5HSRUW
Library of Congress Cataloging in Publication Data '.\fain entry under Litle:
CONTENTS
Group [or tbe Advanc:emem o[ Psychiatry. Commin.:e on Psychiatry and Community. Community psychiatry. (Publicaiion/(;roup for tbe Advancement of Psychiatry; v. 11, no. 113) Includes bibliographical references. l. S.xial p.�ychiauy-Evaluation-Addresses, essays, lectures. 2. Community mental health services Evaluation-A<l<lresses, essays, leuures. I. Group for the Advancement of Psychiarry and Community. II. Series: Publication (Group for the ,\th·anccment of Psychiatry); no. 113. (DN!.M: I. Community psychiatry. 2. 0Jmmunity mental healrh ccmers-01gani1ation and adminisrration. WM 30.6 C882c) 362.2'2 83-5443 RC15S.C6l7 198:l !SB.-,; 0-9109.58-18-1
Copyrighr © 1983 by the Mental Health Materials Center. All rights reserved. This report must not be reproduced in any form without written permission of the Mental Heald1 Materials Center, except by a reviewer, reporter, or commentator who wish to quore brief passages. April, I 983, Volume XI, Publication No. 113 This is the seventh in a series of publications comprising Volume XI. Fur informarion on availability of this publication, plea.\e contact the Mental Health Materials Center, 30 East 29th Street, New York, NY 10016. Manufactured in the United States of America
STATEMENT OF PURPOSE .......................
V
COMMITTEE ACKNOWLEDGMENTS ............. .
xi
1. INTRODUCTION .............................. . 2. THE HISTORICAL BACKGROUND ............. .
Early History................................. . The Development of Community Psychiatry ...... Mcmal Health or Illness? ...................... . The CMHC Program..................... .
6 6 8 15 17
3. ASSUMPTIONS-IMPLEMENTATION AND OUTCOME.....................................
24
Community Care Is Less Expensive than Care in the Hospital ............................. . Community Care Is Better than Care in the Hospital .................................... Comprehensive Care Is a Desirable and Necessary Goal that Can Be Achieved in the Community .... Continuity of Care Is Beneficial ................ . The Design ation of Catchment Areas Enhances the Provision for Services......................... Accessibility co Mental Health Services Is Essential The Social Environment Produces Mental Illness.... Preventive Efforts Can Reduce the Incidence and Prevalence of Mental Illness................... Local Responsibility and Control arc Necessary to Insure the Success of CMHCs ............. .
24 2.7
29 31
35 38 41 47 51 Ill
iv
Contents
4. REAPPRAISAL AND RECOMMENDATIONS..... Summary of CMHC Program................... Conceptual Flaws. . ... . . . . .. .. . . . . . .. . .. . . .. . Excessive Expectations . . .. . ... ... . .. . . ... . ... Problems .. . . . . . . . ... . . . ... . . . . . . . . . .. . . . .. . Successes . . . . . . . . . . . . ... . ..... .. . . .... . . ... . Contributions to Mental Health Care . . . . .. .. .. Recommendations . . . . .. ...... . .... .. . . . .... . . . Postscript ...... ... . . ..... . .. . .. .... . . . . . . . . . ..
61 61 62 63 63 65 67 70 72
STATEMENT OF PURPOSE
THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY has a membership of approximately 300 psychiatrists, most of whom are organized in the form of a number of working committees. These committees direct their effons toward the study of various aspects of psychiatry and the application of this knowledge to the fields of mental health and human relations. Collaboration with specialists in other disciplines has been and is one of GAP's working principles. Since the formation of GAP in 1946 its members have worked closely with such other specialists as anthropologists, biologists, economists, statisti cians, educators, lawyers, nurses, psychologists, sociologists, social workers, and experts in mass communication, philosophy, and semantics. GAP envisages a continuing program of work according to the following aims: 1. To collect and appraise significant data in the fields of psychiatry, mental health, and human relations 2. To reevaluate old concepts and to develop and test new ones 3. To apply the knowledge thus obtained for the promotion of mental health and good human relations. GAP is an independent group, and its reports represent the composite findings and opinions of its members only, guided by its many consultants. COMMUNITY PSYCHIATRY: A REAPPRAISAL was formulated by the Committee on Psychiatry and Community, which acknowledges on page xi the participation of others in the preparation of this V
ĺӄǵ:˗ûüǔʚſƛJȖ ƦȷʢƀɖȗǶ־ȘʂĔǧĕƧƣċǠĻǃƁɩ
12 5L
% " . L E @;6 L >&I L
ʬЩzэϴ˙Ѳʭß ʣ˚Ѽɪ֘ ѽ͔ Ɇ˛tӅĖюՏà' ļN$ϵηó <³uÁĘĒ ęĺ ã Ť MvÜ ĻŤɇ = wœ L%Ť Pûä Ě š Ť QxļĽ)Ť ɫ϶̹Ѿ͕ ɬ ƨӆu̺͖ѿեӇύ *נ͗ ʼ Ԥ 6 ș˜ӈҀĐϷ ƭ͘яѐ͙)¡ ʮ զώϸҁπ֙Ӊ҂¢ ŭἠɗӊρ͚ԥ Ɉ]Ϊz£¤ ʯ˝էϏj҃ς֚Ӌ҄ Ů ľ
ȆͷաբЮ њʍ Ɗ˵ֳԌҝ Ⱦ~˶ϢO¾ ф ϣ̘ ǗӦպԔϤʎ ƋҞψ$mջϥ0 ȦץʾӧԴе¿ ȧ ʿç ʵ ʶ˷ћִͺԵȇͻҟҠЋҡωԶÀ ʏӨԕͼлS0 ǢVҢռ N ņ©ŤS ĦÈ Ťe ú ±ą!ŤhŘ ŇĆñ Ť6ħÉ4,Ť ƪͽө ϊ;ƞ ʷ"w֒ԍңÁ ĵͿќѝȈ ͆2 Ȩǘ Ǚ˸̭ Ġ ʸӪ eԎԷ\ ɋpֵֶս̙ׄԸgϦà Ɍ
ĿȸďαǷ՟ ʃƤƂHȚƮėțůDŽŀɉɭ
Œȿȉ ðʫԹǚʐƟòƢĊɀȩɍɝƌʦƍǣʑǍʧ Čč ɹˀœƶDġʒɞˁ
ȜӌՐ%˞҅ɧ Į^գ ֛_Ϲ҆¥ ŁϐϺ̡OσӍ¦ ĄąĆ § łϑ ϻԦԐ!Ց֎ӎ& įֻ͛֜ γΫfκ͜)̔˟ֿѳ Ưӏ֯֏׀Ӑ҇¨ ʄ͝ ʰЪ ёϼˠѴ Ę ɮӑ k©ª İ`֝ϒ͞ը̻ Ǹ̼ Ʃ͟Ӓ τ͠ʅˡԧвˢ҈+ ę҉υ м͡թ ŃUђЫθô g´üå'0yľŤG*Ť i Ŀ ě Ť p1r zŀµÂæ°Ýç Ť Ű >Ť A͢ Ւׯư ʱӓԨs7 ʲPժϓ"ҊgֹӔҋ« ű;ń
ɺ֦ ԖiҤƠ|΄̮ +Ď΅צƷ˹זΆҥÄŔӫҦҧ Åŕϧ˺ЌԺ ·Իվ'Ҩ Ŗ ǤҩjϋϨ֧Ģх͇ԼЍ̯ϩÆ ŗϪW цӬҪ!տחЎўџΈ1˂ Xè ʪqӭ ˻ ʹĶΉդY ͈ 5 ǥΊ˃קӮԽж2 Ȫ ˄ Ǜ ׅրʨ Ř( ΌѶP&Ç ȫ רƸ[טΎ È řӯҫҬ ʺЏ ѠА˼ѷ ƹ ƺ̰̲̱֨ зcԾ3 ɎϫБчZ͉ήѡԗϬВ̒Ü ɏ˽ _Ê º Ĩ Ť HŤ Ť 2ćĶķËÚÛ Ť 8Ĉňŗđò"Ť T ʼnŊ Ť C˾ՙ՚kցĹ= ɐΏ̳и ȬΐשɟӰ̴ϭΑvѢd3 ȭ<˅é
ŅȹǹǺDžʠƃƄHGdžȝʆƅɘȞĚʇLJȺȟěE EĬʈLjȻ ɯ
ŚɁ˓βȊD εƎƏIȮ ɑɻˆśƻǎģʓɨˇĤȯŸǴ˔˘˕
Ɯ ˣҌ̢ϽիƝ8 ıXԩҍͣլ, ņhͤװŇϔˤխͥ- F̽¬ ?¶ Ĝē ĵŒýèŤ KӕϕͦҎǻ ŲӖՓӂ- ɰ˥̣ V~άӃְԋ ň˦ϖ Ǖӗϗҏ ɱ ǡQe ˧ ʳNծϘϾ ֞ӘҐ.@ 9ʼn® ǖәi Ɔ9 Ǽ˨̤к1 Ŋϙͧկ ґ ֟AЬѓє4 ǽ˩֑ əϿ֠Q â L(φͨ հ¯ʉӚԪՔ̑Ғ̥a/ ŋ˪нlιõ IJͩՕֱԫ % Ʊã ɲ̦Ϛ λμғ ° Ƞcסʽ # ȡä ˋ ɳ֡ͪԑϛͫҔ> : ɴϜRҕξЯͬо̾± ʊׁ̧ձӛҖ² ĜԬЀ ʤ˫ѵЁпų 9,+ C L $ =-:D ?F*/0 L L
Oĉĩ řŤK Ť ` /» Ť ]ÌŚŋ śĪ ²¼ ^ Ť D½ ÍīĖªĬŌĊóŤ Ɛѣq֓֔˿ < ķΒҭd Γ#ÉĥҮүĦԿ̚ӱՀ4 ȋГ̵Ϯ ɒ̀ՁйƑ ŹД^֩5 Ŝϯ́ՂшӲ֪֫ΔւיЕ xaÊʩ̂ê ǜӳϰҰ źӴ ұΕѤu ׳Ƽ ՛ַζԏՃ͊ Ë ŝӵҲ ɼΖ ֺךӶ ׆dz ƽ̃ѥѦΗ̶#Ý Şϱ̄Ԙί|ƾЖw} Ȱ ş Šđ՜ѧ ȌYщѸԢׇЗփ֬Ì ȍИҳҴb̅ԙӷtЙքÍ Ȏlҵ ë ƿΘՄ̷̛ ̸š ȏӸ͋ъКҶ ʔӹԚΙs Ǧ̆ ֕ ǝӺҷ̇օ M M ԛԜΚԝӻՅּ ĸ̈x֭p%Ӽ ΛÎ
?ȼǾǿljʜʝƘƙIȢ ˑýƚžNJŌĝǨƇӜׂ̨ñÞ՞þøȣ
?úĒĂȐǑćʕƥƒɂȱ ɔ֗ˎѯбѨīʖɠ˖ħȲŻ ɡ ǒ8ǓŢʗJÙē
ŴˬאЂ̿ ɚ; Ʋ˭עrа&ղ³ ōϝЃ̩ˮχӝ´ ǐѕ{ @· ÃĝĔ ĞŁþéŤ ɵ֢ͭͮבҗǰ ŵ̕׃Ӟגճг ױŶͯҘדbԭµ Ŏӟv å B˯ 'р̀DZ ǩmέδ Ϟ" ˰́ͰсԒϟnS¶ ˱ A ğÿÖŤ X{ ׳ ê Ť 7ĀŃ āë Ť R|ńŅ Ť Ƴ ̖ͱՖֲɊ̓Ԯ̪͂մ ̫( rהЄіїͲ· Ȁ̓ ŏTԯ т ײLӠ̗ЅҙӡףІ֣ ¸ijͳ֤Ϡʹ ̈́ Fͅ bŔ ĕ¸¡ìŤ B Ť c ¹¢Ä £Ġ Ť ʋÿĀ̬յӢҚ 5ġÅţ Ť dÆ í ŢŤDz qs( ¤ĢÕÞ î Ť Z ïŜ¥ģ Ť CĂØă Ť j¦ŝ}Ť nÇßà§Ĥá~ð Ť ¨ŞŤkĄĥÔŤ Y l+Ť
Ѯöù˒āȁNjʞʟƈːȽȤæȂǟȥʛĭǪB֥Ğǫʌƴɶ ɛʥnjŐƉɷ Ƶ͵уɜ ɸԓЇԱӣ¹ ȃo$ ˲פдͶ! ʴЈն º őϡ˳ЉԲ _ԳշӤқ ȄU ğ Ĵ» ŷ˴ Ҝ¼ո÷չ/ ȅӥЊ וЭјљ ½
' 4L L K (AJ 3 L !G)7#B<8 L H L
Ĩy̜Μ՝ָ Ǭ̝Л Ï ʻ ӽ ֆМ ] ţ {Нο Ťh ОՆԞΝՇևӾҸ ɽП͌ҹΞ ״ơ֖ ΰÐ ѰѱՈӿ Ñ ȳ ˌ ɢР͍С͎̉Ŭ ǭΟתnֈ6 ȴΠǀWכΡ ťԀҺһ Ɠ̊ՠ}ǮԁԂѹТ ÒǞՉ Ó ƫՊΣ ԟԃՋֽ ˍ UċĭŕÎâ ĮŤ[ōŖ\t3 9įČôŠ-Ť m Ť Ŧy`͏KÛ ɾҼ\לΤՌÔ ŧԄы Ѻ̞։7 ȑԅ VÏ ¾ «ÙŤ a Ť ˏRĈΥ֊ Iݬ õşÐ ¿ Ť Ečö÷#Ť
ŨɃȒȓ ʡƔƕɄȵɓɿˈũǁǏĩʘɣˉăĉьGɅƬʀʙɤˊ : ĸĹÓ®Ťf Ť Jı ѯo&Ť ;ĎŎIJďø Ť W ŏŐ.$Ť FÀ ÒijėĴőĐùŤ ż ZҽΦ ɕÚ ǂ̋ό Õ ʁ֮ ǯԆУ. Ȕԇ= ɥì Ɩ͐ Ս͑ Cfνѻ̌Ҿ ĪϲΧםФѩѪΨ* íŪ @̍מХ͒ Ɨ ȕԈՎ)oÖԉҿ [ ЦӀΩ× ѫѬѭî Ž̎ןЧ͓> ï ɦԊ̟̠ШӁ֍Ø ūϳ̏Ԡԡ̐ԣT, ȶ
ƵĦ1Ţ)Őţʵ ôȀʔŤ=ʵ ûɆ ʵ îħʅ pt#Ǔuvʵ Ľ͚ʑ̦г ƙƳ˚Ȯ̀Șș г ƍƴΙƵϹʀDZÇг öƶˬ ɰ г
ēƷГ Țгß гàț˭ȯΚ г ͛ ϲ @Hг ŚƸ$ г ÷ʒƹ>ΛΒȰ ω͜@г ƚ ʁ̧ Μг İÊг íCʮ5ʂȱΝ г ź rˮƺ5ɤ ʓʯ1 г Żƻ г ȁʠƶťʵÃ ʵ ĨɇɴȂǔ ĩɏ]ʵąŦʛ ʵ ı͝КƼΞfг IJUг ĩ͞ f̒1͙г Ǝ`̨гʼnΟƽ}Ȉ;ϊȉ͟Hгøá˖ɼг ȃʆƌƷĪɐʵĝĔ ʵ ´Ɔ%Ǖ4Ʈŗƒɑ>ʵ ŋDŽɶƝljȄȯ ʵÅʭ ^ʵ ï ʇƸʵ¥ ʵ µʈɒɷȅǖ?ʵ ¼Ȇʕīʵ ƞɸʡ ʵ ½ȇʖĬʵ ƄʰȊʔƾΠȜгě*г ƅȲ!̩ȳ ɯΡIг Ŏ͠ϋгá~ʃj j$ г ùdzʱɱг
