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4

i
t

74-19,802
ETHRIDGE, David Allan, 1933A METHODOLOGY FOR THE EVALUATION OF COMMUNITY
MENTAL HEALTH PROGRAMS AND ITS APPLICATION TO
COMMUNITY MENTAL HEALTH SERVICES IN MICHIGAN.
Michigan State University, Ph.D., 1974
Health Sciences, public health

Xerox University Microfilms ,

©

Ann Arbor, Michigan 4810B

1974

DAVID ALLAN ETHRIDGE

ALL RIGHTS RESERVED

A METHODOLOGY FOR THE EVALUATION OF COMMUNITY
MENTAL HEALTH PROGRAMS AND ITS APPLICATION
TO COMMUNITY MENTAL HEALTH SERVICES
IN MICHIGAN

By

David A. Ethridge

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Counseling, Personnel Services
and Educational Psychology

1974

ABSTRACT

A METHODOLOGY FOR THE EVALUATION OF COMMUNITY
MENTAL HEALTH PROGRAMS AND ITS APPLICATION
TO COMMUNITY MENTAL HEALTH SERVICES
IN MICHIGAN
By
David A. Ethridge

Community mental health is a contemporary concept with a heri­
tage that goes back to eighteenth century advocates of moral treat­
ment of the menatlly ill, strengthened by crusades for public care of
the "insane” which lead to the establishment of state asylums or in­
stitutions, and ultimately to the works of Sigmund Freud and the devel­
opment of psychoanalysis.

But, it was probably the advent of the

psychotropic drugs in the mid-1950;s that produced the largest revo­
lution .
Between the period of 1956 and 197) residents in state insti­
tutions fell from over 550,000 to just over 300,000.

During this same

period admissions increased from 185,000 to over 414,000 per year and
the employed staff of these 277 state institutions grew from 153,000
to 226,000.

The result was improved treatment, shorter length of

stay and a speedy release into the community.
With such a change in the service pattern for treatment of
the mentally ill it was inevitable that growing pressures for treat­
ment programs in the community would cause a national interest and

David A. Ethridge

focus on community programming.

President John F. Kennedy in his 1963

Congressional address on mental health called for a "bold new approach,"
a community mental health program where persons could receive care in
their own communities diminishing the need for our overcrowded and
antiquated state institutions.
Many states, including Michigan, had set about the simultane­
ous restructure of their mental health programs to be more in concert
with the community mental health movement.

Utilizing the Federal funds

made available for such development along with new funding mechanisms
for use of state and local funds, a nationwide movement to develop
community mental health centers took hold.

In Michigan, following a

hundred years of state institution developemnt. Public Act 54 of 1963
made possible the funding and development of what is today over 40
such centers with a gross program budget of over $44 million.
As the programs and budgets of these community mental health
programs began to grow, and with the continued reduction in numbers of
residents in state institutions, the public

(legislators, administra­

tors, citizens, clients) began to seriously question both the continued
development and the quality of program within centers.

A cry for pro­

gram evaluation was heard from the highest levels of government down
to the local supporters at the city and county level.
Studies of the rates of admission to state hospitals, impact
of community efforts on these rates, recidivism and readmissions,
utilization rates and estimates of program need, length of treatment
and treatment outcome, costs of services, and the newer consultative
and preventative programs began to appear in the professional

David A. Ethridge

literature.

Although some of these were extensive and well-dopumented

they still represented at most only one or two facets of a program and
generally failed to answer the broader question,

"Is the program any

good?"
It became more and more evident, from the growing pressures for
meaningful program assessment, that a methodology encompassing many of
these previously studied facets but consolidating them into an overall
performance measure was in demand.

This study proposes such a method­

ology and applies it to the 43 community mental health programs in
Michigan in 1972-73.
The methodology is, at first, deceptively simple, utilizing
existing data in a formulation which weights certain facets over others
consistent with the expressed goals and assumptions stated as underlying
the principles of community mental health.

A Performance Score is

achieved by each program which is in reality a ratio of (1) the stand­
ardized cost of persons served in a specific program, reduced by the
standardized cost of those released from treatment in the program, ad­
justed by a cost-efficiency factor, and

(2) the number of persons

served by the program, adjusted by a weighted service-load efficiency
which includes an estimator of need and a penalty for state institution
admissions.

Once the Performance Score is derived through this formula­

tion it can be compared to the scores of other programs or over a period
of time to assess changes within the same program.
An application of this methodology on the extensive data avail­
able for the Michigan progam results in a rank-ordering of programs, an
examination into the varied factors including in the methodology and
their resultant effect on the final Performance Score.

The methodology,

David A. Ethridge

with only minor modification, can be utilized to examine the subtypes of programs

(outpatient, inpatient, residential, day treatment)

or sub-agencies within a comprehensive program.

Such analysis is often

revealing in discerning the portions of the program having the greatest
effect in relation to the goals or objectives specified.
Although the methodology is proposed for implementation by
state mental health authorities, serious concerns are expressed about
the data collection systems, the quantity versus quality programmatic
measures, the non-availability of assessment methods for consultative
and prevention programs, and various other problems as yet unresolved
within the field of mental health.

Suggestions for additional studies,

proposed revisions being considered for the methodology, and administra'
tive considerations in the use of the Performance Score are also de­
tailed.

ACKNOWLEDGMENTS

For their assitance, advice and mostly for their patience, my
sincerest gratitude to my doctoral committee:

Dr. Gregory Miller,

Dr. Maryellen McSweeney, Dr. Richard Johnson, and Mr. Ed. Alehin.
To the members of my staff, their encouragement through the
past few months has been deeply appreciated.

A particular thanks ~fco

Dr. Thomas Schmitz, Mrs. Betty Tableman, and Mrs. Alice Wright, for
their assitance with the manuscript.
Without the efforts of the Data Analysis Staff, tinder the
leadership of Mr. Robert DeVoe, this project would never have been
possible.

Their work is too often unappreciated but perhaps, now, it

may begin to be recognized.
Undoubtedly, the greatest professional encouragement has come
from a man I hold in deepest esteem, Dr. E. Gordon Yudashkin.

It is

doubtful that I can ever repay his friendship, trust and confidence
in me; however, I shall try to live up to this responsibility.
My family has probably endured the most and it is to them I
owe the greatest debt.

To Joni, my dear wife, your encouragement and

help has been the key; to our children, Barry, Deborah, and Todd, the
hope that this will serve as an incentive for you.
And to all those, far too numerous to mention, but who know
that they have played a part, my heart-felt thanks.

TABLE OF CONTENTS

Page

LIST OF T A B L E S .................................................

v

INTRODUCTION

1

....................................................

Chapter
I.

AN HISTORICAL PERSPECTIVE OF MENTAL HEALTH

. . . .

The B e g i n n i n g s .......................................
The Second Revolution .
Community Mental Health
.
"A Bold New A p p r o a c h " .................................
II.

THE HISTORICAL DEVELOPMENTS IN MENTAL HEALTH SERVICES
IN M I C H I G A N .............................................
Establishment of State Institutions
................
The Development of Community Mental Health Services .
Impact of Federal Legislation
.......................
Our Own "Bold New A p p r o a c h " ..........................

III.

THE BIG PROBLEM AND THE LITTLE A N S W E R S ................
The Cry for E v a l u a t i o n .............................
Problems in Program Evaluation .......................
Criteria to be E v a l u a t e d .............................
Summary of Current and Recent Evaluation Efforts . .
Impact on State Hospitals ..........................
Estimates of Need and Utilization Rates
. . . .
Length of Treatment and Treatment Outcome
. . .
Consultative and Preventative Programs
. . . .
Cost Per Unit of S e r v i c e ..........................
The Problem Restated ................................

IV.

A METHODOLOGY TO ASSESS OVER-ALL EFFECTIVENESS

. . .

The Evaluation Process
.............................
Problems of M e t h o d o l o g y .............................
Objectives-Standards to be Considered
.............
A Framework for Measurement of Program Performance
.

3
3
4
7
10

15
16
19
24
25
31
32
37
43
48
48
58
63
68
72
80
83
84
86
91
93

Page

Chapter

...............
Number of Individuals Served (N )
Standard Cost per Individual (C. )
...............
.........
99
Number of Individuals Released
(N )
Standard Cost per Individual Released (cr ) - Actual Cost per Individual ( A . ) ..................102
Population Estimated to be in Need (P ) . . . .
Weighted Admissions to State Hospitals (Nw ) • Performance Score (PS)
.............................
V.

96
97
100
103
105
107

EXAMINATION OF DATA AND R E S U L T S ..................... 110
Number of Individuals Served (N ) and Need Estimate
(P ) .......................S ............................ 112
Standard Cost Per Individual Served (C-^)........... 116
Number of Individuals Released (Nr ) and Cost (Cr ) . .
117
Actual Cost Per Individual Served ( A ^ ) ........... 122
Number of Admissions To State Institutions, Weighted
4 N „ ) ............................................... 126
The 1972-73 Performance Scores (PS) for Community
Mental Health Programs
.............................
131
Other Data C o m p a r i s o n s ...............................138
The Performance Score (PS) For Sub-Programs . . . .
139
Summary of Data and R e s u l t s ........................ 148

IV.

IMPLICATIONS OF PERFORMANCE EVALUATION FOR PROGRAM
A D M I N I S T R A T I O N ........................................ 150
The Data P r o b l e m ...........................................151
The Quality-Quantity Problem ..........................
154
The Consultation— Preventative Services Problem
.
.
157
Other Problems For Consideration
....................
160
Recidivism R a t e s ....................................... 161
Client Satisfaction
.................................
161
Administrative Costs
.
161
Differential Goals for Mentally Retarded Clients
.
161
Administrative Considerations In The Use Of The
Performance Score ....................................
162
Summary and R e c o m m e n d a t i o n s .............................. 168

A P P E N D I X .............................................................. 172
BIBLIOGRAPHY

....................................................

iv

174

LIST OF TABLES

Page
Patient Population in Public Mental Hospitals, 19561972
....................................................

8

Patient Population in State Psychiatric Facilities,
1956-1972 .................................................

20

Patient Population in State Mental Retardation
Facilities, 1956-1972 ....................................

21

Summary of Federal Funds to Michigan Community Mental
Health Centers
....................................

26

Summary of Community Mental Health Development in
Michigan, 1964-72
.......................................

29

Summary of Studies on Recidivism Rates for Psychiatric
P a t i e n t s ........................ ......................

51

Summary of Gross Estimates and Reported Utilization
Rates for Psychiatric Services ..........................

61

Summary of Consultation Outcome Studies in Mental
Health Services ..........................................

73

Number Of Individuals Served (N ), Community Mental
Health, 1972-73 ..............
? .......................

113

Standard (Average) Cost Per Individual Served, 1972-73 .

116

Number Of Individuals Released (N ), Community Mental
Health, 1972-73 ................ r ........................

119

Actual Cost Per Individual Served (A.), Community
Mental Health, 1972-73
. 1 ...................

123

Weighted Number of Admissions To State Institutions,
(N ), 1972-73
..........................................
w

128

Performance Score and Rank-Order, 1972-73

.............

133

...................

137

Analysis Of Data For Extreme Values

v

Table

16.

17.

Page

Performance Score and Rank-Order For Outpatient
Programs, 1972-73
Comparison of Performance Scores and Ranks

vi

...............

141
145

INTRODUCTION

Mental health is a nebulous concept at best.
health is even more diverse in its meaning.

Community mental

They can only be defined

through an historical perspective and a description of services and
programs encompassed within the concepts of each.

A multitude of

theories, techniques and ideas are embodied within these concepts and
it is little wonder, given the complexities and lack of common agree­
ment regarding them, that little, if any, has been done toward the de­
velopment of a system or methodology to evaluate services and programs
across centers or facilities, statewide or nationwide.
The purpose of this study will be, therefore, to examine the
development of mental health services from their beginning through to
the current concepts of community mental health services, to review
current and past efforts at program evaluation (generally as applied
to individual programs), and then attempt to formulate a methodology
which can be applied consistently and fairly across programs, both as
a method of internally evaluating each and, more importantly, as a
method of comparing programs to each other.

Finally, this methodology

will be applied to the community mental health programs in Michigan
with recommendations for its use and implications for further develop­
ment .
Inherent in any effort such as this, a vast number of assump­
tions must be made, some rather global and obvious, others not so.

2

Most obvious of these would be an acceptance of terminologies as being
standard and consistent.

One expects that the words "outpatient," "in­

terview," "per diem cost" and many others will be relatively standard,
no matter what the program or location.

One must assume that, within

certain limits, programs and services, professional activities and out­
comes can be standardized and quantified for purposes of study.

Not so

obvious are certain assumptions which are made about incidence rates,
expected costs and rates of success.

These assumptions will be de­

tailed within the section on methodology, but must be anticipated and
accepted as a precursor to the results and their implications.
It should also be noted that this effort is but a progress
report in time and that strategems and measurement techniques not
available or not considered before are constantly being added to the
armamentarium of the program evaluator.

Add to this the crescendo of

enthusiasm and accent on accountability now surfacing as the theme for
public service

programs.

As such, it is imperative that community

mental health programs intensify a critical inward look if they are to
survive.

George Bernard Shaw is quoted as saying,
What made this brain of mine, do you think? Not the need
to move my limbs; for a rat with half my brain moves as well
as I. Not merely the need to do, but the need to know what
I do, lest in my blind efforts to live I should be slaying
myself .^

1M. F. Shore and F. V. Mannino, ed., as quoted in Mental Health
and the Community (New York: Behavioral Publications, 1969), p. iv.

CHAPTER X

AN HISTORICAL PERSPECTIVE OF MENTAL HEALTH

The present is the past rolled up for action, and ^
the past is the present unrolled for understanding.

To understand where we are in mental health today, one must
unroll the past and examine those events and their sequence to grasp
the significance of the way in which they have impinged on today's
society.

Such a review of the field of mental health can be a lengthy

albeit fascinating pursuit.

Fortunately enough, such a pursuit has

been accomplished by other authors and a brief review of their findings
will suffice, for it is the perspective of movement toward the current
concepts of community mental health that is of interest.
The Beginnings
Most contemporary authors

(Deutsch, 1949; Beliak, 1964; Wolo-

shin and Dennis, 1970) attribute the first phase, or first revolution,
to a French physician named Phillippe Pinel.

His advocacy of a "moral

treatment" and his efforts to "strike off the chains" of the inmates
at the Bicetre and at the Salpetriere near the end of the eighteenth

As quoted in Will Durant and Ariel Durant, The Lessons of
History (New York: Simon and Schuster, 1968), p. 12.

3

4

century have become a popular symbol heralding this Age of Reason.

2

Pinel formulated his moral treatment into a system "so soundly con­
ceived and dramatically presented that it caught the attention of the
public."

3

By 1811, T. Romeyn Beck, a New York physician, could write

convincingly about moral management of the mentally ill, which, he said,
"consists of removing patients from their residence to some proper
asylum and for this purpose a calm retreat in the country is desired
for it is found that continuance at home aggrevates the disease as the
improper association of ideas cannot be destroyed."
concepts of moral management was "human vigilance.

4

Central to the

. ." which "had to

convince the lunatics that the position of the physician and keeper is
absolute" and that "human attendants.
(the patients), never threaten but.
5
have a high sense of honor."

. .shall act as servants to them

. .offer no indignities as they

The Second Revolution
Soon, within this country, a woman appeared on the scene who is
considered by some to be second revolution

(Woloshin and Dennis, 1970),

viewed by others as being the American counterpart of the first phase
2
L. Beliak, "Community Psychiatry:
the Third Psychiatric
Revolution," Handbook of Community Psychiatry, ed. L. Beliak (New York:
Grune & Stratton, 1964), p. 1.
3
A. Deutsch, The Mentally 111 in America, 2nd ed.
Columbia University Press, 1949), p. 6.

(New York:

4
As quoted in A. Woloshin and E. Dennis, "The Romance and
Rodomontade of Comprehensive Community Mental Health," Mental Hygiene,
Vol. 54, No. 2, April, 1970, p. 281.
5Deutsch, op. c i t ., p. 22-31.

5

(Deutsch, 1949) and omitted from the history by still others
1964) -

(Beliak,

This woman, Dorothea Dix, was able to marshall a collective

public guilt and pity for the "poor unfortunates" of the early nine­
teenth century.

Like romantics of previous generations. Miss Dix used

abhorrence of inhumane conditions and the rising tide of emotional in­
dignation as the major tools in her crusade.

She was able to exploit

the general receptivity to the "There, but for the grace of God, go I"
philosophy, widely held in the nineteenth century.

Even so, those who

developed and operated the moral treatment retreats and new asylums of
the 1820's and 1830's had no intention of treating everyone deemed a
"lunatic;" rather, they made a distinction between paupers and pay
patients, a problem which Miss Dix pointed up in a subsequent crusade
for the dependent insane/’

This second crusade is said to have been

the impetus behind the establishment of the state asylum for the insane,
now called the state hospitals for the mentally ill.

The selectivity

of the new asylums of moral treatment meant that those rejected would
be relegated to jails and when Miss Dix's second crusade decried this
practice, the public insisted upon public asylums to offer this same
moral treatment.
As a number of studies of psychiatric history indicate, the
moral reform movement benefitted many.

The records of many states in­

dicate the thousands of persons admitted to their state institutions
and the thousands treated and returned to their homes, but, as Bockoven has suggested, the professionals of the nineteenth century who
had designed a moral treatment had not expected the flood of hungry,

g
Woloshin and Dennis, op. c i t .

6

poverty-stricken inunigrants who came from a different culture and
spoke a foreign language.

The system was eventually flooded with too

many patients and much of moral treatment was doomed to failure.

Thus,

the envisaged small patient-staff ratio asylum gave way to overcrowded,
distant state hospitals that offered "dehumanization rather than moral
treatment."

7

By the 1930’s and 1940's our state institutions had be­

come massive, monolithic communities unto themselves.
Beliak, who omitted Dix from his review, attributes the second
phase, or second revolution, to Sigmund Freud and the development of
psychoanalysis.

In that Freud was able "to provide a rational explana­

tion for these unconscious forces".

. .and elucidate "the relationship

between the early mental functioning of the child and the later func­
tioning of the adult,.

. -the relationship between dreams and waking

life, between normal and abnormal behavior.

. .psychoanalysis gained

recognition as the first rational treatment method for psychiatric
0
disorders."
Again, due to its length and required one-to-one rela­
tionship, psychoanalysis became a treatment available only to the rich.
Whether viewed separately or as a part of a larger revolution,
the next single event to effect the treatment of the mentally ill was
the advent of the psychotropic drugs.

In 1956 there were reported to

be 559,342 patients living in 277 public mental hospitals.

This year

is considered to be the turning point in the history of mental health
in that every year thereafter the figure has declined.
0

Beliak, op. c i t ., p. 2.

By the end of

7

1959 this figure had dropped to 542,721— a decrease of nearly 17,000.
"This reversal of a long-time upward trend began immediately following
g
introduction of the tranquilizing drugs."
However, the reasons for
viewing the drug therapy as only part of a bigger revolution are also
rather evident.

During this same period staff-patient ratios in­

creased dramatically, increased appropriations from state legislatures
provided new impetus and enthusiasm, and a new awareness on the part
of the public caught hold and grew.

Table 1 presents an analysis of

admissions, discharges, staff expenditures in public mental hospitals
■during this changing period and to the present.

It would be difficult

to separate these one from the other in terms of their inpact, but
some authors have steadfastly maintained that the new drug treatments
were the catalyst for what we see today as the community mental health
movement.
Community Mental Health
Such a springboard, with all its bounce and newness, was to
bring about what most authors again agree upon as the third revolution
— community mental health (Beliak, 1964; Woloshin and Dennis, 1970).
A massive study was authorized by the U. S. Congress under the Joint
Commission on Mental Illness and Health and concluded with their re­
port, Action For Mental Health.

This report is generally seen as "a

rallying-point around which the concerned professions and the inter­
ested citizenry can mobilize in a fresh drive to narrow the yawning
gap between mental health needs and resources.
9

Joint Commission on Mental Illness and Health, Action for
Mental Health (New York: Basic Books, 1961), p. 7.
■*"®As quoted from the cover-jacket of Action for Mental Health.

8

TABLE 1.— Patient Population in Public Mental Hospitals, 1956-1972.
1956a

1959a

1963b

1968C

1971d

All admissions
First admissions
Readmissions

185,597
125,539
60,058

223,225
142,881
80,344

285,244
130,025
155,219

365,455
144,566
220,889

414,926
N. R.
N. R.

Discharges

133,208

175,727

247,228

351,461

501,123

48,236

49,640

49,039

39,677

26,835

Resident patients
at end of year

551,390

542,721

504,947

400,681

308,024

Personnel employed
at end of year

153,715

174,721

194,516

217,128

226,247

Expenditures:
Total (millions)
Per Patient Year

$ 663.3
$1,202

$ 854.4
$1/574

$1,084.7
$2,148

$1,577.6
$3,937

$2,036.4
$6,611

Staff-Patient
Ratio

1:3.58

1:3.11

1 :2.59

1:1.84

1:1.36

Deaths in hospital

aAction for Mental Health, op. c i t .
b U.S. Department of Health, Education, and Welfare, Mental
Health Statistics Current Reports, Provisional Patient Movement and
Administrative Data State and County Mental Hospitals United States,
Series MHB-H-8, January, 1964.
CU.S. Department of Health, Education, and Welfare, Mental
Health Statistics Current Facility Reports, Provisional Patient
Movement and Administrative Data State and County Mental Hospitals
United States, July 1, 1967 - June 30, 1968.
U.S. Department of Health, Education, and Welfare, Statisti­
cal Note 60, Provisional Patient Movement and Administrative Data
State and County Mental Hospital Inpatient Services July 1, 1970 June 30, 1971, January, 1972.

9

This report, in addition to summarizing the current operating
practices in the field, made a number of rather broad recommendations,
including:
1.

"A national mental health program should set as an objec­

tive one fully staffed, full-time mental health clinic available to
each 50,000 of population."
2.

. .state hospitals.

. .should be converted as rapidly

as possible into intensive treatment centers.

. . .

No further state

hospitals of more than 1,000 beds should be built, and not one patient
should be added to any existing mental hospital already housing 1,000
or more patients."
3.

"Expenditures for public mental patient services should be

doubled in the next five years— and tripled in the next ten."
further recommended that "Congress.

It

. .should develop a Federal subsidy

program that will encourage states and local governments."^
Other recommendations were included concerning recruitment and train­
ing of manpower, psychiatric units in general hospitals, dissemination
of public information, aftercare and rehabilitation, and revisions of
state and federal laws.
Although the report goes into sometimes exhaustive detail in
describing the lag in services, treatment concepts, community aware­
ness (or better, the lack of), and strategems to "catch up," its lack
of specificity in dealing with the problems of persons being placed
in state institutions, how they got there and how to circumvent this
gigantic debacle of human misery, is somewhat disconcerting.

Joint Commission, op. c i t ., pp. vii— xxiv.

It is

10

interesting to note that the report was affirmed by 42 of the 45 mem­
bers of the Commission with the other three abstaining.

These three

submitted papers of dissent on specific parts of the report and their
papers are contained in Appendix VII (which was probably overlooked by
most readers).

Important in their dissent were two factors:

(1) Lack

of appropriate planning in regard to the existing state hospitals and
their relationship to the proposed community services, and
of the proposed mental health services
the tax structure.)

(2) funding

(specifically their comments on

12

**A Bold New Approach"
Many programs and states had begun undertaking changes even be­
fore the five-year study was completed.

California had adopted the

Short-Doyle Act in 1957 which began their leadership role in community
mental health services. New York adopted an Act 54 of 1958 and began
its programs of community services.. State hospitals all over the
country, already showing declines in populations, began trying new
programs of open wards, sheltered workshops and vocational rehabilita­
tion, community foster-care placement and outpatient screenings to
avert admissions.

As such, the scene was set and the act that was to

follow was at the pinnacle of power.

On February 5, 1963, President

John F . Kennedy gave the first Presidential Address on Mental Health
and Mental Retardation ever presented to the U . S. Congress.
of his Address bear repeating:

Joint Commission, op. c i t ., pp.

330-331.

Portions

11

There are now about 800,000 such patients in this nation's
institutions, 600,000 for mental illness and over 200,000 for
mental retardation. Every year nearly 1,500,000 people receive
treatment in institutions for the mentally ill and mentally
retarded. Most of them are confined and compressed within an
antiquated, vastly overcrowded chain of custodial state insti­
tutions . . . .
The time has come for a bold new approach. New medical,
scientific, and social tools and insights are now available.

. . .

I propose a National Mental Health program to assist in the
inauguration of a wholly new emphasis and approach to care for
the mentally ill. This approach relies primarily upon the new
knowledge and new drugs acquired and developed in recent years
which make it possible for most of the mentally ill to be suc­
cessfully and quickly treated in their own cummunities and re­
turned to a useful place in society. . . .
Such a new mental health program is comprehensive community
care. Merely pouring federal funds into a continuation of the
outmoded type of institutional care which now prevails would make
little difference. We need a new type of health facility, one
which will return mental care to the mainstream of American
medicine, and at the same time upgrade mental health services. . . .
These centers will focus community resources and provide
better community facilities for all aspects of mental health care.
Prevention, as well as treatment, will be a major activity.
Lo­
cated in the patient's own environment and community, the center
would make possible a better understanding of his n e eds, a more
cordial atmosphere for his recovery, and a continuum of treat­
ment.
As his needs change, the patient could move without delay
or difficulty to different services — - from diagnosis to cure to
rehabilitation— without need to transfer to different institu­
tions located in different communities.1*3
With swift and impressive resolve, the U. S. Congress enacted
the Community Mental Health Centers Act of 1963.

This Act provided

for funds to finance, on a matching ratio, the construction of commu­
nity mental health centers and required that a plan be drawn up by
each of the states, identifying catchment areas of 75,000 to 200,000
persons which could be programmed for within each center.

The

As quoted in A. Favazza, B. Favazza, and P. Margolis, Guide
for Mental Health Workers (Ann Arbor:
University of Michigan Press,
1970), pp. 41-42.

12

following year Congress enlarged its commitment by providing funds for
staffing grants for the operation of these centers with funds matched
on a declining ratio.
Regulations, issued by the National Institute of Mental Health,
appearing in the May, 1964, Federal Register, specified the ten re­
quired services of a comprehensive community mental health center:
1.

Inpatient services.

2.

Outpatient services.

3.

Partial hospitalization services "such as day care, night
care, weekend care."

4.

Emergency services available at all times.

5.

Consultation and education services available
agencies and professional personnel.

6.

Diagnostic services.

7.

Rehabilitative services, including vocational and
tional programs.

8.

Precare and aftercare services in the community, including
foster home placement, home visiting, and halfway houses.

9.

Training.

10.

Research and evaluation.

tocommunity

educa­

14

The first five of these were required of any applicant as a condition
for receiving the grant, either for construction or staffing; the re­
maining five were included as deemed appropriate by the applicant to
his specific needs.

The research and evaluation element was only

sporadically included, with very meager funds committed to such pro­
gramming.
14

R. Glasscote, and J. Sussex, et a l ., The Community Mental
Health Center, An Interim Appraisal {Washington, D. C. : American
Psychiatric Association, 1969), p. 14.

13

A total of $135 million for construction was appropriated by
Congress over the three-year period authorized by the law, starting in
July, 1964.

Operating or staffing monies, authorized also for a three-

year period to begin in July, 1965, amounted to an initial appropria­
tion of $19 million, $24 million for the second year, and $30 million
projected for the third year.

By June 30, 1966, the expiration date

for the first year's funds, the Public Health Service had approved 93
construction grants, covering 91 projects and committing almost $42
million for construction.

Fifty-four staffing applications were ap­

proved, totalling almost $16 million.

These programs had been designed

to serve close to twenty million people, or about ten percent of the
total population.

By June 30, 1967, 201 construction grants had been

awarded to 258 centers, with centers operational in every state except
South Dakota and A l a s k a . S i n c e that time the programs have continued
to grow and by the end of 1972 there were "389 fully operational cen­
ters out of a total of 529 funded.
centers

The goal of, say, 1500 or 1600

(by 1980) which would be the amount that you would need to

have to provide services to the whole country, is realistic based on
our experiences of the past eight years."

16

And so. President Kennedy’s "bold new approach" became at
least a partial reality.

The recommendations of the Joint Commission's

^ L u c y D. Ozarin, "The Community Mental Health Center:
Concept
and Community," Mental Hygiene, Vol. 52, No. 1, January, 1968, pp.
76-77.
^Hearings before a Subcommittee of the Committee on Appropria­
tions, House of Representatives, Departments of Labor and Health, Edu­
cation and Welfare Appropriations for 1973 (Ninety-second Congress,
Second Session, March 8, 1972), p. 147.

14

Action for Mental Health seem well along toward their implementation.
Congress has infused literally hundreds of millions of dollars into the
communities to provide both facilities and services.

States have ex­

tended themselves with their own versions of California's Short-Doyle
Act and New York's Act 54 and have extended community services far be­
yond that possible with the federal resources and state hospitals have
continued to decline in population, become more intensive in their
treatment regimes and have developed collaborative relationships with
their new counterparts, the community mental health centers.

CHAPTER II

THE HISTORICAL DEVELOPMENTS IN MENTAL
HEALTH SERVICES IN MICHIGAN

Our stares, being ourselves multiplied, are what we are;
they write our natures in bolder type, and do our good
and evil on an elephantine s c a l e d
Separated from the settled portion of the United States by a
wide wilderness, Michigan did not at first attract immigrants.

While

Illinois, Indiana and Ohio were rapidly becoming settled and becoming
states from 1810 to 1820, Michigan remained relatively unsettled.

Un­

der the second territorial governor, Lewis Cass, the opening of the
Erie Canal and the extinction of the Indian land titles finally en­
couraged settlement.
idly.

From 1830 on, the rate of insnigration rose rap­

By 1835 there were 85,000 people in Michigan, compared with

less than 4,000 only thirty years before.

2

Obviously, with such an increase in population and with most of
these immigrants having come from the eastern United States, the atti­
tudes and mores of the times came with them.

In 1832 the Wayne County

Pest House was established, and began a history which later saw it be­
come the Wayne County General Hospital and include its own psychiatric
^Durant, op. cit., p. 19.
2

.

Michigan Department of Education, Michigan
Library Division, 1967), p. 6.
15

(Lansing:

State

16

hospital, called Eloise.

The beginnings of institutional programming

preceded even statehood; Michigan became a state on January 27, 1837.

Establishment of State
Institutions
As the cry for humane treatment for the derelict and outcast
swept the country, following Dorothea Dix's second crusade, Michigan
began the long history, even to present day, of establishing state
institutions for the mentally ill and mentally retarded.

