Ruth Knee Oral History no date

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Ruth Knee & Jessie Dowling-Smith
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NIMH interview.  The principal interviewer is Dr. Wade Pickren of the American Psychological Association.  We’re talking with Ruth Knee and Jessie Dowling-Smith of the Community Services Branch of NIMH.  So I’m going to ask them to introduce themselves for the purposes of this tape.

Knee:                           You asked for a full name.  That’s Ruth Ella Islan Knee, and I was born in Sapulpa, Oklahoma, in March 1920.  And I’ve lived in Fairfax County, Virginia since 1947.

Pickren:                       A while.

Knee:                           Yeah.

Dowling-Smith:          I’m Jessie P. Dowling-Smith.  I was born in the northwest corner of rural North Carolina in 1918, and I don’t know how much you want to know about my background before I came to the NIMH.

Pickren:                       Well, we’ll get to that.  So as long as we have your full name and where you were born. Well, let’s begin by asking – let me ask you in turn, Ruth, you first, then Jessie, if you would – to talk about when you first came to work for NIMH.

Knee:                           Well, I had worked from 1944 to 1949 in the Mental Hygiene Control Unit of the Federal Employees’ Health Service out of Public Health Service, which was located adjacent to the Public Health Dispensary.  And during one year, that was a part of the old mental hygiene division, and so technically, that was the time that NIMH was being organized.  We were a remote part of it and were in communication with the social workers who came there in 1947:  Dan O’Keefe [sp.], Warren Lambson [sp.], and Melvin Whitman [sp.].  But then I went to [unintelligibl] for several years and came back to the regional office of Region 3 of NIMH in March 1955.  That, too, was located in the same building where the dispensary was, in what’s now the Switzer [sp.] Building, because the regional office was here in Washington. A year later, it was transferred to Charlottesville, and at the same time I was transferred to headquarters of NIMH, good old T6, with a new team that was being set up to do mental hospital improvement.

Pickren:                       What year would that have been that you went to headquarters?

Knee:                           Nineteen fifty-six.  And that was a part of the Community Services Branch.

Dowling-Smith:          I joined the Public Health Service here in Washington in 1956 and spent five years at the Clinical Center.  I was trained as a psychiatric social worker – it’s an old-fashioned term now – at Columbia, getting my master’s in 1945.  But Dan O’Keefe, the chief social worker at Clinical Center, was recruiting like psychiatric social workers to do the medical services at Clinical Center.  He thought we might be able to bring perspective that was above the neck because medical social workers had a tradition of dealing with finding appliances and nursing homes and that kind of thing.  So I assumed a position of supervisor in the Arthritis and Metabolic, Allergies and Infectious Diseases, and Dental Institutes at Clinical Center.

Pickren:                       Is this Building 10?

Dowling-Smith:          Building 10, Clinical Center, which I didn’t recognize the last time I was out there.  Oh my, what a shock!  But I stayed there for five years in those services and then, in 1961, joined NIMH and went to the Chicago regional office as a social work representative – and that was ‘61 – in ‘65, transferred to New York, to the regional office, as a social work consultant.  We had titles:  social work consultant, psychology consultant, that sort of thing.  And then, within a year or two, assumed the job of regional director of the NIMH, Alcohol and Drug Abuse Institutes, which all eventually became ADAMHA.  So then I stayed there until 1981, when I retired.  That was the longest career I ever had in one place.

Knee:                           Speaking of Chicago, I should have mentioned that I got my training in psychiatric social work at the University of Chicago and worked at the Illinois Neuropsychiatric Institute.

Pickren:                       Would you have known, in Illinois, when you were in Chicago, a woman named Mary Ann Simmel, who was there about...  Well, no.  You’d already come to Washington.  I’m sorry.  She was there right after you must have trained there.

Knee:                           Right.

Pickren:                       I just recently talked with her and she was in Illinois for a number of years. I’d like to ask first, beyond your basic involvement with the NIMH, how you came there and all, to describe some of the early efforts of the Community Services Branch as broadly as you know the and understand them.  Now, Ruth, you were there first.  Let me ask you first to broadly describe how community services was organized and some of the things they tried to focus on when you first came to work for them.  This would have been 1955, although it’s interesting that you were there when NIMH actually emerged from the Division of Mental Hygiene.  You must have seen that transformation occur as well.  So maybe that would be a good place to start, is, what were the dynamics of that?  Because you have one very old agency, if you will, or division being phased out and a new one coming in.

Knee:                           Well, that Mental Hygiene Control Unit was a part of a clinic that had been set up as a wartime clinic to work with the civil service employees, primarily, who were brought here during the war.  It was set up at the suggestion of Eleanor Roosevelt and Beatrice Berle, who was a Public Health Service officer but the wife of Adolf Berle.  And so we had a number of traditional Public Health units – nursing, TB control, VD control, nutrition, health education, and mental hygiene control – so we worked in kind of a Public Health model, and our nurses worked with all of the nursing units in the different government agencies, which were our biggest source of referral from mental health problems.  But we also worked with the employee counselors throughout government, with the exception of the Pentagon.  They had their own psychiatrists for their civil servants.

Pickren:                       So government employees were referred to you.

Knee:                           Yes.

Pickren:                       Is that what you’re saying?

Knee:                           Yes, that’s right, for pre-admission exams and for job-adjustment problems.  And it was a very interesting kind of work that we did.  We had a couple of psychiatrists, we had a psychologist and two social workers on the staff during those years.  And the psychologist, the first psychologist there was Ruth Valentine [sp.], who had come from the West Coast, worked with Bob Terman.

Pickren:                       Yes.

Knee:                           And she shared a ménage à trois with Ruth Benedict and Margaret Mead.  So she was a very interesting woman in what she knew and how she involved as a psychologist some of the rest of us.   Now, after the war, she and Ruth Benedict went back to Ruth Benedict’s involvement with Columbia University and eventually Ruth Valentine [sp.] went to the West Coast, back to the West Coast.  But the other psychologists that came to the clinic were never of the same dimension of Ruth Valentine [sp.], so we had a very good working relationship. And the psychiatrist got involved in sort of more diagnostic evaluation.  We really couldn’t do much treatment.  And the first psychiatrists were trying to do public-health approach of treatment of doing job adjustment by adjusting the workplace or working with the counselors in the agencies, and the nurses.  They would do whatever had to be done.  They were very limited in any kind of psychiatric resource here in Washington. In the middle ‘40s, the Vocational Rehabilitation Service started paying for some treatment for people, and so that was one of our main resources, Voc Rehab.

Pickren:                       Was that a division of...

Knee:                           The National Voc Rehab.

Pickren:                       Okay.  Was it part of the Division of Mental Hygiene then?

Knee:                           No.  That was different.  That was the whole National Vocational Rehabilitation Program. So we didn’t really become a part of that Division of Mental Health until, after the war, the Employees’ Health Service became a different division apart from the dispensary, apart from what it had been in wartime, and I guess it still exists someplace.  But they didn’t take mental health along with them.  We were an orphan.  And that’s when the mental health division picked us up, and that’s when they were establishing the study center.  So we then began to work with Mabel Ross because Mabel, who was the first director of the Mental Health Study Center...

Pickren:                       This is the Prince George’s Mental Health Study Center?

Knee:                           Yes.

Dowling-Smith:          Prince George’s Mental Health Center.

Knee:                           Right.  And what we did collaborating _____ with Mabel, when she was getting ready to go to the – I guess it was about the First World Congress of Mental Health – and we had a little study task force on the job insecurities of federal employees, because that was the time of downsizing and the beginning of the attorney general’s list on the communist hunt.

Pickren:                       So it was influenced by the whole McCarthy era House Unamerican Activities.

Knee:                           We’re talking about 1948-49.

Pickren:                       And McCarthy was ‘52.

Knee:                           He came well after his West Virginia speech was given in ‘50.  But it got worse as the years went on.

Pickren:                       Let me ask you a question and kind of interrupt you a bit here. You were there after you were picked out by the Division of Mental Hygiene.  Robert Felix was the director by that time.  And so about this time, the National Mental Health Act of 1946 is passed, which, of course, eventually establishes NIMH in 1949, when your division was phased out.

Knee:                           Well, back in ‘46, when they were working on the legislation, some of the people that came down to testify on the development of the National Mental Health Act visited because either the psychiatrist or the lady who was my colleague in social work-- social worker then – had been very involved in the National Association of Mental Health, its predecessor.  See, remember, there were two mental health associations.  There was one that was more professional and one that was the kind of the wartime one.  She had been involved in the professional.

Pickren:                       Yeah, the National Association of Mental Hygiene.

Knee:                           Mental hygiene.  So some of the people, since we were about the only thing existing in the area and had mental health and public health to its name, some of the people would visit us, go up on the Hill and testify.

Pickren:                       So you met some of those people.

Knee:                           We met some of those people and then, when Milt and Warren came to town, we got together with them, invited them into the social work meetings we were having.

Pickren:                       Milt Whitman.

Knee:                           Milt Whitman.  And I don’t know.  Marian Stokes [sp.] was our psychiatrist, I mean our psychologist then.  I don’t know what ever happened to her, but I don’t think she had too much communication with the psychologists at NIMH, but I know we didn’t with the social workers there. And then it was all the kind of bureaucratic things that you hear about what’s going to happen and what isn’t going to happen, and after...  Well, the NIMH, as it was getting started, wanted to have these two centers, the one in Prince George’s County and one in Arizona, in Phoenix, and they got into trouble with the Phoenix one and they were told to leave town.

Pickren:                       That never worked out there.  Do you know why it didn’t work out?

Knee:                           Why they were told to leave town?  Because Shumacher [sp.] was the psychiatrist.  I don’t know whether Bob Hewlett [sp.] was...  I think Bob Hewlett [sp.] was involved in that.

Pickren:                       Bob?

Knee:                           Hewlett [sp.].  Oh, you don’t know who I’m talking about, this Bob Hewlett [sp.]?

Pickren:                       No.

Knee:                           Okay.  I was told that when they got off the airplane – they were met to move in there, to start they were told  to, by headlines in the paper, “We don’t want any,” in a sense, “We don’t any of that mental health stuff here.”

Pickren:                       No.  So it was community resistance there.

Knee:                           Yes, right.  It was community resistance.  Now, what got it started, but they didn’t want the government planning a clinic. Anyway, Felix, in testifying on the Hill, was questioned about how many of these community clinics he had, and so he talked about Prince George’s County and basically he told the committee that was all he had.  So he had to get rid of us from the clinic.  And, of course, they were wiping out Phoenix anyway.  So then our little clinic had to be transferred into the dispensary and become  dispensary.

Pickren:                       Now, during that era – this is at the beginning of your career, the years ‘44 to ‘49.

Knee:                           In the Public Health Service.

Pickren:                       In the Public Health Service.  And it’s the immediate postwar era, so that means the, kind of the whole notion of atomic weaponry is now a possibility and a reality, and there is some evidence, things I’ve looked at, that indicate that there was kind of a worry that the American population was going to perhaps suffer undue anxiety and dread related to atomic weaponry.  And so you see all of the soldiers in World War II that had to be discharged for psychiatric reasons and then so many VA, the VA was overwhelmed with soldiers needing services.  Was there a concern at that time, any sense that you had that policymakers were developing, say, NIMH as a governmental response to concerns about American mental health out of a real worry that Americans in fact, our resolve or our national mental health was going to deteriorate?

Knee:                           That’s an interesting question, and I think there were some other elements.  There was a lot of energy going into the development of veterans’ programs, and a lot of leadership from this level, and, of course, we knew a lot of the social workers who were developing that whole national program.  The things that it seemed to me that were at least communicated as far as planning and we would, until ‘55, when I was back in the regional office, did hear about this through our American Association of Psychiatric Social Workers, of which during ‘51 to ‘53 I was national president, and through the involvement of the groups here of the importance of mental health education and development of the concept of community mental health services.  It was that direction, you know, working with the schools and working with, maybe in some areas with mothers and newborns and things, and that was the mental health emphasis.  They were deliberately not working with the mental hospitals or the seriously mentally ill.

Pickren:                       It was more on, if you will, problems, to use an old phrase, problems of adjustment or the neurotic American, in some way, rather than the psychotic American.

Knee:                           In many ways, of course, and that’s about the time that Al Deutsch came out with his material, and that sort of started another trend.  And there were a couple of other studies that predated the Joint Commission studies that started. You know, the Council of State Governments did a study in the early ‘50s, and – I’m trying to...  I know I’ve made references to a couple of the others.  Anyway, you started seeing things come together about a broader look at what community mental health was about.

Pickren:                       What was it considered?  Why was that initiated by the Council of State Governments?

Knee:                           That concern was in large part, I think, around the mental hospital issues because there were not just the Deutsch exposé, but some other exposé.

Pickren:                       Wasn’t there a popular film, “The Snake Pit”?

Knee:                           A public impression of the way.

Pickren:                       So the Council of State Governments might have been more concerned about the hospitalized mentally ill than...

Knee:                           Yeah.  And the state’s responsibility for the mentally ill, because state responsibility has been very different. Now, this, by the way, is one of the places where the Vocational Rehabilitation Service comes in, because by the early ‘50s particularly, I guess almost every state had a federally funded vocational rehabilitation service under the leadership of Mary Switzer.  And in 1945 was when vocational rehab, you know, their legislation goes back to the early ‘20s, but in 1945 was when they came out with some monographs and directives and I think had some legislative modification so that they could spend money on the mentally ill.  And Hugh Varney [sp.], who just died recently, was their psychiatrist at the time, back in the middle ‘40s.  And I know they had some psychologists.  I can’t remember their names.  They had a couple of social workers, Adeline Genness [sp.] and Margaret Brian [sp.] and there was another lady.  They were one of the first bridges from the mental hospitals.  And Dick Williams, who was on Dr. Felix’s staff, who was a sociologist, worked closely with voc rehab about what their bridges were to the mentally ill.  And he’s the one that started a whole series of conferences across the country between mental hospital directors, state mental health programs, and state rehabilitation programs.

Pickren:                       In what years were those conferences?

Knee:                           Well, they started in 1955.  That’s one of the first things I got into.

Pickren:                       Were they a Title V?

Knee:                           That’s before Title V.

Pickren:                       Okay.  I think he refers to this. There’s a Jeanne Brand and a Phil Sapir had written and put together a history of NIMH from...

Knee:                           I know, but they ignored Title V in community services.

Pickren:                       But they mentioned it a bit in here, and...

Knee:                           They didn’t think it was scientific.

Pickren:                       Yeah.  A little _____.  Richard Williams contributed.

Knee:                           He was scientific.

Pickren:                       Yeah, _____, and he mentioned some of that.  So _____ separately.

Knee:                           But anyway, it was because those were really a very important series of conferences.  And the regional offices got involved in that planning and in the conference, and it was kind of the first time that the regional offices and when our group got established at headquarters in ‘56 to be – we were called a hospital, mental hospital consultation unit – to bring the community and the hospital together.  And I think it started a certain interaction because that was about the time, you see, the tranquilizers just came in in ‘55.

Pickren:                       So a major change.

Knee:                           And a major change in psychopharm.  And ‘55 was the year that Dr. Felix got very concerned because there were 500,000+ people in mental hospitals.  Of course, somebody ought to be concerned that there are probably 500,000 mentally ill people in jail now.

Dowling-Smith:          And another on the streets.

Knee:                           Yeah, and another 500,000 on the streets.

Pickren:                       _____ cost shifting _____.  I mean, that’s the attitude.

