovation in the recruit.

Among other questions being considered: Whom does the police—
man emulate? Who are his role models? How can the conflict of low
pay—often solved by moonlighting even though this may be forbid-
den—be resolved? What is the importance of physical stamina, cour-
age, and the ability to tolerate a high degree of personal danger?
How important is it to be able to understand human behavior and to
influence people without the use of force? The study’s major premise
is: Police training and police work change a man, but how, and what
are the implications for training?

Drug Abuse

Drugs as an Urban Problem

“Practically every citizen is afl'ected by drug addiction in this city.
Not a single neighborhood is entirely devoid of addiction, although
the incidence may vary.” This statement by a New York City official

58

exemplifies the findings of various commissions, including the 1967
Task Force on Narcotics and Drug Abuse of the President’s Commis-
sion on Law Enforcement and the Administration of Justice and the
1965 DC. Crime Commission. Drug abuse is a fixture in the Nation’s
largest cities. Urbanites are involved generally in this “medical-social
epidemic” because they know addicts, have relatives who become ad-
dicts, or have seen and felt the effects of their use.

According to the US. Bureau of Narcotics, there were 62,045 active
narcotic addicts as of December 31, 1967. More than one-half of the
known addicts were in New York. Most of the others were in Califor-
nia, Illinois, Michigan, New Jersey, Maryland, Pennsylvania, Texas,
and the District of Columbia. In all these areas, addiction is an urban
problem. Ten cities—New York, Chicago, Los Angeles, Detroit, Wash-
ington, Philadelphia, Baltimore, Newark, San Diego, and Buflalo—
accounted for more than 75 percent of the addicts reported. Almost 98
percent of the addicts admitted in 1966 to the Lexington and Fort
lVorth Public Health Service Hospitals were urban residents.

Apparently, more people use marihuana than opiates, but adequate
studies on this point are lacking. Scattered reports indicate that
marihuana is used frequently in depressed urban areas and that its use
there is increasing.

The cost of crimes committed by drug abusers has been estimated
at more than $500 million a year. Though the exact connection be-
tween drug use and cirminal activity has not been established, it is
known that many heroin addicts engage in stealing, prostitution, and
other, generally nonviolent, criminal activities simply to raise money
for their drug.

Police records show that admitted users of heroin who were ar-
rested in New York City in 1965 had been spending almost $15 per
day for their drug. The Task Force on Narcotics and Drug Abuse
points out that while the price of heroin fluctuates, it is never low
enough to permit the typical addict to obtain it with his own money.
So he turns to crime, most commonly to the theft of property. During
a recent 10—year period, an average of 8 percent of all persons com-
mitted to Federal penal institutions had an admitted history of using
drugs, mostly heroin. In New York City, though, surveys of people
under the jurisdiction of the Department of Corrections in 1966—
about 10,000 at any given time—found that almost 40 percent admit-

ted they had used drugs.
. In reports on drug use and crime, the drug is usually heroin. As
for marihuana, views differ. One holds that this drug is a major
cause of crime and of violence; another, that it has no association with
crime and only a marginal one with violence. The Institute, seeking
to clarify these and other important issues, is making a special effort
to expand its program of research on marhuana and marihuana users.

59
335—119—69—6

The President’s Commission on Law Enforcement and Justice was
unable to reach a definite conclusion about the causal connection be-
tween drug use and crime. If drug abuse is eliminated, says the Com-
mission’s Task Force on Narcotics and Drug Abuse, crime reduction
is one result to be hoped for. However, eliminating drug abuse and
treating its victims “are humane and worthy social objectives in
themselves.”

NARA: The Institute Directs a Vast New Treatment
Program

NIMH has the major responsibility for implementing a program to
reduce radically the suffering, disability, crime, social disruption, and
death resulting from narcotic abuse. The Narcotic Addict Rehabilita-
tion Act (NARA) of 1966 stands as the declaration of a new national
policy regarding narcotic addiction. By its passage, Congress author-
ized a comprehensive, medically and community oriented approach
to the treatment and rehabilitation of narcotic addicts—total treat-
ment rather than fragmented efl’orts. NARA provides for the civil
commitment of narcotic addicts, including those charged with or con-
victed of violating Federal criminal laws. Institutional treatment
must be geared toward the supervised return of the patient to the
community. For the first time, provision is made for professionally
supervised aftercare for addicts in their own communities after dis-
charge from inpatient treatment.

Addicts may be committed to treatment under titles I, II, and III
of the act.

Title authorizes civil commitment in lieu of prosecution.

Under title II, an addict convicted of violating a Federal law may
be examined and committed to treatment not to exceed 10 years. Title
II is administered by the Attorney General’s Office. Patients commit-
ted under this title will be treated in special facilities developed by
the Bureau of Prisons.

Title III permits addicts to request commitment to treatment at
Forth Worth or Lexington if State or other treatment facilities are
not available.

During NARA’s first 14 months of operation, ending in August
1968, approximately 575 addicts had been committed for examination
and evaluation, almost all of them at their own or their family’s re-
quest; about 250 of these were committed to treatment. Under the old
system, many of the treated addicts would have been sent to jail with
little hope of receiving rehabilitative services.

Research coordinated or supported by the Institute has shown that
professionally supervised aftercare is essential if the high rate of
recidivism is to be reduced. A 5-year demonstration project, for

60

example, tested the hypothesis that the problems of the addicted
person might be solved, once he had been discharged from Lexington
or some other hospital treating addiction, if only all the resources of
the community could be brought to bear on them (125). The project
aimed to assist community agencies in the extension of a range of
services to narcotic addicts. Selected patients returning to New York
from Lexington were advised to go to the project office if they needed
help. A social worker would listen to an individual’s problems and
then enlist the services of any community group—such as the city
welfare department, the State employ'ment service, and counseling
agencies—that could help solve these problems. It was a frustrating
and educational experience. The addicts were neat, undemanding,
not too difficult to deal with. Most of them seemed genuinely eager
for help in overcoming their addiction, and said they wanted jobs.
But they were also hypersensitive and suspicious. They wanted their
\problems solved in a hurry, and most of them could not admit that
they had any problems except the immediate ones. They seemed puzzled
over what to do with freedom, yet often they could not bring them-
selves to keep appointments whether with the project office itself or
with cooperating agencies. Many of the addicts were placed in jobs,
but most of the j ob-holders soon began using drugs again and left.

On the other hand, a number of the patients did work out better
ways of dealing with strains in their family and social relationships
and stayed away from drugs longer than ever before, and those under
probation or parole tended to do better than the others. This lesson
emerged clearly: For the addicted person coming out of the hospital,
and his family, a guidance center was not enough. He must also have
some resources—an agency or an individual—to provide constant step-
by-step support of his efforts.

Backing up this finding is evidence from several parole boards indi-
cating that intensive parole supervision by specially trained officers
substantially improves the abstinence rate and general adjustment
of former heroin addicts. These programs showed better results than
those observed in routine parole management of postaddicts (196‘).

Under the new program, NARA, aftercare treatment and rehabili-
tation services will be provided in the addict’s community through
contracts with State or local agencies, private organizations, or indi-
viduals. NIMH professional personnel are being assigned to oflices in
the metropolitan areas having the largest addict populations. They
will develop contracts, evaluate the performance of contractors, in-
terpret the program to community groups, and stimulate and aid
communities in correcting deficiencies in services. Contracts will pro-
vide for a flexible treatment program adapted to the needs of the
individual addict. The primary aftercare services required are those

61

which relieve family dysfunction, stabilize financial status, and
develop the patient’s ability to earn a living and cope with the stresses
of daily life. Under the contracts, the recommendations of the hospital
staff will be carried out and the patient helped to develop personal,
social, and vocational competence.

By the early fall of 1968, the first of such aftercare centers had
been established in 25 cities, and about 70 addicts discharged from
Lexington and Fort Worth under the NARA program had been
enrolled in them.

To help implement NARA, the Lexington and Fort Worth Public
Health Service hOSpitals have been redesignated as NIMH Clinical
Research Centers. They will provide new knowledge and new methods
of intervention, treatment, and rehabilitation in the field of drug
abuse, drug dependence, and personality disorders, and will serve
as model treatment, training, and demonstration centers. Plans include
provision for the admission of persons using nonnarcotic drugs.
Eventually patients will be admitted only for specific research projects
in the field of drug dependency and drug abuse. The fundamental
issue of the connection between drug dependency and personality dis-
order will be emphasized.

In addition to the aftercare centers, the Institute is authorized to
develop a network of more comprehensive facilities—community cen-
' ters where patients can receive not only aftercare services but also
complete treatment close to their homes. Community mental health
centers are expected, often, to have an important role in this part of
the program.

A model comprehensive NARA program should provide:

0 Care for approximately 400 narcotic addicts per year

0 A 10—12 bed inpatient unit to be used for withdrawal

0 Residential treatment or partial hospitalization services such
as day care or halfway house

0 Outpatient treatment and followup services—including re-
habilitative, vocational, and educational programs—for addicts
and their families

0 An evaluation and epidemiologic unit to study the extent
and characteristics of the community’s addiction problem

0 Selected ex-addicts on the staff and community advisory
boards
During fiscal year 1968, six of these community-based treatment
programs for narcotic addiction—in New York City, Chicago, Phila-
delphia, St. Louis, Albuquerque, and New Haven—were awarded
matching Federal funds (127). Five of the grantees are community
mental health centers based on medical schools. Project grants totaling
$501,000 were also awarded to support training, demonstration, and ‘
experimental treatment programs in New York City and Boston.

62

Applicants for NIMH funds are encouraged to try both new and
established techniques of treatment. Most of the first six programs
plan to test a variety of treatment modalities, including modifications
of the therapeutic community idea, narcotic blocking agents, metha-
done maintenance, and psychotherapy, all combined with rehabilita-
tion services. They plan to compare the cost of a given treatment ap-
proach, in time and money, to its outcome and to the cost and outcome
of other approaches. They will attempt also to learn which modality
is most effective for which types of patients.

Guidelines require each program to develop an advisory board that
will tie the program to the community through representatives of
the community served and that will help coordinate the efforts of
the treatment center with those of the local health, welfare, enforce-
ment, vocational training, community action, and urban renewal pro-
grams. The use of selected ex-addicts as rehabilitation team members
having significant program responsibilities is encouraged. EX-addicts
accounted for 51 percent of the total staff positions requested by the
six applications approved in 1968. '

Guidelines also require each program to develop an epidemiologic
and evaluation unit. In addition to evaluating the outcome of various
treatments, these units are to develop methods for evaluating the pro-
gram’s impact on the prevalence of addiction. Thus, they will lead to
a comparison of the effectiveness of various treatment methods and
to a better understanding of the forces leading to addiction. They
promise in the end, then, to provide more effective preventive and
rehabilitative techniques. They will also participate with NIMH in
developing a national monitoring and data collection system.

It should be emphasized that in helping to finance and guide the
new centers, NIMH is not interested only in making available more \‘
treatment services. It hopes also to involve some of our major uni-
versity medical centers and other resources in the task of developing
programs so structured that the narcotic addict subculture itself is
the end target. In addition to offering humane treatment for addiction,
the programs are seen as potential agents of social stability and the
nonpunitive social control of a deviant subculture that has become a
major cause of disruption and crime in our cities.

In New York, one of the first cities to come under the new compre-
hensive program, facilities include a day—care unit to handle 30—50
patients in therapeutic groups, three residential facilities for 100
patients each, and hospitalization facilities. A variety of prevention
programs are included in the center’s work. Trained eX-addicts en-
courage drug-takers to engage in treatment (127).

The area served by the Philadelphia center contains about one-third
of that city’s addicts. The program includes inpatient services for 10
addicts, an outpatient clinic for patients and families, separate facili-

63

ties for patients receiving narcotic-blocking medicine and methadone
maintenance on an experimental basis, a halfway house for 10 ex-
addicts, an epidemiology and evaluation unit, and preventive education
(128). .

A NARA center in Albuquerque, N. Mex., which has three store-
front units for intake and aftercare, is an integral part of a Community
Mental Health Center. Twenty selected patients are sent to Daytop
Village, Inc., in New York to be treated and to learn techniques of
group interaction. They return to staff positions and provide residen-
tial treatment (129) .

Daytop (Drug Addicts Treated on Probation) Village, incidentally,
now under the auspices of the Staten Island Community Mental
Health Center, has grown from Daytop Lodge, which was made possi—
ble by an NIMH grant. The program features intense group inter-
actions. An addict gains increasing responsibility and independence
as he shows improvement in behavior and attitudes. Addicts showing
high morale may become important members of the staff (130).

Other Treatment and Prevention Projects

For some years a day-night nonresidential center for addicted per-
sons has operated in New York City. It has offered patients, mainly
heroin addicts, a range of services including counseling, group therapy,
and referral to other community agencies. At the same time, it has
conducted research and educational programs (13]). This project has
now become a Regional Center for Studies in Substance Use with a
comprehensive approach to all aspects of drug use. It will foster
application of present knowledge to the treatment of addicts, assist
other areas and communities in planning for treatment and prevention
programs, and conduct training and research programs. The Center’s
research will be concerned mainly with narcotics and marihuana (132) .

A pilot therapeutic project to meet the needs of teenagers has been
undertaken with the help of another Institute grant. A special “com-
munity” will serve as a place for leisure-time activity as well as
therapy. Youth will be “members,” not “patients” (133). In another
project, a Staten Island residential rehabilitation center for addicts
has gotten in touch with more than 400 addicts in Greenwich Village,
and 20 pre-addicts—young people who have experimented with drugs
but are not yet addicted (J34) . The contacts have been made by volun-
teers, many of them ex—addicts, from Daytop Village. The objective
was to encourage addicts to join a 4- to 8-week orientation course pre-
paring them for entrance to Daytop. Of the 400 addicts contacted,
about 60 expressed interest in the orientation program, a dozen entered
Daytop, and the others in this group of 60 were considered likely
prospects for admission. Another objective was to motivate pre-

64

addicts to stop experimenting with drugs. Young persons who wanted
to give up drugs were invited to a series of weekly meetings. After
five consecutive meetings, if they had stopped using drugs, they were
allowed to attend advanced meetings held twice weekly. Here group
therapy was conducted by former or current drug users. The project
was organized by three young former drug users who became inter-
ested in establishing a prevention program while in group therapy.

For Better Information on the Drug Problem

One great obvious need is accurate and comprehensive data about
the demography of drug abuse on a national scale. Besides defining the
dimensions of the problem, a national case registry of narcotic and
nonnarcotic drug abusers would serve as the basis for longitudinal
studies of the natural history of drug abuse. Built from information
supplied by medical, social, and law enforcement agencies, it could
provide the first accurate body of data for comparing treatment
methods and planning new service programs and research into, for
example, the public health implications of marihuana use.

The Institute now supports a registry of narcotic abusers in New
York City and a State-wide register of drug abusers in Maryland
(135, 136’) . At present, h0wever, it does not have the necessary assur-
ance that names reported to a national registry would be confidential.
If appropriate legal safeguards can be guaranteed, the skills and ex-
perience gained in current programs could be turned to the develop-
ment of a national system.

The establishment of the New York register appears to have in-
creased the efficiency of many agencies and private physicians in re-
porting new cases. In 1965, new reports were 16 percent higher than in
1964; in 1966, they were 28 percent higher than in 1965. These in-
creases have been attributed to more widespread reporting rather than
increases in the incidence of addiction. Under-reporting in specific
areas is being detected and studied. A study of a sample of addict pa-
tients reported in June 1967 by private physicians revealed that only
four doctors were responsible for reporting 67 percent of the cases.
Reports by police correction agencies have still proved most eflicient.
More than 85 percent of the cases reported have been of heroin users.

Making use of the second registry, in Maryland, a study is con-
cerned not only with facts about the actual number of addicts and the
forms of addiction, but also with the characteristics of addicts. It is
partiq'ularly interested in learning which came first: drug abuse or
antisocial behavior.

Several other demographic studies, necessarily rather small in
scale, have been funded by the Institute. In one, concerned with the
college-student user of drugs, questionnaires were mailed to students

65

of five New York City universities late in 1967 and early in 1968. Of
students responding, 6.3 percent admitted to drug use as an under-
graduate. The general impression gained from the replies was that
such use was experimental and did not lead to addiction (137’).
Another college study in Pittsburgh is addressing itself to the ques-
tion of which types of students use which substance, under what con-
ditions, and. with what effects. Measurements of the information and
misinformation which students possess will also be included (138).

In a St. Louis study of marihuana users, no regular heroin user in
the population had escaped ofiicial attention. When marihuana use was
not followed by heroin addiction, though, the user rarely became
known to police. The study found that the younger the individual
when he began to use marihuana, the more likely he was to go on to
heroin addiction. Socioeconomic patterns, the presence or absence of
the father, school behavior—none had any relationship to drug use.
However, the marihuana user who dropped out of high school, or for
whom delinquent trends were predicted, was more likely than other
youngsters to move to the use of heroin (139) .

A study of 119 Puerto Rican addicts treated at the hospital in
Lexington finds that narcotic addicts are self-made, not seduced into
addiction by crafty drug-pushers. For these addicts, heroin use began
in the streets while the subjects were still teenagers, and opiate addic-
tion was commonly preceded by marihuana smoking. The incipient
addict willingly sought to join the addict group and learn the tech-
niques and norms of the drug subculture (I40).

Factors associated with onset of marihuana and opiate use among
Puerto Rican addicts have not changed during the past 40 years, the
researcher noted. More than 90 percent of the 119 subjects reported
that they had smoked marihuana, beginning about the age of 17, be-
fore using heroin. The same group of boys sometimes introduced the
subjects to both heroin and marihuana. Four-fifths of the boys said
addict friends initiated them to opiate drug use. Of the 107 male
addicts studied, nearly two-thirds had started *use of opiates by 19.
The youngest opiate user was 12 years old. In most cases, addiction
occurred 3 months after the first use. _

Delinquency and drug use were found in this study to be closely re-
lated. Only 7 percent of the male subjects had not been arrested.
Almost a fourth had had one or more arrests prior to or concomitant
with using opiates for the first time. Close to 70 percent of the boys
were first arrested after beginning to use opiates.

The investigator noted that part of the onset of heroin use among
the Puerto Ricans of the study is strikingly similar to the onset of
juvenile delinquency in metropolitan areas of the United States. In
both instances deviant peer—group associations constitute the domi-
nant influences. In both instances, members of such groups are per—

66

ceived as friends. But whereas the juvenile delinquent often drifts
out of his gang to work and raise a family, the addict becomes en-
meshed in the drug addict culture, where “hustling” and arrests are
common and in which steady employment and normal family life are
impossible.

Research Programs

Some people appear impelled toward narcotic dependence early in
their lives. Many psychiatrists believe that these are severely dis-
turbed individuals with deep—rooted personality disorders existing
prior to their involvement with drugs. These individuals have failed
to develop mature personalities; they lack the normal drives and moti-
vations which impel others toward marriage and family living, con-
structive employment, and responsible citizenship. They are typically
passive, dependent, irresponsible, lacking in perseverance and self-
discipline. This view of the addict may lead to treatment modes seek-
ing to support the “wea ” individual and to modify his environment in
ways that will enable him to develop better coping mechanisms as
alternatives to drug abuse.