A brief

chronology of these institutions is as follows:
1859

Kalamazoo State.. Hospital
the Insane)

(first called Michigan Asylum for

1878

Pontiac State Hospital

1885

Traverse City State Hospital
Ionia State Hospital (for the criminally insane; later, in
1969 changed to a regional psychiatric hospital)
Newberry State Hospital

1895

Lapeer State Home and Training School (the first facility for
the mentally retarded and initially called the Michigan Home
for Feebleminded and Epileptics)

1906

State Psychopathic Hospital (later transferred to the
University of Michigan as the U of M NeuropsychiaLric
Institute)

1914

Caro State Hospital (initially called the Michigan Farm
Colony for Epileptics)

1915

Detroit Receiving Hospital Psychiatric Unit (later housed in
the City's Herman Kiefer Hospital, and in 1972 converted into
a state psychiatric hospital called Detroit Psychiatric In­
stitute)

1927

Wayne County Training School for the Mentally Retarded
(still operated by the County, now called Wayne County Child
Development Center)

1931

Ypsilanti State Hospital

17

1935

Coldwater State Home and Training School

1937

Mt. Pleasant State Home and Training School

1952

Northville State Hospital

1955

Lafayette Clinic (established as a research and training
facility for the state)
Children's Psychiatric Hospital at University of Michigan

1956

Hawthorn Center

(a state psychiatric facility for children)

Fort Custer State Home and Training School (a "temporary"
facility which was finally closed in 1972, and the only
one of the entire list to have been closed down)
1960

Plymouth State Home and Training School

1961

Howell State Hospital (initially for profoundly retarded
physically handicapped but, in 1972 reprogrammed as a
regional facility for the mentally retarded)

1963

Gaylord State Home (also initially for profoundly re­
tarded physically handicapped, but later, in 1972 re­
programmed as a regional facility for the mentally
retarded

1969

Muskegon Regional Mental Retardation Center

1970

Mental Health Drug Abuse Center, Detroit (formerly the
U. S. Public Health Marine Hospital at Windmill Pointe),
developed mainly for an outpatient drug treatment fa­
cility but also having capacity for inpatient psychiatric
treatment

1972

Detroit Psychiatric Institute (as noted above, formerly
part of Detroit Receiving Hospital but now converted
from 60 beds to 300 beds and made into a state operated
facility)
Northville Training Center (formerly part of the nowreduced-in-size Northville State Hospital, and converted
into a facility for the mentally retarded)
Thumb Treatment Assistance Center (a small psychiatric
facility in the far-eastern Thumb area of Michigan,
located on the grounds of Caro State Home and Training
School)

18

Riverside Center (also a small psychiatric facility in the
center of the state, located on the grounds of Ionia State
Hospital)
1974

Now under construction, to be completed in 1975, the MacombOakland Regional Center (for mentally retarded, size of ap­
proximately 500, being built largely as a replacement facility
to decrease overcrowding and inadequate facilities in other
institutions)
Now under construction, to be completed in 1976, the
Southwestern Wayne Regional Center (for mentally retarded,
also to house approximately 500, also a replacement facil­
ity) 3
Such a chronology deserves comment.

During the period of

"humaneness" of treatment, and following Dix's crusades, came a period
of building in Michigan so that, by 1960 and the "third revolution,"
Michigan boasted of 13 state institutions housing 30,558 residents and
its newest showplace, Northville State Hospital

(affectionately called

"Brown's Country Club," in honor of its first superintendent. Dr.
Philip Brown).

By this time there had been added the newer type of

specialized facilities, such as Lafayette Clinic and Hawthorn Center.
State hospitals for the psychiatric patients stopped expansion (as
had already been noted on the national scene), with no new state fa­
cilities until the early 1970's, when small regional centers developed,
to be housed in pre-existing buildings no longer in use.
The development of state facilities for the mentally retarded
has a somewhat different history, starting later and continuing on into
the present with a new one still under construction.

The banner year

for the reversal in increased residents of state mental retardation
The above chronology has been derived from numerous documents
with the help of the Office of Public Information, Michigan Department
of Mental Health.

19

facilities was not until 1970 or 1971 in Michigan (and has still not
reversed in many other states).

New facilities continued to be added

throughout the period with great emphasis in the 1960's and 1970's.
Tables 2 and 3 illustrate the changing scene in the state mental health
facilities.
The Development of
Community Mental
Health Services
The community mental health program had its first appearance
in Michigan in 1916 with the establishment of a "traveling clinic."
This clinic was operated by Kalamazoo State Hospital

(which, inter­

estingly, was also the first state hospital) and was commissioned to
"help local authorities in the process of precare and aftercare of
persons who had become flagrantly disturbed in their community setting."

4

It should be recalled that, once again, this was in the

period of "humaneness" and prior to the fantastic overcrowding of
facilities which crippled the program in the 1920's and 1930's.

Dur­

ing this period of reasonable staff-patient ratios, estimates running
as high as 20% of patients admitted were being returned to their com­
munities.^

The traveling clinic idea extended to other hospitals dur­

ing this era with the efforts also being extended to include diagnos­
tic services, prehospital treatment and toward a better utilization of
4

Philip Smith, "Benchmarks in Community Mental Health Services
Programs in Michigan," address to Council of Local Community Mental
Health Authorities, Michigan State University, March 6, 1968.
5
Deutsch, op. c i t ., p. 167.

.20

TABLE 2.— Patient Population in State Psychiatric Facilities, 1956-1972.
1949-50

1959-60

1963-64

Admissions

3,741

4,504

Discharges

1,791

Resident Patients
at end of year

1969-70

1972-73

5,020

11,806

14,568

3,263

3,850

12,925

17,142

15,731

19,059

17,843

10,934

7,355

4,080

5,703

Personnel employed
at end of year*

5,941.3

7,307.8

7,516.2

Total expenditures
{millions)

$

Cost per patient
year

$1,122

$1,937

$2,379

$6,915

$14,348

Staff-Patient
ratio

1:3.85

1:3.34

1:3.00

1:1.49

1:0.97

17.7

$

36.9

$

42.4

$

75.6

$

105.5

*Full-time equated positions
Source:

The above information was derived from numerous documents
with the assistance of the Budget Office, Michigan Depart­
ment of Mental Health.

21

TABLE 3.— Patient Population in State Mental Retardation Facilities,
1956-1972.
1949-50

1959-60

1963-64

1969-70

1972-73

Admissions

718

713

748

1,098

3,276

Discharges

261

242

250

1,566

3,587

Resident patients
at end of year

7,957

11,499

11,413

11,618

8,594

Personnel employed
at end of year*

2,153

3,878

4,480.7

6,562.3

6,255.8

Total expenditures
(millions)

$

Cost per patient
year

$1,162

$1,901

$2,477

$5,165

$9,010

Staff-Patient
ratio

1:3.69

1:2.97

1:2.54

1:1.77

1:1.37

9.2

$

21.8

$

28.3

$

60.0

$

77.4

*Full-time equated positions
Source:

The above information was derived from numerous sources with
the assistance of the Budget Office, Michigan Department of
Mental Health.

22

local community resources.

With the ever-ipcreasing demands on staff

time, caused by a rapidly expanding inpatient load, the traveling
clinics began to wane and by the 1930's no longer existed.

They had,

however, touched the community and sparked a desire for services—
services which these traveling clinics had been unable to meet specifi­
cally in their demand for consultative services for disturbed young­
sters.

The need for community mental health services for children had

been highlighted.
Fourteen years after the establishment of the first traveling
clinic, the first of the child guidance clinics was fostered in 1930
by the Children's Fund of Michigan, a private foundation.

It was es­

tablished as the Children's Center of Detroit and served as a model
for those which were to follow later.

In 1937 this same Children's

Fund established a children's clinic in Traverse City, and the year
following the Fund offered a grant to the state to establish another
child guidance clinic in some community which would make a local con­
tribution to the project.

The Junior League of Lansing and the Lansing

Area Community Chest provided such local funds and the pattern of
partnership between state and local community for the establishment of
0
state-local mental health clinics was set.
Between 1938 and 1963, thirty mental health clinics, with an
additional twelve branch clinic operations, were established.

Three

of these clinics began a new type of programming— day treatment pro­
grams for emotionally disturbed children.
0

Smith, op. cit.

In each case, the Michigan

23

State Legislature provided state funds to foster this growth under the
direction of the Michigan Department of Mental Health.

The clinic sys­

tem was a joint endeavor, a precursor of developments to come, between
the community and state, with the state providing the professional
staff and the local communities providing clerical staff, quarters,*
equipment, supplies, etc.
Very little of the services developed through these community
projects was directed toward the adult population and almost none was
directed toward the potential, or former, state hospital patient.

By

1960, as has already been noted, the populations of state institutions
for the mentally ill had begun to decline and the staff-patient ratios
had been improved.

Along with this came the era of the new psychotropic

drugs and many patients were found to be capable of returning to their
communities.

Outposts of aftercare services began to be developed by

the state hospital staffs to serve these patients returning to the
communities and aid in their readjustment.

The Department of Mental

Health formalized this structure by developing a series of aftercare
clinics, fully supported by state funds, and known as Regional Con­
sultation Centers, beginning with one each in 1960 (Detroit), 1961
(Saginaw), and 1962
Lansing).

(Grand Rapids).

Two were added in 1963 (Flint and

As these clinics became established, they found that they

could deal successfully with pre-commitment screening,

further re­

ducing the demands on state hospitals for admissions.
The development of local inpatient treatment capacity has been
more the result of the awareness of local hospitals to the need and the
inclusion of psychiatric inpatient coverage in medical insurance plans.

24

In the mid-1940's there were only three psychiatric units in general
hospitals:

Detroit Receiving, Henry Ford Hospital in Detroit, and

Hurley Hospital in Flint.

Three were added between 1947 and 1955;

and within the next ten years, another 15 inpatient psychiatric units
had been added, accounting for more than 14,000 admissions per year.
No one has

ever

kept a record of the history of the development of

local, smaller free-standing psychiatric hospitals, but, in a 1955
survey, there were 16 such psychiatric hospitals operating in the
state.

A number of contingencies, including licensing laws, the

growth of units in general hospitals, unfavorable consideration in
medical insurance provisions and other factors had resulted in the
number being reduced to 9 by 1965.

Today there are 48 licensed psychi­

atric facilities in the state and together they admitted over 26,000
patients for psychiatric care in fiscal year 1972-73.
Impact of Federal
Legislation
By 1963, with the current development of child guidance
clinics, regional consultation centers, local inpatient treatment
facilities, and smaller, decentralizing and reorganizing state hospi­
tals, the climate in Michigan was very receptive to the "bold new ap­
proach" outlined by Kennedy and the Public Act 88-164, Comprehensive
Community Mental Health Centers Act, which followed.

Even before the

Michigan Legislature took action on its own version of the "bold new
approach"

(Act 54 of 1963), three community mental health construction

applications and two community mental health center staffing applica­
tions had been developed and were in the process of being reviewed

25

and funded by the federal government-

The Grand Rapids Child Guidance

Clinic was the first application for Federal construction funds to be
approved in Michigan, with applications from Borgess Hospital, Kalama­
zoo and Port Huron General Hospital soon thereafter.

Pontiac State

Hospital (North Oakland Center) and Alpena General Hospital had staff­
ing applications underway.
Concurrent with the development of services under the Community
Mental Health Services Act (Act 54 of 1963) in Michigan, many cities
and programs were also developing plans to avail themselves of the
funding resources made available from the federal government.

A sum­

mary of federal financing to community mental health centers in Michi­
gan during the period of 1963 to 1972 appears in Table 4.

From these

totals, it is clearly reasonable to state that federal funds have had
a decided impact upon the development and delivery of community mental
health services in Michigan.
Our Own "Bold New
Approach1’
As early as 1959 a model for a community mental health services
law had been proposed by the Committee of State Officials on Suggested
State Legislation of the Council of State Governments.

This model had

been largely based on the Minnesota Community Mental Health Services
Act of 1957, California's Short-Doyle Act of 1957, and New York's Act
54 of 1958.

For the next three years, a frantic period, fraught with

debate, new proposals, counter-proposals, analyses, correspondence,
and study papers ensued, with the major issues centering around financ­
ing and authority, with little debate about the need for services or

26

TABLE 4.— Summary of Federal Funds to Michigan Community Mental Health
Centers.
Staffing Grants
No. of Grants* Total Amount

Staffing Grants
N o . of Grants Total Amount

1965-66

3

$ 1,405,136

1966-67

3

2,006,571

4

1967-68

1

1,957,368

4

1,033,476

1968-69

958,524

6

1,001,171

1969-70

50,000

8

1,522,269

$

360.071

1970-71

1

295,500

9

1,997,001

1971-72

1

100,000

10

2,624,000

317,915

12

3,436,300

$ 7,091,014

12

$11,974,288

1972-73
TOTAL

9

*Each construction grant is for more than one year, they are listed
only on the year of origin.
Source:

Michigan Department of Mental Health, Bureau of Operational
Planning.

the types of services to be offered.

Finally, the Community Mental

Health Services Law, Act 54 of 1963, was adopted and signed by the
Governor.
The new Act was heralded by Dr. Robert A. Kimmich, Director of
the Department of Mental Health in 1964, as "the beginning of a new
era in the development and conduct of community mental health services
in Michigan.

. . .

After several years of study, Michigan now had a

new and additional mechanism for the development, coordination and op­
eration of more and expanded community mental health service.
partnership basis between the state and community."7

. .on a

The important

provisions of this A c t :
7

Department of Mental Health, Community Mental Health Services
Manual (Lansing: Department of Mental Health, 1964), p. iii.

27

1.

Described the services to be offered as

(a) collaborative

and cooperative services with other health groups specifically centered
around prevention;
sultative services;

(b) informational and educational services;
(d) diagnostic and treatment services;

(c) con­

(e) reha­

bilitative services specifically for those who had previous inpatient
services; and (f) in-patient services.
2.

Determined that the legislative body of a county, group of

counties, or a city of 500,000 could establish such a program.
3.

Allowed for a special tax to be levied to support the pro­

gram (a provision which as to date never been implemented by any
county).
4.

Established the mechanism by which a budget plan was to be

submitted, approved by the state and funds allotted.
5.

Provided initially for a 60/40 funding ratio with a $1 per

capita ceiling (this was later amended to a 75/25 ratio and the ceiling
was removed).
6.

Defined the membership, manner of appointment, term, vacan­

cies and responsibilities of the Community Mental Health Services Board,
and,
7.

Broadly defined the powers and duties of the Department of

Mental Health in carrying out the program but specifically to (a) pro­
mulgate rules;

(b) review and evaluate local programs;

(c) provide

consultative staff service to communities; and (d) emply a director of
community mental health services.

8

g
Department of Mental Health, Community Mental Health Services
Manual, (Lansing: Department of Mental Health, 1964), p. 1-6.

28

Amendments

over

the years have modified parts of the Act but

it is largely the same, the amendments having only added clarity or
extensions of responsibility.

One such extension of responsibility

adds to the powers of the Department that of prescribing minimum stan­
dards for qualification of personnel and quality of professional serv9
ice.
It is now nearly ten years since Act 54 passed the Michigan
Legislature.

Like the experience noted as a result of the federal

legislation, vast expansion of services has resulted from an initial
expenditure of less than $130,000 of the $1.5 million appropriated in
1964 to an allocation of state dollars of over $27 million in 1972.
analysis of the growth of these programs appears on Table 5.

An

Not only

has the amount in expenditures grown but the percent of the population
having access to community mental health services has expanded, and
the numbers of persons actually availaing themselves of these services
has greatly increased.

It should be noted that these increases have

been concomitant with the levels of service increase noted previously
at the state institutions for the mentally ill and mentally retarded
(Tables 2 and 3).
In reviewing the objectives set out in the report Action for
Mental Health, it is interesting to compare Michigan's accomplishments
against those objectives:

(Lansing:

Legislative Service Bureau, Mental Health Statutes, 1972
Department of Mental Health, 1972), pp. 55-59.

TABLE 5.— Summary of Community Mental Health Development in Michigan, 1964-72.

Year

Number
of
Programs

Percent
of
Population

Appropriation
(Millions)

State
Expendi­
ture

Gross
Expendi­
ture*

Persons
Served

1964-65

5

42%

1.5

1965-66

16

68%

2.5

1,634,420

4,582,432

6,882

1966-67

24

£4%

8.8

5,039,829

9,062,591

29,421

1967-68

29

£6%

7.3

7,255,143

13,773,458

47,782

1968-69

29

86%

10.9

9,541,266

17,029,875

53,127

1969-70

31

88%

13.1

12,848,707

22,209,602

74,016

1970-71

33

91%

16.1

15,890,454

28,955,108

82,118

1971-72

35

92%

19.6

19,135,944

35,288,212

114,159

1972-73

43

96%

26.0

25,625,036

44,366,989

121,692

$

126,891

$

946,788

Not
Reported

♦includes federal, local and other non-state funds.
Sources:

Department of Mental Health, Finance Section, Historical Analysis,
Summary, P.A. 54 Boards, 1972.
Department of Mental Health, Bureau of Operational Planning,
Community Mental Health Board Allocations, 1972-73, 1972.

30

Michigan's Accomplishments

National Objectives
1.

One fully staffed, full-time
mental health clinic available
to each 50,000 of population.

1.

During the year 1972-73,
over 98% of the population
had access to fully staffed,
full-time mental health
clinics, provided through 46
local community mental health
boards.

2.

State hospitals converted to
intensive treatment facilities
under 1000 beds and no new ones
built of more than 1000 beds.

2.

Although two facilities re­
main over 1000 as of this
date, they are rapidly
approaching this figure.
Statewide the figure has
dropped from 17,843 to
7,355. The three new state
psychiatric facilities have
20,60 and 300 beds respec­
tively .

3.

Expenditures should double in
five years and triple in ten,
and Congress should provide
subsidies to local programs.

3.

Appropriations for 1963 for
state institutions totaled
$70.7 million. When combined,
funds for state institutions
and community mental health
services reached $212 million
in 1972, triple in nine years.

One might conclude from this that the goals are achieved, all is well,
and we should rejoice.

But it is not so clear as that.

It is merely

the time in which we assess what we do and then, perhaps, formulate new
goals.

CHAPTER III

THE BIG PROBLEM AND THE LITTLE ANSWERS
The "really big show” is really a lot of little shows.
When
the little shows are good, the big show is good. When some
of them fall flat, the "really big show" does too.
But the
ratings for the whole thing are what counts; the rating puts
it all together.1
Community mental health programs, in their present form, under
the federal centers program and, in Michigan, under the state legisla­
tion, have reached the ripe age of ten, having struggled through their
early formative years, and are now approaching (and many feel have al­
ready entered) the crucial decision years.

Senator Walter F. Mondale,

Chairman of a Senate Special Subcommittee on the Evaluation and Planning
of Social Programs, has recently indicated that "to insure the effec­
tiveness of the human services industry, a research and development
program of unprecedented scale must be launched; guidance systems must
be created that will optimize the human services.""

This concern with

evaluation of programs has been building to a "rapid crescendo” to the
point where Congress, as typified by Senator Mondale, is giving

^Public Broadcasting Service, "Media and the Times," April,
1971, a television interview by Ed Sullivan.
Walter F. Mondale, "Social Accounting, Evaluation, and the
Future of the Human Services," Evaluation, Fall, 1972, p. 29.

32

serious attention to the formulation of national social indicators
3
for assessing the status of Great Society programs.

The Cry for Evalua­
tion
Everywhere, at every level, the outcry is for program evalua­
tion.

Ever since man created organizations to provide human services,

he has energetically tried to make them more effective in meeting
those human needs for which the organization was created.

Program

watchers, over the years, have viewed the application of a whole series
of so-called panaceas, beginning with exhortation and moving on to
multidisciplinary teams, indigenous staff, consumer participation,
planning units, coordination schemes, and the most common of all, more
federal dollars.^

While each of these has contributed uniquely to the

whole, those who are the recipients of human service will probably
maintain that the delivery systems still have a good long way to go.
The cry, now, is for evaluation— program evaluation.

And with this

the legislators, educators, professionals, lay citizens and consumer
advocates expect change in the systems that are evaluated.
Spearheading this drive for program evaluation, in addition
to Senator Mondale, have been several high-level, influential govern­
ment leaders.

Noteworthy among these is the former Secretary of

Health, Education and Welfare and former Attorney General, Elliot L.
Richardson.

When asked, in an interview for the new journal,

Schulberg, A. Sheldon, and F. Baker, ed., Program Evalua­
tion in the Health Fields (New York:
Behavioral Publications, 1969),
p. 3.
4

Robert A. Walker, "The Ninth Panacea:
Evaluation, Fall, 1972, p. 45.

Program Evaluation,"

33

Evaluation, why he felt so strongly about the need for program evalua­
tion in the human services, he indicated that "far more money is being
made available for human services than ever before— that in itself
constitutes an important reason for trying to find out just what w e ’re
getting for the money."

But he also added additional reasons beyond

the over-riding financial aspect:

"The demand for services of various

kinds is so great that i t 1s impossible to visualize an amount of money
being made available.

. .that could come anywhere near meeting the

total demand" and, in these times of governmental disenchantment, "an
unsuccessful program can contribute to disillusionment with governmentally-supported services, irrespective of the availability of
funds."5
This governmental pressure is not only at the federal level
but perhaps is even stronger at the state and local level.

In their

study of NIMH and the federal centers program, Ralph Nader's Center
for Study of Responsive Law interviewed a number of state legislators
about the program.

They reported that "in some states, legislative

leaders indicated that mental health programs have reached a plateau
. . .and that further increases in appropriations would require clear
g

demonstrations of effectiveness."

Within Michigan, at the recently

completed budget hearings conducted by the Senate Appropriations Com­
mittee on the 1973-74 budget for community mental health programs,
5Elliot L. Richardson, "Conversational Contact," interview by
Susan Salasin, Evaluation, Fall, 1972, pp. 10-12.

g
F.
Chu, and S. Trotter, The Mental Health Complex, Part I:
Community Mental Health Centers, Washington, D. C. : Center for
Study of Responsive Law, 1972, p. 11-47.

34

Senator Charles O. Zollar clearly indicated that the legislature was
loathe to invest in any more new programs until there was clear evi­
dence that the existing ones had proven themselves to be effective
and making the expected impacts into the problem of mental illness
and mental retardation.

7

As an even further indication of the state

government's concern. Governor William Milliken recently issued his
Program Plan Guidelines for fiscal year 1974-75 and identified two
critical issues in the field of mental health, one being the impact
of mandatory special education and community mental health programs
upon, and as alternatives to, institutionalization of severely emo­
tionally disturbed children, and the other being the need for standards
and their implementation in the community mental health program— both
0
clearly related to {if not, in fact, demanding) program evaluation.
The mental health professionals, themselves, have also been
seeking program evaluation of their programs albeit the pressure seems
to be more at the state administrative levels than at the local service
delivery level.

In one of the earlier manuals on evaluation, pub­

lished by the Illinois Department of Mental Health, the Director
stated that "continuous evaluation is essential for constant improve­
ment in the effectiveness of the Department's program."

Such program

evaluation was seen as a help "to identify the most successful strategies and techniques among the wide variety being employed."
^Senate Appropriations Hearings, Michigan Senate
April 5, 1973.

9

That

(tape),

8..- , ■
- Michigan, Program Policy Guidlines for Fiscal Year 1974-75,
Executive Office of the Governor.

9

Elizabeth J. Slotkin, Manual for Evaluation of Mental Health
Programs, State of Illinois Department of Mental Health, May 1, 1966,
p. 1.

35

concern continues to be expressed particularly by state department di­
rectors.

Here in Michigan, E. Gordon Yudashkin, Director of the Michi­

gan Department of Mental Health, has expressed, some seven years later,
nearly the same need:

"Evaluating the effectiveness of mental health

programs is difficult and has been to a great extent ignored in the
past as a management tool. . . .

As more and more public money has

been appropriated for mental health programs, pressure has mounted for
development of a system of evaluation.

Taxpayers and their legislative

representatives understandably want an accounting.

They want to know

where the dollars are going and for what.1,10
The consumer advocates, too, have been expressing the need for
evaluation.

They are particularly concerned in that, it seems to them

that the result of years of public speeches and the expenditure of
ever-larger sums of public money has been the "growth of a mental
health bureaucracy paralleling, not supplanting, the state hospital
bureaucracy."

They indicate that now should be the time for a "hard

look" at the entire program, for failure to do so and with the current
rate of expansion, the new centers will become as "entrenched and resistant to change as state hsopitals have been for over a centry." 11
The currently-popular and consumer-oriented magazine. Psychology To­
day , has taken up the gauntlet:

"Mental health agencies servicing

the same community cooperate extensively, however:

they make mutual

referrals, respecting various territorial claims, and one never openly
questions another's effectiveness.

. . .

Mental health authorities

10E. Gordon Yudashkin, Current Diagnosis, Link, Vol. II, No. 7,
December 16, 1971.
11Chu & Trotter, op. c i t ., p. 11-60.

36

across the country are so thoroughly preoccupied with preserving these
alliances that their major commitments are to the politics of bureau­
cratic survival."

It is asserted that mental health services continue

to exist with limited scope, questionable effectiveness and prohibitive
price.

It is only the "rare clinical installation” that has a con-

tinuous and objective means for evaluating its effectiveness.

12

Grazi-

ano, a mental health professional himself, but speaking for the con­
sumer, has said:
When critics insist on evaluation, power-structure clinicians
do not respond to the substance of the criticism; instead, they
obscure the issue by attacking the critics for their lack of
humanitarianism and sensitivity.
Only when the criticism is
politically threatening do the mental—health structures begin
to react.
Until we have planned constant and careful evaluation
into every program, we will not progress beyond our current
state, which is dominated by political concerns. The same
rhetoric used to justify these demands (for more resources) also
distracts public attention from the need to evaluate the real
effectiveness of those programs and the wisdom of further invest­
ments .
If there is so much pressure, at the federal, state and local
levle, from legislators, administrators, professionals and consumer
advocates alike, and since that pressure has now been on for some
years, one would wonder what is being produced.

In a review of fed­

eral level evaluation, Buchanan and Wholey concluded in 1969 that "the
most impressive finding about the evaluation of social programs in the
federal government is that substantial work in this field has been
almost nonexistent."

14

Although they suggest that this is certainly

A. Graziano, "In the Mental-Health Industry, Illness is our
Most Important Product," Psychology Today, January, 1972, p. 14.
13Ibid., p. 16.
D. C.:

J. Wholey, et a l ., Federal Evaluation Policy (Washington,
The Urban Institute, 1969), p. 47.

37

not true today, they do indicate that evaluation information is only
sporadic and inconsistent.

More importantly, they are concerned that

after the investment of significant resources and effort over the past
few years, there has been little progress toward "a completely functional over-all evaluation system."

15

Problems in Program
Evaluation
One of the reasons, perhaps, for the confusion about whether
program evaluation is being accomplished or still needs to be done has
to do with the lack on consensus about what program evaluation really
means.

Although all the authors cited above seem to speak lucidly

about program evaluation and write as if they knew precisely what they
mean by the term, none of them have bothered to define it precisely
and one has to assume they are all speaking about the same process or
processes.

Both Schulberg

16

and James

IV

have felt that despite current

ambiguity, the most common usage of the term "program evaluation" re­
fers to the process of determining the value or amount of success in
achieving a predetermined objective.

This is very consistent with the

American Public Health Association statement of definition:

"(Program)

evaluation is the process of determining the success, often in terms
of a value or score, a program achieves in relation to its established
objectives.

It includes at least the following steps:

Formulation

15

G. Buchanan and J. Wholey, "Federal Level Evaluation,"
Evaluation, Fall, 1972, p. 22.
16
17

Schulberg, et a l .,

op

. cit.. p. 6.

G.
James, "Evaluation in Public Health Practice," American
Journal of Public Health 52 (1962):
1145.

38

of the objective, identification of the proper criteria to be used in
measuring success, determination and explanation of the degree of suecess, recommendations for further program activity."

18

As such, pro­

gram evaluation differs from research primarily in that it does not
seek new knowledge, but attempts to mark progress toward a prestated
objective.

For the purposes of this study, the definition of the term

"program evaluation" shall be that of the American Public Health
Association.
Program evaluation has also only lately been imposed on pro­
grams, some of which were established and implemented without concern
or, frankly, even interest in evaluation.

When Dr. Saul Feldman, high­

est ranking NIMH official in charge of the centers program, was inter­
viewed by the Nader staff, he declared that even if he had the
opportunity to do it over again, he would not choose to set up a few
experimental centers, evaluate them, and then go ahead with the rest
of the program.

"Evaluation takes too long," he explained, "and be­

sides I am not convinced that the results of even ten years of experi19
mentation would have been very helpful."

As a result, NIMH has

tended to measure the success of the program on the numbers of centers
established rather than by accomplishments or impacts made by the
centers.

Congress, until very recently, has been very obliging, even

perhaps unquestioning, preferring to buy the concept rather than base
their appropriations on firm objectives and assessed results.
Beyond an earlier lack of interest and confusion about what
is meant by evaluation, there are some fairly valid reasons why
18
19

Schulberg, et a l ., op. ext., p. 6.
Chu & Trotter, op. c i t ., p. 1-9.

39

evaluation is in its primitive stage.

It should be constantly kept

in mind that mental care delivery systems have made considerable prog­
ress in moving from a primarily custodial to a primarily treatment and
rehabilitation orientation over the past decade.

The very highly

visible and often overwhelming demand for services of a dynamic
rather than static program has often been the cause for neglect of
the evaluation process.

To many administrators it has seemed diffi­

cult to justify curtailing direct services to fund a supporting activity like evaluation. 20
services

has,

This "consumer-orientation" in terms of direct

however, turned out to be the subject of criticism by

certain consumer advocates who have felt that the "ever-expanding
clientele" and "growing catalogue of treatable symptoms" has been
little more than "idealistic campaign rhetoric" to assure the mental
health industry an annual slice of government and public funds.

They

even further state that this same "rhetoric" obscures the real issue
of "questionable effectiveness" of treatment.

21

It xs xnterestxng to

note that this "preoccupation" of legislators and mental health execu­
tives with expanded demands upon limited tax funds has been the oftcited reason for justifying program evaluation appropriations.

22

Funds have been one of the major problems in initiating ef­
forts at program evaluation.

The bitter truth is that most states

spend less than one-half of one percent of their human service
20

J. Halpern and P. Binner, "A Model for an Output Value
Analysis of Mental Health Programs," Administration in Mental Health,
Winter 1972, p. 40.
21
22

Graziano, op. cit., p. 12.
Schulberg, et a l ., op. c i t ., p. 3.

40

expenditures to design and measure the services that they support-

The

federal program gave impetus to its program evaluation efforts by spe­
cifically earmarking up to one percent of the appropriations to be
used for evaluation of the programs authorized, but even this did not
start until 1969.

