Origins of Mental Health | Johns Hopkins | Bloomberg School of Public Health

The Realization of an Idea

by Dr. Wallace Mandell

The term mental hygiene has a long history in the United States, having first been used by William Sweetzer in 1843. After the Civil War, which increased concern about the effects of unsanitary conditions, Dr. J. B. Gray, an eminent psychiatrist, envisioned a community-based mental hygiene that would operate through education, social culture, religion and involvement in national life. In 1893, Isaac Ray, a founder of the American Psychiatric Association, provided a definition of the term mental hygiene as "the art of preserving the mind against all incidents and influences calculated to deteriorate its qualities, impair its energies, or derange its movements. The management of the bodily powers in regard to exercise, rest, food, clothing and climate, the laws of breeding, the government of the passions, the sympathy with current emotions and opinions, the discipline of the intellect—all these come within the province of mental hygiene." (Rossi, A., Some Pre-World War II Antecedents of Community Mental Health Theory and Practice. Mental Hygiene, 1962, 46, 78-98).

At the turn of the nineteenth century, Darwinian thinking dominated the biological and social sciences. Within the scientific community, mental deviations, i.e., extreme variations, were conceived as having a biological basis, primarily genetic, representing mutations that were unsuccessful adaptations for survival in the environments in which they appeared. This view provided little hope for recovery of the mentally deviant. Around 1900, some physicians and psychologists became convinced that deviant behavior was an expression of illnesses that lay at the other end of a continuum from mental health. Among leading thinkers of this period, G. Stanley Hall was convinced that early treatment might reduce both the severity and reoccurrence of mental illness. Adolph Meyerwas probably the single greatest proponent of this view. In 1906 he wrote on "The Problem of Aftercare and the Organization of Societies for the Prophylaxis of Mental Disorders" (Winters, E.E., The Collected Papers of Adolph Meyer, Vol. IV, Mental Hygiene. Baltimore, The Johns Hopkins Press, 1952).

By the 1890s, Meyer had become convinced by his experience with mental hospital patients that industrialization and urbanization were undermining human potential for continuous adaptability and constructive activity (Meyer 1921, quoted in Dreyer 1976). Meyer, combining the social reform ideology of the nineteenth century with his training as a physician, held that what man needed was a biologically sound idealism (Dreyer 1976). His concept of mental hygiene sprang from experience with the child study movement of the period. He proposed to apply those techniques to psychiatric hospital patients through study of their life histories, also including family and community factors. By 1908, these studies expanded Meyer's conception of mental hygiene to include reaching out into the community to prevent mental illness and preserve good mental health. Adolph Meyer, one of the founders of the mental hygiene movement in the United States, recalled that this new enterprise arose from "a mixture of humanitarian, fiscal and medical factors" (Meyer 1952).

Clifford Beers, after his release from an insane asylum, drafted the manuscript of his book A Mind That Found Itself, which included an agenda for mental hygiene societies. Under the sponsorship of William James and Adolph Meyer, the book was published in 1908. Beers called for the formation of a permanent voluntary health agency whose prime function would be to prevent the disease of insanity by providing information about it to the public. In the 1908 prospectus of the Connecticut Society for Mental Hygiene, the first in the nation, an article was included that committed it to "war against the prevailing ignorance regarding conditions and modes of living which tend to produce mental disorders." For this purpose the society set about to secure state legislation and appropriations, develop coordinated local programs to impregnate the schools and courts with the preventive view, and disseminate sound attitudes toward mental and emotional problems. Meyers wanted to move the mental hygiene movement, then focused on programs of intervention in social problems, to accept the necessity of basing its proposals on scientific research. He proposed a program of research based on the belief that the causes of mental illnesses were rooted in the interaction between biology and life history events. Meyers began a biographical or "life story" approach to studying mentally ill patients to provide a scientific knowledge base for mental hygiene efforts (Dreyer 1976).

In 1908, William Welch, dean of the Johns Hopkins Medical School, was present at the founding meeting of the National Committee for Mental Hygiene. He became its vice president in that year and later, in 1923, its president. In 1912 Thomas W. Salmon became the medical director of the National Committee. Under these auspices, he compiled statistics about mental illness for the United States. The Surgeon General of the United States Army became interested in the problem of psychiatric casualties in response to data on this problem in the peacetime army compiled by Pearce Bailey Sr., chief of neurology, psychiatry and psychology in the Office of the Surgeon General. Salmon worked with Welch on the problem of psychiatric casualties during World War I. During World War I, the National Committee for Mental Hygiene turned its attention to mental health problems in the armed services. American psychiatrists were able to detect and treat "shell-shock" casualties with success rates believed to be superior to those of other countries (Strecker, E.A., Military Psychiatry: World War I, in One Hundred Years of American Psychiatry. New York, Columbia U. Press, 1944, 385-418). Based on these experiences, William H. Welch and Witcliffe Rose included mental hygiene as part of the course of studies in their prospectus proposing the founding of the Johns Hopkins School of Hygiene and Public Health to the General Education Board of the Rockefeller Foundation in 1915.