I think Ruth’s point about they didn’t include much about this because it wasn’t scientific is very interesting.  It goes back, I think, to one of the major problems that the institute had, probably from the time of its inception, and that is, it was the only institute that took services seriously.  The rest of the NIH did not.  And really the only institute that took clinical training seriously.  Some of the other institutes did it, but not on the scale that NIMH did.  And there was probably even among the – my guess is among the key professional staff throughout the years, much less contact by the people in psychology and in psychiatry with the services programs than there would have been by the social work training group, for example, which was much closer to the service.  And this, I mean, it still plagues the whole field.  I don’t want to restrict it just to that era.  That still goes on, and it goes on, as you know, in your organization.  Okay?  It’s split down, I wouldn’t say the middle.  I think the professionals and _____ have the upper hand at APA now.  But it was responsible for the break between APA and APS, and it’s absolutely difficult.

Knee:                           But, you see, there were several years that the Community Services Branch was named the Research Utilization Branch.  And that whole idea was to make the bridge between what was learned in basic or in applied research to use a whole applied research authority to develop service-related models and to document that, and then to try to get it into the bloodstream of people.  And, you know, it did get in.  A lot of ideas did get into the bloodstream.  You didn’t have to, for instance, go to a community and set up particularly – I’m talking about before the Community Mental Health Center effort started in, say, ‘63 to ‘65 – the community right here about having a daycare program for the mentally retarded.  Well, they might apply for money or they just might do it.  Ideas were contagious.

Pickren:                       Well, part of what community services was set up to do was to be a liaison between NIMH and the various state and local agencies as _____.  And so did a lot of these ideas _____ for things like daycare for the mentally retarded or aftercare.  I assume that was for people discharged from state hospitals.

Knee:                           Right.

Pickren:                       Did those ideas and the initiative for them come from NIMH staff, or did the state and local offices tend to approach NIMH, or was there some mixture of both of those?

Knee:                           All of the above, all of the above.

Dowling-Smith:          Well, they had the demonstration grants _____ they gave ideas about the kind of thing they would entertain, trying new things, something that hadn’t been tried before.  That was fundamental to the demonstration grants.  So, yeah, it sort of went back and forth.  They’d think up ideas at the national conferences and all sorts of places, and then somebody would write a grant, lo and behold.

Knee:                           _____ support a state conference aftercare and talk about all the agencies that needed to be involved in an aftercare program or continuity of care, and they’d bring somebody in to give them some new ideas, but it was kind of up to them to implement them.  But we did have – I think it was over a hundred demonstration study grants in community care of the mentally ill.

Pickren:                       Yeah.  I think the figures I’ve seen are quite a few.  Quite a bit of money went into that.

Knee:                           Yeah.

Pickren:                       What was Bob Felix’s view of that?  Was that something he was really committed to, was these liaison relationships with the states?

Male:                           _____ studies _____.  _____ study center as an example of the kinds of things that could be done in schools and _____.

Knee:                           At that time we had annual formal meetings of the state mental health authorities.  That’s when the grant in aid went to the designated mental health authority, which might be a part of the health department or it might be a part of the mental health department.  In some states, there was a division.

Pickren:                       It’s interesting.  For example, if you take a look at something like the people who used to regularly attend council meetings of AMH, you always had the head of the state mental health groups and also the lobbying sort of representative for that group, just as you had people from the National Association for Mental Health attending the meetings, people from both APAs and NASW and the nurses.  Okay?  I haven’t seen anyone representing state mental health associations at a council meeting.  I mean, I can’t tell you how...

Knee:                           These were official agencies, of course.  As I say, there were the annual formal meetings with resolutions, and it was kind of – the surgeon general would sometimes get involved.  And, of course, the Council meetings; we would go when they were considering community services.  We’d all be there as staff.  At the Council _____, if there was something really critical, a regional office person might come in to a Council meeting.  They always came to all of our basic study section meetings.  The regional offices were always represented.

Dowling-Smith:          And the project grant reviews.  I can remember...

Knee:                           Right.  That’s what I mean, the project _____,

Dowling-Smith:          _____ terminology _____.

Male:                           When did the National Association of State Mental Health _____?

Pickren:                       _____ developed after the _____.

Knee:                           I guess those came in in...  I remember meeting with sone of them after I retired in the late ‘70s.  But, see, Allie Schnebby [sp.]...

Pickren:                       Schniebe, oh, yeah.  Schniebe was...

Knee:                           Schniebe became a force and kind of sucked in a lot...

Male:                           How do you spell his name?

Pickren:                       S-c-h-n-i-e-b-e.

Knee:                           Right. 

Male:                           He still around?

Knee:                           Yeah.  He’s still around.

Pickren:                       Well, if we see Burke, we’ll get a good fix on it.

Male:                           ______.

Pickren:                       We’re going to try to _____, I think, yeah.

Knee:                           Because as that group became more powerful, I would say it was the counter-force to anything that NIMH wanted to do with the states.  And they developed their own database, their own legislative agendas, and it was fine when you could collaborate.  But you _____.  I got into a lot of it with a woman on the Medicare standards, the surveys of psychiatric hospitals and all of that business _____ NIMH.

Pickren:                       So when you came back to NIMH in 1955, then, and then a year later moved into the hospitals area, by this time NIMH had developed, had a pattern of the way they were going to handle their relationship with the state mental health agencies, the community, the funding for community projects, etc.  One of the things that’s curious to me as I’ve worked on this project is, given that mental healthcare had traditionally been a state’s right, if you will – I mean, the states did it perhaps not very well, but they had been charged with this – and now we have the federal government or an agency of the government moving into the area.  Was there resistance from the states?  I know that that’s a great generalization, but was the pattern one of resistance or cooperation or...

Knee:                           Well, the pattern basically was of cooperation, because in the middle ‘50s we were told to be pretty gentle people.  We were not to look down their throats, we were to help support them and bring in information to the variety of what they thought were their priorities.  And we weren’t in a sense forcing a single pattern of working on them.  We were told not to be like the _____ Bureau, that we did not follow the federal dollar down to the _____.  _____ in the ‘60s.

Dowling-Smith:          Very definitely.  Go gently with the states, and what seemed a real eye-opener for a lot of the people in the state agencies was, if they prepared a sloppy grant – and that happened sometimes even with our help, _____ and everybody else – we didn’t _____ get out of here with that crazy thing.  We would offer help in getting it together, hire some consultants if necessary, and take then out to work on it until they got a decent grant.  And if it meant a change of people who were going to operate and so forth, we would gently suggest that, too, or sometimes it would become obvious to the state people that they had the wrong people working on this, and get it so that if it was a good idea, a good kernel of an idea, we would help them develop it to where it would be acceptable and they could get something going.

Knee:                           See, in the _____, we didn’t have many resources.  For example, the District of Columbia and the Virgin Islands were both minimum-grant states.  They both each got $30,000 a year.  Well, you’re not going to do very much influence.  You are a collaborator and a colony.  And even in some of the other states now, in Region 3, there’s North Carolina and Virginia and Puerto Rico, Maryland, all went their own merry way.  And West Virginia.  It was only as...  Well, first...  It’s why I say that _____ have money was new money, and that came in before we had any of this Title V money, which was ‘57, really, before that got going.  And I was elected and by about, in the later ‘50s, we also had a little bit of money that we helped the states with some conferences that they wanted to put on.  But there wasn’t a lot of resource that you were being authoritative about.

Pickren:                       _____.  The community mental health centers...

Knee:                           _____.  Yeah.

Pickren:                       We both mentioned Title V, so why don’t you describe what Title V was.  And at least you came back about the time that Title V was passed.

Knee:                           When I came back in ‘56, Title V was being talked about.  Actually, they started talking about it in ‘55, when, again, Congress had expressed some interest in psychopharmacology and improved services for the mentally ill, and the institute wasn’t doing much about it.  So that legislation was finally passed in ‘56, which set it up, and it was to provide demonstrations, research, pilot studies in improved care and treatment, rehabilitation of the mentally ill, and improved administration of mental health programs.

So our team, the hospital consultation unit, was the team to develop this program, and that’s where Dr. Hewlett [sp.] came in. I thought that maybe you’d heard him.  He was a Public Health Service officer who had been in charge, he’d been at the, I guess at Lexington, and then when the Clinical Center was set up, he’d been really in charge of staffing that and getting it underway.  And then when that got underway, he went to the Community Services Branch and they came ahead of our team and really was the leader in developing this program and was a very down-to-earth and wise person.  After he left the, after he retired, around ‘60-‘61, he went out to WICHE [sp.] and was the director at WICHE [sp.] for several years before he went on to California and was deputy commissioner in California with, what’s his name, Jim Lowery [sp.].

Well, we were using consultation to set up the Title V business.  We used consultation _____ some of his staff, Dick Williams and some of that group in Felix’s office, and an important advisory committee was established which gave a lot of direction and openness...

Pickren:                       This was an outside, nongovernmental...

Knee:                           Nongovernmental _____.

Dowling-Smith:          High-level people in the field.

Pickren:                       When you say high level, tell me what you mean by that.

Dowling-Smith:          _____ in medical schools.

Knee:                           Well, I don’t know.  I think maybe some of the material I gave you had some of it, but Dr. Hauck [sp.], who was commissioner in New York State and one of the leading commissioners.  Let’s see, was Tompkins on there from VA in New York?  Every time I hear about Tuesdays with Morrie, I think about Morrie Schwartz [sp.].  He was on there.  The guy who...

                                                                TAPE 1, SIDE B

Pickren:                       _____.

Knee:                           _____.  He kept a desk in the same office at T-6 that Dr. Hewlett [sp.] and I shared.

Pickren:                       I know that out of Title V they established the Mental Health Projects Grant, and individually there are several committees, like Community Mental Health, Juvenile Delinquency...

Knee:                           No.  They only came into being several years later.

Pickren:                       Okay.

Knee:                           See, for at least for five years, everything went through the same committee.

Pickren:                       The same one, nongovernmental advisory committee.

Knee:                           Well, it got, you know, you had different membership, but it was it was the Mental Health Project Grant Committee.  And...

Dowling-Smith:          And that was different from the Advisory Committee, the NIMH Advisory.

Knee:                           You mean the council.

Dowling-Smith:          The project grant review.

Knee:                           No.  I’m talking about the same committee.

Dowling-Smith:          Oh, okay.

Knee:                           Yeah, because it got...  There was at that same time a community services advisory committee that was a separate committee, and it had people on it like the guy from Kansas City who really started the first community mental health center, one of the first in the country, in Kansas City.  And – oh, what was his name?  He was an African American.  But all of these were very high level, some academics, some _____.

Pickren:                       Were they drawn from different professions, or was it all medicine?

Knee:                           Oh, no, oh, no.

Male:                           Actually, Fritz was a....

Knee:                           Social worker.

Pickren:                       Fritz was a social worker?

Male:                           Yeah.  This is social work.

Knee:                           Yeah.  We had – Emory Moss was on the early Title V committee, and...  It starts with an H, who’s dead, from California.  And we had nurses.  It was a ______.  ______ sociologists, Harvey Smith from North Carolina, Tompkins, who’s a psychiatrist from New York and who set up the VA program.

Anyway, this was like a graduate education, to hear that group talking about both issues and projects.  We all learned.  And, by the way, as a preparation for the staff working on these grants, we had two regional training meetings, one in Charlottesville and one in Boulder, with some of the research people and some of the...  That’s where Harvey Smith got _____ some of the others.  Bob Barnes then was at the Community Mental Health Center in Kansas City.  On applied research.  These were workshops on applied research, so...

Pickren:                       And they were held kind of regionally, these workshops, around the country.

Knee:                           The East Coast and the West Coast, so that all the regional staff could get involved in that.

Pickren:                       I want to talk about the regional offices in just a moment, but I have a question about halfway houses, which you’ve already alluded to, daycare and aftercare.  Were they direct products, if you will, of Title V legislation?

Knee:                           Well, they were, some of the very early ones were funded like _____.  We were funded in part, some aspect of _____ in New York, and as a halfway house, and then there was one in Philadelphia and two or three others.  And daycare.  We funded a couple of daycares with...  _____.  That was up in, probably up in the New England area.  But you’ll see them on that list.  And several years later, to try to ascertain what we’d learned, we might sponsor a conference on halfway houses, which we did down in Lexington, and people...  Were you involved by that time?

Dowling-Smith:          No, but I remember.

Knee:                           That was ‘59.  And trying to get a report out of it.  Eventually some of those reports were published through APA, American Psychiatric Association.

Pickren:                       Do you have any of them?

Knee:                           I may have some.

Pickren:                       I’d love to borrow them if you have them.

So the idea of halfway houses, while it may have been around before, it actually was, they were actually funded through Title V.

Knee:                           Well, some of them were experimental, and _____ one in ‘56.

Part of our staff job was to visit some of these things that were already in existence.  It’s coming back to my memory now.

Pickren:                       If they were already in existence, they would still be eligible, then, for NIMH _____.

Knee:                           _____ or something.  This was by no means a way to establish a service system.  It was a way to demonstrate, and we found very great differences.  Some places, a demonstration would lead to a permanent funding and staffing that would be local or whatever.  In other places, the federal money is gone, it dies.

Dowling-Smith:          What we hoped was it would establish something if they were successful.  Sometimes the project ended with the government funding.

Pickren:                       So sometimes the government would see that perhaps they had contacts, say, the regional office would have contacts with someone in the city, and perhaps a group of people and NIMH, through the regional office, community services would give them money.  I’m assuming they’ve got to apply for it.

Knee:                           _____ before the regional offices.

Pickren:                       And they would establish the center and those centers that had various rates of success.  Some did manage to catch on and...

Dowling-Smith:          Probably, if you look back on it, I don’t know how we can capture that, but probably more succeeded than didn’t.  You know, the project was intended to get something started because the whole proposal was reviewed enough that it looked like something that would make sense.  So we expected that there would be something following from that, but often there wasn’t sufficient _____ for the funding of whatever.

Dowling-Smith:          In the middle ‘60s, I sent staff and consultants around, made a lot of field visits to see what had happened in a lot of these projects.  For instance, Dorothy Schroeder [sp.] went to the funded traditional child guidance clinics and other kinds of community mental health clinics to see what had happened and to get some sense of how they were the ones that were traditionally more traditional, how they were interacting or relating to the community mental health center.  And I sent somebody else around, Al Cohn [sp.] from Columbia University, to look at some of the other children’s projects.  Dr. Hunt went around with some other people, looking at some of the hospital socialization rehabilitation projects.

All these things got written up, but they didn’t get published.  They weren’t scientific.  _____.  They were useful, they were useful.

Pickren:                       Even the scientists had some problem.  They had _____ report that Wade mentioned I had used extensively in writings _____ and the Oxford University Press refused to cite it – okay? – despite the fact that I had the title, because it hadn’t been published.

Dowling-Smith:          Well, the community mental health services I would say are the sloppy democracy part of culture.  It’s just like we’re experiencing right now.  And it was hard to fit it in the scientific _____ very necessary, and of course they _____ badly, sloppily, and so forth, but you were people working with people, trying to get something going.

Pickren:                       Like the old phrase said, that medicine is as much an art as it is a science.

Dowling-Smith:          Yes.  And I guess we were applying the art, more or less.

Pickren:                       Now, let me just filter things out here.  I want to get Ruth’s reaction and Jessie’s reaction to...  A hell of a lot was going on during these years.  Okay?  The budget of the institute, for the times, was growing pretty much by leaps and bounds.  I mean, there was a lot happening, so that in research you had the true beginning, really, of the intramural program starting in the early ‘50s.  The psychopharm branch of the Research Division was, I think, created in 1954, and that may have been a response to a lot of the stuff that _____.

Knee:                           _____ ‘54 and ‘55.  It was just getting started.

Male:                           Getting started, right.