23

It is, however, very interesting to note that

these same funding sources that until recently have minimized evalua­
tion, when making grants have steadily become more and more insistent
on hard evidence to support budget requests.

24

Interest levels, allocation of funds and definition problems
are fairly easily dealt with and resolved.

More insidious and of far

greater concern is the inherent difficulty in evaluating any type of
broad social program.

To date all that has been done is to accumulate

repertoires of numbers:

numbers of centers, numbers of patients,

numbers of staff, etc.

Numbers alone, however, are notoriously poor in­

dicators of success.

This is particularly true with a community mental

health program whose broad social goals do not lend themselves to
simple numerical tabulation.

25

The pluralistic nature of our society,

the variety of structure in delivery systems,
of the

service

24
25

and the nebulousness

mandate have all but made impossible a serious effort

at program evaluation.
23

27

26

There is additionally a problem of sequencing—

Mondale, op. c i t ., p. 32.
Halpern & Binner, op. cit., p. 40.
Chu & Trotter, op. cit., p. II-l.

26

Harvey M. Freed, "Promoting Accountability in Mental Health
Services," American Journal of Orthopsychiatry, October, 1972, p. 761-2.
27

Slotkin, op. c i t ., p. ii.

41

there is no accumulated body of experience in the evaluation of commu­
nity mental health programs from which governing or guiding principles
can be drawn.

28

Attempts at defining what constitute principles in

the evaluation of community mental health programs must depend heavily
on knowledge gained from other areas, often only tangentially related.
Once a body of experience is gained within the field, evaluation effort
seeding one from the other will improve.

Closely related, but also a

serious deficit, is the lack of generally agreed upon standards for
which an agency must aim.

29

Attempts to develop such standards, accep­

table to a broad range of professionals in the field, have generally
met with abysmal failure.

The standards generally available tend to

deal only with physical facilities, qualification of staff and admin­
istrative procedures.

Any relationship to measurable results or ob-

jectifiable data has been most remote.

Concurrent with the need for

evaluation has risen the cry for s t a n d a r d s ^ but until such standards
are developed, any evaluation effort must state for itself the stand­
ards it wishes to apply and the assumptions underlying these standards.
Under such conditions, replication of evaluation studies are almost
never possible.
The major problems, then, seem to be that:
^®Brain MacMahon, et. a l ., "Principles in the Evaluation of
Community Mental Health Programs," American Journal of Public Health
51 (1961): 963-968.
29

Jack Zusman, "Evaluating the Quality of Mental Health Serv­
ices: Criteria for Rapid Informal Judgement," Mental Hygiene, Octo­
ber, 1971, p. 478.
30

Michigan Department of Mental Health, "Community Services on
the Couch," Link, January 25, 1973, p. 1.

42

1.

Program evaluation assumes that each program has a purpose

and a set of objectives that are commonly agreed upon— mental health
professionals have generally made no such assumption!
2.

Program evaluation assumes that objectives can be stated

in quantifiable, measurable terms.

Objectives in the mental health

field have until recently been expressed in general terms, such as "to
lessen the extent of emotional disturbance" or "to improve ability to
cope with the exigencies of life."

These are neither quantifiable nor

measurable!
3.

Program evaluation assumes a reasonably strong centralized

authority or at least the acceptability of developing one.

Mental

health professionals have long been disinclined to accept a strong
central authority, and, indeed, their historical development has gen­
erally mitigated against this development.

Equally important, the

central mental health decision-makers have often been reluctant to
exert an authoritarian manner, copping the plea that "each program
should be allowed to do its own thing," "with the state of flux, who
knows for sure what works best?" etc.

But someone should clearly

state what should be done, what outcomes are expected, and how one
will be assessed!
4.

Program evaluation assumes that the criteria of effective­

ness will be oriented to outcome or productivity.

That has not been

the case in mental health services until recently and, indeed, most
mental health evaluation to date has been in quest of an ever—elusive
and highly questionable professionalism of staff performance, never

43

looking to the outputs or impacts of that performance-

Some mental

health professionals have smugly doubted that outcome measures would
ever be possible
In his statement on evaluation of human services, Senator
Walter F. Mondale summed up by saying, "If we are truly to 'bridge the
gap' between people and their government, if we are to restore pride
of belonging and responsibility as a quality of increasingly enlightened, vocal citizenry, we need some new mechanisms."

32

Most reviewers

or commenters on the current scene in program evaluation would agree.

Criteria to be
Evaluated
In spite of the problems outlined above, and surprising as it
may seem, there does appear to be a degree of consensus about the
criteria by which programs should be evaluated.

Those calling for

program evaluation are demanding that cirtical questions like "Does
the program accomplish what it was designed to accomplish?"
well does it do this?"

"How

"Could it be done better?" and "Does the out­

come justify the investment in manpower and resources?" be answered
if continued funding is to be requested.

33

In order to answer these

questions, and more importantly, in order to know best how to deploy
scarce resources, program administrators must know how many people need
mental health care, the social circumstances under which these people
31

J. Alexander and J. Messal, "The Planning-ProgrammingBudgeting System in the Mental Health Field," Hospital & Community
Psychiatry, December, 1972, pp. 358-9.

32
33

Mondale, o p . c i t ., p. 33.
Richardson, op. c i t ., p. 9.

44

live, the kinds, costs and availability of the needed personnel to
provide the services, and, if possible, some information about the
effects that various treatment maneuvers which we call management and
treatment have on the individual patient, the hospital ward, and the
community.^
In calling for a "systematic, comprehensive approach," Deniston
and associates designed an evaluation "based on the assumption that all
programs in (mental) health can be viewed as consisting of a combination
of resources, activities, and objectives of several kinds."

35

They

maintain that each program is characterized by one or more program
"objectives," each objective implies one or more "sub-objectives,"
"activities" are performed to achieve each sub-objective, and "re­
sources" are expended to support the performance of activities.

Each

program plan (whether that be outpatient, consultative, day treatment,
or any other) would, therefore, make three kinds of assumptions:
1.

The expenditure of resources as planned will result in
the performance of planned activity.

2.

Each activity, if properly performed, will result in
the attainment of the sub-objective with which it is
linked.

3.

Each sub-objective must necessarily be accomplished
before the next one can be achieved and, if all sub­
objectives are attained, the program objective will
be attained.

This scheme provides a "yes-no" evaluation of each sub-objec­
tive, and ultimately a "yes" or "no" to the question of total program

Jerome A. Collins, "Evaluative Research in Community Psychi­
atry," Hospital & Community Psychiatry, April, 1968, p. 21.

35
O.
L. Deniston, et a l ., "Evaluation of Program Effectiveness,
Public Health Report 83 (1968):
323-335.

45

effectiveness.

This fails to answer questions about how well the pro­

gram achieves its objectives, only that it does so.

It does not in­

dicate what areas should be improved to increase effectiveness and
does nothing about the question of efficiency.

A whole new set of data

needs to be analyzed to get at these kinds of questions.

The Nader

report, previously cited, outlines types of criteria that should be
considered in evaluating a program.

They list, among others to be

considered, the following as essential:
1.

Admission, readmission and discharge rates to and
from state hospitals.

2.

The percentage of area residents admitted to the state
hospital after receiving local treatment, and the per­
cent discharged by the state hospital who are picked
up for aftercare.

3.

The social situation of the client at the time they
cease being a client, and the reason for the discon­
tinuance .

4.

Utilization rates as compared with other centers.

5.

Comparative costs per length of stay or unit of service.

6.

Travel time client must spend to secure treatment and its
effect on utilization, and staff travel time in relation
to any change in this utilization.

7.

Any long-term impacts or trends over at least one or
two years, preferably longer.3®

Although this listing closely parallels the listings generally
requested by the federal agencies, it deletes certain of the "vital
nongoal acitivites," such as maintenance, administrative tasks.

36

,

Chu & Trotter, op. e x t ., p. III-5.

46

recruitment, etc., which are also time and cost consuming,

37

but even

more importantly, there is no direct consideration for the extensive
outreach, consultative and educational activities of a community mental
health center other than the possible long-term impacts on social prob­
lems, or trend data.
It would appear, then, that in addition to the rather extensive
array of items to be included in an evaluation, there must also be
several different levels of evaluation.

James had categorized these

levels as:
1.

Evaluation of effort:
How do the practices of the pro­
gram compare with local or national standards? Yardsticks
such as patient-staff ratios provide a sample for limited
assessment of the program's functioning at this level.

2.

Evaluation of performance:
What outcomes have the pro­
gram's effort produced? This approach assumes that
services were provided correctly to those individuals
helped.

3.

Adequacy of performance: To what extent has the commu­
nity 's total problem been solved by the program?
Services directed to a minority of individuals are
less adequate than those focused upon the total popu­
lation.

4.

Evaluation of efficiency:
Can the same end result be
achieved at a lower cost? Screening programs in
public health frequently are evaluated in this manner
by considering the number of false positives and
falso negatives produced by them.3®

Evaluations of effort have become fairly common in mental
health programs and the criteria specified previously are mainly
37

.
Amitai Etzxonx, "Two Approaches to Organizational Analysis:
A Critique and a Suggestion," Admin. Sci. Quart. 5 (1960):
257-278.
38

George James, "Evaluation in Public Health Practice,"
American Journal of Public Health 52 (1962): 1145-1154.

47

concerned with this level.

Evaluations of efficiency are becoming

more and more common/ particularly with the present concerns about
cost per unit of service.

However, an evaluation of total performance

or adequacy of performance is far more difficult and in many respects
seems to be a combination of levels.

It would seem reasonable that

a combination of effort, efficiency and adequacy would present an
evaluation of performance.

It is curious, then, that James, in his

categorization, chose to order them in the manner presented.
It is remarkable that even though criteria have been specified
in some cases for many years, levels of evaluations have been identi­
fied for sometime, and critics have been pushing for evaluation since
the beginning of the program, the still ever-present need is for pro­
gram evaluation.

Why is it that the need for evaluation seems to be

more apparent in the literature than any results of evaluation efforts?
To answer such a quation, one needs to review current literature and
reports of various community mental health programs and examine their
results.

To do so might at first seem to be a formidable task, but

it is not so, for there have been few significant evaluation efforts
in the community mental health field.
partial answer to the question.

That, in itself, provides a

Of probably more significance, how­

ever, is the fact that, with very few exceptions, evaluation efforts
to date have concerned themselves with only one criterion or dimen­
sion and have found no way to combine effectively different measures
to provide a total evaluation.
the answer.

Therein is probably another portion of

But the rest of the answer must come from the review of

current and recent efforts in themselves.

48

Summary of Current
and Recent Evalua­
tion Efforts
Any review of a field so broad as community mental health must
have a procedural starting point.

In a field so young, an historical

accounting of research and evaluation efforts would be nonproductive,
in that

all the efforts have been within the past ten years.

Similarly,

regions

of the country, or schools of thought, do not serve well, in

that professionals in this field seem to be particularly mobile and
one finds researchers and writers employed in an amazing number of
locations in an amazingly short time period.

It therefore seems better

to categorize the efforts (even though this must be done somewhat
artificially sometimes) into common subject areas, sub-program or sub­
objectives of the total concern.

As such, the previously reported

criteria to be evaluated serve a most useful means.

Impact
program

on State Hospitals.— "The original goal of the centers

was to supplant state mental hospitals," or at least say the

consumer advocate groups.

39

Yet, between 1966, when the first centers

started operating, and 1971, the number of state supported mental
hospitals in the United States increased from 307 to 321, the total
number of patients treated in these hospitals rose from 802,216 to
836,326 as admissions rose from 285,244 to 414,926 and the mainte­
nance expenditures for these hospitals soared from $1,300,380,295 to
over two billion dollars.

39

40

In Michigan, a similar trend has taken

Chu & Trotter, o p . c i t ., p. i.

49

place-

There were 15 state mental hospitals in the state in 1963

(when Act 54 programs were authorized) and there are 25 today.

Gross

expenditures in these facilities amounted to $42 million in 1963-64
and the current 1972-73 budget for these facilities amounts to $105
million.

Admissions have risen from 5,768 in 1963-64 to 17,744 in

1972-73.
Although the above data seem to indicate otherwise, there has
been very little debate regarding the philosophy and intent that com­
munity programs would impact at least, if not "supplant," the state
mental hospitals-

The community care ideology developed from the grow­

ing realization that the mental hospital as it existed did much to
isolate the patient from his community, to retard his skills and, in
general, to induce a level of disability above and beyond that resuiting from the patient's condition.
nor new-

41

The idea is neither original

During World War II in Prance, many "state hospitals" had

to close their doors due to food shortages.

Their patients were sent

home, where many improved considerably, thus "dramatically demonstrat­
ing the therapeutic potential of the community."

After the war,

rather than rebuild their state hospitals, French health officials be­
gan a program of "sector psychiatry," developing mental health treatment clinics and ancillary services in each sector.

42

This was fif­

teen years before the catchment area and community mental health center
era began in this country.
41

David Mechanic, Mental Health and Social Policy (Englewood
Cliffs, New Jersey: Prentice-Hall, 1969), p. 63.
42 .
Michael A. Woodbury and Margarita M. Woodbury, "CommunityCentered Psychiatric Intervention: A Pilot Project in the 13th
Arrondissement, Paris," American Journal of Psychiatry, November,
1969, p. 619.

50

Even though the country has been "sectored" or "catchmented"
and community mental health programs have been vastly expanded in the
past ten years, even though admission rates have increased as costs
spiraled in even more state hospitals than there had been previously,
Dr. Stanley Voiles, Director of NIMH, still was able to claim "impact"
on state hospitals as early as 1969-

"This program has really gone

across with the people of the United States and its results are im­
pressive. . -largely because of the impetus of community mental health
centers we have seen a startling reduction of patients in mental
hospitals."

43

This "startling reduction" refers not to the admission

rates, obviously, but to the in-house population which, during this
same period from 1963 to 1971, was reduced from 504,947 to 308,024.
That the community mental health centers have been responsible for
this reduction in debatable, as has been previously noted, but NIMH
officials seem to have made such a claim in support of the centers
program-

Others have been far less than enthusiastic about the im­

pact being made by community programs.

In the same year Dr. Yolles

claimed impact, 1969, Dr. Henry Davidson (Superintendent of Overbrook
Hospital, New Jersey) claimed that "community mental health centers
offer us no help, no matter how ambitious their plans."

44

He reasoned

that a certain portion of the population would always be in need of
involuntary admission and that community programs were neither inter­
ested in, nor equipped to handle, this segment of the population.
43

U.S., House, Hearings on Community Mental Health Centers
Act Extension before the Subcommittee on Public Health and Welfare
of the Committee on Interstate and Foreign Commerce, 91st Congress,
1st session, November 18-20, 1969, p. 38.
44 Henry A. Davidson, "The Double Life of a Psychiatric Hospi­
tal," Mental Hygiene, January, 1969, p. 19.

51

The claim of "impact" made by NIMH becomes even more dubious
when one tries to examine where the ex-patients of state hospitals
have gone when they returned to the community.

Although there is no

comprehensive documentation on where former state hospital residents
have gone, existing evidence suggests that fairly sizable numbers are
being transferred "en bloc to nursing or so-called foster homes, where
conditions are frequently worse than those in state hospitals."

45

Since the impact attributed to reduction in size of state hos­
pitals is far more obscure than some would claim, the more critical
factor in assessing impact is the admission rate from the community
to the state hospital.

Rates of admission have varied from less than

1 per 1,000 population to over 4 per 1,000, both nationwide and be­
tween counties within any given state.

It becomes necessary to look

at how a patient becomes an admission to a state hospital and whether
he really needs to be admitted for his problem.
scarce and most scant in their results.

Such studies are very

Psychiatric screening and

civil commitment proceedings for mental patients were studied in one
midwestern state and revealed several disturbing findings.

Shah re­

ported that psychiatric interviews on the screening examinations
ranged in length from 5 to 17 minutes with a mean time of 10.2 minutes.
Court hearings were conducted "perfunctorily and with lightning rapid­
ity" with the mean time observed in one court only 1.6 minutes.
investigator concluded that the decisions

The

(of both the psychiatrists

and the court) were based largely upon "presumption of illness" in the

45

Chu & Trotter, op. cit., p. 11-35.

52

patients.

46

In a detailed analysis of decisions concerning psychiatric

hospitalization in California, Mendell and Rapport discovered that 84
percent of patients hospitalized would not have required it if more
adequate family and community resources had been available.

47

This is

consistent with the remarks of George Albee, former President of the
American Psychological Association, who argued that as few as 10 per­
cent of present first admissions need to be hospitalized in a pro­
tective environment.

He reasoned, "Elderly senile people, alcoholics,

and others lumped together as persons with personality disorders or
psychoneurosis, who constitute nearly three-quarters of all first ad­
missions to mental hospitals, simple don't belong there!

The remain­

ing quarter is really the smaller pool from which might be drawn the
limited number of persons society must lock up.

...

If you will

agree that not more than half {of these) are dangerous, we are down
to close to 10% of present first admissions.

And, if you agree that

many of these people would not be dangerous, if properly controlled
by intensive care programs, we arrive at a point at which we have
practically eliminated the need for the state hospital for first admissions altogether."'

46

Saleem A. Shan, "Crime and Mental Illness: Some Problems in
Defining and Labeling Deviant Behavior," Mental Hygiene, January, 1969,
p. 27.
47

W. Mendell and S. Rapport, "Determinants of the Decision for
Psychiatric Hospitalization," Archives of General Psychiatry 20 (1969):
321-328.
48 ’
George Albee, "Models, Myths, and Manpower," Mental Hygiene
52, 2 (April, 1968):
176.

53

Certainly these authors would not advocate preventing anyone
from receiving needed treatment but they do seriously question whether
the great majority of those who are committed to state hospitals really
"need the 1treatment’ they receive.”

49

Even though it is true that

state hospitals using newer methods of psychotherapy and treatment with
more intensive care than was the case in the mid-1950's produce far
more active treatment and greater economic efficiency,

50

the question

as to whether this constitutes what the patient needs is still open.
Penn and his research staff in Wisconsin have even concluded that, on
the basis of "a number of systemic, carefully done studies, using
relatively objective measurements and independent criteria of funtioning,

(demonstrating) the negative effects of institutionalization.

. .

commitment to a mental hospital often produces more psychologic harm
than good for many people."'*'*'

What these authors do seem to be advo­

cating is to prevent state institutionalization by treatment in com­
prehensive programs within the community, the same philosophy espoused
by the Joint Committee in Action for Mental Health (1961) and Presi­
dent Kennedy in his Address to Congress (1963).
To consider only first admissions, or initial commitment, is,
however, only a part of the total picture.

With the progress made

in treatment of the mentally ill in recent years, an increasing
49

N. Penn, et a l ., "The Dilemma of Involuntary Commitment:
Suggestions for a Measurable Alternative," Mental Hygiene 53, 1
(January 1969): 5.
50

Kenneth M. McCaffree, "The Cost of Mental Health Care under
Changing Treatment Methods," American Journal of Public Health 56
(1966): 1019.
^Penn,

et a l . , op. c i t .

54

percentage of those admitted are soon able to return to their commu­
nities.

When this occurs, aftercare services become critical as an

"impact" on recidivism rates.

Many studies have been done regarding

the number of persons who return to state hospitals after their re­
lease, the length of time between admissions, and the causes and pre­
vention of recidivism.

Collins, in reporting on a study in England in

1968, reported that 43 percent of released patients were readmitted
within the first year and that an additional 13 percent of the rest
(those that still remained in the community) were "deteriorated markedly, although.

. .not readmitted."

52

Studies of recidivism rates

are so numerous, however, that they have been summarized by author,
location, and time period on Table 6.

Anthony and associates, in

their review of the literature on various aspects of psychiatric re­
habilitation, concluded that "though the studies differ in years
sampled, geographic location, and type of institution, their results
are remarkably similar, and suggest a recidivism rate for a one—year
period of approximately 40%-50%."

They did, however, conclude that

'fex-patients who attend aftercare clinics have a lower rate of recidivism
than non-attenders."

Perhaps even more surprising is that their re­

sults indicated that "it does not seem to matter whether hospitalized
psychiatric patients receive eclectically oriented group therapy;
psychoanalytically oriented individual or group therapy; or drugs,
shock, individual or group therapy.

Regardless of the type of tra­

ditional therapy patients receive, their recidivism and employment
52

Jerome A. Collins, "Evaluative Research in Community Psy­
chiatry," Hospital & Community Psychiatry 19, 4 (1968);
22.

55
TABLE 6.--Sun«nary of Studies on Recidivism Rates for Psychiatric
Patients.
Time Span
1 Yr. 3 Yr. 5 Yr,

Researchers

Location

Ycar 3 Mo. 6 Mo.

Miller
(1967)a

California

1956
1963
1965

404
404
484

California

1966

534

Chicago

1963

Cleveland

)964

Savino 6
Schlamp
(1968)k
Orlinsky 6
D'Elia
(1964)c
Friedman,
von Mering £
Hlnko .
(1966)
Freeman £
Simmons
(1963)°
Bloom G Lang
(1970)^
lorei
(1967)9
Wilder, Levin
6 Zwerling
(1966)
Fairweather,
et. al.
(1960)1
Olshansky
(1968)3

154

304

464

334

504

Massachusetts 1962

704
754

674

384
424
394
4S4

Pour States

1959

Boston

1966

404
654

aD..Miller, "Retrospective Analysis of Post-hospital Mental
Patients' Worlds," Journal of Health £ Social Behavior 8, 2 <1967):
136-140.
^M. Savino and F. Schlamp, "The Use of Non-professional Re­
habilitation Aides in Decreasing Re-hospitalization" Journal of Re­
habilitation 34, 3 (1968)i 28-31.
CN. Orlinsky and E. D'Elia, "Rehospitalization of the Schizo­
phrenic Patient," Archives of General Psychiatry 10 (1964): 46-54.
*^I. Friedman, O. von Mering, and E. Hinko, "Intermittent
Patienthoodi The Hospital Career of Today's Mental Patient," Archives
of General Psychiatry 14 (1966): 386-392.
eH. Freeman and O. Simmons, The Henal Patient Comes Homo (New
York: Wiley £ Co., 1963).
^L. Bloom and M. Lang, "Factors Associated with Accuracy of
Prediction of Poothospitalization Adjustment," Journal of Abnormal
Psychology 76 (1970): 243-249.
q
T. Lorei, "Prediction of Comunity Stay and Employment for
Released Psychiatric Patients," Journal of Consulting Psychology 31
(1967): 349-357.

hJ. Wilder, G. Levin, and L. Zwerllng, "A Two-year Follow-up
Evaluation of Acute Psychotic Patients Treated in a Day Hospital,"
American Journal of Psychiatry 122 (1966)t 1095-1101.
^“G. Fairweather, et al., "Relative Effectiveness of Psycho­
therapeutic Programs," Psychological Monographs 74 (1960).
^S. Olshansky, "The Vocational Rehabilitation of Ex-Psychiatric Patients," Mental Hygiene 52 (1968): 556-561.

56

rates are not differentially affected."

53

It would appear that no

matter what the treatment modality, type of institution, diagnosis or
condition, a substantial portion of patients leaving the hospital
eventually have to be readmitted, and even then, many of the ex­
patients who remain in the community are unable to perform the roles
that are normally expected of them.

54

In their Manual for the Comprehensive Community Mental Health
Clinic, Knight and Davis underscroe the importance of aftercare pro­
gramming with the following conclusions:
1.

Unless an extensive aftercare program is established,
one-third to one-half of discharged mental patients
will relapse.

2.

The problem of readmissions is clouding the excellent
record that mental hospitals are making today (refer­
ring to the reduced census and shortened time stays).

3.

Readmissions are a drain on the economy, causing capital
expenditures and budget increases.

4.

Aftercare is one logical solution to the problem of
admissions.
Aftercare can prevent relapses, cut re­
admissions in half and eventually make it possible
for hospitals to operate at less than capacity.^5

Therefore, it is important to consider not only first admissions
to state institutions but also the readmission rates for those who
have been released if one is to study the impact of a community mental
health program on state institutions.

Levy and associates have

53

William Anthony, et. a l ., "Efficacy of Psychiatric Rehabili­
tation," Psychological Bulletin 78, 6 (1972) : 448.
54

T. Northcutt, et. a l ., "Rehabilitation of Former Mental
Patients: An Evaluation of a Coordinated Community Aftercare Program,"
American Journal of Public Health 55 (1965):
570-577.
55

J. Knight and W. Davis, Manual for the Comprehensive Commu­
nity Mental Health Clinic (Springfield, 111.: Charles C. Thomas,
1964), pp. 40-41.

57

chosen to term this as the "rate of extrusion" and classified it as
one of the general indices that should be routinely examined.

The

rate of extrusion is a "basic index that tells how many people are
being disengaged from the normal community process and evacuated to
noncommunity resources."

It is based on the assumption that mentally

ill and mentally retarded should be, for the most part, cared for in
their own communities, and, "any mental health program that purports
to be serving the community's needs should have an impact on the
rates of extrusion into these various {state) facilities."5^
There is, however, another factor which has been found to
have a dramatic relationship to rates of admission, and one which is
beyond the control of either the admitting hospitals or the community
mental health program.

In an extensive study of mental hospitalization

in New York State from 1841 to 1967, Brenner found that admissions to
mental hospitals bear a striking inverse relationship to economic
change.

57

In other words, mental hospitalization increases during

economic downturns and decreases during economic upswings.

Brenner

concluded that employment opportunities, adequate housing, and the
widespread provision of social services

(in which he included out­

patient psychiatric services) were a far more rational way of coping
with mental health problems than large-scale hospitalization

(in which

he included not just state hospitals but also psychiatric wards of
general hospitals and private inpatient facilities).

56b. Levy, A. Herzog, and E. Slotkin, "The Evaluation of State­
wide Mental Health Programs:
A Systems Approach," Community Mental
Health Journal 4 (1968):
340-349.
57 H.

Brenner, Mental Illness and the Economy, unpublished
manuscript, expected to be published by Harvard University Press,
1973.

58

But, whatever the cause of admission or readmission, whatever
the rates of extrusion, there seems to be consensus that community
mental health programs should at least have "impact" if not fully
"supplant" the state hospitals.

Since this is a clearly stateable

objective, and easily measurable in terms of gross data, it has been,
and will probably always be, one of the major criteria upon which to
evaluate a community mental health program as to its effort, efficiency,
and performance.

Out of a variety of products that a mental health

program might produce, perhaps the most important single "product" is
the patient who is returned to function in the community.

58

In ad­

dition to this humanitarian aspect, the economic aspect is also allur­
ing.

Richardson, former Secretary of Health, Education and Welfare,

feels that "the dollars we invest in making mental health services
available on an out-patient basis, easily accessible within the commu­
nity, will return savings in the cost of not hospitalizing people,
which can often result in a longer period of treatment than if the
patient remained in the community."

59

Estimates of Meed and Utilization Rates.— Need is to be
assessed, according to the federal regulations, on the basis of pre­
valence of mental illness and emotional disorders, both in terms of
rate and absolute number of persons a f f e c t e d . E p i d e m i o l o g i s t s have
58

J. Halpern and P. Binner, op. c it., p. 41.

59 .
Richarson, o p . cit■, p. 16.
60

H.
Schulberg and H. Wechsler, "The Uses and Misuses of Data
in Assessing Mental Health Needs," Community Mental Health Journal
3, 4, (Winter, 1967):
391.

59

repeatedly encountered difficulty in measuring the extent of actual
disorder in a population because of the absence of clear-cut defini­
tions and because of the broad range of available methods for obtain­
ing a count, all of them resulting in widely varying rates.

Earlier

studies tend to base their data on reported neurotic and psychosomatic
symptom patterns resulting in a gross

understating

of the problem,

whereas the more recent population survey methods have brought in
enormous frequency rates, far in excess of that commonly thought to
be the extent of need.
"What is a case?"

This disparity brings up the old issue of

When does a case become a case?

when a case should be counted and when not?

What determines

This problem is still un­

solved, although it has been clarified considerably through the at­
tempts to measure functional impairment rather than diagnostic
categorizations.
On a nationwide basis, in March 1972, NIMH Director Bertram
Brown told a House Subcommittee on Appropriations that "maybe forty
million Americans need psychiatric care."

62

As a gross measure of

need, forty million out of a population of some 210 million Americans
would calculate to an across-the-board 19.1 percent in need of psy­
chiatric care.

Note also that Dr. Brown included only "psychiatric

care" and did not include those in need of services due to problems
of mental retardation, another three to six percent, depending upon
61

Paul Lemkau, "contributions of Psychiatric Epidemiology,"
American Journal of Psychiatry 126, 11 (May, 1970) : 1643.
U.S., Department of Health, Education and Welfare Appropria­
tions for 1973, Hearings before a Subcommittee of the Committee on
Appropriations, House of Representatives, 92nd Congress, 2nd Session,
March 8, 1972, p. 97.

60

degree of retardation and estimation methodology.
running as high as 23 percent,

63

and others

With some estimates

indicating

"as high as

47 percent in the lowest socioeconomic group and at least 13 percent
in the advantaged groups,"

64

the service populations become so large

as to boggle the mind of the mental health service planner.

In Mazer's

recently reported study of cross-matched multi-problem households, he
found a much more realistic 6 per 100 (or 6 percent) within the total
population with psychiatric disorders, but, more importantly, he found
that only 2 percent had ever been treated for that d i s o r d e r . ^

There­

fore, the contrast between the percentage of population potentially in
need, the percentage actually in need, and the percentage receiving
services in relation to their need, is vastly different.
A variety of reported utilization rates appear in the litera­
ture , varying from less than one per hundred to nearly three per
hundred.

A summary of gross estimates and reported utilization rates

appears in Table 7.

Two serious problems result in using reported

utilization rates as an expected or standard for purposes of estimat­
ing caseload:

63
L. Srole, e t . a l ., Mental Health in the Metropolis: The
Midtown Manhattan Study (New York: McGraw-Hill, 1962), p. 167.
64

Simon Auster, "Insurance Coverage for 'Mental and Nervous
Conditions': Developments and Problems," American Journal of Psychi­
atry 126, 5 (November, 1969):
698.
Milton Mazer, "Characteristics of Multi-Problem Households:
A Study in Psychosocial Epidemiology," American Journal of Orthopsy­
chiatry 42, 5 (October, 1972):
794.

61

TABLE 7.— Summary of Gross Estimates and Reported Utilization Rates
for Psychiatric Services.
Researchers

Location

Srole et. al. (1962)° Manhattan
New York
Auster (1969)b
Mazer (1972)c
Brown (1972)d
Gardner (1967)e

Woodbury (1969)^
Glasser
s Duggan (1969)g
Goldensohn et. al.
(1969)h
Avnet (1969)^
Green (lOGO)1*
Tischler et. al.
(1972)k

Martha's Vine­
yard, Mass.
Nationwide
Rochester, N.Y.