äÓжƹȰ¦ʵåxʵóʐ ÒÊ ʵ§ Ē yĆ¾æÝʵ Ɔ͡Ƿ Dϳľ г .ƿ̓ΓǸn г ŧȴ г_̪ ˛ г Ũ ơ ¡г Ɠĭ"2ȬŧɈɵȈǗʵ Ëȉ3NJĮ*ʵ Ìʵ ÍȊ6ʜ ʵ üŚǀŘ2ɓʑƟǁ @ʵ ðŊ ʵ ĿІ˯ʲЇόгƏȋ Ck;ǹȵ ¢г ƛd ʳ̫ʄϴ̬͢£г ú г ư˰ʴ ȶύгĤ гƐpͣDl г ̐ĔώϺΌ ¤г śDz $ г ƇͤǺȷξϻгâ г Ƒͥ ͦЛ г ȸИɥ˱Фг [ Ϗ&г ûǀ ;ɽг '* % #$ * " ( * ü zʵɲг
ê×ØrĐđ©ʮʵëàʵĉ¸ʳú ñªēĊÁ ʵ {öʯʵ ìȸƻĵǢśȑʵ bʵ ÏƣƎƗɺƊȩ.ʱʵ Ȓɣɻ/ǣIʵ Ķ8ɤcJʵ Ăʟ ˀ ΘɊήϗͳ̸г ïɋρ͘eF5гYǒ"ȣ˗ɪίOг ZǵǽF=ȤʊɌ'г şǓϘϙ г Ɩʠʹ̖ǔϚгĝ г- ̹ˁϛIг ăʡ ɫ гĶu ¯г ď г ÷ȓōű3ʃʵ ³"ÐɥȔǤdʵċǍ;ʰɦȕǥKʵ Ù ʵ ¡ȖǦķ&Ŝğ:ģ9 ʵ¹ĸǎǏŲȹɧ' ʢ ʵĠĕĹɨƘƤǧƏɼȗ- ʵ ¢e ʵ øȘŎųȺɽșʵÑʵÉƥǐŴǨŵʫLʵ Āĺǩʵ|Ǫɾ.ǫƦȚMʵ ČŶʞ ʵ Š˂˶G̺г ŋ d̗ ΰÐгł ȏ˞Ϝ͵̻Kг š˃ϬϭÑг Ţɬ Е˄ гƓ Ǿϝʢv̼°гƜǕϞʣ<̽ʋ%Ύ̾±гĖ Ą г
ÆŨȱɍʩʵŜ г ÎũʗƲɔ Aʵ &įɕBʵ ćʲʝ Cʵ ƔİƠȲȭŪȳɖȋǘʵ ŀͧʕ̭г ģUг ãgǁ̔ ¥г Īǂs}ȹϐД ˲ ɦ¦г ĥzǃ+г 0ͨǻkο%гý ̮ȌE §г ũ МгƢͩΣ &г Ū ƣ г ƒG4̯˳ȺХгij г Ĝ˴ȝΤȻȞ г îɧ̂̕# вг \DŽϑϒ г ÇȌƕǙʵ ± ʵ ²ʉǚ ɋ\ȴɗȫɊq Dʵ Ƈ(NjȍǛȵEʵ Ôıɘəʵ _ʵ ŝͪ t гäËг ŏ< ϼ @ г þʖDžΔȼ гĴʶ ̃Qг ū - г Łͫʗ̰г ī г Ő̱ͬͭȽЦ г ĕ4̍˵džϓJгƕȾУ г .ʘa ? ϔг ż г Ŷ YΥtm~'г Žʙ< hȿ Ε:ʷLJ¨г ]Ljг ÈȎƖǜʵ ý ʵþɹȶIJ6ɚɛ ʵ Þūʘʵ·ijʒŬǝFʵ ȏǞ+ ʵ
ç`ĤƈÕʵdž<ơĈa¨ʵèßʵ ÿé ¿zƯlʵÀɜɝʁwɌ ɞʵ Ĺlj̲гåг X ʅnΦTг ŬɀНг_ͮΧ˧)г ŭÖƪשг ÿʚNJu ɁΨϕ̳ͯг )* ƱļÌг ŭǟǠ#ǡƍʂďGʵ ! * & * ėưǂ'Ƣ njʵ õ ʵ ŮĴȷ ɟƺůŰ ʵ Ȑɠřȧ, Hʵ Ö ɡɢ ʵ bЈ гØň г Ĩ ̴˜ªг ʸ Njȟɨ̄ :ʹnj«г ǍÍг ĵm̵ΩЧг Ĭ2 ЄLг [sʆʛ ǎ"Ƞг 2EyRг ĺ ̅ г ƈͰȡɂΪʺȍ гĭ π͗Ƀ¬аPг őͱгæ ʇɩ Ʉ Îг ĀǴ ɾг ŞǏ̶ʜǐг ŊʻF˝ΖbϵΫʼȎ˨)г ŒͲϖг ç"ʈɅ Kг āǑ ʽ8,г žɆά Эг ŷϽϾɇ̷ǼɈέʉ®г ſʝʾ̆cȢɉ Ηʞʿ ƀcÏг
ƉAǿɍ̿гţ˅ȐqɎ˷ ²г ̏ɏ гƤB ˟(г ƫÙ³г ąʤǖ α oςϮͶ г ºŷǬȻʣʵġĖfʵ 4ț ƧǭNʵčʊőɩȜǮ Oʵ }ȼƨʬ ʵ ŃǶlϟгƔ г ĞǗ Ώ̀ гńβ Lг 0 ȑ˦Йˆ ̇ɐ г ŤȥÒг «ʋƐ ǯŸʵ gʵ ®Ź$! ǃɪĻǰ ʵ Ƚȝ0ƴ ʤDZ ʵ á Ĝmʵ ^ͷˠЮг Шγǘ|г ŌǙδǚϯВMг ŮɑОгƥεˡ(г ÓƬ г ~*ŝȾźĢʓʵ ò ʵ ĥƼȞ5ȿ$ɫȟDzPʵ ļǑŏɀƩŞƑŻQʵ Ú ɬɭRʵ Ɲ˘? = ̘г / г ŸɴɵȒ́y Ǜ̙Я´г ťˇ ПǜЉˢ66 г ˈϠVг œɒÉˉϡг Ŗ г ƊBȀȁr"Ϣµг Į˸ɓ͂г Ź1˫¶г ů Ʀ г è̈̉ǝ̓г Wг Ƌͺϣɔ̈́Ȃ %GNгŔǞŅͻ̊̋ǟ·г ĆǠ{ˊ8,г
ćǡζ˹ͼϤгĈ г é˺Ȧɕͅ¸гņσ+ г ðЊɳɿ˻ г Ű Ƨ г Zʥ3η AЅÜψ г įÔг ñ`ȃȗ#ȓˣ¹г ]ˋ ϶ϥȄЋθ9ʦºг ƁǢ г ğιˌȔгê г òǣЌ̚'г Xˤκͽ͆Oг Þгʧˍ г āȮżdzŒŽɁʵ Ľʥƽ ʵ »Ƞʌɮƾ/+Sʵ Ďžʟʵ ëǤτΐ͇гƗÕг ó7ȕ˥»г Щ ͈ɖР; h¼г Ƃǥ г / г ĉʨλwϦ%>Ǧ͉гô ɗ Pг űɘСгƨBC Nг ƭ г ĂƪşǴ ʦʵoſɂǒľǵTʵ ĘĿɯƙƫ,!ɿȡ- ʵ £h iʵ ˙ ɺ əiг õ Ϳ ̛ȅɚμʌ½г .ǧ̜ȆEˎȧʍ ¾г \Ǩϰϱ¿г Ƙʩ̝ ϧг ŗ г ̑ ǩ͊͋>Ȗ˩Jг ˼̞˽3)г ĊǪ{ˏ8,г ķWг ōɛː гĸ г Ȩ ɜÀг ėϷˑ ʪǫ̟ г Vċ г ʵ Û Ƕƀ7ʵ ɎʪŀǷLjʵ ăŁǸʵ¯5 ǹœ% ŔȢUʵ DžƬƉnʵ ¬ʙŌ ʵ ę ʵ ʍɰɱƁVʵ ¤ʎ1ƚłǺsWʵ LJ ʵ ƌ ȇɝχЃг Ų г ЍϿ ɞνQг ų6ТгƩA ˪Èг ̎Ʋ Ʈ г ĠЎʎɟ͌7гŦ г Č ɶɷɠЪÁгŇ Rг ÝϨʫ˒!ʏ # г Ę Đ *г 3Џ?г-ʬȩɸɹ(гƞ4ϩqv͍ʐЀΑ͎Mг č г ÂŃ)ʵŘÚг б г (ʼnǿŕʧjʵ íǻʀńɉƱȣXʵ ǼŅŠņʵ ĄŇǽƋȪɃšʵÄ ʵ ȤƛƂǾYʵ 0ʴʄȨʏ ʵ Üňɲɳʵ Ɵ= Ǭ̠г ę+г ĚǭЖ˓ȪϪ͏͐Âг e ˔͑9ϸ΄!Ãг đ г ř̌΅Ыiг Ē г ġ Ǯ̡Sг Ŵǯ ʭЗx ɡSг^ ͒!*г ŕΆАw гĎ г Ģ͓9 ˕$pÄг ƃ·̢Έ͔ Tг ŵ Ư г 0ǰЬ̣#͕ȫг Ħɭ Ȭ| ͖Åг Б˾ȭɮυÆг /Ή˿Ί г ì ɻφɢgг ħ 2Dϫ:7 ̤&г Ơx ̥oЁЂɣ г Ļ Ûг ɄŖƜƭƃʵùkʵ °ȥƿƄʨZʵ âƅʚʵĚȦɅƳ[ʵ ã ě ʵ
ÖĽ̀ ßʹĦ̀ľ̯đ ĿħDž?(3̰̀ Ɠʂʰ˳VAà ŀ̀ ȝ̀ Ƣá̛Ł̀ ƣâU6̀ »Ƥʍł̄̀ ɜƌ̀˒ƥŃ̀ %ãĨńʱL̀ džȳ̀ ˓ƦŅ̀ƒǻƆȐĩ̀ɝƍ̀Ē >Ȟ̅ȴLJʻ[̀ȟņ S Ȃ̀ ƧŇĈP,̀ ĉ̀ ēɞ ʽ̆ȑ˴ ȵ ʾ̀ Ĕ ̀ Ḃ ̀ :Ƞ. Rňʼnẁ ¼Ŋ ȶ ̀ Ìx̀ Ć́*ʎ ĕƨỳ Ʃ ̀ z`̀ ̥ Ò ɟ ʏ̀ ʐŋ(̈ȃäʑ̀ Ȅă Ė*Ṑ ¯{̀ ȅ˔˵ȒōLɠ ̀ ɡȷʿ̉ȓRåȸ ̀ ˀƪŎ̀ ̀̽ɢʒȆŏĪ̦̀Lj˕ƫ̀ ˖Ƭ$̀ ɣ8ȡlj˗˘Őő̀ī̊ʓNJȹƘ̀˙ƭŒ̀œȺ˚NjHŔ̀˛nj9ŕ̀ʔŖʌWǍʺ&Ĭ̀˜C̀ʄ ŗʅ ʕŘ̀˝Ʈř̀ ʲƇʆC ˞̀ ´ ̀ ÝÞǺæʳʴė?̀ ©̋ ɛ à Å ª b̀ç̀ʇǎ ȻŚśʖ̀Ǐ ̀FM̱!Ưǐè̌ǑU ̀]ÄĭɤȇɥỜ̺éȼ#̀1Ƚ̀ĘɦȢȣ̍ȾǒT\̀Fˁ̲ę-Ǔê̂K̳c̀ ƙë̜Ŝ̀̎˂̀ ì̀ʗ ̝ǔş̂̀ɧƎ̀ ̀ ZŞíIǸɨƏ̀ Ě Ǵ̞Ǖ˟.ş˃̀ǖȿ̀ˠư ̀ ɩ78̏ɀǗ ̻̀¿Š ˶ Ȉ̀µš 2ˡƱ̀9D̟ŢȤţɁˢ̀ DŽî ̀Mʵǵ:̐ȉ ̑̾Į̀ V ̀ ˣƲǘɂǾǙɃƚ ̀ ¸ïěǿ̀ Ü ˄ȥ d̀ À|« è 'BʘȦŤʶ ̴̀ ð̀ƑćĜ̒Ȋ ȧť7ĊŦH̀ ǚ ̀ ˤ+ŧ̀ÆʙɪƛʚñȨ̀ ƔEʛ̀ÑʜòǛ@ǜɄ)̀¡ɫ<̿̀ ȩ̓Ʌ/˥[̀Ç˅\ĝǃǶ IǝˆPˇ̀ó˦̀¢ɬȋ ȪċǞ ̀ÔɆǟ̠%ʝˈǠ̃Z̀^̀ q _̀ô į̀ ǡʞŨĞ˷ɿʟ̀ '̀˧Ƴũ̀£Ūɘ ūʠ̀ƕʃJ̀®GǢİŬȫǣɭ3 ƜǤ!̀ ÍS̚ıǷƈˉ̀0ɇ̀ץo ǥɈơpDɉ̀Ǧ ̀ ƴŭ̀ Nf̀ ˊ ʈGȔǸ IJ̀Wˋ̨̀ǧ˨Ƶ̡̀ ȕX ČȌ ̀/ ƖEʡ; ˩0ɮÀõč ̔˪̀˸-Ů̀ijů̢Ɖ4 ʉ<ŰɊ˫̀ɯƐ̀ ƶű̀ °ŲĴųʢöȖȗ̵rƗYɋ#Ŵĵ̀ ¤ɰȬȭYɌ1Q̼̀Á ə˹÷ȍ̀ ¶Ɗą4 Ʒ̀ ¥ŵȮ ʣ̀ ʊʤ Ɲ øȯ}̀ ÒƸʥŶ&̀³Ǩ@ˌĎ̕ʦƞ̀±ğȘș ̩ ̪̀ɱʧȀŷĶ̫̀ǩˬƹ̀˭ƺ ̀¦ɲ;ʷɚǪ˺˻Ÿʨ̀ ̀ˮƻŹ̀ʩĠʋɳɍ~̀ÓƼź̶̀ùʪġǽɴƽɵ̀¹g̀ÕúȎȁŻʫh̀ ì ÊǫĢƾûKķ̀ØƿǬ˼˽żɎsÎ ɶ̣ 2ȏj̀ Ǽ½¬ k̀ üɏĸ̀ËŽďžģlý̀ ɷ Ƌʸm̀ à tþ̀Û$Ț5ɸ̬̀Ĺ̖Jǭɐ)̀˯ǀǮˍ̀ÿĤĀĺſȰǯ"̷̀ƀāʬ ̀ ʭ ̀ Ù+ǰ˾˿ƁɑuÏ ʀ̤ țȜ̀ ¾̗ʼ Ļ̀ Tʁ̀ ɹ̘ʮ̀ȱƂƃ̀ǹɒƟˎ̀ ˏ̀ ̀ÈɺːQv²Ƅ65ɻ̭̀§̙ƅO ̀ ºɼ,ɓ̀ Ðĥǁ̮ Đǹ Ȳɔ=DZ˰˱ ̀ɽɕ̀Éˑ̸"ǂDzĂ˲ʯ ̹̀ ɖļ̀¨ɾ=>Xɗdz
Ú·̀
I INTRODUCTION
In 1964, community psychiatry was proclaimed the third psychi atric revolution, equal in significance to Pinel's unchaining of the insane and Freud's discovery of psychoanalysis. It was described optimistically in the 1967 GAP Report, EDUCATION FOR COM MUNITY PSYCHIATRY, as ·.,I
''... an evolving aspect of psychiatry in which the psychiatrist accepts responsibility within a population ... for promotion of mental health, prevention, early case finding, and treatment, ... an emerging sub specialty of psychiatry." 1
But not everyone shared the enthusiasm for community psy chiatry. Kubie feared that community psychiatry would "suffer the fate of all good intentions not guided by mature judgment and experience" and that psychiatrists might be misled by its illusions and practices. 2 In calling it "The Newest Therapeutic Bandwagon," Warren Dunham expressed skepticism about its fucure. 3 He viewed it as mainly a reorganization of mental health services geared toward work with patients, their families, and supportive agencies in the community. Dunham doubted the "adequacy of our knowledge to develop significant techniques for treating social collectives or for developing techniques on the community level that will really result in a reduction of mental disturbances in the community." 4
The skeptics were closer to the truth in their predictions than the enthusiasts. During the l 970s, community psychiatry not only failed to emerge as a subspecialty, but its status became progressively more controversial. By the beginning of the 1980s, optimism about the Federal Community Mental Health Centers
ʐ ʑ
ºvǑɥļßíʒ]¿ǥîʒĦǦʒǧĬbʒƗïH ÊlŷɶʒĽƅkʒÛkƿKðʒȮ ʒȯ ñľǨʒ ǀƘ Ȍ ʒÇ * °Ŀǩ0 NʒòĥǁǪɊȭʒ HàʒĤɢHáKʒ ǒɯÀǫ+ʒ ĭ ʒ ɦ ƻOŀǂ ʒ Ēʒ2 h ŭlƆƢóȍȎʒYɷʒŁ iđ2 A ħʒO ʒ ǬB Òł i ȏʒ ē ƣ|Xoʒ ɸ Ů Ƥ âʒ :ɹʒC J ɧŃ eʒ Ȱ ʒǡ5 můȁɺʒ ĔʒEfc ʒ ń ʒȱ ôʒÓǃ q Ņɓʊ
Ô ¼ ʒ ǭ ĕ ǮȐʒȲ ʒ& `ʒ± ã ǯWƓŸɻ ?ɣƥ, äʒ¨VU©ȑ , ɨ Ź % _ʒ Ʀ-õǰʒ öʒ 8R3%ņZ÷Ȓʒ DŽĖʒ² åø ËFʒ ź ĨŇ Ż zňs ʒ § ʒ ʒ Ƨùɰʒ $ǖȂ Įʒ Á × ú ɋ Eʒ ż{ ʒ Õ ʒ ȳʒ Pû.ʒ( 4 DZyʒ Ê × $ ɩʼnæ ʒ - .ʒ u ʒ Ǖʒ ȴ1üʒ I mFɼʒŊƇFʒ ŋƨʒ ʒÜ ɖ B ʒÈ /ʒ  % ɪ |ʒ QÏʒ ŌGƈ# ȓʒ ç ʒ Ã × ĩɗō- "Ŏ wʒ Ʃèʒ ŽÁ Ȕʒ ġǓ ɘG }ý.ʒ ŏ žɽʒ;6ʒ³ * Gʒ8 Ő Tʒ ª = ȃ ʒ ) ə ʒȵ ʒ Âȶ ʒ *ʒ~į ʒĞÍ~ ʒ ėʒ ʒ«7µ¬ʒ$ 8 ʒ ' ƙ ʒ Ð Ɍĺʒ dȊs ʒ ɴő ȷɾʒ ) &ʒ ȸ þʒ Ǣ5 EA 6ʒ Ęʒ \ ʒ ?ǔJʒ ȹİ ʒ L ɚȕſɿʒ ɍ pƀ6ʒ ŒƉƊʒ C#ʒ @ ʒ < ƚƛ rCQSʒ >ʒ Ģȋ ʒ Ǘ ǘƁ0ɵœ ʒ ) ʒ Ǚ ʀ ȺDzS¦ʒxʒ Ȅ " ʒ D ʒ 1 ʒ ǚ Tʒ ½@ÿȖ ʒ tI ȗʒ ʒ Ö 2%DžR -Āéʒ;Sʒɛƪ 9Ŵ 'ʋʒ Ydž NʒɎĻ ʒĠŵȘ<WƔʒ?ɤ 5 āʒ ęʒȻ ĂʒǛ e 9 ʒ #/ʒŔOșʒP Ț ʒ gĚʒƫ ʒ udz [ ʒ Ǵ " '! ƬL !ǜʒ Ã × ^ŕ Xƕʒ êʒ ! Ƌʒ ț ɜǵZ M¡ʒ ¾ ʒ LJģ4ăƭʒ >ŖȜ9 Q ʒ rȝ0ǣ wʒ ěʒ . #L4D ɝȼD ƌŰʌ ʎ ʒ ı ʒ Ī /ʒ $$ IJ M! ʒ :t Nʒ'ij ʒ dğ <ȽBɫ Ʈ 33ʒ cʒ (7¶Ȟ¥ ʒV Ư6ʒƜa z nƂʁ Anƍʒǝ Ƕȟ ưxʒ Ƿ ʒ Ǹ`oʂʒƃ / Ą,ʒŗƱʒ 5 Ƞʏ Ř ʒ Lj ʒř ʒ ; _ à , = ʒ 2 ȡʒ Ś ʒ Ⱦ ʒ× ɞ śȿʃʒɱ ą ʒ @ ʒ gɬ ʒƎfɀ}" ʒ ʒƲ ʒ &Îʒ1 ÌƖɏ1ʒ ¢ʒ ¹ JȢʒ ʒ) I ʒ[ȅ ɲ^ +ʒ ŜƼ ljʒ Ǟ "ʒ ŝƳyɕɁɟØŞ ƴȣ NJǹʒ Ǻ ʒ ş ʒ ɂʒ Ƅ Ćʒ ɳĴa ʒ { ʄʒ Ñ \NjƝćʒɭŠÝ&šƞȤʒnjǻʒɮŢÙɐűƟţʍĈǼȥ£ʒ ´ǍǽʒɃĵĉʒƠǎȦɄʒǟÄȆɑʒ®¸·¯ȧʒ ǾĊʒ Ʌʒ ɔŶŲƵīʒÅëċǤɠÆɆČʒ]ÉȇčʒǏĜʒɇĶbʒK Ť RȨjʅʒ *ʒ ķ ťÞ jƏʆʒ ƶ4 pƐʇ ųƑhʒ ɈŦ Ʒ&ȩ¤ » ŧ 'vʉ Ȫʒ Ú ɡȈȉ ƽ ʒ ìĎ ƒ Ƹ0ʒ ǐĝʒ Ũƾɒ ďȫ ʒ ũƹʒ ɉĸĐʒ (7U(ʒ % ǿ ʒŪMʒ+ Ȭ Ȁ >ʒ:ʈʒPĹ ʒ+!ơ 3 ūƺ ʒ qǠ Ŭ ʒ #ʒ= u× , /×ÑR¯I× J¡ !K ¢×05fvS°T w ×16Ux£ V±Ì²W y hUÖ ³X z×Y¤×´L7×"¥#M8Ò i× C× Ä 2ZÅg { j× _|¦µ[Æж\ } × §9·¸]~H¨× Ç^$Ík pÔ× ¹ º:× q; » l× N © _É mª × w3× ¼O<× - w%Î = ½× >Ó w«` × D× & rsÏ~aËÕ ¬?4× F '\nb¾c@× G × ¿PA× ( ?× E× )Q d*× t+w. o× ÀeBwÈ® ×