However, the relation between personality disorders and all forms
of socially deviant behavior presents a major research challenge.
Little is known about the dynamics of faulty personality development
or the mechanisms underlying specific symptomatic manifestations of
personality disorders. The insights gained from the study of manifes-
tations of personality disorders will lead to a better understanding of
the mechanisms that produce such socially deviant behavior as drug
abuse. Research by NIMH grantees and at the Clinical Research
Centers in Lexington and Fort Worth will increasingly focus on the
potential addict and the discharged patient rather than on the physical
and psychological symptoms of addiction per 86.

But work on these aspects of addiction will continue. Scientists at
Lexington now are developing and testing “narcotic antagonists,” so
called because they block the eifects of heroin and assist in the rehabili-
tation of addicts, which is especially difficult because even after a
person drops heroin, the drug continues to have certain effects on his
body, some of which may last up to half a year and may make him turn
again to narcotics. The new medicines seem to ensure that if the
patient returns to the use of heroin, he will get no pleasure from it nor
become physically dependent on it. So he is more likely to remain
abstinent.

Other research should lead to the meaningful classification of
addicts, which one NIMH narcotics authority says is the key to under-
standing addiction and developing successful treatment programs.
Since it is recognized that there are differences among addicts and that
there are a number of possible treatment modes, it is imperative to

67

determine which treatment is “right” for a particular addict. Before
that can be done, however, the attitude and character differences among
addicts must be described more clearly than in the past. .

Many, if not most, addicts do stop using drugs at some point in their
lives, this authority notes. In one study, as many as 80 percent of a
group of addicts had stopped using drugs at the time of followup
(141). If it can be determined when and why most addicts are likely
to quit, timely and appropriate intervention may serve to hasten the
process. The likelihood of permanent abstinence from drugs is de-
termined by personality, this investigator believes, and many other
authorities agree.

As noted elsewhere in this chapter, a number of studies are con-
cerned with various aspects of marihuana use. A new basic research
project will examine the effects of this drug on thinking and percep-
tion—a subject on which little systematic work has been done.

Environmental Factors

A number of Institute-funded investigations are concerned with the
effects of environment upon drug use. One, for example, has been
analyzing the psychosocial network of the adolescent user of dangerous
drugs. Youths between 13 and 19 involved in the use of marihuana,
barbiturates, LSD, heroin, or glue-sniffing have been studied, along
with their families and others with whom they had contact. Four drug
users and their families are being studied in depth (1.42) . The hope is
to obtain information useful both for prevention and treatment.

To assess the extent to which an individual’s environment determines
his exposure to marihuana and his use of it, another investigator is
studying 200 identified marihuana users in a large city (143) . A longi-
tudinal study of the careers of drug users in an urban slum seeks to
determine step-by-step how a person becomes a drug user and then
an addict (14.4).

Two investigations in the Haight-Ashbury area of San Francisco
are of particular interest. The first will study and describe the social
and psychological characteristics of a drug-based subculture, including
the backgrounds of individuals. This subculture will be compared to
others on such bases as organization, social structure, patterns of com-
munication and friendship, rituals, and heroes. The effects of various
drugs on different personality patterns will be examined. The project
will be concerned also with the community’s health and welfare needs
(145). The second study will depend in part on the records of the
Haight-Ashbury Medical Clinic to define patterns of drug use and to
evaluate techniques of treatment and prevention (146) .

The hippie subculture will also be studied by an NIMH grantee in
New York State. Adolescent hippie drug users from the suburbs and
adolescent hippie drug users from the city will be compared to

68

adolescent nondrug users. The study will provide information on
which to base preventive programs at YMHA centers (J47 ) .

To shed light on some of the reasons for the high rate of recidivism
, among drug addicts, NIMH has initiated a study to examine the role
that drug procurement and related activity play in sustaining group
life among addicts and in providing a basis for personality integra-
tion in the group. The investigator believes that addicts have difficulty
in sustaining social contacts without activity such as drug procurement
to serve as a promoter of group life (148) .

In the legal area, NIMH is supporting a study of marihuana law
enforcement practices. The investigator has undertaken a review of~
existing knowledge about hallucinogenics and a survey of legal control.
He will explore various types of legal control with the hope of making
recommendations for action to better coordinate the products of scien-
tific research with legal decision-making (14.9).

Prescription Drugs

In its work on drugs, the Institute’s interest extends beyond such
substances as heroin and marihuana to encompass legally sold psycho-
tropic drugs. Questions include the extent to which they are used and
the attitudes and emotional problems of those using them.

As the Institute’s Director told the Senate Subcommittee on J uven-
ile Deliquency in 1968:

. . . in trying to understand scientifically the problem of drug
abuse, one must look beyond the specific problems of such agents
as LSD, marihuana, amphetamines and barbiturates to some of
the underlying causes of widespread drug use and abuse. We live
in a drug-oriented culture. From aspirin to sleeping pills, from
tranquillizers to ‘the pill’, Americans, of all ages, are ingesting
drugs in greater variety and greater numbers than ever before.
I think that if we are to get to the root of this problem of drug
abuse, we must be prepared to investigate and identify the under—
lying problems which lead people to choose to distort or ward off
reality with drugs.

In 1966, the Institute undertook a project concerned with legally
sold psychotropic drugs, primarily the stimulants and depressants
and secondarily the hallucinogenics and some “over-the-counter”
preparations. The study is yielding evidence that many persons feel
guilt about taking pills which free them from customary tensions or
anxiety. The preliminary findings on another question, whether peo-
ple—trying for “kicks” or greater relief—exceed prescribed doses, in-
dicate that people are conservative: they tend not to use up an entire
prescription or to avail themselves of all the refills they are entitled
to (150).

The research program encompasses a large number of studies being
made in different parts of the country. In one urban clinic, an analysis

69

is being made of 16,000 psychotropic drug prescriptions written for
12,000 different patients by 40 physicians during a 1—year period. The
doctors are being asked why they order a given drug for a given type
of patient. The patients are being followed to see just what use they
make of the prescriptions (151) .

In another study, a survey crew is visiting homes chosen at random.
Questions delve into each subject’s lifelong experience with drugs and
examines his attitudes on drug use. He is asked about his emotional
problems and ‘how he seeks relief—through drugs, for example, al-
cohol, church going, or other means. So far, most of the people who
have taken drugs have reported them to be tranquilizers. The study
finds an unusually high incidence of depressive symptoms in the sam-
ple of people interviewed, and these symptoms are usually being
treated with barbiturates or tranquilizers. Amphetamines are also
widely used (1552).

Training and Education

Drug abuse problems do not seem to hold great interest for many
scientists and physicians. The Institute is concerned, therefore, with
the training of workers who will apply their skills to the special
problems in this field. Under one NIMH grant, for example, a school
of social work has been giving its students field training by having
them observe and assist a hospital-based treatment program for nar-
cotic abusers (153) . Two psychiatric training grants have emphasized
drug abuse‘problems. One has supported advanced training of psychi-
atric residents in community mental health principles (154) , the other,
basic residency training, including a period of working with narcotic
abusers in inpatient and outpatient settings. (155) .

A social science training grant has provided intensive training in
the sociology of deviant behavior and given instructiOn on recogniz-
ing and helping drug abusers (156‘). Another grant has been used to
help train law enforcement officers to cope effectively and humanely
with mentally ill and socially deviant persons (157’). Mental health
professionals who work with children in a metropolitan area have
been trained in the psychopharmacology of drug abuse (158).

An Institute-supported training project at a medical school helped
nonprofessionals who work with youth become more knowledgeable
about drug abuse (158). The program originated in response to the
complaints of youth workers that the youngsters they worked with
knew more about drug use than they did. Training concentrated on
the pharmacological and psychological aspects of drug abuse so that
‘the workers were better able to counsel the young people. The 200
trainees included school teachers, counselors, social workers, ministers,
juvenile officers, and recreation workers. In addition to these training

70

sessions, the project staff conducted outside workshops on the pharma-
cology of drug abuse. Involved in the workshops were family service
agency staffs, police department administrators, indigenous medical
aides, PTA groups, the clergy, inner-city youth groups involved in
drug abuse, and groups of subprofessionals working with drug-using
youth (158).

At another medical school, NIMH has established an interdiscipli-
nary, community-oriented training program for nurses and social
workers in the treatment of addicts. The trainees, who are assigned both
inpatients and outpatients, will be directly involved in all rehabilita-
tive activities. Graduates of the program, it is expected, will be pre-
pared to initiate and promote rehabilitation programs within com-
munity agencies and to aid in the development of educational
programs (159).

NIMH has begun a series of public education programs. Through a
contract with the National Education Association, information will
be disseminated to teachers on how to deal with and teach about drug
abuse (160). Through another contract, a nationwide information
campaign on drug abuse has recently been launched, including a series
of television and radio spot announcements, printed advertisements,
billboards and posters, and related materials. Messages in the cam-
paign are specifically designed for Spanish-American and Negro
groups as well as for the general public (161) . Planned for the imme-
diate future are a film for ghetto audiences, additional television and
radio spot announcements featuring former addicts and sports celeb-
rities, and conferences for high school students.

71

 

What Is a. City but the People?
—William Shakexpmre

BRINGING MENTAL
HEALTH SERVICES
TO THE COMMUNITY

Introduction

During the past few years, a revolution in mental health care has
quietly been sweeping the country: the program for comprehensive
community mental health centers. This provides for treating the men-
tally ill close to their homes and sometimes even in their homes;
for working with troubled people, directly or through other agencies,
to prevent, relieve, or remove conditions leading to illness or to un-
productive lives; for bringing the principles of mental health to
those people—such as teachers, judges, ministers, employers—most
likely to shape the lives of other people; for training and research.
By March 1968, NIMH had allotted nearly $50 million in staffing
and construction grants to centers in the Nation’s 20 largest metro-
politan areas. By the close of the 1968 fiscal year, centers funded to
serve urban poverty areas numbered more than 50.

Some of those inner-city centers are in a planning or construction
stage. Many others, though completely operational, are also in a
sense in a planning stage—the kind of planning that must constantly
accompany an innovative program whose function is to serve the
community and to anticipate and respond to individual and community
needs.

Another change in the delivery system of mental health services
has occurred in the functions of State hospitals. By means of Hospital
Improvement Program and Hospital Staff Development grants, there
have been major program innovations aimed at bringing community
and State hospitals closer together. Already 15 State hospitals have
become affiliated with community mental health centers—in transfers
of patients, arrangements for aftercare, provision of specialized serv-

73

ices, sharing of records, and other essential functions. In addition, a
new procedure—the unit system—enables a State hospital to focus
on one geographic responsibility. The New York State Hospital sys-
tem has been divided into separate catchment areas, each of which
has five community mental health centers which are affiliated with
that unit of the hospital system. In Arkansas, plans call for each com-
munity mental health center eventually to have a State hospital branch
on the premises to eliminate the administrative difficulties and psycho-
logical hardships produced by geographically separate facilities. These
improvements in State hospital functions increase the feasibility of
continuity of care among mental health facilities and help make State
hospitals part of a community-oriented system.

In addition to encouraging and helping to finance the development
of mental health centers, and to improving existing mental hospitals,
the Institute heavily supports other measures—sometimes in connec-
tion with the centers, sometimes not—t0 meet the mental health needs
of our cities. A number of these, particularly concerned with prevent—
ing and offsetting the eifects of cultural deprivation often suffered by
children of the slums, have been discussed in an earlier chapter. Others,
to be discussed later, emphasize the recruitment, training, and use of
indigenous workers—people who come from the very neighborhoods
most in need of mental health programs—and the development of pro-
grams and techniques that fit the services to the people being served
instead of forcing upon them the techniques and programs developed
for patients who have been in quite different circumstances. The pres-
ent chapter deals largely with the community mental health center and
its role in meeting the mental health needs of urban residents.

In the following material the emphasis will be on presenting a wide
array of the ways in which specific community groups have gone about
organizing their mental health center programs to meet particular
needs and concerns in those communities. No attempt will be made
here to assess the effect of these new programs or to discuss the prob-
lems, the successes, or the failures experienced by the centers.

The Development of Centers

Community mental health centers are organized through partner-
ship arrangements between private and public sectors and among
Federal, State, and local agencies. These sources are cooperating in
the provision of facilities and services as well as in financing.

For example, Rochester Mental Health Center in Rochester, N.Y.
results from a merger of the Rochester Alcoholism Treatment Cen-
ter and the Rochester Child Guidance Clinic with the Rochester Gen-
eral Hospital (16%). The Kansas City General Hospital and Medical
Center and the Greater Kansas City Mental Health Association have
affiliated with the State Division of Mental Diseases (the State mental

74

hospital system) to form the Western Missouri Mental Health Cen-
ter (163). The West Side Community Mental Health Center in San
Francisco has been formed more recently out of an affiliation of nine
social agencies, voluntary associations, and community hospitals (164) .
They have combined in a closely knit consortium to provide a Wide
range of services to some of the high-risk groups in San Francisco,
notably residents of the Haight—Ashbury neighborhood. The Hill-West
Haven Community Mental Health Center is a joint enterprise of the
Department of Mental Health of Connecticut and Yale University
(165). Affiliated with the Center are Connecticut Valley HOSpital,
Yale-New Haven Hospital, Yale Child Study Center, and New Haven
Alcoholism Clinic.

Patterns for financing centers are as diverse as the center programs
themselves. The basic system is a matching arrangement between Fed-
eral grants and State and local funds.

Mental Health Centers: Accessibility

By 1980, when the Institute hopes that 2,000 comprehensive com-
munity mental health centers will be in operation, the greatest imme-
diate problem of people who need mental health services—accessibility
to those services—will be largely met. This problem is especially
serious among the people in our inner cities. Getting help has always
been more difficult for the least sophisticated, yet it is these who need
help most. A community mental health program helps to insure that
those for whom services have not been readily available because of
location and prohibitive cost will have modern, comprehensive facili- '
ties at their disposal.

To make certain that services will be available and relevant to a
particular community, every center has a specific area that it serves,
a catchment area. The number of people in such an area does not
exceed 200,000, and is, on the average, 155,000. When a grant is con-
sidered, special attention is given to the accessibility of the proposed
center to all the residents to be served. Though well located from this
standpoint, many centers are establishing outposts and traveling teams,
for they know that unfamiliarity with most neighborhoods except
one’s own, distrust of agencies and institutions, and apathy combine
to keep many poor people from getting the help they need.

For example, Tufts New England Medical Hospital Community
Mental Health Center is mounting outposts in various sites at the
Columbia Point Housing project in Boston (166'). These outposts will
be manned by professionals and specially trained mental health aides.
The Hahnemann Mental Health Center in Philadelphia sends four
or five teams out to neighborhood service centers (167). In Washing-
ton, D.C., the Area B Mental Health Center maintains an office in a
neighborhood center (168). The comprehensive services provided by

75

the new mental health center of Maimonides Hospital, Brooklyn,
which serves a low-income, predominantly white population, includes
psychiatric “first aid” teams to go into patients’ homes (169). The
Medical Center Complex Community Mental Health Center in Chicago
has opened storefront clinics in Mexican-American and Negro neigh-
borhoods (170). As a demonstration, the Lincoln Hospital Center, in
the South Bronx, whose poverty-stricken population is about 40 per—
cent Negro and 55 percent Puerto Rican, opened storefront counseling
centers next door to bars, pawnshops, and restaurants (171). Such
satellite centers are in busy shopping areas, located Where public trans-
poration lines converge. No appointments are necessary, and there are
no waiting lists. The informal atmosphere, not often found in a social
agency or psychiatric clinic, makes services psychologically accessible
to people who would be “turned off” by stifl', impersonal agencies.
Services become an accepted part of daily activities. St. Joseph Hos-
pital Mid-Houston Community Mental Health Center has also estab-
lished outposts in multiple-service centers (172). The outposts not only
offer services by mental health personnel but also provide centralized
screening and intake by representatives of welfare, vocational rehabil—
itation, and employment counseling services. Such a program goes a
long way toward cementing a cooperative relationship among urban
agencies and, thus, increasing the effectiveness of their individual
programs.

One of the barriers to the accessibility of mental health services
tailored to one’s needs has been financial. Under the new program, in
most States, centers set fees on the basis of ability to pay. In other
words, they have a sliding scale; if a patient can pay nothing, he is
not turned away. In a number of centers, for example, the Hill-West
Haven Community Mental Health Center in Connecticut (165 ), fees
are handled not by the centers but by the State Department of Mental
Health. In any case, mental health services offering more than perma-
nent or recurrent institutionalization are now coming within the reach
of those who cannot afford private treatment.

The language barrier, too—which sometimes has made it difficult
for the professional to understand patients, who all too often are then
judged untreatable—is being attacked. The Lincoln Hospital Center
(17]) has Spanish-speaking personnel to help people who cannot speak
English. Spanish-speaking staff will be employed for a program in
a New Jersey area that includes large numbers of migrant farm work-
ers. The same is true of the program of the Bernallillo County Com- *
munity Mental Health Center, Albuquerque, N. Mex., which serves a
large Mexican-American population. The community mental health
center at Pacoima, Calif, in collaboration with Casa Loma College,
plans to train Spanish-American as well as Negro workers. Persons

76

familiar with “ghetto talk” are being recruited for staff (173) mem-
bership in the centers of many large cities.

Prospective applicants for mental health center grants, moreover,
are encouraged to do whatever they can to make their programs and
facilities a welcomed and freely used part of the community. If new
buildings are to be constructed rather than existing ones renovated,
they are to blend with the surroundings rather than stand out as for-
midable institutions. Temple University was not in a good position
to build new facilities for its center because residents of the area, in
an earlier situation, had objected to tearing down badly needed hous-
ing. So the University has established the center in renovated build-
ings: a previously unused church and a few vacant row houses (17.4).

A description of the Partial Hospitalization Building at Temple
will indicate the effectiveness of the remodeling. Under the supervision
of a decorator, the building has been converted into an attractive com-
promise between institutional and overly luxurious styles. The floors
are carpeted and the furniture is attractive, but not so expensive as to
be totally unlike what the patients are used to in their own homes.
There is a kitchen and a dining room with many small tables—a center
for informal patient socializing. Numerous living rooms on the first
floor also serve as places where patients can get together during the
day. One of the rooms is equipped with a piano, another has a phono-
graph. On the second floor are offices and meeting rooms, and on the
third floor are beds for the night patients. In all, the setting is func—
tional, pleasant, and consistent with the accustomed living arrange-
ments of most of the patients.

The Maryland State Department of Mental Hygiene has a grant to
build facilities for a center in a ghetto area of Baltimore, near the
Medical School (175). A large walkway connects the two centers of
activity. Oflices and service units are arranged about a. plaza that
serves as a meeting place for the school and the community. The plan
includes organized activity centers, such as a swimming pool, art
exhibits, music, games, and a “marking wall” on which demonstrative
residents may express themselves Without recrimination.