Paris, France

Year

Estimated Reported
Need
Utilization

1960
1966

23%
47% Poor
13% Rich

1971
1972
1960
1961
1962
1963
1964
1967
1967

Detroit

1966
1967

New York
Los Angeles
California

19651968
1965
1968

Connecticut

1970

6%

2%

19.1%
.85%
1. 33%
1.44%
1.50%
1.60%
1 .8 6 %

1.5%
.64%
1.04%
1 ,1 %

5.0%
2.36%
1.27% Poor
.99% Rich

aL. Srole, et. al., Mental Health in the Metropolis: The Midtown Manhattan Study (New York: McGraw-Hill, 1962), p. 167.
^Simon Auster, "Insurance Coverage for 'Mental and Nervous
Conditions': Developments and Problems,” American Journal of Psy­
chiatry 125, 5 (1969): 698.
cMilton Mazer, "Characteristics of Multi-Problem Households,"
American Journal of Orthopsychiatry 42, 5 (1972): 794.
d
U. S., Department of Health, Education, and Welfare Appropria­
tions for 1973, op. cit.
8Rli»"r A, Gardner, "The Use of a Psychiatric Case Register in
the Planning and Evaluation of a Mental Health Program," Program Evalua­
tion in the Health Fields, ed., Herbert Schulberg, Alan Sheldon, Frank
Baker (New York: Behavioral Publications, 1969), pp. 543-544.

^Woodbury & Woodbury, op. cit., p. 620.
*^M. Glasser and T. Duggan, "Prepaid Psychiatric Care Experience
with UAW Members,” American Journal of Psychiatry 125, 5 (1969): 676.
^S. Goldensohn, et. al. "Referral, utilization, and Staffing
Patterns of a Mental Health Service in a Prepaid Group Practice Program
in New York," American Journal of Psychiatry 125, 5 (1969): 689.
Scelen Avnet, "Psychiatric Insurance - Ten Years Later,"
American Journal of Psychiatry 126, 5 (November, 1969): 671.
^Edward L. Green, "Psychiatric Services in a California Group
Health Plan," American Journal of Psychiatry 126, 5 (1969) : 686.
G. Tischler, et ■ al., "The Impact of Catchmenting,'* Adminis­
tration in Mental Health# Winter 1972, p. 29,

62

1.

In most instances, the utilization rate applies to t

s e r v i c e ■entity conducting the study, with their caseload,

and does not

include those persons in the community seeking psychiatric care from
private practice, going outside the community for services, including
those served by the state hospital.
2.

Rarely are utilization rates studied over a period of years

to provide a comparison between times when services were not readily
accessible as contrasted with a time when there is easy accessibility.
There is no known study in which saturation has been reached to pro­
vide an index as to how many would actually avail themselves of serv­
ices were they to be offered.

In one study, however, in Rochester,

New York, between 1958 and 1968, caseloads increased by 49.2 percent
with the availability of new services, while the total population in­
creased by only 22.1 percent during the same p e r i o d . ^

This seems to

indicate, as have other studies, that utilization rates increase as
services become more available and known to the population.
The serious question, also as yet unresolved, is whether the
service delivery system will ever be able to meet the increasing de­
mands.

As has been noted above, increasing availability and amounts

of service have only tended to increase the demand for service.
Toffler, in Future Shock, postulates that the rate of change in our
time is so rapid that, unless man quickly learns to control the rate
of change in his personal affairs as well as in society at large, we
are doomed to massive adaptational breaks.

67

Mental health

66

A. Satloff and C. Worby, "The Psychiatric Emergency Service:
Mirror of Change," American Journal of Psychiatry 126, 11 (May, 1970)1630.
c *7

A. Toffler, Future Shock (New York:

Random House-, 1970), p. 87.

63

professionals, beset by increasing demands for service, both in quality
and quantity, have responded in a number of different ways:

by provid­

ing indirect service to larger client populations through consultation
and community education, by swelling their ranks with paraprofessionals,
and by experimentation with a variety of focused, brief therapeutic
techniques.

68

It is, therefore, virtually impossible to view the ex­

pected outpatient caseload without also looking at those being served
by other than direct service.

Even so, it seems reasonable that some

reasonable percentage should be expected to be in direct service, as
an active case, at any one given time and given minor variations for
economic differences, accessibility and availability, that given per­
centage could partially serve as a standard against which to measure
clinic productivity.

Length of Treatment and Treatment Outcome.— With the everincreasing pressures for more and better service, the long-term, oneto-one psychoanalytic model is rarely found in a community mental
health program.

The various insurance programs referred to in the

previous section averaged between 7.8 treatment visits in the HAW
study to 14.2 visits in the New York prepaid group program.

A recent

study of 35 agencies in Michigan revealed an average of 7.2 contacts
per case, with a range of from only one contact up to 26 contacts.

A

surprising 35 percent had only one or two contacts, and over 50 percent

^^Naomi Rae-Grant, "Longevity, Mobility, and Spare Parts:
Future Imperfect and Human Service Delivery," American Journal of
Orthopsychiatry 42, 5 (October, 1972):
835.

The

64

had four or fewer contacts.
seen more than ten times.

Twenty-three percent of the clients were

69

These data are quite consistent with

those reported by other studies and in other states.

Such information

has led to two quite opposing views on the subject of length of treat­
ment :
1.

In one study in New York, very similar to that above,

Ginzberg was quite critical that over half the patients were seen only
once or twice.

He indicated that his suspicion was that a client

"doesn't go anywhere in clinics.

. .they are not 'cured' or effectively

diagnosed, they just don't come back."

He criticized the data and felt

that a person should not be counted as a client until his third visit.
2.

70

The opposing view is that there is very little difference

in terms of ultimate outcome between long-term and short-term therapy.

71

Others have indicated that a short-term, goal-oriented structured be­
havior change program was better in the long run in that it counteracted long-term dependency.

72

Taylor, in examining the relationship

between success and length of therapy, found a "failure zone" between
the twelfth and twenty-first interviews.

tie concluded that a short­

term contract with a client for less than twelve interviews was the
most desirable but when treatment could not be concluded in this
69

Michigan Department of Mental Health, "Number of Contacts
per Case," Management Information Report #128, December, 1972.
^°Eli Ginzberg, "Practical Considerations in Financing Mental
Health Care," American Journal of Psychiatry 126, 5 (November, 1969):
766.
71

G.
Pascal and M. Zax, "Psychotherapeutics, Success or
Failure?" Journal of Consulting Psychology 20 (1956) : 325-331.
72

E. Phillips and D. Wiener, Short-term Psychotherapy and
Structured Behavior Change (New York: McGraw-Hill, 1966), p. 19.

65

limited time, a much longer period would be necessary to counteract
dependency and "deep-seated problems."

73

Since the controversy still rages, and has for the past fifteen
years at least, it is quite impossible to assess a program solely on
the average number of contacts per client.

Far more study is needed

in this area but in the meantime, it would seem that one could assess
the operating procedures of a given clinic by comparing deviations of
a standard curve of closures charted by number of contacts.
Very closely related, as was noted above, is the outcome of
treatment no matter what the number of contacts.
to be a subject of great controversy.

This, too, has proven

A most definitive study of out­

comes of treatment, now over thirty years old, set the stage for many
similar type studies, all tending to have very similar results.

In

this original article, Knight studied outcomes of 592 cases at the
Berlin Institute form 1920-30; 74 cases at the London Clinic of Psy­
choanalysis from 1932 to 1937; 100 cases at Menninger Clinic, Topeka,
Kansas, from 1932 to 1941; and 60 cases from private psychiatrists
from 1936 to 1938.

74

After a lengthy analysis, Knight concluded that

56 percent were greatly improved or cured and only 10 percent showed
no change or were worse.
In 1952, the eminent Professor Eysenck of the London Institute
of Psychiatry, severely criticized Knight's landmark study and indicated
that his "figures fail to support the hypothesis that psychotherapy
73

J. W. Taylor, "Relationship of Success and Length in Psycho­
therapy," Journal of Consulting Psychology 20 (1956):
332.
74

Robert P. Knight, "Evaluation of the Results of Psychoanalytic
Therapy," American Journal of Psychiatry 98 (1941) : 434.

66

75
facilitates recovery."

A long and heated debate has ensued ever

since and there is no resolution in sight.

In 1964, following suit,

Strupp took the liberty of severely criticizing Eysenck for the invali­
dities in his data and returned to Knight's criterias of assessment,
arguing that the therapists were the better judges of success than
their patients.

76

Eysenck issued forth a return volley and summed up

that both he and Strupp were right, each o ther’s research has been
"incompetent, irrelevant, and immaterial;" as a matter of fact "all
the research done

(on outcome of treatment)

is completely worthless"

and, as such, his conclusion that the "figures fail to support the
hypothesis that psychotherapy facilitates recovery.
triumphantly vindicated."

77

. .would be most

Research has continued in spite of these

philosophical differences with a study published in 1967, with very
similar results to that reported originally by Knight but with vastly
better methodology.

This study, reported by Kaegler and Brill, claimed

60 percent as improved, 37 percent as unchanged, and only 3 percent as
worse.

These claims were made on the basis of the therapist's opinion

of outcome, and when the patient himself was queried as to outcome,
their opinions were generally more positive than the therapist's.

It

is interesting to note that this research also affirmed the previous
research that under twelve interviews is best, and the most successful
75

H. J. Eysenck, "The Effects of Psychotherapy:
Journal of Consulting Psychology 16 (1952):
319-321.

An Evaluation,"

^ H a n s Strupp, "The Outcome Problem in Psychotherapy Revisited,"
Psychotherapy 1, 1 (1963) : 1-13.
77

H. J. Eysenck, "The Outcome Problem in Psychotherapy:
Reply," Psychotherapy 1, 3 (1964):
97-100

A

67

of the group studied had had under ten contacts.

Many reviewers of

research on outcomes of therapy have concluded that with the currently
high attrition rates of patients who drop out in the course of their
treatment and the prevailing differences between therapist and patient
evaluations of outcomes, it is doubtful whether satisfactory evaluation
of outcome is p o s s i b l e . ^
It would appear, then, in their present state of dispute, the
field is unable to make successful use of the criteria of length of
treatment and outcome of treatment as program evaluation techniques.
This is truly unfortunate and holds back successful program develop­
ment.

An evaluation of any program must ultimately answer questions

like, "Did the program produce the desired outcome?"

When an assess­

ment of that outcome is clouded by total disagreement, both as to
methodology and to interpretation of results, it becomes clear that
the "state of the art" is not sufficiently advanced to permit evalua­
tion.

Just as it may be necessary for the field to establish norms

for treatment lengths, it may also be necessary for the field to
establish norms for treatment outcomes.

Then, when it was observed

that a certain clinical team or staff veered significantly from this
norm, further study could be undertaken to discern the reasons for
the deviation.

At the present time no such norms or standards exist

and it is distinctly possible that any effort to establish such might
meet with the same utter disagreement within the field, but, if pro­
gram is ever to be totally accomplished, some resolution must come
78
(New York:
79

R. Kaegler and N. Brill, Treatment of Psychiatric Outpatients,
Apoleton-Century-Crofts, 1967), p. 102.
Phillips & Weiner, op. c i t . , pp.

32-35.

68

within the areas of appropriate length of treatment and assessment of
outcome.
Although the above discussion has concerned itself solely with
outpatient treatment, the situation in inpatient care, partial hospitali­
zation and day treatment, or residential and foster home care, is even
more abysmal.

There are virtually no existing studies in the litera­

ture which address themselves to either length of treatment or treat­
ment outcome in any of these other treatment modialities.

Additionally,

all studies to date, besides being concerned only with outpatients,
have also made the assumption that recovery was possible as an outcome,
thereby completely neglecting the severely chronically ill for whom a
lesser but still acceptable treatment outcome is merely mantenance in
the community at minimum distress level.

80

It may ultimately be easier

to establish treatment outcome assessment techniques in some of these
alternate modalities, from which might spring insights into techniques
with which to assess total treatment outcome.

Consultative and Preventative Programs.— More than fifty years
ago,

Adolf Meyer wrote:

"Communities have

to l e a r n w h a t

Lhey p r o d u c e

in the way of mental problems and waste of human opportunities and
with such knowledge they will rise from mere charity and mere mending,
or hasty propaganda, to well-balanced, early care, prevention, and
general gain of health."

81

Forty years ago, Harry Stack Sullivan

80

R. T. Rada, et. a l ., "An Outpatient Setting for Treating
Chronically 111 Psychiatric Patients," American Journal of Psychiatry
126, 6 (December, 1969) : 789.
81

Task Force on Community Mental Health, Division 27, Ameri­
can Psychological Association, Issues in Community Psychology and
Preventive Mental Health (New York:
Behavioral Publications, 1971),
p . 1.

69

expressed a similar point of view:

"Either you believe that mental

disorders are acts of God, predestined, inexorably fixed, arising from
a constitutional or some other irremediable substratum, the victims of
which are to be helped through an innocuous life to be a more or less
euthanasic exit.

. .or you believe that mental disorder is largely

preventable and somewhat remediable by control of psycho-sociological
factors."

82

Thus, the early calling for professionals to look not

just to the disease entities and psychological disturbances which were
confronting them but to look to the society and community which pro­
duced the problems was well echoed by many of the leaders.

The press

of clinical duties and ever-expanding caseloads mitigated against any
organized preventative, or even consultative, programming until many
years later when the community mental health centers were called upon
to provide such a required service.
More basic than the question of whether preventative and con­
sultative services are being implemented, however, is the question of
whether prevention can be accomplished and whether the results of con­
sultation can ever be assessed.

In seeking to define the parameters

of prevention, it seems best to look at the subject from the publichealth-epidemiologic model which focuses on "target conditions" and
"high risk populations" rather than on individuals, and embodies the
idea that changing the environment to prevent "disease" from occuring
in the first place is more effective than diagnosis or treatment.
O O

Ibid., p. 2.
83
Chu & Trotter, o p . c i t ., p. 11-17.

83

70

Thus, in the terms of Gerald Caplan, one of the early leaders of the
community mental health movement, the concerns of a community mental
health center are supposed to include "primary" as well as "secondary"
and "tertiary" prevention.

Caplan has defined these terms in the

following w a y :
Primary prevention is the reduction of the incidence of
mental disorders of all types in a community.
Secondary preven­
tion is reduction of the duration of a significant number of
those disorders that do occur.
Tertiary prevention is the
reduction of the impairment which may result from these dis­
orders.®^
Such a definition of prevention may well be helpful in expressing
levels and types of services, but it does little to clarify the problems
related to program evaluation.

If one were to use this definition, it

would be necessary to assume that the goal of all services was "pre­
vention" and then assess them in terms of precisely what was prevented.
It therefore is preferable to assess the secondary and tertiary levels
by more behaviorally-oriented goals having to rely on more indirect
methods of assessment only in the primary prevention phase.

Consulta­

tion and education are generally the methodologies used which would
require indirect assessment but they arc also, probably inherently,
the least practiced and most poorly understood.
A variety of authors dealing with the subject of consultation
have attempted to deal with the objective of such services.

Summing

these up they might be expressed as:
1.

84

The influencing of large segments of the population
about mental health and their environment.

G.
Caplan, "Types of Mental Health Consultation," American
Journal of Orthopsychiatry 33 (1963):
470-481.

71

2.

Extending mental health principles to other groups.

3.

Developing mental health potential in other groups.

4.

As a help in relation to a critical manpower shortage.

5.

Fulfilling the expressed need for expert advice.

85

As can readily be seen from the above, objectives such as these are
difficult to translate into measurable criteria and are, therefore,
very difficult to assess.

Assessment becomes even more obscure with

the current trend in the field where the professionals are beginning
to say that "if we continue to serve only those who come for psychi­
atric help, we will be helping only a very select population.
not directly helping our primary client— the community."

86

. .and

Some

have indicated that the reason for providing consultative services
did not stem necessarily from an "altruistic feeling that we should
share our knowledge, or even an intellectual awareness that the size
of the problem required broader participation, but out of a desperate
concern to increase the skills and efficiency of other agencies so that
they become better able to be of real help to us."

87

Others, more

philosophically based, feel that "a potentially more effective mental
health model for the future is that of promotion of competence rather
85

U. S., Department of Health, Education, and Welfare, Consul­
tation Research, Public Health Monograph #79, 1971, p. 1.
86

S.
Nagler and S. Cooper, "Influencing Social Change in
Community Mental Health," Canada’s Mental Health 17 (SeptemberOctober, 1969):
12.
87
Jules Kluger, "The Uninsulated Caseload in a Neighborhood
Mental Health Clinic," Development of an Urban Mental Health Center,
H. G. Whittington, ed. (Springfield, Illinois: Charles C. Thomas,
1971) , p. 95.

72

than cure-

. -the basic model should be educational rather than thera-

peutic.M88
In view of all of these difficulties with conceptualizing, de­
fining and implementing consultation, it is not surprising that there
is very little substantive research in this program area.

Also, it is

not surprising to find that most of the research done to date has
dealt mostly with the process of consultation, who does it, who re­
ceives it, and so on, with almost no research having been reported on
the results of consultative efforts.

A summary of those research ef­

forts dealing with outcome of consultation appears on Table 8.

Al­

though in these outcome studies much of what passes under the label of
consultation is not spelled out or differs widely from one situation to
the next, still the evidence as presented appears to indicate that con­
sultation does have a positive effect.

Unfortunately, there are no

reported studies of the effect over various time intervals.

It would

also appear that all studies thus far have concerned themselves with
the outcome effects on the consultee or the client specific to the con­
sultation.

No studies have been located in the mental health field

which deal with the results of consultation on the system at large.
Such studies are not readily apparent from any field, but two studies
in closely allied fields shed some light into the problems and results
of such studies.

In one study, in the dietary field, Foster and Hart­

man provided a consultative service to dieticians in general hospitals
and were able to observe positive effects on the total hospital system
88

Rae-Grant, op. c i t ., p. 840.

73
TABLE 8.— Summary of Consultation Outcome Studies in Mental Health
Services.
Positive Effect *
Consultee System Client

Researchers

Date

Control
Group

Eisenberg3

1958

Yes

Mariner et. al,b

1961

No

Yes

Cutler and McNeil

1964

Yes

Yes

Yes

Dorsey, Matsunaga
and Bauman^
e
Chapman

1964

No

Yes

---

1966

No

***

Yes

1968

Yes

No

...

1968

No

Yes

Yes

1968

Comparison
Group

---

Yes

Pierce-Jones, Iscoe
and Cunningham^
q
Townes et. al.
Hunter and Radcliffeh
Bolman et. a l .1

1969

Yes

Yes

No

a L. Eisenberg, "An Evaluation of Psychiatric Consultation
Service for a Public Agency," American Journal of Public Health
48 (1958):
742-749.
^A. S- Mariner, e t . a l ., "Group Psychiatric Consultation with
Public School Personnel:
A Two Year Study," Personnel Guidance Journal
40 (1961):
254-258.
c

R. L. Cutler and E. B. McNeil, Mental Health Consultation m
Schools;
A Research Analysis (Ann Arbor:
University of Michigan De­
partment of Psychology, 1966).
d

J. Dorsey, G. Matsunaga, and G. Bauman, "Training Public
Health Nurses in Mental Health," Archives of General Psychiatry
11 (1964):
214-222.
eR. F. Chapman, "Group Mental Health Consultation— Report of
a Military Field Program," Military Medicine 131 (1966):
30-35.
fJ. Pierce-Jones, I. Iscoe, and G. Cunningham, Child Behavior
Consultation in Elementary Schools: A Demonstration and Research
Program (Austin, Texas:
University of Texas, 1968).
g

B. D. Townes, et. a l ■, "The Diagnostic Consultation and Rural
Community Mental Health Programs," Community Mental Health Journal
4 (1968):
157-163.
^W. Hunter and A. Ratcliffe, "The Range Mental Health Center:
Evaluation of a Community-oriented Mental Health Consultation Program
in Northern Minnesota," Community Mental Health Journal 4 (1968):
260-267.
XW. M. Bolman et. a l ., "An Unintended Side Effect in a Commu­
nity Psychiatry Program," Archives of General Psychiatry 20 (1969):
508-513.

74

following their consultation program.

89

These effects were in terms

of improved patient satisfaction, increased interdepartmental coopera­
tion, reduced employee dissatisfaction, etc.

In another study, in the

education field, it was found that providing consultative services to
elementary school teachers

(on curriculum and group processes)

failed

to show positive outcome effect on class standing, as measured by
standardized tests of pupils.

90

These must, however, be considered

as studies on a mini—system when compared to the goals of mental health
as studies on a mini-system when compared to the goals of mental health
consultation, to affect a large segment of the population through in­
direct services.
Since research efforts in consultation outcome have been so
meager to the present time, despite extensive literature on philosophy
and techniques, one is left having to rely upon subjectively-based
assumptions in regard to assessing a comprehensive community mental
health program in terms of its consultative-preventative program.

The

evidence suggests that consultation does produce a positive outcome
to both the consultee and the clients he serves and, on that basis
alone, one is safe in assuming that such services should be a part of
a community mental health program and that in evaluating such a pro­
gram (in total) such services should be included within the evalua­
tion.

But, since so much of the community mental health philosophy

is based upon changing the systems through indirect services, and until
89

J. Foster, and J. Hartman, " A Project in Voluntary Consulta­
tion for Hospitals," Public Health Report 74 (1959):
607-614.
90

R. A. Schmuck, "Helping Teachers Improve Classroom Group
Processes," Journal of Applied Behavioral Science 4 (1968) : 401-435.

75

there is evidence to the contrary, the assumption must continue to be
made that consultative services also produce positive effects on the
system or community at large.
has made such an assumption:

Rae-Grant, in a very recent article,
"It is becoming increasingly and pain­

fully apparent that the price of non-intervention (into the social
system) is later social and emotional disorder, that problems identi­
fied early in childhood will not be miraculously outgrown, and that,
as with organic handicaps, behavioral and emotional problems that begin early in childhood do not necessarily disappear."

91

Having made both assumptions, that consultative services pro­
duce outcomes on both the individual client (or the consultee) and
the population at large, and knowing that, as yet, there has been no
methodology offered that can adequately assess the outcomes of such
consultation, it is difficult to include within the total program
evaluation criteria any assessment of the impact of consultation.

One

is left with the only technique being a count of consultations, the
time devoted to such efforts, or a percent of effort being directed
in this area.

We do not, however, have the basis for "a blueprint to

determine the precise balance of priorities which should be attained"
among mental health direct services and indirect services.

92

The

Director of Psychiatric Services over Denver's community mental health
programs has indicated that "the typical team initially devotes 10
91
92

Rae-Grant, op. cit., p. 836.

Richard Williams, "Trends in Community Psychiatry:
Indirect
Services and the Problem of Balance in Mental Health Programs," L.
Beliak, ed., Handbook of Community Psychiatry (New York:
Grune &
Stratton, 1964), p. 355.

76

percent of total time to consultation, gradually increasing consultive
services to 25 percent team time.

It is anticiapted that the clinical

caseload of generic teams will decrease and consultation will occupy up
to half of the total team time."

93

That fifty percent of total staff

time should be devoted to an area of concern that has neither been
adequately researched nor has any established performance standards
only further bespeaks of the difficulty in attempting to assess commu­
nity mental health services.
A study, released in 1969 by the Joint Information Service of
the American Psychiatric Association and the National Association for
Mental Health, indicated that 57 percent of professional staff activity
time was spent in "activities directly related to patient care" while
only 5 percent was spent in consultation (the remaining 38 percent
split among administration, staff meeting, teaching, travel, etc.).

94

The consumer advocates cited these results in their criticism of pro­
fessional mental health workers and concluded that "the more highly
trained a staff member, the less time he spends treating patients and
the more time he spends in the bureaucratic maintenance of the center."

95

It would seem that a far more cogent criticism could have

been made about the very minimal 5 percent time in consultation that
was reported.

And so a controversy ensues, with some feeling that

more and more time should be devoted to direct patient care, and some
93

H.
G. Whittington, "The Generic Mental Health Team,"
ed: H. Whittington, Development of an Urban Mental Health Center
(Springfield, Illinois:
Charles C. Thomas, 1971), p. 65.
94

R. Glasscote and J. Gudeman, The Staff of the Mental Health
Center— A Field Study, Washington, D. C . : Joint Information Service,
American Psychiatric Association and National Association for Mental
Health, 1969, pp. 18-19.
95

Chu & Trotter, o p . c i t ., p. 11-14.

77

feeling that more and more time should be devoted to consultation (in­
direct services).

With such a controversy, philosophically based, and

the absence of any clear standards on which to measure outcomes, it
would appear that the only manner available to include consultation
services within a program assessment would be through gross, numbercounting methods, and, just as was indicated in the previous section
on Problems in Program Evaluation, "numbers alone, however, are notoriously poor indicators of success."

96

Cost Per Unit of Service.— The cost per unit of service
(whether that

be in terms of cost per interview, cost per inpatient

day, cost per

client served, or some other unit cost) has been even

more lightly considered in the literature with even less done in sub­
stantive research.
recently that

It is quite safe to state that it

has been only

cost of services received any attention and then only a

result of two separate pressures, neither of which was concerned di­
rectly with program evaluation but more concerned with an appropriate,
billable, cost per unit of service.

The third-party-payee insurance

carriers were the first to study this criterion at the time the group
insurance plans and union contracts first began to include mental health
services within their program.

In the first year of the outpatient

services provision of the UAW program, those availaing themselves of the
services "received an average of 8.5 services and (were) paid claims
averaging $135.50 per patient.

For those who received inpatient care,

in 1965 t h e y .were hospitalized an average of 12.3 days for a cost of
96„
See page 40.

78

$466; in 1967 they were hospitalized for 12.6 days at a cost of $603."
Citing very similar cost per patient and utilization rates, the spon­
sors of the Prepaid Health Insurance Plan of Greater New York esti­
mated that the total cost came to about 90C per month per enrollee, or
a per capita yearly cost of about $10 per year."

98

Costs have risen

dramatically in the past five to six years since these figures were
reported, with current estimates averaging to about $250 per client
served and a per capita yearly cost of approximately $15 per year.

99

To ascertain the cost per client served and per capita total
cost many serve a useful purpose for the insurance carriers, but the
second group of persons interested in this criterion— the mental
health administrators— has been far more interested in a unit of cost
per service (interview, treatment, hour).

Their Association has even

undertaken the development and publication of a highly sophisticated
and complex manual on cost finding and rate setting.

Their impetus

for doing so has nothing to do with evaluation of their centers but
the hard fact that to qualify for third-party reimbursements and the
new federal entitlements they must establish such procedures to be­
come eligible for reimbursement for the clients they serve; and with
97
98

Glasser, op. cit., p. 679.
Goldensohn, op. cit., p. 696.

99

J. Sorensen and D. Phipps, "Cost Finding:
A Tool for Manag­
ing Your Community Mental Health Center," Administration in Mental
Health, Winter, 1972, pp. 68-73.

100

J. Sorensen and D. Phipps, Cost-Finding and Rate-Setting for
Community Mental Health Centers (Lansing, Michigan:
Association of
Mental Health Administrators, 1972).

97

the aforementioned decline in federal dollars and limited state and
local resources, their programs are virtually dependent upon gaining
these third-party

payments.

Again, it should be pointed out that

these efforts have not been in relation to program evaluation but di­
rected toward financing.
Some of these administrators have even indicated that their
efforts could not be used in program evaluation efforts and have built
impressive rationales for their positions.

Freeman and Sherwood have

argued that "in terms of all programs, the efficient one is that which
yields the greatest per unit change, not the one that can be run at the
least cost per recipient.

What costs the most, takes the longest, and

involves the greatest manpower in gross terms may have the greatest net
efficiency."^'*'

Unfortunately, they offer no further clues on how to

measure the "greatest per unit change."

Sorensen and Phipps, in making

a similar disclaimer, have indicated that their cost-finding techniques
cannot be used to compare one community mental health center to another;
"treatment modalities vary widely from center to center.

Some centers

favor the use of high-cost intensive therapy with a high patient turn­
over.

Others use a longer term approach with lower cost per patient

for a given time period and a much lower patient load.

Such differences

make comparison of cost per patient meaningless.

^01H. Freeman and C. Sherwood, "Research in Large-Scale Inter­
vention Programs," ed. H. Schulberg, e t . a l ., Program Evaluation in the
Health Fields {New York:
Behavioral Publications, 1969), p. 86.
102„

Sorensen & Phipps, op. cit., p. 70.

80

Others, however, are not so ready to dismiss costs as a portion
of their evaluation efforts.

Although the efforts of some have been to

measure the impact of social costs by reduced income and subjective
losses,103 it has become more recently accepted that some methodology
for including cost data into a program evaluation is essential.

Hal-

pern and Binner have recently published a "model" for an output value
analysis which includes two basic measures:

"(1) An estimate of the

value of what the program has produced, and (2) an estimate of the
costs involved in achieving that product."

104

The legislators, con­

sumer advocates, state mental health administrators, and local program
administrators are all echoing the same refrain; costs must be a part
of any program evaluation, even though there are philosophical dif­
ferences between types of treatment in different centers, even though
a full-range of services may not be available to all clients, and
even though the public expects certain services to be available no
matter what the cost.

The dilemma remains; the unsolved problem of

how to use cost data in a total program evaluation effort.
The Problem Restated
That the community mental health program has never been evalua­
ted as to either its efficacy and effectiveness or efficiency and
economy, as many of its critics have implied, is only a partial truth.
As this review of literature has demonstrated, segments of the program
have been sometimes exhaustively evaluated, other segments seem to
Fein, Economics in Mental Health
1958) .
104

Halpern & Binner, o p . c i t ., p. 44.

(New York:

Basic Books,

81

have been overlooked by the evaluators, and in still other segments
the data is too nebulous or too circumspect to draw any conclusions.
Still, the criticism seems valid.

To have evaluated segments of the

total community mental health program is insufficient, even to have
evaluated all segments of the program individually would still be in­
sufficient.

The public, the legislators, the administrators, and the

client are all looking for the answer to a deceptively simple question,
"Is the community mental health center any good?"

They want a simple

answer like "yes" or "no," not an answer that indicates that the ad­
mission rate to the state hospital has declined

(or risen), or an

answer that indicates that more outpatients are in treatment now than
before, or even a more confusing answer that implies that consultation
and education have diminished expected referrals.

They somehow want

all of these separately identifiable segments or sub-programs
objectives, or criteria) amalgamated into one response.

(or

Such a re­

sponse should take the direction of being comparative across programs
("This center seems to be doing very well, that one not so good, the
other one even better, etc.") but also be able to discern why any
given center would appear to be doing worse or better.

The problem,

then, is to decide upon the legitimate areas in which to evaluate a
community mental health program, apply a measure to each of these
identified areas and then devise a system for putting each of these
pieces of information into a consolidated rating with the goal being
to assess each program as to its overall effectiveness as compared to
the like-programs in the rest of the state, region, county or other
group.