ó W 0ɪ G ɪ Ð?Ìͱɪ ¡ ɪ DZ Dzɪ oɪ Ɋ Ə C ɪ YCȺ ȑĦ ɪ. a5 ħ Ȓɪ ɪ 3 ƨ%ȻɩɨřGɘɪ Eək Ś Ǖ£¿ɪ ò ɪ ɒ ɪ ɪ 67Ɛ Ǎ + [ɪ s IJȓɪ ŃǮ 8ɪ ÊË÷ + O ɪ á ɔśƵ %ɪ ɪ ôǪ ^ E Ŝ"ŝ /ɪ HBg!ɪ #j, Ȯ ɪ%ȼ+ ɪ ijɪ ɋɪ ǃ+x ɪ qDǖ/ɪ *ɪ aB ɪ > ɪ Ĵɪ Ȕ- ɪ l 0ɚÀɪ øDŽĎ üƑɪ â &Ş 7 %ɪ Ƚ 5dz ɪ u ȕɪ ɪƉ Ǵɪ& ɪýɪĉş y3 ɪņŠ J0 ɪ ĵɪþ <ÿɢ Ôɪ7 ƒ ƶɪ oɪš) ɪ"zďȖ ǵɪŢ ɪ Ƕ¤Z Ƿɪ¡ d ɪ ^ Ɍ ȯɪ NJ $ ɪ 0ɪ© 9 W Áª ê ɪ m ; ²ɪ õ Dž ĨǸǹ'"ţǺ ɪ Ȑ r ǻ ġɪ ɍ _ ɣ Ʃ Ƣɪ ɕ ( . Ʒ Õɪ ƪ Ĉɪ Ɲ ɪǗ ɪń ɪ ɪ«Q ¬ɪ $ƓSɤ V ³ɪ ǼƔȾ ɪ {*Ť Ƹǽ´ɪ ǘɪ @ą8.ƕ¥ɪ Ċ ƍ 1 ȿ µɪ ƹĢɪ 6 ɪ W(R 11 Đȗ®ɪ <*|Gɀ Ǿɪ Ķɪ <ŋUǙǿÂɪ út ɪ Ō ɪ " / ɪɓ ɪ!V ɪ2 }: ɪ ɪ pɪ#Ɩ! ) " Ȁɪ ]ɪ 6 ɪ ;¦ cƫÃɪ ã> ':rɪ Șō ɪ 9{9ĩș, ƺHŎɪ đĪ:ȚɁ ¨¶ɪ × ,ǚťĒM:ɪ F¦ɥ 36$ ¥ɪ 2 iC ɪ 7\ ǛU < ɪ . ɪ >+ ɪ ɖ ǜ 8 ɪ ɪ Lfɪ æĄƊȸ;ɪ ä %ɪ pɪ ù Èɪ Ø ɪ ɪ țv5ɪ ÑKKÓɪ L E >ȁ ) ɪ ǫ ǝ %ɪ ADǞɪ 2 Āǟ ɪ ǀȰOƣɪ ǎ =X Ȃɪ X ɪ Ǡ Ɏ ɪ - ȃÄɪ ë ɪ ɪ ƗɪK?Î ·ɪ ö Ȝ ɪ ģɪÜ Ŧɪ ɪ dȄī ɪ ɪ &ɪ £ ɪ ķɪļĆēŧƘ )ɛ¾ȝŏ ɪ ɜĔŐ ɦ N ŨRɪ zȞN ɪZ ɪũ(ɪb6 ɪ3 Ƭƭɂ . eɪ ( ɪ SŪ ɪȱ ɪ kȟū" ɪ )` !Ʈ !ɪ ȠV !ɪ& cƙ ɪ y( ɏ ɪ@ć Ŭ §¸ɪ A ¹ɪ Tɪ 4h ɪ T$ ɪ Ǐǡ Gx)$ _ Åɪ ûő ɪ 3 ȡɪ džĸɪ Ņȷ 1ĕ 1 ɪ PƤȅ ɪQ ɪb ɪ Ǣ ŭ Ĭɪ !5 = Öɪ .! ɪ Ů/ [, ǁ *$LJ ɪ ǣ ǔJ ^ ɪ Œ ɪ AĽ Ǥ ɪ Ĺɪ ǐ ɪ ň ȹ :ů ɪh ɪ 4ŰPƥɪ& `Ǝ5 ɪ&B ɪ ƞ 2 ǥO ɪ&ű œɪ Ȇɝ ŲgH ų ȇÆ ì ɪ - ɪ AƋ_ *ɪ lN ɪ ĺɪ Ȣ ';ɪ 9 J §ºɪ B ɪ ' @ƧɃ m Fɪ Ljɐ,Ĥɪ ÙƯ XĖ ɪ ȈeėuŴ ȣǯeɪ Ɵ] ɪ aljɪ Ȥ ĭɪ Ę ư Ʉƻŵȥɞɪ M nɪ #Ŷnɪ ȦŔ,ɪ ŁNjd b' ɪqnj ɪ w ɪÝ /8J ' ¤ɪï Ȳ [ɪçU# !ŕɪ/ " ȳÉɪå ɧ =ɪ ¢ ;ɪ - ɪ ð \ iƦɪ è¨ ŷ ɪ ɑ ɪ $ Ÿ Y ɪ ċɟɪÞ ŹŇ ` ɪ ÚĮ ¯ȉɪ c2 ę#= ɪ Ļɪ &vź4Ŗɪ ɗ Tɪ w ɪ ¢ įȧRŗ Sɪ4 $ Ż ɪż ɪ ɪ ȊǑŽ<P ȋÇɪí ɪÒ?Ï?»ɪÛ Ȍɪ Ǧʼn |ɡ ɪ - ɪ ñ I7 ā ɪ ß C8 Ȩ ɪ łDǧɪ L ( ɪ éɠ Y ( ɪ ȴ ɪ ZƠ Ě ɪ ɪ ɪ Ʊ * ɪ- ɪ Ǭ 0 %ȍɪ ɪ ě ɪ s ɪǒ>Č žĜ¼ɪ ɪ) ɪ " + = ɪ Ǔ Ŋ1 %Ȏɪ \ ɪ ' ƚ ȩ~ ɪ@DǨɪſ ǭ "~ ɪ 9ȵ#ƛɪ ƀ Ȫ}ȫɅ Ɓ ƼFfɪ îƽɪ Ăĥ Ƃ ƃ ƾɪ ɪ Ƅ Fɪ İľĿ Ȭȏɪ ]ɪ #ǩ Ɇ ɪ ɇč ƅĝɪ Ğ ğıǰɪ ăj ɈIɪ Ʋ HMƜɪ ơƿ ½ɪ Ř ɪ à Ƴƴ ȭ* ° ɪ E ɪ Ɔ Ƈŀƌ4# Iɪ Ġ ǂȶ0 Qɉ ƈ ɪ I ɪ t ɪ
-ƲƳ LÒɿ ɿȮŨ ɿĶ ¦ ɿǧřɿȯ ŏɿ4 Dž³ qɿŵ TËɿ ú , / ǥ8 ɿ ĮȒ ɿ ¿7Ŷ ɿ ɿƬɿóì% ɿDz§ } } rɿ ɿ ɟ ɿ ǶŐɿ) J ķ ɿ ɿʼn6* $ ŷ¹Åɿ ¤MÆĸ(Ÿ ȰǷɬɿ ɿ džɿ 8 ɿ ɠ À9 Iɿ Ǩ]ɿ ȱ: ɿ v 4fəLJŹȲrɿ Č ȳġ ɿ w ɿ 4 Ä Ljȴɿ ȵũ Iɿ 1ź ɿ ț ɿ Ż.ɿ ¶Ū ɿ Ĝ `ȶ 1ɿ Ĕ¾ ȷ Oâɿ ĀǸ z ɿ ÷ǹżȸ Žljɿ NJ Ĺ#ő ɿ ɿ č .ȹ ɿ Ă ɿB= ´ ɿ & ɿ Ǻ #ɿ R ŋɿ ɡ ÀNj "ɶɿ'6m!žPC ſɹ oa Tɿ Ę ɿ ! ɿR ǻ ɿ/ FĺÇɿpĢ ɿ" Þ @Ⱥ Yɻ )Ȝ ɿ ɿü ɿŤ=ɿ ɿš7 µɿ ƀ ɿ0 h& ɿȻ ɿY E njƁ ɿ Śɿ¶ ɿýK ɿ 2ɿV =ĬɿB> C· ¢#ɿǀ « ɿ¸: Ǎɿ ɿZ .ɒ$¦Åɿ = G +èɿ 9ɿĎ Ș ~ ¯ ÁE^ɿ ûĭɿwǩȝ!Ƃ Ôɿø- Ǽ ǽɿŒȞ į 3L' ɿ9 ɿBū 7 ! ɝ9ƃZɿĕ ĻƄ ;ɿù ɚİɿşǰǾɿ 8 ɿ ǿ) Q rɿ ɿ 'ȓ ƅ ƴƵqɿe £»{ƶ ɭɿ3 t ę: ɿŢ>ȟ ɿ ɮɿ' 0jƆP| ɿ ɨ 0ɿ J 5 Ōɿ)ǎɿU ļ pãɿ ɿē "Ƈ ɿb ģÂEɞ° # ɿ#Ŭ ɿ¹Ȁ ɢ ƷƸ35Eɿ ŭ f ɿ K ɿ<" Ŧk 4ɿb ɿ *@º ȁ s W Ȕƹ ɿW 7ɿ Ććɿ Ƞ!$+? 1ɿ 1ƈ Ǐ ɿ * , ɿ ȼ R § ɿ&Ǫ*HQ -nÈɿ 7ɣƉ& ȡäɿ Ě( ɿ dzɛı ƊĽɿ Sz±ɿ IJ Ƚ:ɿ LQ+!ȂƋȢ ɿ ǐ ɿ ¨ ɿ YÈɿ ½ œɿ ¤ȃ , ľ ɿ 2ɿ 8 ƭɿ ƺ . NNɿ ƌǑɿ ȾŮ ɿ H ƍȿĤ©ɷɿ ȣ Ț ĿŔ²tɿ yǒɿ Ǵ© ɼ ¿ #ƎǫǓɿ Ȥ ? ŕ Ə5 Õɿ êÖuòï×é%%ɿ H ǔɿ p K ɿ DZÁ. ɿ ɓ ɿ D ɿ g ɽ nF ¡ ƻɯɿ ɜ c³ɿ ťªɿ ªÄG ɿ ɿ uð%Ø%%%ɿ Ñɿí%Îɿ 2ɿ `OZ( Ȅ MÓɿ ɩ ȅ ɿ Ȇ {M 1ɿ ș 4ɿ Ɛ, ɿ² «ɤƑŀ ɿD [ ÃL ɿǬ2ɿ Ŗ ɀ ɿ Ǖ ȥOåɿ B: ɿ ā , ȕ * ɔɿ = Ȧ! ɿ ¬ ƒ& ; ɰæɿ ě ɿ V ɿ x ɿ ɿ śɿëôîñɿ ? # ɿ ɿď ǭ5X ɿ Ąǖȧ ƓɁÃɕ ɿǮŜɿV h¼X ɿx o ɿƔǗɿ 6? ŗɿ ɿ ɥ ɿÌ ů ɿ#ȇ| ƕǯǘX;ɿ<$ )Łɿ' P ɿ /il6 &Űɿ <<da ɿ» ɿ ɿ Ǚ· dɿ ^ ɂ ɿ c Íɿ ǚ ɿ A_Řɿ ĝ ´ ¬ ȨÏɿ ǁƖIƗ >ĪɃƘ ɿ @Pĥij ƙ@ű ɿȩi łƚ ;ɿ ǦµĦ ɿ Ʉ'ɿ@ ",a 0Tɿ + .
."* .
! . % & , #. ' . ( .
- )$.
ɿ * GŃ ɿ ¥ É () Ʌ+ɸɿ Ȉ ɱɿ ] ȉɿ Ğ ¨Ʈ ɿ W Kɿ Ĉĉɿ ŧ ɿ Ɇ ɿ & I ɿ o_ ɿ ǂ ǛA ɿ Ų ɖųɿ NɲN gsɿ Ė * ɿ ]ɿ ¼^ ɿ460ɇɿ i? gF ɿ S Ȋ ɿ Ŵ ɿ 3¡[l m ōɿ ¥"ƛɦ ɿ Šcń ɿ j" Ņ ņ ɿ ɿj É ¸+qÙɿ þ"-Ň ɿ ċ3h ǃ Ðɿ ɿ , J ɿ 2ɿ ȖƜ b ɿ ( ¯Çɿ ǜ ɿ £A\l,\5º ǝÚɿ 9 ɿ < )5 ɿ ɿ ɿţȋ Ɉɿ ɳɿ ' J) ħ ɿ ƝǞɿĐ6ȗ ɿ e k &Ĩɿ ɿ ɿ Ƽ ǟɿ U * +3 ɿ ą Ȫ ƞ8$8 ɿ - ɿ U .ɉ> C;Ûɿ ɿ ɿ ĴƯƟ H\ ɿ ŝɿ ɿ ɫ/ Ơ ɿ 0 īƿɿ > Dơ ½Ƣ ¢ɿ !° " eßÿ Q ɗ ƣ ɿ ă $0 àG ɿ đ Rɿ ğ 7Ʃɿ vƤɘÊç yɊ_ Ȍɿ Ǡ ɋ ~ƽ ɿ f ɧ mɿ ɪ k ɿ Ŋ DŽ$ ƥ Êɿ /±ɴ[ Ɍ+Æɿ S ȍ õɿ ɍ ɿ D+ ƫ. ɿ $/ɿ Şɿ ư Ȏ ɿ ėA A ɿ /Ʀ Ʊ ɿ ɿ Ċ ǡȫ Ȭɿ Ǣ ɿĒ SɿĠ ȏƪɿƧǣ¾ ɿ ň ǤɎ® `ɺ Ŏɿ 1Üɿ ɏ ®Ýɿ Ȑĩǵ(ƨɾ ƾɵáȑ Cɐ ɿ$ - öɿ ' ɿ ȭ ĵ M 9ɿ 2ɿ d F# ɿ( !-n Oɿ ɿɑ( ɿ
ÕÞɠ
, ɠ ɠ ŒŔDɠ Ʃ ɠ u Įƪ ɠ 8 šDNXǬ«ɠ *6 0!~Z ɠ !~ Ţ ¬ɠ ɀ a p0ɠ ŕ r&ƘUG H ɠ- 4ɠ O ɠLJn 9 <ǭɠÜßfT ,ǐɠ 5 ɗɠ ɇ ?ƓÀV ɠ ) ¤&Đ ɠ ɠ ,& # ɠ 6 # ɠ ¢ )®ɠ Ȳ ţ cɠ ģ? U ɠ{dž5ɠÿȌĄȍ ɠ )( Ȏ ƙɠ =Ť ¯ɠ |įɠȳǮ ɠƺļɠ ȴ ť¡dɠ đ. ɠ ©ɠ g Ä°ɠ ɠ ɠ >,:Ē ǯªɠ ɠ % /ɠ ? 7ɠ Ɋȏ 6 ±ɠ ɠ ɠ İ ; ŖɠS^ ɠ /Ȑ 4 Ŧ ɠ ɠ7 ȑĉƣ9¦ ƒ %Åɠ M ɠ Ċ Ơ9 xɠ Ȓɠ 3 I !ɠ / ƫ ``ɠ Ǒ Ŋ@ Qȓ Ĩɠ ŧǣǃ 'vƬ q@ɠ Ũ[z@bÁ ìÆ ɞɠ ē ɠ @ ɠ ɠ # + ǒ F#ƻ ɠ ũ ɠ Ĕŗ ƚ ɠ ɠ Lj0 Ɍ 5 b% gɠ M ɠ ? ǰ+ Ūƭ ɠ T 5I ɠ Ľɠ$ = !ɠ YE ɠ Ŏ DZ. ƛ ɠ ɠ 3ɛ (ı Dz E ɠŌB ²ɠ& ɠ( Ȫ³ɠPdɠ ɠP,5 ɠ,dz ɠ xɠ ( ľ ū % X ɠ ĩɠ u ,)ɠ 4Ɣ Ǔ Çɠ l+ Ǥ ɠ Ŭ[ɠ h2jj´ɠ #% ŭ Ʈ ɠ ɠ ɠ 10ɍɠJCIJɠ Ŀɠĕ A 1 ǥ ¦Ů ɠ \ ɠ \Ė 'ůȰ Dɠ Ɂ 0Ƽ a ɠ& ɠ Ĥ Ƨ ȵ Ɏɠ cė Lµɠ F ɠ Ű Ư ɠ ȶ ɠ ɠ ú ɠă 1 ɠl= * ɠ ij EąƜɠŘƽ ljV O ɠĪǔ NJ ɠS^ ɠȔ}wɠyƐ Ǵȕɠ űƨĴɠŲ ɠ ɠ Ę =ȷǫLÈɠ ü ǵ ę ɠų ɠǶ ŴnYɠ ɠ ƾ$$K +dɠ ( ɏ oȖ LɠŋƦ ȸ # 7 tÉɠ k ɠ Ö2áàeɠ m<N * ưɠ Z ɠ mĚ Ǧĥəɟ ǷQǕŵċ ɠ ȱ ɠ ŏ s Ǹɠ ƿŀɠCI -Ņɠ ɜ Ʊɠ ɠ ȗ Hɠr . 4Òɠò ɠh2âè¶ɠð A0 ɠ ɠý ! ǹ>]Ɉ ɠ řĆ ɠ VǺNj ǧ ¡wɠ _ H ɠ ɠ ( ]¤. ɠ ɠ yņ 1 <ɠ ě# $W ɠ ȹ `Êɠ ó%ɠȘŚ ɠ N ɠɐ :·ɠ í K !X ǻ : C ɠ£ ɠ U$nj = ƲĜ ɠ Łɠ Ⱥ ɠ ɑ W )ɠ Ŷ ɠ ș ɠ }ǀ) ŷE !ɠ Ëɠ õ ɠ ×2ãê¸ɠ ö Ÿ 8 [ɠ p ɠ 8 ɠ Ħ ƕĵ6Ǽɠ Ǎ ɠ ʼnƑ ɠ 8 Ź ɠ Ț8 +ɠ 3 K Lɠ 9 ɚ F ɠ ɠ ǽ ź ɠ ț ɠ$ %ȜO ɠƏ/ơ ÓÛçɠ kZɠØ2äÙ¹ɠï -Ň " ( . ɠ ɠ " * ȝ. ɠ 9 ,: ɠ ń/Żł ɠ# ɠ + !ɠ śǁǾǎżȞoƤǿÌɠ ôƳɠ Úëåݺɠ ĀǨDŽ/Ķɠ ɠ ŽȀɠĝ / "œȻķ) 5ȫ ɠ< *ɠ !ɒɠ iéɠ ( ȟɠ Ńɠ< ɠ ÷. Ƞ »ɂ ɠ ǖ ž Ȭȁɠ ɠ Č * ɠ c Ǐ* f-Ǫ ɠ ɠ-ȿ Gſ ƢAɓɠ ȼ ƀ_ Íɠ M K ¼ɠ ɋȡ ƴ ɠ Ȃ "1 7ɠ" Ƀ& ɔɠ Ǘ ɠ ɠ $ Db'ɠ ȭ 6 ɠ ' Ƚ%Ɓ ɘÃP ȃĸ ɠ Ȅ Îɠ øJȅħDžɠȆȢćȣĹȇɠȤŜq ɠǘvȈ ĈǙĞŝɠŐ\ ȉɠīǂsȾ'RƵȥ ɠȦŞ ɠƝƂ Ɩɠčĺ ɉRRƶɠ ɠ ƷɄƃǩ $ ¢ɠ" ɠ ƥH ½ɠ 3 4"* ɠ ɠƄ 3 ɠ ɠ {Bǚɠ : ɠ$ I ƞɠ 0 ɠ Ɨ ;Ȋ¾ɠ ɠ -ň _ ɠ ɠ§ & %Ȯƅ ɠ Ǜɝ GJ Ɔ ¥ɠōBǜɠ ğ Yɠ 4 Ϩɠ āş ɠi2æÔȋɠ 6 ɠ> ¥ɠ W ɠő1ɠ ĠƇ !ɠǝ zBǞ'ɠ ɠĻ ƈ ġ ɠĎɕÐɠ ] ; 3)ɠ S^ǟɠ Ɖ >ď Ǡ7 ɠ | "Ɵ+ ɠ Ģ ɠ " tɠ ' ɠ ƊȧƋ Ñɠ ñ ƌ a ĬɠQ Ƹ 1ƹɠ- ǡɠȨ ɠ & ĭɠ ɠ Ǣ ɠ ɠȩ ɠ FŠ ɠ Ă ;ɠ ɠ û Gɖeɠ + ɠ î Ʌ#Aɠ þƍ T£ ɠ ù Ɇ ' ȯ¿ɠ ɠ ;Ǝ JCɠ
14
Community Psychiatry: A Reappraisal
liberation fronts. The Federal Government attempted to achieve "maximum feasible participation" on the part of the citizenry. 51 Optimism reigned and a spirit of hope swept mental health circles. Manv believed chat a Federally-budgeted program could be designed �o deal with almost any social or economic problem an attitude later characterized by former Budget Director Schultz as the "throwing money at problems attitude." 52 The Levines 53 have pointed out that, historically, psychiatry s-wings bet\.veen sociopolitical conservatism-when proble:ns are deemed intrapsychic and treatment is geared to the in dividual-and sociopolitical liberalism-when problems are thought to be environmental and social intervention is aimed _ _ toward reducing the incidence of disease. Dunng conservative times resources are used mainly to provide treatment to the manifestly mentally ill But during liberal eras, the prevailing beliefs are that primary prevention is attainable, that group action can solve problems, and that the human resources are greater than just the number of profession�s in the mental health disciplines. Zusman noted that the philosophy of com _ _ munity psychiatry paralleled Kennedy's "Camelot''-"O�um1suc, - romantic and liberal ... social conditions cause mental illness so .. - [one must] change social conditions." 54 -·�-- · In 1961, the final report of the Joint Commission, Actwn far Mental Health 55 called for: more money for mental hospitals and research; the establishmentof community clinics connected with general hospitals that would serve no more than 50,?0� pers�ns; expanded community services; the location of psych1amc serv�ces near patients' homes; community education t? foster prevennon; and greatly increased numb�r� of non-profess10nal !11ental h�alth workers. Although a few cnucs, such as Caplan, 5 complamed that the Report favored services to ill adults over P:evention, most authorities believed that the recommendations were balanced. President Kennedy's 1963 Congressional Message on Men�! - Health, however, presented a "bold new approach," a drasac
The Historical Background
15