In line with the thinking about the emerging role of local departments of public health, in 1915 Meyer envisioned community mental hygiene districts in which the services of schools, playgrounds, churches, law enforcement agencies and other social agencies would be coordinated by mental health personnel to prevent mental disorders and to foster sound mental health (Meyer, A., Organizing the Community for the Protection of its Mental Life. Survey, 1915, 34, 557-560).

Apparently Welch was looking for a leader for the mental hygiene activity and considered offering the position of professor of Mental Hygiene to Salmon in 1918. However, Salmon was not interested (Lemkau 1961). Despite the lack of a professor, social and mental hygiene were included in areas of study for candidates for the degree of Doctor of Public Health in 1920 (Preliminary Announcement, School of Hygiene and Public Health, Baltimore, Johns Hopkins Press, 1981.)

C.E.A. Winslow, professor of Public Health at Yale, was also concerned to include mental hygiene in public health education. He described mental hygiene in 1933 as "an organized community response to a recognized community need; and it lays its prime emphasis on the detection and the control of those incipient maladjustments with which the physician qua physician never comes into contact, unless specific community machinery and far-flung educational facilities are provided for the purpose." (Winslow, C. A. E., The mental hygiene movement and its founder, in National Committee on Mental Hygiene, The Mental Hygiene Movement, Garden City, NY, Country Life Press, 1938, pp. 303-17.)

The first International Congress on Mental Hygiene convened in 1933. Included in the purpose statement there was the idea that it was necessary to determine "how best to care for and treat the mentally sick, to prevent mental illness, and to conserve mental health" (in National Committee for Mental Hygiene, The Mental Hygiene Movement). By World War II, the mental hygiene movement had expanded to the ideas that 1) maladjustments that are not psychiatric but that bring the child into conflict with the law are of concern to mental health; 2) even slight deviations from harmony with the environment in the social world of the school and nursery are close to the roots of ultimate difficulties that produce mental disorder; 3) institutional programs should be encouraged that are favorable to the creation of a mentally healthy environment; 4) community forces should be coordinated to supply mentally health environments; and 5) mental health principles should be integrated into the practices of social work, nursing, public health administration, education, industry and government.

The mental hygiene movement, as it was called, was criticized in some medical circles for its lack of an objective scientific basis for its proposals and its "unscientific" focus on sociological factors as being the key to the prevention of mental illness and preservation of health. The mental hygiene movement was torn by differences between psychiatrists devoted to treating the mentally ill through biological means and mental hygienists attempting to promote mental health by changing societal institutions.

In an attempt to increase the scientific basis for mental hygiene activities, a mental hygiene study unit with full-time personnel was established at Johns Hopkins in 1934 (Dr. Ruth Fairbank, psychiatrist; Dr. Bernard Cohen, statistician; and Miss Elizabeth Green, social worker) (Lemkau 1961) to be the urban counterpart of a rural study carried out in Williamson County, Tennessee. In this first study, in the Eastern Health District of Baltimore City, all cases of mental disturbance, illness or retardation were identified from agency records and self reports of symptoms and were analyzed in terms of age, sex, geographic location and socioeconomic status.

Adolph Meyer proposed a young physician, Paul Lemkau, whom he had trained as a psychiatrist at Johns Hopkins, to continue the work on the precedent-setting Baltimore Study of Chronic Illness at the School of Hygiene and Public Health. In 1936, further data were gathered and analyzed by the Lemkau, Tietze and Cooper team (Cohen and Fairbank, American Journal of Psychiatry 1937-38; Lemkau, Tietze, Cooper, 1940-41). This study was pioneering in that it included data on the extent of mental illness in a defined population sample using both survey methods and institutional records. Working with Dr. A. W. Freeman, Lemkau became convinced that epidemiological study of the prevalence of mental disorders was possible.
Clinical psychiatrists of that period rejected symptom inventories as an inadequate basis for determining the prevalence of disorder (Kleiman and Weisman). Lemkau believed, accordingly, that mental hygiene would have its foundation in research based on the treatment of individual patients. He held that theories could be formulated from this clinical research that would serve as a basis for preventive programs directed toward whole populations.

Working with Meyer, Lemkau had developed a deep commitment to the view that mental disorders had a biological basis, and a conviction that life events were the precipitants of illness. These events, identified by the life history method, would provide the database for a theory on which prevention programs could be based. Meyer had envisioned the nation divided into mental hygiene districts in which psychiatrists would catalyze friendships and cooperation among teachers, playground workers, charity organizations, ministers and physicians, to help individuals and families maintain their mental health by teaching people constructive tolerance for individual differences. In 1941, Lemkau presented the first course at the School of Public Health, relating the material arising from personality development research to public health practice. Working with the faculty teaching public health practice to future health commissioners, he became convinced that the expanding public health system would provide the institutional opportunity to bring mental hygiene to the population. As he envisioned it, mental health practitioners in public health would use the tools of epidemiology and biostatistics to diagnose the mental health needs of the population while mental health education could produce effects analogous to immunization for mental disorders.