Centers at Winter Haven and Daytona Beach, Fla, include small
auditoriums that are available for community meetings (176', 177’).
The Rainbow Mental Health Center in Kansas City proposes to con-
vert an old quarry in front of its new buildings into a public park so
that residents of the area, whether or not they are clients of the center,
can enjoy play areas and landscaped walks (J78). Some centers offer
day care for children, so that mothers can get needed help. Mothers
receiving day care may even be encouraged to cook the family’s evening
meal at the center and take it home at the end of the day.

Experience indicates that a building able to house all elements of a
program may not be as effective in reaching people as a scattering

77

335—41‘19—609———7

of smaller units. Hence the Mid-Houston Mental Health Center plans
to build four separate facilities in different sections of its area of
responsibility (1752). Other centers plan to locate day-care units in
outlying rural areas.

The key problem of accessibility is actually two problems: physical
accessibility, either bringing services to the people or bringing the
people to the servces; and psychologcal accessibility, or making serv-
ices available in ways most acceptable and meaningful to recipients.
The first problem is being met by the Community Mental Health Cen-
ter program and by the Neighborhood Service Center program (which
is discussed later). The same program also meet to a considerable
extent the problem of psychological accessibility, and new ways of
meeting it are being tried. The best tested so far is the training and
use of indigenous mental health workers—people who in every sense
can speak the language of the disadvantaged persons needing mental
health services.

Another highly promising approach is the use of mental health
center personnel and facilities to reach those people in the best position
to notice mental health problems early and to do something about them
early—provided they have learned what to look for and where to get
help. The stafi' of the Touro Community Mental Health Center, New
Orleans, whose service area includes many poor people, teachesand
works with clergymen, social work students, personnel directors, pro-
bation officers, general practitioners, and others who often come in
touch with troubled people. This is a reaching out into the community
to find those who need help and at the same time to strengthen the
capabilities of those who give it. A number of other centers hav'l
similar programs.

As centers establish strong lines of communication with such insti—
tutions as schools, police, the medical profession, social agencies, and
churches, and as they stimulate community concern for an active,
realistic approach to mental health problems, great strides will be
taken toward the prevention of mental illness in individuals who,
without the benefit of early intervention, might have experienced a
severe emotional crisis or reached a state of chronicity. This phase of
the accessibility effort is discussed more fully under “Consulting and
Educating.”

Making Services Relevant to the Community’s Needs

A community mental health center must have more to recommend
it than accessibility to the people it serves, for these people are likely
to be highly diverse. People differ in personalities and problems. All
members of a minority are not the same. One slum is different from
another.

Each center endeavors to gear its services to the needs of the com-

78

munity. The area served by the Maimonides Center in Brooklyn, for
example, has a high incidence of behavior problems among children
and adolescents and also, among the teenagers, high incidences of
alcoholism and drug misuse. So the center provides specialized inpa-
tient and outpatient services, including counseling and educational
activities, for the community’s young people (169) . After the Chicago
riots in the spring of 1968, the East-West Garfield Park Community
Mental Health Center, located in the area that had been hardest hit,
promptly established day-care services for children, began providing
consultation on problems related to housing, and moved to help meet
other problems connected with the rioting (179). During the crisis,
incidentally, Negroes in the area affected kept the center’s staff
informed and protected.

To help make sure that services will deal with local problems and
will reach those who need help, each community center is required to
show evidence of citizen participation in its planning. Evidence of
such participation may be an advisory board that includes advocates
of the interests of those using the center’s services. The Institute con-
sistently raises the question of representation of poor people and
minority groups on such boards. In Chicago, as one example, a center
works with an advisory board composed of approximately 20 persons
from the neighborhood (180). Representing a wide variety of politi-
cal, social, and religious values, they take part in all major decision-
making. The center’s stafl' defines the technical aspects of a problem;
the advisory board informs the staff of the community’s attitudes
toward the problem.

The Maimonides Center has formed two organizations: a local
Mental Health Coordinating Council, composed of all the health, wel-
fare, education, and law enforcement agencies serving the catchment
area, and a Mental Health Committee of indigenous leaders of social
organizations in the catchment area (16.9).

In dealing with inner-city families, it is now being recognized that
distinctions must be made among the unemployed poor people, for
example, and the unemployable poor, the people with a long history of
employment in low-paying jobs, the men who are underemployed,
the intermittent workers, women who support families, and so on. A
better fit is being sought between the needs of each group and the
services offered. Professional mental health workers are beginning to
realize that new treatment methods have to be developed and new
ways found to reach the lower socioeconomic groups. Greater differen-
tiation is required if the needs and expectations of these clients are
to be met. Merely opening up traditional agencies to the poor is not
enough. On the lower East Side of New York it was found that 24
public and private agencies offered mental health care to the disad-
vantaged residents of that area. However, only six of those agencies

79

were located on the lower East Side and almost all the agencies had
long waiting lists. (Waiting lists have been found to be discouraging
to clients, many of whom have already waited before coming to an
agency and need help immediately.) Although many residents of this
area speak only Spanish, Italian, or Yiddish, few agencies offered
more than an intake interview in a language other than English.

A Demonstration in Helping Residents of a Slum

The South Bronx has one of the worst slums in the country. Its popu-
lation of 350,000—larger than that of Toledo, Ohio, or Little Rock,
Ark—is almost entirely Negro or Puerto Rican. The people have gone
to New York—as others have gone to Detroit, Chicago, Newark, and
other large cities—looking for opportunity and have found instead
an environment that crushes many of them. Their homes are in large
tenements owned by landlords who live elsewhere "and who, in many
cases, will abandon the buildings rather than repair them. The schools
are overcrowded. Unemployment is common. Rates of mental illness
and related social problems such as juvenile delinquency and drug
abuse are very high.

In this area the Lincoln Hospital Community Mental Health Center
is trying out promising new ways of making help readily available to
everyone needing it (171) . After several years of experimentation, the
hospital has adopted a walk-in system. Any person who comes to the
clinic is seen by an experienced clinician—psychiatrist, psychologist,
social worker, or nurse—for an immediate diagnostic assessment and
decision about treatment. There is effort to remove all barriers to
full use of clinic service. The patient is greeted by a receptionist who
speaks both Spanish and English ; the professional staff is multilingual;
the waiting room is a pleasant place, and coffee is served.

Social problems or concerns almost always accompany the psycho-
logical symptoms presented by the patient. Consequently, treatment
generally must include a good deal of attention to urgent practical
problems. To help restore and maintain the patient’s equilibrium, the
staff attempts to mobilize the patient’s own resources, those of his
family, and, finally, those of the community. A great deal of contact
with other agencies in the community, public and private, is usually
required.

In a forerunner to the pilot Neighborhood Service Program dis-
cussed later, the hospital in 1965 began the development of neighbor-
hood service centers, located in former stores. There were four of
these, each in a shopping district and close to transportation lines. Any-
one in the neighborhood might walk into "a center, immediately talk
to someone, and get some degree of assistance. The first contact was
with a nonprofessional but specially trained person from the same gen-

80

eral area as the person needing help. This aide was backed up by pro-
fessional mental health workers in the center itself and in the parent
institution. Each storefront center served directly an estimated 6, 700
persons a year.

Much of the work of these neighborhood centers dealt with social
problems. Complaints about housing were so common, for example,
that groups were organized to discuss them, learn how to assess housing
code violations, and decide how best to negotiate with landlords.
Through the centers, the residents of the South Bronx were informed
about legislation affecting poor people, also about their political power
and how to use it through such means as voting, letter writing, and
attending public hearings.

The neighborhood centers worked with the schools to prevent, solve
or ameliorate problems caused by disruptive children. In one center,
a group of children suspended from school or in danger of suspension
began meeting with a community mental health aide to plan and carry
out activities, and their behavior improved markedly. When a child
was suspended, it was found, the parents were usually much concerned
but too loaded with other problems to handle the new one. So, often,
the child stayed home or roamed the streets. A number of other groups
were organized, some to help the children directly and some to help
them through their parents.

All the personnel in these neighborhood service centers (a demon-
stration project) were recently moved, with additional mental health
workers, to the recently opened Hunt’s Point Community Mental
Health Center. The move was in accord with the. original plan pro-
viding that the new center when completed would service that part of
the South Bronx containing the storefront units.

One psychiatric team from the Lincoln Hospital has been assigned
experimentally to a school as a diagnostic, treatment, referral, and edu-
cational unit. Members of the team found that teachers and administra-
tors tended to want children either cured in a hurry or expelled, while
the team wanted to keep them in school. Recommendations stemming
from this work so far include: the establishment of a “cooling off”
room for disruptive children; more remedial work so that children
can keep up with their classes more easily and so that no teacher need
face an impossibly large range of educational levels; and the recruit-
ment of community school workers similar to the community mental
health aides.

This method of providing services to a poverty-stricken area is
being evaluated in NIMH-supported research, which should yield
information of decided practical value in the operation of mental
health centers in other such communities (18]).

81

Other Examples of Community Mental Health Centers

All centers have a 24-hour emergency service. At Hahnemann Com—
munity Mental Health Center in Philadelphia, this comprises the ac-
cident ward, a crisis clinic, a walk-in clinic, and 24-hour telephone
service (167 ) . Most people go first to the accident ward, where a mental
health team composed of a psychiatrist and a social worker is on duty
24 hours a day, 7 days a week. This team may give emergency treat-
ment immediately or send the distressed person to the crisis clinic,
where immediate help is also available. Among the personnel are
workers skilled in child therapy and others fluent in Spanish. If ex-
tended psychotherapy is required, the patient is referred to the out-
patient service at Philadelphia General Hospital. Mental health
workers responding to telephone calls have been trained to handle
situations of varying clinical urgency, from a request for information
to a call from a person needing help at once.

Many centers take the practice of crisis intervention out of the clinic
and into the community by delivering emergency care to the home.
These home visits may be in response to a distressed call for help or
to a threat of suicide. Mental health workers are able to get to the
scene quickly, and provide emergency treatment. In an urban environ-
ment, this kind of service can intervene in a group, as well as an in-
dividual crisis, as has been demonstrated in several cities when civil
disturbances have threatened. Nonprofessionals affiliated with a center
have patrolled streets and helped to quell unrest and allay tensions and
fears.

Outpatient services also have a great deal of appeal to urban resi-
dents. An ambulatory patient can avail himself of the full range of
treatment with the least amount of disruption to his daily functioning.
At the Sound View-Throgs Neck Community Mental Health Center
in New York City, for instance, each patient is assigned to a clinical
team staff that conducts individual, family, and group psychotherapy
as well as part-time activity programs and emergency Visits to the
home, as the need may be (182). Social, recreational, educational, and
vocational activities are concomitants to psychotherapy.

Partial hospitalization, involving either daytime or nighttime in-
residence treatment programs, benefits patients who need supportive
care on more than an outpatient basis but who are able to sustain an
adequate part-time adjustment, working at a job or taking care of the
house, within the community. This type of service is particularly valu-
able for those residents who for one reason or another have no family
contacts within the community.

The day program of Temple University Community Mental Health
Center in Philadelphia tries to stimulate a sense of identity and
personal worth in the alienated urban dweller (174). The program is
founded on the concept that a therapeutic community is the primary

82

means by which constructive change can be brought about in indi-
viduals. Within the setting, the participants attempt to relate to each
other as individuals, each having something of value to contribute.
Everyone, including staff members, is addressed by his first name, and
the people being helped are called members, not patients. Each mem-
ber is assigned to one of four working committees—membership, so-
cial, kitchen, or maintenance. There are ongoing evaluations and
seminars as well as therapy by the staff and group discussions by the
members. A weekly psychodrama session affords opportunities to play
one’ own role first and then that of someone else, and thus to reach a
better understanding of attitudes and behavior. A married couples’
group meets once a week. Daytime patients eat lunch with the staff,
and both patients and staff help prepare it and clean up afterward.
Such joint activities, in which personal worth rather than status is
stressed, are credited with having helped to develop high morale
among members and staff.

The effectiveness of emergency treatment programs, outpatient serv-
ices, and partial hospitalization is shown in the declining use of in-
patient hospitalization, especially of long duration. A patient is no
longer automatically regarded as an incompetent whose future must
be decided by an apathetic custodial system. He is a person of value
who needs assistance in fulfilling his potential. By receiving this assis-
tance at facilities within the community, the possibility for his rein-
tegration within society is markedly increased. Denver General Hos-
pital Community Mental Health Center, for example, has a small but
active 15-bed inpatient service that cares for a large volume of
patients on a short-term basis (183). Several other centers including
Mid-Houston have modified their grant applications in order to re—
quest a fewer number of beds than originally thought necessary. These
centers are able to meet the needs of their catchment areas by support-
ing other caretaker groups or receiving patients earlier and then treat-
ing them promptly for each personal crisis.

Consulting and Educating

The requirement that mental health centers provide consultative
and educational services is proving of utmost importance. For it is
these services that link the many agencies of a community so that
mental health becomes indeed a community effort. Thus preventive
measures are strengthened, and people in need of help are recognized
and helped early.

The staff of one center, located in a largely Puerto Rican neighbor-
hood, is educating medical and nonmedical personnel (such as police,
teachers, court officials), in the characteristics of their community
(171). Group sessions utilize films, role playing, lectures, discussions,
clinical case histories, and fictional and news stories to teach and il-

83

lustrate such subjects as conversational Spanish, community orienta-
tion, the culture and history of the Puerto Rican people, and sensi—
tivity to mental health problems. Efforts are being made to enlist the
cooperation of neighborhood druggists, grocers, ministers, physicians,
and school personnel in community mental health endeavors.

Western Missouri Mental Health Center in Kansas City provides
consultation to the Kansas City Police Department and to the Re-
habilitation Institute (184). A course in “practical psychiatry” is
given to police officers at a level relevant to police work. A “General
Practitioner’s Training Program” is offered to practicing physicians
in the Kansas City area. The Greater Little Rock Comprehensive
Community Mental Health Center has addressed itself to the problem
of child neglect and suspected abuse by holding consultations with
court officials, police officials, and child welfare personnel (185). The
staff of Temple University Community Mental Health Center con-
sults with eleven agencies, including public assistance and welfare,
recreation, probation and parole, employment, and schools, and col-
laborates with case workers in these agencies to improve their ef-
fectiveness (17],). Stafi' members are also on the boards of a number
of agencies throughout Philadelphia. In these and other cities, net-
works of social service, educational, training, and medical agencies
are being formed to assist in the delivery of comprehensive community
care.

Neighborhood Service Programs and Health Centers

In theory at least, and usually in practice as well, community men-
tal health centers have an unlimited concern with people. If a patient
has a physical ailment, needs financial help, could hold a job if only
he could find some way to be trained for it, or offers other problems
associated with his emotional difficulties, a mental health center’s job
is to work on its own and with other agencies to help him find solutions.

The provision of concrete services seems necessary to meet the needs
of the usual, lower socioeconomic class person, who comes expecting
help with some concrete problem and who all too often, up to now, has
been met with an “evaluation.” One mental health group working
in a large slum has found that all its clients come in with social as
well as psychological problems (18]). As the staff has been able to
give immediate help—by providing medication, for example, ar-
ranging appointments, seeing a landlord or an employer—the clients
have become more effectively engaged.

Now the Institute is participating in a new program, involving sev-
eral Federal agencies, to test the value of making many service avail-
able to the poor in one convenient location. This is the pilot Neighbor-
hood Service Program, similar in concept to the Community Mental

84

Health Center Program but intended to oifer the gamut of social serv—
ices, including health, welfare, vocational rehabilitation, and employ—
ment counseling. In the broadest sense of “mental health,” it IS indeed
a mental health program, though a more appropriate te1m is probably
“human service” or “social health.” Agencies cooperating in the new
effort include the Departments of Labor; Health, Education, and
Welfare; and Housing and Urban Development; and the Ofiice of
Economic Opportunity. The test cities are Boston, New York, Phila-
delphia, Washington, Louisville, Chattanooga, Jacksonville, Cincin— .
nati, Detroit, Chicago, Minneapolis, St. Louis, Dallas, and Oakland.
The Institute and OEO are also cooperating in a program to
strengthen health systems in poverty—stricken urban areas by offering
as many health services as possible in neighborhood health centers.

Just how the new centers will be linked with community mental
health centers remains to be worked out. The latter usually serve pop-
ulations of between 75, 000 and 200, 000, while neighborhood centers are
usually thought of as serving much smaller groups. Inpatient services
are probably too specialized and expensive to be decentralized to the
neighborhood level, but many other services—for instance, consulta-
tion and aftercare—could be highly effective at the neighborhood level
and are, in fact, being offered at that level in the programs having
satellite centers. Perhaps the neighborhood center will come to serve
—among its other functions—as a port of entry to the Community
Mental Health Center Program. In any event, the Institute is exploring
methods of relating the two kinds of centers most effectively. One
project is studying the process and outcomes of forging linkages be-
tween the two service systems in a specific community, the Roxbury
area of Boston, which has both a multipurpose center and a compre-
hensive mental health service program (187) .

Rehabilitation Work

Among the urban problems to which mental health centers are ad-
dressing themselves is the high unemployment rate among males in
the inner-city. The unemployed include people with educational and
physical handicaps, the mentally retarded, and former psychiatric
patients who are unable to find jobs. Many centers have started their
own rehabilitative programs or have joined forces with other urban
institutions. One center, for instance, has developed a comprehensive
rehabilitation program for all its patients—inpatients, day hospital
patients, and outpatients (182). This center has been guided by the
principle that psychiatric patients generally want what “normal”
people want—companionship and the right to earn a livelihood. The
services incorporate a full—time sheltered workshop and a day hospi-
tal. The major innovations are on-the-job apprenticeships and train-

85

ing programs and supervised group placement in business and indus-
try. The experience at the workshop offers an opportunity to earn
pocket money, acquire basic work skills, and socialize with peers. This
flexible program permits immediate employment after hospitalization
and tends to reduce the rehospitalization rate.

Rehabilitation means more than preparing a handicapped or dis-
advantaged person for employment. It means helping an individual
who is in a period of psychological transition to arrive at an optimal
level of adjustment. Halfway-houses provide comfortable living ar-
rangements and guide the participant to independent functioning
within the community. Horizon House, an affiliate of three Philadel-
phia community mental health centers, has a rehabilitation program
that stresses both social and vocational rehabilitation and provides a
wide range of activities (188) . These include visits in the community,
cultural events, volunteer assignments to other community nonprofit
organizations, group discussions of personal adjustment and current
events, and cooking, health, and nutrition classes. A vocational re-
habilitation program is coordinated by the patient’s counselor. After
a preworkshop evaluation and job testing in a preparatory sheltered
workshop, the patient begins training at one of three paid sheltered
workshops offering training for industrial, clerical, food-handling or
maintenance jobs. The program also includes job counseling, job
placement, and job followup, with the employer as well as the patient
kept in mind.

In New Orleans, a State vocational rehabilitation counselor visits
the Touro Community Mental Health Center once a week to consult
with the staff and arrange for jobs or for training for the patients
likely to benefit from them (111). One psychiatrist, asking the Center
to take a patient into its day-care program and to help him find work
when he was ready for it, said: “This young man doesn’t have to go
back to a hospital : he needs to get on with his life.”

