National Mental Health Advisory Council A Retrospective Assessment by Eli Ginzberg A. Barton Hepburn Professor of Economics, and Director, Conservation of Human Resources, Columbia University National Mental Health Advis•ory Council A Retrospective Assessment Seventeen years after I was first appointed to serve a four­ year term on the Council (1959-63) I have been asked to reflect on my experiences in order to assist a former staff member of the National Institute of Mental Health (NIMH) who is currently engaged in writing a history of that era. The following is a response to that request though I have not sought to refresh my memory, check facts, or otherwise clarify my views by referring to my files. r What follows is an·impressio1s~c, not scholarly account. It is more evaluative than analytical. To complicate matters, I find it difficult to distinguish sharply between my views at the time and my views today. I have changed in the interim and these changes cannot be neutrnlized in presenting my views as of 1976. However, I am able to set out a limited number o~ points that I have made repeatedly orally and in writing about my experiences on the Council that have been largely uncontaminated by the developments of the intervening years. I will subsume these under the heading of contemporary views; set them off from my retrospective views; and deal separately with my assessments in perspective. Contemporary Views In the four years of my service, the budget of the NIMH increased more than threefold from around $50 million to $180 million annually. I kept insisting at the time that there was a serious danger in such a rapid rate of increase. -2- Friendly appropriations committees could approve budgets at the $50 million level without careful scrutiny but once a budget reached a multi-hundred million dollar level it could no longer escape critical review. I suggested that we would be on safer ground for the long pull if we were sure that we were making ef­ fective use of our increasing revenues and could demonstrate such accomplishment when the issue was raised. There was no under­ standing or support for the position, not from the NIMH staff nor from the other Council members, all of whom were strong believers in the doctrine that more was better. I was appalled about how little understanding they had of legislative dynamics. I was talking primarily to myself. -----The Council met usually three or four times a year. My recollection is that the research funds available for external support amounted in 1959 to about $10 million, and in 1963 to $50 million annually. This meant we approved between $3 and $13 million of grants and contracts at each meeting. After each meeting I returned to New York deeply unsettled, if not depressed, by having agreed to spend so much of the taxpayers' money on research much of which appeared.to me to be trivial with little or no prospect of contributing either important knowledge, much less new therapeutic leads for the treatment of the mentally ill. Did I vote against most of the proposals? The answer is no. The money was there to be allocated. The Council tried to pick the most promising projects from among those submitted. I do not recall anybody ever suggesting that we return unspent funds to the U.S. -3- Treasury. At one point the President's budgetary advisors insisted that we do not fund projects that failed to receive a respectable score from the reviewers--a type of quality control aimed at saving dollars. My recollection is that the scoring system accommo­ dated to the new rules and that all available funds were allocated. -----The upbeat that characterized the mood of the NIMH staff and the Council reflected the belief that at long last mental illness was yielding to therapeutic intervention. The evidence repeatedly cited to support the growing optimism was the reversal of the trend in patient census in mental hospitals. After a steady if not steep rise, the figures were beginning to drop and promised to drop further. Credit was given in the first instance to the new drugs. I kept asking whether the figures were to be taken at face value. Could the drop in the mental hospital census be accounted for by the increased use of general hospitals and nursing homes? What import was to be given to the fact that admission rates remained high? What were the individual and social costs of possibly premature release? Despite the fact that the NIMH had a talented bio-statistician on its staff, Dr. Morton Kramer, the sorry state of the operating data never enabled him to provide the Council with responsive answers. There was no basis for challenging the growing optimism, at least not with statistics. ------An interesting game that was played during the ·Eisenhower years with considerable success not only by NIMH but by the National Institutes of Health was the success that the several institute -4- directors had in end--running the Secretary ~f HEW, the Bureau of the Budget, and the President in the budgetary appropriations process. Through close ties with the powerful chairmen of the Hbuse and Senate substantive and appropriations committees and through alliances with the principal public interest· groups, academic and philanthropic, the budgetary ceilings recommended by the White House were constantly disregarded by the Congress that appropriated more money on the informal recommendations of the health bureau­ crats. It was a tricky game that was being played but the NIH senior staff played it well. -----The election of President Kennedy was viewed as a great boon to the advocates of an expansionary mental health policy especially after the decision was made in the White House to support legislation for community mental health centers and new institutions for the mentally retarded. Dr. Robert Felix, the dominant and enthusiastic head of NIMH kept the Council completely in the dark about these new programs until they had gained Presidential approval at which point the members had no option but to go along. I would be the first to admit that had he asked our