change in emphasis-away from the hospital-based services recommended by the Joint Commission and toward the develop ment of"comprehensive community mental health centers." 57 His message was followed by the passage oflegislation, PL88- l 64 in 1963 58 and PL89-105 in 1965 59 (the CMHC Act and Amend ment), that established the CMHC program. Thej oint Commis sion had recommended improved State hospital care, early intervention, provision for aftercare, travelling clinics, and psy chiatry in the community. 60 However, in its bureaucratic journey from Report to Congressional legislation, the travelling clinic became a "center" serving a "community." Although community psychiatry had developed major concepts and approaches, it was soon overshadowed by the Community Mental Health move ment which took tangible form with the launching of the CMHC program. By failing to mandate aftercare as a required service, the legislation allowed CMHCs to concentrate on the less severely disturbed. In 196 7, Freedman presciently wrote, There is a danger rhat in paying increased anencion to the socially deviant and the neurotic in the community the traditional responsibility of psychiarry for caring for the severely Jisturbed or psychotic will be minimized or abandoncd.61
MENTAL HEALTH OR ILLNESS? Definitions of mental health fall into several broad categories the absolute and the relative. An example of the former is the World Health Organization's statement that health "is a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmiry." 62 In contrast, the relativistic point of view is expressed by Laughlin who views mental health and illness as conditions on a continuum: "the 'normal' imper ceptibly merges into the borderline, and the borderline into the
=3ʽɅ@ʇ[Řĕüˢ įä³ǯǰˢ ȇAʈƞ ɆˢƮɠˢåƟ ˢʉɇ Ŝ´ó´Ï> ½ˢŝũ Ǘ>ƯæưAcˢB¢ˢƠ ǝq§ˢ ɡˢ nơ ˢ Pˢ(¤ˢŞ\ɢ -ɣ zˢ Īdˢç¨QˢęĠĝėÚ wˢtƢ eˢèƣŪˢĥȨ&bʾȈ]Fvˢ| =é :ˢĨP _o!ˢ'ȩˇ ǹ ïˢ ú.iˢʊ ǜ fWˢɤ© E3ăˢ Ƙ µpº Çɥˢ Əˢ ä/;ˢƤ /$qªˢʋūÈşŬ ˢʌ ˢ '* Hˠ jƱû4ˢŁ ʍ!ˢR CʎƲC 1aˢ0ȉ ˢkÐ ¶1Äˢt %<, ŭ#ÉYĄˢ Ȋ ąˢ 1pˢ¾ Ĵɦéˢ +_· ¸sDZ˖Ćˢ ˎ %Dz,łS dXˢˏ lˢQɂõ ê Oˢt¸Fƥˢ Õs2ʏƳ ȋˢ Ê ˢɧ ¶ ¿ˢI ¼öÛ 'TȌʳĖˢ Ĭ ɈǞˢ |Ů??ƴËƙ hĂˢɨˢ ĚġĞĜˢ ɩʐĵ Ǻ Ȥʴˢ ȸƵʑȪǻƶ˝ůŠˢ ˢ ǟȫȍƚĎɪʒ ȎšƷȏ¦ˢ ˈƸ5ːˢ@Ɛˢ Ű>G `ˢ « :ʓ«ģˢ *J ā éÊā A i Kā L¡Û ā M, oā Ëā Nā-B êÌÜ çābāpë ¢ā7Oz mÍā Ý āP :qā ®ÞrQ¿ā £Cāõā s āö¯È Dā.8 āß ā÷{àtā ā ú| ì ā°cā gh ; ò R ā/¤Eā u ¸¹}¥ Î$ā)(
İ÷ŊƦˢ ˢ ƹ ½³Üʔ¹ŋˢ M ǘeµî¹ ˢ ȬƑˢ Æ6 ëĶ%ˢ ¬űK;çƧď ÅŃ Ţ˗[c7ˢ /ȹrIñǚ ćˢ ɫ Ō[ $ˢ ¼ʿɬò Ȑ wˢ J ˢ ˉŲȑˢ ++ƺȒųÝɭĐ6kê-ńǠƻÞ ˢ HˢƛCHÀˢʕ® ìˢƨK ˢ ˢ ɘB ˢ*B*ˀǡ ɉˢ *Õ %zˢIJ8Ŵˢ˘3 ×eƼ>7ˢ¥ȷ×ˢɮˁō¯ˢķȓˢ ƽ 0%ˢ ř ? ^ʖƾȭÌˢ XIù ˢ \&*ŵGõɯˢ ʗ ˢ r" ˢ EÑ)Ɋa˙ˢ ÐËLŶÖʘ˂ Ǣƿ˞U Ĉˢ 9 Ýí#:˚ˢ ɰ WȔ5ţĉˢö ʵ lʙT xˢ Ⱥ4dz`,Ǽ ;Ǵˢəˆɱªˢǀfʚ(ˢĦĭĩħˢ Ȼɚȶ7g jđˢ ~ 6ˢ ȼ® ǁßˢ ÏÍˢǽ ȥʶ.¾ˢ Ʃ Âr"ˢJ`à@ˢǣ Nˢ ʷ)ˢ k˃ŎˢŏDÍ Ƚ ɲˢ ˢ ~!ȮÆ/ßˢ ı˟.ɳûā ˢý uʛ¬ˢȯ£ˢǾ ȦFĸ<ˢ ǂ$ǵȕ6ɴɵĒþˢ īȖˢ ěĢğĘyˢ © ˢ VŚÃ2Ø Nˢ F 1pxˢ ŀɋˢ ɞȰǿˢ Ņ ºÈƜˢ Ĺ ˢ ŷ ʜǃôvĊˢ Ȁ ȗGĺǤˢ DŽǶǷ=Ÿmmˢ ˑ-ɶˢ ȁŹɌƎǸ˛ˢ ˢ Ť ˊDž ] ˢƖɟ(Ȃˢ î źˢ ɍȃˢRlʝ adžá9S ˢņ˜ˢÿȾɷuŐ¨Òâ őLJ $ċˢ Żʞ°Lj ǥyˢ 0 ˢ Ǧ4¦ Ãˢ ÔȘ ż+ʟâēĀˢ } ŽɎˢ˒h·ʠQɏɸˢ ǧÞ ˢ Œɐ»U ˢ ï8žˢP¥ƕſœʡ ˢ )ƒˢ Ǩ Ň ǩ#șXˢ0Ț ˢɹĻ ɛļǪˢśC ɜ(ǫˢ ȿhÓ ƀɺáƁɻˢDÌˢsƭ4ˢŔ ˄Û ˢ ˢng ð ðˢ Ó¢ˢ& ȧʸ2ǬˢMljÚȱgM5ɑɼ{ˢ Į Ù B Üˢb ] ʹĽNJ ťĤˢ + ā À ā ±ÁSā ~ a ûā ²ā ¬èTºÃUáā 0ā F dj <í âüā ¦ā 1 ā G ó Hî2 Ïā kð l §nā ³ āÄ´ VāWù» = ¨Ðā Ñā3āI Ò Å9 >Xā ©ā? ¼4@ ý!ā % &"ā ā ªYÓÔ#ā v5 ā Õā ÉñZā «āµ w[Æā ÿ½\ ā eā ¶ ã ]Öāø äxā åy Çā Ā¾^×ā ·fāô6 ï_ā ØþÙæ` Ú'ā
ij8Ƃˢ &ɀƪ2ɽNjmˢAțˢȄƃȜʢ-$ˢ¯ ;ñ§Čˢ ʣƫ3ˢ Ƀ÷ ënjȝƝˢȲ£ˢȅ ?ʺKǭˢ²5 <ò9ˢ ˓Ǎʤ"ˢ Ɂʥ ʦǎÔȞˢ ȟOˢɾȳŕ» Áˢ ŦǛøɿʼR ʧčˢ Oˢʨ°Ƅˢˋ^U˔ˢʩ8 ʪˢ ʻˢ ǖÄ¿Ƞ ijˢ Ǐʀˢ ˢ àÑŖ^ Áˢ Ö9 Îȴ' Îȵ ˢ Z ùTˢ Z ˢ Ɨɒ,Ø LZ#=Yˢ D ʆ ˡ Ʉøƅ ƆʁĔˢ } Ƈˢ Ɠˢo!Sˢ'@ãʫˢã#Y ǐ Ǚŗ ȡʬˢ dNˢ+ɝÒň Ȇ è LˢúJʂˢo"ľʭˢ ˢ ±ǑW!¡ɓˢEÙǒDɔǓʮuˢ˕ ʃˢ7\ˌƈÇˢqAˢʯ² ˢEɕƉˍƊ ì fˢ(Ɣˢb Én :ˢǔÀ_ÊViʄˢG± cˢ ó)ˢôƬƋˢ åɖVĿí&ƌȢʰˢ)¤ˢæ"ƍˢÅ ȣʱ.<ǮvˢŧǕʅʲ˅ɗʼn¡Ũ{ˢ
20
Community Psychiatry: A Reappraisal
The Historical Background
REFERENCES 1. Jarvis, E. Report on Insanity and idiocy in Massachusetts by the Commission on Lunacy. Boston: Wm. White, Printer to the State, I 855, p. I 06. 2. Grob, G. N. Afental Institutions in America: Social Policy to 1875. New York: The Free Press, 197 3. 3. Rossi, A. Some pre-World War II antecedents of community mental health theory and practice, Mental Hygiene, 46: 7 8-98, 1962. 4. Musto, D. The Community Mental Health Movement in historical perspective. In An Assessment ofthe Cormnunit)' A1ental Health Movement, W. E. Barron and C. J. Sanborn (Eds.). Lexington, MA: Lexington Books, I 97 5, p. 2. ...... _. 5. Galt,]. M. The farm of Sc. Anne,.Amen· canjoumalofinsanity, 11 :352,,., · ,·' 357, 1855. 6. Copp, 0. Further experience in family care of the insane in ,, Massachusercs, Arnericanjuumal of Insanity, 63:361-365, l 907. 7. See citation 3. 8. The Institutional Care of the insane in the United States and Canada, Vol. I, H. M. Hurd (Ed.). Baltimore: Johns Hopkins Press, 1946, pp. 258-280. 9. A century of debate surrounding community care, Hospital & Community Psychiatry, 27:490, 1976. 10. Beers, C. A Mind That Found itself New York: Doubledav, 1908. 11. Meyer, A. Organizing the community for the protec;ion of its mental life, Suroey, 34:557-560, I 9 I 5. 12. Healy, W. The Individual Delinquent. Boston: Little Brown, 1915. 13. Grob, G. N. The State and the Mentally Ill: A History of Worcester State Hospital in Massachusetts, 1830-1920. Chapel Hill, NC: Universitv of North Carolina Press, 1966, p. 350. 14. Salmon, T. W., and N. Fenton. The American expeditionary forces. In The Medical Department of the United States Ann)' in the World War, Neuropsychiatry. Vol. I 0. Washington, DC: USG PO, 1929. 15. See citation 3. 16. Frank, L K. The society as the patient, Americanjournal of Sociology, 42:335-344", 1936. 17. Caplan, G., and R. B. Caplan. Development of community psy chiatry concepcs. In Comprehensive Textbook of Psychiatry, A. M.
18. 19. 20. 21.
21
Freedman and H. I. Kaplan (Eds.). Baltimore: Williams and Wil kins Co., 1967, pp. 1499-1516. See citation 4, p. 7. Jarrett, M. C. Mental clinics. In Clinics, Hospital and Health Centers, M. M. Davis (Ed.). New York: Harper, 1927, pp. 426-452. Bierer, J. The Marlborough experiment. In Handbook of Community Psychiatry and Community Mental Health, L. Bellak (Ed.). New York: Grune and Stratton, 1964, pp. 223-228. Querido, A. Early diagnosis and treatment services. In Milbank
Memorial Fund: The Elements of a Community Mental Health Program.
New York: Milbank Memorial Fund, 1956, pp. 158-181. 22. Felix, R.H. Mental illness: Psychiatry in prospect, Americanjoumal of Psychiatry, 103:600-604, 1947. 23. Whittington, H. B. Psychiatry in the American Community. New York: International Universities Press, 1966, p. I 5. 24. Mora, G. Recent American psychiatric developments (since 1939). In Handbook ofAmerican Psychiatry, S. Arieti (Ed.). New York: Basic Books, Inc., 1959, pp. 40-41. 25. Glasscote, R., D. Sanders, H. M. Forscenzer, and A. Foley. The Community Mental Health Center: An Analysis ofExisting Models. Wash ingron, D. C.: Joint Information Service, 1964. 26. Lindemann, E. Symptomatology and management of acute grief, American Journal of Psychiatry, 101: 141-148, 1944. 27. See citation 3. 28. Becker, A., M. Murphy, and M. Greenblatt. Recent advances in community psychiatry, New England Journal of Medicine, 272:621626, 1965. 29. Ibid. 30. Jones, M. The Therapeutic Community. New York: Basic Books, Inc., 1953. 31. Caplan, G. A community approach to preventive psychiatry-a conceptual framework. In An Approach to Community Mental Health. New York: Grune and Stratton, 1961, pp. 1-31. 32. Sivadon, P. Techniques of sociotherapy. In Symposium on Preventive and Soci.al Psychiatry. Washington, DC: Walter Reed Army Institute of Research, 1957, pp. 457-464. 33. See citation 22. 34. Appel, K. The present challenge of psychiatry, American journal of Psychiatry, 111:1012, 1954.