Central City Community Mental Health Center, Los Angeles, has
directed attention to redefining delinquency and antisocial behavior
and mental retardation in children (J89). Experience with area chil—
dren has impressed the staff with the difficulty of distinguishing be-
tween the traditional emotional disorders, including those with an
organic element, and the effects of psychosocial and economic blight.
Hence, the Center is starting a rehabilitation program that features
special classrooms for children who need special help. These are chil-
dren whose behavior~because of cultural, emotional, or organic dif-
ficulties—cannot often be dealt with properly in ordinary classrooms.
The center is also establishng a program among married Negro males
to serve as “Big Brothers” to children without fathers.

86

Improving State Hospital Services

At the same time that the Institute is pushing the new approach,
comprehensive community mental health centers, it is working suc-
cessfully to improve the old approach: treatment of the mentally ill
in special public (mainly State) hospitals. These continue to be the
primary resource for services to chronic patients, who, for a variety
of reasons, are likely to be poor people. Such hospitals will continue
to serve large numbers of patients for a long time. Consequently the
Institute works through its Hospital Improvement Project program
(HIP), inservice training grants—Hospital Staff Development pro-
gram, or HSD—and the Community Mental Health Centers program
to raise the quality of care the hospitals can provide and to enable
them to offer new services. HIP or HSD grants or both have now been
awarded to approximately 85 percent of all State and county mental
hospitals. Hospitals in the largest cities have tended to use HIP grants
to develop work therapy and rehabilitation programs, establish treat-
ment units to reach more people, and to provide such services—typi-
cal of those offered by community mental health centers—as emer-
gency home visit teams, day care, and followup care for patients who
have been discharged (190) .

Indeed many State hospitals located in metropolitan areas can de-
velop comprehensive mental health centers themselves and can serve
also as supportive resources for centers in surrounding areas. The In-
stitute helps them to do so. As noted earlier, many are already work-
ing actively with local centers.

The staff of Boston State Hospital, which has been expanding its
programs under a HIP grant, is committed to the rehabilitation of
both acute and chronic patients (191). Approximately 150 hospital
employees and supervisors and more than 600 patients are involved
in the 38 work programs. While engaged in their clinical duties, ward
personnel and therapeutic staff are also concentrating on work re-
habilitation. Administrators, professional rehabilitators, students and
volunteers are also incorporated into the program. The hospital is ex-
perimenting with the assignment of one professional rehabilitation
counselor to each hospital unit to work with a member of that unit’s
team. With the help of the other unit professionals, this counselor
will be responsible for in—hospital and post-hospital placement and
followup. Attempts will be made to evaluate patients promptly and
place them in appropriate job opportunities so that their work skills
will not deteriorate. One of the major mechanisms to speed patient
progress is a central employment office with a card recording system
and job directory. Patients referred here receive interviewing, voca-
tional counseling, placement in hospital industries, monthly evalua-

87

tion, and assistance in locating jobs and living arrangements in the
community. Paid work programs and social club activities help pre-
pare the patient to resume life outside.

Mobilizing City Residents Themselves

When there is leadership backed by the needed funds, demonstration
projects financed by the Institute have shown that both the agencies
and the residents of an urban neighborhood can work for its improve— ,
ment. In Denver, for example, a community center in a neighborhood
faced by blight organized an Improvement Association and an Inter-
Agency Commitee. Action through the improvement association re-
sulted in the installation of more street lights, in street repair, in the
cleaning up of various substandard conditions in the area, and in the
development of a community newspaper, praised by one reader be-
cause “it lets you know what is going on so you can holler about it.”
Deterioration was checked. The project worked for good neighborhood
attitudes for dealing with and preventing such social problems as al-
coholism, crime and delinquency, school dropouts, dependency, and
family breakdown. The Inter-Agency Committee planned and helped
carry out the city’s first poverty-area election related to the War on
Poverty program (34).

In Los Angeles, another NIMH-sponsored program has centered
on mobilizing the residents of a deteriorating area into three groups:
a lay group representing influential residents of the area; a profes-
sional group representing those agencies and institutions serving
young people; and a youth group, representing teenagers (10] ). As in
an earlier and successful project in Santa Monica headed by the same
investigator, the groups involved have had seminars and workshops
to study the neighborhood’s problems, particularly those concerned
with young people, to identify the resources available for meeting
these problems, to work out new ways of meeting them if necessary,
and to plan a unified community approach.

The investigator reports the following results, among others: the
establishment of an employment committee to increase training and
work opportunities for the area’s young people; the institution of
tutoring sessions in which 200 high school volunteers are assigned to
help elementary school pupils throughout the area; summer preschool
programs for disadvantaged children; the establishment of a youth
board to provide a common meeting place and interesting programs——
political, cultural, historical—for youngsters from different schools
and different ethnic and socioeconomic backgrounds; and the estab-
lishment of a Treatment and Rehabilitation Committee to increase the
resources for preventing delinquency and offering counseling services.
In one high-delinquency neighborhood, the project has worked with a
social work agency and the police department to stop or forestall

88

delinquency through therapy for both the adolescent and his family
and through the training of indigenous aides. The teenagers in the
program have recognized the need for low—cost guidance services on a
walk-in or mobile basis, and the program is considering ways of pro-
viding them.

Mental Health Protection for Workers

Contemporary industrial life often leaves profound imprints on the
mental health of workers. Changes in living patterns produced by new
technologies—increased leisure time, demands for frequent changes
in jobs, skills, and home communities—can create widespread tension
and anxiety. Alcoholism, absenteeism, accidents, low productivity, and
high personnel turnover are concrete industrial problems significantly
related to mental health and illness.

Careful studies during the past 15 years have shown that the seg-
ment of the population commonly referred to as “blue collar workers”
has not generally understood the nature of its mental health needs, nor
has it enjoyed adequate access, including the economic means, to avail-
able mental health facilities.

Two major trends have begun to alter this picture in recent years:
the growing community mental health center movement, and the
expansion of insurance coverage for health care for the approximately
17 million wage earners in the United States who are members of trade
unions. Mental health benefits are relatively new among health plans
evolving through union-management negotiations. Reflecting, in part,
expanded activities of the NIMH in this area, however, significant
strides have been taken recently in broadening insurance coverage, and
in developing special mental health programs for or under the auspices
of employee groups. Moreover, achievements made through the labor
union system have an important impact on benefits offered to nonunion
workers, white collar employees and management staff in industry;
moreover, they affect the entire field of health insurance coverage as
offered by the various insurance underwriters.

One research team examined disability insurance claims of members
of a union prior to the availability of a mental health program. They
found that help was sought by patients primarily from their general
practitioner, with the employee often going from one doctor to another
complaining of “nervousness.” Community clinics, counseling agen—
cies, and nonpsychiatric mental health workers played no significant
role in treatment. On many occasions the patient “integrated” his own
care, collecting prescriptions and therapies that had often been pre-
scribed in ignorance of his other ongoing treatment. Some patients
even had several series of shock treatments given by different doctors,
each of them unaware of the treatment being given by the others.
Almost all the claimants diagnosed as psychotic were'hospitalized,

89

usually in municipal or State institutions. Heavy use was made of
drugs. Very few patients had any individual psychotherapy or out-
patient mental health care. Many were in and out of hospitals fairly
quickly, but too often returned with grim regularity (1.92?) .

As a result of these findings, support was provided for a mental
health program at an outpatient health facility cosponsored by the
New York Joint Board of the Amalgamated Clothing Workers of
America and the New York Clothing Manufacturers of America.
Thirty thousand workers in the men’s clothing industry and their
families have been eligible to seek services through this demonstration
project.

Addressing itself to those with emotional disorders, the program
has three prime objectives: to find ways to locate, as early as possible,
workers whose emotional problems threaten job security or contribute
to severance from the labor force; to devise techniques to engage these
workers in a therapeutic and rehabilitation process; and to develop
procedures for both treating patients and influencing their work
environment to assist the emotionally ill individual maintain employ-
ment or return to work. A team of mental health professionals has
worked closely with union and management representatives in collabo-
ration with selected community mental health facilities to implement
these goals. In setting up the mental health program, the clinic did
not try to duplicate services already “available in the community; it
made arrangements for preferential admission to city hospitals and
had staff from these hospitals join the clinic staff in all phases of its
program.

By its emphasis on keeping the client productively at work, the
clinic has gained the full cooperation of the union, its members, and the
employers. This emphasis avoids such problems as loss of income,
excessive free time, strain on family relationships, fear of personal
deterioration, loss of self-esteem. Since the union population is
familiar with and comfortable about the industry clinic, the danger
of perceiving psychiatric treatment as a threat is reduced. The clinic
staff has worked extensively with the business agents of the union to
help them become case—finders and to use the services of the clinic for
the benefit of the members. The members’ faith in union-sponsored
activities has eased their acceptance of the mental health program.

One of several studies to discover the need for services took place
in a small shop of about 100 employees. It‘showed that 13 employees .
felt that they had mental health problems, 14 thought they had
physical problems, and 67 stated they had no problems. Everyone who;
filled out a questionnaire was thanked by letter in his own language;
All were invited to be aware of the mental health program and to uses.
it, and those who had physical or mental problems were given appro-' -
priate appointments.

90

Persons who needed help with emotional problems were told that
they would see a doctor about their difficulties, not that they had an
appointment with a psychiatrist. Such persons were concerned that
their employers would know about their difficulties but rarely that.
their coworkers would know. In fact the entire working group would
often be well aware of the treatment process. On one occasion, after
a patient was referred by his foreman and successfully helped, each
member of his group eventually sought help.

Many of the communications, both by staff and by clients, were by
phone. Appointments were held on streets, in neighborhood lunch
counters, and industry shops as well as in the clinic. Visits lasted from
10 minutes to 2 hours. The staff’s familiarity with industry conditions
helped solve the crucial problem of getting people back to the job or
assigning them to different work. In deciding whether or not a person
may return to work, the staff believes, psychiatric findings are less
' important than a functional diagnosis about whether the person can

do the work and not suffer. Since the clinic’s staif knows the varying
requirements of each position, it is in a good position to judge this
issue.

Those in need of mental health- services represented the entire spec—
trum of union membership. Most were considered extremely stable.
Many owned their homes. Three-quarters of the claimants had worked
in the industry for at least 10 years. Only a handful were separated or
divorced.

In a little more than 2 years, the program has seen more than 400
patients and their families. Most of the patients have been helped in
eight sessions or less, the staff reports, and almost a third have been
helped in a month or less. About a fifth have been seen for as long

‘ as 6 months. In order to feel a part of the therapeutic process and to
utilize the treatment fully, the staff reports that it is not necessary
for a patient to pay a fee. Indeed the staff feels that because the work-
ers are on tight budgets, a fee would interfere with their use of the
clinic.

The project has successfully demonstrated that severely disturbed
workers can be maintained on the job with appropriate adjustment in
work settings and supportive services. It has also validated the impor-
tance of early casefinding in preventing disability. Most important, the

_ effort has provided ample evidence of the willingness of all groups
involved—whether worker-union, management, health center, fellow
employees, insurance company—to collaborate in a mental health

_ rehabilitation program when it is appropriately developed (192).

Also under NIMH auspices, the Health Insurance Plan of Greater

New York (HIP) is currently engaged in research to determine how

V the family physician and the patterns of medical care he provides for
emotional disorders are affected by the introduction of new mental

91

health services (1.93). The largest of the 31 medical groups in HIP,
the Jamaica Medical Group, established a mental health center to-
provide services to that group’s subscribers and their families. Three
in five members of HIP are members of employee groups which came
into the program through contracts with city agencies such as the
board of education, police, fire and sanitation departments, and the
transit authority. Union health and welfare funds constitute the next
largest source of enrollment.

Preliminary findings indicate that since the advent of the mental
health program, family physicians report that they spend less time
discussing the patient’s emotional problems with him and concentrate
in providing specific medical care. The family physician does, how—
ever, play an important role in bringing mental health services to
those patients with a low propensity to seek such treatment, as well
as those who may not recognize or tend to minimize their emotional
problems. The involvement of the family doctor in the referral process
appears to direct to mental health services a broader spectrum of the
population that might otherwise not utilize these services on their own
initiative.

A significant outgrowth of this research project was the decision
of HIP to offer fully prepaid outpatient mental health services for
its members in New York City and Nassau County as of July 1, 1968.

/HIP members now eligible for such mental health benefits include
Federal employees and their families and Medicare and Medicaid
enrollees. The mental health program is available as an option for
an additional monthly premium of 90 cents for one person, $1. 80 for
two, and $2. 70 for a family of three or more (195’).

Another example of activity in support of mental health services
for workers is found in the efforts of. the large industrial union
bargaining ’with nationwide corporations. On September 1, 1966, as
a result of negotiations between the United Auto Workers Union and
the Nation’s major automotive and agricultural implement companies,
2.75 million blue collar workers and their dependents in 77 cities
in 34 States and the District of Columbia (including retired workers
and their families) became eligible for prepaid mental health services
which extended inpatient care and, for the first time, coverage of
outpatient care. The same benefits also were incorporated into the
insurance benefits available to a million professional, technical, and
clerical salaried workers employed by these companies. Collective
bargaining negotiations in 1967 extended hospital benefits and added
accredited psychiatric hospitals to the category of participating hos-
pitals. Drug benefits which will shortly become available will, of
course, also cover psychotropic drugs.

NIMH research efforts are now directed at a comprehensive analysis
of utilization patterns by workers and their families during the first

92

three years of the UAW program (1.9.4). In Baltimore, a smaller
research project is devoted to studying in depth the union population
in that city, to determine the factors that hamper or encourage utili-
zation of mental health services. These services are part of a demon-
stration UAW outpatient clinic in which the Maryland Blue Cross-
Blue Shield organization is cooperating in an experimental funding
arrangement (1.95). In general, the UAW mental health benefits were
the first major negotiations to incorporate NIMH guidelines for early
referral and treatment, removal of economic barriers to care, involve-
ment of family members in the treatment program, emphasis on
community treatment, and the appropriate involvement of the entire
spectrum of mental health professionals.

During the summer of 1968, four national agreements were signed
which, in 1970, will make available to millions of workers and their
families in the aerospace, steel, aluminum and can industries, mental
health benefits similar to those obtained earlier for the automotive
and agricultural implement workers. These accomplishments reflect
not only a growing understanding, demand, and support for mental
health education and mental health programs for workers, but also
indicate that the increased availability of community mental health
resources and new advances in psychiatric care make insurance cov-
erage for mental health services economically feasible.

Services for Older People

In recent years there-has been an emphasis on rehabilitating and re-
leasing mental patients who have been hospitalized, but the geriatric
patient often has been the last to benefit. That he can benefit is demon-
strated by a group of Institute-supported investigators who have de-
veloped a form of milieu therapy oriented toward normal community
life (196'). Within a large State hospital, and with little additional
time from the psychiatric staff, they have shown that even chronic,
backward, geriatric patients can be helped to resume a more inde-
pendent life, to work, and in many cases to leave the hospital.

About one-third of the patients in this hospital are 65 years or older.
Most of them are from urban backgrounds and from the lower middle
and lower socioeconomic groups. To make life in the hospital more
like ordinary living, the investigators set up an experimental ward
marked by bright colors, open doors, and ordinary noninstitutional
furniture. Full-length mirrors were hung, and clocks and calendars
added. Men were given free access to razors, and women to facilities
to wash and dry their hair. A washing machine, dryer, and a small
kitchen were made available. The nursing staff wore street clothes.

In a sheltered workshop, patients were employed on assembly and
other jobs contracted for with outside organizations. Or the patients
made craft items, which were sold in local stores. The workshop had

93
335—1119—69—8

time clocks and time cards. Patients were paid on an hourly or piece-
work basis. Nursing personnel were encouraged to mingle with the
patients. Patients were expected to work regular hours but were per-
mitted to work longer if they wished.

The patients responded quickly to the changes. Poor self—care vir-
tually disappeared. Involving patients in work programs, or even in
ward chores, it appears, is more successful than occupational and
recreational therapy programs.

Another study reached the same conclusion: programs of occupa-
tional and recreational therapy are not as successful in involving the
geriatric patient—raising him from apathy and meaningless activi-
ties—as a work program or even ward chores. When hospital life is
made like normal life as much as possible, older patients become more
independent (1.97). Mental illness and lack of ability to function, re-
port the investigators, need to be fought as vigorously in the aged
person as in the younger. It is not acceptable to relegate an aged person
to custodial care until it is thoroughly determined that this is all that
can be done. It is not inevitable that old people must live a dependent,
meager, dormant, isolated life and sit patiently until mealtime, and
then again until bedtime, until they die.

This work has shown that even c‘honically ill geriatric patients often
can be helped to resume a life outside the hospital provided that a suit-
able place to live can be found. Retirement hotels or residences often
provide the answer for those who can afford them. But too often the
older person can afford only a room in a deteriorated hotel or board-
ing house. When marriages are dissolved ‘by the death of one partner,
life—long patterns of emotional support are lost and the survivor often
ends up in a mental hospital mainly because of a lack of more appro-
priate facilities.

Older people who have spent years in a mental hospital often find
upon release that the changes in the world are almost impossible to
absorb. A psychiatric rehabilitation project in Harlem (196) reports
that even supermarkets overwhelm such people—as, in fact, they some-
times do younger and 'healthier persons unused to doing the weekend
shopping. The investigators noticed that their clients who tended to
lead exceedingly isolated lives would shop for one item at a time in
small stores—both to keep the job manageable and have the benefit
of human contact.

Several Institute-supported projects have been trying to find better
answers to the needs of the urban aged who cannot depend upon their
families for a home and cannot afford good private residential ar-
rangements. One project, for example, has been providing an
advisory service for four public housing units, in a slum, having a high
concentration of older tenants (1.98). The population was largely
female, primarily Negro and Puerto Rican in two buildings and White

94

in others. Many of the white tenants had Jewish, Italian, or Scandi-
navian backgrounds. All the older tenants—about 1,000 were more
than 60—‘had low or very low incomes. Many had lived in the city
only a few years and were still unfamiliar with the complexities of
urban life.

To provide advice and emotional support to the older residents,
five middle-aged women—in good health, warm, tolerant, and able to
speak at least one language besides English—were chosen. Each build-
ing was assigned one worker; the fifth worker filled in where needed.
A 13-week training session included information about psychological
and sociological problems and community resources. In addition, each
trainee spent 138 hours observing and participating in the activities
of a large social work agency. In the housing units, the workers’ serv—
ices, which went toward helping the elderly tenants meet a diversity
of problems, were avidly received. During the first 11—month period,
contacts either with or on behalf of the residents averaged almost
seven per tenant.

Another Institute-financed project assessed the effects of placing
geriatric mental patients from State hospitals in private nursing
homes (199). The subjects were 106 nursing-home patients. Half of
these had been diagnosed upon admission as having psychiatric dis—
turbances. A study of the other half, not officially diagnosed as men-
tally ill, showed that 91 percent actually did have significant dis-
turbances, usually of psychotic proportions. When older patients from
State hospitals are placed in nursing homes, the study reported, neither ‘
the mentally ill nor the other patients are seriously affected.