advice we would most probably have supported the new departures even though some of us were restive about the value to attach to the ~ritish experiments, the uncertainties governing long-term financing of the new centers, and their ability to attract and hold competent psychiatric staff. But it appeared to me strange at the time--and strange today-~that the federal government would not even consider it necessary to ask its own -5- advisors about such a major new initiative. This episode helps explain why so many critics believe that all advisory groups are rubber stamps, little more. What these "contemporary views" emphasize is that NIMH, in the early 1960s, was the beneficiary of strong Congressional sup­ port, reflected in large increments in annual appropriations; that the Council members never asked hard questions about the allocation of the increasing funds; that an uncritical optimism about advances in psychiatry dominated the atmosphere; and that the Director of NIMH knew what he wanted and got what he wanted with little or no interference from the Council. Retrospective Views Now that my memory has been jogged I am reminded of many other aspects of my service on the Council the more important of which I will comment on briefly. -----For the most part, the quality of Council membership was high. Most of the professionals from the field of psychiatry, the other health professions, and the social sciences were strong individuals. Considering the amount of time that they devoted to meetings and preparation for meetings--not to mention additional assigments on sub-committees--the NIMH got very little return in terms of new ideas at any level--administrative, research, program. But it is necessary to emphasize once again that the Director while taking pride in ~aving a strong Council made sure that it did not upset his operations. -6- Aware of the implications of the members' inputs into policy and program, I led a revolt to streamline the operations of the Council most of whose time was consumed by reviewing and accepting the Study Group's recommendations on projects. Although the reforms of our sub-committee were accepted and time was saved the Council seldom addressed serious problems seriously. The agenda remained in the Director's hands. During most, possibly all of the time, that I spent on the Council, a fellow member was Mike Gorman, the principal lobbyist of the mental health movement, an associate of Mrs. Albert Lasker, the key figure on the Washington scene leading the crusade for more federal dollars for health. Gorman was an informed and con­ cerned advocate but it bothered me at the time, and I am still restive, as to whether he should have been a long-time Council member. He was constantly on the lookout for politic al openings that he could move into to advance his organizational and programmatic objectives. -----The peer system of project review was well-established by the early 1960s and its methods of operations were considered by most beyond the pale of criticism. I for one, have found it seriously defective on several grounds. The head of the research branch, Mr. Philip Sapir, who had great influence in determining the membership and shaping the procedures of the Study Committees was inclined in my view to rely unduly on the sophistication with which the project proposal was drafted in terms of methodology, with too little attention being paid to the questions that were being explored or the potential relevance of the findings for -7- therapy. As a consequence, academic psychologists, because of their superior raining in statistical methodoloqy,, had the inside track. -----I was also concerned about the secondary consequences of the peer review system. A non-conformist such as Dr. Nathan Kline at Rockland State Hospital in New York, an early experimenter with drugs, had great difficulty in getting funded. I had to bully the Council into making a grant to a black social scientist in a Southern college whose proposal, lacking methodological refinement, was slated for the scrap heap. I was once asked to go on a site visit to the Judge Baker Clinic in Boston to discover belatedly that the purpose was pro forma. The record had ·to show that a site visit had been made but the decision to continue funding was never in question. -----There was one NIMH funding mechanism that appealed to me greatly. It involved making small grants, in the $10,000 range, /d on the basis of a letter of intent from the researcher .WB-O upon review appeared reasonable. Any qualified young person who could write two coherent pages about a modest research effort that he wanted to institute was likely to be funded without any fuss or feathers. When the Department of Labor in 1962 was authorized to initiate an external research program it was able to put this facet of NIMH experience to good use in developing its disserta­ tion and small grant program. -----On a rare occasion Dr. James Shannon, the head of NIH, presided at a session of the Council. I cannot recall whether his presence was linked to communicating authoritatively some -8- important departure in NIH or administration policy; whether it reflected his desire to gain some impression of the quality of the Council; or some combination of both. But what stands out clearly in my memory is his testiness in having Council members engage him in any serious discussion of the NIH basic policies or procedures. If Felix ran a taut ship, Shannon's behavior was imperial. A Council member could ask a question, but to go beyond to discuss or argue a point was out-of-bounds and treated thus. -----Of the three senior staff associates who made regular presentations to the Council I recall responding positively most of the time to the Chief of the Training Branch, Dr. Raymond Feldman who seemed to know what he was about and whose programs were directed to accomplishing a series of realizable goals. But some of the thrusts left me uneasy. The NIMH was facil~tating tbe conversion of general practitioners and other physicians into psychiatrists. The funding