World War II intervened, and in 1941 Lemkau entered the Army and was assigned to Walter Reed Hospital. He continued to direct the mental hygiene study and teach at the School of Hygiene in the evenings. This led to efforts to integrate wartime psychiatric experiences into public health. Working with psychiatric casualties convinced Lemkau that early detection of mental disorders and early treatment could reduce the duration of episodes of mental illness. He observed that individuals provided with rapid short-term treatment at front-line psychiatric clinics were less likely to develop enduring neurotic disorders. Weaving these strands of experience together, Lemkau conceived the idea of locating mental hygiene activities in local health departments close to community sources of stress. He envisioned a psychiatric clinic located in each local health department. Health department psychiatric outpatient clinics would heal the sick and also prevent future disorders (Lemkau 1955). Based on his war experience, he believed that the damaged personality could be changed in outpatient treatment by the verbal reconstruction of improperly assimilated past stressful experiences. For those individuals who had sustained injury leading to a chronic mental condition, clinic treatment would return them to efficient living through education to replace missing functions. The observation that "personality tends to recover from mental disease when the etiologic agents such as stress have been removed" (p. 8) suggested that the psychiatric clinics should also work to decrease stressors in the community uncovered during the course of treatment.

Lemkau propagated the concept that mental health could be promoted by health department psychiatric clinics through educating the population about how individuals might process stressful experiences more healthfully. Training in appropriate processing would produce personalities that could better withstand stress (Lemkau, Pasamanick and Cooper 1953). He believed that the promotion of resilient early personality development was complementary to the traditional public health activity of protecting the brain from damage, and would therefore fit well with the work of public health agencies.

At a meeting of the nation's public health officers in 1948, and later as part of the committee charged with designing the new National Institute of Mental Health after passage of the National Mental Health Act, Lemkau was able to promote the idea that mental hygiene and public health belonged together. This concept was expressed in his 1949 book, Mental Hygiene and Public Health. In 1949 the Maryland State Health Department invited Lemkau to be the director of a new Division of Mental Health. Four years of experience in that position convinced him that, while the mental hygiene clinics must continue to promote activities preventing psychogenic mental illness, other agencies charged with combating extreme poverty and providing public education would reach larger segments of the population. Since these agencies were not staffed by mental health personnel, mental health personnel would have to influence these farther-reaching agencies by means of epidemiologic studies that would convince them to establish policies and programs promoting mental health. He observed that professionals operating psychiatric clinics within local health departments tended to isolate themselves from other personnel, continuing to deliver traditional outpatient psychiatric services (Mental Hygiene and Public Health, 1955 edition). He saw the need for specially trained mental health professional personnel who would work from the public health department as a base. He called for experimentation in expanding mental health professionals' roles to include education and consultation to health and other agency personnel. Mental health personnel would need new skills, including those required for changing public attitudes through mass media, for providing in-service education to human services personnel, and for consultation with community leaders and community groups.

Lemkau began an active study of the options for organization of mental health services at the national, state and local levels. Lemkau supported decentralized mental health services, with the responsibility for coordination of treatment and prevention services resting within the local health department, whether or not psychiatric hospitalization services were joined with preventive services at the state level. He proposed regionalization of public mental health services and the use of traveling clinics to improve the delivery of care to the mentally ill. Lemkau also supported the development of strong, independent, nongovernmental, voluntary mental health organizations as a political constituency to support the development of public mental health services. He saw these voluntary organizations, when they maintained their character as representatives of the people, as the most effective means for educating the public. He was aware that voluntary groups want more rapid program development than public agencies, but maintained that these sometimes stressful differences between official and non-government organizations were to the general benefit of society.

Lemkau took leave from the School of Public Health to serve as the first Director of Mental Health Services for the New York City Community Mental Health Board. The second edition of Mental Hygiene and Public Health, published in 1955, filled an important need by offering a systematic approach to organizing mental health services in a society increasingly demanding those services. Published in 12 languages, it had worldwide influence. Lemkau used the Mental Hygiene Division of the School of Public Health to create a model and personnel for his approach. The expansion of the teaching of Mental Hygiene under the auspices of the National Institute of Mental Health led to the formal designation of the division as the Department of Mental Hygiene as a regular part of the School of Hygiene and Public Health in 1963.

His work provided a firm foundation for mental hygiene and public health; it endures in mental health services throughout the world and in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health.

Dr. Mandell wrote this article in 1995 during his tenure as department chair (1993 - 1997).