One research group has surveyed all retirement housing in Cali-
fornia, with the exception of hospitals and nursing homes, and inter-
viewed people living in various types of such housing including a
retirement hotel, a low-cost rental village, a high-rise apartment
building under church sponsorship, a retirement village with houses
for sale, another with apartments for sale, and a life-care facility
in a college town (200). At one extreme, the hotel, the family income
of most of the residents was less than $3,000 a year; at the other
extreme, one of the purchase villages, half of the residents had incomes
of at least $10,000; 90 percent, of at least $5,000.

The common argument against retirement housing—that it segre-
gates older people from younger ones—was not raised by most of the
residents interviewed. Almost two-thirds said they see all they wish
of younger people. A large proportion of the better housing for the
elderly, the investigators find, is being financed, for profit, by private
enterprise. It is available primarily to people with substantial finan-
cial means, and is inaccessible to the majority of our older people.

95

 

 

The city is the teacher of the man.
~Plutareh

SUPPLYING THE
MANPOWER

Introduction

The research and service contributions described in the previous
chapters depend, in the final analysis, on the availability of sufficient
manpower dedicated to the field of urban mental health. The Insti-
tute’s extensive manpower training programs are increasingly con-
cerned, therefore, with developing more effective ways of serving
people in disadvantaged urban centers. One major emphasis is to sup-
port the training of a new type of mental health worker—a nonprofes-
sional person who is from a disadvantaged area himself. Another
important effort is to provide incentives to members of minority and
low socioeconomic groups to enter into and complete professional
training as social workers, nurses, doctors, and so on. Other programs
are directed toward increasing the skills of all mental health workers
in dealing with the special problems of the poor.

The NIMH training grants program provides direct support to
public and private nonprofit institutions to help defray teaching costs
and to make financial assistance in the form of stipends available to
students being trained. More than 37,000 persons have received stipend
support since 1947, when the program began. Participating in this
program are almost all departments of psychiatry in schools of medi-
cine and osteopathy in the United States, most of the graduate schools
of social work, public health, nursing, and graduate departments of
psychology. Other participants include many of the Nation’s mental
hospitals, collegiate schools of nursing, child guidance clinics, research
centers, nonprofit psychiatric treatment centers, and institutions for
the mentally retarded. Fellowships and career awards are also pro-
vided for persons who wish training in research in the mental health
fields.

This section first offers brief overviews of the new approaches to
training programs in the major mental health disciplines. Then it
describes some of the even newer approaches to the manpower problem,
in particular the training and use of indigenous workers.

97

Training Professional Manpower: in Psychiatry

The Institute’s psychiatry training program includes emphasis on
the training of psychiatrists in the concepts and practice of compre-
hensive community mental health care. NIMH supports significant
community psychiatry components in basic residency programs as
well as the advanced training of specialists in this area. The aim is to
give the psychiatrist greater knowledge of the diverse socioenviron-
mental factors which influence individual personality and behavior,
and to encourage him to become more involved with the community
and the delivery of services to people at all economic levels.

Residents are increasingly assigned for field work not only to hos-
pitals but also to other community agencies. One program places its
residents in a youth house, home for the aged, child development clinic,
community mental health center, and women’s house of detention
(201). Visits are also arranged to a court, a police precinct, and lower
income neighborhoods. Another has a “court clinic” in the Hall of
Justice where referrals from judges, justices of the peace, and the
probation department are seen (202) . Trainees also listen to cases in
court and are often called upon to advise and testify. Other programs
offer such diverse experiences as spending a weekend at a police station,
riding in a patrol car, and liaison work with prisons, vocational re-
habilitation programs, city councils and civic planning agencies, public
health departments, housing projects, and the Office of Economic
Opportunity.

Advanced specialty training in community psychiatry aims to pro-
duce qualified administrators, consultants, and specialists in program
development and civic planning.

Some community mental health advanced training programs, though
located in departments of psychiatry, are open to professionals in such
disciplines as psychology, social work, psychiatric nursing, and public
health and administration as well as psychiatry. The faculty is inter-
disciplinary as well, and teaching stresses the preventive, consultation,
planning, and research aspects of the area.

In addition to the training of psychiatrists, there are programs
which provide psychiatric training to physicians whose major clinical
interest is in the provision of comprehensive health care either as
pediatricians or as family physicians.

Psychology

The profession of psychology, too, has responded vigorously to
the increasingly apparent and pressing need for finding solutions to
social problems, and the Institute supports a variety of research and
applied training programs in psychology that are closely related to the
problems of urban life.

98

One school psychology program has as its major aim the training
for psychological services in the urban slum school (203). The field
training is in conjunction with an interdepartmental program which
addresses itself to the education of socially disadvantaged children.
Students are placed in elementary schools where they may learn
to help with the special cognitive and affective development problems
which these children have, and counsel teachers in handling them.

Other programs work to provide specialists in community psychol—
ogy (204). Their students are being trained to offer assistance with
the problems of community groups and institutions including schools,
courts, churches, antipoverty agencies, and mental health centers.
The ability to assist such groups implies, of course, the ability to
assist the individual as well.

Another training program has a Psychological Services Center,
where the student gains experience in providing consultation to such
“caretakers” as the police, the clergy, and the teachers (205).

A pilot program aims to give undergraduate psychology students
an introduction to community psychology (206'). After preparatory
courses, they do field work at a psycho-educational clinic or a neigh-
borhood youth center. It is felt that this experience will have a
valuable effect on the students, Whatever field they enter, because its
chief aim is to help them grasp the nature and potential of man in
society.

Other Social Sciences

NIMH is supporting several programs in addition to those in
psychology that will augment the social science resources available
to facilitate research on urban mental health problems. For example,
one research training project is working on the assumption that the
efl’ectiveness of treatment in a hospital, a prison, a clinic, or some
other institution depends greatly on the type of person selected for
a particular type of institution (207). So the courts and other referral
points are being studied in order to understand the selection processes
and thereby, it is hoped, help to improve them and thus speed the re-
turn of people to productive activity.

Another example is an interdisciplinary research training program
involving the relationships between mental health and the urban envi-
' ronment, with particular attention to poverty, social disorganization,
culture change, juvenile delinquency, crime, and alcohol and drug ad-
diction (5208). Though the student may receive his degree from one
department (for example, anthropology, sociology, history, political
science, economics, divinity, law, education), he will have had a back-
ground in urban studies that should prove valuable to the community
as well as to himself, no matter what his profession.

99

Social Work

Many of the training programs in social work receiving NIMH
support are based in urban service institutions. Some of the strongest
schools of social work have turned their attention to training for work
in community agencies, such as health and welfare councils, the N a-
tional Urban League, housing and urban development authorities,
and other organizations serving low—income and high—delinquency
areas. The graduates often continue to work in the communities in
which they were trained.

In psychiatric social work, there has been a shift from one-to-one
casework techniques toward group «and community methods. The
trainee obtains experience in such activities as directing volunteers
in a clinic, doing group work with patients and their families, and
consulting with the courts, Head Start programs, vocational reha-
bilitation agencies, and other such resources.

One university involves its trainees in a followup study of the
criminally insane who have been treated and released and in a study
of discharged patients and their use of drugs (209). Another involves
its students in a family life education group for Negro mothers of
nursery school children and in a program for potential high school
dropouts (210). A third provides experience in a community action
program and the local Boys Town (21]).

With NIMH support, programs in school social work have also
become increasingly involved with urban problems. For their field
work in such programs, students often work not only with dis-
advantaged children but also with their parents. One training pro-
gram emphasizes work in a newly integrated school, where the train—
ees are trying to ease the problems caused by differing behaviors and
Value systems (212). The social workers here are active in group
therapy for the children, after—school recreation programs, tutoring,
and Head Start. Also they are organizing a PTA—like organization
for the mothers and grandmothers.

The most rapidly growing area in social work training dealing
with urban problems is that of community organization. The attempt
here is to strengthen community life and thus build a favorable milieu
for satisfactory social functioning and personal development. Train-
ing aims to equip the social worker to function ‘in a settlement house
or housing project, where he will assist the people in forming a
group to identify their needs and seek a solution. Emphasis in one
training program is on integrating the schools, exposing consumer
frauds, working for fair employment practices, organizing a job
development and skills bank, establishing an educational center in a
public housing project, and forming a local organization to upgrade
the neighborhood (215’) . Techniques for developing indigenous leader-
ship are taught.

100

Skill in the training of local people as nonprofessional mental health
counselors is the goal of another training program (5214). Students
supported by another grant help tenement families establish some
minimum rules and standards for living (5215). These are multiprob-
lem families, often plagued not only with poverty but also with drug
addiction, sickness, legal trouble, and other problems. In another
project, the trainees encourage secondary school students to develop
positive attitudes toward education, society, and the future (216).
Included in this program are supplementary school activities, youth
action programs, and job training for dropouts.

One project prepares social workers to become professionals in the
correctional field, specializing in group work with juvenile delinquents
(217') . Another uses a home for dependent, neglected, and delinquent
boys, a juvenile court, and a prison in its training (2.78). Trainees
also have been active doing preventive group work in a settlement
house, since it was found that many of the boys were being referred
to court for “ungovernable and uncontrollable behavior” simply be-
cause the neighborhood lacked the resources to help them.

Nursing

Programs in psychiatric nursing include special training for pre-
ventive, clinical, and rehabilitative work with the underpriviliged,
training for indirect services such as consultation, and training for
supervising the indigenous worker and the less skilled nursing
personnel.

Special programs in community mental health nursing are being
supported, as are programs incorporating community mental health
concepts into programs in adult, child, and juvenile delinquency psy-
chiatric nursing.

Recently support has been extended to mental health training in
graduate programs in public health nursing. While these programs
already provide special training in work with the urban poor, the
grants are designed specifically to help explore and develop new ap-
proaches in community nursing services in relation to mental health
and social problems and to define the most efiective training ap-
proaches. One such program conducts clinical work in the community
and stresses brief psychotherapy, aftercare, crisis intervention, family
psychotherapy, and mental health consultation and education (219).
Graduates are thus prepared to be planners, consultants, teachers,
supervisors, and clinical specialists.

Efforts to develop even more effective training programs for mental
health nurses are being made.

Other types of training include a series of conferences to help prac-
ticing nurses learn and utilize the newer mental health concepts in

101

working with patients and their families and with allied professionals
(220) .

Grants also enable community mental health nursing to be included
in the undergraduate curriculum. All baccalaureate programs in nurs-
ing place heavy emphasis on the health, cultural, and social problems
of poor people and members of minority groups, and their implica-
tions for nursing. These programs include clinical training in the care
of poverty—stricken families and information about health and social
legislation and service programs as these meet or fail to meet the health
needs of the poor.

One program has its students work in a nursery for mentally re-
tarded children and function as liaison agents with the schools (2321).
Other projects include consultation to nurse-midwifery programs,
which have proved instrumental in reducing infant and maternal
mortality rates among the poor, and to alcoholism and drug addiction
centers, the purpose here being to help develop programs that will
prepare nurses for work with alcoholics and other addicts.

Efforts are being made to increase the number of minority group
members who enter the ranks of registered nurses.

Experimental and Special Training Projects

Programs under this heading have several main purposes: to encour-
age the development and evaluation of new methods of teaching in the
mental health field; to focus on training for work in significant but
often neglected problem areas; and to develop training programs (a)
for persons whose work is related to mental health and (b) for new
types of mental health personnel. A number of the projects are dis-
cussed at some length in the section of this chapter dealing with
indigenous manpower.

In one project youths from a ghetto area are being helped to receive
a college education so they may be prepared to enter social work and
the allied helping areas (222). Trainees are youths age 18—25 with
leadership ability and interest in the welfare of others but with poor
educational achievement, police records, and other experiences that
would generally rule them out for college. Some are high school drop-
outs. Under the plan, they will be given educational counseling and
help with such matters as college enrollment, course selection and study
habits, as well as remedial education and tutoring. On-the-job experi-
ence at an agency will help maintain motivation while the students
are in the academic program. It is believed that these trainees will
represent a decidedly valuable contribution to the mental health man-
power pool. -

Grants to several community junior colleges have been made or are
being considered to aid the development of mental health workers,

many of them disadvantaged persons. Under the plans, stipends are

102

provided for those needing financial assistance, for counseling to assist
the trainees in their adjustment, and for remedial courses to com—
pensate for academic deficiencies.

The Institute also sponsors programs to improve the effectiveness
of those who are already professionals. One program provides for
training sessions for agency personnel and professionals who work with
people from the lower socioeconomic levels (223). Its aim is to make
the trainees more aware of and sensitive to the meanings of human
behavior and thus more effective in their work. Another major concern
is to increase the ability of school personnel to develop the social com-
petence of children from disadvantaged areas. NIMH has several
programs to train child development specialists or consultants to work
with the emotionally disturbed. One model project trains nursery
school teachers to help emotionally-disturbed preschoolers.

Finally, there are special training projects for people who are not
mental health professionals but whose work brings them into contact
’with disturbed or deviant individuals. One project is concerned with
developing a model training program to give clergymen a better under—
standing of the many factors of the urban environment that affect the
development of the individual (22],). Such clergymen, it is hoped, will
instigate helpful work within their congregations and will know how
to cooperate most effectively with civic agencies for the alleviation of
social problems. Another example is a program in mental health and
deviant behavior for upper echelon law enforcement oflicers from all
over the country (2,95). The officers will develop training material for
police academies so that the patrolman will be better able to manage,
refer, and bring help to the disturbed people he encounters.

Continuing Education

Through its Continuing Education Program, NIMH also plans,
administers, and coordinates a national program for inservice training
to upgrade the efliciency of personnel employed in mental health
agencies and to provide and improve postgraduate education and staff
development of mental health and allied personnel.

The Institute supports approximately 90 projects providing non-
psychiatrist physicians with postgraduate education in psychiatric
subjects, and the majority of these projects reach physicians practicing
in large urban areas. Many of these doctors see a sizeable number of
patients from poverty groups, but only three projects are aimed pri-
marily at physicians seeing such patients. (Some of the new commun-
ity mental health centers offer both consultation and education to
doctors who are not psychiatrists.) In one of these, child psychiatry
instructors teach pediatricians as part of a comprehensive health pro—
gram for children from poverty families seen at the Bronx Municipal
Hospital. The Institute also finances a number of continuing educa-

103

tion grants for other types of mental health personnel, and about 90
percent of these projects include professional and allied personnel who
work with poor people.

All such work is continuing to expand.

Research Fellowships

Research fellowships are awarded by NIMH to students and pro-
fessionals in a variety of disciplines, both for training for research
and for supporting actual research projects. The bulk of such work is
sponsored by universities. Many of these projects are directly related
to urban problems, including those in such areas as community plan-
ning, alcoholism, drug addiction, education and mental health of
children, crime and delinquency, and mass violence. Much of such
work has been noted earlier in discussions of research projects. The
overall aim of the Research Fellowships Program, as distinct from
that of the research program itself, is the production of skilled re—
searchers who will continue to work on these problems during their
professional careers.

Training People From the Neighborhood as Mental
. Health Workers

The usefulness of nonprofessional workers in the fields of health
and social service has been demonstrated for many years in agencies
and institutions across the country. Such workers, of course, do not
necessarily or even usually come from economically and culturally
deprived backgrounds. What about a person who is indigenous to a
poverty-stricken urban area? Can he be trained to provide mental
health services to his own kind of people? Some of the most heartening
of all the Institute-supported projects are providing a strongly affirm-
ative answer. Studies show that such persons are now being used
deliberately rather than as a last resort, and that their status as mem-
bers of the mental health team is being raised. Other projects offer
firsthand evidence of the value of such workers. Consequently the
Institute gives high priority to programs and projects that incorpo-
rate the training and employment of people from the neighborhood
for work at a variety of mental health tasks.

The indigenous worker may start with many disadvantages, includ-
ing a limited education. But he knows how his neighbors think and
feel, and what their problems are, so he can apply, immediately, knowl-
edge that an outsider may acquire slowly, if at all. Specially trained,
he can greatly extend the reach of the professional mental health
worker. And he can broaden the knowledge and understanding, and
thus the effectiveness, of the people from outside who work with him.

104:

The indigenous health worker or aide—or the “community mental
health worker,” which one pioneering group has adopted as best de-
scriptive of his work and competency—is in direct contact with the
mental health professionals of the community but in many ways
remains the peer of his neighbors who need services. He can intervene
directly and become involved in their lives. He can attend funerals,
weddings, parties. He can attempt to teach, to influence, and to help
a client overcome the difficulties of the neighborhood.

Indigenous personnel may be used to help disturbed individuals and
families cut away red tape and get whatever services they need.
Some of them provide what amounts to treatment, under professional
supervision. Others serve around the clock to intervene in crises. One
young worker met a drunken client in a bad snow storm and walked
with him for several miles, interfering with the man’s attempt to
get more liquor and pushing, cajoling, and cursing at the man to see
that he made it home instead of ending up in a snowdrift. In another
city an alarmed mother telephoned a nearby church for help in han-
dling a disturbed son. As it happened, a group of aides in training, who
had been supervising activities for neighborhood children, were still
at the church. Dispatched to handle the emergency, they organized an
impromptu group therapy session on the apartment stoop. The crisis
was allayed, the mother calmed, and the aides encouraged by their
professional accomplishment.

Some of the Values of the Indigenous Aide

In the sensitive area of racial relationships, it can be valuable to
have the insights and experience of the Negro indigenous nonprofes-
sional in an agency, especially if the professionals are white and
the clientele are Negro. Even in agencies where the professionals are
Negro members of the middle class, the contribution of the nonpro-
fessional can be valuable. One group of Negro aides maintains that
the most important difference, and impediment to understanding, be-
tween people is one of class, although a difference in color can accen-
tuate the situation (5226‘). Also it has been noted by persons involved
in the training of the nonprofessional that many of the problems that
have to be met in this process are the same ones that impede the
therapeutic process with the disadvantaged client. 80 a great deal has
been learned that must be integrated into the professional body of
knowledge about the disadvantaged. Far from being insensitive and
unmotivated, the disadvantaged client is often so sensitive as to be
immobilized.

Through the indigenous workers the professional staff also learn
that economically poor people differ widely among themselves. Some
may live for the moment, others carefully and frugally plan ahead.

105

Some are liberal and some conservative. Some escape living on wel-
fare; others do not. They learn that some men work hard at any job,
others are subemployed and perpetually frustrated, others never
work. They learn a great deal about the middle class, too—~not all
of it flattering—as the aides’ perceptions are reflected back. Many
stereotypes and prejudices are uncovered on both sides. The profes-
sionals receive an education at the same time as the aides.

The aides tend to work for very concrete reasons. The job offers
them better pay than the one they had before, or it gives them a chance
for education and advancement. One group was selected, among other
reasons, because they generally felt a rise in self-esteem from “helping
others”—particularly, in this case, because they “helped their poor
black brothers” (1.96) . They often feel that those they help may some-
day help them. For many of the aides, the job represents entry into
the society in a way that they have never before had open to them. They
enjoy the opportunity to confront the middle-class institutions in
a constructive way.

Although only one of these programs is frankly therapeutic for
the nonprofessionals, most of them offer opportunity for self-improve—
ment, insight, and advancement (226’) . All the programs offer a form
of sensitivity training which helps the aide learn to respond effectively
to his own feelings and perceptions of the clients.