arrangements were quite liberal and I was not convinced that the taxpayer should be dunned $100,000 or so over a three-year period so that a forty-year-old general practitioner caring for 100 or more patients a week should be able to specialize in treating a much smaller number of psychiatric patients. I was especially restive about NIH policy that provided for career grants to selected investigators. Here was a very large commitment, up to a million dollars per recipient, that appeared to be less geared to medical research than to university endowment. -9- A third, and even more fundamental question that bothered me was the absence of a direct payback to society for the funds expended on training young psychiatrists the overwhelming majority of whom would enter private practice and devote their time to patients suffering from neurotic difficulties who could pay their charges. To increase the pool of psychiatrists with an aim of strengthening the staffing of public mental hospitals was a goal that could command support. But why should the taxpayers' money be used to set up young psychoanalysts to practice among the affluent on Park Avenue, New York City? The third branch chief was Dr. Jonathan Cole who headed up the research program on drugs_. While his presentations and reports were strong and crisp I had little confidence that the NIMH had a strategy for testing the efficacy (and the dangers) of these new · drugs that would hold up under critical scrutiny. But the subject was too far out of my ken to permit me any reaction other than skepticism about the eventual payoff from the large and sustained effort. -----The NIMH had the authority to approve demonstration as well as research projects and with respect to the former I was constantly conflicted. Many of the proposals on their face made good sense. What the investigator indicated he planned to do appeared to be within the requested resources; accomplishable within the proposed time period; and likely to improve patient treatment. But then what? If the demonstrator proved successful -10- could it be implemented? Where would ongoing operating funds come from? Would we know whether the intervention really worked? The list of questions could be extended indefinitely. The critical point is that it was next to impossible to persuade an investigator with a good demonstration project to build in a significant research and evaluation mechanism. Nor am I sure had we been successful, that we would have agreed to pick up the tab. Research tied to live experiments is usually very costly. -----The greatest frustration of my Council service grew out of our inability to contribute in any significant fashion directly to the quality of care in the nation's mental hospitals where most patients were confined, receiving little more than minimum maintenance. The stance of the NIMH and the federal government was clear. It would not become directly involved in funneling monies to the state mental hospitals. Such an involvement could quickly lead to an excessive new burden on the federal treasury. Since I saw little prospect of the research, training, demonstration or even drug programs contributing significantly to the improvement of the state mental hospitals the NIMH appeared to me to be operating only partially in the real world • .Most of the problems lay in an area which were beyond its reach. It would be an exaggeration to suggest that at the end of a typical Council meeting the members, including myself, felt frustrated to the point of questioning whether the entire NIMH effort was worthwhile. That is not so. The positive orientation of the Director and his staff kept such doubts, if they arose, -11- submerged. The one thing that the Council never did was to take a hard look at the program as a whole--its goals, programs, potential. We operated on the assumption that the reduction of mental illness was a desideratum and that the NIMH was doing its best to speed its reduction and eradication. Assessments in Retrospective From here to the end what I have to say reflects my experiences and judgments up to 1976. They take off from my service on the Council in the early 1960s but they report views and assessments informed by intervening developments and lengthening perspectives. I will offer my assessments of four critical dimensions of the governmental advice-giving process with particular reference to councils or advisory committees, the funding of external reiearch, program evaluation, and conflicts of interest. On the basis of my three and a half decades of continuing service with the federal government I have concluded that while Presidents and agency heads see advantages to the appointment now and again of a committee to look at a particularly thorny problem and upon the completion of its assignment (preferably in less than two years to have it disband) they balk at being saddled by permanent committees and if forced by legislation to live with them, do everything in their power to see that the bureaucracies stay in control. This is understandable. The operation of a complex agency is difficult enough without the head running the risk that out­ siders over whom he exercises no direct control may press for -12- actions that he cannot pursue and results that he cannot assure and if disappointed may take their case to Congress or the public. I am reminded of a White House Task Force on which I served under President Johnson which was set up with multiple disguises so that its existence could at any point be deriied, .and all copies of its final report were commandeered and permanently kept from public scrutiny. For advisory committees to function at an acceptable level of effectiveness requires at a minimum that they have a strong chairman; a say in the development of the agenda; some staff support; and officials with sufficient self-confidence not to be negative just because the advice comes from outsiders rather than their own staff. On each of these counts the NMHAC gets a bad mark: by legislation the director served as chairman; the members