The research training started basically in about ‘57.  The psychologists convinced Felix to bring in people in biological and social science, so Fred Almagin [sp.] was brought in from biosciences, and Clark Vincent for social sciences.  Psychology began research training about two years later, so we had a dual sort of thing.  It was clinical training, and a lot of it was _____.

Pickren:                       Norm Garmazi [sp.] was there.  Right?

Male:                           Garmazi [sp.] was not – Garmazi [sp.] had already left by that time, I think.  Yeah.  Garmazi [sp.] was there early on, with Max Levin.  Actually, John Everhart [sp.] was the original guy in training, and I think Garmazi [sp.] and Levin followed him, and then Ken Little came in and brought in Irv Alexander, brought in Passowitz [sp.], brought in Speesman [sp.], and I think I was the next guy to come into that program.

Then, of course, there was this major thing of the commission at the end of the ‘50s, and then they really took off, I think, when the beginning of the ‘60s started.  I mean, there were a lot of interesting things that happened.

When I first came to NIMH, one of the first things I got involved in – everybody was doing it – was reviewing state plans for community mental health centers.  It didn’t matter what you were doing in the institute.  I happened to have the state plan for Maryland.  I just moved here.

Pickren:                       That’s kind of one thing I’m kind of working toward, is getting the sense of the regional offices and then the whole effect of the Joint Commission on mental illness and mental health and how...  My question really is, I reviewed for today, was, to what degree did some of the Title V efforts – the halfway houses, etc., the community projects – actually pave the way for, then, the 1963 act on community mental health centers and mental retardation.

Male:                           It did, it certainly did.

Dowling-Smith:          That was a natural progression.

Knee:                           And we used to have to bundle together information and send it here, there, on what was going on or _____. 

Male:                           But this wasn’t only happening in the United States.  It was happening all over the world.  Actually, the Dutch were doing all kinds of things.  The English were doing all kinds of things in the therapeutic communities.  So you were getting...  I mean, the whole issue of _____ really _____.

Pickren:                       Yeah.  You could intervene at the environment, if you will, in a preventative way to lead to better _____.

Male:                           And you could bring things from other places.  You began to bring in some of the ideas that came from Holland and from some of the _____.

Dowling-Smith:          I don’t know how many speeches I made during the period after I went to the regional office and referred to the Belgian plan.  They did not have hospitals.  They kept people in the community and had different ways of doing it.  They were promoting community mental health.  Yeah, terrific.

Male:                           So it was a real international _____.

Male:                           That’s a good point.

Pickren:                       Yeah, it’s a very good point, very good point.

Knee:                           Staff made visits and a lot of these consultants that we used and that went on site visits, they had been on visits abroad and they brought other people so that you’re right, there was a lot of interchange with Europe, and a little bit with Australia.  We had some people up here from Australia.

Pickren:                       One of the other things that also happened around this time – and NIMH was a pretty generative institute...  You take a look at NIH now.  There are at least four or five institutes that sprang from the brow of NIMH.

Knee:                           That’s right.

Pickren:                       And some of the things that we had at that time, we gave up.  One of the first things I remember doing when I came was moving our grants in mental retardation and in gerontology to the new, a new institute, which really now has been split into two.  It’s not NICHD and NIA.  But the whole areas of retardation and gerontology were originally supported in NIMH, as were, of course, drugs and alcohol, and even portions of what now is the Institute of Neurology.

Knee:                           See, those original Title V grants, again, quite a few of those went to mental retardation, and when we started the mental hospital improvement program in 1963 as a subgroup of the Title V program, we were, our targets were every state hospital, every institution for the mentally retarded in the country.  But we couldn’t give all grants to all of them at once, so, again, they had to apply and be worked out.  And we gave grants for the institutions to the retarded until the political machinations of the Kennedy family pulled that out of the...

Male:                           That’s right.

Dowling-Smith:          _____.

Male:                           Oh, yeah.  They were _____.  That was an area they were very interested in because _____.

Knee:                           So we lost that, all those grants.  And like you say.  And we lost the other grants to NICH.  _____ meetings _____.

Pickren:                       Was that a problem to give up the grants to the new institutes, or was there territorial battles about that?

Knee:                           We had plenty to do.

Dowling-Smith:          _____.  There was plenty else to do.

Male:                           Plenty else.

Knee:                           I think the people in mental retardation thought that they had more political leverage over the grants being elsewhere, and some of them went, not just to NICH, but there was another part of the Public Health Service that was zeroing in on mental retardation that was a spinoff, I guess, of Children’s Bureau.  But anyway...

Pickren:                       Let me ask about the regional offices.  Jessie, this is something, of course, that you were intimately involved with.  We spoke, as I said earlier, with Will Edgerton [sp.] down in North Carolina, and he...

Dowling-Smith:          My major source of memory.

Pickren:                       He was quite informative, actually, a very good informant.  He recently sent me a great photo, in fact, of all the regional directors, which I think that you...  He described...  He was, of course, in Chicago with – he must have been there with Bill Hollister [sp.].  Would that have been right?

Dowling-Smith:          Uh-huh.

Pickren:                       Well, anyway, he’s quite a friend of Hollister [sp.].

Dowling-Smith:          Well, Bill Hollister [sp.] had come into the central office, so he may have been there.  _____, wasn’t he?  I didn’t remember Bill as a regional.  He was _____, because I didn’t remember him associating with Chicago.  Will had been there a few years before I arrived.  I don’t remember how long.

Pickren:                       What was the work?  When you came in ‘61, I think you said you went to the New York regional office in ‘61 and became the...

Dowling-Smith:          No, to Chicago.

Pickren:                       To Chicago in ‘61.

Dowling-Smith:          And then I went to _____ in 1965.

Pickren:                       Sixty-five.  So in ‘61, were you actually with Will then?

Dowling-Smith:          Oh, yes.

Pickren:                       He was the regional director.

Dowling-Smith:          He recruited me.

Pickren:                       What was the nature of the work that the regional offices...  Kind of, what was your mission there at the regional offices?

Dowling-Smith:          It’s very interesting hearing the perspective of Ruth of the development of the institute and its national viewpoint.  That’s a big viewpoint.  I can give you sort of a worm’s eye view from the standpoint of one regional office at a time.

When I got there, our mission, quite simply stated, was to promote the development of mental health services, although we didn’t neglect development of other things, but our emphasis was mental health services in the states, and develop a perception among the state agencies and other people in the states.  We made lots of speeches to lots of groups throughout the states and so forth, just trying to generate the idea of the importance of mental health services.  And it was very interesting for me because I had worked for Veterans Administration from 1946 to about ‘57 in West Virginia and in Washington, and it began as mental hygiene clinics became mental health clinics with the returning, returned veterans, and I had quite a perspective on what the mental health situation was in this country and what had generated the interest and emphasis, because we had so many veterans with such disabilities that what I learned chiefly was that there were so many people drafted into the Army who shouldn’t have been because they were part of a whole culture of – I can’t say mental illness – mental incapacity, simple schizophrenics.  They were taken out of the rural areas and put into this complicated Army situation and couldn’t function.  So, for all practical purposes...

Knee:                           Socially inadequate personalities.

Dowling-Smith:          ...they were called socially inadequate, but they were called simple schizophrenics in those days and _____.

Knee:                           _____.

Dowling-Smith:          But I don’t know how many simple schizos we treated.  And then if they were really bad and in their defenses developed the delusions of grandeur, they could call them paranoid.  _____ my background in mental health.

Knee:                           Yes.

Pickren:                       So a lot of the postwar work with the VA was with those folks.

Dowling-Smith:          And so then it was sort of a natural progression for me to go into NIMH – there were some other reasons, too, eventually – and work on the development of services that had been slow to develop in the postwar period.  So the early years, all the years in Chicago, we did not have community mental health center money to operate with, but we were still working with the Title V program, which was a national program, but we were involved in generating interest and seeing spots where something should be developed and responding to people in the states with ideas for projects that would demonstrate something to the public, whatever.  And so I would say, in simple terms, that was our mission:  to be as useful as we could be in the regional office.  We were responsible for the five states:  Illinois, Michigan, Wisconsin, Indiana, and Ohio.  Gosh, I can even remember.

Pickren:                       Heavily industrialized states.

Dowling-Smith:          Heavily industrialized, complicated states.  And heavy...

Knee:                           Heavy mental hospitals.

Dowling-Smith:          Oh, yes.  And, you know, all the horror of mental hospitals.  You didn’t see the difference across state lines just because Illinois was maybe a more sophisticated state with Chicago.  Their hospitals were equally horrible to a hospital in southern Indiana, you know, that sort of thing.  As I said a while ago, snake pits.  That’s what they were.

Knee:                           Wisconsin used county hospitals.

Dowling-Smith:          And Wisconsin had – they were a very independent state, so they had delegated authority right down to the counties, so they had never developed...  They had a research hospital at Madison, mental hospital.  But patients were treated in county hospitals.  And guess what they were?  They were like the old county poor farms.

Knee:                           They were the old county poor farms.

Dowling-Smith:          Yes.  People who were unable to participate in the community, function in the community, were brought into the county hospital, so they had people with various kinds of disabilities, physically disabled to the point where they couldn’t function, to whatever they called mental illness in those days.  But when you visited the county hospitals, it was a real mixture, many older people who were suffering sometimes _____.  So that was the situation.

We busied ourselves visiting the state mental health departments regularly and then visiting various communities where something was going on, and then we were invited to do a lot of speechmaking to county mental health associations, state mental health associations, sometimes just to a civic club to talk about what might be done in relation to mental health problems and the government’s role.

Pickren:                       When you were invited in to give speeches, I assume you _____ a lot of this.

Dowling-Smith:          Yeah, all of us were.

Knee:                           Yeah, we all _____.

Dowling-Smith:          If we _____.  Some people didn’t care to make speeches.  I didn’t particularly, either, become a speaker.

Pickren:                       Were these the folks that you were inviting, I assume some of them would have been hospital superintendents, county mental health officers, whatever, were they asking you out of some hope that you could tell them something they could do, or did they want you to justify the status quo, or were they looking for innovation?  What were they hoping for with your presence there?

Dowling-Smith:          They were looking for information, surely.  It wasn’t that...  I can’t remember any instances where they were disappointed because I didn’t support the status quo.  I mean, _____ new idea.

Pickren:                       They tended to be somewhat forward-looking.  They wanted to do something better than they were doing.

Dowling-Smith:          They wanted to do something, and we were aware, of course, that the county mental health association was having its annual meeting, and they needed a speaker.  One person that called me one time said that she was disappointed I couldn’t come.  I had a conflict of schedule.  She said, “Oh, we were hoping we’d get somebody that didn’t cost anything.”  It was somebody who didn’t cost anything, so I thought, well, good enough, I was glad I was busy.  At least don’t be so darned frank about it.  But that was partly it.  But we tried to make ourselves useful and give them some ideas about something to do, told them what wasn’t being done, what was possible.  As I say, I had my Belgium example if all else failed.

And I know you are interested in what psychologists did, I’m sure, as different from what somebody else did, and I think one of the conversations that Will and I frequently had was that he and I were a lot closer in our thinking about problems in the community and how to approach community problems and so forth than probably he was with many of his psychology colleagues that he met with or I was with social workers who were involved in agencies doing individual casework practice.  We had no idea.  It was something you learned.  I didn’t have it in my bones.  You sort of learned it by being in the regional office and doing, because communities, states, areas were your clients _____ do individual casework. And so we were really quite together in our approach to problems and so forth, and we had psychiatric nurse, we had a Ph.D. sociologist who’d been at the University of Chicago, and that was sort of the range.

And usually we hardly ever – no regional office had a full-time psychiatrist unless we had a psychiatrist in training with the Public Health Service and they had to do two years of duty or something.  But we had part-time psychiatrists.  We would use them as consultants and use them regularly, and the person – we would have a sort of chief consultant who appeared on the scene a few times a month or as often as we could get them.  So it would be somebody who was aware and knew what was going on in the regional office.  And then we used other psychiatrists for other technical kinds of things.  Sometimes we had a research project.

Knee:                           _____ they did have some full-time psychiatrists.  But that got less and less by the _____.

Dowling-Smith:          In a place like Chicago or New York, the psychiatrists were otherwise occupied.  It would have been impossible.

Now, we did, once we had Alan Collins, whom I still hear from, who was training with the Public Health Service, and he spent two years with us in the regional office, and he was already – he’d done an internship and residency, so he was a full-fledged psychiatrist.  But he still had to give back some of his time to Public Health Service.  And we trained him to be a community psychiatrist, so he was forever grateful because all he knew when he came to us was individual therapy.  And he loved what he did.  I don’t know whether you remember Alan or not.  Now he’s chief of psychiatry at one of the East Side New York hospitals, a private hospital.  I thought of the name and then I forgot it, but that’s a function of old age.  I do that frequently.

Pickren:                       When you and Will were at Chicago together, it’s when the monies first became available to establish community mental health center.

Dowling-Smith:          Well, by the time – we had not had money in the Chicago office, as I remember, up to 1965.  By the time I went to New York, the community mental health center money became available.  So then I spent the next 18 years or whatever it was working on community mental health center projects in the New York regional office.  That was our main concern.  We were pretty much focused on the development of the...  We went with the money and we developed our own...  Up to that point, Title V grants were reviewed in the central office.  We did our own review in the regional office.  And then, of course, we passed on them and sent them to the central office for final approval.  They still had to be approved in the central office.  But the responsibility was decentralized to the regional offices, and we gathered a group of consultants as a review committee.  Again, people from state programs, private programs, and the usual kind of mental health team, a variety of people, eight to 10 people, I guess, comprised our review committees.

Pickren:                       And you drew those people from the professions in the communities where the mental health centers were going to be established?

Dowling-Smith:          No, no.  We had a regional office review committee.  The applications were sent to us, and in New York we covered New York, New Jersey, Pennsylvania, Delaware, the Virgin Islands, and Puerto Rico.  Then we lost Pennsyvania and Delaware, I guess, to the other region and we concentrated on the islands and New York and New Jersey.

Pickren:                       So I assume you went to the islands in January and February for your reviews.

Dowling-Smith:          I tried.  You know what?  Sometimes I was down there for a whole week and I never saw sunshine.  So the sun would be shining, but I would be inside an office working all day, and by the time I came out, the sun had gone down.  It was busy.  They really ate you up when you got there for consultation, and we went as often as we could because they were very needy, and that was one reason they sort of reduced the size of the region – we were in great demand, of course, in New York and New Jersey – so we could give sufficient time to the islands and down and back.

I’m always accused of having long vacations in the islands.  I still hope to go to the islands sometime and vacation.

Pickren:                       Jess, were you on a visit to Puerto Rico and you had a little problem with an institution down there?

Dowling-Smith:          I vaguely remember.  I remember you and Harold Goldstein.  Were you there at the same time or at different times?

Pickren:                       No, no.  Harold and I were...

Dowling-Smith:          My memory is quite _____.

Pickren:                       I was there when Glen Mitnick [sp.] and Bruce _____ were.  Glen represented the alcoholism.  Bruce was the head of our grants management.

Dowling-Smith:          If you’ll name the problem, I can tell you.

Pickren:                       The problem was in a small professional school that had been started, and the students were not being paid their stipends, which we sort of heard about.

Dowling-Smith:          Oh.  Well, that was _____.

Knee:                           No, I was _____.

Pickren:                       It was a place where the Episcopal archdiocese in New York was involved, and the Dominican fathers down in Puerto Rico.  It was a complicated thing.  One of the students...

Dowling-Smith:          Oh, I would remember that.

Pickren:                       ...was the daughter of the former governor of Puerto Rico.  So that was a real...  I mean, I never visited that _____ in my life.

Dowling-Smith:          _____ politics _____, Puerto Rico was _____ example.