Ġ
M Ì2 ¨ ēĠ ÷Ĕu¢$ ú03CĠEĠ b ++- ©ím'Ġ
ė # ɣ 1&̧ Ş ̧ . ̧kɤ ʪ ɷ̧ Źˁ̜@.ȓƒ˖ʫȔw̧kM˂ʓ@ȕ ˗ ɸ̧D ̧ʬ ɚs˘Ȗ ̧ :0+ ȗƫt ̧ʣ4 Ƭ ȘƓ% ¡̧F ç½ Ġ¿Õ2ê ÀĠÖ Ġ`lv ªnûì4Ġ äå(Ļ̌æYĵ¢̧ ç ij Ă8[ Ɣ G ɹ6̧ Ś ̧ \ÍğÎw¾Á îĠ* Ġ]ä Ď "ď ĠGĕx£#o 0Ğ Ġ = ̧̒* ʭ ļ̌ ˃E ̧ 4£ p DŽ Ş è ĤćÇ ă̧ĥ]̧ ƁAǓ̧ ƭD ˙ș ̧øĮȨ̀ gįÉ Ƃ ǔ̧ Ʈ ƕ˚ ̧ùáÊ ̓ &̧ ƍ7̧ ş ¤̧ ũ ̧ n ̧ Ɩ K>ǽ¥̧ ̧ oÞ̧ ś ˄˛ N¦̧ !̧ Ő ̧ = ̧ ŭƗ{˅ g ƋˆȚ1ǿ̧Dž ɥɦ˽ɺț˜̧̝uȀǕ ƯȜǖ4̧ȝ ̧ CǗ̧˝ʮ,Ƙ˞ɧǘɻ ̧ʤK ȁKƙɨ̧ ̧ ̧%ʯƚ̌,H ɼȂ x H|̧ȃ˾ NJ ɽ Ǚ̧z 1Ȟ@&̧ ü &Ġ Ė « 5Ġ 'eĿ ĦúYĄĬ9§̧ é (ħ Ĉd ŋ-ɛ s ¨̧ Ū\̧ ƇȊ-̧ ư ɩʥ ǚ - ˇȟ̍Ǜ̧wʔɪɫ˿ Ƞ ̧$ ̞Ʊȋ ̧ $ʰIȄ3 0̧ ȡR ̧ Šʕˈ$Ȣ ɜ ̧ ǜǝ̧ Ʋȣ˟ ˠȤ ̧ ûd ĉô ƃ ɬʦˉʖɾ6̧ <7©̧ œ ̧ żʗˊˋV̧ l ̧ ŕɿȅɒǞŢ Nj̧ Ŗ\̧ ťȥ̎ˌ ʀ ̧ Ř ˍȦƤȧɓȨR ̧ Ƕ dž ɭɮ̀ʁȩˡ ̧ LJɝȪʂȫy̧ ʱB ˢɯǟ ̧ Ǽʢ ̧ ˣ ˤ ̧ ɰǠʃ˥ ɔ̧ " Q2Ȭ˦ ɕ U̧ :Ů; H,y ¬Đ ïĠ Z , Â× 'Ġ^ðė §® ýé36Ġ İâŀĨf̦ĭ9ª̧ êĶĘıË ĊüÌ z ¯ Ġ åĠ V!Ïþ ÃĠ ÿ AĠ k!Ġ P°ÐpÄĠ c âØ.ċĠ Ù Ġ Ā¤ ĠT $ āĠ N ((±1 #Ú Ġ W Ñ ĠRË ñ Ġ Ò Ġ Ĉ BĠ Ų ̧̔* Ł̧ 5ȭ ̧ F5«̧ Ţ Lja¬̧ ë 8õ ċh] óɱV̧ƀß̧ ̧ ʘɲɳ ʄȮ˧̧̟ʲBM OȯƥȰ# ˨̧̠Ǿ3̧ɴǡ % /̧ Ǣ?#˩Ȍ̧ȱʅ̧Ō Ȳ ƈ A̧ųǣ˪"B njM®̧> {̧= ̧* LF̧ ˫ ˬ ¯̧_òĘ{¥²q -³|Ġađæ .Åę7Ġ ąãł)IJČZ ) ĩ°̧ ì (8Í ''[ uʆ˭ʙ ±̧:^̧<^²̧vʇǍ̧ů ̧ ̧ Ƴ ̕ ʳˮ̤ ̧ i¦ Ġ;X rÆĠQ ù´Ă Ç<Ġ Ŵ ̧̖Ǝ ʴ Ń Pȳƴ̧ōʚ F4³̧ ţ ljà´̧ í ęč7 ĎĚ_ šʛ ȴʈȆPC ƛǎµ̧ Ŋ ̧ Ŏ ¶̧ !̧ ř_̧ őÎ̧ ŽǤ!ɞɋƵȍ`̧ dÛ}% ÈĠ Ġ S &Ó ó DĠ IĠ OÜ %ăĚĠ eĄ ě=Ġ ŵǥ̧̗* ɏņ́Ť Ȏ ̧rȵɖ+ ̧ !̧Ƅ ˎW̧ î ij ďĠa m ̂ǏȶG/·̧ r ̧ źʽ ƪ#Ǧɵ5̧IǷ̧/ǧ |Ǩ3 " $̧ȷ ̧˯ȏ ̧ ̏ǩʾ˺̧Ɯ !̧ ̐Ǫʉ̧ˏ ȸ / ː%ʿ̋z ̃ʵǫ̧ Ņ̀J5̡ƶȐȹ ˰ʶEƷ̧ . Q$Ⱥ˱ Gˑ ̧ }Ƹ̧ƹȻ˲?RDʜ ̧ ý¸̧2 Ï̧ ĐěZ )đ ĒĪÐ ŦǬȼȇ" ʠʊ¹̧ ;Ņ̃ nÒ̧ [ Ġ ¼øĠ U ¡µÝ >Ġ Ŷ~ ̧Ə ʷ Ņ̧ lƝOȽƺ̧ º̧ pʋƻ S ï (ķÓ ēij Ŝ Ǻǻ ʌU̧ ŗÔ̧ J Éč)ô?Ġ ŷǭ̧̘Ɛʝʸɐņ̧ Ŕ ̄Ʀɗ ǐ ̢̧ Ǒ̧ Œ ÕX̧ ðĸġö Ĕ Ö ʡɘǮ»̧ ū ¼̧ Ɖ ̧ Ĝ ̧ ŧƞʍȈ1ǯ Ţ ̧ b̧ ŰȾƼ , ½̧ ǰ ̧ vɢ ̧ ĉ Ġ ą K: /*ãÞ ¶õ Ġ j ĠY· ĆßĒ)Ġ Ċ s ĠfČ Ĝ@Ġ ƌʞɟç f̧ȿʎ̧ -̧ƊȑIɶ Q̧;×̧ m žDZ ,̧ƅ+ Ɍ P̧ɀʏ̧ ʟƽɁƟ ̧Ż˒̣yCɂ ˳L Ø̧ Ÿ+̧̙Ƒ ʹɑŅ̌qƾŝ3?̚Ã<Ƀ#H&̧eĹ)þ` Ɔ ̧ƿɄ˴Ơ˵Ʌ ̧ĕX̧ 2 ̧ ĺÙ ĝ÷ ſ ƧɆ 6̧ Ũb̧ ŏÚ̧ q ̛ɇ0̅0̧ǹ~ N ƨə ̧ʧơʺ ǀ 2Ƣ˶Ɉ ʐņ̌ ȒDz̧ ʻ ȉɉʑ˓¾̧ Ɋ J ɍÄ ǁ>˷E ˕̧ ʒǒ̧ ǂ̆ ˀdz ˸̧ %t˹̇O¿̧ /"~ ĠL ĝĠ à ¸ć¹ Ġt Ġ gá º Ê h » Ô ö8Ġ ĆĴĞʼņñ'Æÿ À̧ òĻĢļ ğĀ x.̈ɠ˻̥Á̧ Û̧Ŭç "Ģ́J̉ƩɡɎǃ̧̊N ̧ ̧ ʼ ̑ƣ }̧ ˼ǵLA˔ W̧ ë è19Ġ ű ̧ó ī̧9 ʨʩÜ̧ ĖhÅģāÝ
č]¡Ü ÊÔ¢$ ,čT |¶ ā č
¸½ɑ
J. ɑ ėŨȽƍDŽũzɑS {ɑ ŝɑõ ɑR ȾƎ ɑ Mč }£u·č ¤= ;CčÐčê č ½Ò¥ :Ą¦ Ý č Ġ Ɂɑ ľǙ Ʋéɑ öhhƴŪ DžAN eou:ɉAN Ǫźrȗ|ɑ äÚ¯ ɑ Łȸȅd }ɑ ē ɑ IJƄ ɑ ǭ ƏƵ'Ȇ'Ǯƅ]ŏɑ ō ȇ^ ɑ ſgDZɑ $ɑ Ŝ( 7t8ƐȘ=ɑ dž[ɑ Ȉ ŐƑX&ɑ ȉɊZ ƒ șȄv ɑ # ɑőƓ łȚƔǚ ɑÂ~ɑ ǯ ɑ ÛCG ɑ # ūɑŒƕ țƖ( ɑI¹ ɑ ÉÎ ɑ ī ɑ œƗȜ pƘǛLJɑ¿Ó¡ɑ /Ø ɑ ĕŬ Lj %=@ɑ ć ɑ 1 ;n$ ɑ Ɓȃ) ɑq ŭɑ ĤDz _% 8<ɑ ǜŻɑŔ\ ɑ ĸ9aq %ɑ Ĭȝ Ȟ Ȋɑ dz ƺŃȮ_ȿ ɑȟ)ɑƽ ȠW ɑƙb ȋȌɑ Şɑ7 ɑiŮȡ Ǿş Ȣƚflj>ɑN 8*# Áµ6Ă< ¸č jç~)§ AÙĊFč - °êá¼ BKHÜ ɑ ,LÖâɑ / ɑ z. č ` ąč č b ? ¹č n @ Ú ë* Âč Z º ¨ Þč č UË ©ìDč c í -č .î č V ï :ßč äð ñª č O!òč Ï č V kƆƛ ƃȯf ɑ Ąýëɑ ĹĭċĥĢ ɑ , ÔÀ£ɑ Ê Dɑ {,« č a Ćč q' č d v/č o ó 7 A+4Ãč [ % - ô+ àč Ä č WÌ ÿ õĈč e B »č w¾ü č X Åö ×æč 53å÷Øă ? 53č P Bč Q2&Æ 2 @>č 4 č 3 Ƈw Ɯ Ȱǫ ɑ Pþìɑ ĺĮ0Ħģ ɑ ² ×Ë ɑ !E ɑ Ćɂŋȣ ɑĔɑ 2 ɑ 2 Z'ƾ Š$ȤƝ 9mɑ ƀgǴɑńɑ ȥƞǝ ƶɑ 7 ȱ Ʒɑ ƈůW ȲƉɑ +ǵ)w Ƃi ƿíɑ #ȹ ǀY:v ɑ # ɑ ŕ^< ȦƟǞ ɑ Iº ɑ ɑ ĿƠ]CɆɇɈơƢƣ ɑ ÏF¬ɑ ĈǶ š ɑM ɑ S ɑ č`;sǬjƤŖ4&ɑŅ [ɑ Ƹa ƥŗ$&ɑǿ ȳnɑǟżɑȧƊ ɑO*ǁǂt Ʀpɋɑ d Ǖ ņ ɑ QŰXcȴ6ɑ ÿűNJȨŲǷȍɑ ÷Řȩ ɑ R 7 " Çč _Í < 0č Ñč h8 ' ÓGĉ#(¬x ;CHč HÝîÄ Þ Å Æ ɑ ø+ Ʊ ?ɑ ³ !K ɑ " ɑ 3ǠȀcŢɑ Ď Ōȵ ɑTj ƧɎ s`*Nj ɑ UƌŸɑ \ Õ=øč UŹǖɑ t Ûč Î čù &č s 1 č ¼ Eč i Č ® Kč 0 njųɀ4ïɑ 3QT ɑ ,LÌ ɑ + ɑ Ç/å ɑ !¾ ɑ R Ⱥ 6bƨ ɑ ď¤ɑ ę ɑr čf Ā9 á > č V4Ȏ Ʃ (9>ɑ PĀðɑûuǍ :Ƀǡȁo\l?ɑ æ!ß ɑ ¥ "Á ɑ 1 ǎǏƪ ɑ Ė ɑ ùɑ ĪȻǢȪ ţɑ ƫǐɑú Ť Ǹȏ)Ǒ ɑ ă ɑ Ě ɑ 2 ɑ ĉ ɑ ĜǣȂȶ( ɑ Ňǒ% ě ļ¦ɑ 0ǹŴ Ǔ ɑ Y À ȯþč ^ 0 č įȷ®ɑ ĘǤȼƬȐñɑ ij ŵɑ O ɑ ĻDɑ ĝǥȑŎɌɑ āǦ§ ´çàâ ɑ ǰ ɑ .¨ "J ɑ İɏ Ȓɐ ɑ Ĵ ɑ ĵ6 ɑ ɍȫ ɑ'Žɑ eȬŊƼɑƭ& ȓl@ɑ S ²% čkè ) / Ič µÍòɑ¶ .B -·ã ɑ F ÕE ÐÑ ɑ ħYǺkǧ Ȕ ɑĶ©ɑ 6$³y¿čp !ú čňǗŧɑl Öâ É 1°ýċLč ġ5Ʉɑŀ* ƳôɑķƋ ɑĊǻ55ɑĨǼ *žɑČƹ ǔř Ŷ ɑ è"È ɑ +ªɑ G - ÒÙ ɑ ĞŚąǨ8ʼnƻť ɑ 1«ɑ Ă ɑ ĩǽŷ ƮŦ ǘ ɑ ȕƯ mɑ ğĐɑ ı=Ȗȭ ǃ;ɑ Mś<ɑ ư rǩɑ Ʌ mé"(± û9´ č g ćãJč Ľüx»ɑđyóɑĒ ɑ ±
ÑÐɳ
J fMŘú Jɳ ɳ F« Òɳı {ɳQ ɳƜ - ŀ=ɳǷ - ɳ 7Ⱥ ;&=ɳ Ǟ± ¤ j Ǹɳ L ɳ1 ǟƛÅɳ ƽ ɳ ĕ Ȼ : ř $Ė »ɳ >ǹɳ 1 ƨ ɳ ɳ H 3 $ Îɳ å ɳ ÔßØÕ ɳ Bb ƾ|ɳ k êȑɳ ŚȒɳ ® Ǻɳ ĊśĵƓûɆƩmɳ £ ɳ Ĭĭ* ɳ Ǡɳ j ɳ ɇ 5ɡɳ ȓW ǻ ɳ }ŜM Ǽ ɳ Ƕŝ ɳ ƿɳ ɳ $Ɉ Ş¥¯¼ɳ gǚ xş ! ¯ɳIJb ɳ? H x !!"ɳƑ [½ɳ ǽǑüŠ .!"ɳ šǾ ñF ċɳ n- ȎɳN ɳ M ɳ ĶƔ ė ȼɳ ľǀČǿɳ ijb ɳ Ęɓ#6ɳ jW ɳ ý gŢ Y ȀËɳ PàÙP¡ɳ? /d L ɳ1 ɳâȔ ȕ ɳ K ţ s.Kɳĸ ɳĿ {ȁɳ dzǒƲɳȖ ɳ Q$+ɳ ² Lº¸ɳ ǁ)ɳĹ ɳ ɳ Ȃ % ɳć %$' Ť 2ɳ8 ɉe &ɳĺ ɳ ť ɳ [ë ęɮ * ȽÏɳæ ɳ ƒCX¤ ɳ0 #ɳòɊǡ) ɳ Aɳy ɳĻ ɳl ɳ Ǣ ' \"ɳ ȾuƯ 2ɳ !=ɳ & +ɳÖáÚPJɳ ¥ ɳ Hɳ;Ņ ɳ/ ɳ Ɲ / DZ ɳr ɳƞ ɳ0ð Dɳ Rȃƙɳ Ĩ³ɳc ɔ `ȿŦ Ł´ɳ ǎɀQ ɳŧƪ &hOɳ çņ¬&¾ɳ ɢɳ Ɵ CĚčɳ ȗŇ ɳ Ƴ n3 ɳ ň ɁXɳȄɣȅ ɳNʼn . ɳ6 Șɳ ǣŨ Cɳ V ǜ "ɳļ9ɳ ɳTŊ ,? [!"ɳ ǂĎɳ șŋ ɳ @ Ơ°ɳũ ƫÌɳ Ü ɳ I W Ū( ɳ ū ɳ ɳ 4ddě4ư ǃDɳ > ɋ% Ț, DŽɳ țŌ ɳN ȏɳ ɕRf- óơɤɳŬǏɂ c ¦ ¿ɳ 3Ȝɳ ȝŭ ¡ɳ ɳ ŮK U ! "ɳ§E Ȟɳ : ɳ -ƴ / ;ů ɳ þ oƢ ɳ ȟɳ JȆŰSƣɥɳS ɳ ÿōűĜɖ Íɳ ׫ ȠŎ+f/ Ǥ Àɳ s;nĝ ȡiɳ ɳv ɳ Ğ h ɗ ɳc9 ? ɳ 9 v\ $ ɳǥ ¢ɌƬlŲ łɳ BǴ Ƶɳ ¨ŏğɳ Ǔ(*Ǧ*ɞȢ*] ų ]ɳ Aɳƶ*G< ɳ .: ɳ ȇ ɛYy pɳ ÞŴ ɳ I@ɲ 'ǧ ɳ ɳSɍ 'Ā8 ȣ- ɳ ( HÆǨ DoF ; Džɳ ĴɒDzɃ ɳ r ɳ Z% Ƥ Ʒ#^0 kŵ Gɳ BĮ ǵ ɳ ɳ§ #ɳ ɟ©@ ȤɳȥŐ Ȧɳz % 8Ġ #dž Ŷɘġɳ% ª>.ɳ ő >ƭ<Eɳ g ( U ɳ ɳ% ǩ ɳǔĩɳ ɳ Œ ɳ : ɳ ɳ Ǫ 5,:ɪqɳ
è ɳ ĽɎ9L ɳƸ ƘǕ ɳ ' LJÇm ɳ ŷLj ȧ2ɳ Aɳz ɳŸȈɳ w ^ ɯ įƖāŹ4Ʊɳ ljďɳ ǖ ƥĐɳ ô ɳ ì œź ( ɳõ2ɳ 9 ÈE ɳ Ż< ɳ e ŃżGɳ ɳ w ȨŔɳ ƹ VŽ ɳ 4 đɳ Ăž 5ɳ µ1 öÉȩ Ê0 $÷¶ɳ m ĒſȪƀ ] Oɳ éƁȫŕǗɏ£ɳ ^± Ƃ ' 0ɦÁɳ ¦ɳƃ ɳ í K |ɳ ɳ t 7ɄȉɳN \ɳ _ Ȭɳǫ ă+ƄM~ɳa +)~ēɳ îe ɳ 36}ɳ1ƅƮFɳ DIĢ ȊÓɳ BɅ ɳkE ɳ ǘ ǝ' ģɳƆ ɳ ɠ ȐƇ( Âɳ ə ø5 ɳ 8 i ƈȭt. ɫ ȮƉ 7Oɳ Û ɜ ɚĤǬÃɳ Ą _0 ɐƊȯ2ɳ ƺ3ƋƦiɳ Ȱ ɳ ǭƌ¢ƚɳ Īɳ NJɰ ąǙoǮï ƍ` ɳ + a ɧqɳ Ý`ɳ ǯR ȱ Äɳ 6 ɳ/ Ȳɳ ƎȋT ƻƏ ȳ ɳù ɱ ® ĥ7ɳĦķƕĈ, Nj =ɳ T@ 8°ɳĉ © 7ɑ,l2ɳ )ɳ ɳa V5 h&ɳ) _) ɨɳ ɳȴ ħɳ&"Ȍ Ƽpɳ ãU 1unjɬɳ ɳ äĆŖɝ ªɭɳ İƗ Ĕɳ ȵY6¬,ȶɩɳ īɳ 4ǰ#ɳ ɳ ȷ ɳ · Ƨ ƐǍCɳ Aɳ ɳ Z#ǐ¨¹ ɳ I G ɳ ȍ ɳ<ŗ <ɳ ȸ ɳX !Ǜɳ ńZ( ɳ ȹɳ "ɳ
# # # ! # # " #
# # # #
Ñ ɚ ¸¾¼ºɚ _Ë`%ɚ Áí ɚ ƼH ƿ ɚ îpɚ D/× ɚ /6ɚ M ɚ ŃIr Ďąɚ ńƓȃ6ɚ = e* ď, ɚ Đ -ɚ e [ Ņ s ɚ ½»£ ɚ ɚ ¹ ¤ ɚ đǀ Ɣ ɚ â m ǁ ɚ ɚÃÌÅ%ɚ ȫ" ɚ2 ɚ - ãź - ɚ Ä Ż ɚ Ǣï 2 ɚ ɉɚ ɚ 8#ɚ Ȭ Ȅɗ¢ɚ 1 ǣɚ lŵ ®ɚ & " F& #R J xS n5G^A K H &eo T/ _'Z`B( ) p* Uz3+f aamW 2+q bVE?y6 D 1+W1g c37 ,z3L8 Xh rY 9Z+!ZMZI:" Z N$ i;+s %<$ O[{ Q <|=-t \0 d]d C }>\P u ~4. D v k+wSl \j@