The remainder of this study will address itself to this

82

problem; the development of a methodology to take a multiplicity of
criteria (each having its own data), apply appropriate weightings to
each criterion, and result in an overall measure of program effective­
ness.

This methodology will then be applied to the community mental

health programs in Michigan and the results reported and analyzed.

CHAPTER IV

A METHODOLOGY TO ASSESS OVER-ALL
EFFECTIVENESS

To evaluate a human service enterprise is, in simple
^
terms, to examine and then assign a value to the program.
In their 1969 "Interim Appraisal" of two community mental
health centers,

(eight were originally included in the study but only

two were included in the report because the other six were experienc­
ing "organizational and developmental problems"), Glasscote and associa­
tes indicate that social programs can be measured in three stages j
(a) the establishment of facilities;
service; and (c) effectiveness.

(b) the delivery of units of

As was noted in the previous chapter

mental health services almost never go beyond the first two of these
stages.

As such, quite a lot is known about the numbers and kinds of

facilities, and most agencies have systems to report the units of
service that are delivered in the course of a year; but, as yet (and
it is just as true today as when it was written in 1969), "almost
nothing is known about effectiveness, and this sad observation applies
even to the longest-established facilities."

2

^Walter F. Mondale, "Social Accounting, Evaluation, and the
Future of the Human Services," Evaluation, Fall, 1972, p. 29.
2

R. Glasscote, e t . a l ., The Community Mental Health Center,
An Interim Appraisal (Washington, D. C . : Joint Information Service
of the American Psychiatric Association and the National Association
for Mental Health, 1969), p. 31.
83

84

Discussions of methodology in this field are all too often con­
fined to a consideration of only data-gathering techniques.

Insuffi­

cient attention has been given to the more fundamental questions of
the choice of variables or criteria to be considered, the impact or
inter-relatedness of one activity on another, the viability of various
units of observation, and the analytic designs to be used and their
relation to the over-all program.

3

That the field has not progressed

beyond data-gathering and into a better conceptualization of the total
process is not really surprising.

Even one of the foremost proponents

of program evaluation, former Secretary of Health, Education, and
Welfare, Elliot Richardson has repeatedly asserted that "evaluation is
still at a relatively early stage in its own development as an effective technique."

4

The Evaluation Process
It would seem, therefore, that with the relative newness of
the concepts of evaluation to the field of community mental health,
it is incumbent to examine the evaluation process in general as a
precursor to any statement of specific methodology.

Schulberg and

his associates at the Harvard Medical School described the evaluation
process in the health fields as a circular one, stemming from and
5
returning to our value system.
Graphically this is portrayed as
follows:
3
Herbert Menzel, "Scientific Communication:
Five Themes from
Social Science Research," American Psychologist, 21 (1966) : 999-1004.
4

Elliot L. Richardson, "Conversational Contact," interview by
Susan Salasin, Evaluation, Fall, 1972, p. 15.
5

H.
Schulberg, A. Sheldon, and F. Baker, e d . , Program Evalua­
tion in the Health Fields, (New York:
Behavioral Publications, 1969),
p. 30.

85

The
Valuation
Goal Setting
Appraising the Effect
of the Goal
Determining a Measure
of the Goal
Putting the Goal-attaining
Activity into Operation
Measuring the Goal

Identifying the
Goal-attaining Activities

It would follow, then, that most of the previous efforts at evaluation,
in addition to mostly being merely data-gathering efforts, have largely
been without influence of some specific value-oriented goals, leading
to certain goal-attaining activities which are then assessed in rela­
tion to the value-oriented goal.

A measure of effectiveness would then

establish the degree to which an organization realizes its goals under
a given set of conditions.
That this process can be accomplished in the community mental
health field has been doubted by many.

Even Schulberg and his associa­

tes, who detailed the evaluation process and drew together many evalua­
tion projects in the health fields, wonder whether program evaluation
was "so complex that assessment attempts only produce overly simplistic
6
Amatai Etzioni, "Two Approaches to Organizational Analysis:
A Critique and a Suggestion," Admin. S c i . Quart. 5 (I960):
257-278.

86

formulations" since it is "impossible to develop a practical design for
this type of s t u d y . P r o f e s s o r Ernest Gruenberg of Columbia University,
and a prolific writer in community mental health, told the Task Force
of the Center for Study of Responsive Law in 1972, that "the objective(s)
must be stated in such a way that objective data can indicate whether
or not the desired state of affairs is present;" but he then continued
to state that "present methodologies are in a primitive state of de­
velopment" and as such, "a scientifically valid evaluation of the commug

nity mental health centers program is unfeasible at the present time."

Problems of Methodology
There are then at least three major methodological problems
which have led to the pessimism noted above but also which must be
dealt with in any study:
1.

Complexity:

There can be little doubt of the complexity of

any organization which deals with human behavior through varied modali­
ties and attempts impact on society in general.

Historically, the

organizational form constructed to promote accountability has been the
pyramid.

Pyramidal structures were designed for the implementation

of policies and programs initiated by those at the apex.

Some have

suggested that to promote responsiveness of those workers closer to
the base, the pyramidal form should be flattened, allowing for more
feedback and initiative at all levels.

A more viable concept is to

7

Schulberg, e t . a l ., o p . c i t ., p. 4.

8

F. Chu and S. Trotter, The Mental Health Complex, Part I:
Community Mental Health Centers (Washington, D. C . : Center for Study
of Responsive Law, 1972), p. III-2.

87

describe the organizational form as an arena, tending to highlight the
negotiations and exchanges among various groups in the community mental
health setting.

Such an image is clearly more realistic than the pyra­

mid in that it takes into account the interrelationships of outside
groups

(other service agencies, professional organizations, private

practitioners) with the community mental health program.

The defi­

ciencies of such an organizational concept are most obviously its
complexity and the apparent absence of any directional thrust.

Since

there is not a "top" to the command structure, the arena relies on
"negotiations" among the various parties for the determination of any
action.

9
2.

Goal Setting:

Traditionally service has been viewed, and

in some rather vague ways measured, in terms of that which is offered,
such as counseling, psychotherapy, group therapy, even advice, and so
on.

Good service was viewed as that being offered in a professional

manner, by a qualified person who is, in turn, supervised by a qualified
supervisor.

Service has generally been viewed in terms of process but

to be evaluated in terms of goal-setting, service must begin to be
viewed in terms of impact.

Success must be viewed in terms of outcome

rather than in terms of the supposed quality of the procedures u s e d . ^
Professionals in the community mental health field have not readily
accepted such a non-traditional approach but with the pressures for
evaluation, projected shortages of funding and expansions of
9
Harvey M. Freed, "Promoting Accountability in Mental Health
Services,” American Journal of Orthopsychiatry, October, 1972, p. 763.
10H. E. Freeman and C. C. Sherwood, "Research in Large-Scale
Intervention Programs," Journal of Social Issues 21, 1 (1965):
11-28.

88

technology, these professionals are becoming more acclimated to the
notion.
3.

Adequate Controls:

Probably the greatest difficulty in

the assessment of any social program is to create truly adequate con­
trols that can tell what the program has accomplished as distinguished
from the impact of other forces on the situation.1'*' Since such con­
trols are not generally possible, it often becomes necessary to make
assumptions regarding the relationship of certain activities and re­
sults and the pre-established goals or objectives.

For example, em­

pirical research has not clearly demonstrated (at least to the satis­
faction of most) that providing psychotherapy, however loosely
defined, to a person in acute emotional distress is the best course of
action to achieve the objective of a person without acute emotional
distress.

We must assume the validity of such activities without full

research proof.

12

Closely related, but of even further difficulty, is

the notion of establishing control groups in the truly experimental
model type evaluation.

Often we are dealing with total reported

population and we must compare with other populations, compare the same
populations over periods of time and other such quasi-experimental
type designs.
It would seem, then, that the best type of controls that could
be established would be in terms of standards for the delivery of
service and then compare each program against these standards.

11Richardson, o p . c i t ., p. 9.
12

Schulberg, e t . a l ., op. c i t ., p. 33.

But,

89

standards for community mental health programs have not yet been de­
termined, particularly in terms of objective measurement even though
the Michigan Department of Mental Health has established a task force
to develop such standards.

13

It is understood, however, that a stand-

are is a practical objective, and once established serves as a measure
of progress. 14

In the absence of clear-cut, professionally-accepted

standards, any evaluation methodology must state some reasonably well
accepted goals, translate these into measurable activities, still
assuming for the most part the relationship between the activity or
occurrence and the desired outcome or impact.
With the complexity of the program, the number of program
goals that might be possible, and virtually unlimited number of stand­
ards or controls that might be applied, it becomes necessary to
determine which specific activities or occurrences have more import
than others.

A number of different researchers have come up with

systems of weighting to portray the different values ascribed to each
of these factors.

Walker, in a recently reported study on the ef­

fectiveness of a manpower program dealing with the hard-core unem­
ployed, used a system of value points for each of three major goals,
interrelating the length of employment, hourly wage received and
program costs into a "composite score representative of overall pro.,15

gram success.
13

Michigan Department of Mental Health, "Community Services
on the Couch," Link, January 25, 1973, p. 1.
14
15

Schulberg, e t - a l ., loc. ci t ., p. 34.

Robert A. Walker, "The Ninth Panacea:
Evaluation, Fall, 1972, p. 47.

Program Evaluation,"

90

Donabedian, clearly pointing out that the assignment of weights is
completely arbitrary, has applied a weighting scheme to a number of
evaluation projects in medical practice.

16

Rice and associates, by

combining pieces of data related to deaths, patients transferred, re­
leases via escape or against medical advice with those who were re­
leased after maximum benefit, were able to achieve a score, or
effectiveness rating, fairly measuring the "social restoration performance of public psychiatric hospitals."

17

In a very similar fashion

they assembled an effectiveness score in regard to the success of
those patients released from the hospital.

In another study,

Georgopoulos and Tannenbaum constructed three indexes, each measuring
one basic element of a delivery system in a study of organizational ef­
fectiveness.

When combined, their total score of effectiveness was

"significantly correlated with the expert ratings given to the thirtytwo delivery stations."

18

Quite recently, within the past few months,

a "model" for a value output analysis has been developed to be applied
to mental health programs.

The "model" makes extensive use of weight­

ings within the formulations with the following rationale:

"The trans­

lation of program activities and results into economic weight permits
the aggegation of different facts about input, process, and output into
a unitary measuring system; it focuses analysis on the value rather
than the volume of activity or output.

Even this small step should

16

Avedis Donabedian, "Evaluating the Quality of Medical Care,"
Milbank Memorial Fund Quarterly 44 (1966):
166-203.
17

C. E. Rice, et. a l ., "Measuring Social Restoration Perform­
ance of Public Psychiatric Hospitals," Public Health Report 76 (1961):
437-446.
18

B.
Georgopoulos and A. Tannenbaum, "A Study of Organizationa
Effectiveness," American Sociological Review 22 (1957):
534-540.

91

be an important improvement over simply counting the numbers of patients
admitted, attended, or discharged, and relating these to the amount of
money spent."

19

Therefore, along with any standards which may be used

to measure the effectiveness of programs must come a system of weight­
ing so that each piece of data relating to each goal can be afforded
its proper weight in respect to the other peices of data to be con­
sidered.
Ob jectives-Standards
to be Considered
There is an almost endless number of objectives of a community
mental health program that could be considered in any study.

Similarly,

there is probably an infinite number of standards that could be estab­
lished in support of these objectives.

Any study must delimit itself

to those objectives and standards that are deemed to be most important
and which can be quantified in a manner which lends itself to analysis.
Discussions of objectives not considered within the confines of this
study will appear in the conclusions with recommendations for additional
research and data collection devices which will make possible the in­
clusion of additional objectives and data and a modification of the
proposed framework which is not possible currently in the present
state of program and technological development.
In delimiting this study, the following major objectives of
community mental health programs will be considered:
19

J. Halpern and P. Binner, "A Model for an Output Value
Analysis of Mental Health Programs," Administration in Mental Health,
Winter, 1972, pp. 40-51.

92

1.

A community mental health program should decrease the ad­

mission rate to the state institutions by providing services locally,
within the community, and, for those who have been in need of state
institutionalization, the community mental health program should assist
their return and retention within the community without need of being
returned to the state institution.
2.

There is, depending upon the estimating mechanism employed,

a certain percentage of the population in need of mental health serv­
ices at any given time and the degree to which the staff of a community
mental health program meets that need is measurable in terms of active
caseloads and reportable indirect services provided to that community.
3.

There will be a reasonable turnover in the caseload with

a percent of the population having improved sufficiently within a
given time frame that they will no longer be in need of mental health
services.
4.

Indirect services

(consultation and educational services)

should be provided both as a means of assisting the clientele receiv­
ing the direct services and also as an adjunct to the community socio­
logical processes aimed at providing a better environment in which to
live, thereby improving the mental health of the community as a whole.
5.

The cost per unit of service or per client served will be

within some reasonable and acceptable standard in comparison with like
services in other programs.
Underlying each of these objectives are a number of assumptions,
some which seem to be substantiated by the empirical research previ­
ously reported but some, most obviously remain purely assumptions

93

since neither a methodology nor a means of data collection has yet
been developed to substantiate their validity.

The major assumptions

made for purposes of this study are:
1.

That it is better for a person to receive community mental

health services in resolution of his problem than to admit him to the
state institution for care and treatment,
2.

That the treatment or program that the client receives

does, in fact, aid him in the resolution of his mental health problem
to the extent that in reasonable time he can be discontinued from
costly and specialized services as improved and no longer in need of
such services,
3.

That indirect services, such as consultation and education,

are of worth and should be provided to the community, other social
agencies and individuals for the betterment of the mental health of
the community, and
4.

That costs for services are reasonably standard across

agencies and that deviations from a reasonably standard cost are more
a factor of administrative influence and efficiency than of actual
differential in the services provided.
A Framework for Measure­
ment of Program
Performance
The development of a framework which will combine each of the
stated objectives into one composite estimate is an intricate and
complex task.

The formulation which follows is still, of necessity,

in the developmental phase and is being reported at this time for the

94

purposes of portraying the current level of development and as an aid
for further work and refinement.

It is the intent to refine and modify

the formulation as more information becomes available, as more research
is completed to substantiate or refute the assumptions, and as better
assessment techniques are developed.
It would seem, however, that if performance is to be estimated
or measured on the basis of output data related to each of the stated
objectives of community mental health it will be necessary to give
greater weight to certain of the objectives than to others.

For in­

stance, from both the humanitarian and economic point of view, it
would seem that local, community treatment of persons in emotional
distress rather than admitting them to a state institution is a much
higher and more worthy objective than providing community educational
programming on mental health concepts
issue).

(although this is a debatable

But if such is assumed to be true, and for purposes of this

study it is so assumed, then a system of weighting the data regarding
admissions to state institutions must be incorporated within the
formulat ion.
An analysis which would include such factors as a costeffectiveness of those clients currently being treated in a community
agency versus some specified standard incorporating whatever weightings
were deemed appropriate could result in a ratio useful in comparing
the performance of agencies or programs.

Keeping in mind the previ­

ously stated objectives of a community mental health program and their
underlying assumptions, the following format is proposed as a framework

95

to achieve a performance measure for individual programs and as a
comparison across programs:

[vci>-w ]
PS =

A.

__i_

C.
i

, where

[“ -■]
PS - Performance Score,
N

= Number of individuals served within the time period; or,
Active Cases at the beginning of the period plus cases
activated during the period,

C. = The Standard (or Average) Cost per Individual, either as
a statewide established and accepted standard or, in the
absence of such, the average cost per individual served
in all programs,
N

= Number of individuals released during the time period;
or, the number of cases closed during the period,

C

= The Standard (or Average) Cost per Individual Released
or terminated from programs established on the basis of
statewide program experience,

A. = The actual cost per individual for the given program to
be evaluated,
P^

= The population estimated to be in need of mental health
services at any given time, based on some given percent
of the population, and

N^ = The weighted number of admissions to the state institu­
tion during the time period.
The numerator of the format is, therefore, a cost index of those persons
currently receiving services adjusted by the program's cost-efficiency
ratio; and the denominator is the number of persons served adjusted by
a'service-efficiency ratio.

If all factors are working to their maxi­

mum (the cost per individual is equal to or less than the standard,
the number of individuals served is equal or greater than that

96

estimated to be in need, and there are zero admissions to the state
institution), the resultant performance score (PS) will equal or near
0.

Any other score is in a negative

(Example:

-.69) and expresses a

poorer performance the farther it moves from 0.

A discussion of each

of the factors, how they are derived and how they affect the total
performance score, follows.
Number of Individuals Served (Ns ) •— This factor is a composite
score of the number of persons admitted to the active caseload during
the time period plus those already active on the caseload at the be­
ginning of the time period PLUS the number of consultations performed
by the staff during the time period.

The number of

consultations is

included in this factor for a number of reasons:
1.

Consultations are provided to individuals who must be

counted as the recipients of service even though there is no active
case for the individual; it is an indirect service (Example:
consultation with a school teacher regarding one of

A

her students for

whom there is not an active mental health case).
2.

By adding the number of those served through consultation

(indirect) to those who are served by direct programs, we have still
only achieved the minimum number who were served in that it is entirely
possible and anticipated that consultations may serve more than one
individual but with the unavailability of data to better discern
actual numbers being served, the consultation is only counted as
serving one.
3.

With the debate still raging regarding the proportion of

time that should be devoted to indirect services as contrasted to

97

direct

services,

and until there is research evidence to support

either those percents of time or a percent of population that should
be in receipt of consultative services

(similar to the percent factor

in need of mental health services), it seems now only wise, but fitting,
that these data items should be added to produce a composite score.
Example - Sample County
Reported
Reported
Reported
Reported

Number
Number
Number
Number

of
of
of
of

Persons
Treated in Outpatient Services 3,495
Persons
in Day Treatment Services
393
Persons
in Community Inpatient Services 139
Consultative Contacts Made
2,633

Total Number of Individuals Served,

(Ns )

6,660

The effect of this factor on the total performance score is
directly in relation to the total number served in proportion to the
total population of the service area; the greater the proportion of
individuals served the better the score, the lesser number served the
poorer the score.
Standard Cost Per Individual

(C_^) .— In several of the previ­

ously reported prepaid group plans it was determined that a standard
cost per individual covered, and a cost per individual served was
not too different from the per capita allocations of state funds that
are being spent in state community mental health programs.

It would

therefore seem possible for a standard cost per individual served to
be ascribed to a program.

Most assuredly, should a national health

insurance covering mental health services come into being, a standard
cost per individual served would have to be developed.

Most states

have been loathe to establish such a standard, particularly in the

98

face of vastly and rapidly developing programs which have yet to reach
maximum capacity and in view of the steadily rising costs for services
year after year.

Instead, most studies have used as a "standard" the

average cost over a range of programs and then assessed each as being
above or below the average.

Use of an average as a standard, however,

tends to flatten somewhat the end result; that is, a standard is gener­
ally applied that can be achieved by some but most fall below the
standard, both for purposes of analysis and for motivational purposes.
However, since there are other factors which more drastically affect
the final performance score than the standard cost per individual

(C^),

it has been determined that the average cost of all programs will
suffice for the standard for purposes of this study.
cost per individual

The average

(in this case interchangeable with the standard

cost per individual) is calculated by the average cost per unit of
service delivery (per interview, day of treatment, or contact) and
multiplying that sum by the average number of contacts per individual,
as per the following example:
Example - Demonstration State
Total number of reported contact items per time period
Reported expenditures for services during time period
Average cost per unit of service

1,680,391
$35,288,212
21
$
350,081
4.8

Total number of individuals served during time period
Average number of contacts per individual
Average (Standard) cost per individual served
$21) , (C^

(4.8 x
$

100

Since the Standard Cost per Individual applies to all programs and the
same figure is used in all calculations, it has the effect of being a

99

stabilizer in the formula.

Within any one given time period, whether

the figure is large or small is quite immaterial.

However, if the

formulation is to be used in successive years or time periods to evalu­
ate performance of programs over a series of time periods, it becomes
critical that the same methodology is used for calculating the standard
each time.

When done so, the smaller the standard cost in each succes­

sive year the better the final score will be.

To receive a score equal

to that of a previous year (in view of steadily rising costs), it is
necessary for the program to be increasingly efficient economically or
the score will be poorer in the successive years purely as a factor of
inflation.
The average cost per unit of service

($21 in the above example)

or the average cost per individual served ($100) is a liability against
the total funds available for the year.

Each of the 350,081 persons

served in the above example used $100 worth of service.

To reflect

this as a liability against the whole, the standard cost per individual
is

expressed as a negative, or a -21

(or -100) in the formulation.

Humber of Individuals Released (N ).--Movement through the pro­
gram measured by a count of those persons who were formerly on an
active caseload but who, during the time period, have been discontinued
as no longer in receiving services.

Such a count carries an implica­

tion of therapeutic "success" and until better measures are developed
to better reflect individual client outcome, a gross measure such as
those released from the program suffices for this factor.

Obviously

the closer this number to the number of individuals treated, the more
positive the effect and the better the score.

Consideration might be

100

given, at some later date, to weighting this score as on offset
against the consultative contacts being an additive in number of per­
sons served (N ) if there could be drawn a relationship between the
s
consultative program, to better the environment within the community,
and those released from active treatment, to function within that
community in which the consultation is made available.

No such rela­

tionship can be drawn and, as such, the number of persons served (N )
5
will always be larger than the number of persons released (N^) by what­
ever portion the program is encumbered in indirect services

(and the

number of cases not able to be closed or released from treatment during
the period).
This may appear to be, in some respects, a penalty weighting
in favor of direct services, since clients can be released only from
direct services.

Such a factor, however, prevents a program from be­

coming imbalanced and devoting a disproportionate amount of its re­
sources into indirect services to the detriment of those in need of
direct services.

Since it has not been demonstrated that indirect

services do, in fact, lessen the demand for direct services, such a
factor and its effects are felt justified.

Example - Sample County
Reported Number
Reported Number
Reported Number

of Persons Released
of Persons Released
of Persons Released

from Outpatient Services
from Day Treatment
from Inpatient Services

Total Number of

Individuals Released (N^)

2,731
301
107
3,139

Standard Cost per Individual Released (C ).— Just as described
_______________
r
in developing the Standard cost per Individual

•

it is possible to

101

discern from the data the number of contacts or units of service re­
ceived by those persons released from the program.

For the purposes

here, it will also be possible to use the average cost per individual
released as the "standard."

Since it has already been determined in

the previous example that the cost per unit of service is $21, once
the average number of contacts or units of service received by re­
leased cases is known it is possible to establish the Standard Cost
per Individual Released:
Example - Demonstration State
Total number of reported contact items per time period
Reported Expenditures for Services during time period
Average cost per unit of service

1,680,391
$35,288,212
$
21

Total number of individuals released during time period
Total number of reported contacts for released indi­
viduals
Average number of contacts per individual released
Average (Standard) cost per individual released
$21), (Cr)

92,614
388,975
4.2

(4.2 x

$

88

As previously indicated the

number of persons released will always be

substantially less than the

number of persons served.

Similarly, the

number of contacts per individual released will always be less than
the average contacts per individual served since the latter contains
consultative contacts made in the context of comprehensive programming
and not traceable to an individual client.

Since the cost per indi­

vidual released is a part of the total cost of the program, it, too,
is considered as a liability against the total cost and is, therefore,
also expressed as a negative

(-21, or -88 in the formulation).

102

The resulting sum

£n s

(C^) - N^_ ^cr|j

is the cost liability

for those individuals actively receiving service including the indirect
or consultative services performed within a given program.
however, has been standardized across programs by using
constants.

This sum,
and C

as

Each program receives the same initial liability for each

client reduced by the same liability for each released client.
remaining portion of the numerator

A.
_x
C.
i

The

adjusts the standardized

cost liability by the cost - efficiency ratio of the specific program.
Actual Cost Per Individual

(A^) .—

In the same manner in

which the average cost per individual was calculated for the statewide
program, the actual cost per individual is calculated for each program:

Example - Sample County
Total number of reported contact items per time period
Reported expenditures for services during time period
Average cost per unit of service

36,721
$1,033,774
$
28

Total number of individuals served during time period
Average number of contacts per individual
Actual cost per individual served

(5.5 x $28),

The effects of this factor are quite obvious.
individual served is less than the average

(A^)

6,660
5.5
$

1.5$

If the actual cost per

(standard) cost per indi­

vidual served the better the effect on the total performance score;
but if the cost should exceed that of the average

(standard) cost per

individual the program is penalized by this factor and the resultant
effect is that of a poorer score.

Just as C^ and C

are considered

to be liabilities against the statewide total funds available, ■

103

similarly the actual cost per individual served in this sample county
is a liability against the total funds available for the county.

In

this example each indivdual served represents $155 liability against
the total funds available, $1,033,774.
pressed as a negative

As a result, it is also ex­

(-155) in the formulation.

Population Estimated to Be in Need (pe )•— Earlier, in Table 7
the estimated population in need of services ranged from 6 to 47 percent
depending upon the population surveyed and the survey methodology.

The

reported utilization, however, had a much narrower range, from .64% to
2.36% with only one study exceeding that range (and that one only to a
5% figure).

In a preliminary study, as a part of the development of

this methodology, data were collected from all known possible sources
as to the actual number of clients being seen for mental health serv­
ices as of a given time.

These sources included the public mental

health services, public state institutions, veterans facilities, li­
censed private psychiatric facilities, major third party insurance
carriers, prepaid group insurance plans, and private practitioners.
Result o f t h i s

survey

indicated

lation were receiving services.

that

20

in

Michigan

some

6% o f

the

ponu—

However, in the public community

mental health programs, with no apparent waiting list, there were 3.2%
of the population being served.

Since this study purports to assess

only those public community mental health services and since there
were no waiting lists for service, the number of persons currently
20

Michigan Department of Mental Health, "Estimate of MR Popu­
lation in State," March, 1972, Special Report #107.

104

receiving services is accepted as the number to be in need of services.
It should be pointed out that this percent is used only because of the
previously pointed out problem in arriving at an acceptable estimate
of those in need of services, and, as was also previously pointed out,
it is not felt that a saturation point for mental health services has
been achieved in any location so that the absolute maximum percent of
population to be expected on a caseload is as yet unknown.
Example - Sample County
County population as reported on the 1970 Census
Estimated statewide population in need of service
Estimated County population in need (P )

163,560
3.2%
5,294

Since the 3.2% factor is applied to the population for all programs,
this, too, tends to serve as a stabilizer, or constant within the
formula.

As programs grow and develop, it is entirely possible that

the 3.2% estimator will be too small and a re-assessment of the need
or a different methodology will need to be employed to arrive at this
program standard.

It has been suggested that, in the absence of a

standard and since it is possible that individual programs may already
exceed the 3.2% estimate, an alternate would be to accept the highest
percent of population seen in any given program as the "standard for
the year" and use such a percent in place of the 3.2% factor.

This

would tend to penalize all programs with exception of the one which
established the standard and for purposes of this study
cation is deemed too harsh;
used across programs.

therefore,

such an appli­

the 3.2% estimator will be

105

Weighted Admissions to State Hospitals

.— As was noted in

the earlier discussions on the impact community mental health programs
were making on rates of admission to state institutions, the rates of
admission have varied from less than one per thousand to over four
per thousand population.

If, as has been assumed, one of the prime

goals of community mental health programs has been to reduce the ad­
mission demands for state hospitals, the individual programs or centers
should be evaluated as to their achievement in this area.

A simple

modifier within the formula to account for the rate, change in rate,
or increase in rate does not seem, at this time, to give sufficient
import to this prime goal.

Although the specific rates may vary, a

far greater factor than this variance is the cost; not only the cost
in terms of the individual hospitalized, to his family, and to the
economy at large,

21

but also the differential in cost between the cost

to the state for each person hospitalized in a state institution versus
the cost of treating that same person in the community

without relying

upon the costlier admission to the institution.
By placing a "weighting" factor,

(w), within the formula the

economic differential is given extensive impact upon the final per­
formance score (PS).
Mental Health,

22

In a study done by the Michigan Department of

it was determined that the average cost to the state

per admission to the state institution was $5,969 and that the average
cost per person treated on an outpatient basis through the community
21
22

Halpern & Binner, op. cit., p. 46.

Michigan Department of Mental Health Special Report No.
"Summary Performance Measures for MI Hospitals — ETf 1971-72,"
November, 1972.

126,

106

mental health programs was $185.

As such, the treatment within the

state institution costs 32.3 times as much as that in the community
programs.

By weighting each admission by a factor of 32.3, the penalty

for increased admissions, or for admissions above the state average,
is in terms of the differential cost of the different modalities.

The

closer any specific program's admission rate comes to 0, the less the
impact of this penalty weighting and the more accomplished the program
in terms of the prime goal of reducing or preventing admissions to the
state hospital.

As admissions increase, demonstrating less impact

on state institutions, and less accomplishment toward the prime goal,
the penalty becomes more dramatic in its effect on the performance
score.
Example - Sample County
Number of Admissions to State Institution
(within the year)
Weighting factor
Weighted admissions to state institutions

164
x
(Nw )

32.3

5,297.2

Over the past few years there has been a dramatic increase in the cost
per person treated in a state institution (a combined effect of in­
flation and increased staff-patient ratios).

The weight applied to

these admissions can be adjusted as this factor varies.

Similarly, it

has been assumed that as community programs begin to treat the more
severely impaired (who normally require state institution admission),
the cost per person treated in the community may rise.

This may offset

the rising cost in state institutions to some degree or even reduce
the weight applied, but this may also be adjusted with experience-

107

Performance Score (PS).— The performance score is the ratio of
the standardized cost liability of those being served in the program
£ Ns *C i^ ~ Nr ^Cr^ J

adjusted by the cost - efficiency of the program

A.

1

C.

, and the number being served in the program [100 (N ) ] adjusted

i J

N

by the service - efficiency of the program
P

e

(Note:

+ N

The

w

100 is added to the denominator as a constant to bring the resulting
sum closer to the perfect score of 0.
a -1.44 rather than a -144.0.)

In the example this results in

When all the factors described above

are put into the context of the formula.

PS =

[N s

(C. ) - N
(C
x
r

W

■']
N

[lOO (Hs )]
P

e

+ N

w

the result will indicate the difference from a perfect score of 0 the
program has achieved.

The final performance score

negative score (-1.67, -2.93, etc).

(PS) results in a

In carrying through the above ex­

ample, the performance score would be:

Example - Sample County

PS -

£

6660 (-$100) - 3139 (-$88) ]

|l00 (6660 )J

6660
5294 + 5297

f- $155 ]
L- $100 J

= -1.44

108

Several factors are notable in the above example.
cost per individual served within the county

Note first that the

, $155, is higher than

the standard cost per individual served (C^)/ $100.

