Research and Service Programs in the PHS: Challenges in Organization (1991)

The history of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), established in 1973, and its predecessor, the National Institute of Mental Health (NIMH), established in 1946, illustrates the continuing concern with the potential advantages and disadvantages of administering research programs in conjunction with health service programs. These concerns date back to the formation of NIMH, which adopted a model approach to mental disorders that stressed the interrelatedness of research, training, and services. The balance of the “three-legged stool” has shifted over time, leaving advocates for each side concerned that they may receive less funding and less support if the other is in favor.

This chapter traces that history, including a summary of the questions addressed and the findings of two previous major studies in 1973 and 1987. Leadership has had a strong impact on the history, first by successfully resisting attempts to break apart the agency, later by changing its focus to emphasize service delivery, and most recently by shifting its focus to biomedical research.

This history also reveals a pattern of responding to concerns raised by Congress and the administration. In recent years, Congress has reversed its policy focus: 1981 block grant legislation put the administration of service-funding programs into ADAMHA's central office; but since 1986, appropriations for service-related programs and demonstrations have shifted responsibility back to the institutes, as well as giving rise to two new offices within ADAMHA, the Office for Substance Abuse Prevention and the Office for Treatment Improvement.

Like the institutes established within the National Institutes of Health (NIH) during the postwar years, the creation of NIMH reflected a shift in federal policy that dramatically increased support for biomedical research programs that target specific diseases. From the beginning, however, the mission of NIMH was unique. The institute 's authorizing legislation, the National Mental Health Act of 1946, incorporated three distinct missions:

1. to support research relating to the cause, diagnosis, and treatment of psychiatric disorders;

2. to train mental health personnel by providing individual fellowships and institutional grants; and

3. to award grants to states for the establishment of clinic and treatment centers and for demonstration studies dealing with the prevention, diagnosis, and treatment of neuropsychiatric disorders. ¹

In short, NIMH was founded on the premise that there is an inherent interrelatedness among the components of the “three-legged stool”—research, training, and services. This premise, reflected the views of Robert Felix, then director of the Division of Mental Hygiene, who drafted the proposal that led to the National Mental Health Act. ² Felix regarded mental disorders as a public health problem, one that required not only the discovery of the causes of the disorders but also improved training of personnel and better methods of treatment and prevention.³ Felix attempted to realize this vision as he helped to shape NIMH and later served as its first director, a position he held for 15 years (1949–1964).

From the inception of NIMH, there was controversy over its placement within the Public Health Service (PHS). Since it would incorporate the Division of Mental Hygiene, a services agency, some argued that NIMH should be placed in the Bureau of State Services. Others, including Felix and the National Advisory Mental Health Council (established under the act), argued that NIMH should become an institute of NIH, in order to focus its efforts on research and training and to clearly identify mental health and psychiatry with the field of biomedicine. ⁴ The latter view prevailed, and NIMH remained in NIH until 1967.

To some extent, however, the research portfolio of the NIMH differed from other NIH institutes. In addition to basic and clinical biomedical research, NIMH strongly supported behavioral research and some social science research. The enthusiasm for including

behavioral and social science in the NIMH research agenda was understandable: there was little knowledge at the time regarding the biological causes of mental disorders, whereas there were abundant data and explanatory theories of normal and abnormal behavior put forward by psychologists, psychiatrists, and sociologists. ⁵

The placement of NIMH in NIH did not settle the controversy over the institute's threefold mission, however. As the service mission of NIMH continued to grow during the 1950s, spurred on by new congressional legislation, the director of NIH began to oppose including service programs within the agency. A 1960 proposal to reorganize PHS would have dismembered NIMH, retaining its research programs within NIH but moving its training and service programs to other PHS bureaus. Felix strongly opposed this move, ultimately successfully. Defending the threefold mission of NIMH, he wrote to the Surgeon General:

An analysis on a point by point basis shows the disastrous results of this dismemberment of a presently integrated approach to a major health problem that appears to require, even more than other areas, integration of effort in all areas of approach: research, training, service, control.⁶

During the 1960s, congressional interest in mental health shifted toward an even greater emphasis on service development. Congress enacted grant programs to improve state hospitals, to establish community-based psychiatric treatment, and to develop separate community-based treatment centers for alcoholism and drug abuse. In particular, the Community Mental Health Centers Act of 1963 led to a profound shift in NIMH budgetary priorities. Opponents of the Community Mental Health Centers (CMHC) program objected to the creation of a separate system of care that isolated the treatment of mental illness from the mainstream health care system and from existing state systems of care. However, the CMHC program received strong congressional support.