Ò? ɚ ȭ Ē = " ɚ ņ:Ň ɚ Ǥɚ 9 Ȯ ɚ Ÿ ǂɚ 2Uē .¯ɚ Ï Y ɚ * ɚ ı8 ɚ ɚijǃ EFɚ ? ǥɚ 2 ƕɚ ɚ ƖĴȯƗ ň ɚ >ɚ ɚ # ,ȣɚ ɚ / ɚ< ɚ0DŽ ʼn Ŋ Uɚ' ɚ ġɚ ɚ +ƍȰƘ4Fɓ°ɚ ÈWɚ Ó ɚ%ƫ ) ƴ ɚ Ģɚ% + @ ¿ɚ Ôĺ ɚÐSƬDžȅɚ%ŋ$)ȱŌ ɚXģɚȆĻ ɚa dżɚ Æ Ɔ; ɚ Í I # 5;¥ ɚ b ɘ ȇ0 ɚ ǦȨ·ØȈ .ɚ ļ ;ɚ ɚ + ɀ B 5;ɚ ǧɚ A džtIJ ɚ ɚð ( ȉɚ >ɚ( +BHƙōȊ ɚ Ȳȋɚ ƽ JȌĠV ɚ] LJ^ Ǩ &ƚ 4ƛĵɚu0±¡ɚ  ɚ" &- ɚŎ ƵŽrñv Aɍ¦ɚȍ ɚò&GĄ +3 ɚ 93 ɚɊ&ǩɚvƪ0 ƜĆ Oɚ G ɚ Ǚ6Ɂŏ ɚƶ Eɚ w *ɚ ɚ' $@ ɚǪ óŐLƊɚ ȩ 6$Ź§ɚ ɚ = LjőEȎ ôɚ Ĥɚ ă ƎƏȳƝŒȏœP ɚ1Ľ lj ɚ ǫ õ!Kžɚ V!ĥPɚ !Ǭɚ ~KŔ ȤKŕƞĔćɚ äɎɚ )ƭ+B ɚ ȴ: B:¨ɚǭ* ɚǮ Ȑ!# -©ɚ 5 ɚ )<Ŗɂ ɚ ǚ ŗö Ɵɚ Ħɚ \*iɚi ȑŘ ɚǯ ÷ř Ȫ ɚ ɚ ~ Ȓȓ NJǰɚ ĭĮ 'ȔŚ ɚ * ɚ1PVİNj ɚ ħɚȕľ ɚ! åś^ ȵ x0ɔɚù 0 ^ G ȥ:²ɚÖq Gɚ ɚ I 9ſ { ɚ Zɚ<S ɚ Ŀ . ɚø yDZ[u Dɚ ] ɚæ ɚ Y Dz 5 ɚ ɚ D<ɚ J$4dz ɚ Y ,@ Lƌ|ɏɚ ɚ , ɚ M ɚ ǴȶCknjŜƐC7ǵjĈɚ7Ơɚ&ɚĶǛ7ȷƷɚ7ĨɚƸjXCƀkɚXǍɚÙǜȦŝįŶúŞÚƇƈɐɚCǝ7ĉȸûĕĊɚçɑɚ \TQɚƑQ QɚċR şķ c ŠƮ ɚƯĩɚ TRɚcǎRÛɚÜüýư ČšơĸɚȧƲɚȖTĖɚƢȹƒèėǏɚƱĪɚŢȗǶɚ 8 ţhĘ Ƿ³ɚ a W ɚf ŤȘ@fǸɚ é "ų Ƀ ɚ /ɚ ɚ_Î`%ɚ ǹɚ șs}Uɚ ǐ( 4ƣoɚ ť ´ɚ l ɚ&ɚþ6 Õ ęɚ .Ⱥ# Ŧ ɚF ;ɚ Ǒ ŧ ɚ 4ê!ƁwF ɚ Dɚ .E 8 ɚ Ț ɚy, ȿǞ ɚț ɚ ɚ: ǡ ÿ ɚɋ H" ɚM ɚƹ Ʉx hɚ[ ɚ ƉAɚ Ǻ Ƥ ɚ ƥɚ ɚ .! , ɚ ɚ Z $ ɚ nǠ #ɚ bȻëƂ =ɚÇ L}/?ɚ ]' Zɚ 1Ũ ɚ qũ'ɚ č ǻ\$ Ȝ µɚ É ɚ 1 ɚ N "Ŵ I ɚ ȝŀ ɚ mŷW ɚ $ ƺŁ ɚ ɚ >ɚ9 Ǽ ǽŪN ƃ ɕɚ Ɍ " ɚ ū Ʌ ɚ ƾHáƋŬ/ ɚ >ɚ( 8 ɚ Ý5 ɚ Ʀə łd gĚɚ ĀgěǾ ŭìŮƄzȞ ɚ ƧOɚ ɆÞz|ßNůAŰ ɖɚ īɚ Ĝ ɇűā3ǿ¶ɚ Êà 3ǒªɚ S3 ɚ Ɉ ƨȟ oĝ-ɚ 9 ɚ Ğ ȼ# Ǔ Àɚ ? ɚ' <) Ƞɚ ǔ ɚ1 ȽƅOɚ nƳȀ Ǖɚ ) t ȾŲȡɒɚ Ĭɚ( ǖ «ɚ (Ǘ ȁ ɚ Ȣpğɚ 2 ǟ Ȃɚ ɚ Ă ǘ ¬ɚ J{ ɚ Ĺ ƻ ɚ Ʃɚ
' ( ' & ( # (# ( ' %( (! (& #"($ (
Ȋ
ă L, Ö´Æă ă Ç ă ×' æ ă5Iñ} ă ./ă ăTÿUÈB~$Văçw ă $'ă¾º ¯ ă ¿É ø °( , ă 6 Mă ÊW XN 7 ă s öY¡CZă ¢ă " ă £ >[ËØă qă Dè ă Ìă À ±ò 8 ăÙ t\"]ÍÚă ¤ ă x^ăvÎ -Ûă ? Ü ă21
° Ȋ Ǽ Ę "f5fȊ X+Ȋ Ȋ Ǵ Rk , Ȋ ùȊ Ǭė 0 Ȋ Dž # 2" Ȋ 3 Ȋ ę Ƨ Ȋ 6S Ȋ % Ŋ ŏȊ ũ Ě. # Ȋ Å ÞȊ 3 5Ȋ 7Æ ,= ƬȊ ¿æÇ bçȊƌ ŐědžĜÈ Ȋ 'Ƒ %3% Ȋ § Ȋ =gȊ ƒĝLJ\Ɛ yȊp¯ 9 őȊƭm9 Ğ -m Ȋ Ȋ¢ǹ šğŪ LjY Ȋ úȊljČèȊ ¨E&ǭ /zqȊ ± À GGȊÉĠNJ ßȊ ƮǽÊč"¾ƓWhNjƯȊǶĎ Ȋ x Cď ưġȁé Ȋ Ȋ ĢƔȊnj ōȊ T ǮŒ ȊO Ȋ ƀ]ģ4)˸ ȊX # Ȋ Ȋ Ʊ Ĥ @Ȋ Ċ Ȋ ƕ Ȋ Đ Ȋ ĥ ƖN EJÌ >ÍȊ Î rȊ ®ê đ C0Ȋ H Ȋ A hHȊĂ¼ ´Ï ) Ȋ ÐĒëŢ Ȋ ƲȊ ƈ 1 ȊO7Ȋ Ɨ0 "µ Ȋ Ȋ, ȃ A Ȋ1 Ħ œȊ ħ Ƙ) Ȋ Ȋ Ȋ . B ȊƳ Ȋ ƴȊ S Ȋ1 @ǯ4 Ȋ6 Ȋ @Ȋ n ŔƁ Ĩ: Ȋ ƨƉÁ FKȊ ³ Ƶ ūȊ ƶÜ ĩ àȊ 9 ^ ċĪÑ şȊ ƍ , ÒT ƷȊ īÓ Ȋ Ȋ Ȋ ìŬH Ȋ * ` &/Ȋ /Ȋ í > Ȋ £!Ȋ QĬÔ Ȋ < {Ȋ ĭ Ȋ j Ȋ ? Ȅ ƙ Z ŭȊ ûȊǍ Ȋ á; "¶ ǎȊ î Ǩ ř nȊYaŚȊ I ȊIē Ȋ Į ƸǏƚ |Ȋ µÝ(ă _¥) ă y Þ! +=%ă ¦Oă ÁÏ ß¶§%ă 9àă û`ă !#aáb¨* Āă © üă éz ă <āă P & ÂÃc:Ðă)·ă@dE eă ªă Q « âêÑ;ë ùfă¸uFgăý{ G|ăJ»²óÕ¼ ãă* hăþ ÒiĂ A ÷ &ă ¬RăìÓj í kîă Kï ú läă răåH + m#nSă Ä ð o³ô ă ă ÅÔ ¹®p 0ă34
¤ Ȋ ǰ UȊ ǐįA ȊǷ Ȋ ǩdz8 ŕJȊi ï Ȋİ Ȋs ıŮ tȊ Ȋ; IJƩ ȅ ţ! ǪȊ>FȊ ǑȊ &ǾȊǫƊȊQ(ǒ e + Ȋ ¬Ȃ D* 0 &Ȋ 5Ȋ Ȋ Ȋ }ȊƂ 7Ȋ Ȋ Ǝ ƛ ůǓȊ üȊ ȊMª¥ wȊ Ȋ ǔNāýȊĔ Ȋ $ Ȋ ś P Ȋ Ǖ Ȋ Ǻǖ. Ȇ k$ ȊÕƃŰ Ŗ űȊ Ɯ; Ȋ Ȋ $Ö Ȋ ƄþȊǗĕ ȊðǻǘƝ b ƞ¹aȊ ZŤñ Ǹ Ȋ' Ȋ Ɵ LȊ Ȋ ƪ ƹ C< ijo Ȋ= ] Ų4Ȋ Ĵ ' ť ĵǙǿȊ . Ķo ķ ƺ Ȋ ƠĸŦ ƫ7Ȋ ƅ8Š1Ȋ $ Ȋ ǚ Ȋu âĹĉȊÿ ·ȇ Ǜ - %Ȋ ĀȊ3 Ȋ Ý ŗ~Ȋò× ų c? Ȋ Ŵ Ȋ* ƻǜ?2l2* 8_Ȋ ĺ- +ŧ ŵǝȊ Ė Ǟ à Ȋ º^W(Ŷ Ļ ŷ Ȋ J Ȋ d! ơ ļ Ȋ ãȊ Ɔ e Ƽ KvȊ ©ŸȊ Ȋ ¡DZ # ä E:D)Ä ȊĆ /ȊĽ Ȋ V Ȋ iƽl# jľƇŹȊ ǟȊ Ȋ ƾ Ŀ Ȋ óźǵ[- Ż żǠȊƏdƋ Ø! ȊŨôBǡ½Ȋ ŀ Ŝ ƿȊ Ȋ D Ł:Ǣ( Ȋ6 ǣȊ «¦MǀȊ DzŘ Ȋg ŽȊ õ+' Ǥ ƢȊ %öƣł ǁȊ ŃąŋÙ ŝIń ǂȊ ćƤȊ 4< Ȋ Ĉ Ȉ _ [ Ȋ $ F Ȋ ȉ
²V ƥ Ȋ ǃȊ Ȋ \å Ú Ȋ Ȋ ŅB ņ Ȋ U Ȋ ƦŎŌ RȊ Ȋ ǥ P c žŇGȀȊ øŞȊ õ½ă 5 2Ȋ »`Ȋ 6ň÷ſǦDŽȊ &Ȋ ăĄ(Ûǧʼn !L
R Ĕ^ ĕþpÕƲ Ā Ů Ʋ9 Ʋ ƨ Ʋ 'Ʋ Ŗ ~Ʋ T: Ʋ Ʋ ) ňƮ 4 Ʋ õƲ,¼Q,Ʋ Ʋ à Ʋ ƌ Ʋ Ċ "Ʋ 5MUqƲ Ńŗ P 88 ƲO H Ʋ F ` / 2 Ʋ öƲ ą &Ʋ& Ė 5 Ʋċ Ʋ = 1 ė +Ʋā.Ʋ ?( H rƲ ů żĘŽƲ Ʋdv Ʋ ;-Č žę ƲÇÖ× s =u+Ě ĆƲ Řř= Ʋ Ä Ʋ Z ƲØ Ʋ kſ Ʋ 6 Ʋ Ʋ W ?Ʋ% W ƀ Ʋ @) Ʋŝ 0 Ʋ ) ƲÑ ƲêAü <Ʋ« Ʋ/f Ʋ% ě Ʋ ÷Ʋ:il Ʋ& 7; Ʋ Aý H Ʋ Ʋ ã Ʋ Ʋ Ʋ X Ʋ2 3 ƲÒ+Ʋ ĜY Ʋ ƲÓ!Ʋ ( ĝ Ʋ 44 LĞ F Ʋ ½ 3bƲ - ( z+Ʋ zğ IƲ Ʋ Ʋ#²,Ʋ Ġ 3$ Ʋ : ëƲ# $ʼnƲ³!ćġ Ʋ# * MƲ T ' ƲAv Ʋ Ʋ &ƍĢ Ʋ Ʋ ( ŷ ŊƲ aƲ e 'Ǝč+ƲÙ 19ģ Ʋ ì %ŋ fŞ "Ʋ `Ʋ ÈƲ Ơ ŰņƲ øƲ Ú 4şơ ;Ʋ Z Ʋ X Ʋ 0% jÛƲ 0Y Ə Ʋ ¬ Ʋ" Ʋ ƲŌ Ʋ 0%q2ÜƲ Ƣ ū J ƲdŪ ƲÝ Ĥ Ʋw6 .ËE Ʋ$ E ƲÉ ƲL íƲ {? ît/2 GƲ aƲ Ɲ ōƲ ń ƁƲ ƣš o'Ʋ ĥ6Ʋ B Ʋ J Ï Ʋ Ʋ | [ Ħƭ Ʋ ]Ƨ k( ƲS Ŏ ƲS$ Ʋ ·¸ Ʋ Åh Ʋ¹ ħŧ Ʋ® Ĩ Ƃĩ Ʋ V7 äƲ ŏ!Ʋ Ʋb OƲ! ƃƲŐ Ɛ 6Ʋ gUƑƲ/gïƲ # ƟrƲ Q! Ʋ # ƞ Ʋ x Ī Ʋ Ʋ . * ī FƲ h åƲ P Ʋ NðŢ9n Ʋÿź Ʋ Ʋ Ņ Ʋ Í Ʋ Ĭ K<Ʋ Ö ·N y oÖ + kÄGÖ B rÖ ¨H Èf Ö Î O!Ö ¸I,Ö P©dÖ =Ö; ª9Ö § rQ«-Ö RzÖ ."É ½b {Ö? Ö /½Å0 Ös1|Å gÖG/ oÁG Ö #Ö@ Ê¬Ö zÖ¹J2Öt 3Öu $4ºÖC qÖ <Ö%S®¯5vTy »U{DÖ ¨Ë KÖ V}> £r ¼W yÖ Ì½Ö r/ ½ oÖ Xlm~6°°Ö ±Ö ¾L.Ö Í hY Ö 7/&²Ö 'ÖÐ yÆ¨Ö Z Ö (9¡Ö ½ Ö ¢. E [Õ6Ö ¨Ò M i F\ oÖA£w¨Ö =Ö¨] e{6¨³Ö 'Ö Ç Ö ´¿¤^Ï8Ö ÀÖ Ö _ @ w9)Ö U ` Ö >Ö a½¶Ö ¥.µ y¶U `nc½ÓÖ Á Ñ ¦*Ö ÂG6Ö x:yà kjÔÖcop Ö
ÁƤÞĎƲ Ì{tĭ Ĉ Ʋ (LƲ ţď ñ] Ʋµ Ƅ $ Ʋ eòƲ Į Ʋ Ʋį 3İ ó Ʋ Ʋă Ś Ʋ ¾ű ı> Ʋ º^ Ƭ Ʋ D | Ť Ʋ ¢©§¥Ʋ ĉ Ʋ ¿} * Ư C Ʋ 8Đ ő Ʋ Ô Ʋ IJ Ʋ l ƅƒƲ Ųij ų 9 Ʋ < Ʋ Ʋ  Ʋ yŴ ) uM ) Ʋ â 5- Ʋ Ʋ ' ƪƲ% Ʋ >@* Ŭ Ʋ ¯ m- Ʋ » ť æƲ Ÿ Ʋ Ĵ ĵ Ʋ ùƲ - Ķ Ʋ m5" * C Ʋ çƲ Ʋ Ʋ i ƆƲ Kư ķ Ɠô Ʋ đ$ Ʋ xyŒ1 èƲ Ʋ Gß ƥ œƲ cŻ O ŇƲ Ă Ʋ ) ĸ* Ʋ ŭƇ;àBn 7+ Ʋ Æ @Ʋ± Ʋ° Ʀ V C Ʋ Ʋ Ź Ʋ Ʋ& s Ĺ ~ Ʋ Ʋ ƲĄ Ʋ Ʋ¦" Ʋ¶G . " ŜƲ, 8Ʋ úƲ, j ƲÀ !&Bĺ ƔI!Ʋ Ê ƲR[ Ļ Ʋ ´ ś Ʋļ Ʋ£ª¨¤ ƕ Ʋcpŵ ƖƲĽ Ɨ . Ƙ1 'ƲŠ ƙP Ʋ é >Ʋ Ŕ Ʋ ƚ Ʋ Ē Ʋ I J Ʋ w} Ŧ ľŨ Ʋ ûƲE /ÐƲ ƈƱ 7 Ŷ Ʋ Ʋ ¡Ʋ # !Ʋ ƫ\ Ŀ ƛ ŀƉ"ƊƲ Ł 0ŕ Ʋ Ʋ :D łK o\Ʋ_Ʃ áNÎNDũ Ƌ Ɯē_Ʋ
! # # " #
dž ådžśŤ 5 6 džmƂ ÊWā ƒs dž÷8 dž8ŸŹ[6 dž»X dž *3 dž c\O dž Ī ť dž dž / ! ƃ ǁ dž " 5 Ă dž ă dž 7dž B ,ľdž ø ,h (dž ô % ǃ I] dž « dž ĭ'dž džT 7dž Ƅ' Ya Ą v dž dž dž ą dž#+Á Ć;dž W g dž 5 dž ùdž dž Z ?%dž ædž#4:Į]Pdžú Ʀ(dž <dž ) ĸ4 dž ŇI įdž @ =dž &&~ dž ňdž w> dž ËƬŦpć ƭ dž òŧdžŁ ʼn dž Ũ dž µ0dž dž İdž£¡ & dž 1ũ ŊƓĈƵ džŜźŗ Ū łƅdžĉŋdž1Ɔ Ì-Ċ Ɣqƾdž îƫ džū & Ń:ıß džƇ ;ċ IJdžG UřŬ dž " ¨dž x dž Sñ w dž ! dž&" *Č dž çdž dž ^ tdž džK ŭ džij_ ī Ødž dž dž ! dž¼ dž džº ƼdžÀ Ùdž dž ! dž¬čƶ.ddžN ûx&džC 6 ) dž | 9 dž dž Í Ď dž ¶0dž ¤¢ dž ƕY dž ¯ ,Adž ² Ʒ 2 dž " <dž Ɩ dž " Ů dž ƈ Î ď yů` I džƧ dž Ï mƗdž dž (8@c õ dž Tdž s 6Đ đ ödž Q ŰtüĒ džēŌdž O ńŅƮ [v dž/ j Adž ƨýdž Ż V ° ndž o dž ű Ĕ ĕ dž ōuƘ àHdž Ė dž +)ė 'dž$ ' ! ƙo dž ÂżŘ dž z á dž R Ų dž Uƀ dž dž1Ɖ Ð-Ę p ÑdžÚ ŝ qƚ ƛƊdž { dž Ƹ Fdž D ƺdžVƴę Ě Hdž óGdž Ɯ- dž ŞƋ Ò . něƌƝ dž ş è ƍ Ĝ dž Ž dž N Ŏ dž ± Ĺ ņ dž + dž®. ųdž édž¹·¸³ dž Q¥dž F)Ê #Ê 'Os*x P ªÊ =Ê tu¾yQ«ÆÊ v+z¬ rÊ G, h¬HÊ ¡-Ê Ê $R¢²Qy Ê K ng.yA/Ê @ Ê £Ç IS ® T¡¯¤ Ê Ê Ê Ê ¡Æ"JU ° ÉÊ G ¥Ê y Ê 0 oÊ p±1 ²VÂ2Ê Ê ¹WÃ3 Ê Qy°-kiXB3{³Ê ºY Q ´Z yÊ[|Ê µK4Ê?Á¶À 5Ê ¿}? h%\yCÊ >Ê6Ã7}»¡ Ê
ªÃ Ưƞdž > dž 9C džƟĝB džM #Ĵ D Hdž K dž be dž dž ¦dž ] i8Ê ÅGd!K Ê ¦K ¾j&Ê .Ê 9 'Ê ÇÊ/Ä- ÉÊ §È L^ · e Ê /¨_':}¼Ê y'Êw<}½ jÊ I; q¸MÊ Å f/ Ê `~Ê ° ayb DÊ ¡Ê Å<lmÊ ¡Ê ÉÊ ¶N ©<Ê ÅK Ê <Ê <yC E<(Ê c Ê