Language, too, is another barrier the indigenous worker helps to
break; indeed, is often the first one he is called upon to break, because
the delivery of mental health services depends very greatly on verbal
communication. Usually the problem arises because the professional
speaks one language, English, which his patients understand only
poorly, if at all. The catchment area of Resthaven Hospital, Los An-
geles, for example, contains not only a Negro section but also China-
town, a Mexican—American section, and a section of elderly immi-
grants from Europe (227’). To meet the special needs of its com-
munity, Resthaven employs professionals who can speak more than
one tongue. Other centers, finding difficulty in employing enough
bilingual professionals, have relied heavily on nonprofessionals from
the neighborhood served.

Then too, a language barrier can result from the use of special terms
expressive of the life style of a subculture. The subculture of the Negro
ghetto, for instance, has a language that is technically English but
differs from that of “the Establishment,” and this difference alone is
sufl‘icient to hinder communication between ghetto dwellers and repre-
sentatives of city institutions. In one program, staff members found
that relationships between the professionals and the nonprofessionals
frequently suffered because the latter’s language or word usage was
not being understood. So a Dictionary of Local Terms was developed

106

and a weekly program called “Slang Vocabulary Workshop” was
begun (5226'). To judge from the rapport between the professionals
and the young nonprofessionals, these efforts have been fruitful.

Samples of Training Programs

Outstanding examples of programs for training indigenous work—
ers through staffing grants to community mental health centers are
to be found at Lincoln Hospital in New York and Temple University
in Philadelphia (228, 22.9) .

Under the training program at the Lincoln Hospital Center, in the
South Bronx, selected persons from the neighborhood received in-
struction in such skills as interviewing, letter writing, and filling out
forms; participated in discussions of attitudes and self-understand~
ing; and spent part of each week getting actual experience in neigh-
borhood service centers, the clinic at the hospital, the schools, and
other service institutions. For the 9-month training period the work-
ers received tax-free grants of about $3,600; afterward they were em-
ployed by various agencies in New York City at salaries starting
at $5,000, $6,000, and even higher. The demandfor these workers
greatly exceeds the supply.

Preliminary experience shows that the aides soon are undertaking
a variety of functions far beyond what had been envisioned. Originally
they were used as translators (for Spanish—speaking members of the
community) and as expediters to assist patients in dealing with other
city and State agencies. After 6 months they were being used less in
these ways and more in several new ways. One worker was a foreman
of a sheltered workshop program. Another was serving with a psychia-
trist as a co-therapist of a therapy group. Several workers were doing
crisis intervention therapy with community residents, often making
home visits, especially in cases in which the person had threatened or
attempted suicide. Because these workers have been so successful, the
mental health professionals working at Lincoln Hospital Center have
requested that more aides be trained for placement in a wide variety
of services offered by the center.

Well over 50 persons, most of them between 25 and 40 years old, have
been trained either in the NIMH-supported project or in an earlier,
shorter project Whose graduates went to work in neighborhood serv-
ice centers and continued to receive training on the job. While Lin—
coln’s professional staff believe that the workers’ main value lies in
offering information and direct assistance, some have shown them-
selves capable, as well, of working rather intensively with clients
presenting emotional problems.

To meet the need for manpower in deprived areas, preliminary
plans are being made—by the Lincoln Hospital Mental Health Serv-

107

ices staff, City College, and Yeshiva University—for a Health Careers
Institute, which would enable anyone able and interested to receive
training for positions in the health field. Some would interrupt or
stop their training after being certified as a health aide (with or with-
out a high school education); others would proceed to a degree of
Bachelor of Sciences in health services; some would go on for degrees
in social work, medicine, nursing, or other fields. Some of the aides
trained under the Lincoln program, it is expected, would go to the
proposed Institute for further training.

Lincoln’s program for training indigenous workers is being evalu-
ated by an Institute-supported research project which seeks to de-
termine the most effective training methods, the tasks that can be
carried out most effectively by this new type of worker, and the
attitudes of mental health professionals who are in contact with the
nonprofessionals. The research is expected to yield information of
decided practical value in the establishment and operation of mental
health centers in other poverty areas. ’

Under the program at the Temple University Center, which, too,
serves a disadvantaged area, trainees start to work almost at once but
continue to participate in group training sessions. Those who complete
the program successfully get jobs at the center, where they perform
a variety of functions, among them working as psychotherapists for
individuals and as co-therapists in groups. Supervision is provided by
the Center’s professionals. Mental health aides also work out in the
community, serving as leaders and advisors to various groups trying
to obtain needed services. Twenty out of 40 persons completed the first
course for mental health, assistants. Temple then began training an-
other group of 40. Some members of the first group, promoted to
supervisory status, are participating in the training of the second
group as well as in some of the supervision of the initial group.

Another program supported by N IMH involves a day center for
chronically ill, post-hospital patients in Harlem. Going on the as-
sumption that the social, economic, and psychological problems of
post-hospital patients from the lower socioeconomic levels are inter-
related, the program attempts to help its 100 patients cope with en-
vironmental stresses as well as emotional pressures. Nonprofessionals
drawn from the neighborhood, and familiar with the same kinds of so-
cial and economic problems encountered by the patients, take a leading
role in the program. They act as therapists as well as models who have
learned to cope with the problems of the ghetto rather than to be de-
feated by them.

Some patients long hospitalized and removed from urban life are
reluctant to join the program. In such cases, an aide goes to the home
of the patient and accompanies him to the program’s day-care center
and back home again, until he is able to make the trip himself. Aides

108

also shop with patients, take them to clinics, visit them if they have
to be rehospitalized, and help them when they are again discharged.
For the families, many times, the patient’s illness was an old story
and elicited little concern. One family had to be persuaded to let the
patient attend the day center because “anything might make him sick
again.”

The Pilot Program of Baker’s Dozen

Both the Lincoln and Temple projects are serving as prototypes
for the development of similar training programs. So is another
pioneering project, which has trained eight adolescents from the
Cardozo area of Washington—an area in the Capital with the highest
incidence of poverty, unemployment, delinquency, and school drop-
outs—to provide a significant mental health service. Each now works
with disturbed teenagers.

This pilot program in Washington has been under the direction of
Baker’s Dozen, a youth center connected with the Institute of Youth
Studies at Howard University (226) . The trainees ranged in age from
17 to 21. Several had dropped out of school around the seventh grade;
one had finished high school. Reading levels ranged from fifth to
eleventh grades. All the trainees came from socially deprived families
and four had police records. (In the matter of such records, the only
requirement was that no court action be pending that would interrupt
the training.)

The aides were paid $20 a week during the initial training period
of 3 months. Classroom work—which the young people at first found
almost intolerable because of their previous school experiences—in-
cluded courses in interviewing, record keeping, and group observation.
In other parts of the training, the aides Visited a juvenile court, a psy-
chiatric facility, and other social institutions; saw many films on
mental health and child development; participated in a group psycho-
therapy program; and received on-the-job training, which continues.
At the end of 3 months, weekly payments were raised to $75 and later
to $80. The aides are considered to be at Government Service level 2
($4,231), and provision has been made for moving them up to GS—3
and GS—4. The District of Columbia Health Department has written
job descriptions and positions into its budget so that jobs will be
aSSured even when the demonstration phase, financed by NIMH, ends.

Each aide is now responsible for two groups of children, about 20
altogether, ranging in age from 12 to 16, most of them referred be-
cause of school problems, difficulties with the police, defiant attitudes
toward authority, and other symptoms of personal and social mal-
adjustment. (Social workers call them multiproblem children. Said
an aide, speaking of one such child, “When I say he gave the secre-
tary a hard time, I mean he pulled a gun on her.”)

109
335—1119—69—9

The aides act as leaders, planners, and helpers. They conduct ac-
tivities at the youth center, take the youngsters on visits to places of
interest, intercede with the schools and other agencies if necessary,
guide grdup discussions, and act as confidants. They try to combat the
feelings of helplessness, isolation, and indifference found in these
youngsters, and which were common to the aides themselves when
they started training. The aides seek to improve the behavior of their
clients.

These major findings are reported:

0 Young people from a destitute neighborhood and with many
serious problems in their own short histories can be trained for
community mental health work.

0 The aides apparently see their clients’ roblems clearly and
want to help the youngsters get out of be avior patterns that
would lead to trouble. With professional supervision, the aides
have been performing many functions and handlin many dif-

ficult Situations. All have been working at an accepta 1e level.

0 Major changes seen in the aides themselves can be attributed
to their steady, meaningful employment, which has enabled them
to support themselves and stabilize their lives. Marked personality
change has not occurred, but social adjustment has improved
considerably.

There have been problems. The trainees as a group were much more
comfortable with activity and movement than with verbal expression.
So they had considerable difficulty talking about their feelings, and
not all of this has been overcome. They still tend to greet each new
topic with silence. On the other hand, they have shown a far higher
tolerance for frustration than had been expected. They feel the pro-
gram has changed their lives and are strongly attached to the staff
and loyal to the agency.

Now that they have good jobs, though, they would like to move out
of the ‘Cordozo area and probably will do so when the demonstration
program, with its requirement that they live nearby, ends. Their con-
tact with middle-class professionals—most of them Negro, as are all
the aides—has given them a new view of life. While the aides still
feel that the “system” is closed to them, and wonder whether they will
really be able to get jobs when the demonstration project ends, sev—
eral hope to go back to school to further their careers. Research un-
derway is trying to show how the aides have affected the area, and it
may indicate what changes can be expected if they move out and cease
being ever—present models to the other young people. The Institute
of Youth Studies at Howard University reports that it has now trained
more than 150 multi—problem youths, who are working in Washington
schools, settlement houses, and the recreation centers of children’s
institutions. The dropout rate has been less than 1 percent.

The Institute—sponsored demonstration program at Baker’s Dozen

110

(the name comes from a group of 13 women, graduates of Howard,
who opened a settlement house that has since been deeded to Howard
and provides free community service) has become the basis of a nation-
wide program to train young people for public service jobs. More than
5,200 youths, who were either unemployed or living in poverty, have
begun training in 22 States under the New Careers Program of the
Department of Labor. The program is aimed at slightly older persons,
22 and above. But the general goal is the same as in the Baker’s Dozen
model: to train, place, and upgrade young people in such preprofes-
sional jobs as mental health aides, nurses’ aides, social worker assist-
ants, and teacher helpers.

To make training projects as effective as possible, NIMH supports
several efforts to develop model programs. One is under the auspices
of the Albert Einstein College of Medicine of Yeshiva University, of
which the Lincoln Hospital project is a part (230) . The grantee in this
case is also working to extend and enrich the training of presently em-
ployed indigenous workers, supplement the training of their super-
visors, and develop texts and other teaching materials.

As an illustration of what such programs mean to the worker him-
self, a Negro man doing rehabilitation work in Harlem commented:

If you but realize what the future has in store for the man from
the black community, man ambitions would be achieved that the
individual could not see ‘fiefore. In my own case it seemed as
though a new and brighter light was shining, all that was left
for me to do is to move in that direction and problems would be
solved that never had been overcome in my environment.

I feel that I have arrived in the work I want to do because I am
helping my own people the ‘Black Man’ to rise out of the slums
and reach out to live a normal and more fruitful life. There is a
superior feeling over one’s old self in contrast to the new. Plans
can be made that I could not depend on before with a definite goal
in mind. All that it takes now is time and patience.

New Techniques: Protests, Advertising, and the
Telephone

Along with the Wider use and the upgrading of indigenous nonpro-
fessionals have come new techniques in helping people meet mental
health and related problems. Most prominent among these are new
techniques for directly involving the urban resident in the solution
of his problems, as noted earlier under the subsection, “A Demonstra-
tion in Helping Residents of a Slum.” (pp. 80—81)

Often in agencies serving primarily the middle class, the problem is
to help their clients adapt themselves to their society. In a lower socio-
economic group, the most healthful objective may be to help the clients
reject the situation in which they find themselves. They may need to

1911

find better housing or argue with their landlord about improvement.
Political education generally is needed, and so is information about the
potential gains to be achieved through organization—and how to
organize. Often the lower socioeconomic person feels a victim of cir-
cumstance, with some reason, and must be helped to feel a sense of
control over his life and a sense of dignity. The nonprofessional mental
health worker often seems to understand better than the professional
the need of the disadvantaged client to have some mastery over
circumstances.

As work with lower socioeconomic groups has grown, another in-
teresting new development has occurred: the use of advertising to
bring in the new migrant, the abysmally poor person, the unsophisti-
cated. Instead of the discreet signs of the traditional middle-class
agency, some urban counseling centers put up large and even gaudy
signs to compete for attention on a busy street. One agency located
in a highly congested multilingual slum has a number of signs in its
window ofl'ering assistance with housing problems, financial problems,
alcoholism, and help in. dealing with such agencies as the Welfare
Department and the Veterans Administration—each sign in Spanish
as well as in English (181). Such advertising appears to be a healthy
outgrowth of the perceptions of indigenous nonprofessionals about
what is needed in social agencies. The clientele do not seem to feel any
invasion of privacy or any chagrin at being seen in such a well-marked
establishment. A labor union clinic makes use of advertising in another
way (231) . Letters from patients to business agents and union officials
praising the clinic are made available to the union population (with
the names of professionals omitted) , thus spreading the good word.

Some agencies, fearing that they will be overwhelmed by clients,
rely for protection on the fact that many people do not know about
them. For instance, one agency found that less than 10 percent of
those interviewed in a survey of the neighborhood had ever heard
of the services offered; however, half of those who had heard of them
had used them (181). This agency had advertised initially to recruit
aides and to acquaint the neighborhood with its program. But it
stopped “the advertising when it found itself working beyond its re-
sources. All of the agencies who recruit aides inevitably advertise the
agency’s function along with the recruitment request. The use of the
Negro radio and press, the Puerto Rican press, and the labor union
press is a healthy step towards getting the best use of services. So far,
television has been little used, though a study in Detroit showed that
most of the ghetto residents relied on TV first, radio second, and
newspapers last for information (19).

Several projects have found that contact by telephone can be very
helpful to clients. Although the telephone has been used extensively
and successfully in suicide prevention work, it is rarely given an im-

112

portant role in routine psychiatric care. One labor union clinic uses
this medium so that clients can continue work and still keep in contact
with members of the clinic’s staff during critical periods (23]). A
counseling service in a public housing unit also uses the telephone to
reach its clientele. A geriatric rehabilitation project found that for
non-English-speaking older patients, contact with their family and
friends could be more easily maintained by telephone than writing
(232).

Some Projects in the Planning Stage

The Institute hopes to expand its support of projects capitalizing on
the potential of the poor as active contributors in the mental health
field. These projects include :

0 The development and evaluation of a model training program
for mental health aides recruited from disadvantaged areas—con-
ducted by the Division of Social and Community Psychiatry,
University of Southern California School of Medicine (233).
Training would be provided to 24 new persons each year within
the Los Angeles County General Hospital (3 months) , the Central
Cit Community Mental Health Center (3 months), and in the
fiel , each trainee being assigned to a specific agency (3 months).

Clearly, past and current projects show that the indigenous worker
can make an extremely important contribution to improving the
mental health of the poor. Additionally, these programs have an
enormous potential for filling many of the gaps that now exist in
mental health manpower. They serve not only as a source of direct
service personnel but also as a demonstration of how the professional,
through participation in training and consultation work, can effec-
tively extend his services to more people.

If capitalized on, this new aspect of the mental health field as “an
employer of the poor” will have an economic and social impact as well
as a therapeutic one.

113

 

 

 

As soon as public service ceases to be
the chief business of the citizens, and
they would rather serve with their
money than with their persons, the

State is not far from its fall.
—-]ean jacques Rousseau

THE FUTURE OF
URBAN AMERICA

The National Institute of Mental Health is dedicated to reducing the
toll of mental and emotional illness among Americans and to enhanc-
ing the quality of life through increasing the capacity of individuals
for intellectual, emotional, and social self-fulfillment. These goals are
clearly threatened by the crises and stresses buifeting the contempo-
rary urban citizen. Not the Institute alone but social scientists through-
out the country view the future of our cities with some degree of
alarm: such phenomena as increased crowding, the decay of the inner
cities, and the polarization of racial and ethnic groups threaten the
entire fabric of urban life. To alter this prognosis, commitment and
tolerance perhaps unparalleled in American history will be required
of all citizens—black and white, young and old, rich and poor, ghetto
resident and suburbani'te. In addition, the Nation’s social institutions
must respond creatively to human needs, and government at all levels
must demonstrate a flexibility and responsiveness equal to the chal-
lenge. Americans can cope successfully with the serious and complex
behavioral and social problems that confront the Nation’s cities only
if:

0 Programs in mental and physical health, education, housing,
employment, welfare, urban development, and mass transportation
attract sufficient funds and brainpower, public and private, to
ensure that cities will be habitable.

0 Disadvantaged Americans—Negro and white—view with
understanding, tolerance, fortitude, and forbearance the progress
that has been made in political participation, jobs, income, hous-
1ng, and education, and work Within the polltical system for the
changes still needed.

115

0 Businessmen and industrialists, blue- and white-collar
workers, managers, and professionals demonstrate tolerance of
the values, asplrations, language, and life-style of the disadvan—
tage subcultures 0f the city, and where it is esssential that people
overcome handicaps, work with great patience and common sense
to help them do so.

0 Varied programs—educational, industrial, agricultural—are
developed to encourage the unhappy, impoverished people who
now flock to the cities to remain instead in their home regions or in
regions not greatly removed.

Most important, perhaps, the Nation must harness its technology and
marshal its manpower and brainpower to plan for the cities of the
future. The city has, indeed, become America’s frontier.

Social Planning

To some, social planning may seem contrary to the American ideal
of individual freedom. Although it was perhaps unnecessary during
the early days of the American republic, when space and natural re-
sources appeared unlimited, planning is increasingly necessary to
preserve American ideals. Without adequate planning, the Nation’s
natural resources could be depleted and the people might be engulfed
in their own wastes; uninhabitable cities or destructive, repressive so-
cial institutions might develop; the already strained relationships
among different ethnic, socioeconomic and age groups could break,
with disastrous results; the simplest needs of the people for goods
and services could be frustrated.

Social planning does not imply authoritarian control; a planned
society does not mean a closed society. Techniques are now emerging to
guarantee that planning will enhance, not diminish, the power and
influence of individuals in controlling their destinies and achieving
their personal goals. “Advocacy planning” and “participatory democ-
racy” provide for the inclusion of all interested groups and individuals
in the planning and decision-making processes.

Changes in our cities can be planned with full consideration of the
social consequences of such changes. Yet the history of some urban
development projects and certainly of highway construction in some
metropolitan areas indicate that this has not always occurred. Fre-
quently, planners have not fully considered how what they are plan-
ning will affect the lives of the people involved. As a step toward
encouraging the development of planners with a broad social outlook,
the Institute has awarded a training grant to the University of Cali-
fornia at Berkeley to establish a doctoral program in “social policies
planning” (231;). The program, conducted by the University’s de-
partment of city planning, involves a variety of other departments
and professional schools.