The Johnson administration's War on Poverty resulted in the expansion of NIMH activities in the areas of drug abuse and alcoholism. The National Center for Prevention and Control of Alcoholism, established within NIMH in 1966, included programs in research, training, and services. In the same year, a Center for Studies of Narcotic Addiction and Drug Abuse was created within

the NIMH Division of Special Mental Health Programs. Attempts to link alcohol and mental health treatment facilities date from this period, when amendments to the Comprehensive Mental Health Centers Act in 1968 provided for construction of alcoholic treatment facilities, to be operated in conjunction with CMHCs.

By 1967, the budget for the CMHC program exceeded the entire NIMH research budget. This led to concern in the research community that research funds were being channeled into service programs and that research had been downgraded as a programmatic priority. This concern was heightened by external pressure for a shift in focus in the NIMH research program. While the Johnson administration launched the Great Society programs to address social ills, including alcoholism and drug abuse, it questioned the relevance of research and particularly the balance between basic and applied research. ⁷ NIMH responded to administration and congressional pressure by targeting more of its research budget toward research into social problems, a shift in emphasis that was not welcomed by the director of NIH.

In addition, NIMH was by 1967 the largest institute in NIH, accounting for 22 percent of the total NIH budget. ⁸ NIMH's leadership and its various constituencies believed that its budget and its combination of research, training, and service activities gave NIMH enough size and stature to be an independent agency. Under a major reorganization of the PHS in 1967, NIMH became the only institute ever to leave the NIH. NIMH was elevated to bureau status, equal to the NIH. This reorganization occurred despite the opposition of the director of NIH and others in the research community who expressed concern that the NIMH research agenda would suffer as the agency sought to satisfy other priorities and fulfill other responsibilities. ⁹ In 1968 there was yet another reorganization of the PHS: NIMH was moved into the Health Services and Mental Health Administration (HSMHA), a new agency created to coordinate all PHS service delivery programs.

Over the next several years, the controversy over the relative status of the components of the NIMH mission was joined by a second controversy concerning the placement within NIMH of the rapidly growing alcohol and drug programs. In response to demands to expand efforts to address the needs of persons with alcohol problems, the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 mandated the establishment of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as a separate institute within NIMH. From the beginning, NIAAA chafed under its status as an institute within an

institute. ¹⁰ In addition, heightened interest in combatting drug abuse resulted in the extensive growth of NIMH's drug abuse programs. This led to the passage of the Drug Abuse and Treatment Act of 1972, which mandated the establishment of a National Institute on Drug Abuse (NIDA).

In the view of Bertram S. Brown, then director of NIMH, the problems of alcoholism, drug abuse, and mental illness (the ADM disorders) were inextricably related, and ongoing research into the sources of mental disorders should provide insights into the etiology of alcoholism and drug abuse. The presumption of inherent interrelationships among the three areas led the Assistant Secretary for Health to believe that community-based treatment services in the three areas could best be provided through affiliation and coordination among these activities. An internal management study in 1972 concluded that the NIH model—separate institutes working under an administrative umbrella —could be applied to the NIAAA-NIMH relationship. However, NIMH was not reorganized into this structure, pending a further reorganization of the PHS.

While NIMH was experiencing this internal pressure, external controversy over the research and service mission of NIMH and the PHS surfaced again. The Nixon administration was not enthusiastic about federal support for service and health manpower programs, nor did it support the behavioral and social research thrust of the 1960s. Seeking to limit the federal role in the direct provision of services, the administration moved to break apart HSMHA and to allow the authorities for “unnecessary categorical” programs (including those for drug abuse, alcoholism, and community mental health centers) to expire, despite strong opposition from Congress and constituency groups. Although services at that time represented 50 percent of the NIMH budget, the 1973 reorganization (the last major reorganization of the PHS), moved NIMH back to NIH with all of its programs intact, “because of its anticipated role as primarily a research institute.” ¹¹ This transfer proved to be very short-lived. Instead of allowing the authorization for support of services to expire, Congress appropriated increased amounts to community agencies and states for ADM treatment programs.