M "f ŏ ư dž dž}ƻ @ ƹ dž kÓ $ fdž ĺdžíŚ dž$ ` Ɓƿdž $2 J Ğ 0dž ( |dž ğŔ E ^ ) e dž J /$> \ǂ dž J_2 E ĵdž ð * dž Ä Ʊ dž = dž âƠa g Ldž êdž B ĩ 2dž / ŕ ½Ŀdž % * Ŵ3dž 7 Ǝdž Ļ dž ŐĬő K dž ´ dž %% Ûdž Z dž jz Ķdž hƩ!dž Üdž Å dž #ž ơ Ýdž Œ<dž CSD ¾ dž Aļœ u dž ( ŵ Æ'dž * Ô dž Ç'§dž dž dž )Ə Ġ dž yX dž 5 ġ ÈĢ b ǀdž ëdžF=L ģ ¿ŀ dž #3 -l dž džƐ Õ P~ ƢƲſ,ddžƑ41DŽ Fi. %©dž Þdž dž k :?Ĥ0 džŠ $? dž dž š dž + ã ïƳiĽLdž7 ƣþdž Ŷ 3Dž džŷ ; rr E dž dž džķĥì dž Ħƪ+ }ħ dž ÿ Ƥdž4# dž{Ā džÖ ƥ 9Gƽdž ţ É Ĩ dž dž dž ä dž ldžR × Ţ Ŗ dž
ñ ɘ ǐ* µɘ Ǒ Ŝ 3ɘ.' 5 ǹɘ{ ]%Ȩ ɘ"°ɘ! ɘ © ¼ɘ ɀ ½ɘ ƽ@ ɘ ø/ mɘ ɘ " ɘ ɘ - ( ɘ :B ɘ ȳ" ŝ ɘ W 7% ɘ dž Ɗ ć7ǺËɘ ò #(#ɘ 6ɘ ƦƇ Ȳ ɘ IĈC 7+ń)ɘ cŞ Ʋĉ ɘ ɘ 6 LJ ¥ɘ 8 ɘ ǻCZ Ăş,D ɋɘƾĴ¾ɘ 5ɘȋ ɘ Ċ *`<ɘŁ ¿ɘ. Š /±ɘ ; 3ȩ% ɘ&ǯ ǰ !ɘ ɘȌv ɘłEƖȴǒ ɘ ĵɘk ȍ '\ɘb ɘk Ěȵ=Ȏɘ Ɨ ȏšƿ ɘ Ǔ ɘĶȶDZa ǔɘ ƍ 3 ɘ ɘă VD @ɘ7 ɘ ª ɘ&[ ÿƱ ɘ ' ɘ [ Œ$Ƙ Ìɘæ Ɍɘ ÚçáÛǼɘ ùě ɘ ǀ ƙɍɘ Ǝ ɘ ķʼn5 ɘ K ɘ = LjƚɎɘ S œɘ ß ƛɘ ɕ Iɘ u Ǖɘ C 0 °ɘ ; * ɘ ɘ & ǖ &JÀɘ %4ɘ lj Dz8Áɘ " ɖ «ǽ ɘ ²ɘ ȷ ¬ ƧMɘ | ɘ £ɘ dz Ĝȸ ɘ ; ȹ Íɘ ïǁƫ ɘ NèON ɘ + Ǘɘċ Ţ E ɘ ĤǸ * ɘ ɘj ɘ ɘŊǘ ɘ sɘ. +- Ƕ<ɘ % ɘ 0Ƴnɘ Ȑ #ǙǾɘǚ ǿ8 ȑɘȒ $ ɘ Ǜ Ɂ ȓ} Jɘ ƬJɘ ɘhɘ¶ ,ţ e·ɘ ÷ ! ɘ. ! GȪȀɘ ɘ B ɘ ȁ U } $>ɘɂŤ ɘ @ɘ ǜ~ '<ɘ 4 ƴɘ Pɘ "Mɘ Xh4ɏɘ ɐČ |úȔ 696ɘ MÎɘ Oĥɘ > 4 n ( ɘ ¸+ ǏȺ ^rɘ uƉ ťȕŦ ɘ Rɘ Z Jɘ ɘ W Əɘ tɘ ' Ħû5)w¹ɘ ]v ɘ üb Ȗɘ iƐ ɘEYɘNJ T Hɓɘ&ǝ Ƀ ȗŧ eɘ ã ɘ¡Ŕ ɘȂ ƭ ɘ; ƈ Âɘ ľK Hɘ Ǟ 1ij¯1 ɘ DɈȯ<ɘ\ ª T ȃɘ Rɘ Ń L ɘ ɘS NjZ ɘ 3^ ɘ ýƜ¢BÃɘÝ Ũ ɘ č lV«ĝ oɘȘŕ ¢ºɘ! ÊĎ ƨ oɘ / ) njƝ !ɘ ĸɘ 4 ƞɘŖ´ 1 ɘ / ɘ Ō ɘ Ɵ ō Y ɘ ș ǟɘ ŗ YɘȄ Ț ũ ɘ ĹɘĄ ;2 /ɘ Ř$ ɘ> ɘ"ħɘ. țɘ* ɘ / >ȜŪ Ä»ɘ ř ɘ ū ɘ$ ɘ2 AĿ ȱ Åɘ ɘ £ɘ§ś Ǡ ɘ{ ɘƵ ɘ Ƒƶ ¯Gɘ Ǎ #c ƷȝŬɄ#ɘ - ¬ ɘ A 'ɘ ¤ ɘ Ʈ Ƌ (ɘ ɑ I Iɘ ¥ɘ : $ ɘ $-ĨÏɘ ä ɘ ) Æɘ Xĩ ȫ ɘB# FȬ ɘ p ď Ȟ ɘ ɘ U:9W ɘ ǡɘ ȟ $ ɘ UņĐɘ Ğɘ Ǣ đ iƪɘ b ɘ] FVɘ ¦w ɘ "F2ĘÕɘ éȻĒ ɘ ĺɘ Śrɘ % 2ē1 ɘ tɘ % Ƿ³ɘ & ©C ɘ && ǣ ɘ L ɘ" ɘ ƌ ŭŅ ɘ ğɘ <ɘ ɉ , ŮƸɘ ɘ Ǵǵ ȭɘ , ƒ ů Ŏɘ @ɘǎ5 R Ơɘ + §Q 8ɘ+ ɘ Ű_Ðɘ óz ! ɘĔ Ƞ )D \Çɘ Q®Ī(Èɘ ³ɘą ɘȡ ɘy ( xɘ ƹqɘ ɒɘ Ǥ S K ɘ yīɘ l Lű ȼŲ ɘ ɘ ɘ Ɋ ơ ǥ?ɘ ´!ɘ ɘ ų [ ɘ `x ɘ ( Ƣɘ qEȢŴ !ɘ Ļɘ ƣŵs ɘ Ġɘ ȣ H "µɘ Ƚ= ɘ Āɘ Ŷ! ±Ñɘ ë Lɇŷ ¤ Ÿ ŏɘ % Ĭ Ǧĭ Pɘ ȅƓ 1 % dɘ ę Gɗ _2 Ź3 ɘ Įǧ ɘ Pɘ 8 ɘ ìǨįȆź İƺȰȇɘ Ü ƯưŻȈȉżǂ ɘ Gɘ êıƻ 0Ƥɘ O Ʃ9 ɘ:ǃɘ c ɘ ɘô Ɣɘg #Fɘ Ƽɘgǩ Ʌ 9 Òɘ å ɘŽ ɘØ (ž,ɘÖf×fɘ í# DŽ ¨dɘ ¦ ɘN X ſȊ6$ ɘ ƀɔ ɘ z?ɘ ġɘ A ɘ _Ɓ Ⱦ mɘ Aŀ 7 ɘ Ǫ ɘ $ ²ɘ ' ¨* Óɘ ðƂŐ Ňĕ Ȯ MÉɘňɆ ɘ ļɘȤ ɘ ƃő ɘ ǫ - IJ p T ɘ þ ) ȥ ɘ a ȦƄDž ɘ ¡ ɘ āĢɘ Ć aȧ Ǭɘ = H ɘ ŋ ɘ Ė ƅƥ # ɘ0 ɘ9 ɘ ɘ ģ? Ɔ ",?ɘ. ® :~ #ɘ- ȿǭ Ôɘ Ù ɘâÞöɘõ ƕɘà Ǯė ɘ ^0j ɘK ɘ Q! ɘ ɘ ɘî & '`ɘ Ľɘ
" " ! "
¿ºǺ
Zƿ # Ǻ ǀŢ /ƬǺ Ǻ ?GǺ K Ǻ Ŭ Ǻ Ǻ Ǔƀ-© Ǻ E 7 AǺ / ţ Ǻ ĎD ǁǺ Ǻ H Ǻ Ò " Ǻ ƍǺ Þ úǺ 3ň ,Ǻ Ǻ ƣ ) ŤǺ ƎĜ Ə l ƭǺ v Ǻ@ Ǻ + ǺŐ Ǻ . Ǻ Ǻ | f g !%ƮªǺ Ú (\EǺ ~ i + & Ǻ đ ƌ= ś Ǻ ė S Ǻ ! Ǻ Ǻ o Ǻ L Ǻ Ǻ ǬǶ 6 ĝ ŭǺ ĂǺ Ę Ǻ ǂǺ m Ǻ I Ǻ '! ŜF Ǻ ,F ǺŇ pǺ Ğ «Ǻ Ì #B ƐǺť Ŋ Ǻ Ƥ n -Ǻğ Ǻ C MǺßǘ ûǺ Ů ǺÓ ù " mǺ 4u ǺbƩ Ǻ ď Ǻ ůƯ Ǻ ì _ 1Nư Ǻ w Ǻ Ġ 9ġ h Ǻ cƪ Ű >Ǻ Ǻ Ǻ ç G TǺċ{ƑǺ Ǻo ñ őǺ ǚǃǺÍƥ ǺZ DŽ Ǻ "ǺÔ è,Ǻ @ ` Ǻ ƒ Ǻ ă Ǻ ƓDž Ǻ Ǻ 4 ƆƔ dž Ǻ Ǻ B ǺG tǺŒ ¡Ǻ Ģ P5 Ǻ Ǻ Ǻ cǥ ę Ǻí é Ǻ aǺ 8ģ Ĥ 8Ǻ `Ǻ ]ŌǺ aǺ Q ¬Ǻ Ý $ Ǻ /* Ǻ ƱOǺ Ʋ ĥ Ǜ Ǻ 0 Ǻ Ǻ T* Ǻ * Ǻ Ǻ Ǻ Ǻ î Q#Ǻ (Ɓſ/ pǺ ƕǺ Ƈ KǺč qǺ 9Ǻ J Ħ Ǻ Ɩ ħ Ĩ Ǻ [ Ǻ # r Ǻ űƳ ü®Ǻã ǺD Ǻ %äFŝǯǺĩ Ǻ OƦ œËǺ [.3{9ǔǜŲ LJ r ¢Ǻ dýǺy % ƴǺ ĄǺ %Ǻ Ŕ £Ǻ tŞ>Ǻ ąǺL þǺ n Ǻ Ǻ Ě ų! $E >ǺĪş ¤Ǻ Ɨ Ǻŕ ƵLjǺ ŴǺ 5ljī ?,Ǻ P Ǻ ƘǺ Ē <4 :Ǻ ŵ Ǻ ƫ¯Ǻ Ü @ Ŗǰ¥Ǻ òƂ ŦǝŶ >Ǻ ] ŗǺ Ĭ Ǻ Ǟŷ 8ÃǺ ĭNJǺ ō Ǻ ŠǺ Ǻ -ÿ ƶǺ' Ǻ IǺ ŧ Ǻ 6 Ǻ ǺĮ Ǻ 6H #Ǻ 7 ǭiƷNj Ǻ Ǻ njd °Ǻ à . Ǻ Ǯį Ǻ Ǻ ĆǺ '3s ƸǺ 0 =/Ǻ Aƙ -Ǻ j 95#D ¦Ǻ " ŘWǺ Ǻ3Ǧ & ē±Ǻ ÎYÕÏ Ǻ ƈ ƚǺǕ Ǻ ƧŎǺ #Ǻ Č ( İ Ǻ * ÁǺ V¶ Ǻ " Ǻı Ǻ Ǻ ,Ǻ} ǖ + Ǻ0 Ǫ Ǻ +ǍIJDz Ǻ Ǻ ÄǺ ¸ Ǻ PC Ǻó& &dz% Ǻ ƛ Ǻ 6Ǻ ǎƜ ij' Ǻ Ǻ - & K ÅǺ » Ǻ Ǻ Ĵ Ǻ ǟ#ǠêǺ " } Ǻ LT 'Ǻ ǧĵ ƹǺ Ǻ J k Ǻ ćǺ ÆǺ Ǻ Ǻ½ Ǻ <C Ɲ Ǻ & Ǻ åǺ ) ŸRĶŹ Ǻ ^ x^ Ǻ ǡMǺ Ǻ ķ Ǻ ) $ Ǻ ²Ǻ Ø Ǻ XÛÖX:Ǻ 2 ŋz źĔǺŨz_2ƞæN%ǺƺǢ(ô1 Ǻ ě1Ɵ2Ǻ 2ǺƉƨ ï 1ũƻǺǫʼnN*ǺwĀĕ ĸ f 'Ǻ Ǻø Ż R;³Ǻá ƃ ǺÐY×ÑƼǺ ĹǏ Ǻ " = Ǻ s Ǻ Ǻ õǷ Ǚ ĺǴ Ǻ UÂǺ Ǻ· Ǻ Ǻ ř ŏǺ ĈǺ Ơ <l BĻ ;Ǻ Ǻ. Ė ! ļ ÇǺ ¹ Ǻ Ǹ Ǘ 8 Ǻ g Ľǵ Ǻ Ǻ ĉ : ľ ëǺ Q ÈǺ ¼ Ǻ; Ŀ Ǻ Ǻ0 Ǻ k ÉǺVǺ¾ ǺŚ!M š ǺĐ(ǣ Ǻ Ǻ Ǻ ƽǺ ĊǺ * Ǻ| Ɗ Ǻ Ǻ Ǻ JǨ% ÊǺ?7 Ǻ À ( S " ŀ Ǻ S Ǻǐ + Ǻ y Ǻ ơ´ â Ǻ ā Ǻ Ǻ Ǻ +OUǺ&' Ū Ǻh Ǻ ż!I)WǺ ǹ Ł7)§Ǻ \. Ǻ ū Žj 5ž Ǻ $ Ǻ $q Ǻ Ƣ $ Ǻ ! Ǻ ł $ Ǻ Ǻ = Ǻ ǤH Ń vµǺ ÙxǺ ö ¨Ǻ ńǑǺ R; Ǻ ð Ǻ ÷ uƋ Ǻ DZǺ Ņ :Ǻ ƄǺ A4 Ǻ Ǻ e )e Ǻ~ <UǺ bƅ Ǻ ǩ Ǻ ǒ Ǻ ƾ Ǻ ņ Ǻ
56
Community Psychiatry: A Reappraisal
16. Steenfeldt-Foss, 0. Elements of a comprehensive psychiatric service, Southern Psychiatric Qyarterly, 48( 4):14-1 7, I 974. 17. See citation 11, pp. 277-280. 18. Schwanz, M. S., and C. B. Schwanz. Social Approaches to Mental Care. New York: Columbia University Press, 1974. 19. Ibid., p. 171. 20. Wilder, J. F., G, Levin, and I. Zwerling. Planning and developing the locus of care. In The Practice of Community Mental Health, H. Grunebaum (Ed.). Boston: Little Brown & Company, 1970. 21. Bachrach, L. L. Continuity of care for chronic mental patients: A conceptual analysis, American Journal of Psychiatry, I 38:1449-1456, 1981. 22. Hansell, N. Services for schizophrenics: A lifelong approach to treatment, Hospital & Community Psychiatry, 29:105-109, 1978. 23. Test, M. A. Continuity of care in community treatment, New Directions in Mental Health Services, 2:15-23, 1979. 24. Panzetta, A. F. The concept of the community: The short-circuit of the mental health movement, Archives of Gen.era[ Psychiatry, 25:291297, 1971. 25. Ibid. 26. See citation 21. 2 7. Foley, H. Community Mental Health Legislation: The Formative Process. Lexington, MA: Lexington Books, 197 5. 28. See citation 24. 29. Weston, W. D. Development of community mental health con cepts. In Comprehensive Textbook of Psychiatry, A. M. Freedman, H. I. Kaplan, and B. J. Sadock (Eds.). Vol. II. Baltimore: Williams and Wilkins, 1975, pp. 2310--2322. 30. Kaplan, S. "The Use and Abuse of Federal Derived Health Delivery Funds as Instruments of Political Action: The Lincoln Hospital Mental Health Center." Unpublished manuscript. 31. Report ofthe Presi.dent's Commission on MentalHealth: Task Panel on Rural Mental Health Vol. 3. Washington, DC: USG PO, 197 8, pp. 11551190. 32. Glasscote, R. M., J. N. Sussex, E. Cumming, and L. H. Smith, The Community Mental Health Center: An Interim Appraisal. Washington, DC: Joint Information Center Service, 1969.