Pickren:                       Anyway, it was a riot.

Knee:                           And they couldn’t hold a candle to the Virgin Islands in terms of their...

Dowling-Smith:          Oh, my gosh.  _____ ingrown and inbred.  Well, anyway, that was the kindest thing we dealt with.

Pickren:                       You know, you’re the first person that I’ve spoken with who was so, who had responsibility in that era when the community mental health centers were rapidly expanding.  And so I’d really like to hear more about that, the role of the various professions involved, how they were actually established, who took the initiative in establishing them, what was the process like of getting approval.

Dowling-Smith:          Well, we did not – we didn’t develop a plan and say, “Now, here should be a center, here should be a center,” and work with the state.

Pickren:                       But there were guidelines that...

Dowling-Smith:          There were guidelines for how the community mental health centers should be organized, not where they should be, and there was a real difference there.

Now, we worked first with the state mental health department, and they would make...

Knee:                           Were they assigned catchment areas?

Dowling-Smith:          Oh, yes.  The state-level health department did...  I mean, we wouldn’t decide on one catchment area over another.  That’s what I mean _____.  They had to cover a certain catchment area.  And the state departments did their own catchment-area plan, which we reviewed and approved, but we did not get involved in doing the actual planning of where these things should be, but there were guidelines for, you know, so much population and not over and covering only enough territory so that the services would be available to the people within the catchment area so they wouldn’t be coming from the corners of the state to the central place to get treatment and get discouraged and not do it.  Bring the services close enough to the people that they will be available.

And then the states would sort of decide where there was enough interest.  And, of course, there always had to be a lot of local and state resources because we never funded a community mental health center.  Maybe in the initial stages, but we never funded it into perpetuity.  We would fund enough so that they could get started, and then there was always the expectation that when...  I think funds were withdrawn completely.

Pickren:                       Was it seven years?

Dowling-Smith:          There was a time limit.  Is it seven years?  I’d forgotten that.

Male:                           Did it diminish over that seven years?

Dowling-Smith:          They diminished each year.  And then one thing we had to watch was, at the time our money began to diminish, would they cut back the staff and services accordingly.  Would sufficient money come in to maintain the kinds of services they had started in the first place?  You know, this was a moral commitment, it wasn’t a legal commitment, and we were – I don’t think we ever brought charges against anybody if they were not meeting the commitment they had made in the contract.  We weren’t enforcers.  We would try our best to help them find the resources, generate other private resources or have the state come through with more money.  Of course, the state was dependent on the legislators, and they’re not any more generous than our own Congress, maybe less so.  So it was a matter of getting community mental health centers started and then helping perpetuate them.  And, again, it was like Title V.  We succeeded in a lot of instances, and sometimes we did not succeed.  But what we tried to guard against in helping plan with them – and we did very detailed planning with them; our staff were assigned different parts of the region and they were, you know, like one staff member would be responsible for what went on in a particular state, so they would stay on top of what was going on.

And one of our real problems was helping them plan sufficiently so they would provide relevant services in a good way, but not overplan just because this pot of money was available.  And there was not too much limit on how much money they could have.  It all depended on what it took to finance the service.  And I don’t think there was a ceiling.  I can remember grants over a million dollars in a sophisticated place in New York and...

Male:                           There were two kinds of grants.  There were construction grants and staffing grants.

Male:                           That came later.

Male:                           That came later.

Pickren:                       Construction was the first pot of money.  Right?

Dowling-Smith:          _____ different services.  That’s right.  That’s interesting.  I _____.

Pickren:                       _____ forgot about?

Dowling-Smith:          We had architects and people like that involved _____.  He was the pioneer.

Knee:                           _____ lives over on the Eastern Shore.

Male:                           We tried to find him and...

Dowling-Smith:          Oh, he could give you _____ what he went through in designing.

Pickren:                       What was his last name?

Dowling-Smith:          Clyde Dorsett, D-o-r-s-e-t-t.  He and Fred Spaner [sp.] were the consultants that we made the most use of in New York, and they _____ helpful.

Pickren:                       And Clyde Dorsett was an architectural consultant?

Dowling-Smith:          Yes.  But he would sit down with people with their blueprints, and he’d get out his magic pen and, oh, my, things would happen.  He’d be a good person if you can find him.

Male:                           Did you actually contribute and consult on the state plans?

Dowling-Smith:          Oh, we did it all.  Whatever we could do to be helpful.  Whatever we could do to be helpful.

Knee:                           At any level.

Male:                           At any level.

Pickren:                       ______ the state plans _____ help them work on them.

Dowling-Smith:          And we...  There was no antagonistic relationship.  It was all cooperation and help.  We liked each other.  And we had differences of opinion.  We weren’t patsies in the situation.  And neither were they.  But it was a very positive, always a very positive kind of thing, although there would be people along the way who would disagree and make things unpleasant for a while.  But we always tried to work on that, so...

Male:                           The psychiatric organization was against some of this.  Weren’t they against the staffing grants and the money from the federal government and some of the training?  I thought American Psychiatric was really giving a hard time opposing...

Dowling-Smith:          If they were, it was sort of like a...

Male:                           You had a different group of people...

Dowling-Smith:          ..._____ windowpane ______.  We went right ahead because we had a mission, and the states were so interested, and localities.  You know, they saw the money coming in.

I think some of the problems we had, now that you mention the construction – I would have thought about it, but – was areas getting a construction grant and then proceeding to try to use it the wrong way.  We did have a controversy in Buffalo that we finally had to refer to the Justice Department where they built a beautiful building for a community mental health center and then named it the so-and-so psychiatric pavilion, and that’s exactly what it was, a place for private care, period.

Knee:                           See, and what some of then got concerned about was their catchment area.  They thought that was too rigid.  Are they _____?

Dowling-Smith:          They had expansive ideas about making it bigger than it needed to be.  But I don’t remember...  And the state had a right to modify their plan up to...  You know, if they found the first catchment-area plan didn’t work too well, they could modify it, but we still had to approve it.  And we were looking at it in terms of the accessibility to the population.

Pickren:                       There was limited _____ hundreds of thousands could be served by one center.

Dowling-Smith:          Yeah.

Knee:                           Right.

Pickren:                       Two hundred thousand or something like that?

Knee:                           But the geographical area, too.

Dowling-Smith:          I can’t remember if there was a figure _____ consideration of population, geographical area, transportation.

Knee:                           There was a joke, you know.  _____ floor was, say, 75,000 or something, “Well, what if somebody died and...”

Dowling-Smith:          _____ on your catchment area.

Knee:                           But you know, _____ that during those years, I was not – I was kind of _____ over here with the hospital improvement program because I was supposed to improve the hospitals _____ centers.

Dowling-Smith:          That’s right.  We were paying attention to that at the same time.

Knee:                           Also, I was very involved with a, as what developed the whole issue of financing of services through Medicare and through insurance, etc., and with a committee that was a joint committee between American Psychiatric and the American Hospital Association, and I was the mental health person from the feds on that committee.  Now, one of the things that committee did to sort of help this process along is that, with the American Hospital Association – and we helped to pay for this, too, from NIMH – we had a whole series of regional meetings, began involving the regional office and the state mental health authority and the general hospitals to see how they would link together in the community mental health center program and how the general hospital could play more of a role.

Pickren:                       When you say general hospital, you are specifically not meaning a mental hospital.

Male:                           Psychiatric units in general hospitals.

Knee:                           Psychiatric units in general hospitals.

Male:                           That was a big push.

Knee:                           _____ George _____ big push on it.  _____ and I wrote an article for the American Hospital Association publications and stuff.

Dowling-Smith:          General hospitals were often the applicant for community mental health centers.

Pickren:                       Oh, really?

Dowling-Smith:          They developed through their psychiatric...  Well, Albert Einstein in the Bronx, and Metropolitan Hospital in New York City was a city hospital.

Pickren:                       ______ would be an outpatient _____.  At a separate site or would they want to do _____ site?

Dowling-Smith:          Well, sometimes they would have...  Sometimes we’d build them a building if they made a proper application and it seemed necessary.  But sometimes they would expand part of the hospital to do the range of services, or they would have facilities on other sites.  You know, it didn’t have to be within the same four walls if, like the daycare center would be accessible, but it might be a building two blocks away from the hospital.

Knee:                           See, between, I would say, 1955 and 1965, there was a great deal of growth in how many general hospitals had psychiatric units.  It was really a switch, and later on, when Medicare came along, they would pay for an elderly person in a psychiatric unit of a general hospital much easier than they’d pay in a state hospital.

Dowling-Smith:          Yeah, right.  _____ a state hospital.

Well, I don’t remember any state hospitals applying to develop a community mental health center because they were a different phenomenon and probably on their way out.  Do you remember _____?  Because they were so isolated that they weren’t in a catchment area and they were serving _____.

Knee:                           I think maybe someplace in the country, some of them, some did.

Dowling-Smith:          Yeah.  Some rule _____ facility.  But I don’t remember.

Knee:                           But it was not the general pattern.

Dowling-Smith:          No.  General hospitals...  Sometimes a university medical school, but I can’t give you an example.  Well, Albert Einstein _____ whole medical school complex.

Knee:                           I don’t know whether they ever got their grant or not.

Dowling-Smith:          Harvard?

Knee:                           Parkland in Dallas.

Dowling-Smith:          Oh, Parkland.

Pickren:                       Parkland?

Dowling-Smith:          Parkland, yeah.

Pickren:                       Let me ask you a question before _____ this point, both of you.  One of the major changes, of course, that happened in the institute in the ‘60s was it left NIH, and the basic reason it left NIH really had to do with its interest in services more than any other single reason, I think.  And it became a bureau, or it was supposed to become a bureau kind of in its own right.  First it was in an organization called Health Services and Mental Health Administration, HSMHA, and then ADAMHA was created.  And, as a matter of fact, between the two, there was a hiatus of about two months when we had to be returned to NIH because we didn’t have somebody above us that was _____.  Now, what difference would you say that made to what was going on in services?

Dowling-Smith:          I don’t remember when it happened, so I’d have to say...

Pickren:                       Nineteen sixty-seven, January 1^st, ‘67.

Dowling-Smith:          _____ around, and I guess I was aware that organizational changes were happening, but the impact all the way down through the region.  I would have been in New York then.  If I could recall some incidents around it, which I can’t, so...  Usually I can recall things that were very upsetting or made a difference.

Knee:                           Well, I would say some of the leadership changes in NIMH itself were probably just as significant because, of course, we’d gone from Felix to Stan, and then we went from Stan to Burt, and then...

Pickren:                       This was sort of right in the middle of Stan’s Yoliss’s [sp.] tenure.  And Felix left in ‘64, and Yoliss [sp.] came on.  And Burt came on in 1970.

Male:                           And both of them had been at the study center.

Pickren:                       That’s right, yes.

Dowling-Smith:          Yeah.  _____ developed there.

Male:                           _____.  Stan was the director of the study center.

Pickren:                       That’s right.

Male:                           And Herb was on staff.

                                                                TAPE 2, SIDE A

Dowling-Smith:          Yeah.  And so we were answerable to them, but administratively, you know, like coming to work on time and stuff like that.  We were under the Mental Health Administration.

Pickren:                       There were all sorts of...

Male:                           Nixon decided we would _____.

Pickren:                       ...machinations going on.  It was incredible.

First of all, it’s very interesting.  I find so many other threads in this.  At the time that all of us were in, came into public service, it was a really honored thing to do.  I mean, we were really on a high during the ‘50s and the ‘60s.  It was a great, an incredible place to be.

Dowling-Smith:          Yeah.  Very expansive. 

Pickren:                       Right, right.

Dowling-Smith:          Wonderful.

Pickren:                       When Nixon came into office, he was so suspicious _____ federal government of anybody, I think, and things began to shift.  One of the first things that happened...  Well, he came in in ‘68, but toward the end of his first term, I think that was the pit of suspiciousness and difficult...

Dowling-Smith:          That’s when they fired a hundred administrators around the government.

Pickren:                       That’s right.

Dowling-Smith:          Dr. Wilson, the head of HSMHA, was fired.  And John Martin, the head of Aging, was fired just arbitrarily.

Pickren:                       Arbitrary.  That’s when they terminated all funds for training.

Male:                           Isn’t that when he vetoed the community mental health _____, the _____ when he said that community mental health centers were experiments and they had proven their point, and therefore _____ federal level, and therefore he vetoed it and they overrode his veto.

Pickren:                       That’s right.  So, I mean, there was this whole thing going on sort of above us at the same time that, or shortly before ADAMHA was being born.  And I was always curious, since it had been the services aspect of NIMH that was so prominent in, I think, stimulating the institute and stimulating NIH to let go of NIMH, which was also part of the thing that had to be negotiated.  I mean, this was...

As a matter of fact, we were the biggest institute in NIH, and it was before...  At the time, it was before the cancer, the war on cancer was established, which made NCI by far the biggest institute.

But there was a period there with our service’s money – that’s both construction and staffing – and the training funds were at their peak, and you were beginning to get an enormous unrest among the research constituency that it was being left out, which leads to a whole succession of other developments later on.  But NIMH was then, in terms of...

Dowling-Smith:          I can remember congressmen and senators terribly interested in what we were doing, and they were supporting...  You know, they knew the public wanted this and they were supporting our efforts.

When the community mental health center, _____ Hospital in Brooklyn was dedicated, Senator Javits sent his apologies that he couldn’t come, but he sent his wife, and so she and I were on the platform together, and that often happened that we would be at some function in relation to the mental health movement with people like that.  And, of course, we were very glad to answer questions and present it.  And we always got very positive...  Of course, the ones that showed up for something like that were the ones who were interested in it.  But we always thought we had the support, from our vantage point, of the Congress in general, but who can account for a guy like Nixon.

Pickren:                       What about staffing in this era?  My understanding is that it was never stipulated that a psychiatrist had to be the director of a community mental health center.

Dowling-Smith:          Oh, never.

Pickren:                       So that opened the door, then, for other professionals.

Dowling-Smith:          _____ a variety of nurses.

Pickren:                       It was assumed _____ that that was _____.

Male:                           _____ the problems of the American Psychiatric Association.

Dowling-Smith:          I don’t...  If it did, _____.

Male:                           _____...

Pickren:                       Oh,  I’m sure.

Male:                           ...because of the _____.

Dowling-Smith:          Yeah, but way back, it wasn’t.  I don’t remember.  Will was head in Chicago.  He was a psychologist.

Knee:                           _____ talking about the clinical, the actual community mental health _____.

Dowling-Smith:          _____ community mental health.  Often the directors were another professional, but they had to show that they were providing adequate psychiatric services.

Knee:                           Yeah.  And that was...  Psychiatric services were clinically supervised by a psychiatrist.

Dowling-Snith:           There was no question about that.

Pickren:                       And originally there was – I remember 10 required services, reduced to five.

Male:                           There were five that were required and five _____.

Pickren:                       Additional.

Dowking-Smith:         Five specific, and then they could have five optional.

Pickren:                       It brings me back to one of the things that I was thinking about before when you were discussing what was happening in the state hospitals.  A good barometer of that in terms of what was going on in _____ was whether the psychiatrists would use the state hospitals to train their own people.  And there came a time when the NIMH Psychiatry Branch – by that time there was a branch – said no, we’re not going to provide funds for psychiatric training in these places.  And that was a _____.

Dowling-Smith:          _____ long overdue.

Pickren:                       But, Jessie, you must have been there then.  You retired in ‘81, and you had been at New York the whole, from that era, ‘65 to ‘81.  Was there kind of, to use an old phrase for it, kind of the rise and fall of community mental health centers in that time period, where they began to diminish?