The research community continued to express concern about the perceived negative effects (on research funding) of combining the

administration of services and research programs in the same organization. This led Assistant Secretary for Health Charles Edwards to establish a task force in 1973 to examine the relationships among the ADM disorders and to determine how to administer the needs for research, services, and training. The Mental Health Task Force, chaired by Elmer Gardner, analyzed professional issues relating to the three fields and how these concerns were coordinated within the structure of NIMH. Interviews were conducted with mental health professionals and health professionals, both inside and outside the government.

The task force report, delivered in August 1973, presented a number of organizational options for structuring ADM activities within the PHS (Figure 2-1 ). Ideally, the task force favored the integration of ADM research, training, and services with the larger health care system (option 5). Yet despite the fact that PHS, except for NIMH, was organized functionally (i.e., research at NIH, prevention at the Centers for Disease Control, clinical training at the Health Resources Administration, and service delivery at the Health Services Administration), the task force concluded that the continuing social stigma attached to the ADM disorders precluded their integration into the general health agencies of that time. The task force perceived a need for continued visibility and leadership, especially in the areas of drug abuse and alcohol abuse, which were important national priorities. The task force recommended either of two temporary options and estimated that it would take about five years to make the transition from either option to the goal of a fully integrated PHS (research in NIH; prevention in CDC; services in HSA; training in HRA).

The Secretary of Health, Education, and Welfare chose the option that created the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) as an umbrella organization, with a presidentially appointed administrator providing general supervision and policy direction for three institutes: the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). This option placed NIDA and NIAAA on an equal footing with NIMH.

The task force concluded that the drug abuse and alcohol abuse fields should gradually be combined, in part because basic research and training for these fields were thought to be similar but also because there were an increasing number of people who abused both. On the other hand, the task force noted some important differences between the substance abuse and mental health fields, despite their close historical association. ¹²

Each of the component institutes of the new ADAMHA agency continued to combine research, training, and services in its mission, but controversy about this mission had not ended. From 1973 to 1982, the largest proportion of ADAMHA funds were used for services programs. By contrast, allocations for research fell, in part as a reflection of the Nixon administration's dislike of behavioral and social science research. This fueled the belief among the research community that research is shortchanged when it is administered by an agency that also administers services programs.

Changes in program funding mechanisms during the Reagan administration brought about further profound changes in the structure and functions of NIMH, NIAAA, and NIDA. In 1981, the categorical and formula grant programs at all three institutes, including most ADM services activities, were combined into a single Alcohol, Drug Abuse, and Mental Health (ADMS) block grant to the states. Since then, the focus of the three institutes has been on improving the quality of their biomedical and behavioral research efforts. This concentrated focus has been welcomed by many in the research community, particularly in light of promising recent breakthroughs in biological and psychosocial approaches.

On the other hand, some service advocates see the emphasis on basic research as an abandonment of the original leadership mission assigned to the ADAMHA institutes for the enhancement of effective services. Under the previous system of categorical grants, the three institutes were able to exercise national leadership through their authority to develop, select, and monitor services and service-related programs, including demonstrations. Under the ADMS block grant,

however, these responsibilities devolve to the states; the ADAMHA institutes have no authority to guide, shape, or assess federally supported state programs.

Despite the shift to the block grant program, service-related constituency groups have continued to look to ADAMHA for national leadership on policy issues such as reimbursement for mental health and substance abuse services. Such groups have expressed an interest in having ADAMHA take a more active role in working with other federal agencies on these issues. Particular concern has been expressed that, as the institutes within ADAMHA redefined their mission, previous leadership roles in services policy diminished or disappeared and were not taken up structurally at other levels of the organization.

Although the ADMS block grant program is a substantial part of the total ADAMHA budget, the program has not been a top priority. The 1980s saw decreasing interest in programs for services development, and the organizational placement of the ADMS block grant program within ADAMHA has changed on an almost yearly basis since its inception. The actual administration of the block grant program has moved from the Office for Policy Evaluation and Legislation, to the Office of the Associate Administrator for Prevention, to the Office of Financing and Data Policy, to the Office of Policy and Legislation, to the Office of Communications and External Affairs, and, finally, in 1990, to the Office for Treatment Improvement. In each case, the block grant program was a stepchild to another primary function and the block grant office continued to have only two or three full-time staff members. The change to the block grant program also coincided with the implementation of the 1981 Office of Management and Budget Paperwork Reduction Act, which severely limited the authority of federal agencies to collect data and standardize report formats on state-administered federal programs.