Had the actual

cost per individual served been closer to the standard cost, or even
perhaps lower than the standard cost, the result in the Performance
Score (PS) would have been closer to the perfect score of 0.

If, for

instance, the actual cost per individual served would have been $85
rather than $155, the result would have been a performance score of
-.79, substantially different than the -1.44 resulting from the higher
than standard cost per person served.

Similarly, had the admission

rate to the state institution been reduced there would have also been
a dramatic result in the performance score.

If, for instance, the

number of admissions to state institutions had been 92 rather than
164, the performance score would have been -.84 rather than -1.44,
once again nearer 0, the perfect score.

Taking both of the above

modifications, a lower actual cost per person served and a lower ad­
mission rate to state institutions, an even better performance score
(nearer to 0) would have been achieved, in this case a score of -.46
rather than the score of -1.44) which was the initial result.

There­

fore, as one moves nearer the goals for community mental health pro­
grams, the score on the performance, as assessed by this formulation,
comes nearer and nearer to a 0 score, showing less distance between
actual performance and expected performance.
An index score or performance score, such as those cited
above -1.44, --79, or -.46 has very little meaning, however, unless
compared with scores for similar agencies, or unless they are compared

109

over a period of years from the same agency.

Such is the intent of

this study; initially to compare performance score among the various
community mental health programs in Michigan and to examine why differ­
ences within those scores occur, but also as a baseline against which
each program can measure its effectiveness over a period of years.
Since the formulation lends itself easily to computerization, the
massive data for statewide programming in a state as large as Michigan
can be easily handled.

CHAPTER V

EXAMINATION OF DATA AND RESULTS
To use evaluation results for policy-making, we need to
know what goes into the formulation of an evaluation study, ^
what its limitations are, and what its findings really mean.

The reporting of data and the presentation of evidence is al­
ways the most difficult in any evaluation effort.

All too often the

manner and format in which the findings are presented will determine
the degree of acceptance or non-acceptance granted the work by clinicians and administrators.

2

This work is no exception and in an effort

to forestall inevitable criticisms, particularly of the performance
score formulation itself, each integral part of the formulation will
be individually reported prior to being included in the calculation
of an overall performance score.
As indicated previously in Table 5, during the 1972-73 fiscal
year, there were 43 community mental health programs in Michigan with
geographic areas of responsibility in which 96% of the state popula­
tion resides.

These programs reported service to over 120,000 persons

requiring the utilization of over $44 million of public funds.
^Selma J. Mushkin, "Evaluations:
1, 2 (1973):
35.
2

Use With Caution," Evaluation,

Edward A. Suchman, Evaluative Research (New York:
Sage Foundation, 1967), p. 163.

110

The

The Russell

Ill

Michigan Department of Mental Health, in June, 1973, implemented a new
data reporting system which required extensive demographic reporting
of every client served (excluding name and other personally identify­
ing data as prohibited by law and which could potentially result in
violation of client confidentiality), the types of services provided
each client and the number of times each client availed himself of such
services, and a report of outcome of services upon the completion of
services to the client.

3

Obviously, such a system results in an im­

mense data base with literally millions of transactions posted annually.
During the first year of implementation of this massive system there
were, quite understandably, reporting problems, processing problems,
programming problems, and naturally, analysis problems.

To apply an

evaluation methodology as has been suggested in Chapter IV to the data
resulting from a new data system experiencing implementation problems
might be considered by some to be foolhardy at best, but to fail to
do so seems even more ludicrous in view of the massive effort of
thousands of professionals who diligently applied themselves to the
accurate reporting of data with the full expectation that such data
would be used to evaluate program performance both to justify their
continued existence and budget but, more importantly, as an effort to
better understand and hopefully improve their service delivery to a
clientele too long neglected and poorly understood.
The data used in this study are, therefore, the first year data
base of a new data reporting system.

Many of the problems inherent in

the implementation of such a system have long since been resolved but
3
Michigan Department of Mental Health, Community Mental Health
Services Data System (Lansing, June, 1973).

112

some were not resolved until some months into the year.

It is with

great anticipation that the second year data are awaited to repeat or
modify these procedures.

For the most part, however, the data which

follow are consistent with those reported in previous studies and are
presented as a base for understand and evaluation, subject to reevaluation and refinement in the light of knowledges and experiences
of future years.
Number of Individuals
Served (Ng), and Need
Estimate, (P )
____________ e_
The number of individuals served in the various programs of
each community mental health service board (county or multi-county
area) is reported in Table 9.

Since the populations of these geo­

graphic area vastly differ it is necessary to calculate a ratio per
population for comparison purposes.

The methodology for this study

does not require the calculation of such a ratio since the population
estimated to be in need (P ) is based on the actual service area popue
lation.

The ratio is, however, reported in Table 9 to illustrate

the range, from .99 per 1,000

(in Lapeer County) to 40.41 per 1,000

( in Mason county), and as an aid to understanding the implications
such a difference can make when contrasted with a standard 3.2% of the
population or 32.00 persons served per 1,000.

It should be noted that

only 2 of the 43 areas exceed this standard, Mason county
Kalamazoo county

(33.75).

(40.41) and

It would be necessary to serve 2.3 times

as many persons statewide to achieve this standard.

113

TABLE 9.— Number of Individuals Served (N ), Community Mental Health,
1972-73.
S

Geographic Area3

Alger-DeltaMarquette

Number
Served,(N )
s

Area
Population

Served Per
1,000

Estimated
Population
In Need,(P )°
e

2,534

109,589

23.12

3,507

Cooper Country

542

54,965

9.86

1,759

Dickinson-Iron

666

36,799

18.10

1,178

Menominee

381

24,207

15.74

775

REGION NO. 1
SUB-TOTAL

(4,441)

(225,560)

(19.69)

(7,219)

1,662

99,428

16.72

3,182

Northern

501

63,672

7.87

2,038

North Central

406

44,076

9.21

1,410

Manistee

122

20,119

6.06

644

Northeast

REGION NO. 2
SUB-TOTAL

(2,829)

(227,295)

(12.45)

(7,274)

Allegan

1,237

68,230

18.13

2,183

Kent

6,945

418,374

16.60

13,388

Lake

15

5,675

2.64

182

909

22,495

40.41

720

4,267

157,707

27.06

5,047

Newaygo

166

28,570

5.81

914

Oceana

154

18,159

8.48

581

Ottawa

1,899

133,684

14.21

4,278

(15,592)

(852,894)

(18.29)

(27,293)

Mason
Muskegon

REGION NO. 3
SUB-TOTAL
Ionia

774

46,274

16.73

1,481

Montcalm

548

40,303

13.60

1,290

REGION NO. 4
SUB-TOTAL

( 1,322)

( 86,577)

(15.27)

( 2,771)

114

TABLE 9.— Continued.

Estimated
Population
In Need,(P )C
e

Number
Served,(N )
s

Area
.
b
Population

Bay-Arenac

1,663

103,035

12. 79

4,161

Gratiot

1,144

39,476

28.98

1,263

Midland-Gladwin

1,480

79,844

18.54

2,555

(249,355)

(18.13)

( 7,979)

389,857

27.77

12,475

(389,857)

(27.77)

(12,475)

Geographic Area3

REGION NO. 5
SUB-TOTAL

(

Clinton-EatonIngham
REGION NO. 6
SUB-TOTAL

4,521)

10,825
( 10,825)

Served Per
1,000

91

33,681

2. 70

1,078

Saginaw

3,835

224,573

17.08

7,186

Sanilac

324

35,206

9.20

1,127

Huron

REGION NO. 7
SUB-TOTAL

(

4,250)

(293,460)

(14.48)

( 9,391)

5,218

456,827

11.42

14,618

54

54,373

.99

1,740

1,852

64,874

28.55

2,076

7,124)

(576,074)

(12.35)

(18,434)

Berrien

3,344

166,132

20.13

5,316

Calhoun-Bra nch

1,942

180,203

10.78

5,766

470

44,703

10.51

1,430

6,997

207,328

33.75

6,634

854

48,346

17.66

1,547

1,356

57,579

23.55

1,843

(704,291)

(21.25)

Genesee
Lapeer
Shiawassee
REGION NO. 8
SUB-TOTAL

Cass
Kalamazoo
St. Joseph
Van Buren
REGION NO. 9
SUB-TOTAL

i

( 14,963

(22,536)

115

TABLE 9.— Continued.

Geographic Area3

Number
Served,(N )
s

JacksonHillsdale
Lenawee
REGION NO. 10
SUB-TOTAL

(

Area
Population

Served Per
1,000

Estimated
Population
In Need, (P )°
e

1,535

182,506

8.41

5,840

542

82,459

6.57

2,639

264,965)

( 7.84)

2,077)

(

(

8,479)

Livingston

847

63,072

13.43

2,018

Monroe

663

121,335

5.46

3,883

2,925

240,699

12.15

7,702

425,106)

(10.43)

( 13,603)

Washtenaw
REGION NO. 11
SUB-TOTAL

(

4,435)

(

Macomb

6,198

664,810

9. 32

21,274

Oakland

7,929

946,544

8.38

30,389

St. Clair

2,748

122,307

22.47

3,914

REGION NO. 12
SUB-TOTAL
Detroit-Wayne

( 16,875)
32,438

(1,733,661)

( 9.73)

( 55,477)

2,660,683

12.19

85,142

(12.19)

( 85,142)

14.00

278,073

REGION NO. 13
SUB-TOTAL

( 32,438)

(2,660,683)

STATE TOTAL
ALL REGIONS

121,692

8,689,778

J

aThe geographic areas are portrayed on the m a p , Appendix I .
^Michigan, Executive '
Office of the Governor, Bureau of
Program & Budget, Research Division, Michigan Population Data Notes,
Vol. 1, No. 4, December 26, 1972.
c

Estimated Population in Need calculated as 3.2% of area
population as per Chapter IV, page 103-104.
State Total population contains only those areas served
by community mental health programs.
Gross total population for
1972 including areas not served by community mental health programs
estimated to be 9,040,751.b

116

Standard Cost Per
Individual Served
(Ci)
Calculation of standard

(or average) cost per individual served

for the 1972-73 fiscal year makes use of all the service units reported
for individual clients, reported by client case number, on the Staff
Activity and Client Attendance reports of the new data system,

(Table

10 ) .

TABLE 10.— Standard
Program Costs
(Gross)

$41,448,563a

(Average) Cost per Individual Served, 1972-73.

Individuals
Served,(N )
s

Cost Per
Individual,(C^)

Average Contacts
Per Individual

$340.60C

11.14d

121,692b

Cost Per
Contact
$30.57e

aTotal expenditures amounted to $44,366,989.
Board adminis­
trative costs, not program related totalled $2,918,426 and were de­
ducted from gross program costs.
Source:
Michigan Department of
Mental Health, Bureau of General Services, finance Section.
b

From Table 9.

cProgram Costs/N^ = C^
d

Source:
Michigan Department of Mental Health, Bureau of
General Services, Data Analysis Section.
eC^/Average Contacts Per Individual = Cost Per Contact

It should be noted that the Standard

(or Average) Cost Per Individual

(Ci) , at $340.60, is mid-range of costs per individual previously re­
ported in Chapter III. Those costs ranged from a low of $135.50 to a
4
high of $603.
Although the average number of contacts per individual
M. Glasser and T. Duggan, "Prepaid Psychiatric Care Experience
with UAW Members," American Journal of Psychiatry 126, 5 (1969): 679.

117

and average cost per contact are not essential for completion of this
portion of the formulation, the average cost per contact will be used
later in calculating the Standard (or Average) Cost Per Individual
Released

first impression, the average cost per contact,

$30.57, might seem disproportionately high, however, it should be
borne in mind that this is a composite average cost which combines the
average cost of an outpatient interview, the average cost of a day of
partial hospitalization, the average cost of a day of in-patient treat­
ment and the average cost of a day of residential care.

Number of Individuals
Released (N ) and Cost
___________ r___________
tCr)
Upon termination of services a closure report is submitted for
each client served indicating the condition of termination;
(2) Further Treatment Not Recommended,
ance,

(4) Discontinued, No Improvement,

Recovered, and (7) Other.

(1) Improved,

(3) Self-Determined Discontinu­
(5) Referred Elsewhere,

(6)

The Department of Mental Health, interested

particularly in assessing reported outcomes of service prepared a
series of reports by agency and by geographic area which detailed the
average number of contacts clients had received by each condition of
termination listed above.

5

Using these base data reports, the average

number of contacts per individual released

(or terminated) has been

calculated and is reported in Table 11 along with the standardized
cost per individual released

(C^.) .

As an example of the procedure

5
Michigan Department of Mental Health, "Contacts Per Condition
of Termination," Reports No. 190-223, August, 1973.

118

for such calculation, the Clinton-Eaton-Ingham outpatient services
terminations and average contacts are as follows:

Condition of Termination
1.
2.
3.
4.
5.
6.
7.

Number Reported

Improved
Further Treatment
Not Recommended
Self-Terminated
No Improvement
Referred Elsewhere
Recovered
Other

Average Contacts

1,011

8.4

158
1, 395
317
165
46
193

4.4
4.4
5.8
5.4
10- 3
6.1

3, 280

Total
Area Average

6.7

The Average Contacts Per Released Client ranges from 5.2 in
Mason county to 7.5 in St. Clair county; the Standardized Cost Per
Individual Released,

therefore,

ranges from $158.96

(in Mason) to

$229.27 (in St. Clair) in contrast to the previously calculated Stand­
ard Cost Per Individual Served at $340.60 (Table 10).

As was previ­

ously noted, in Chapter IV, the number of contacts per individual re­
leased will always be less than the average contacts per individual
since the latter contains consultative contacts not traceable to the
individual client.

As a result, the Standardized Cost Per Individual

Released will always be less than the Standard Cost Per Individual
Served.
The ratio or percent of clients released of the total clients
served, although not used in the proposed formulation, is an interest­
ing index and illustrates movement through the program.

As can be

noted in Table 11, this ratio ranges from 0 in Manistee county to .74
in Mason county

(coincidentally contiguous counties in the northwestern

119

TABLE 11.— Number of Individuals Released (N ), Community Mental Health,
1972-73.
r

Number
Released
(Nr )

Geographic Area

Average
Contacts
per
Released
Client

Standardized
Cost Per Indi­
vidual Released
<cr)b

Ratio:
Released/
Served0

Alger-DeltaMarquette

939

6.5

$ 198.70

.37

Copper Country

201

6. 7

204.81

.37

Dickinson-Iron

144

6.6

201.76

.21

Menominee

130

6.8

207.87

.34

(6.6)

(201.76)

(.31)

REGION NO. 1
SUB-TOTAL

(1,414)

Northeast

616

6.3

192.59

.37

Northern

168

7.3

223.16

.33

North Central

174

7.0

213.99

.42

Manistee
REGION NO. 2
SUB-TOTAL

0

0

0

958)

(6.7)

(204.81)

(-33)

167

7.2

2 2 0 ,10

.13

Kent

3,720

6.7

204, 81

.53

Lake

7

5.4

165, 07

.46

673

5.2

158. 96

.74

2,027

6.5

198. 70

.47

Newaygo

27

5.8

177. 30

.16

Oceana

72

6.8

207. 87

.46

Ottawa

821

6.4

195. 64

.43

(6.4)

(195.64)

(.48)

(

Allegan

Mason
Muskegon

REGION NO. 3
SUB-TOTAL

(7,514)

Ionia

309

6.3

192.59

.39

Montcalm

127

6 .3

192.59

.23

436)

(6.3)

(192.59)

(.32)

REGION N O . 4
SUB-TOTAL

(

120

TABLE 11.— Continued

Geographic Area'

Number
Released
(Nr )

Average
Contacts
Per
Released
Client

Standardized
Cost Per Indi­
vidual Released
(Cr )b

Ratio:
Released/
Served0

213.99

.22

7.1

217.04

.44

7.1

217.04

.50

(7.1)

(217.04)

(.35)

Bay-Arenac

367

7.0

Gratiot

512

Midland-Gladwin

744

$

REGION N O . 5
SUB-TOTAL

(1,623)

Clinton-EatonIngham

4,954

6.7

204.81

.45

(4,954)

(6.7)

(204.81)

(.45)

20

7.0

213.99

.21

Saginaw

2,237

7-0

213.99

.58

Sanilac

129

6.6

201.76

.39

(6.9)

(210.93)

(.56)

805

6.1

186.47

.15

6

6.0

183.42

.11

1,011

6.6

201.76

.54

(1,822)

(6.5)

(198.70)

(.25)

1,337

6.8

207.87

.39

680

6.5

198.70

.35

36

6.9

210.93

.07

2 f466

7.0

213.99

.35

St. Joseph

413

6.7

204.81

.48

Van Buren

409

6.6

201.76

.30

(6 .8 )

(207.87)

(.35)

REGION NO. 6
SUB-TOTAL
Huron

REGION NO. 7
SUB-TOTAL
Genesee
Lapeer
Shiawassee
REGION N O . 8
SUB-TOTAL
Berrien
Calhoun-Branch
Cass
Kalamazoo

REGION N O . 9
SUB-TOTAL

(2,386)

(5,341)

121

TABLE 11.— Continued

Geographic Areaa

Number
Released
< v

Average
Contacts
Per
Released
Client

Standardized
Cost Per Indi­
vidual Released
(cr )b

Ratio:
Released/
Servedc

JacksonHillsdale

962

6.5

$ 198.70

.62

Lenawee

198

6.6

201.76

.36

(6.5)

(198.70)

(-55)

REGION NO. 10
SUB-TOTAL

( 1,160)

Livingston

337

6.5

198.70

.39

Monroe

321

7.1

217.04

.48

1,179

6.9

210.93

.40

( 1,837)

(6.9)

(210.93)

(-41)

Macomb

2,290

7.0

213.99

.36

Oakland

2,822

6.6

201.76

.36

936

7.5

229.27

.34

Washtenaw
REGION NO. 11
SUB-TOTAL

St. Clair
REGION NO. 12
SUB-TOTAL

( 6,048)

(6.9)

(210.93)

(-35)

Detroit-Wayne

11,680

6.6

201.76

.36

REGION N O . 13
SUB-TOTAL

(11,680)

(6.6)

(201.76)

(-36)

STATE TOTAL
ALL REGIONS

47,173

6.7

204.81

.38

The geographic areas are portrayed on the map, Appendix I.
Standardized Cost Per Individual Released (C ) calculated
as Average Contacts Per Released Client X Cost Per Contact ($30.57)
from Table 10.
c

Ratio:
Released/Served calculated by Number Released
divided by Number Served, from Table 9 or N /N .
r s

122

section of the state).

As is evident, Manistee released no-one from

the program during the year with no movement through the program while
Mason released from service 74% of those served during the year.

Actual Cost Per Individual Served (A^)
Just as it was possible to calculate the state-wide average, or
Standard Cost Per Individual Served

Cc^) i-n Table 10, it is possible to

calculate the geographic area average, or Actual Cost Per Individual
Served (A^).

Again, board administrative costs have not been included

in calculating the cost per individual served at the county or geo­
graphic area level.

These costs are not service directed and have been

deducted from the program expenditures reported for the 1972-73 fiscal
year.

The 1972-7 3 Gross Program Expenditures

(excluding board adminis­

trative costs), the Actual Cost Per Individual Served (A^), Actual
Number of Contacts Per Client, Average Cost Per Contact, and CostEfficiency Ratio (A^/C^) are reported in Table 12.
The range of actual cost per individual served in the various
programs is from $69.37 in Mason county to $1,145.26 in Huron County.
The cost-efficiency ratio (A^/C^) would, as a result, show a range of
.204 to 3.362 in these respective counties.

Average number of con­

tacts per client has a range of from 3.64 in Manistee county to 26.02
in Huron county.

Similarly, the cost per contact ranges from $12.75

in Mason county to $115.68 in Monroe county.

Note that the STATE

TOTAL, ALL REGIONS Average Contacts Per Client (11.14) and the Average
Cost Per Contact ($30.57) have been previously reported in Table 10.

123

TABLE 12.— Actual Cost per Individual Served (A.), Community Mental
Health, 1972-73.
1

Geographic Area

Alger-DeltaMarquette

Program Costs
(Gross)

Actual
Cost Per
Individual
(A. )
i

$

$

713,167

Average
Contacts
Per
Client

Average
Cost
Per
Contact

CostEff.
Ratio
(A./ C .
\\1 1

281.48

11.25

$ 25.00

.826

Cooper Country

127,759

235.71

6.86

34.33

.692

Dickinson-Iron

171,696

257.80

7.85

32.81

.757

Menominee

138,650

363.91

12.67

28.70

1.068

(259. 23)

( 9.53)

(27.18)

(.761)

500,888

301.91

12.10

24.90

.884

99,835

199.27

12.58

15.83

.585

153,609

378.34

8.24

45.91

1.111

34,135

279.80

3.64

76.76

.821

788,467)

(278.70)

(10.67)

(26.11)

(.818)

448,230

362.35

4.72

76.76

1.064

Kent

3,383,318

487.15

7.44

65.44

1.430

Lake

5,419

361.26

11.66

30.97

1.060

63,062

69,37

5.44

12. 75

.204

1,501,567

351.90

15.47

22.74

1.033

Newaygo

38,374

231.16

10.61

21.78

.679

Oceana

37,876

245.94

10. 53

23. 34

.722

Ottawa

545,669

287.34

12.42

23.13

.844

(386.32)

(10.01)

(38.59)

REGION NO. 1
SUB-TOTAL

( 1,151,272)

Northeast
Northern
North Central
Manistee
REGION NO. 2
SUB-TOTAL

(

Allegan

Mason
Muskegon

REGION N O . 3
SUB-TOTAL

(6,023,515

(1.134)

Ionia

122,426

158.17

7.92

19.96

.464

Montcalm

122,621

223.76

3.45

64.74

.657

245,047)

(185.36)

REGION NO. 4
SUB-TOTAL

(

( 6.07)

(30.53)

( .544)

124

TABLE 12.— Continued.

Geographic Area

Program Costs
(Gross)

Bay-Arenac

$

695,279

Average
Contacts
Per
Client

Average
Cost
Per
Contact

CostEff.
Ratio
(A./C.
i i

418.08

10. 22

$ 40.88

1.227

Actual
Cost Per
Individual
(A.)
$

Gratiot

220,873

193.07

7. 35

26. 24

.567

Midland-Gladwin

355,676

240.32

15.37

15.63

.706

281.31)

(10.65)

(26.40)

(.826)

283.58

14.14

20.05

.833

283.58)

(14.14)

(20.05)

(.833)

REGION NO. 5
SUB-TOTAL
Clinton-EatonIngham
REGION NO. 6
SUB-TOTAL
Huron

( 1,271,828)

(

3,069,806

( 3,069,806)

(

104,219

1,145.26

26.02

44.01

3. 362

Saginaw

1,051,391

274.15

13.39

20.46

.805

Sanilac

70,703

218.21

7.12

30.62

.641

288.54)

(13.19)

(21.87)

(-847)

2,097,858

402.04

14.44

27.83

1.180

27,989

518.31

18.92

27. 39

1.522

274,346

148.13

6.77

21.87

.435

REGION NO. 7
SUB-TOTAL
Genesee
Lapeer
Shiawassee
REGION NO. 8
SUB-TOTAL

( 1,226,313)

( 2,400,193)

(

336.91)

(12.59)

(26. 76)

(.989)

1,041,211

311.36

17.93

17.36

.914

Calhoun-Branch

568,184

292.57

12.92

22.64

.859

Cass

120,222

255.79

8. 79

29 .07

.751

1,628,168

232.69

10. 78

21.58

.683

St. Joseph

127,190

148.93

8.49

17. 54

.437

Van Buren

231,956

171.05

6. 10

28.01

.502

(20.63)

(.729)

Berrien

Kalamazoo

REGION NO. 9
SUB-TOTAL

( 3,716,931)

(

(248.40)

(12.04)

125

TABLE 12.— Continued

Geographic Area

JacksonHillsdale

Program Costs
(Gross)

441,667

$

86,474

Lenawee
REGION NO. 10
SUB-TOTAL

$

Average
Contacts
Per
Client

Average
Cost
Per
Contact

CostEff.
Ratio
A./C.)
i i

287.73

19.20

$ 14.98

.845

159.54

9.27

17.20

.468

528,141)

( 254.28)

(16.61)

Livingston

231,777

273.64

15.08

18.14

.803

Monroe

367,153

553.77

4.78

115.68

1.626

1,529,404

522.87

18.47

28.30

1.535

Washtenaw
REGION NO. 11
SUB-TOTAL

(

Actual
Cost Per
Individual
(A.)

( 2,128,334)

( 479.89)

{ 15.30)

(15.78)

( 30.41)

(.747)

(1.409)

Macomb

1,903,462

307.10

11.11

27.62

.902

Oakland

2,882,216

363.50

14.65

24.81

1.067

597,888

217.57

10.69

20. 35

.639

( 5,383,566)

( 319.02)

(12.70)

(25.10)

(-937)

13,685,615

421.90

8.45

49.88

1.239

REGION NO. 13
SUB-TOTAL

(13,685,615)

(421.90)

( 8.45)

(49.88)

(1.239)

STATE TOTAL
ALL REGIONS

41,448,563

340.60
= C.i

11.14

30. 57

1.000

St. Clair
REGION NO. 12
SUB-TOTAL
DetroitWayne

126

Number of Admissions
to State Institutions,
Weighted (Nw )
Great emphasis has consistently been placed on the desirability
of community mental health programs having an impact on the rate of
admissions to state institutions.

The Michigan Department of Mental

Health has clearly indicated that one of the prime goals of community
mental health programs shall be the reduction in utilization of state
institutions for treating the acute and chronic mentally ill and emo­
tionally disturbed.

As one of the prime goals it is entirely appro­

priate that the rate of admissions to state institutions be weighted
within the formulation so as to act as a "punishment" to those pro­
grams which fail to reduce the rate and to "reward" those which have
had impact.
Weights are purely arbitrary in nature and are administratively
determined.

They can be varied depending upon the emphasis desired

and may be changed as warranted.
in this study.

Such is the case with the weighting

In Chapter IV it was reported that the average cost to

the state per admission to the state institution was $5,969 and that
the average cost per person treated in a community mental health pro­
gram was $185, or 32.3 times as costly to be treated in the state in­
stitution in 1971-72.
this relationship.

Recent data indicate a significant change in

As has already been reported, the average cost per

individual served in a community mental health program has risen from
$185 in 1971-72 to $340.60

(C^) in 1972-73.

Concomitantly, the average

number of contacts per individual served has increased from 4.8 to
6

Michigan Department of Mental Health Special Report No. 126,
"Summary Performance Measures for MI Hospitals - FY 1971-72," November,
1972.

127

to 11.14 which would seem to indicate that more severely handicapped
persons are being treated requiring more contacts per individual over
a longer period of time.

This, in itself, would change the differen­

tial to 17.5 times as costly in state institutions.

However, a similar

change has taken place in relation to state institutions.

Although the

number of persons admitted for treatment has steadily risen over the
past few years, and 1972-73 continued in this same trend, the length
of stay of persons admitted has been steadily decreasing.

As a re­

sult, the cost per individual admitted declines as the number admitted
increases.

The data for 1972-73 indicate that 23,520 persons were

treated at state psychiatric institutions at a cost of over $84 million.
The average cost per person treated at a state institution in 1972-73
is now reported to be $3,572, or 10.5 times as costly as the average
cost per individual served in a community mental health program.

7

For

purposes of this study, and to be consistent with the Department of
Mental Health goals, the factor of 10.5 will be applied to each admis­
sion in calculating the Weighted Number of Admissions to State Institu­
tions.

The number of admissions and the weighted factor are reported

in Table 13.

Also reported in Table 13 is the combined factor of the

Population estimated

to be in

Need (Pe ) fromTable 9 and theWeighted

Number of Admissions

(N ) or,
w

(P

e

+ N ).
w

The Service Efficienty Ratio# or

N

g

—----—— , assesses the
P + N
e
w
to which the specific program is serving the number of persons
that should be served.

degree
(weighted)

To achieve a ratio of 1.0 it would be necessary

Michigan Department of Mental Health Special Report, "Summary
Performance Measures for MI Hospitals - FY 1972-73," Unpublished to
date.

128

TABLE 13.— Weighted Number of Admissions to State Institutions
1972-73.

Geographic Area

Number of
Admissions

Weighted N o .
of Admissions

Weighted Admissions plus
Estimated Need
(N + P )
w
e

(N ) ,
W

Service Eff.
Ratio:
(N /N + P )
s w
e

Alger-DeltaMarquette

50

525

4,032

.628

Copper Country

22

231

1,990

.272

Dickinson-Iron

27

284

1,462

.456

Menominee

12

126

901

.423

REGION NO. 1
SUB-TOTAL

(

111 )

( 1,166)

( 8,385)

(.530)

Northeast

57

599

3,781

.440

Northern

95

998

3,036

.165

North Central

82

861

2,271

.179

Manistee

61

641

1,285

.095

REGION NO. 2
SUB-TOTAL

295)

( 3,099)

Allegan

104

1,092

3,275

.378

Kent

155

1,628

15,016

.463

Lake

19

200

382

.039

Mason

29

305

1,025

.887

Muskegon

64

672

5,719

.746

Newaygo

24

252

1,166

.142

Oceana

13

137

718

.214

Ottawa

82

861

5,139

.370

REGION NO. 3
SUB-TOTAL

(

(

490)

( 5,147)

(10,373)

(32,440)

(.273)

(.481)

Ionia

92

966

2,447

.316

Montcalm

42

441

1,731

.317

REGION NO. 4
SUB-TOTAL

(

134)

( 1,407)

( 4,178)

(.316)

129

TABLE 13.— Continued.

■
Geographic Area

_
Number of
, .
Admissions

Weighted No.
,
of Admissions

Weighted Admissions plus
Estimated Need
(Nw + P e )

Service Eff.
..
Ratio:
(N /N + P )
5 ”
6

Bay-Arenac

58

609

4,770

.349

Gratiot

25

263

1,526

.750

Midland-Gladwin

51

536

3,091

.479

REGION N O . 5
SUB-TOTAL

(134)

Clinton-EatonIngham
REGION NO. 6
SUB-TOTAL

{ 1,408)

( 9,387)

(.482)

2,352

14,827

.730

( 2,352)

(14,827)

(.730)

224
(

224)

Huron

17

179

1,257

.072

Saginaw

38

399

7,585

.506

Sanilac

13

137

1,264

.256

715)

(10,106)

(.421)

REGION NO. 7
SUB-TOTAL

(68)

Genesee

(

116

1,218

15,836

.330

Lapeer

47

494

2,234

.024

Shiawassee

38

399

2,475

.748

(20,545)

(.347)

REGION NO. 8
SUB-TOTAL

(

Berrien

201)

( 2,111)

94

987

6 ,303

.531

218

2,289

8,055

.241

24

252

1,682

.279

325

3,413

10,047

.696

St. Joseph

38

399

1,946

.439

Van Buren

80

840

2,683

.505

Calhoun-Branch
Cass
Kalamazoo

REGION NO. 9
SUB-TOTAL

(

779)

( 8,180)

(30,716)

(.487)

130

TABLE 13.— Continued.