116

The Institute also supports a new program at Florida State Univer-
sity, Tallahassee, which is teaching graduate students in urban and
regional planning how to design cities to meet more successfully
people’s social and psychological needs (235) . The curriculum, which
has included work in urban design, regional planning, transportation
planning, and administration and policies planning, now has courses
also in social planning, social psychology, and social welfare and poli-
cies. During the summer between the two years of the program, the
students receive field training in a metropolitan planning agency or
the office of a mayor or city manager.

Fellowships recently awarded by the Institute include studies of
the influence of the physical structure of parks on behavior, the
acculturation of minority groups, and systems of organizing and
delivering social services in big cities. Such studies help prepare plan-
ners, or consultants to planners, to consider human factors in restoring
the cities.

One investigator has developed a model that predicts the form and
magnitude of ghetto development in his city, including the number of
new housing units required (236’). Now he is studying ghettos in four
other cities in order to set up a more detailed model of ghetto growth.

One major factor being studied is housing demand, based on demo—
graphic projections. A second major factor is white reaction to Negro
neighbors, which helps determine the future spatial configuration of
the ghetto. The project expects to predict not only the overall demand
for housing but also the number and type of units—that is, whether
they are rented or owner-occupied——in specific neighborhoods. The
information will be useful in planning mental health and other
services.

The difficulties in planning for human services are compounded by
the fact that numerous agencies are inevitably involved—including
mental health agencies, health agencies, schools, courts, police, wel-
fare, churches, urban renewal, public housing, economic opportunity
programs, and general city planning. The mix is public, private, and
voluntary; local, State, and Federal. Hence, two groups of investi-
gators under NIMH grants are studying how the agencies interact
with one another and can be helped to interact more effectively in the
interest of needed social change at the local level (237, $238) .

Intergovernmental Cooperation

Psychotherapy cannot erase the anguish of hunger, there is no drug
to induce knowledge and self-respect, and the best community mental
health center cannot function well in a community that is not at peace.
NIMH, of course, does not have the mandate to effect the sweeping
social changes required to save the cities, nor is it by any means alone
in its work t0ward a healthier society. Accordingly, the Institute has

117

established effective relationships with other Federal agencies and with
the States in the interest of achieving our common goals.

One of the most signficant 0f the Federally funded service programs
for urban communities is the development—thus far on a pilot basis— ,
of Neighborhood Service Centers. NIMH collaborates in this effort
with four other Federal agencies. These centers represent a sophisti-
cated systems-oriented concept of urban mental health, a concept that
includes. not only the health needs of each resident but also the social,
welfare, employment, and recreational needs. The centers try to meet
these needs by close afiiliation with the local agencies providing various
services and by rapid systems of referral and of records exchange. This
program is based on the fact that, regardless of the number of con—
cerned agencies, people’s needs are not fragmented: mental health
depends very directly on those needs being met in an integrated and
balanced fashion. An experiment is now underway to interlock a com-
munity mental health center and a neighborhood multipurpose service
center, both of which serve the same ghetto. Changes in policy, service,
education, and research are expected to result (1,8).

The Model Cities program, administered by the Department of
Housing and Urban Development, is another attempt by the Fed-
eral Government to renew the cities with systematic attention to
human and social needs. NIMH has helped to review the proposals
submitted by nearly 200 cities. The review team has been concerned
not only with the quality of planning for health, education, and wel-
fare services but also with the plans for integrating those services
with one another and with the measures intended to meet housing,
employment, transportation, and recreation problems. It has been
concerned, too, with the plans for involving the residents of the areas
to be served, in order to ensure that they will get the services they need.
This comprehensive approach to planning was initially difficult for
the cities, many of which had not previously addressed themselves to
questions of relationships among programs and of the relation of all
the programs to the quality of life. NIMH also supports a specific
study of the nature of the mental health services incorporated in suc-
cessful Model Cities plans (239) .

Enlisting Those Who Can Help

Increasingly large numbers of professionals must be trained and
tuned to the mental health needs of our cities—some dedicated to
research, others to clinical work of many types, others to leadership
in making the best use of community resources, existing or to be
developed. There will perhaps never be enough psychiatrists, psy-
chologists, psychiatric social workers, and psychiatric nurses to meet
the mental health needs of the American people. But, as we have seen,
the mental health field does not belong exclusively to any group of pro-

118

fessionals. If such frontline social agents as the teacher, the clergyman,
the policeman, and the welfare worker can recognize signs of poor
mental health and can turn to the community mental health center for
advice, and if general practitioners will acquire the skills and accept
the responsibility for dealing with many of the emotional problems of
their patients, prevention and treatment will be far more effective than
in the past.

The Institute sponsors training programs, many of them striking
out in new directions, to greatly increase the supply and the com-
petence of mental health personnel working in inner-city neighbor—
hoods. In particular, the Institute encourages and finances programs
that train poor people themselves as mental health workers. Under
the Technical Assistance Project program, mental health stafl’s in
the regional oflices of the Public Health Service hold symposiums for
nurses, social workers, clergymen, and others on such subjects as alco-
holism, aging, crime and delinquency, emotional disturbances in chil-
dren, and special problems of rural areas. The staff of the NIMH
Center for Studies of Metropolitan and Regional Mental Health Prob-
lems has consulted with a number of individuals, groups, and govern-
ment organizations seeking advice on the prevention of urban riots.
In a variety of other ways, the Institute disseminates information to
increase the capacity of individuals and agencies to recognize and do
something about mental health problems.

Bold Research, Better Information, and Sound
Evaluation

Clearly, the best intentioned service programs are doomed to fail
unless they are based on sound information. Though steps toward
immediate amelioration of a social problem are often plain to see,
and should be taken quickly, the full solution is frequently complex
and sometimes only research can reveal the whole scope of the problem.
Often, too, an intended solution is applied, and then no effort is made
to learn whether or not the people affected really are better off. Care-
ful evaluation of any program, approach, technique, or hypothesis
is clearly necessary if we hope to plan successfully for the future.

Community decision-makers today must plan for human services,
and fix budgets for them, on the basis of opinion and inadequate fac—
tual data. A project in New Haven seeks to remedy the situation
by developing information about the use being made of the communi-
ty’s care-giving system, composed of health, welfare, and related
agencies (240). As the first comprehensive effort to record and study
the human service systems of a metropolitan community, the project
holds promise not only for motivating agencies to change, but also
for indicating the services that need special emphasis. For disadvan-

119

taged groups not receiving adequate services, the nature of their
needs will become apparent and measures to meet them can be taken.

The task ahead remains formidable. New avenues of research must
be opened and older ones more fully explored; new techniques for
treatment and rehabilitation must be developed, tested, and refined.
We must learn more about human responses to social and physical
density. We must uncover the relationship between psychiatric dis—
order and the sociocultural environment in a big city as compared
with the relationship in a rural community.

Finally, and most importantly, we must inspire the American peo-
ple, and particularly the younger generation, to devote themselves to
the sweeping social changes that are needed to liberate the American
city from its psychological and social ills. The wars against poverty,
ignorance, and hatred are wars fought in the name of every citizen.
In the final analysis, the mental health of each citizen is affected by
the maturity and health of our society—from the smallest unit to the
largest. The structure of the home and the well-being of the family,
the compassion of the surrounding community, the social conscience
and social action of our government and its citizens—all of these
are crucial. If we fail at any point, the outcome is clear :' We shall
walk a treadmill of pathology and social unrest. If we succeed, the
grandest dreams of the American heritage can become reality.

Carl Sandburg sang:

I am the people . . . the crowd . . . the mass.
Do you know that all the great work of the

world is done through me?

120

REF ERENCES*

(J ) McClosky, Herbert
Personality and Social Beharior
University of California
Berkeley, Calif.
(2) 'Lewis Oscar
The 07ulture o f Poverty in Puerto Rico and New York
University of Illinois
Urbana, Ill.
(3) “Cities in Crisis, The Challenge of Change,” DHEW,
Welfare Administration, Publlcation No. 20.
(4) “The Shape of Poverty in 1966”
Social Security Bulletin, March 1968.
(5) Rennie, Thomas A. C.
The Epidemiology of Mental Disorders in a Metropolitan
Population
Cornell University
\ New York, N.Y.

(6’) Klee, Gerald L.
Friends of Psychiatric Research
Maryland Psychiatric Case Register
Baltimore, Md.

(’7) Hollingshead, August B.
Ten—Year Followup 0 f Psychiatric Patients
Yale University
New Haven, Conn.
_(8) Kohn, Melvin L.
Laboratory of Socioenvironmental Studies, NIMH
(9) Lewis, Hylan
I mprooiny Uhild Bearing in Low Income Families
Health and Welfare Council of National Capital Area
Washington, DC.
(10) Short, James
Street Corner Groups and Patterns of Delinquency
Washington State University
Seattle, Wash.
(11) 'Gouldner, Alvin W.
Social and Community Problems in Public Housing Area
Washington University
St. Louis, Mo.

*References to NIMH projects identify project titles, sponsoring institutions,

locations, and, where relevant, principal investigators—not the individual pub-
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121

(12)
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(14)

(15)

(16)

(17)

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122

Goodrich, Wells

Child Research Center, NIMH

Pasamanick, Benjamin

Behavior as Dependent Upon Prenatal Treatments
Ohio State University

Columbus, Ohio

Clausen, John A.

The Berkeley Growth Study Patterns of Development
University of California

Berkeley, Calif.

Caldwell, Betty

Infant Learning and Patterns of Family Care
Syracuse University

Syracuse, N.Y.

Held, Richard M.

Sensorimotor Coordination in Man and Monkey
Massachusetts Institute of Technology

Cambridge, Mass.

Green‘berg, Na‘hman H.

Psychophysiological Studies During Infancy
University of Illinois

Chicago, Ill.

Forgays, D. G.

Factors Affecting the Efliciency of Infant and Adult Learning
Cornell University

New York, N.Y.

Clark, Kenneth

Dark Ghetto; Dilemmas of Social Power

Harper and Row, New York, p. 121.

The Challenge of Crime in a Free Society, A Report by the
President’s Commission on Law Enforcement and Adminis-
tration of Justice

US. Government Printing Office, 1967, p. 71.

Luby, Elliot D.

A Social Psychological Study of Detroit’s Civil Disturbance

Lafayette Clinic

Detroit, Mich.

Sohaefer, Earl

Laboratory of Psychology, NIMH

MoCaloe, Alice R.

The Intellectually Su erior Child in a Socially Deprived Area

Community Service gociety of New York

New York, N.Y.

Gray, Susan

Parental Identification, Sex Role, and Adjustment

Peabody College for Teachers

Nashville, Tenn.

Klaus, Rupert A.

Earl Training for Culturally Deprived Children

Mur reesboro City Schools

Murfreesboro, Tenn.

(94)
(95)
(96)
(97)
(98)
(29)
(30)
(3!)
(39)
(33)
(34)
(35)

(36)

Lourie, Reginald S.

Prevention of Culturally Determined Retardation
Research Foundation of Children’s Hospital
Washington, DC.

Weissman, Harold H.

Supportive Play Groups for Underachievers
Mobilization for Youth

New York, NY.

Swander, Constance N.

A Pre-School Program for Spanish-Speaking Children
Good Samaritan Center

San Antonio, TeX.

Schifl', Sheldon K.

Evaluation of a Gommunity—Wide Program in First Grade
University of Illinois College of Medicine

Chicago, Ill.

Korts, Anita

Social Grou Work with the Socially Deprived
Cam Fire irls

Los nge‘les, Calif.

Golin, Stanford

Self-Esteem and Goals of Indigent Children
University of Pittsburgh

Pittsburgh, Pa.

Reiser, David E.

Antisocial Behavior in Early Ghildhood

James Jackson Putnam Children’s Center

Boston, Mass.

Brown, Racine D.

Crisis Intervention in Pre- and Early School Years
South Carolina Department of Mental Health
Columbia, SC.

Rosen, Bernard

Family Structure, Achievement, Motivation, and Economic
University of Nebraska

Lincoln, Nebr.

Foley, Matthew F.

Arriba J untos—F orward Together

Catholic Charities of the Diocese of Brooklyn
New York, NY.

McCoy, Earl

Intervention in the Face of Neighborhood Blight
Auraria Community Center

Denver, Colo.

’Saalwaeehter, Gene

Berkeley Workreation Program

Berkeley Work-Recreation Committee

Berkeley, Calif.

Educational Counseling Service

Board of National Misswns

United Presbyterian Church

New York, NY.

123

(37) Jackson, Luther
Utilizing Research Findings on the Urban Poor
Health and Welfare Council
Washington, DC.

(38) Bacon, Margaret K.
A Cross-Cultural Study of Alcohol Consumption
Yale University
New Haven, Conn.

(39) Lippitt, Ronald
Social and Psychological Factors in Juvenile Delinquency
University of Michigan
Ann Arbor, Mich.

(40) Whiting, John W.
The Development of Self—Control in Children
Harvard University
Cambridge, Mass.

(41 ) Scanzoni, John H.

Change a Family Organization
Indiana iversity Foundation
Bloomin n, Ind.

(42) Blauner, Robert
Ethnic Manhood Orientations
University of California
Berkeley, Calif.

(43) Schoor, Alvin L.
Slams and Social Security
US. Department of Health, Education, and Welfare
Social Security Administration,
Research Report No. 1

(44) Calhoun, John
Laboratory of Psychology, NIMH

, (4,5) Terman, C. Richard

Early Social Experience and Population Asymptote
College of William and Mary
Williamsburg, Va.

(46') Hocking, Frederick H.
A Study of the Late E fleets of E wtreme Environmental Stress
Monash University
Melbourne, Australia

(47) Hall, E. T.
Ethnic Use of Micro-Space in Interpersonal Encounters
Illinois Institute of Technology
Chicago, Ill.

(48) Jesness, Carl F.
Treatment Typology in an Institutional Setting
Institute for the Study of Crime and Delinquency
Sacramento, Calif.

(.49) Simmons, Ozzi G.
Urbanization of the Migrant—Processes and Outcomes
University of Colorado
Boulder, Colo.

124

(50) Thomas, Dorothy
Migration and Mental Disease
University of Pennsylvania
Philadelphia, Pa.

(51) Parker, Seymour
Mental Illness and Migration
Jefferson Medical College
Philadelphia, Pa.

(5.?) Breed, Warren
Characteristics of People Who Commit Suicide
Tulane University
New Orleans, La.
(53) Hirabayashi, James
A Social Survey of American Indian Urban Integration
San Francisco State College
San Francisco, Calif.
(54) Graves, Theodore D.
Study of Nauaho Urban Relocation in Denver, Colo.
University of Colorado
Boulder, Colo.
(55) Goldberg, Martin
Mental Health of Persons in Flight
Travelers Aid Society
Philadelphia, Pa.
(56‘) Lindemann, Erich
Relocation and Mental H ealth—Adaption Under Stress
Harvard University School of Medicine
Boston, Mass.
(5’7) Bandler, Bernard
Mental Health Seruices During Relocation Crisis
University Hospital
Boston, Mass.
(58) Blumberg, Leonard '
A Study of the Prevention of Skid Row
Philadelphia Diagnostic and Relocation Service Corp.
Philadelphia, Pa.
(59) Caplow, Theodore
Homelessness: Etiology Patterns and Consequences
Columbia University
New York, N.Y.
(60) Bradburn, Norman M.
Social Psychological Factors in I ntergroup Housing
National Opinion Reasearch Center
Chicago, Ill.
(61) Byrne, Donn E.
Interpersonal Attraction and Reinforcement Variables
University of Texas
Austin, Tex.
(6‘2) Feshbach, Seymour
The Organization and Regulation of Anger and Aggression
University of California
Los Angeles, Calif.

125
335—119—69—10

(63) Rotter, Julian B.
Psychological Factors Influencing Interpersonal Trust
University of Connecticut
Storrs, Conn.

(61,) Thune, Jeanne M. _
A Study of Racial Attitude Changes in Older Adults
Senior Citizens, Inc.

Nashville, Tenn.

(65) Lane Mary
The IVursery School in Preventive Mental Health
San Francisco State College
San Francisco, Calif.

(66) Kelman, Herbert
Social Influence and Behavior Change
University of Michigan
Ann Arbor, Mich.

(67) Lauman, Edward O.

Stratified Association in an Urban Community
University of Michigan
Ann Arbor, Mich.

(6’8) Tuden, Arthur
Support for Field Study by NIMH Research Fellow
Universit of Pittsburgh
Pittsburg , Pa.

(69) Elmer, Elizabeth
Neglected and Abused Children and Their Families
Children’s Hospital of Pittsburgh
Pittsburgh, Pa.

(70) Van Amerongen, Suzanne
Interaction in Families with an Antisocial Child
Douglas A. Thom Clinic for Children, Inc.

Boston, Mass.

(71) Lidz, Theodore
Interpersonal Family Environment in Schizophrenia
Yale University, School of Medicine
New Haven, Conn.

(72) Lehman, Joseph D.

Study of the Comm/unity Content of Delinquent Behavior
University of California
Berkeley, Calif.
(73) Miller, Walter B.
Control 0 Gang Delinquency
Boston niversity
Boston, Mass.

(74) J ansyn, Leon
Post-Gang Career Followup Study
Southern Illinois University
Carbondale, Ill.

(75) Toby, Jackson
Subcultural Delinquency in Five Industrial S ccieties
Rutgers—The State University
New Brunswick, NJ.

126

(76) Sellin, Thorsten
E wterwion Character of Delinquency in an A ge-C ohort
Universit of Pennsylvania
Philadelp '51., Pa.
(77) Gold, Martin
National Survey of Youth
University of Michigan
Ann Arbor, Mich.
(78) Con er, John J.
The arly I dentifloation of M aladaptive Behavior
University of Colorado Medical Center
Denver, Colo.
(79) Robins, Lee N.
Childhood Predictor of Mobility and Criminality
Washington University School of Medicine
‘St. Louis, Mo.
(80) Herzog, Elizabeth
About the Poor, Some Facts, Some Fiction
The Children’s Bureau
Health, Education and Welfare, 1967

(81) Quay, Herbert G.
Dimension of Personality in Juvenile Delinquency
Northwestern University
Evanston, Ill.

(82) Wheatley, Spencer W.
Youth Rehabilitation via Individual Planning and Care
Children’s Home Finding and Aid Society of North Idaho, Inc.
Lewiston, Idaho

(83) Ikeda, Tsugo
Eflectiveness of Social Work with Acting-Out Youth
Seattle Atlantic Street Center
Seattle, Wash.

(84) Farris, Buford E.
Neighborhood A yproach to Mexican-A merican Gangs
Wesley Community Center
San Antonio, Tex.

(85) McKee, John
Self-Instructional Program for Youthful Oflenders
Draper Correctional Center
Elmore, Ala.

(86‘) Grant, Douglas
Developing Ofenders for Crime and Delinquency W orh
Institute for the Study of Crime and Delinquency
Sacramento, Calif.

(8’7 ) Minuchin, Salvador
Families of Children in Residential Treatment
Wiltwyck School for Boys
New York, N.Y.

(88) Wilner, Daniel
Assessment of Group Treatment in Correction Agencies
Universit of California
Los Ange es, Calif.