Dowling-Smith:          It was coming to the point where, you know, something new always comes up from behind.  Look out, who’s coming up behind; make the most of the opportunity.  And we really had a heyday.  I mean, those were our salad days during the time when we were developing community mental health centers, and that would have been ‘65 to ‘81, 16 years, and that was a long span because we were in development and things were great all over.  But then, let’s see, when did the...  Some of the poverty programs were taking precedence, and some other things.  So we were...  I think we had been top man on the totem pole for a while, and we never, in my time I was there, we never went to the bottom.  But some other things had ascended to the top, and we’d gone to eight levels down.  And that figures, you know.  As I say, we had a long honeymoon with the federal government, longer than most programs do.

Knee:                           Well, I guess about that time was when they were also shifting some of the grant mechanisms for ongoing support of state services.

Dowling-Smith:          Yeah, and they were talking about grants in aid and _____.

Knee:                           And the combined grants, and that meant you really had to shuffle at the local level.

Dowling-Smith:          Giving the states more authority to decide where general grants and aid money went.

Male:                           Was that the block grant?

Knee:                           The block grant.

Male:                           The block grant.  Well, the block grant came in when Reagan came in.  See, what happened was, during the Carter administration, there was this big mental health task force convened, which Rosalyn Carter headed.  And its main charge, I think, was really to examine the community mental health center program and tell the institute whether it should or shouldn’t be continued.

Knee:                           And to broaden it.

Male:                           And to broaden it _____.

Knee:                           _____ better view.

Male:                           Yeah.  As a matter of fact, the interesting thing about the Senate program, Wade, is that it never got big as it was planned to be, even in the early days.

Pickren:                       Right.  Wasn’t it initially projected to be 2000 centers?

Male:                           That’s right.

Dowling-Smith:          That’s right.

Knee:                           To blanket the country.

Male:                           Right, to really blanket the country.  And there were things...  I mean, a lot of the things that went on at the time that made for problems here, psychiatry, which has always been the leading discipline in NIMH, developed a small portion of people to be community psychiatrists.  Basically the field never took it seriously; it really didn’t.  I mean, psychiatrists were, first of all, committed to private practice, and in those days it was mostly psychodynamic private practice in the earlier days.  And then it became committed to drugs, which is basically where they are now.  And they’re hard.  I mean, Felix was way ahead of his time in his own profession, way ahead of his time.  And they really never caught up with this.  Or if they did, they weren’t committed to it.  Now, there were a few who were, certainly, but it never made that much of an impression on the...

Knee:                           Well, I want to disagree in part.

Male:                           Okay, go ahead.

Knee:                           But I’m going to raise a point of order.  We’re not going to finish this topic today.  It’s a quarter of one.

Dowling-Smith:          And I held you up on the first part.  I don’t know _____.

Male:                           That’s all right.  Don’t worry about it.

Knee:                           And I have some other things to do this afternoon, so I think that we may need to make a plan, after you’ve absorbed what we’ve been talking about, to continue the conversation because we’re really just into the ‘60s.

Dowling-Smith:          Has this been useful?

Pickren:                       Oh, very much, yeah.  I mean, we really have very little on _____ services.  And there are never questions _____ ask about.

Should we stop for today, then, and then pick up...  Well, we can arrange a time when we can all meet again.

Knee:                           We can arrange a time.  We can – I can have you join me for lunch downstairs.  We cannot use paper or any _____.  If you’d like to have _____.

Male:                           _____.

Knee:                           Yeah.  We can talk if you want to continue talking for the next 45 minutes or so, or we can have some lunch along with it.

Male:                           We should pay you for it.

Knee:                           Well, we’ll settle that later.

[Tape turned off.  Then interview continues.]

Male:                           ...feeling was that the major point that he was concerned about at the time was the issue of stigma and the fact that these patients were so stigmatized and he felt it really almost needed a separate look as a sort of...

Dowling-Smith:          _____ carving out.  It’s like the carve-outs _____.

Pickren:                       See, it’s one of the features that you might be tempted to forget about from time to time, the stigma.

Knee:                           Well, historically, historically.

Pickren:                       It’s very strong.

Knee:                           The NIMH was to be community and health and not do anything about the morass of the state hospitals and the seriously mentally ill.  And it only came in the ‘50s, really, when the pressure started with the drugs available.  And Congress and people like Hill and Fogarty _____ putting pressure on it that they develop the drug, the psychopharm branch and the mental hospital program that we had in community services.  And, actually, since these were, in many states, set up separately, since NIMH had pushed the community programs elsewhere, into the health department, for example, that it meant bringing things together at a state level, too, and bringing people a broader concept of what mental health was about and maybe not dealing as much as should be with the stigma but trying to deal with...  At the same time, you know, Milbang Fund sent that bunch of psychiatrists, Bob Hunt and I guess Walter Barton and some of the others, over to England to study methods, and the Milbang Fund had a big symposium on it that the message was there’s hope.  And so that was...  And that you start with unlocking the doors, bringing in more, you know, getting out of the sloppy clothes and into better clothes, into better food, into better atmosphere.  And voc rehab, I think I told you all earlier, started building that bridge to outplacement, and some of the states had their outplacement...

Male:                           Could you comment a little more on the mental hospital aspect of community services?

Knee:                           Well, I can comment a lot on that.

Male:                           Because part of the residue of this was the stuff on the shame of the states, which started even before World War II, if I remember correctly.

Dowling-Smith:          Magnified.

Male:                           Yeah.

Knee:                           Well, it started before I think Al Deutsch [sp.] was first writing stuff in the...

Dowling-Smith:          _____.

Knee:                           Well, but his book then came out in the early ‘40s, and then, after World War II, there was a renaissance.

Now, you know during World War II, a lot of social workers and psychologists were conscientious objectors and served in mental hospitals, and they formed a group that added new life to the mental health association.  You know, the first mental hygiene association was started about 1908.

Male:                           _____.

Knee:                           Yeah, right.  But then they started another one which then got combined into the current association.  So by 1948, there was quite a lot of, you might say – I started to say yeastiness, and it may have been, in terms of the young Turks that took over the American Psychiatric Association and that they were going to do things about these different problems.

Male:                           Is that the gap group?

Knee:                           The young Turks were the corps, the corps of the gap group.  But the...

Male:                           Can’t quite _____ it.

Knee:                           The Council of State Governments did a study of mental hospitals in the country that came out about 1950, and the – oh, what’s his name down in Oklahoma, also did an expose of mental hospitals across the country.

Male:                           The guy who went to UCLA?

Knee:                           No, before his time.  Actually, he was on one of the advisory committees.  His name will come.  But there was almost more public pressure and legislative pressure that meant that NIMH couldn’t just stay on community.  It had to start doing some things about mental hospitals.  But the way that grant may have been set up, it really couldn’t particularly be used for hospitals.

Now, by that time – we’re talking about the ‘50s – several of the states had already developed well-established aftercare programs to get people out of mental hospitals.  New York, California...

Dowling-Smith:          _____.

Knee:                           ...Illinois, Massachusetts had outstanding programs with foster care.  And the VA was doing a lot with foster-home placement and community placement follow-up on mental hospitals.

So, first the Joint Commission on Mental Health and Mental Illness was set up as a congressional committee.

Male:                           In 1948.

Knee:                           In ‘54.  And then in ‘55, they started the legislation related to both the psychopharm and the grants to mental hospitals.  So that was then passed in ‘56 with the psychopharm branch and the mental health project grants, which were Title V, really targeted towards the improvement of care, treatment, and rehabilitation of the mentally ill.  But then the add-ons of broader community service and the improved administration of mental hospitals.  That was another piece of that original thing.  So we talked about how the mental health project grant started with that as a direction and then moved into community and moved...  And actually, the institutions for the mentally retarded were included within that.

Then, roll the clock forward a few years.  The mental health project grant program had expanded.  It was like water running down the river and went in every _____ that was open, because that kind of money was needed across the board.  It was not strict research and it wasn’t just a service subsidy, but it was either demonstration or study or experimentation in improved methods.

And then there was still the feeling that not enough was being done to improve all of the mental hospitals and all of the institutions for the retarded, and that was kicked around for a while:  Well, how will we do it? Just give some grant-in-aid money to the state?  No, that wouldn’t do it.  You wouldn’t have enough handles on it.  Well, another grant program?  Well, how would it be different?

So, finally, after the joint commission report came out in 1960 and the follow-up to that focused on community mental health, and then there was sort of the realization of the various groups and all of them talking about, you can’t just leave the hospital population behind.  And in that interim also, there had been a joint program between the study, between NIMH, the state mental health and mental hospital authorities, and the Hill-Burton authority, and that came out as a, I think as a surgeon general’s report.  Ed Flynn worked on that, and Bob Hewlett _____ all the rest of us did stuff with it.  But Ed more or less wrote that report.

And, of course, that had to look at facilities, but it was always our feeling you can’t look at facilities without looking at the program and who it’s going to serve.  But it talked about what facilities _____.

Anyway, it was decided, with all the developments moving ahead for the community mental health centers, that you needed a parallel mental hospital improvement program, which was authorized in ‘62, and it was – that was designed to, over time of a 10-year period, have $100,000 a year for a few years to every mental hospital and institution for the retarded.  But it would still be awarded on merit and it would still be awarded in terms of a state plan for improvement.  So we set up a separate review committee for that, and it was Title V money, but you might say a sub-appropriation for it.  And that started...  Well, _____.

And there was also the program of training.  The training branch had training and community services, or whatever we were called – at the time, I think we were called research utilization – and the hospital program.

Pickren:                       Now, was training separate from the research utilization?  I mean, this project you’re talking about, training money was coming out of the training branch, not out of...

Knee:                           Right.  So it was HIP, hospital improvement, and the other was hospital training.  There was another acronym for that, HIP and HIT or something, inservice training, hospital inservice training.

Cowling-Smith:           _____ applied for _____.

Knee:                           _____.  So was Eleanor Friedenberg [sp.].  You know, she’s still around.

Pickren:                       Yeah, Ellen is still around.

Knee:                           And Warren is still around, but he lives over at – not on the Eastern Shore but on this side of the Chesapeake.

Pickren:                       What’s his last name again?

Male:                           Lamson.

Knee:                           Yeah.  He had been in community services and moved over...  He and Jerry Carter both moved over to training, _____ service training.

Dowling-Smith:          At some point, that research utilization branch was relevant.

Knee:                           _____ research utilization _____.  _____ was running _____.  And then, when things got reorganized again for the brief time I _____.  But anyway, the...  And, of course, Ed Flynn and Sam Bucher [sp.] were very involved from the grandstand point.

Male:                           Is Sam still alive?

Knee:                           No.  He died a long time ago.

The thing I was thinking about just the last couple of days, we had enough thought and struggle and problems trying to think how you would send some limited money to 300 mental hospitals around this country and maybe 100 institutions for the retarded, and how you would work with the state-level people and the hospital people to do improvement jobs and not just throw the money down the drain and to, in a sense, to be accountable but to be innovative.  It took a while to get that program off the ground.  It made progress for several years, and then – well, it was after I left NIMH – then it got folded under by...  What was her name, the lady who _____ _____ rehabilitation and community care.  Well, anyway...

Dowling-Smith:          I don’t quite remember.

Pickren:                       She was where?

Knee:                           She was in whatever the reincarnation of the community services, was in the mid- to late ‘70s.

But back to what I was saying about the problem with the 300.  I do not see how suddenly the federal government is going to give money to 3,000 counties around this country to improve schools...

Dowling-Smith:          _____ anything else.

Knee:                           ...and make any change, because, believe me, our change efforts had to work on a whole long basis of study and research and development and all these regional offices _____ were encouraging _____.

Dowling-Smith:          Yeah.  _____ encouraging them to apply _____ what they were doing.  The states, even progressive New York state, wanted to get the money and throw it into their general administrative funds and then...

Male:                           Remember the delinquency prevention programs that they threw money to the states and they ended up buying tanks?

Knee:                           Yeah.

Male:                           _____ take care of the kids.  They bought tanks and guns.

Knee:                           Well, that wasn’t delinquency.  That was that LIAA.

Male:                           LEAA.

Male:                           Law enforcement.

Male:                           Law enforcement and then _____.

Knee:                           Yeah.  The HIT money we had because when the HIT program was being developed, we were also asked to develop a program on facility improvement, and so we worked on that and how those grants, what kind of grants you would want, how you would want them to validate _____.  Then that got shot down by people like Cecil Whitson, who he _____ as an advisor, but he was a very shrewd politician, and he knew...

Male:                           Where was he?

Knee:                           He was the Nebraska.  He knew what a cesspool that would be no matter what we said about it.  So he went to some higher-ups and I know got that shot down.  But a lot of the hospitals were using some of the HIT money to renovate.  So we had to be careful and put some constraints on that, that they use it primarily for staff.

Dowling-Smith:          _____ the remodeling _____.

Knee:                           Right.  And, of course, we lost the thing for the mentally retarded.

Male:                           Yes.  _____.  The training went in ‘63.

Knee:                           It probably went in, maybe in ‘64.  But it...  Because I know we worked on those applications, and our first set of applications, we were ready to present to council when council was adjourned because the word had gotten in that the president had been shot.

Male:                           _____ council.

Knee:                           Yeah.

Male:                           Unforgettable council.

Knee:                           Unforgettable council.  That _____ so that we didn’t get those programs started, you see, until January ‘64 _____.  But I think the bridge between hospital development and hospital reaching out in the community and the community mental health center development worked well in some places and was very tenuous in other places.  And Stan used to ask me about some of this.

Now, we’re suddenly talking about 1964 and ‘65, and that’s when they started working on the Medicare legislation with coverage for psychiatric care as, say, the last thing that came on into that plan, but it then became a great thing through the Medicaid program, and this was the federal government getting into it from another angle and having to relate to what we knew about mental hospitals, but with their own approaches because there had to be standards.  At that time, the only approach to standards for mental hospitals were what the American Psychiatric Association had, and that really wasn’t covering...  The joint commission really didn’t have anything.  And the joint commission did certify some hospitals, but it was for their surgery and their general hospital approach.  So we had to prepare some groundwork.  And one of the things we did was to have a grant that really basically went to the American Psychiatric, and we were working with the part of the Public Health Service then that was developing provider standards across the board in Medicare, and so the American Psychiatric, calling other people together, started developing provider standards for Medicare.  This was about the time we were finishing up on our Philadelphia state hospital survey.

Dowling-Smith:          Yeah, _____.

Knee:                           Because we were still doing state hospitals _____.

Dowling-Smith:          _____ ‘65 and we did that the latter part of ‘65 and ‘66.

Knee:                           Right.  And then, also, it was important to, as time went on, to not just have this, the provider standards that, of course, we’d worked with, but really had to look like they were Public Health Service standards accepted by the Medicare program part of Social Security, the hospital insurance program. 

So then, by ‘66-‘67, the NIMH had reorganized itself, and Community Service Branch was no longer, but you had a Division of Mental Health Service Programs, I guess.  And a part of that, we developed as a branch that would work with Medicare and Medicaid and the other health insurance programs, but, again, with hospital standards and community standards.  So we had extra contract money to work with the other aspects where mental hospitals had to shape up to deal with Medicare.  And, for instance, utilization review and chart of accounts and medical records because there were specific things in the general legislation and the specific legislation for psychiatric hospitals, which is still in existence, are that the two important records of records to reflect the treatment and the team assessment and treatment plan.  The clock goes ahead.  This stuff is all worked on and educational programs and communication about it.  It took a lot of doing to get together with the Medicaid people because they were using their money quite differently then.  They did not, in the beginning, the Medicaid people did not have to use the Medicare standards for the state hospitals, so it depended on the state what was happening there, and some states were getting a lot of money and used to build roads or whatever.  And it was...