Geographic Area

Number of
Admissions

Weighted No.
of Admissions
< V

JacksonHillsdale
Lenawee
REGION NO. 10
SUB-TOTAL

(

Livingston

Weighted Ad­
missions plus
Estimated Need
(N + P )
w
e

Service Eff
Ratio;
(N /N + P ;
s w
e

199

2,090

7,930

.194

46

483

3,122

.174

245)

(

2,573)

( 11,052)

(.188)

36

378

2,396

.354

Monroe

103

1,082

4,965

.134

Washtenaw

248

2,604

10,306

-284

REGION NO. 11
SUB-TOTAL
Macomb
Oakland
St. Clair

{

387)

4,064)

( 17,667)

(.251)

490

5,145

26,419

.235

1,413

14,836

45,125

.176

57

599

4,513

.609

REGION NO. 12
SUB-TOTAL

( 1,960

Detroit-Wayne

6, 321

REGION NO. 13
SUB-TOTAL

( 6,321)

STATE TOTALS
ALL REGIONS

ll,349a

a

(

(20,580)

( 76,057)

(.222)

66,371

151,513

.214

( 66,371)

(151,513

(-214)

119,173

397,246

.306

Does not include admissions from counties not included in
the community mental health program.

131

to be serving at least 3.2% of the population and have eliminated ad­
missions to the state institution.

The ratio could also be achieved

by treating 10.5 times as many persons as there were admissions to the
state institution in addition to the 3.2% necessary population base.
This ratio is also reported in Table 13.
The Service Efficiency Ratio ranges from a low of .024 in

Lapeer

county where the new community mental health program has just been in­
itiated to a high of .887 in Mason county.

It should be noted that

the program in Mason county served 4% of the population

(higher than the

3.2% standard) but experienced 29 admissions to state institutions.
To completely offset such an admission rate it would have been neces­
sary to serve an additional 116 persons or a total of 1,025, 4.6% of
the population.

Other counties also achieved rather high ratios such

as Gratiot (.750), Shiawassee

(.748), and Muskegon

(.746).

In each

case they had served a caseload which approached or exceeded the 3.2%
standard and have dramatically reduced admissions rates as compared to
other counties.

An even more desirable effect would have been achieved

in Mason county had the admission rate been

reduced to 18 instead

of 29.

This reduction would have resulted in a 1.000 Service Efficiency Ratio
in view of their increased service population.
The 1972-73 Performance
Scores (PS) for Commu­
nity Mental Health
Programs
The performance Score is an indication of how community mental
health programs compare among themselves and a single performance
score by itself is meaningless.

In order to make more evident this

132

comparison the Performance Scores are rank-ordered from those scoring
closest to 0 on to those having the larger negative values.
of key factors

A summary

(the standardized cost liability of each program, the

cost effectiveness ratio, the service effectiveness ratio), the Per­
formance Score, and the Rank-Order are presented in Table 14.

The

programs of specific geographic areas are ranked from one to fortythree;

regional sub-totals separately ranked from one to thirteen.

Following is an example of the calculation.
The combination of variables produces a range in Performance
Scoresfrom -.51 in Mason county to -203.07 in Lapeer

county.

This

is

a rather extensive range but with the majority of programs clustering
within a ten point range

(30 programs scoring between -2.40 and -11.15).

With such a distribution it seems reasonable to assume that there may
be extreme values at either end of the distribution significantly in­
fluencing the mean.

A number of the variables along with the final
g

Performance Score were subjected to analysis, a test for outliers,
to see if any of the critical variables or the final Performance Score
did, indeed, include such extremes.
By observing the values at either end of each distribution
selected for examination it can be noted that the higher values ap­
pear to be influencing the mean of each distribution causing what can
be described as a "medium effect."

Such an effect would result in a

decision rule at the .10 critical value level with samples of over 25.
These critical values are cited in Table 15.
8
W. J. Dixon and F. J. Massey, Introduction to Statistical
Analysis (New York; McGraw-Hill Book Company, Inc., 1957), p. 275.

133

TABLE 14-— Performance Score and Rank-Order, 1972-73.
^
Program Cost
. , ., .^
Liability

_
Geographic Area

Cost
Eff.
.
Ratio

Service
Eff.
,
Ratio

„
Performance
Score3

RankOrder

Alger-DeltaMarquette

-

676,501.10

.826

.628

-

3.51

12

Cooper County

-

143,438.39

.692

.272

-

6.73

21

Dickinson-Iron

-

197,786.16

.757

.456

-

4.93

15

Menominee

-

102,745.50

1.068

.423

-

6.80

22

( -761)

(.530)

(-

3. 96)

( 2)

REGION NO. 1
SUB-TOTAL

{-1 ,227,315.96)

Northeast

-

447,441.75

.884

.440

-

5.40

16

Northern

-

133,149.72

.585

.165

-

9.42

29

North Central

-

101,049.34

1.111

.179

- 15.44

36

Manistee

-

41,533.20

.821

.095

- 29.42

40

(-

767,349.42

( .658)

(.273)

<-

6.53)

( 8)

Allegan

-

384,565.50

1.064

.378

-

8.75

27

Kent

-1 ,603,573.80

1.430

.463

-

7.13

23

Lake

-

3,953.51

1.060

.039

- 71.63

41

Mason

-

202,625.32

.204

.887

-

.51

1

Muskegon

-1 ,050,575.30

1.033

.746

-

3.40

9

Newaygo

-

51,752.50

.679

.142

- 14.90

35

Oceana

-

37,485.76

.722

.214

-

8. 21

25

Ottawa

-

486,178.96 ‘

.844

.370

-

5.83

17

(-481)

(-

5.80)

( 7)

REGION NO. 2
SUB-TOTAL

REGION NO. 3
SUB-TOTAL

(-3 ,840,596.24)

(1-134)

Ionia

-

204,114.09

.464

.316

-

3.87

13

Montcalm

-

162,189.87

.657

.317

-

6.13

19

(-

366,303.96)

( -544)

(.316)

(-

4.77)

( 4)

REGION NO. 4
SUB-TOTAL
Bay-Arenac

-

487,883.47

1.227

.349

-

Gratiot

-

278,521.92

.567

.750

—

10. 31

32

1.84

3

134

TABLE 14.— Continued.

Program Cost
Liability

Geographic Area

Midland-Gladwin
REGION NO. 5
SUB-TOTAL
Clinton-EatonIngham
REGION NO. 6
SUB-TOTAL

-

(-1,187,596.68)

-2,672,366.26

-

Sanilac
REGION NO. 7
SUB-TOTAL
Genesee

REGION N O . 8
SUB-TOTAL

( .826)
.833

Performance
Score3

.479
(.482)

(-

.730

RankOrder

3.41

10

4.50)

( 5)

2.81

8

2.81)

( 1)

(.730)

26,714.80

3.362

.072

- 135.01

42

827,505.37

.805

.506

3.43

11

84,327.36

.641

.256

6.51

20

4.47)

( 4)

(-

( .847)

(.421)

(-

-1,627,142.45

1.180

.330

-

11.15

33

17,291.88

1.522

.024

- 203.07

43

426,871.84

.435

.748

1. 34

2

(.989)

(.347)

8.25)

( 9)

(-

Lapeer
Shiawassee

.706

Service
Eff.
Ratio

( .833)

(-2,672,366.68)

Huron
Saginaw

342 ,610.24

Cost
Eff.
Ratio

-

944,271.02)

(-2,064,403.00)

(-

Berrion

-

861,044.21

.914

.531

4.43

14

Calhoun-Brunch

-

526,329.20

.853

.241

9.66

30

Cass

-

152,488.52

.751

.279

8.73

26

Kalamazoo

-1,855,479.86

.683

.676

2.6

/

5

St. Joseph

-

206,285.87

.437

.439

2.40

4

Van Buren

-

379,333.76

.502

.505

2.78

7

(.729)

(.487)

REGION NO.9
SUB-TOTAL

(-3,986,164.13)

(-

3.98)

( 3)

Jackson—
Hillsdale

-

331,671.60

.845

.194

9.41

28

Lenawee

-

144,656.72

.468

.174

7.17

24

(-

476,328.32)

(.747)

(.188)

9.11)

(1 0 )

REGION NO. 10
SUB-TOTAL

(-

135

TABLE 14.— Continued.

Geographic Area

Program Cost
Liability

Cost
Eff.
Ratio

Service
Eff.
Ratio

Performance
Score3

Rank—
Order

Livingston

-

221,526.30

.803

.354

-

5.93

18

Monroe

-

156,147.96

1.626

.134

- 28.57

39

Washtenaw

-

747,568.53

1.535

.284

- 13.81

34

(1.409)

(-251)

(- 14.21)

(12)

REGION NO. 11
SOB-TOTAL

(-1,123,082.59)

Macomb

-1,621,001.70

.902

.235

- 10.03

31

Oakland

-2,131,250.68

1.067

.176

- 16.29

38

St. Clair

-

.639

.609

-

721,372.08

2. 75

6

REGION NO. 12
SUB-TOTAL

(-4,471-920.36)

( .937)

(.222)

(- 11.18)

(11)

Detroit-Wayne

-8,691,826.00

1.239

.214

- 15.51

37

REGION NO. 13
SUB-TOTAL

(-8,691,826.00)

(1.239)

(.214)

(- 15.51)

(13)

STATE TOTALS
ALL REGIONS

-31,786,793.07

1.000

.306

aExample of calculation of Performance Score

8.53

(PS) .

A.

1

[ Ns<c i> - w

]

PS =

C.
l

N
100 N
.
£

1

P

e

+ N
w

[2534 1-340.60) - 939 (-198 ■70)]
= -3.51

[100 (2534)]

[ 350f f 525]

25.5

136

The variables of (1) the number of persons served per 1,000
population,

(2) the ratio of those released to those served, and (3)

the service-efficiency ratio were found not to include extreme values,
far removed from the main body of the data.

These factors all relate

to the population being served and/or in need of being served and it
is, therefore, safe to assume that all the programs are serving a
percent of their populations and that percent is distributed over a
single distribution.
The cost of these programs, however, does contain some extreme
values as reported on Table 15.

The highest value of each,

actual cost per individual served,

(1) the

(2) the average cost per contact,

and (3) the cost-efficiency ratio, are significantly different from the
other cost-values of the distribution and do represent extreme values.
The second highest value of each was not found to be significant and
is not considered to be extreme.

Two programs produced these three

extreme cost indexes; Huron counties with a cost per individual served
of $1,145.26 and the resultant cost-efficiency ratio of 3.362, and
Monroe county with an average cost per contact of $115.68.

None of the

lower values of either the population data or the cost data were found
to be extreme and were within the normal distribution.
The combination of variables resulting in the overall Per­
formance Score, when subjected to analysis for extremes, contains a
number of significant values at the high end of the range.

Specifi—

cally, the Performance Scores for the following programs are extreme
values:

Lapeer county (-203.07), Huron county (-135.01), Lake

county (-71.63), Manistee county (-29.42), and Monroe county (-28.57).

TABLE 15.— Analysis of Data for Extreme Values.

Variable

Number Served
per 1,000

3rd
Highest
Value

40.41

33.75

28.98

.74

.62

.58

3rd
Lowest
Value

2.70

2nd
Lowest
Value

Lowest
Value

2.64

.99

Significancea

No

Released/
*
—1
rH
•

Ratio:
Served

2nd
Highest
Value

Highest
Value

.07

Actual Cost Per
Individual

$1,145.26*

$553.77

$522.87

$148.93

$148.13

$69.37

Yes - *

Average Cost Per
Individual

$

$ 76.76

$ 76.76

$ 15.63

$ 14.98

$12.75

Yes - *

3.362*

Service-Efficiency
Ratio
Performance
Score
4th value
5th value
6th value

No

1.626

1.522

.437

.435

.204

Yes - *

.887

.750

.748

.072

.039

.024

No

-203.07*

-135.01*

-71.63*
-29.42*
-28.57*
-16.29

-1.84
-2.40
-2.67
-2.75

-1.34

-.51

Yes - *

£
(r25+)

= -360, 1st value; .367, 2nd value; etc. per Table 8e, Dixon and Massey, p. 412.

137

Cost-Efficiency
Ratio

115.68*

0

138

In view of the cost data already being considered extreme for Lapeer
and Monroe counties, it is not surprising that the Performance Score
is also considered an extreme value.

The combination of effects of

high cost data (although not extreme) and low service population

(also

not extreme) results in Performance Scores for Huron, Lake and Manistee
counties which are high enough to be considered extreme, sufficiently
far enough removed from the remainder of the data.
Although these values may have been found to be extreme, they
have not been removed from the data base.

The purpose of any evalua­

tion of ongoing programs is to discern information which may be ex­
treme and warrant further study.

Discussion of factors which may have

contributed to producing these extremes will be included in Chapter VI.
Other Data
Comparisons
It is interesting to compare the Program Cost Liability on
Table 14 with the Gross Programs Costs on Table 12.

The Program Cost

Liability is the projected standardized cost of continuing in service
those clients who were not released and without adding any new clients
in the forthcoming period.

Quite reasonably, if the Ratio:

Released/

Served in Table 11 is high, then the Program Cost Liability is low in
that there are fewer clients continued over into the forthcoming year
as a liability to the program.

Since the Program Cost Liability is

standardized, those programs that have a higher Cost Efficiency Ratio
(from Table 12) will have a reduced Program Cost Liability to such an
extent that they could not continue their present service delivery
pattern if this amount were projected as the budgeted amount for serv­
ices .

139

Both the Cost Effectiveness Ratio and the Service Efficiency
Ratio are reported on Table 14.

As the Cost Efficiency Ratio is re­

duced to the lesser values, and the Service Efficiency Ratio increases
toward 1.000, the Performance Score improves

(comes closer to 0).

In

other words, a program's performance is considered improved when more
clients are being served at lesser cost.

Quality of service at lesser

cost is, of course, problematic, however, as a general principle in
public programs, the quantity/cost factor is an important one.

Pro­

gram quality will be discussed further in Chapter VI.

The Performance Score
(PS) for Sub-Programs
The total program of most community mental health services is
sub-divided into four sub-programs:
hospitalization, and residential.

outpatient, inpatient, partial
Not all the geographic areas in

Michigan have all four sub-programs in operation, however, they all
have in operation the basic outpatient services.

Through some minor

modification of the Performance Score formulation, it is possible to
individually assess each of these four sub-programs.

Since not all

four sub-programs are in operation throughout the state, only the
outpatient services will be reviewed in this study.
The modification necessary to apply the formula to outpatient
services only is in the portion dealing with the Estimated Population
in Need.

There is no clear evidence to indicate what portion of a

population in need should be served in each of these sub-programs or
in what proportions.

In the absence of such evidence

(which could be

used as standards), and assuming that each of the four types of service

140

are needed to some as yet unspecified degree, it is proposed that the
statewide percent of persons receiving service in each sub-program be
accepted as the standard.

For these purposes, counting the 121,692

persons served in 1972-73, 76,343 were served by outpatient programs,
or 62.73%.

This percentage could be applied to either the Population

Estimated to be in Need

(P ) or to the combined factor of the (P ) and
e
e

the Weighted Number of Admissions,

CP + N ).
e
w

The latter has been

chosen for purposes of this study, and the results when utilizing this
methodology on reported outpatient data and expenditures for fiscal
1972-73 is summarized in Table 16.

It should be noted that the stand­

ard (or Average) Cost per Individual Served

for Outpatient Serv­

ices is $335.96; or $23.17 per contact with an average of 14.5 contacts
per individual.
Since 62.73% of all persons served by programs are outpatient,
it was not anticipated that there would be major differences between
the overall and outpatient rankings, however, it was expected that some
shifting of ranks would occur.

For instance, Mason county ranks first

on both, Shiawassee second on both, but Van Buren has moved up to
third on the outpatient rank-order while only 7th in the overall score.
St. Joseph, although third in the overall scores, dropped to sixth on
the outpatient ranks.

At the other end of the scale, Lapeer county was

43rd on both, Huron 42 on both. Lake 41 on both, but Detroit-Wayne
dropped to fortieth on the outpatient rank-order from a position of
37th on the overall rankings.

There are, in addition, many other inter­

esting shifts, reported in Table 17.

TABLE 16.— Performance Score and Rank-Order for Outpatient Programs, 1972-73.

Geographic Area

Alger-DeltaMarquette

Number
Served
(N )
s

Number
Termin­
ated (Nr)

Cost Per
Individual
Released

Actual Cost
Per Individ­
ual (A^)

“V

Population
Estimate
(P + N x
w
e
62.73)

Cost
Eff.
Ratio

Serv.
Eff.
Ratio

Perf.
Score

RankOrder

2,108

730

$ 150.60

$ 176.02

2,361

.524

.893

- 1.67

4

Cooper Country

472

157

155.24

224.99

1,248

.670

.378

- 4.81

15

Dickinson-Iron

504

140

152.92

253.98

917

.756

.550

- 4.03

11

Menominee

263

124

157.56

380.04

565

1.131

.465

- 6.37

23

(150.60)

(211.02)

( 5,091)

( .628)

(-657)

(- 2.69)

( 2)

REGION NO. 1

{ 3,347)

( 1,191)

Northeast

983

493

145.97

316.99

2,372

.943

.414

- 5.99

22

Northern

497

164

169.14

168.98

1,904

.503

.261

- 5.40

19

North Central

364

174

162.19

345.85

1,425

1.029

.255

-10.43

36

Manistee

122

0

0

206.99

806

.616

.151

-13.71

38

(155.24)

(214.00)

( 6,507)

( .637)

(.302)

(- 5.70)

( 7)

REGION NO. 2

( 1,966)

(

831)

Kent

3,044

1,308

155.24

459.02

9,413

1.366

.323

-11.39

37

Lake

15

7

125.12

360.98

240

1.074

.063

-47.33

41

905

673

120.48

69.00

643

.205

1.407

3,205

1,233

150.60

232.04

3,581

.690

Newaygo

166

27

134.39

229.02

731

Oceana

154

72

157.56

246.00

450

Mason
Muskegon

.36

1

.895

- 2.14

7

.682

.227

- 9.44

32

.732

.342

- 5.61

20

-

TABLE 16.— Continued

Geographic Area

Number
Served
(N )
s

Ottawa
Allegan
REGION NO. 3

Number
Termin­
ated (N )
r

1,275

486

575

167

{ 9,339)

( 3,973)

Cost Per
Individual
Released
(Cr)

$

Actual Cost
Per Individ­
ual (A.)
l

Population
Estimate
(P + N x
e
w
62.73)

Cost
Eff.
Ratio

Serv.
Eff
Ratio

Perf.
Score

RankOrder

148.29

$ 304.98

3,217

.908

.396

- 6.41

24

166.82

303.01

2,048

.902

.281

- 9.23

31

(148.29)

(304.98)

(20,323)

(.908)

(.460)

(- 5.39)

( 6)

Ionia

424

229

145.97

186.99

1,535

.557

.276

- 5.19

17

Montcalm

368

103

145.97

198.00

1,086

.589

.339

- 5.13

16

332)

(145.97)

(191.98)

( 2,621)

(.571)

(.302)

(- 5.20)

( 5)

1,282

351

162.19

369.05

2,986

1.098

.429

- 7.46

26

670

312

164.50

232.03

957

.690

.700

- 2.56

9

1,368

728

164.50

191.96

1,939

.571

.706

- 2.01

5

REGION NO. 4
Bay-Arenac
Gratiot
Midland-Gladwin
REGION NO. 5
Clinton-EatonIngham
REGION NO. 6
Huron

{

792)

(

( 3,320)

( 1,391)

(164.50)

(267.95)

( 5,882)

(.798)

(.564)

(- 3.78)

( 3)

7,127

3,280

155.24

232.05

8,952

.690

.796

- 2.29

8

(155.24)

(232.05)

( 8,952)

(.690)

(.796)

(- 2.29)

( 1)

( 7,127)

( 3,280)

87

20

162.19

1,013.93

789

3.018

.110

-81.95

42

Saginaw

2,044

733

162.19

335.02

4,758

.997

.430

- 6.44

25

Sanilac

324

129

152.92

215.02

773

.640

.419

- 4.20

13

TABLE 16.— Continued.

Geographical Area

REGION NO. 7
Genesee
Lapeer
Shiawassee
REGION NO. 8

Number
Served
(N )
s

{ 2,455)

Number
Termin­
ated (N )

Cost Per
Individual
Released

Actual Cost
Per Individ­
ual (Ai)

Population
Estimate
(P + N x
e
w
62.73)

Cost
Eff.
Ratio

Serv.
Eff.
Ratio

Perf.
Score

RankOrder

$(343.98)

( 6,320)

(1.024)

(.388)

(- 7.35)

( 9)

cy
(

882)

$(159.87)

3,092

413

141.34

337.94

9,927

1.006

.311

-10.26

34

54

5

139.02

348.99

1,401

1.039

.039

-85.40

43

1,602

881

152.92

134.97

1,553

.402

1.032

(150.60)

(269.99)

(12,881)

(.804)

( 4,748)

( 1,300)

-

.98

2

(.369)

(- 6.42)

( 8)

Berrien

2,250

599

157.56

338.96

3,948

1.009

.570

- 5.21

18

Calhoun-Branch

1,557

549

150.60

302.01

5,047

.899

.309

- 8.23

29

434

30

159.87

191.02

1,055

.568

.411

- 4.49

14

4,754

1,497

162.19

243.98

6,282

.726

.757

- 2.73

10

694

359

155.24

151.03

1,221

.449

.568

- 2.02

6

1,002

387

152.92

90.02

1,697

.268

.590

- 1.26

3

(157.56)

(250.06)

(19,230)

(.744)

(.556)

(- 3.82)

( 4)

Cass
Kalamazoo
St. Joseph
Van Buren
REGION NO. 9
JacksonHillsdale
Lenawee
REGION NO. 10

(10,691)

( 3,421)

1,335

870

150.60

304.97

4,968

.908

.269

- 8.03

27

376

144

152.92

191.04

1,958

.568

.192

- 8.20

28

(150.60)

(280.02)

(.833)

(.247)

(- 8.32)

(10)

( 1,711)

( 1,014)

( 6,926)

TABLE 16.— Continued.

Number
Served
(N )
s

Geographical Area

Number
Termin­
ated (N^)

Cost Per
Individual
Released

Actual Cost
Per Individ­
ual (A^)

(Or)

Population
Estimate
(P + N x
e
w
62.73)

Cost
Eff.
Ratio

Serv.
Eff.
Ratio

Perf.
Score

RankOrdei

843

333

$ 150.60

$ 275.00

1,503

.818

.561

- 4.03

11

Monroe

663

321

164.50

457.00

3,108

1.360

.213

-16.37

39

2,431

1,100

159.87

490.07

6,452

1.458

.377

-10.20

33

3,937)

(1,754)

(159.87)

(438.05)

(11,063)

(1.304)

(.356)

(- 9.70)

(12)

Macomb

4,635

1,701

162.19

310.97

16,546

.926

.280

- 9.14

30

Oakland

6,576

2,197

152.92

285.03

28,229

.848

.233

-10.37

35

St. Clair

1,322

600

173.78

350.06

2,824

1.042

.468

- 5.72

21

(4,498)

(159.87)

(300.98)

(47,599)

( .896)

(.263)

(- 9.49)

(11)

Washtenaw
REGION NO. 11

REGION NO. 12

(

( 12,533)

Detroit-Wayne

14,377

3,943

152.92

568.01

84,301

1.690

.171

-29.06

40

REGION NO. 13

( 14,377)

(3,942)

(152.92)

(568.01)

(84,301)

(1.690)

(.171)

(-29.06)

(13)

155.24

335.96

237,696

1.000

.321

- 8.71

29.

STATE TOTAL
ALL REGIONS

76,343

27,810

144

Livingston

145

TABLE 17-— Comparison of Performance Scores and Ranks.
Geographic Area

Overall Performance:
Score
Rank

Outpatient Performance:
Score
Rank

Alger-DeltaMarquette

- 3.51

12

- 1.67

4

Cooper Country

- 6.73

21

- 4.81

15

Dickinson-Iron

- 4.93

15

- 4.03

11

Monominee

- 6.80

22

- 6. 37

23

<- 3.96)

( 2)

(- 2.69)

( 2)

Northeast

- 5.40

16

- 5.99

22

Northern

- 9.42

29

- 5.40

19

North Central

-15.44

36

-10.43

36

Manistee

-29.42

40

-13.71

38

(- 6.53)

( 8)

(- 5.70)

( 7)

Allegan

- 8.75

27

- 9.23

31

Kent

- 7.13

23

-11.39

37

Lake

-71.63

41

-47.33

41

Mason

-

.51

1

.36

1

Muskegon

- 3.40

9

- 2.14

7

Newaygo

-14.90

35

- 9.44

32

Oceana

- 8.21

25

- 5.61

20

Ottawa

- 5.83

17

- 6.41

24

(- 5.80)

( 7)

(- 5.39)

( 6)

Ionia

- 3.87

13

- 5.19

17

Montcalm

- 6.13

19

- 5.13

16

(- 4.77)

( 4)

(- 5.20)

( 5)

Bay-Arenac

-10.31

32

- 7.46

26

Gratiot

- 1.84

3

- 2.56

9

Midland-Gladwin

- 3.41

10

- 2.01

5

(- 4.50)

( 5)

(- 3.78)

( 3)

- 2.81

8

- 2.29

8

REGION NO. 1

REGION NO. 2

REGION No - 3

REGION N O . 4

REGION N O . 5
Clinton-EatonIngham

146

TABLE 17.— Continued.

Geographic Area

Overall Performance:
Score
Rank

Outpatient Performance;
Score
Rank

REGION NO. 6

{-

( 1)

(- 2.29)

( 1)

2.81)

Huron

-135.01

42

-81.95

42

Saginaw

-

3.43

11

- 6.44

25

Sanilac

-

6.51

20

- 4.20

13

(-

4.47)

< 4)

(- 7.35)

( 9)

REGION NO. 7
Genesee

- 11.15

33

-10.26

34

Lapeer

-203.07

43

-85.40

43

Shiawassee

-

1.34

2

.98

2

(-

8.25)

( 9)

(- 6.42)

( 8)

Berrien

-

4.43

14

- 5.21

18

Calhoun-Branch

-

9.66

30

- 8.23

29

Cass

-

8.73

26

- 4.49

14

Kalamazoo

-

2.67

5

- 2.73

10

St. Joseph

-

2.40

4

- 2.02

6

Van Buren

-

2.78

7

- 1.26

3

(-

3.98)

REGION NO. 8

REGION NO. 9

( 3)

(- 3.82)

( 4)

Jackson-Hillsdale

-

9.41

28

- 8.03

27

Lenawee

-

7.17

24

- 8.20

28

(-

9.11)

(10)

(- 8.32)

(10)

Livingston

-

5.93

18

- 4.03

11

Monroe

- 28.57

39

-16.37

39

Washtenaw

- 13.81

34

-10.20

33

(- 14.21)

(12)

(- 9.70)

(12)

Macomb

- 10.03

31

- 9.14

30

Oakland

- 16.29

38

-lO.37

35

St. Clair

-

6

- 5.72

21

(11)

(- 9.49)

(11)

REGION NO. 10

REGION NO. 11

REGION No. 12

2.75

(- 11.18)

147

TABLE 17.— Continued

Geographic Area

Overall Performance:
Score
Rank

Outpatient Performance:
Score
Rank

Detroit-Wayne

-15.51

37

-29.06

40

REGION NO. 13

(-15.51)

(13)

(-29.06)

(13)

STATE TOTALS
ALL REGIONS

- 8.53

25.5

29.5

- 8.71

In the above it is particularly interesting to look at dramatic
shifts such as that of St. Clair county, in 6th rank with a -2.75 score
for the overall performance but dropping to 21st with a score of -5.72
for outpatient services.

Examination of the data indicates that their

average cost per outpatient was substantially higher

($350.06) than the

average cost per individual served program-wide ($217.57).
must be receiving services in one of the other program types

Persons
(inpatient,

partial hospitalization, or residential) at a cost sufficiently low to
reduce the program-wide average to that stated.

This differential is

further illustrated by the cost—tjfficiency ratios:

.639 for the over­

all program-wide performance, but 1.042 for the outpatient performance.
In terms of population served, the service efficiency ratio is less
for the outpatient program (.468) than for the overall program (.609).
This would tend to indicate that more persons are being seen proportion­
ately in the other program types than is expected on the basis of the
state-wide averages.

As a result of these effects, the Outpatient

Performance Score is lower than the overall Performance Score.

One

would expect one of the other program types performance score to be

148

better than the overall score (and in fact such is true:

the Perform­

ance Score for inpatient services in St. Clair county is -.27 with a
rank order of 2nd.

Note:

State-wide data for the other program types

are not presented as a part of this study but are in the process of
being developed by the Department of Mental Health.)
In contrast, Livingston county scored better on Outpatient
services (-4.03, rank 11th) than for the overall Performance Score
(-5.93, rank 18th).

In examining the data from Livingston county, the

cost per individual served is very nearly the same; $273.64 in the
overall performance and $275 in the Outpatient performance.
difference was in the population served.

The major

The Service Efficiency Ratios

are .354 in the overall, and .561 in the outpatient.

It should be

noted that the number of persons served in the overall is 847 and in
outpatient 843; apparently only 4 persons were served in other than
outpatient services.

In this case the standard of 62.75% of the need

estimator has worked in favor of the Livingston outpatient program but
/

illustrates the desirability of a well-rounded program utilizing all
program types if the overall program-wide Performance Score is to
achieve at a higher level.
Summary of Data
and Results
Data have been presented in regard to both the service popula­
tion and the costs for each of the community mental health programs in
Michigan.

The data have then been subjected to the methodology pre­

sented in Chapter IV resulting in a Performance Score
program.

(PS) for each

The Tables presented in the text provide illustration of the

actual data but also the procedure for using the methodology.

The

149

Performance Scores are then rank-ordered to discern those programs
which are achieving at a higher level than others based on the method­
ology as presented.

Further, sub-sets of the data by type of program

may be utilized for out-patient services to the exclusion of the other
program types has been demonstrated.

The results of the Out-patient

Performance Scores are then compared with the overall Performance
Scores to examine factors that may be contributing to shifts in ranks.
The methodology, therefore, provides a vehicle with which one can
look at programs across the state in some standardized and sizeequated manner to make judgments about the rankings of programs in
relation to the Department of Mental Health, and, for that matter, the
nation-wide goals for community mental health.