127

(8,9) Polsky, Howard
E mploration of Psychological Pathology and Treatment
Hawthorne Cedar Knolls School
Hawthorne, N.Y.
(.90) Konopka, Gisele
The Adolescent Girl in Conflict
School of Social Work
University of Minnesota
Minneapolis, Minn.
(91) Morton, David
I mproving a Program for Sexual Psychopaths
Dr. Norman M. Beatty Memorial Hospital
Westville, Ind.

(.92) Chamberliss, William J.
The Identification and Processing of Social Deviants
University of Washington
Seattle, Wash.

(.93) Warren, Marguerite
An Evaluation of Oomnuunity Treatment for Delinquents
California Youth Authority
Sacramento, Calif.

(.94) Shireman, Charles
Experiment in Casework in Probation
University of Chicago
Chicago, Ill.

(95) McEachern, A. W.
Probation and Treatment in Delinquency
University of Southern California
Los Angeles, Calif.

(96') Lohman, Joseph
E fleet of Variation on Probation Supervision Practice
University of California
Berkeley, Calif.

(.97) Toby, Jackson
Gradual Community lie-integration of Delinquents
Rutgers—The State Univers1ty
New Brunswick, N.J.

(98) Beck, Bertram
Mobilization for Youth-Action Grant
Mobilization for Youth
New York, N.Y.

(99) Porter, Hercules
Work Therapy Pro ram for Adolescent Delinquents
Jewish Vocational ervices
Milwaukee, Wis.

(100) Shore, Milton
Mental Health Study Center, NIMH
(10]) Sigurdson, Herbert

Social Change as a Function of Gommunity Education

University of Southern California
Los Angeles, Calif.

128

(102)

(103)

(104)

(105)

(106)

(107)

(108)

(109)

(110)

(111)

(112)

(113)

(114)

Grant, Douglas

A Typology of' Violence According to Purpose
Institute for the Study of Crime and Delinquency
Sacramento, Calif.

Megargee, Edwin

The Psychodynamics and Prediction of I ndinidual Violence
Florida State University

Tallahassee, Fla.

Wallace, Samuel

A Study of Interpersonal Violence

Bureau of Applied Research

Columbia University

New York, N.Y.

Schafer, Stephan

Criminal-Victim Relationship in Crimes of Violence
Florida State University

Tallahassee, Fla.

Wolfgang, Marvin E., and Ferracuti, Franco
The Subculture of Violence

Tavistock Publications Limited

Great Britain, 1967

Kurland, Albert

Study of Psychotic Murders

Spring Grove State Hospital

Baltimore, Md.

Connolly, Arch

Improving Patient Care of Maximum Security
Rusk State Hospital

Rusk, Tex.

Warren, Marguerite

Center for Training in Diflerential Treatment
Institute for the Study of Crime and Delinquency
Sacramento, Calif.

Irving, John

National J unenile Court Judges Training Project
National Council of Juvenile Court Judges
Chicago, Ill.

Touro Infirmary CMHC

1400 Foucher Street

New Orleans, La.

Spiegel, John P.

Origin and Control ofCommunity Violence
Brandeis University

Waltham, Mass.

Caplan, Nathan S., and Matlick, Hans
Floating B eha/vior and Inner City Delinquency
University of Michigan

Ann Arbor, Mich.

Bernstein, Saul

Adolescent Group Aggressions Phenomena
Boston University

Boston, Mass.

129

(115) Wilkinson, Charles B.
Epidemiological Study of Kansas City Riots
Greater Kansas City Mental Health Foundation
Kansas City, M0.
(116') Raine, Walter J.
Study of the S read of Civil Disorder
Universit of alifornia
Los Ange es, Calif.
(117) Seaman, Melvin
A Comparative Study 0 f Alienation in Work
University of California
Los Angeles, Calif.
(118) Danzger, M. Herbert
Civil Rights Conflicts and C om/m/anity Power Structure
Research Foundation of State University of New York
Stony Brook, NY.
(11.9) Quarantelli, Enrico L.
Organizational Respomes to Major C own/unity Crises
Ohio State Univers1ty
Columbus, Ohio
(1:20) Fogelson, Robert M.
A Study of Pamticipation in the 1960’s Riots
Columbia Univers1ty
New York, NY.

(121) Conant, Ralph W.
Workshop on Research Problems in Community
Brandeis University
Waltham, Mass.

(122) Thune, Jeanne M.
E flects 3f Racial Violence on Interracial Prejudice
Senior itizens, Inc.
Nashville, Tenn.

(123) Watson, Nelson
Changes in Role Concept of Police Officers
International Associatlon of Chiefs of Police, Inc.
Washington, DC.

(124) Rapoport, Anatol
Studies 0 f Conflict and Cooperation in Small Groups
University of Michigan
Ann Arbor, Mich.
Steiner, Ivan D.
Personality and Responses to International Conflict
University of Illin01s
Urbana, Ill.
Blumberg, Leonard
A Study 0 the Prevention 0 f Skid Row
Philadelp ia Diagnostic and Relocation Service Corp.
Philadelphia, Pa.

(125) Duvall, H. J., Locke, B. Z., and Brill, Leon
Follow—up Study of Narcotic Drug Addicts Five Years After

Hospitalization

Public Health Reports, March 1963

130

(126‘) Diskind, Meyer H., and Klonsky, George
Recent Developments in the Treatment of Paroled Offenders
Addicted to Narcotic Drugs
New York State Division of Parole
Albany, NY.
(127) Bear, Larry A.
Lower Manhattan Catchment Dome
New York City Addiction Services Agency
New York, NY.
(128) Wieland, William I.
Tri-Catchment Area Narcotic Addiction Treatment Program
West Philadelphia Community Mental Health
Philadelphia, Pa.
(129) Hollingsworth, S. W.
C omprehensioe Heroin Treatment Demonstration Project
Bernalillo County
University of New Mexico
Albuquerque, N.Mex.
(130) Kleber, Herbert D.
Narcotic Addict Treatment Program
Conn. Mental Health Center
New Haven, Conn.
(131) Brotman, Richard E., and Freedman, Alfred M.
A Dag-Night Center for Addicted Persons
New York Medical College
New York, NY.
(132) Brotman, Richard E.
A Regional Center for Studies in Substance Use
New York Medical Colleg
New York, NY. .
(133) Korchin, Sheldin J.
Therapeutic E a Zorations with Adolescent Drug Users
University of alifornia
Berkeley, Calif.
(J34) Shelly, Joseph A.
Therapeutic Community and Testing Program for Drug
Addicts ’
Probation Department—Supreme Court
Brooklyn, NY.
(135) Densen, Paul M.
Establishing a Narcotics Register
MeIdical and Health Research Association of New York City,
nc.
New York, NY.
(136) Pilot Study on Illegal Drug Abuse in Maryland
Friends of Psychiatric Research, Inc.
Baltimore, Md.
(J37) Pearlman, Samuel
Patterns of Student Drug U so and Abuse in Urban Universities
Brooklyn Collage of City University of New York
New York, N. .

131

(138) Goldstein, Joel W.

Extent and Patterns of College Student Drug Use
Carnegie—Mellon University
Pittsburgh, Pa.

(139) Robins, L.

History of Marihuana Users
Washington University
St, Louis, M0.

(140) Ball, John C.

NIMH Addiction Research Center
Lexington, Ky.

(14]) O’Donnell, John A. '
NIMH Clinical Research Center
Lexington, Ky.

(142) Speck, Ross U. ,
Psychosocial N etworlcs 0 Young, Dangerous Drug Users
Hahnemann Medical Co lege and Hospital
Philadelphia, Pa.

(143) Geode, B. Erich
A Sociological Study of Marihuana Users
Research Foundation of State University of New York
Albany, N. Y. '

(I44) Zola, Irving K. v
Career of Lower Socioecomonic Drug User
Florence Hiller Graduate School
Brandeis University
Waltham, Mass.

(145) Wallerstein, Robert S., and Pittel, Stephen M.
Psychosocial Factors in Drug A buse
Mt. Zion Hospital Medical Center
San Francisco, Calif.

(146) Meyers, Frederick H.

Drug Practices in the Haight—Ashburg Sub-Culture
University of California Medical Center
San Francisco, Calif.

(J47) Holmes, Douglas
Drug Use in Matched Groups of H ippies and 1V on-H ippies
Association of YM-YWHA’s of Greater New York
New York, N.Y.

(148), Gordon, Robert S.

Integrating Functions of Drug Addiction
Johns Hopkins University
Baltimore, Md.

(149) Stone, Christopher D.

Legal Significance 0 f H allucinogenic Drug Research
Law Center, University of Southern Calif.
Los Angeles, Calif.

(J50) Levine, Jerome

NIMH Psychopharmacology Research Branch

132

(151) Herbert, Charles C.
Natural History of Psychotropic Drug Use
Kaiser Foundation Research Institute
Oakland, Calif.
(15%) D. E. M anheimcr Survey of Drug Use Patterns
Langley Porter Institute
San Francisco, Calif.
(153) Kindlesperger, Kenneth
Psychiatric Social World (M S W)
University of Louisville
Louisville, Ky.
(154) Brotman, Richard
Residency Training in Community Psychiatry
New York Medical College
New York, N.Y.
(155 ) K‘aplan, Harold
Psychiatry—Basie Residency (Graduate)
New York Medical College
New York, N.Y.
(156) Turk, Austin
Research T raining—S ocial Sciences
Indiana University Foundation
Bloomington, Ind.
(157) Pittman, David J.
Mental Health Training for Law-Enforcement
Washington University
St. Louis, M0.
(158) Levin, Joseph J.
A Psychopharmacology Training Program for Youth Workers
The Chicago Medical School
Chicago, Ill.
(15.9) Mayer, Joseph
Drug Addiction
Boston State Hospital
Dorchester, Mass.
(160) Drag Abuse Education
NEA Journal, March 1969
National Education Association
Washington, DC.
(161) Public Education Campaign on Drug Abuse
Grey Advertising, Inc,
New York, N.Y.
(162) Rochester Mental Health Center
1425 Portland Avenue
Rochester, N.Y.
(163) Western Missouri Community Mental Health Center
600 East 22nd Street
Kansas City, M0.
(164) VVestside Community Mental Health Center, Inc.
c/o Mount Zion Hospital
1600 Divisidero Street
San Francisco, Calif.

133

(165 ) Hill West Haven Service
Connecticut Mental Health Center
34 Park Street
New Haven, Conn.

(166') Tufits New England Medical Hospital
Community Mental Health Center
Boston, Mass.

(167') Hahnemann Medical College and Hospital of Philadelphia

Community Mental Health Center

Hotel Philadelphia

314 North Broad Street

Philadelphia, Pa. .

(168) Howard University Community Mental Health Center

( Area B )

DC. Department of Health

Indiana Avenue, NW

Washington, DC.

(169) Maimonides Community Mental Health Center
4802 10th Avenue
Brooklyn, NY.

(170) Medical Center Complex
Illinois State Psychiatric Institute
1601 West Taylor Street
Chicago, Ill.

(17]) Lincoln Hospital Mental Health Center
333 Southern Boulevard
Bronx, N.Y.

(I72) Mid-Houston Mental Health Center
St. J oseph’s Hos ital
1919 LaBranch treet
Houston, Tex.

(173) Golden State Community Mental Health Center
(Hathaway Home for Children)
11600 Eldrid e Street
Pacoima (L. .) , Calif.
(I74) Temple University Community Mental Health Center
3401 North Broad Street
Philadelphia, Pa.
( 175) Community Mental Health—Mental Retardation Center
Fayette and Pearl Streets
Baltimore, Md.
(176) Winter Haven Hospital
200 Avenue 2, NE.
Winter Haven, Fla.
(177 ) The Guidance Center
1220 Willis Avenue
Daytona Beach, Fla.
(178) Rainbow Mental Health Center
36th and Rainbow Boulevard
Kansas City, Kans.

(I79) Garfield Park Service Mental Health Center
Chicago, Ill.

134

(180) Garfield Park Community Mental Health Center
Chicago, Ill.

(18]) Peck, Harris
Study of Neighborhood Centers and Mental Aides
Lincoln College
Albert Einstein School of Medicine
Bronx, N.Y.

(182 ) Sound View-Throgs Neck Community Mental Health Center
2527 Gelbe Avenue
New York, N.Y.

(183) DeCnver General Hospital Community Center Mental Health
enter
West 6th Avenue and Cherokee Street
Denver, C010.
([84) Western Missouri Mental Health Center
600 East 22nd Street
Kansas City, M0.

(185 ) Greater Little Rock Community Mental
Health Center
4313 West Markham
Little Rock, Ark.
(186) Boston University Community Mental
Health Center
15 Ashburton Place
Boston, Mass.
(187 ) Bandler, Bernard
Evaluation of Facilitators in Community
Mental Health
Boston University Hospital, Department of Psychiatry
15 Ashburton Place
Boston, Mass.

(188) Pennsylvania {Hospital Community Mental
Health Center
8th and Spruce Streets
Philadelphia, Pa.
(189) Central City Community Mental Health Center
4272 South Broadway
Los Angeles, Calif.
(190) DiFuria, Guilio
Preparation for Transition
Western State Hospital
Fort Steilacoom, Wash.

(191) Boston State Hospital
591 Morton Street
Boston, Mass.
(1.92) Weiner, Hyman
Mental Health Rehabilitation for
a Union Population
Sidney Hillman Health Center
New York, N.Y.

135

(1.93) Fink, Raymond

(194)

(1.95)

(1.90)

(1.97)

(108)

(1.9.9)

(200)

(201)

(202)

(203)

(904)

(205)

136

Psychiatric Treatment and Patterns

of Medical Care
Health Insurance Plan of Greater New York
New York, N.Y.
Glasser, Melvin
The E flects of Prepayment on Use of Psychiatric Care
Michigan Health and Social Security Research Institute
Detr01t, Mich.
Spiro, Herzl
Psychiatric Care Among a Group of Union Workers
School of Medicine, The Johns Hopkins University
Baltimore, Md.
Christmas, June Jackson
Psychiatric Rehabilitation with Nonprofessional Aides
Columbia University, College of Physicians and Surgeons
New York, N.Y.
Cragg, Logan
A Community Placement Program for Chronic Patients
Eastern State Hospital
Lexington, Ky.
Carey, Jean
Senior Advisory Service for Public Housing Tenants
Community Service Society
New York, N.Y.
Stotsky, Bernard
Study of Mental Patients in Nursing .Homes
Northeastern University
Boston, Mass.
Wilner Daniel
Psychological Factors of Retirement Housing
University of California
Los Angeles, Calif.

McLeod, Stuart

Administrative and C om/munity Psychiatry

New York School of Psychiatry

New York, N.Y.

Romano, John

Community Psychiatry

University of Rochester

Rochester, N.Y.

Doctoral Program-School Psychological Services

Yeshiva University
New York, N.Y.

Field Training in Clinical and Community Psychology
South Shore Mental Health Association, Inc.

Quincy, Mass.

Clinical Psychology

University of Cincinnati

Cincinnati, Ohio

(£06) Undergraduate Training—Pilot Project
Yale University
New Haven, Conn.

(207) Research Training-Social Sciences

University of Illinois
Urbana, Ill.

(208) Research Training-Social Sciences
University of Chicago
Chicago, I11.

(209) Psychiatric Social Work, MSW
Universit of Denver
Denver, 010.

(210) Psychiatric Social Work, MSW
Florida State University
Tallahassee, Fla.

(211) Psychiatric Social Work, MSW
University of Texas
Austin, Tex.

(212) School Social Work
Tulane University
New Orleans, La.

(213) Social Work, Community Organization
Columbia University
New York, N.Y.

(214) Social Work, Community ZlIental Health
New York University
New York, N.Y.

(215) Social Work, Community Mental Health
Adelphi University
Garden City, N.Y.

(216) Social Work, Community Organizations
Howard University
Washington, DC.

(217) Social Work, Corrections
University of Minnesota
Minneapolis, Minn.

(218) Social Work, Aging
Florida State University
Tallahassee, Fla.

Social Work, Community Planning
Boston College
Boston, Mass.

(219) Nursing, Community Mental Health
University of California
San Francisco, Calif.

(220) Inseroice, Community Mental Health Nursing
University of California
Los Angeles, Calif.

(221 ) Community Mental Health Nursing
Boston University
Boston, Mass.

137

(222) H opelessness to Leadership
Special Service for Groups, Inc.
Los Angeles, Calif.
U 86 of 1V on-Pro fessionals in M H Work
American Psychological Assn.
Washington, DC.

(223) Pilot Project-Mental Health Training Program for Community

Workers

Temple University
Philadelphia, Pa.

(5224) Internship for Clergy in Mental Health
Western Reserve University

Cleveland, Ohio
(225) Mental Health Training for Law Enforcement ()Jficers
Washington University

St. Louis, Mo.

Continuing Education

Washington School of Psychiatry/Associated Faculties
Program

Washington, D.C.

Continuing Education

University of Southern California

Los Angeles, Calif.

The Settlement Worker and Inner—City Violence—A
Conference

National Federation of Settlements and Neighborhood Cen-
ters, Inc.

New York, N.Y.

(226) Fishman, Jacob
Baker’s Dozen; A Program of Training Young People as Men-
tal Health Aides '
Institute of Youth Studies
Howard University
Washington, DC.
(227) Resthaven Hospital
Los Angeles, Calif.
(228) Lincoln Hospital Mental Health Center
333 Southern Boulevard
Bronx, N.Y.
(22.9) Temple University
Community Mental Health Center
3401 North Broad Street
Philadelphia, Pa.
(230) Yeshiva University
Albert Einstein College of Medicine
New York, N.Y.
(231) Serivners, Sylvia
Sidney Hillman Health Center
New York, N.Y.

(232) Donahue, Wilma
University of Michigan
Ann Arbor, Mich.

138

(233) Rogauski, Alexander
Studies in Psychoanalytic Theory
State of New York—Downstate Medical Center
New York, N.Y.

(234) Webber, Melvin
Social Policies Planning
University of California
Berkeley, Calif.

(235) McClure, Edward
Social Planning Management
Florida State University
Tallahassee, Fla.

(236) Rose, Harold M.
Analysis of Changes in Spatial Units
University of Wisconsin
Madison, Wis.

(237) Connery, Robert H.
Mental Health Programming in Urban Areas
Duke University
Durham, NC.

(5238) Warren, Roland L.
Community Structure and Development
Brandeis University
Waltham, Mass.

(239) Warren, Roland L.
Mental Health Agencies and Model Cities Programs
Brandeis Univers1ty
Waltham, Mass.

(240) Hollingshead, August
Monitoring Human Services in a Community
Community Council of Greater New Haven
New Haven, Conn.

139

ACKNOWLEDGMENTS

This report was written by Herbert
Yahraes under the direction of Dr. Julius
Segal and with the assistance of Bayard
L. Catron, Bonnie Eisenberg, Joy
Finnegan, Helen Hyre, Gay Luce, and
Clarissa Wittenberg.

140

“.5. “OVERNMENT PRINTING OFFICE: [989

 

U.C .BEHKELEV LIMARIES

CDE‘IEBLEU?

A Publication of the
National Clearinghouse for Mental Health Information

0. 4i
x o ”I I: El

01‘

Public Health Service Publication No. I906

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
Public Health Service-Health Services and Mental Health Administration

National Institute of Mental Health