had no real say over the agenda; it had little by way of staff support; and the agency was defensive. In the area of funding external research there are no best ways of assuring that the grant money is spent productively~ Peer review has advantages but it favors the establishment; discourages risk-taking; contributes to indirect bureaucratic control by assuring that the staff has no real responsibility for the out­ comes; and is exceedingly expensive with respedt to the reviewers' time. In a caustic mood, I once referred to the process as good people wasting their time looking over poor projects! No large-scale governmental research program can get on without outside advisors but I believe that there is merit in -13- forcing governmental officials to assume responsibility commensurate with their influence on the decision-making mechanism which is always substantial and often determining. Another important approach is to encourage the evaluators to take some reasonable chances and not to restrict themselves to the safe that is likely to turn into the unproductive. Finally a large-scale external program should be sensitive to facilitating access to funding by young people just starting their careers. On all of the above, except the last, the NIMH gets no better than a passing grade, if that. On the critical issue of program direction and evaluation it is safe to say that any responsible management, inside or outside government finds it exceedingly difficult to look at what it has been and is presently doing in any hard, objective fashion. There are just too many people with too much ego involved in the earlier decision-making who face too many losses if the critical reassessment should reveal that they have made serious errors in formulating and carrying out their program. Hence the last thing that any management does is to undertake, in the absence of out­ side pressures, really tough reassessments of its program. Government agencies consider that they are subjected to such reviews not once but several times a year--in the case of NIMH by NIH, the Public Health Service, the Secretary of HEW, the Bureau of the Budget, and then by the substantive and appropri­ ations committees of House and Senate, in all, eight reviews per year! -14- But those who have had experience with this review process, especially in the earlier period of NIMH, know that the NIH did not do much more than attempt to keep the several Institutes in broad alignment and to assure that this year's budgetary request would not be too far above last year's appropriations; that the Public Health Service and the Secretary's Office, in the absence of major new initiatives that required prior White House clearance as in the case of the Community Mental Health Centers, were concerned with specific budgetary and administrative rather than substantive measures; that the Bureau of the Budget did look for program items that could be reduced or eliminated but had no real influence on a reassessment of progr~m goals; and that in the years under discussion the Congressional Committees and Sub-committees were in the NIMH's corner looking for ways to give it more money, not reviewing its program goals versus accomplishments in any objective or critical fashion. While it is true that not every informed individual or interest group in the country was enamoured by the program emphasis of NIMH or the allocations which it made, the amount of criticism was muted and there was little by way of serious counterproposals that encouraged either the Administration or the Congress to take a closer look. The steep rise in annual appropriations meant that the NIMH was able to do something for most of the claimants. There was little interest and less support at the time for any serious reappraisal of the program goals of NIMH either from -15- within or without the federal government. While I have not kept closely informed of developments since then it is my impression that while program emphasis shifted from time to time there was little by way of serious assessment of the productivity of the research programs; the lessons to be extracted from multi-year demonstration efforts; a fundamental redefining of the drug testing programs; an effective plan to modernize the informational base so that the impact of managerial and therapeutic interventions on the flow of patients could be closely monitored. Nor have I seen a study in depth of the costs and benefits of the large federal commitments in the training of psychiatric manpower in terms of the later deployment of this scarce personnel. The thrust of these remarks is not to claim that serious program assessment was more deficient in the case of the NIMH than the other Institutes or for that matter in the case of parallel efforts in other sectors of the federal government. My aim is simply to highlight the tasks that were not performed not because they were unimportant or unnecessary but because of the anxiety and danger that they evoked. I know of only one instance in the federal government where the responsible agency officials (Employment and Training Administration of the u.s. Department of Labor) requested on their own a thorough external review by a committee appointed by the National Academy of Sciences of its research and development functions. This brings me to the last dimension, conflicts of interest, that must be briefly reviewed to round out this reassessment. -16- The issue is complex and if one wants to go beyond moral indig­ nation constructive answers will not be easy to fashion. The trouble starts with the fact that there is no clearcut separation between governmental officials and others at any occupational strata, and surely not within the research community. Secondly the NIH structure provided by legislation for the con­ tinuing participation of outsiders in an advisory capacity through Council membership. And the Peer Review system, once it became institutionalized gave the outsiders a major place in the alloca­ tion of research and demonstration funds. Finally Congressional committees