CHAPTER VI

IMPLICATIONS OF PERFORMANCES EVALUATION FOR
PROGRAM ADMINISTRATION

A major paradox of the twentieth century is this: while
organizations are becoming every more important as a way
of meeting human needs, they are also becoming less
manageable.1
To examine the implications of the performance evaluation
methodology presented is, in itself, a major undertaking and could,
no doubt, be the subject of a series of studies in their own right.
An attempt will be made to highlight the major issues centering around
the methodology previously presented, the areas of concern not yet ade­
quately covered by the methodology and some recommendations, both as
to further refinement of the formulations and to its uses and imple­
mentation in the state program.
In recalling the original motivation for the development of the
performance evaluation methodology, the legislator, the citizen advo­
cate, the client, and the mental health staff themselves, all seem to
be asking "Is the program any good?", "How do you know if it's any good
or not?", "What are we getting for all the money?", and other closely
related questions.

The degree to which the methodology presented here

answers those questions is probably debatable but at least there are

^Bertram M. Gross, Organizationa And Their Managing (New York:
The Free Press, 1964), p. vii.
150

151

some answers suggested, although they may still have to be hedged in the
terms of our present knowledge which is admittedly meager but growing.
We can now, for instance, say "yes, that program looks like it is doing
a good job (in relation to our goals, the other programs, and on the
basis of this methodology)"; or we can say "This program looks good/
not-so-good because the cost per contact and number of persons served
is good/not-so-good (in relation to the other programs)"; and we can
quite clearly say, "All that money goes to provide "X" kinds of serv­
ices to "X" number of persons at "X" cost each, with "X" results."
Even the latter kind of statement is a vast improvement over the pre­
vious kind of justification which usually came out something like "All
that money goes to buy the kind of program that, in our professionsl
judgment, is the kind of program the people need."

There are, however,

a great many problems still unresolved and our answers to such decep­
tively simple questions are tentative at best.

It is in the interest

of those still unresolved problems that this last chapter is addressed.
To merely cite problems, however, is counter-productive; attempts will
be made, therefore, to offer suggestions or at least approaches
toward their resolution.
The Data Problem
The data problem is really a two-fold dilemma; a problem first
of getting accurate reporting and second of processing and retrieving
the information.

Careful examination of the reporting of at least two

of the programs considered in Chapter V, clearly demonstrates a

152

reporting problem.

Both Huron and Monroe county have had community

mental health programs prior to the 1972-73 reporting period.
county reported 663 clients served in 1972-73
statistical data from fiscal 1971-72

2

Monroe

(Table 9) but previous

indicates that they served 1,127

(or almost double that reported in 72-3) and reported 12,114 client
contacts (as contrasted 3,180) or an average of 10.7 contacts per
client (contrasted with 4.8), and with the same number of professionals
on the staff.

The resultant costs, instead of an average of $21 per

contact in 1971-72, are now over $115 per contact (over 5 times more
costly) .

One of two possible conclusions are suggested;

(1) the

Monroe county staff put in as many hours of employment but accomplished
far less in reportable services, or (2) the Monroe county failed to
report a large portion of their reportable services so that the yearend print-outs of their data do not accurately reflect their true
work-load of delivered services.

The latter has been determined to

be true by Department of Mantal Health staff and corrective action
has been initiated to assure
1973-74.

correct

data reporting in fiscal year

The situation in Huron county is very similar, with vast

amounts of work effort never being reported on the Community Mental
Health

Services

Data System, resulting in a serious deficit in the

data being used to calculate their Performance Score

(PS).

As the results of the Performance Score, and other Department
of Mental Health data analyses, become available it would seem that the
staffs of these and other programs would recognize the necessity of
accurate data reporting and make efforts to comply with the Department
2

Michigan Department of Mental Health, "Statitical Report,
Part 2, Community Services, Final Year End, June 30, 1972," Systems
and Data Processing Division, July 31, 1972.

153

of Mental Health requirements.

It is for this reason that the Huron

and Monroe county data, even though known to be inaccurate, were not
deleted from the data base and the methodology was applied.

To draw

an analogy with the old farmer who hit his mule between the eyes with
a board before saying "Gidde-up," and explained, "You have to get their
attention first:"

If nothing else, their extremely poor Performance

Scores should get their attention.
The data from three other programs produced Performance Scores
which were considered to be extreme
Lake and Manistee counties.

(as reported in Table 15), Lapeer,

Each of these three programs were completely

new in fiscal year 1972-73 with the problems of beginning services, re­
cruiting staff, finding office space, and making known the availability
of their services.
full fiscal year.

As a result they were unable to operate for the
It would have been preferable to have pro-rated

their services over the full year as an estimate rather than to have
used :he part-year data as if it were full-year; insufficient informa­
tion was available to accurately project a full-year estimate.

Their

poor Performance Scores must be considered in light of this knowledge,
and any decisions or corrective actions contemplated by either the
program staff or the Department of Mental Health on the basis of this
performance evaluation would be best deferred until the methodology can
be repeated

for a later time period

(fiscal 1973—74, or at least the

six month period of July - December 1973, which data are now available).
It would seem important, as other new programs develop, that adequate
information be collected as the program phases in so as to accurately
project their data to full-year.

154

The other dimension of the data problem, once the reporting
has achieved an acceptable level, has to do with the processing and re­
trieving of the reported data.

Although the new data system of the

Department of Mental Health has accumulated millions of entries in
over 18 months of operations there is still a paucity of statistical
reports available of the virtual myriad possible.

It would seem that

equally important in a balanced data system would be accuracy and
promptness of reporting in both directions —

data coming in from the

agencies and statistical reports flowing back.

Discussions of the

factors included in the performance evaluation methodology between the
Department staff and the program staff should do much to highlight
and resolve this problem.
One particularly pessimistic administrator has even reported
that, "A great part of the information obtained.

. -is contradictory,

a still greater part is false and by far the greatest part if doubtful,
. . . (it is) fortunate if these reports in contradicting each other
produce a sort of balance and themselves arouse criticism."

3

. .
Utiliza­

tion of methodologies such as that proposed along with other reporting
feed-back mechanisms should go a long way toward stemming such utter
pessimism as that expressed above.
The Quality-Quantity
Problem
Age-old, this problem rears its emotionally-laden head in al­
most any data-based evaluation effort.

Even the ancient Roman phil­

osopher Seneca declared that "it is quality rather than quantity that
3
M. J. Moroney, Fact From Figures
1956), p. 3.

(London:

Penguin Publishers,

155

matters."

The other extreme was expressed by Lord Kelvin, early twen­

tieth-century British physicist; "when you cannot express it in numbers,
your knowledge is of a meagre and unsatisfactory kind.”

Summing up

this historical controversy, Loontief points out that "the dialectical
juxtaposition of quality and quantity, of uniqueness and repetition,
of abstract theory and concrete description, has from far back been the
'leitmotif of the running methodological controversy in social
„4
science.
No attempt will be made here to resolve this controversy.
to have ignored its existence would have been folly.

But,

This study, this

methodology, as has been the case with so many others, will be subject
to criticism for its failure to relate to the quality of client serv­
ices rather than the quantity of client services.

Responses which re­

late to a cost factor and an outcome factor will do little to appease
the insistant detractor.

It is, therefore, deemed far better to admit

the fault and suggest avenues for further study with, hopefully, re­
vision of the methodology to follow.
Services, in contrast to goods, once produced, immediately
vanish.

They are more "ephemeral than the shortlived butterfly."

5

A

service, even though it may be given over a long period of time, ceases
to exist the minute it is over, except as it is recorded or in terms
of an impact it has made.

To assess quality of service then, rather

than quantity or time, requires far more complex mechanism at two
4
Wassily Leontief, "The Problem of Quantity and Quality Econ­
omics," ed., Danial Lerner, Quality and Quantity {New York:
The Free
Press, 1961), p. 117.
5
Gross, op. cit., p. 392.

156

possible junctures.

Fortunately, it is felt, both can be measured

and instrumentation is in pilot process to attempt both.
A community mental health program in Hennepin county, Minnesota,
(Minneapolis) , began work in 1968 on a particular assessment methodology
called "Goal Attainment Scaling,"

g

an intricate arrangement whereby

different clinicians with the client, set goals for treatment and then
assess the degree to which these goals are attained.

In a pilot project,

currently funded by a grant from the Michigan Department of Mental
Health, drawing from this previous body of knowledge, the Shiawassee
county community mental health staff are attempting to standardize the
multi-dimensional goal-setting process, quantify the results and com­
puterize the processing of data.^

Should their efforts prove success­

ful, the next logical step would be to introduce into the Performance
Score methodology either a new variable within the population served
portion of the formulation, or preferably a weighting of those served
by the degree to which the goals established were being attained,
assessed at periodic intervals.

This would introduce a spark of qual­

ity - assessment of services which could dramatically influence the
population served and cost-efficiency (numerator) of the formula,
thereby influencing the quantity assessment with a quality factor.
Should the efforts of Shiawassee county prove to no avail, the Depart­
ment should continue its effort toward the development of such an
6
Center:

Z. Stelmachers, e t . a l ., "Hennepin County Crisis Intervention
Evaluation of Its Effectiveness," Evaluation, Fall, 1972.

^Shiawassee County, Community Mental Health Services Board,
Model For Evaluating Community Mental Health Services, Department of
Mental Health Project Grant No. 6-74 (March 21, 1973).

157

assessment technique to assess quality of professional services over
some measurable indices.
The Performance Score formulation already contains the beginning
of an index on which to assess outcomes of services but unfortunately
the data systems design prevents full utilization of the data to ac­
complish this end.

As was earlier discussed (in Chapter V ) , the condi­

tion on termination is currently reported when services are terminated
for every client.

The seven possible conditions:

further treatment not recommended,
ment,

(5) referred elsewhere,

(1) improved,

(3) self-terminated,

(2)

(4) no improve­

(6) recovered, and (7) other, are over­

lapping and not mutually exclusive.

It is quite reasonably possible

for a client to have terminated with "further treatment not recommended"
because he has "improved" or "recovered," and these two conditions alone
seem to be a redundancy.

It is even possible for services to have been

terminated with "further treatment not recommended" within the agency,
because "no improvement" has been seen and the client is, therefore,
"referred elsewhere.”

A revision of this portion of the termination

report should be made, with care given to make certain that categories
are exclusive and not overlapping.

When such is done weighting along

a quality-of-outcome criteria can be made of the number of persons re­
leased.

This factor would also influence the number served— cost ef­

ficiency ratio, thereby effecting the total performance score.
The Consultation—
Preventative Services
Problem
That the methodology described in Chapter IV and reported in
Chapter V fails to take into account extensive consultative and

158

preventative services offered by various community mental health pro­
grams will be a cogent argument for those wishing to employ i t .
the earlier discussion of consultation

In

(in Chapter III), the scarcity

of substantive research in this program area was reported.

Even more

disheartening than its scarcity is the apparent waning of interest into
research in this area as evidenced by the lesser frequency with which
this research appears in the current literature
mid-1960's).

(in contrast to the

A renewed interest is desparately needed particularly to

study the effects

(or lack thereof) of mental health consultation on

the human services system.
Mental health professionals reported upwards of 25% of their
time as being spent in activities related to consultation with other
agencies and educational programs and other community contacts concern­
ing "mental health"

(emphasis on the "health"), with none of these con­

tacts in relation to a specific, identifiable client.

Philosophically,

this time commitment, probably accounting for millions of dollars, in
cost, is not in question.

The question is, how long can a program com­

mitment of this magnitude be justified on purely a philosophical basis
rather than a performance-output basis?

Not one viable methodology

for the assessment of impact from consultative or preventative pro­
grams has been noted, and, dismally, one does not even seem emergent
on the horizon.
It would seem that the air has become too cluttered with no­
tions and commentaries about consultation and prevention and little
has been done to define either the goals, in precise measurable terms,
or the procedures, in clear-cut step intervals.

Again, with some

159

appreciation for the problem the Michigan Department of Mental Health
has proposed and is in the process of conducting a far-reaching study
of current mental health delivery practices to result in a "Standards
Manual" for all community mental health programs included consultation
g

and prevention.

It would be hoped that the Advisory Committees and

staff of this project would sufficiently address themselves to the
definition problem so as to stimulate some research which might result
in a methodology to assess these seemingly important but non-measurable
program elements.

Until such time we must accept, but not be content

with, the knowledge that such services do exist but with an impact that
is generally only reported in the subjective.
Notable exceptions are evident such as the Pre-School Program
for Detecting Learning and/or Emotional Difficulties as implemented in
Mason county.

9

This program includes as assessment and follow-up of

every child entering school, in Mason county.

The objective of this

program is to detect potential and existing problems before they be­
come critical and plan a strategy with the school and parents to
remediate so as to prevent a future referral to the clinic staff for
treatment of a full-blown mental health problem.

The follow-up over a

period of years will hopefully demonstrate a reduction in incidence
of mental health symptomatology in the population served.

Such is a

laudable goal, but is hardly a sufficient methodology to assess the
8 . , .

Michigan Department of Mental Health, Standards for Community
Mental Health. Project Grant No. 6-74 (Aguust 16, 1973).
9 .
Michigan Department of Mental Health, Development of PreSchool Program for Detecting Learning and/or Emotional Difficulties,
Replication Series No. 1, Lansing, Michigan, December, 1972.

160

impact for there is no way to control for extraneous variables; movement
in and out of the county by both families and teachers, events subse­
quent to the screening not noted or recorded, other treatment or remedia­
tion events, etc.

It does, however, suggest an avenue which might be

traveled toward some assessment methodology.

If the consultations or

preventative efforts in any one given geographic area can be suffi­
ciently narrowed to one goal-directed activity for a period of time,
and data collected related to this specific goal, it seems possible
that a measure of impact could be developed.

As an example, a population

that repeatedly appears in sizeable proportions are children who are
experiencing the crisis of parental separation and divorce.

A wide-

sweeping consultative-preventative program that would work with lawyers,
courts, and educators who might first come in contact with any member
of such a family, giving attention to ways of meeting the needs of
children in such crisis, might be expected to result in some inpact
on the number of clinic referrals for such children.

Even this more

narrowly conceived population may be too complex for adequate impact
assessment, but, somewhere hopefully the research will begin and a
methodology for assessment of consultation and prevention developed.
Other Problems for
Consideration
At the risk of thoroughly and completely negating any positive
results that might be achieved by implementing and utilizing the per­
formance assessment methodology set forth in this thesis, there still
remain a number of problems which should have at least fleeting refer­
ence, and, even so, the following list is not exhaustive:

161

Recidivism Rates.— The present methodology makes no distinction
between a first admission and subsequent readmissions to state institu­
tions-

Consideration might be given to differential weights for these

admissions Client Satisfaction.— Most service deliverers fail to ask the
most important source, the client, about the success of program or the
quality of services.

A client reporting mechanism might be developed

which would also have the possibility of providing weights to those
served or released.
Administrative Costs.— These costs are excluding in the present
methodology for purely convenience reasons.

Using generally accepted

accounting principles, a step-down method of assignment of administra­
tive cost could be u s e d / ^

Such an accounting process is in imple­

mentation stages for the community programs and future applications of
this methodology will benefit from this more precise cost data.

Differential Goals for Mentally Retarded Clients.— The pertormance assessment methodology and, in fact, the orientation of this
and most other evaluation methodologies is directed toward the mentally
ill or emotionally disturbed.

The notions of treatment success, move­

ment through the program, releases rates is far more related to psychi­
atric clientele than mentally retarded.
factors are irrelevant,

This is not to say that these

just that they are probably not as relevant as

some others, like adjustment to handicap, achievement to maximum
10

J. Sorensen and D. Phipps, Cost-Finding and Rate-Setting for
Community Mental Health Centers (Lansing, Michigan: Association of
Mental Health Administrators, 1972) , p. 38.

162

capacity and many others.

It may be necessary to develop a completely

separate and different assessment methodology for mentally retarded
but at least for the present they are included in the overall program
evaluation.

The service and cost data does permit a separation and it

might prove fruitful to separately consider these distinctly different
populations in future applications.

Administrative Considera­
tions in the Use of the
Performance Score
The major problem, other than internal or methodological prob­
lems, that any program evaluation effort must face is its acceptance
and utilization by the program administration itself.

This is particu­

larly true of an operational evlauation such as the one described in
this study.

"Operational programs are often highly entrenched activi­

ties based upon a large collection of inadequately tested assumptions
and defended by staff and field personnel with strong vested interests
in the continuation of the program as it is."^"^

Nowhere could this

be more true than in the field of community mental health— our assump­
tions are largely untested and there is decidedly a highly entrenched
set of activities defended by a sizeable group of professionals with
a vested interest in maintaining their jobs.

A program evaluation that

runs the possibility of saying that they are doing a bad job, or that
they are missing the objective, or even that they need to change their
delivery pattern is not always welcome.
It is, however, inevitable.
will not go unheeded.

The demand for such evaluation

Studies such as this, and probably many more to

■^Edward A. Suchman, Evaluative Research (New York:
Sage Foundation, 1967), p. 142.

The Russell

163

come, are beginning to be noticed in the literature as evidenced by a
whole new journal entitled Evaluation whose inaugural issue is as late
as Fall, 1972.

It would seem, therefore, that the program administra­

tor should accustom himself to the certainty of program evaluation and
make the best of what is to come.
Prior to citing the ways a study such as this might be used by
the administrator for positive development of his program, it seems
relevant to review the usual forms of evaluation abuse, candidly des­
cribed by Suchman:
"Eye-wash"— or picking out just a peice of the program which
appears to be successful and neglecting the weak parts.

St. Clair

county for instance might herald its inpatient program as the "best
in the State," but fail to mention that its outpatient program ranked
2 1 st .

"White-wash"— a diversion tactic in which praise is heeped on
a program by another group in an effort to counteract the outcome of
an evaluation effort.

Provincial pride is often at stake when county

programs are compared and local politicians or prominent citizens
sometimes offer glowing "testimonials" for questionable program ef­
forts .
"Submarine"— an attempt to "torpedo" a program, no matter
what good it might be producing by citing only its weak points.

New

programs, such as those in Lake, Lapeer or Manistee counties, whose
performance scores were extreme (but who were unfairly penalized by
the inability of the assessment methodology to pro-rate their data),
might be unfairly maligned by local persons who had opposed the develop­
ment of the program in the first place.

164

"Grandizement"— over-emphasis of the "scientific" or "profes­
sional" nature of the evaluation to impress the public but neglect the
recommendations that might have come forth from the evaluation.
"Fact-finding"— waiting for the "storm to blow over" so the
report can be forgotten while hiding under the shelter of committees
and sub-studies to look into the recommendations.

12

Although these are described as "abuses," a little of each is
good; administrators should discern where their bright spots are, they
should develop local pride in their efforts where warranted, they
should expect criticism when results are disappointing, they should be
"scientific" and "professional," and they should study the recommenda­
tions.

But the point is, they should do all of these things, not one

to the neglect of the others.
There are, of course, some fairly specific uses of this perform­
ance measure at different levels of program administration:
1.

The program staff, in

reviewing

the evaluation and com­

parison with other programs, have the opportunity of broadening their
professional expertise by some in-depth study of those programs that
seemed to produce better results.
process and an across-program

Professional growth is an ongoing

evaluation,

such as this, can assist a

professional staff in seeking out programs worthy of further study.
2.

The program administrator, or director, can probably put

an evaluation effort such as this to its best use.

Charged with the

responsibility of achieving a program of the most public good at a
12„
Suchman, op. c i t ., p. 143.

165

price the public can afford, a program administrator can ferret out
those parts of his program which are either non-productive or toocostly and initiate steps to bring about change.

He can lead his staff

in their study of other program techniques and in innovating new pro­
grams to improve performance.

He must also be sensitive to the possi­

bility that long-espoused ideas or programs might have to be altered,
reduced, or even abandoned.

His attitude about the performance evalua­

tion and the resulting recommendations will set the climate for that
of his staff.

The utilization of this kind of evaluation report can

have its biggest impact at this level.
3.
public employer.

The community mental health board is the policy-setter and
Properly utilized, the performance evaluation scor­

ing and ranking can help them to assess if they have established a
reasonable direction for their program through their policies, and if
their staff (mainly, their director) are implementing and directing
their policies to a satisfactory degree.

It is known, for instance,

that the policy of Monroe County Community Mental Health Board has
been and continues to be full compliance with the data reporting re­
quirements of Michigan Department of Mental Health.

The failure of

the previous program director to comply with this (among other)
policy ultimately lead to his replacement.

13

Board

Although one of the

dangers of such a report is the possible over-reaction of such a board,
it nevertheless is sometimes the first objective evidence of poor
^Personal interview with Rev. Douglas Lowery, Chairman,
Monroe County Community Mental Health Services Board, November, 1972.

166

administration.
kid gloves.

"Any such rating system, however, must be handled with

. -the magic number resulting from precise quantification

will mislead many people into seeing in such rating systems a signifi­
cance far greater than would be attributed to them even by their
proud inventors.
4.

The Department of Mental Health, particularly the regional

executives, are charged with providing consultation on the development
and administration of local programs, review and approval of budget,
and recommendations about budget improvements or decreases.

It would

be virtually impossible for these regional administrators to know the
inner-most intricacies of the many programs under their purview. Through
utilization of the Performance Score and its ultimate rank-order, the
regional administrator can assist a faltering program to get back in
stream and help keep a good one from falling aside.

He is particularly

helpful when cross-fertilizing programs by bringing in ideas that have
worked elsewhere and that might help in a different setting.

His other

major function, that of budget influences, can be significantly aided
by knowledge that, in one instance, the outpatient program of a specific
area exhibits an excessive cost per contact and a limited number of
client contacts, but is requesting expansion of outpatient staff in
their forthcoming budget request.

Misdirected programs, consultative

programs with no treatment capacity and vice-versa, outpatient pro­
grams with no inpatient capacity and high state hospital admissions,
and so on, can be redirected when objective evidence is made available
14 _
Gross, op. c i t . , p. 385.

167

to assist those responsible for direction.

Such a process is well

within the public charge of the administrators of the Department of
Mental Health.
5.

The legislators and county commissioners, who appropriate

the funds for support of these public programs, can best utilize a
program evaluation to make certain that their public policies and
legislative intent is carried out.

They must, however, resist the

temptation to become the program administrators.

By weilding the

mighty power of the purse, they can, with the stroke of a pen, cripple
or abolish a program; they must be particularly sensitive to possible
premature judgments.

But, when presented with repeated evidence of

program failure and the lack of sure administration and public support,
they must boldly protect their public charge and reduce or eliminate
funding.

Too often, the pressures on them are in only this direction,

to cut funding.

It would be hoped that a performance evaluation effort

such as this, sustained over a period of time, would also convince them
of responsible leadership, productivity of staff, positive direction
toward realistic goals, and provide them with encouragement to expand
deserving programs by their legislative support.
6

.

The public, the citizen on the street, is, after all, the

'raison d'etre'; he has the right to know that the services available
to him meet some acceptable standard of performance.

Although he will

probably never see an evaluation report of the agency that serves him,
he must be afforded the opportunity to review such a document should
he, his consumer advocate, elected representative, or legal counsel
choose to do so.

This aspect is probably the most frightening to the

168

unenlightened professional person, that his client might become aware
of his own or his agency's inadequacies.

But such is the stimulus for

professional growth in the 'true professional' and no better purpose
can be deemed possible for an evaluation effort like this.

Summary and
Recommendations
This study has traced the development of community mental health
from a history of mistreatment and misguidance into a period of human­
istic and perhaps even altruistic programming.
ment has come the cry for program evaluation.

Along with such develop­
Although segments of

programs, certain techniques, and demographic studies have been in the
literature for years, organized, comprehensive evaluative efforts have
only begun to surface.

This study is an effort in that direction.

Through a fairly complex formulation, a methodology has been
devised which will produce a goal-weighted Performance Score allowing
for both a rank-ordering of programs to discern those of greater merit
but also allowing for an inside assessment of portions of programs,
critical variables, and program expectations.

The methodology makes

use of various kinds of common data and adds dimensions from data
newly available only with new collection and processing armamentarium.
By arranging such a collage of information in a methodical, goaloriented procedure, a Performance Score can be assigned in relation to
peer programs at the local, state, or even national level.
The community mental health programs in Michigan, in varied
states of development, have been subjected to this methodology and
emerged in an almost anticipated spectrum from excellence to neglect.

169

The intent has been to assist in the ever-difficult upward struggle
toward excellence knowing that to achieve such shall not often happen.
But it does appear that some programs have such merit that further
study is warranted.

It is the sincere hope that this effort will be a

constructive step in the development of community mental health pro­
grams of which we can all be proud and which the public richly de­
serves .
The recommendations, therefore, are quite simple:
1.

Further study should be initiated to resolve those problems

of data collection and methodology and the formulation presented here
should continue to be refined as knowledges increase.
2.

Efforts to develop assessment techniques of consultation

and prevention programs deserves special emphasis by the Department of
Mental Health and stimulation,

funding and support of programs of this

nature should receive priority.
3.

The current methodology should be fully implemented, com­

puterized and produced by the Department of Mental Health on at least
an annual basis but probably more effectively on a semi-annual basis.
The advantage of this would be to provide programs an opportunity of
correcting their data if such were found to be a problem on the six
month period report.

The annual report would then have increased

validity and usefulness.
4.

A course of orientation to the Performance Score, its

development, methodology and implications should be developed by De­
partment of Mental Health staff to provide a wide discussion base and

170

clear understanding of the performance assessment methodology to the
field staff and program staff of the various programs.
5.

A rigidification of the current methodology would serve as

a deterrent to its on-going usefulness. To guard against such, the
Department of Mental Health should make use of an advisory committee,
made up of Department staff members,

local program directors and board

members and other selected knowledgeable individuals who would provide
recommendations regarding change of the scale when appropriate and re­
ject changes deemed inappropriate.
6

.

Caution must be exercised in over complicating the currently

reasonably unencumbered methodology.

As more and more becomes known

about specific program types it might be in the best interest of the
programs to separate out various types and have special and different
criteria for each case.

Such has already been suggested for the

special programming for the mentally retarded.

It may prove to be nec­

essary for special handling of consultative and preventative programs
rather than the incorporation of such data as new items or weights on
existing items.
7.

As reports are prepared from the basic data and the result­

ing Performance Score and ranking, individualized area reports should
be prepared detailing both the important ramifications of the evalua­
tion for the specific programs involved but also detailing, where
possible, the Department recommendations for improvement or resolution
of noted problems.

Such narrative must be prepared as a joint effort

between the data analysis staff (in view of the extensive knowledge

171

of the data) and the regional programs staff (in view of their knowledge
of the specific programs).
8

.

Upon receipt of such reports, the program director and his

Board should be charged with the responsibility of studying the report
and recommendations, and within proper time, responding to the recommen­
dations formally with the indications of corrective steps taken where
appropriate.
9.

When so indicated, programs repeatedly demonstrating poor

performance should be closed, and clients referred to agencies demon­
strating higher levels of performance.

Such drastic action should be

taken only after concerted study, possible administrative re-direction,
and extensive staff counseling.

Should these fail, the public charge

of the officials responsible will have been violated if they fail to
take action.
10.

Willingness to completely discard this methodology when

better techniques are developed is tantamount to the evaluative process
itself.

The techniques and assumptions in this study should be sub­

jected to the same scrutiny than any endeavor utilizing public funds
might experience.

As other methodologies develop, simultaneous evalua­

tions might take place and a comparison of results made.
is the essence of professional growth.

This, too,

APPENDIX
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Region in Michigan

172

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BIBLIOGRAPHY

174

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in p a r t i a l f u l f i l l m e n t of t he r e q u i r e m e n t s
for the d e g r e e of
DOC T O R OF PHILOSOPHY
Department

of F o r e s t r y

1974

ABSTRACT

MAPLE

SAP P R O D U C T I O N

ECONOMICS

IN M I C H I G A N

By
John

Five
were

aspects

stu died:

(1)

syrup producers,

(buckets
t he

of

industry

in M i c h i g a n

of M i c h i g a n ' s m a p l e

the r e l a t i v e c o s t a d v a n t a g e s

two b a s i c t y p e s

a mo u nt ,

cost,

for v a r i o u s

labor,

input

of the m a p l e s y r u p

and p r o ­

of sap c o l l e c t i o n

system

and v a c u u m p u m p e d p l a s t i c t u b i n g n e t w o r k s ) ,

type,

quired

Gunter

the c h a r a c t e r i s t i c s

(2)

f i t a b i l i t y of the

E.

time

s i z e s of o p e r a t i o n s ,

and d u r a t i o n

fo r s p e c i f i c

operations,

and

an d u t i l i z a t i o n o f e q u i p m e n t

tasks

(5)

of p e a k

involved

(4)

the

the s i z e o f o p e r a t i o n

re­

utilization

labor periods,

in m a p l e

(3)

and

labor

sa p c o l l e c t i o n
that

is m o s t

profitable.
Data were
1972

to all m a p l e

g a t h e r e d by m a i l i n g
syrup produ c e r s

fo r w h i c h a m a i l i n g
selectively
taphole

address

s ap p r o d u c t i o n

to k e e p t i m e
operations

over

and cost

f or

the

in

in t h e S t a t e o f M i c h i g a n

c o u l d be o b t a i n e d ,

recruiting cooperators

range,

a questionnaire

the

500 t o

records

1972 a n d

a n d by
3 , 00 0 -

fo r t h e i r m a p l e

197 3 s e a s o n s .

Analytical
linear-

techniques

ana lysis ,

corre lation

analysis

employed

covairiance ,

of

m

break —■

a
.
nst Xy sis.
The
(56

s
u
.
r
r
v
o
^

percent ) of

some

kind

of

of

sl

n

X9 72 .
same

A

we r
r
e

had

Xocration.
Ten

primar i Xy
syrup

retired,
age .

those

and

between

heli eved

its

tuh in g

V
7
hi Xe

part

of

(5X

to

X9 72
a

ti
r
o

ha<

t
i
l

Xar-gei
]

increc

and

X9 71

before

(4f

X9 '

outweic

p roduce rs

rep

buckets _

m os t

sy rup

pe rcen t )

thei r

<

Xei

of

minority

tubing

and Xes s

ma jo rity

the

advantage s

one— f
o
u
.
r
r
t
.
X
i of

of

percent

p Xanned

p 1as t ic

a

ma jor:

producersin

who

T
VIthough

n um]

years -

with

producers

tried

The

23

~7

from other

syrup

ende.

produce a
r

for-

and

m
,

and

operations

The aver-age

in

Michigan

sign ifican t

advanced

producers

the

agrxcu Itu
.
i
ta1

occupation .
producers

fi
rx
c
f
i
i
n
g
s

syrup

on

of

is

so 3.

Mi oh i<
g

the

who1