Special Interests Can Derail Even Successful Programs

You win some, you lose some, and sometimes you resign on principle, said Carl Bell, M.D., as he received APA’s annual Solomon Carter Fuller Award at APA’s 2011 Institute on Psychiatric Services in San Francisco in October.

The award honors “a black citizen who pioneered an area which has significantly benefited the quality of life for black people.”

Credit: Ellen Dallager

Bell is president and CEO of the Community Mental Health Council and Foundation in Chicago and a clinical professor of psychiatry and public health and director of the Institute for Juvenile Research at the University of Illinois at Chicago.

In his talk, Bell looked back over his career as a clinician, researcher, and advocate for mental health, especially among African Americans.

“I want to talk about some of the things I’ve done that have been successful and some that have failed, and maybe learn some lessons,” he stated. “It takes a resolve and a focus to set yourself aside to help other people and have compassion and empathy for people who are less fortunate than you.”

As an example, he cited Cradle to Classroom, a program that provided mentoring and health care for pregnant and parenting. The program ultimately kept 98 percent of the girls in school and placed 78 percent on a track to college, he said.

That should be considered a success and a good reason to continue the service, said Bell. However, the superintendant of Chicago’s schools ended the program because it had “solved” the problem it addressed and, incidentally, “cost too much.”

Another time, in the McLean City neighborhood of Chicago, Bell instituted a program that kept families together and cut by 62 percent the number of children placed in foster homes.

“We assumed these were families in crisis, and not evil, so let’s help them,” he recalled. The program kept families intact, but it also reduced the income of five private foster-care agencies, which were, in his words, “harvesting black children.”

That collision soon put him at odds with both the agencies and state officials who sent investigators around, trying but failing, to find any wrongdoing on Bell’s part.

Bell emphasized his belief that far more attention ought to be paid in psychiatry to what prevents mental illness. For instance, he recalled a study showing that only 30 percent of children with conduct disorder went on to become career criminals. “I wonder what protects the other 70 percent,” he asked. Their surroundings probably played a major role.

“Sixty percent of those children living in toxic environments became criminals, but only 15 percent of those in healthy environments did,” he said. “Risk factors are not predictive because of protective factors.”

Besides being a leading community psychiatrist, Bell is an experienced researcher, having published more than 450 articles, chapters, and books.

Researchers working in community settings need to learn ways to work effectively with the people they were studying, he said. “You have to work with people you’re trying to help. You need both community success and research success.”

When organizing a project, he explains the value of research to community members. “If we help the people in the study but we can’t prove it, those are all [of the people] we’re going to help.” To the researchers, he says: “If you get great science and it doesn’t do anything to help anybody—what’s the point?”

Bell has never been afraid to speak his mind, whether at an APA meeting or in the halls of power. Along with its better-known research agenda, the National Institute of Mental Health (NIMH) is charged with “strengthening the public health impact of NIMH-supported research,” to infuse new knowledge into public health. However, the institute was not doing so to Bell’s satisfaction, so earlier this year he resigned in protest from the NIMH Mental Health Advisory Council.

He recalled that one of his mentors, former U.S. Surgeon General Julius Richmond, M.D., told him that sustaining a policy requires a good knowledge base, good implementation systems, and public support.

Perhaps that’s why many good policies fail, he said. They encounter a lack of political will and too many people with some proprietary interest in keeping things the same, he said.

“I’ve learned that if I don’t stay on it, promote it, and push it, it falls apart,” said Bell. “Others see it ‘fixed’ and lose their motivation to keep things going.”