Well, in ‘67, the Senate asked for a report of what was happening to all of this, and that was spearheaded by Dorothy Rice in the Social Security health insurance data program, but I was her co-chair of it, and that came as a health insurance report.

Pickren:                       Do you have a copy of it?

Knee:                           Yeah, I have a copy of it.

Pickren:                       I’d like to see that.

Knee:                           And the...  So that was kind of a baseline.  And it was later that, in some later amendments, that Medicaid had to come under the same standards as Medicare in the state hospitals.

Let’s see.  What was the next step along the line?  Sixty-eight.  What happened in ‘68?  I had a thought a minute ago, but in my senior moment it’s _____.

Pickren:                       When did you leave NIMH?

Knee:                           Well, I went on to the nursing home reform stuff in the – actually, the spring of ‘72, but I’d been working on the task force on the Nixon initiatives and nursing home reform.  It was a logical progression on that.  But all along the line, say, from ‘67 to as long as I was there, it was in the interweaving...

Oh, I know what happened in ‘68.  That’s the summer we spent in Baltimore.  Sixty-eight was the summer...

Male:                           _____.

Knee:                           Well, again, they were evaluating the Medicare program, so they set up a bunch of task forces, and our little group from our little branch had to staff several things.  Mike Gorman [sp.] was our psychiatrist _____.  He went to the West Coast.  But we had several other people.

There was one task force that was supposed to look at mental hospitals.  There was another task force looking at community mental health as a Medicare-related thing.  And there was a...  Then we had to kind of feed into the general thing.  Then there was a big group that the Medicare people and Pearl Beerman [sp.], for the public health part of it, set up to look at the independent practitioner issue, and that independent practitioner issue included chiropractors, speech therapists, physical therapists, psychologists, and social workers.  And that was a hard-fought study _____ we were – you will have the history of the psychology part of it in psychology, because the social workers and the psychologists were gung-ho on independent practice.  The chiropractors went off in another direction.  The physical therapists and the speech therapists – I guess occupational therapists were in on that too...

Male:                           _____.

Knee:                           What?

Male:                           ______.

Knee:                           That was another deal to decide...

Male:                           _____.

Knee:                           Yeah, that was another deal.

They were willing, in a sense, for physician referral, but sort of independent practice in organized settings.  And what social workers were offering was physician referral and the practice in organized settings, but they didn’t particularly want that.

Dowling-Smith:          Well, they resented – most of the suggestions were that they had to be supervised by a psychiatrist _____.

Pickren:                       What year was this, Ruth?

Knee:                           Sixty-eight.

Pickren:                       _____.

Knee:                           Yeah, right.

Pickren:                       This is the report that eventually comes out of all these task forces, right?  I mean, these recommendations.

Knee:                           Well, I think it was more than one report.  There were...  Oh, gee, I have a copy around my house.  There was one called the McNurny [sp.] Report and one called the...  I’m blocking on the name of the other report.  There were several reports that came out of that period of time.  And, as I say, they came out of either the, what was then the health, the Bureau of Health Insurance that was Social Security.  See, this was before they were brought in HCFA.  Or maybe from the Cashman’s [sp.] shop.  Dr. Cashman was the Public Health Service person that was in charge of the, along with Pearl Beerman [sp.] as his deputy, of the basic Public Health Service thing.

I know what I was...  The other thing that happened in ‘68 I was going to tell you about.

Okay, so we’ve got some standards out there that are Medicare provider standards.  But who’s going to survey on them?  And the state...  We had a big battle.  There was more than one big battle.  The state surveyors that were for the Medicare program were in the health department.  The state mental hospitals and the mental health people had their own survey group.  They set their standards as state standards.  They didn’t want anything to do with these state health department people, although we got them together in some meetings, but it was pretty...  _____.  And the...

                                                                TAPE 2, SIDE B

Knee:                           ...some psychiatrists and social workers, psychologists, etc., to be consultant teams that could go with the state Medicare surveyors to look at mental hospitals.  And we got some money transferred over from the Cashman [sp.]-Beerman [sp.] operation to us to pay for this, and we set up some teams _____ a roster of people that could be used. Well, the separate teams for psychiatric surveys, we ran out of my office for a while.  When I left, there were still...  _____ and Dorothy Collard were still running it in the ‘70s.

Now, along the line, the dear friends, Cashman [sp.] and Beerman [sp.], played little games with the money, so we had to then make the direct deals with Social Security for the money.  But that worked.  And I don’t know.  The regional offices were always notified of this.

Dowling-Smith:          Yeah.  We were not too much a part of that.

Knee:                           Not too much.

Dowling-Smith:          _____ going on _____.

Knee:                           We wanted them to know what was going on, and we wanted them to join in visits.

Dowling-Smith:          We did on occasion.

Knee:                           And on occasion, they did.

Well, that program has survived in name.  It’s gone through HCFA, gone through independent.  It’s now run by outside contractors, but it’s still being run with questionable, sometimes questionable, sometimes really good results.  But I know a couple of people that are still doing surveys for Medicare.  And, of course, Lucy Osering [sp.] did those for a long, long time.

Pickren:                       _____.

Knee:                           Right.

Pickren:                       _____.

Knee:                           Yeah.  Well, Lucy kept up with those for a long time.  But you see how some of these things spun off into different _____.

Pickren:                       _____.

Knee:                           Yeah, right.

Pickren:                       _____.

Knee:                           You put the nickel in.

Pickren:                       _____ lot of reason.  I thought to myself, it’s impossible to get a totally full report on what went on _____ because the...  I mean, Ruth’s picture of about a half-hour ago _____ possible.  It was absolutely true.  And _____.

Dowling-Smith:          _____ story in doing this.  There was no such purpose.

Pickren:                       That’s right.  We had...

Knee:                           Nobody wanted _____.

Male:                           _____.

Knee:                           Well, Dick phased out of this early on.

Male:                           Yeah.  There were a few others that worked on it, too.

Knee:                           Dick Williams worked on the very beginning, before we started the Mental Health Project Grant Program, because he was the one who did the original work with the voc rehab and set up those original, with Adeline Genasin [sp.], voc rehab, and Dick, and then I got when I came aboard in ‘56 into that team, did these regional meetings to talk about, again, hope in the treatment of the mentally ill and why mentally ill could consider being vocationally rehabilitated and placed in _____.

And then we had a whole other – road shows all over the country on aftercare, on community placement, on other aftercare programs.  And by ‘65, we had, oh, I don’t know, maybe over a hundred Title V programs in aftercare.

Pickren:                       What was the relationship of these aftercare programs to the development of halfway houses?  I know it’s not the same thing, but...

Knee:                           Well, that was in the big building in the picture of aftercare, halfway houses, day centers, and some other foster placement.  But...

Male:                           _____ continuity of care.  _____.

Knee:                           Yeah.  _____.

Male:                           _____.

Knee:                           Yeah.  And then there were single-occupancy places.  I know one time we did a roster of single occupancy.  We were always trying to collect bits of information, and I think that you’ll see in that stuff that you have from the Title V programs different groupings like halfway houses and community things.  The Fountain House was one.

Male:                           _____ Fountain House _____.

Knee:                           But, you know, our team was sent to visit a bunch of these things in ‘56.  We went up to Montreal to visit their pioneering day hospitals, and their hospitals, their psychiatric units in general hospitals.  Hal Hildreth [sp.] was part of our team.  Hal was always visiting things, and then _____ and I _____ social worker team would visit a bunch of halfway houses.  You know, anyplace you’d go in the country, you’d visit whatever was new and different.  And then we did fund some of these little symposiums or technical, what we called technical assistance projects, where we’d give the state up to $5,000.

Dowling-Smith:          _____ conferences and things, spread the word.

Knee:                           Harry McNeil [sp.] from the New York office was a taskmaster, pulling together the...  You know, there was a lot of ways to pull together ideas, to expand ideas, and to market ideas on that.

Male:                           I mean, the creativity was just unbelievable at that time.

Dowling-Smith:          There was no limit.

Male:                           There was no limit, and it was based on _____.

Dowling-Smith:          Somebody always built a good mousetrap and _____.

Male:                           And _____ he said, “You know, usually when you come to a place, they say, ‘You can’t do it.’”  He said, “You guys say, ‘Try it, see what happens.’”

Dowling-Smith:          That was always the attitude.  Certainly it was the office attitude _____.

Male:                           The amount of money really increased so exponentially during those early years.  As a matter of fact, it was research that was probably behind everything else.

Knee:                           Right.

Dowling-Smith:          The poverty program _____ because _____ became the next most popular thing and a lot of funds went to them.

Knee:                           Yeah.  The programs I’m talking about didn’t increase an awful lot over those years.  They knew money came in with the Title V program.  New money came in with HIP.  Then some of this other money, you see, came around in different _____.  The gal’s name I’m trying to think of is Turner.  She was...  Anyway, she kind of tried to put together...  And they stopped the Hospital Improvement Program in the late ‘70s and moved it into a community-based _____.

Male:                           She was in NIMH?

Knee:                           Yeah.

Dowling-Smith:          I can’t remember the name.  _____.

Knee:                           Maybe you’ll recall it.  But I’m sure that was the name.

Dowling-Smith:          What was her persuasion?

Knee:                           Well, she worked in rehab.  She was a...  I don’t know, a rehab specialist, whether she had a social work background or not.  She was a very persuasive woman, I can tell you that.

Dowling-Smith:          _____,

Male:                           _____.

Dowling-Smith:          Oh, yeah, a ball of fire.

Knee:                           Yeah, may God rest her soul.

Dowling-Smith:          _____.

Knee:                           Yeah, right.  This was after Murray’s time.

Male:                           This was after Murray’s time.

Knee:                           After Murray’s.  But they _____.  I know in the ‘80s, they were talking about several new programs that involved the state in planning kind of coordinated community care, and they – two or three names...

Dowling-Smith:          That may _____ been there in ‘85, left in ‘81.

Knee:                           Yeah, yeah.

Dowling-Smith:          Because the name doesn’t and the description...

Knee:                           No, they’re gone.  The description...

Dowling-Smith:          I usually remember.

Knee:                           And they worked some, you know, the state hospital director, Snibby [sp.], and that whole group _____...

Male:                           _____.

Knee:                           ...were other important actors in this whole mix _____ group.

Male:                           There was also...  You have to try to follow each one of this spreads and everything.

Knee:                           Yeah.  _____.

Male:                           And you come back to the issue of the state hospitals, for example, one of the things I think I remember, although we can check this out with the American Psychiatric Association, they used to be used for training purposes.  And then something took place, and they were no longer being used for training psychiatrists.  Now, a lot of other stuff was going on at the time because of the Vietnam War.  There were programs really arranged for these young psychiatrists to come in to NIMH.  It was an analog of the career development program, but it wasn’t a scientific program in the way that Ruth’s program was.  It was a program really _____, if I remember correctly.  Before he came into our division, Fuller came through that program, I’m pretty sure.  So a lot of things took place in the ‘70s.  I mean, Nixon at one point stopped funding a lot of stuff, too.

Knee:                           Incidentally, one of the other building blocks back again in about ‘68 was working with Walter Barton – I gave him a contract or a grant; I’ve forgotten; we had to manipulate whether we’d do a grant or a contract – to set up the planning for the standards that JCAH could use for psychiatric hospitals.  So that meant working with American Psychiatric and getting a staff person from them that worked with JCAH and a committee going on it so that they ended up with JCAH psychiatric hospital standards.  And then, of course, later on, that spun off into alcohol and different components.  And, of course, that whole JCAH scene is very different now than it was _____.

Male:                           By that time, the other two institutes were already spawned, they were separate, which took place in the early ‘70s.

Knee:                           Yeah.  They were beginning, although in the ‘60s, we still had to answer questions about, from Medicare, about alcohol _____ disability.

Dowling-Smith:          Yeah, well, the requirement for the community mental health center, for them to include some kind of units for the treatment of alcohol and drug abuse, and then they got into a political realm and _____ snatched away from us under the _____.

Male:                           Yeah.  I think alcoholism was first _____.

Dowling-Smith:          Right, right.  One area that doesn’t belong in this kind of discussion, but sometimes the long struggle still goes on about the difference in payment for mental health services and the other kinds of _____ services, and it has been in the paper recently about it.

Pickren:                       Well, I think it’s part of the secession.

Dowling-Smith:          It’s such a big one.  It’s putting some of the others first.

Knee:                           It’s always been discriminated against from the get-go.

Dowling-Smith:          Yes.  And _____ never was _____ or Medicaid money to pay for chronic care and never will be.  That just boggles people.  It’ll take all of the whole U.S. Treasury to do it and it’ll never be resolved, but then they’ve been equally niggling about payment for all other _____.

Knee:                           See, Medicaid money is used for chronic care.

Dowling-Smith:          You mean year after year?

Knee:                           Yeah.

Dowling-Smith:          Okay.  Well, I _____.

Male:                           Medicaid.

Dowling-Smith:          I know Medicaid.  Yeah.  Well, I know _____.

Knee:                           Medicaid.  But in different ways, you know, because for the chronically mentally ill of aging and then they lowered to some extent the age group.

Male:                           And finally, of course, well, there are two major things that happened _____.  One was deinstitutionalization.

Pickren:                       Yeah.  I wanted to ask about that.

Male:                           And the other was simply the removal of the whole services program from NIMH.  This took place early in the Reagan administration, at which time services had the largest budget in the institute, if I remember.  I’ve got the budget figures here.

Knee:                           But, see, they’d gone through that whole – and Jessie can tell you about this, and you were there when they were working on it, weren’t you, on the community, on the new bill?

Dowling-Smith:          I left at the beginning of ‘81.  I didn’t leave because Reagan got elected, but, hell, I’d planned my retirement before the election that fall.

Knee:                           Yeah.  But, see, in the Carter administration, _____ whole other deal.

Male:                           That’s right.  They had more data to study.  _____.

Knee:                           I was the _____.

Male:                           And the mental health _____ came out.  _____ prevention and _____.

Knee:                           _____ discrimination payment.  _____ things hidden in our...

Male:                           This was part of that Carter commission?

Male:                           _____.

Knee:                           I said the task force I was on was on ethics and the legal issues.  And so we made a big thing out about the discrimination, not just stigma, but _____ discrimination in the Medicare and in other insurance programs.

Male:                           That was such a bright light because we finally got that system _____.  It got passed by Congress _____.

Knee:                           Got wiped out.  The first thing that we wiped out under Reagan.

Dowling-Smith:          _____ now.

Knee:                           That’s what’s going to happen now.

Pickren:                       Well, I know that the two of you were no longer _____, at least I think I’m hearing it right, by the time that services was removed from NIMH.  But I would like to know more about that, about how that happened.  I mean, even though you may not have been there, you may know the players who were involved or may have followed it somewhat.  And, Stan, you were still active at that time.

Stan:                            Oh, yeah.  They simply decided that they wanted to put the money into block grants _____.  I mean, this was an overriding feature of the early Reagan presidency.  I remember that Stockman was head of the Office of Management and Budget at the time.  Okay?

Dowling-Smith:          What happened in the New York regional office was _____ because we were a staff of, what, six, seven, or eight professionals.

Knee:                           Yeah, right.

Dowling-Smith:          And clerical staff and so forth.  We were a big part of the health service setup in the regional office.  And, as I say, I left as Reagan came in.  And almost, I guess within a year, there was one person there who was under community public health, over in the Public Health.  NIMH and the regional office were wiped out.  And one person was retained in the whole health services complex in the Public Health Service to represent mental health interests, one person for a whole region.  And so its services were no longer there.  But there was no monitoring.  There was nothing _____ going on.

Male:                           _____.