have long sought the advice of outsiders, representatives of interest groups and academic experts as a balance to the informa­ tion provided by the bureacracy. Wnat this comes down to then is ' that the advice-giving, decision-making mechanism across the whole A of the federal establishment are so structured as to create an environment where conflicts of interest are not only likely but inevitable. There was nothing unique in the conflicts of interest that existed or later manifested themselves in the operations of the NIMH. But they were present to a degree that warrants considera­ tion even if solutions will be hard to fashion. By law, the Council had several representatives from the field of psychiatry among its members. While they did not vote when grants_ originating in their own department, school, or university were called for action, the Study Group members, the NIMH staff and the other Council members were not oblivious to the relationship between the interested Council member and the specific grant request~ -17- But this was the least troublesome matter. More pervasive and more subtle were the background interchanges between informed insiders on Study Groups and Council and the staff about projects and grants affecting colleagues in whose work and activities they had a personal interest and concern. There were powerful cliques among the insiders who operated as a mutual defense league, taking care of each other thereby guaranteeing more or less that each would get a reasonable amount of the swag. There were different ways whereby reviewers and staff com­ municated with each other about their strong preferences and what outcomes were preferred and what outcomes would result in creating turmoil. In a complex bureacracy, working with a complex structure of advisors it soon became evident to any evaluator, outsider or insider, that if he wanted to increase the circle of his friends and keep his enemies to a minimuP1, he had better follow the signals and play the game. Although the federal government has rules and regulations about the types of employment that civil servants are permitted to accept--and the time period that must pass before they can enter certain proscribed domains--these limitations do not generally apply to those who have ·been handling health and research dollars. It would be an illuminating exercise to ~trace the post-governmental employment of the senior staff of NIMH in terms of the relation­ ships of their employers with the Institute. -18- Nothing appeared more anomalous to me at the time, nor since, than the three-cornered game that was played among the bureaucrats, the friendly Congressional committees, and the leaders of the profession who were called to testify. The bureaucrats advised the Committee staff who could be relied upon to give strong testimony -in favor of a new program initiative, more funding, or some other goal that the NIMH and the Congressional leaders had singled out for action (often behind the back of the President's staff). More often than not, the same people who testified would become major beneficiaries of the new program in the sense that their institution would receive a considerable slice of the new funds appropriated. It was not accidental that President Johnson finally moved to break the hold of the Eastern Establishment on the health research dollar in the mid-1960s, a hold that had developed from the cozy three-way deal among the academic leaders, the bureaucrats, and the Congressional committees. In retrospect, it is difficult to see how such linkages could be severed without more loss than gain. Congress and the Administration ha~need for outside advice. Those solicited A will include many .in leading positions with the greatest prestige. By assisting the government, the chosen experts become more powerful by access to information and funding. And the feedback mechanisms continue with the linkages getting ever stronger. Moreover, bureaucrats, especially the more able among them early come to recognize that their present influence and leverage is enhanced if they have the support of influential outsiders, -19- support which they seek and for which they offer in return opportunities to serve and an inside track when it comes to external grants. But these bureaucrats also recognize that sooner or later they may want to move on into the non-governmental world and it is never too early for them to acquire well connected friends. Favors that they extend today to those on the outside will, it is hoped, be requited at some time in the future when they are ready to move. In matters of economic policy, defense policy, environmental policy, Congress has no great difficulty in hearing contradictory testimony from competent persons. But who will volunteer to testify that the NIMH program is growing too rapidly, that the research is of questionable value, that the anticipate~ gains from the proliferation of ambulatory care centers will probably not pay off? This is testimony that Congress might profit from hearing but is unlikely to hear unless some well-informed members make a special effort to identify knowledgeable critics, skeptics, conservatives who would be willing to go public on their views and recommendations. In the heyday of NIMH's expansion such testimony was almost never offered. A Concluding Note There is a negative overtone to my retrospective views on advisory committees, research funding, program evaluation, and conflict of interest issues. When added to my far from flattering contemporary views of my membership on the NIMH Council, the whole adds up to a poor tale. I am willing to stand by it, subject only -20- to one emendation. Poor in comparison to what? Poor in relation to the claims advanced by the insiders who built the NIMH and their outside collaborators. Poor in relation to what a more tightly organized and supervised governmental structure should tolerate. But no poorer than the level of effectiveness that has charac­ terized most federal agencies, and possibly one or two notches better than the mode.