Many in the research community supported the removal of services responsibilities from the ADAMHA institutes, the renewed focus on biomedical research, and the appointment of scientists to top-level agency positions. It was only a short time, however, before Congress, under pressure from advocacy groups, began to authorize additional demonstration and service programs for special populations, to be administered by ADAMHA. The Office for Substance Abuse Prevention (OSAP), established within ADAMHA by the Anti-Drug Abuse Act of 1986 (P.L. 99-570), began awarding demonstration grants to community agencies to provide prevention services to youth at high risk of substance abuse. NIDA also received a large infusion of funds for demonstrations to target drug abusers at risk for AIDS.

The Homeless Assistance Act of 1987 authorized more demonstration programs and a services block, grant targeting homeless mentally ill and homeless with substance abuse problems. Other legislation mandated the establishment of a services program for Protection and Advocacy for the Mentally Ill, to be administered by NIMH. The ADAMHA institutes have been reluctant to incorporate some of these demonstration and service programs, which they considered to be organizationally out of line with their research focus.

The organizational placement of the research and services development and demonstration components of the ADAMHA institutes became an issue again in 1987. Some scientists and an advocacy group, the National Alliance for the Mentally Ill (NAMI), expressed the view that funding for research programs was lagging because of NIMH's location within ADAMHA. These advocates supported the introduction by Senator Daniel Inouye of legislation (S.164) to transfer NIMH to NIH again. NAMI also favored the transfer of NIDA and NIAAA to NIH, although it was not part of the proposed legislation. The goals of the proposed reorganization were to enhance the perceived quality of NIMH research, to place NIMH on an equal footing with other NIH institutes in competing for research funds, and to reduce stigmatization, which some believed decreased the agency's ability to command priority in obtaining the needed level of research funds. Others in the field opposed the move, citing the gains to be achieved when the same agency administered both services and intramural and extramural research programs.

The Senate requested a position statement from the Department of Health and Human Services (DHHS), which in turn commissioned Lewin and Associates to investigate the organizational options for ADAMHA and the organizational preferences of interested parties. Lewin conducted 62 interviews with key PHS officials, state health administrators, advocacy groups, service providers, and scientific researchers. The “Lewin Report,” submitted in January 1988, identified five organizational options (Figure 2-2 ). ¹³ The interview results showed no strong preference for or against changing the organizational structure of ADAMHA, although choices of respondents split along interest areas (i.e., biomedical researchers, state officials, and service providers chose options consistent with others in their interest area).

Of particular interest to the current study, respondents were also asked whether, in their opinion, organizationally separating ADM scientific research programs from ADM service-related programs would harm either or both. Although a majority of respondents favored keeping research and services in the same organization, it was felt that connections between research and services “range[d] from weak to non-existent,” at the state and local levels as well as at the federal level. Respondents identified the consolidation of ADM services programs under the 1981 block grant legislation as a contributing factor. In addition, some respondents reported that

federal demonstration programs have inadequate scientific rigor, and therefore fail to act as useful bridges between research and services. Other respondents pointed to the inadequacy of traditional dissemination techniques, particularly in the area of substance abuse, which may require greater federal intervention (i.e., clinical training and demonstrations). A majority of respondents favored efforts to ensure greater continuity of leadership at ADAMHA, such as “depoliticizing ” the appointments of key institute personnel in order to attract eminent scientists. This could also serve to improve program stability and insulate research from changing political priorities.

The DHHS working group report, submitted in February 1988, presented the five organizational options as part of the larger organizational question: the relative merits of change versus no change. ¹⁴The working group identified three overarching policy issues that needed to be addressed before this organizational question could be answered:

1. Clarify the nature and scope of the federal leadership role in services and prevention activities in the ADM fields. In addition, the relationship of research to ADM services and prevention needs to be better defined. Consolidation of ADM services under the block grant program eliminated federally directed services programs, yet the states and service providers continue to look to ADAMHA and expect the agency to play a strong role in mental health services research, policy direction, and advocacy in the ADM fields. It remains unclear, however, if the institutes should be expected to take an advocacy role on policy issues or if this role should be assumed elsewhere in the federal government. The lack of consensus on the role of ADAMHA in all of the above issues was evident.