Knee:                           I think Doreen survived a little longer in San Francisco.

Dowling-Smith:          I don’t know exactly when it happened, but it seems to me it was pretty...  _____.  _____ resignation _____.

Male:                           There were always things that you could do in San Francisco that you couldn’t bring off in New York.  _____ very interesting.

Knee:                           Well, that may be _____ San Francisco.  You ought to try to talk to Doreen Lowson.

Male:                           Who?

Knee:                           Doreen Lowson, who ran that office. 

Dowling-Smith:          She was still around.

Knee:                           Right.

Dowling-Smith:          _____ has the story of how it all went _____.

Knee:                           Right.  Because she was very involved in that systems bill.

Male:                           _____ people within the profession itself pushing for the split.  I mean, _____ was not just, it was not just the forces of Reagan.

Male:                           Oh, no, no, no.  As a matter of fact, there had been...  These are some of the things we had to put in this...  I keep thinking about tensions within the institute.  Of course, basically, if you look at that, within any given program and between programs, I still say, when I go down there,  some _____ divisions are still not talking to one another.  _____.

Knee:                           _____ played both sides of the street on this one, because I remember fussing with him and with – I’ve forgotten in what kind of meeting context it was – but fussing with him about letting the regional offices go down the drain, because I think that he was still around for a little while.

Male:                           He was around ‘70 to ‘77, basically.  Okay?

Knee:                           Well, he was...  But he was still...  We’re talking about Reagan came in in ‘81...

Male:                           That’s right.  Burt was dethroned totally when Jerry Cornerman [sp.] came in.  I mean, there’s no doubt about that.  He was given a small office down in the B wing.  He remained around for a little while.

Male:                           But Cornerman [sp.] wanted to be the ultimate scientist.

Male:                           Well, basically, what I was going to say was that what was happening was, because of a whole development of so-called biological psychiatry.  What was happening was a tremendous amount of pressure from a certain portion of the psychiatric research group.  And don’t forget that, historically, what you’ve got going on here is a conflict between what had been predominantly a psychoanalytic framework in psychiatry during the earlier years of the institute now rubbing against this biological thing.  I mean, departments of psychiatry separated from departments of neurology and all of that stuff.  Now the nervous system was becoming a major focus.  And it was a very, very significant group that really was arguing...  I mean, what they would do at every council meeting was to show what was happening in the rest of the NIH institutes to research budgets and to show what was happening in NIMH.  Of course, the National Cancer Institute, which was made a special case by Nixon, was absolutely going through the ceiling, whereas our research budgets basically did not move that much.  And this group had a great deal of power.  And the whole...  I always have thought of this as such a seminal conflict in the whole thing.  The whole conflict between those who made the discoveries and those who were responsible for getting _____ people _____ really an...  If this institute could have solved that one problem, it would have been absolutely incredible.

Dowling-Smith:          _____ experimentation _____.

Knee:                           Some of those people that are very active in that prevention coalition were in a sense playing both sides of the street on this, because they’d been the ones Beverly _____ had been pushing for research all along.  But...

Male:                           She is so angry at my having written that _____ prevention piece.

Knee:                           Is she?

Male:                           ______.  Beverly and I said I didn’t think that the NAS thing was worth very much _____ piece that the National Academy of Sciences did.  She said, “Okay, write.  Criticize it.”  And she thought I wouldn’t do it.  And I did it ______.

Male:                           As a matter of fact, this was also complicated.

Knee:                           But she wasn’t completely unhappy about services.  But she’s been the spearhead for some of this other...

Male:                           For the research.

Knee:                           Yeah.

Male:                           Also, you also have to realize that the Mental Health Association really was the kind of broader service-oriented outside counterpart of what NAMI developed into on the other side _____.  And departments of psychiatry, the American Psychiatric Association, was still a major outside player in the institute despite the fact that a lot of these other groups – Schibby’s [sp.] group and the Mental Health Association and so forth and so on, and the other professional associations – there was a time when in every council meeting, somebody was there from the American Psychological Association.

Knee:                           Oh, yeah, sure.

Male:                           And nursing and social work.

Knee:                           We were all liaison people.  I was a liaison person.

Male:                           That’s all gone, absolutely gone.

Knee:                           But we didn’t sit in for the whole council meeting.

Male:                           No.  You didn’t sit in.  You sat in for policy.

Knee:                           Yeah.  We sat in for policy.

Male:                           You didn’t sit in on the grant review stuff.

But what people were, I think to some extent – and I remember very well in this _____ – to argue for increased research presence and budget became the way to sort of argue for an increase for the whole institute.  You have to take that into account to some extent.  Okay?  Because it was very clear that, I mean, there was not only this fight within psychiatry about too much money is going to the services, research is being starved.  I mean, Danny Friedman [sp.] and that whole group _____ institute years before our return to NIH really happened.  Okay?  And that was a continual war.  So there was a group that was absolutely delighted when services were taken out of the whole institute.

Male:                           _____ put in.

Male:                           Yeah, yeah.  Well, this was after _____ was put in.  I mean, _____.

Male:                           _____ resented that.

Male:                           Oh, yeah.  Jerry got there, I think, in ‘77.

Male:                           And he put in...  Guess who he put in as his scientific advisor?  Charlie Krauthammer [sp.].

Male:                           Charlie Krauthammer [sp.], indeed.

Male:                           _____ was writing all these wonderful things.

Male:                           This is one of the most _____.

Knee:                           _____ came in with Burt.  Burt brought him on.  No, Burt brought him in.

Male:                           Burt brought Charlie in?

Knee:                           Yeah.

Dowling-Smith:          Did he bring him in?

Knee:                           Yeah.

Male:                           I _____ clearly _____ patient.  When Charlie broke his neck in the pool at Harvard, Kuhnman [sp.] took him on as a patient, and I thought Kuhnman [sp.] brought him in because he was _____.

Knee:                           I think he was there.  He may have gotten elevated.

Male:                           I remember _____ him.

Male:                           What a guy.

Male:                           Jerry thought he was _____.

Male:                           Oh, I was at a meeting.  I _____ said to Ed – Jerry was presenting his conception of NIMH and his role, and I said to him, “You’ve got the whole piece there?”  _____ obligation of the society to see that its people are _____ mentally healthy?”  He said, “That’s not our job, that’s not our job.  We weren’t given that mandate.”  So I said, “What about Head Start?”  He said, “That’s not our job.  That’s ICYF.”  I said, “What about the work and the role of work in adolescence?”  “That’s not our job.  That’s the Labor Department.”  _____.

Dowling-Smith:          And thank God it was psychiatry’s gain when he became a newspaper columnist.  But when he changed his profession and _____ suddenly became aware _____.

Male:                           He went to the New Republic.  _____.

Pickren:                       Let me ask about some things from the ‘60s.  This work of, role of services in the larger picture of civil rights and social changes, I’d like for you to reflect on that.  I mean, and Stan has talked quite a bit about NIMH efforts in the late ‘60s to begin training minorities.  But what about services related to minorities?

Male:                           Oh, there was a minority...  Wasn’t there?  Elliott Lepole [sp.].

Male:                           Elliott was _____.  That was the _____.

Male:                           Yeah, but originally _____ also a center for minorities _____.

Male:                           _____ Jim Rausch [sp.].

Dowling-Smith:          Well, I think all the time we were reviewing the project, the Community Mental Health Project Grants, that was one of the factors we were _____ for, population coverage for minority groups, and they had to show demographic data and so forth about how they would serve minority groups.  So I think it was blended in, became part of our...

Knee:                           It was blended.

Dowling-Smith:          And I remember what stimulated me in New York.  In the regional office, we had responsibility for reviewing those grants and then we sent our recommendations to the central office, where they were finally approved by advisory council.  But those reviews had been closed in NIMH and in the regional offices to the people who were responsible, the staff and the consultants that we brought in to do a review.  And so I was getting a lot of complaints, not just from minorities, but from the community in general:  Don’t we have a right to come and see what happens to our applications?  And so we decided on our own to invite the applicant group to come and hear the review and invite interested community members, members of organizations, and then whatever interested people wanted to come in.  It looked like a map of the United States by the time our conference room got filled with the kinds of people who came in.  And that was really frowned upon by the rest of Public Health Service.  I guess some of the people at NIMH said, “You’re going to get in trouble.  You didn’t even ask whether you could do this or not.”  And I said, “Well, I believe you do it and then let them object, and then we’ll present our case.”  And one of the people in one of the unnamed regional offices was very concerned, and he thought it was just never go over, and within a year, he was doing it himself and taking credit. I won’t tell you who he was.  But it became a wonderful thing because here they were hearing the reviews.  Now, we did go into executive session when we made the decision about what to do about it.  But then we would call the applicant group back in and tell them what we had decided right there on the spot, and they would get a formal report on what needed to be fixed or _____, and then we would work with them on fixing it.  But that was the greatest thing in the world.

Male:                           The involvement of the community.

Dowling-Smith:          We had these people coming in, participating, and they were not disruptive.  Once we had a group from, probably a Harlem group when we were reviewing one of their grants, and so we’d gone into session and we had a lot of people sitting around the room and so forth, and this militant black group walked in with their arms folded and _____.  So I stopped things and asked them who they were and what their concern was, and we got them chairs and they finally agreed to sit down.  They were standing in a very stiff posture.  And they unbent enough to sit down and finally were participating.  But they didn’t know who we were, so they came in there really, you know, like big government, do it their way, and they found that we were just as concerned about doing something _____ they were.

Pickren:                       Jessie, while you were in the New York regional office, wasn’t it during the period when the – I want to call it the Lincoln Community Mental Health Center, but I may be wrong.

Dowling-Smith:          Lincoln Hospital.

Pickren:                       I’d like for you to describe the _____ because it achieved some notoriety, not only in its own time, but historically it’s referred to.

Dowling-Smith:          Is it really?

Pickren:                       Oh, yes.

Dowling-Smith:          I’ve read some of the recent _____.

Male:                           _____.

Dowling-Smith:          Right, right.  He was the only time I ever made the New York Times.  I was quoted twice.  _____ Lincoln Hospital.

Male:                           _____?

Male:                           Yeah.

Dowling-Smith:          I can’t give you the details.  I haven’t thought about it for years, although it gave me nightmares for quite a long time.  But that was an instance where we found out, after the grant had been given, that the money had been totally misused.  They had put it into – I don’t remember whether they were the ones that were intending to or had achieved the private psychiatric pavilion with some of the construction money we’d given them.  It was a stipend grant and construction money.  And enough horrible things had happened in misuse of the funds, and I think the grant had been given even before I went to New York.  And then, of course, we didn’t monitor all that regularly.  So we closed it out and told them to reconstruct and that sort of thing and give us a whole new plan.  And so their first move was to go to the newspapers and the public and complain that the government’s interfering with what they wanted to do.  And I don’t remember all the struggles now.

We were not – it was all of NIMH that was up in arms about this.  It wasn’t just the regional office, but we were having a lot of meetings in the regional office.  But we were not the ones solely responsible because all of NIMH was concerned, so the much bigger issue _____.

Male:                           There were other kinds of funds _____.

Male:                           _____.

Male:                           Well, it was associated with Einstein at that point.

Dowling-Smith:          Well, Lincoln Hospital always was with the Einstein Medical School.

Male:                           It was associated with Einstein.  And it was, of course, located in what was probably one of the most impoverished _____, in the Bronx.  _____.

Dowling-Smith:          _____ the Bronx’s Harlem.

Pickren:                       The funds were misused for, in terms of what?

Dowling-Smith:          I would have to look at the record to tell you because _____.

Male:                           ______.

Male:                           Here’s kind of where I want to go with this.  I think you’re describing one aspect of it, but unless I’m misunderstanding what I’ve read in the past – and I may be mislocating it as well – either it was at Lincoln or another one related where there was a staff takeover of the community mental health center.

Male:                           That was the _____.  That was Lincoln.  That was the Bronx.

Dowling-Smith:          Metropolitan Hospital had trouble, and that probably was part of it.  I would have to _____.  I wouldn’t want to cast blame _____.

Male:                           _____.

Male:                           _____.  We had it written up _____ in that book.  We have a description of what their program was to be, and _____.  _____.

Male:                           _____.

Male:                           You’ve seen it?

Male:                           Yeah.  But you loaned me a different book.  I don’t have the other book.

Male:                           You don’t have the _____?

Male:                           No.  You sent me a different book.

Male:                           I’ll send you a copy of that one.  But they _____ Bronx _____.  At that time they didn’t have _____.

Male:                           ______ something like this would happen.

Dowling-Smith:          Oh, yeah.  I wrote innumerable reports, but I have no – I’ve moved so much since I left there, I _____ became records from the past.  And I doubt if _____ regional office wouldn’t have any.  There may be some at headquarters if they have filing done that way.

Knee:                           _____ probably in St. Louis or wherever.

Dowling-Smith:          It’s probably in St. Louis.  It might be retrieved under some kind of _____.

Knee:                           A lot of things in St. Louis _____.

Dowling-Smith:          It’s too bad _____.  _____ still around _____ details about that because our staff, of course, has long since scattered.

Male:                           Yeah, dispersed.

Dowling-Smith:          ______ thing.  And _____ idea.  He was a very hostile person anyway.

Male:                           That’s what I heard.

Dowling-Smith:          Oh, just...

Male:                           And arrogant.

Dowling-Smith:          He was a mean, arrogant man.

Male:                           Yeah, very arrogant.

Dowling-Smith:          And he was not – he would admit to no wrong.  And his idea was that we were all wet anyway.  He knew a lot more about this than _____ regional office.  And he was going to _____ through and do it their way.  And, of course, we _____.

Knee:                           Give us the money, we’ll...

Dowling-Smith:          Yeah.  Give us the money and we’ll do our own _____.

Male:                           ______.

Knee:                           That was _____.

Dowling-Smith:          ______ wrote a proper grant or the one that passed muster anyway, and then they put _____ it was all done, you know ______.

Knee:                           You know, all along, the problem of accountability has been a very difficult one.

Dowling-Smith:          Oh, very.  That was a lot of the reason _____.  And, of course, we had many wonderful encounters with people _____ to see how to do it.

Knee:                           Some people have been very accountable.

Dowling-Smith:          But _____ like him _____.

Male:                           _____ a great deal of money dispensed through grants.  There are people who are opportunists.  You see that _____.

Knee:                           But they’re the ones who say, you know, why should I...

Dowling-Smith:          _____ private psychiatric pavilion.  Well, that was just so blatantly out of the _____ that we turned _____.  

Male:                           Occasionally we’d run into something like that.

Male:                           You ran into that, but, you know, recently – what was it, about four years ago, three years ago – they tried to get Burt because they claimed that a lot of money was misused for the community mental health centers, some of the _____ and stuff like that.  And they couldn’t do it, they couldn’t do it.  But they had an investigation.  Some guy was trying to investigate and show _____.

Knee:                           Well, _____.

Male:                           ______ really _____.

Dowling-Smith:          He was another hostile person.

Knee:                           Right.

Male:                           Oh, yeah.

Dowling-Smith:          He used to come up to the regional office.

Male:                           ______ was an interesting guy.  When he came to our division, he was basically in charge of the paraprofessional training program, and he had done some very interesting work.  _____ had a degree in anthropology, if I remember, as well as psychiatry.  And he had been on one of these remote Aleutian islands and in charge of medical _____ services there, one of the islands, way out, you know.  And I remember working with Fuller.  But he’s become...  _____ so obsessed with particular theories of the causes of schizophrenia.

Male:                           ______.

Male:                           He basically _____.

Male:                           _____ test tube.  I’ll never forget it.  He said, “I have the answer for this schizophrenia right in this test tube.”

Male:                           But he – that really followed on stuff that he had changed a fair amount.

In training, I remember we had one program.  Training was usually ______ simply blatantly trust university administrators either.  _____ in terms of ______.  I mean, they think that’s very safe and all of that.

We had funded a professional school of psychology in Puerto Rico, and it was under a reputable psychologist.  There were some other people who were working with him.  It also was, strangely, supported by the Episcopal archdiocese of New York and the Dominican fathers down in San Juan, just outside of San Juan.  And I had done a site visit down there with a consultant at the time, a consultant who had been a predecessor of mine in a training grant, as a matter of fact, Durham Alexander [sp.], from way, way back then.  And it was reviewed.  He submitted some work.  Then I began hearing about the fact that the students were not receiving their stipends from the training grant.  That’s a pretty bad thing.  Okay?  So we went down there and we were confronted – somebody from the regional office, and it was your regional office because _____ region I that had Puerto Rico.  One of the students, Victoria Moreno [sp.], was _____ daughter, and she was a fire _____ and she knew everything that was going on.  So the FBI was also in on this thing.  And finally, after finding out how badly _____ used, _____ came back and went in to see Burt.  And I said, “Burt, _____ discontinue funding this program.”  _____ no way that we can continue doing this.  But that was really the only time...  The Lincoln Center thing is much bigger.  It’s _____.

Dowling-Smith:          Don’t blame Lincoln Center for that _____.

Male:                           Right.  This was a training grant.  And, as a matter of fact, they had one in alcoholism.  And Len, who was then in the Alcohol Institute, came down with me at the same time with one of his colleagues, who we had this amazing visit down there.  And there was really no choice.

Male:                           Well, what ever happened to Lincoln?  Did they close?  Did it finally close?

Male:                           I don’t think so.

Male:                           No?

Male:                           I don’t think so.

Dowling-Smith:          _____ opened up under a new, revised plan _____ new direction.

Male:                           I knew they got rid of _____.

Dowling-Smith:          He was bad news all along.

Male:                           But I didn’t know whether they were reopened or _____.

Dowling-Smith:          Well, you see, our concern was we’re not like this new administration who’s going to close the bad schools, punish them by closing them.  We closed it because the money wasn’t being used right.  And our concern was to get those people ______ community mental health center, and we wanted to _____.  As I remember, I can’t tell you specifically, but we would have worked on revising the plan and getting a new administration and going ahead, because all of Lincoln Hospital wasn’t _____ with people like Harris Peck.

Knee:                           The difference in whether you try to help people gain a knowledge base to use the resource and _____.

Male:                           And hold them accountable as you _____.

Dowling-Smith:          _____ help you do this as _____ as we can, get experts in here and do all kinds of things.

Male:                           This is the other _____.

Knee:                           Back to one of the things you asked about before Lincoln.  After ‘64, I guess, when the legislative, the federal legislation meant that mental hospitals had to integrate, and this was a great problem for the places in the South.  Now, when we’ve done hospital surveys, we always went to the black units, the Negro units, as well as the white.  Sometimes they were separate facilities, separate locations.  Sometimes they were simply separate buildings.  And so you’d come out with some pretty scathing things about what happens.

For instance, in ‘64, at Millageville [sp.], I just...

Male:                           I knew it was going to be Millageville [sp.].

Male:                           Where was Millageville [sp.]?

Male:                           Georgia.

Knee:                           Oh, God.  That was a terrible summer.

Dowling-Smith:          The snake pit of the South.

Knee:                           That was a terrible summer.  But they allowed the blacks to be butchers and everything else, to have a regular  _____ there, they had all these knives, but _____ the blackboards.  There were no knives.  They served mush or grits three times a day.  And people like Dick Elwell [sp.] would go out and visit all these wards at night.  And, of course, particularly in the black wards, they were all on the floor on just pallets.  And they were big, big strapping guys.  I said, “You know...”

                                                                TAPE 3, SIDE A

Knee:                           ...’82 to ‘90.  And, well, anyway, we can’t go in with a shovel and change it.  And I may have told you my story about the black cemetery at Millageville [sp.].  But they dug the graves with a backhoe.  They...

Anyway, when it came time for those hospitals, they had to combine their populations.  They were under great stress.  And some of them did it better than others.  Some of the regional offices, the Atlanta regional office, Shirley Middleton was particularly – she was a nurse; she’s dead now – was particularly trying to help, and Clare Calhoun [sp.], a psychologist, really tried to do what they could to help bridge this thing.  And we missed a good chance to study, you know.  If there could have been...

Male:                           Oh, we missed _____.

Knee:                           _____ study.  But what they tried to use was transfer trauma to show that the whites couldn’t be transferred to be a part of this.  But, anyway, it gradually happened.

And then, you know, the Justice Department got into the act, their civil rights group.  Now, not just...  In a way, when you went out to the hospitals, you were looking to see, help them move towards it.  But the Justice Department civil rights group had a special study of mental hospitals, and we recommended a number of consultants that they used, Bob Hunt being one that I remember particularly, as they visited mental hospitals to see how they were complying with civil rights.

I guess there’s better demographic...  Ron Mandershein [sp.] must know right now what the data is on _____.

Male:                           _____ research that.

Knee:                           Oh, right.

Male:                           Well, we could have...  I once said to Pardess [sp.], _____ Pardess [sp.], I said, “You know, we missed the boat on the women’s movement.”

Male:                           Of course.

Male:                           The whole...  And, you know, why couldn’t we have done a major NIMH-funded study of what has happened to women in our society as _____.

Knee:                           Well, they had a unit then that was focused on rape and...

Male:                           Yeah, but _____.  _____?

Male:                           That was like, you know, you brought something up from another world, which was, it was _____.  As matter of fact, it was interesting that the Reagan administration not only took the service aspect of NIMH away and put it _____, but in research, they also did away with the support of social research with _____.  A lot of the social research at the time had to do with the effects of poverty on mental health.  Now, this I thought was...  When we first heard about it – and you can imagine _____ sort of up in arms – and it had a very profound effect on social psychology.  I can go over that with you in fairly great detail.

Last year, at the APA meetings, Alan Lushin [sp.] was giving a talk.  Alan is now head of the Drug Institute.  He had been deputy director of NIMH and I’ve known Alan for years.  And Alan gives a very, very good talk about the whole drug unit, standing room only.  And at one point he finally said, “You know,” he says, “in all the research, there’s one thing that really shoots across every problem that we’ve got to deal with _____ poverty.”  _____.  I said, “Alan, I’m so delighted to hear somebody _____.”  _____.

Male:                           _____ at the meeting _____ kept saying.

Male:                           It wasn’t that we didn’t know.

Male:                           The major _____ always comes out.

Dowling-Smith:          Well, and there’s a sort of a sidebar, but NIMH was very progressive in putting women in charge of things, like I was in charge of New York regional office, Cafritz [sp.], Doreen [sp.], and Ann Toomey [sp.] in Boston, and we were sort of a phenomenon within the regional offices, and there was a little bit of discrimination against us, and that’s like mental health.  They have a _____ woman in charge _____ get the undercurrent.

Male:                           _____ liberal.

Dowling-Smith:          Yeah.  Well, when I went to the New York regional office – speaking of discrimination, not just against women – I looked around, and this regional office occupied a whole floor within the first year in the new Federal Building, in the public health part of it, _____, not even see from one side to the other.  There was not one black professional staff member in 1965 in New York City.  And so I said, “Things have got to change,” so I started looking particularly for qualified blacks, and to the extent that once I was on the carpet for selecting two blacks.  I had two positions to fill and two blacks were on the staff of mine, and one white person.  The white person was bringing charges against me through personnel for discriminating against a white man.  I won it.  I learned after I left the agency – it was still being worked over when I left, and I learned after I left that I had been completely exonerated and they sent me a commendation for what I’d done.  You know, really, I had to prove over and over and over again why I chose these two black people.  And by then, HEW had furnished me with a lawyer, and he said, “Don’t ever say, in any of these meetings, that you picked these people because they were black.”  By then you couldn’t even say.  But I had – I was careful in doing it.  I picked them on their merits, each one of them, to a supervisory position, and each one of them had a little more experience and supervision in managing people than the other one did.  But that was how the case was finally won.  So, speaking of discrimination, the Public Health Service itself was...

Knee:                           Well, my husband always said that he thought that the National Institute of Mental Health discriminated against women.

Dowling-Smith:          Well, and they did, but they were the only ones that would recognize _____ something.

Male:                           _____.  And we had a tremendous amount of trouble when Rita _____ became deputy director.

Male:                           Oh, really?

Male:                           Oh, yeah.  First of all because she was a nurse, she was black, _____.

Knee:                           _____ had a lot of energy.

Male:                           Oh, yeah, yeah.  She was marvelous.  But there was a tremendous amount of resistance to that.

Male:                           They were trying to, unfortunately, you had people who were not qualified to do a good job.  So they put a woman ahead of the mental health study center who was a psychologist – I wonder if you shouldn’t talk to her even though I don’t like her.

Male:                           Oh, Berriss [sp.].

Male:                           Berriss [sp.].  And she did such a lousy job that the staff revolted.

Dowling-Smith:          Well, that also happened, and they began to recognize...

Knee:                           She marches to a strange drummer.

Male:                           Herself.

Pickren:                       Ruth, you have some materials out.  Is there something there you want to...

Knee:                           Well, Jessie and I thought you might like to have some green files here.

Dowling-Smith:          You might want to know whom you’re talking to.

Knee:                           _____ highlights.  Actually, this was put together on this form.

Dowling-Smith:          _____ it gets better on the back page.

Knee:                           _____ this club because they wanted to know your publications and speeches over the years to judge you _____.

Male:                           _____ to give you _____.  Ethics of research.

Dowling-Smith:          Did I put my former name on that resume?  I thought so.

Pickren:                       Dowling doesn’t appear.

Dowling-Smith:          Yeah, Dowling.  So if you’re looking for files, _____ stuff you might need to know.

Male:                           I’ve been through _____.

Knee:                           Oh, have you?

Male:                           Yes.  _____ where it is.

Knee:                           It’s right next to Tulsa; it’s west of Tulsa on the interstate.  So if you’ve gone _____ Highway 40.

Male:                           Yes.  That’s _____.

Knee:                           Incidentally, you know, _____ in there about the NASW.  _____ president was one of the first award winners of the Knee-Whitman award at NASW.

Male:                           Oh, really?

Knee:                           Yeah.

Male:                           Who was this?

Knee:                           Pat Daleo [sp.].

Male:                           Award winners of the Whitman award.

Knee:                           Of the Knee-Whitman award.

Male:                           _____.

Knee:                           Yeah, right.

Male:                           I didn’t know that _____.

Male:                           _____ Milt Whitman.

Knee:                           NASW has an award in my name and Milt Whitman’s.

Pickren:                       Ah, okay.  And Pat won it.

Male:                           And Pat won it.

Knee:                           And Pat won it several years ago.

Male:                           Also, Pat has a Hildreth [sp.] award also.

Knee:                           Yeah.

Male:                           And Pat’s got a lot of _____.

Knee:                           Well, Hal, you were asking about some, again, in integration.  Hal almost got assigned as some special deals, and he was one of the special deals he worked on, was that Prince Edward County, Virginia school system, where they shot down the public schools in their refusal to integrate, and Hal worked on that, he and I, and _____ some alternative ways maybe in the little pockets of federal money.  It was not out of our direct grant programs, but to help in that.  And I’m trying to remember whether we...  You know, some of our studies were disguised under other names, like the Highland [sp.] Lewis study.

Male:                           That was the one that Elliott was involved in.

Knee:                           Oh, here in the district.

Male:                           In the district.  He _____ Halley’s [sp.] Corner _____.

Knee:                           Right, yeah, right.

Male:                           Over at the study center.

Knee:                           Right.  Well, that was the Title V study.

Male:                           Was it a Title V?

Knee:                           Yes, right.

Male:                           _____ last year or two years ago.

Knee:                           And that was first called, oh, I don’t know.  We made him change the title of it because...

Male:                           But that’s where Elliott got his funding _____.

Knee:                           But it was through that study of Negro teenagers in the District.

Male:                           Teenagers and also the men, the _____ men.

Knee:                           Well, it started out with teenagers.  And some of their first findings were when the teenagers got to be 12 or 13, they were no longer under control of their mothers, and their mothers – that was their family.  So basically they were no longer under family control.  But... What was that?  Childrearing in the Slums, I think was the name of the first...

Male:                           _____.

Male:                           _____.

Knee:                           Yeah, right.

Male:                           And NIMH, I mean, we really did _____ Corner.

Knee:                           And then Ronnie Mitchell had that baker’s dozen thing, which was a kind of a community thing.  And...  Well, I’ve forgotten whether we funded it or not.  I think we did, because Ed and I made a site visit to Richmond, California, to their community center there, where they were, and that was a hot, black area then, on what they were trying to do.  There again, I was looking for Title V funds.

Ed Flynn and I said that we thought a lot of these things, people were getting the money from Title V to gear up to get the OEO money, and in a sense, the Title V money almost had to be a bandaid, if not a demonstration, because it couldn’t cover as wide a scope as some of the OEO money was supposed to do.  I know we all _____ some efforts from Nate _____ Bill Smith to from – that would have been Burt’s office – to Arstan’s [sp.] office to pull together some of these programs that were coming, these different streams, including Children’s Bureau, etc.  And we would make group site visits, like we visited the _____ homes and a whole lot of other services in New Orleans one hot summer.  Again, it was an integrated service, but it was an equal rights kind of visit, too.  That one must have been the summer of ‘70.

Pickren:                       So you – when you were in special grants any of this time, what was the relationship between what you were doing and, say, some of these specialty centers, like metropolitan problems or minority studies?

Knee:                           They didn’t exist.

Pickren:                       In the late ‘60s, they did, though.  That’s when they were created.

Knee:                           I know, but this was...

Pickren:                       You’re talking about before that.

Knee:                           I’m talking about before that, because from, actually ‘65, but specifically ‘67 on, I was in this, the point person for Medicare and Medicaid and funding.  So a lot of this general across-the-board stuff we did...  When was...  In ‘65-‘66, when they reorganized a lot of the programs, I know we had that retreat out at _____ House in ‘65, when they really played poker with our programs.

Male:                           I didn’t think I was there.

Knee:                           Well, I don’t think you were.  Jim Osbrook [sp.] was our branch chief then.

Male:                           _____ services.  That was a services thing.

Male:                           Training was not involved in that.

Knee:                           To a certain extent, they were, because, you see, it was ‘65-‘66.

Male:                           Well, ‘67, when we left NIH.

Knee:                           No, but I’m talking about when they pulled apart, you know, Title V had grown big, and we had these several review committees.  That’s when they pulled it apart into several different review committees.  And Howie Davis went over to some of them, and other people, and started some of these other places.  And Phil Suratkin [sp.] and – what was his name, Feldman?

Male:                           Yeah.  Saul.  Saul Feldman.

Knee:                           Well, no, Saul hadn’t come on then.  No, the fellow in training.

Male:                           Ray.

Knee:                           Ray Feldman.  _____.

Male:                           Ray was in charge of _____ when I came here.

Knee:                           Saul probably came on after that community mental health center group got geared up.

Male:                           We probably should stop, though.  We’ve kept you two hours and I don’t want to...

Knee:                           Well, I made a lunch reservation for us, so we can sit around the table.

Male:                           Okay, and talk.

Knee:                           But have we given any sense to _____?

Male:                           _____.

Pickren:                       What I would like to do, though, is I’ve already listened to tape one again, is I’d like to be able to come back to you maybe over the phone and say, “Can you clarify this for me?”

Knee:                           Sure, sure.

Pickren:                       But thanks for the day.

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