2. Determine how best to foster connections between research and services at the federal level, and whether such connections are desirable. Although research, training, and services are co-located in ADAMHA, there was little evidence to suggest that there were significant connections among these areas in any ADM field. Thus, the issue becomes not whether these connections should be continued, but whether there could or should be attempts to nurture them. A second part of this question is whether these connections could be developed if ADM programs were organized functionally like the rest of the activities of the PHS.

3. Decide what, if anything, should be done by DHHS to promote ADM mainstreaming. This means the integration of ADM research, medical education, and services delivery activities with the broader health system. Some argue that ADM programs, particularly sub-

stance abuse, are not yet well enough developed for mainstreaming and continue to require the added visibility and special focus of a separate ADM agency. Others argue that separating ADM disorders encourages stigmatization, which reinforces attitudes leading to discrimination both in the provision of care and in health insurance coverage.

Thus, the working group concluded that, although destigmatization and integration of ADM activities are appropriate goals for DHHS, organizational change alone would not achieve these objectives. Clarification of administrative policy and continuity of leadership are prerequisites to effective organizational change. No organizational change in ADAMHA resulted from the Lewin Report.

The Anti-Drug Abuse Act of 1988 raised the Office for Substance Abuse Prevention (OSAP) to a status equal to the ADAMHA institutes. The act authorized further expanded research demonstrations on drug abuse and a major prevention services demonstration program for substance-abusing pregnant women, as well as demonstration programs to target improvement of treatment for substance abusers. It also authorized for the first time a federal set-aside from the ADMS block grant program, to be used by ADAMHA to conduct services demonstrations and health services research, to collect data, and to provide technical assistance to the states. The 1988 legislation resulted in the administrative creation of the Office for Treatment Improvement (OTI) to administer many of these new programs as well as the ADMS block grant program. The current study was also authorized under this legislation.

1. G.N. Grob, “The National Institute of Mental Health,” Washington, D.C., 1991, unpublished.

2. S.D. Nelson, “A Case Study of the National Institute of Mental Health,” paper prepared for the IOM Committee for a Study of the Organizational Structure of the National Institutes of Health, Washington, D.C., 1984.

3. Grob, “The National Institute of Mental Health.”

4. C. C. White and R. S. Hanft, “The Changing Relationship of the National Institutes of Health and the Alcohol, Drug Abuse, and Mental Health Administration,” paper prepared for the IOM Committee on Co-Administration of Service and Research Programs of the NIH, ADAMHA, and Related Agencies, 1991; available from the National Technical Information Services, Springfield, Va.; * Grob, “The National Institute of Mental Health.”

5. Grob, “The National Institute of Mental Health.”

6. E. Carper, The Reorganization of the Public Health Service, Inter-University Case Program No. 89 (Bobbs-Merrill Company: 1965).

7. Nelson, “A Case Study of the National Institute of Mental Health.”

8. R. A. Walkington, “The Health Resources and Services Administration: Evolution and Current Programs,” paper prepared for the IOM Committee on Co-Administration of Service and Research Programs of the NIH, ADAMHA, and Related Agencies, 1991; available from the National Technical Information Services, Springfield, Va.; R. E. Miles, The Department of H.E.W. (New York: Praeger Publishers, 1974); Nelson, “A Case Study of the National Institute of Mental Health.”

9. White and Hanft, “The Changing Relationship of the NIH and ADAMHA.”

10. White and Hanft, “The Changing Relationship of the NIH and ADAMHA.”

11. E. A. Gardner, Final Report of the Mental Health Task Force (Washington D.C.: Department of Health and Human Services, 1973).

12. Gardner, Final Report of the Mental Health Task Force.

13. Lewin and Associates, Examination of the Advisability and Feasibility of Restructuring Federal Alcohol, Drug Abuse, and Mental Health Activities (Washington, D.C.: Lewin and Associates, 1988).

14. DHHS Task Force, Options for the Organization of the Alcohol, Drug Abuse, and Mental Health Administration (Washington, D.C.: DHHS, 1988).