Assumptions-Implementation and Outcome
57
33. See citation 25, Chapter 2. 34. Regester, D. C. Community mental health-for whose community? American journal of Public Health, 64:886--893, 1974. 35. Ozarin, L. D. Community mental health: Does it work? Review of the evaluation literature. See citation 4, Chapter 2. 36. National Study Service. Relative Impact of Various Factors in the Devel.cpment of Mental Health Resources. Contract HSM 42-70-108. January 1972. 37. Viability of the Catchment Area. Contract HSM 42-72-96. Cambridge, MA: Arthur D. Little Co., 1973. 38. Tischler, G. L.,J. Henisz,J. K. Myers, and V. Garrison. The impact of catchmenting, Administration of Mental Health, 1 :22-29, 1972. 39. Huffine, C. L., and T. J. Craig. Catchment and community, Archives of General Psychiatry, 28:483-488, 1973. 40. See citation 67, Chapter 2. 41. Lasch, C. Haven in a Heartless World. New York: Basic Books, Inc., 1977. 42. Bateson, G., D. D.Jackson, H. Hale, andj. H. Weakland. Toward a theory of schizophrenia, Behavioral Science, 1:251-264, 1956. 43. The Mental Health of Rural America: The Rural Programs of the National Institute ofMentalHealth,J. Segal(Ed.). Rockville, MD: NIMH, 1973. 44. Personal communication, U.S. Bureau of the Census, April, 1982. 45. Bachrach, L. L. Human Services in Rural Areas: An Analytical Review. Human Services Monograph Series No. 21. Rockville, MD: Project Share, June, 1 981. 46. Ibid. 4 7. Seely, J. R. Social values: The mental health movement and mental health, American Academy of Political and Social Science, 286: 15-24, 1953. 48. See citation 41. 49. Szasz, T. The Myth of Mental Illness: Foundation of a Theory of Personal Conduct. New York: Dell, 1961. 50. See citation 42. 51. Wynne, L. C., I. M. Ryckoh,J. Day, and S. Hirsch. Pseudomucuality on the family relations of schizophrenics, Psychiatry, 21:205-220, 1958.
52. See citation 45, Chapter 2.
PĈĉ ę+è ĊK_ øÐ : Ě»é ł à ł ě êÛ ł
ĐèÐ ļɽ }Ű 1ʞ Ň ʞ % ʞ ĸ Ǹǹ ȇ ʔʞ:Ⱥ ƊƽDžkɖȹʙªʞ ɗƾƦʞ ƧʒƨȻɘʞ əƿ{Ȳ7: ɾ t Ƃ F 7H «ʞ 3 ±¼ĵ ċł1®łZ 3 ÑłkĘĹ º½s;ÿ Bł éAĢ#2 X ê Uʞ ! čĄ ø hs ƙ*¬ʞ ʞ @! #Ñ Ōƃ w* Ă ōƄ ƚ 1ʞ ʞ #!A ʞ$ ʞ ůɿȼǺ ʞŕ ʞ 6 ǻǼ dž ;ʞ 0ȽʕƋ LJ7 ʚʞLj9ʞ ëĝ 2ģʞ ,.ǽ ʞ ʀ& NO Ⱦʞ ƛ Ʒƀlj' ȳxN®ʞ gČĺ ²¾ Ĝ ( ł m Ć ăJł BBĤcĘʞ <đ?ąSʞ ^Ğ ä ʞ b ĵ Ƙ}ȡű&~¯ʞ ŗ ʞ Ř ʞ IJʞ t 9 0ɚ l8ʞ &ǀʞ /ʞF 9ȿ NJ ɛNj 8-ʜ ɜ ° \ë ù& -ł£ʞ ìÜ ¿ıł h Ļ ĸ<ĂAÀł 3"ĥ$4Ā<ĆĒę±ʞ ì+ē ŜȔ Ȣ²ʞ ř ʞ ţƩɀz ȣƌ ʞ ʞ P ʞ O u njŲǩʞ Ȥ m ʞ ƵʞɁ ¡ȕʝ ȥy Ǎ Ħʞ ʞɂʁǾǿų ;ʞȦz .)ɶ³ʞ 6) áÎí ÝtÒł ©łič? $Á ĝ8@Cł !"CħC3"< bāíVʞ î Y Ĕʞ Òʞ EqJƅ PSʞ ʞE( n)wʞ7ʞ:ʂƆǪ-ƍʞ:(8 Ǝ;ʞ/ ʞɝ~ ʞƏ ȴ ǎvʞ Ȉ Iʞ ɞǏ ȉɼʞ 5' ł`îijĄuÓł 4:³ úĎļ ´'vĞĀ Dł ć2Ĩa WĈ ´ʞ ï5då]ʞ ĕ Ó ĹʖLȧ Ƀ µʞ Ķ ʞ Ŗ ʞ šƺǤ ʞʍ-Ʉǐ ʞ /ʞ OʗvǁǑ ) ɅɟɆĩʞ Ş Qǒ 9 ʞ Ƈʃ oɷ/Mʛ Ȁ ƜǓ&o ʞ Ɛ ƪʞ ɇʄ x Īʞ Ū ť ʞ ð54$Ìñ 4C¶ʞQ Ķ ł ğ łþï ł rĠw,ł â , %łnġ Ģ&ď ( Đł ģ łe įÍð Ôł Ĥ ûłªñ ł Õİ%ło<xĥÂđĦà ĒMł % Ɉ ǔ Hɠ( · 6īʞ ňľūʞŢ ƈǫǕƑʞ ʼn ŴǬɡ ʞ , Mʐ ƒ ʞş Ôʞ ù Tʞ ʅ|ʆNɢʞúĉ¸ʞ ò ¹ʞ L=ʞ "* ?Õ Ť ƻǖ ȨTʞ ʞ ij ʞ qµ ł 9? ¶Ä ħ4Å ł S ; üł )5 ĨòýOł ł Y ! ã° 6¡ ł p ¢ Æ"ēN gĿ%ʞ¤ jgĴ§ʞŝ ȩ Ɲʇ ʞ¢aûÖʞŬ ɉ | ºʞ 6Ĭʞ ŊD%» ŔʈȊ ʞ ü#¼ʞ _ × ^ ŎƉǗGZ ýØ eŵȵʌ ½ʞ ŃZʞ ŏ ʞ ƓȪ- - ǭʞ ʞ ɣ ʞ Ɋʉȸʑ ŶǮʞ (ƶʞƔ ȁʊȋ ʞ Ȃ ɸ ǯ ' ¾ʞ 7* äa >Þ Öł1#łlĽ $Çyĩ8@Eł _"Ċĭ@æAğÍóç ċ1ʞ ô5 d "Ù eƫ8Dzmǧ¿ʞ i ʞf( ȃʋ ǘP ʞȄƬȌRk ʞ ǂ žIɤǃÎR ʞ;ƭlȫɋʞǰ ɥƮȬ=ʞ Ő ʞRł T0 ÈĔ£ ]z. óôÏł õ«łUö ßĴ.É=ľł c¤åĪ{׳ ^¥|Øī·Fł Śáʞ ķƯdzǴpǨʞ ¥ŀƞÚ¨[ʞ Šưʓʞ ŮȖȭǦĮ ńȶ ȍƱʞ ŷȎƟʞŦɦȷŽɹɺȗ Àʞ őʞ+ʞĖʞBÁʞ ȞÛʞ þ ă ,{ ʞ &Ǚ ɧ ʞėʞ Ě$Ü ŭ Âʞ iâʞ ĺYʞ f Ȯ) ʞ Ȝ 0ɨɌʞ Ÿs ɻʞ ɍ ǚ¡(0DŽȯƲȏǛƕɎʞ nȐFʞ ƸƁ ǜJʘ ) ' ǝ ɏ ɐUʞ b÷ ą -ł 2¯łf¦çL/ ł } !ł d æ=~Ùł XÊ ĕGł õĎ+į ÿX +à !Ġě@ ĜďÝ ŧɩƳ K1ʞ ś ʞ h>Äʞ Ź Ơʞ jÞʞ >ʞ E ɑɪ*ʞ ' M źɫǞʎ ɒʞ ɬȘʞ ȑɭſǶʞ șɓ0 ɮ ɯ) p ȅ KQßʞ œãʞ Ļ/ u ɰ q ʞ .ơ 'Vʞ ȰyŻR ƴ ɱʞL Hȱ ȆÅʞ ż ƢʞƗǵǟ Ǡ&rǷ ʏrJ ɲ ȚKÆʞ 7 Ëķ§ ł 2#ł[" ¨ ÚłjĖĿ ¸Ì Ĭā Hł` İ#ġ3W`54Çʞ ö ?\ * , ʞƖǡ . ʞ Č = Ņ.Iƣ Q Èʞ ŨàʞD ʞ, ' ɳ GʞG ƹǥȒǢɴ ]ʞŒ ʞV/ ĭėł ¬łW0 > *IJł 9ŀ ¹+Ł ĮćIłũ ʞŁ ʞņ DZƤɔ ȝȓʞ¦łƥ ©\ʞ% ɕ ǣ Ƽɵț ÉʞĽ6ıʞ ŋD%Êʞ ÷ c$ËʞȟȠ>ʞ!+$Ï 32#[
60
Community Psychiatry: A Reappraisal
89. Mustard, H. An Introduction to Public Health. New York: Macmillan Co., I 944. 90. See citation 42, Chapter 2. 91. Kennedy, J. F. Message from the President of the United St,ates Relative to
4 REAPPRAISAL ANO RECOMMENDATIONS
Mental Illness and Mental Retardation, House ofRepresentatives Document No. 58, 88th Congress, 1st Session, February 5, J 96J. Washington, DC:
92. 93. 94. 95. 96. 97. 98. 99.
100.
USGPO, 1963. See citation 26, Chapter 2. See citation 89. Feldman in citation 89. Feldman, R. H. Foreword. In Caplan, G. Principles of Preventive Psychiatry. New York: Basic Books, Inc., 1964. See citation 95. Felix in HEW Task Force on the Report to the President from the President's Commission on Meneal Health: DHEW Publication No. (ADM) 79-848. Washington, DC: DHEW, 1979. Caplan in citation 97. Zusman, J. Primary prevention. Secondary prevention. Tertiary prevention. ln Comprehensive Textbook of Psychiatry, Vol. II. A. M. Freedman, H. I. Kaplan, and B. J. Sadock (Eds.). Baltimore: Williams and Wilk.ins, 197 5, pp. 2326-2345. Davis, J. A. Educationfor Positive Mental Health: A Review of Existing Research and Recommendatwns for Future Studies. Chicago: Aldine Publishing Co., 1965. See citation 97.
101. 102. Task Panel Re ports Submitted to the President's Commission on Mental Health. Appendix Report of the Task Panel on Prevention. Vol. rv. Washington, DC: USGPO, 1978, pp. 1822-1963. 103. See citation 97, p. G-5.
In this final section we shall summarize the development of the CMHC program-its conceptual flaws, problems with imple mentation, and the recent effects of reduced funding. Then we shall review the successes of the Community Mental Health movement and of the CMHC program that, along with the disappointments, have made distinctive contributions to the theory and practice of modern psychiatry. We shall conclude with suggestions for mental health care and for the directions that community psychiatry might take if it heeds the lessons learned.
SUMMARY OF CMHC PROGRAM During this century there has been a trend away from the hospital toward community care of the mentally ill. By 1955, when more than 558,000 persons were in State or County mental hospitals, 1 public willingness to accept greater responsibility for the mentally ill was marked by the establishment of the Joint Commission on Mental Health and Illness and later by the CMHC legislation of the early 1960s. The CMHC program of the l 960s-a new service pattern for the care of the mentally-ill-was created in response to a need and was promoted by the climate of public opinion. It was based on the successes achieved by early community psychiatry pro grams, many of which were in operation in the l 950s. Spear-
61
Ţ ŰL#aɝ ɝ ïýkkÑɝ ¥ »ɝ¼ ɝ! ɝ0 ŚDz ɝBN ɝĄČćąɝ; +dz ¦ɝ ȑɝ ĝY7 xåɝ Ĉ ɝ ðmøúÒɝ Â6 Ǵ ɝ ǵľɝ [\ ɍű 8Ɏɝióùg(ë(ɝ N Ȓ<ŲÌ e ųə Gɝ ; ȦŴ b hɝ ăɀ gɝ ´ Ŀɝ ǧ \$ ħɏɝ ȧ$ ±ɝ Dɝ ɝ²$ŀ ɝ= ȓɝ à yɝ ,ºŬ ɝs ɝAǶ ¾ 3ɝ ɝ Ř 1 ƪɊňUɐɝ Í2Ɂ] HÎɝs!ɝ Ʊ 1 ɚ A ǎɝ, ɝ³O ɝĨ ɂ S ɑɝ # ɝE Ǐɝ ³ɝƲ ɝ< Aŵ XƳDɝ 2 ř> xɝtɒɝ ·$ ɝb> ǐ* ɝ ) Ȕ ɝ ɝǷ I %&&Ŷ &á´P ɝÏ Æ ƴÇŷZ4ɝH æÐɝ Đţ ɝ '9u ɝ ʼnɝ IJLj __Ÿ ǑȕɝP Ȗɝ X &½ɝcǸŹǨƵŁzɝźǒɝµQǹ ɝ3 pij ?Óɝ ŕȏ§ ɝ ñöjÔjûlɝ Ż ɝ ĉɝm÷(ɝ §ɝ Ğ 'Áɝ ôiõÕ((ìɝ ż ɝ Ċɝþüíçɝ o ɝ ¬ Bɝ " ĩ ĕȗ ɝŽǓɝ Ť ɝ Ƀ ğ ɝ ɝǩ Cž C ɝ ɝ ſĴ v ɝ yɝȨ# ɝL« ¶ ·ɝ ƀZ ɝƁ ɝ { T Ƃ @ɝĠ ŭɝ 21. Ǻ }ɝƃ ɝ Q ɝòÿlî èɝ ɝ ǻ Ŋ Ǽɝ Kɝ; ȩ ÂȘɝś ljɝ ɝ# =Ƅ ƶɝB-ɝȸŮ ɝĪ-NJNjɄǔƅȽɘɝ *ɝ dɝġ ɝș ɝ = w < ¸¨ Öɝ °ɝƆ ɝ\ ` Ģǀ ɝ¹$ Cɝ0 Ȫ ǽɝǾ ` Ʌ]F ɝ Jɝ v ǰ _ɝ Ǥ ɝ > |' 7 +ɝ * Ț Ƈ â ŗȻ ɝ G ƈ@?Ɖ Z&ã %M ɝť É ɝ È Ç ĵĀɝ đŦ ɝ ȫɝ ț ǿSǢîɝ :}ɝ [ Ɗ ȬƋ ɝ <ȍ 0 ×ɝ a ƌģ'ȭ EƷ ɝ ɝ O ɝ I 1Xƍ ɝ ɝȮ ɝnº e ɝR ©Ǝ U ɝ ǡ~ɝ ɝ¶R ɝƸ īưɝ ŋɝŜ *Ə 4ɝ Ōɝ ) Wɝ Ǫ ŝ ¯Øɝ Ɛ ɝ 5 »ɝ ɝƹ Ş ɝ t Ȁɝ Kɝ 6 ɝFŧ Ƒ ¡8Dɝ Ǖ²q¡¢!ɝ7Yǁɝ /^ ɝ Kd ɝ 8 *L Jɝ% ɝ ĖĶ DZ ȯ ɝ Äȁ ɝN-9 Ȝɝ ėǖķɝ Ĥ Ȃ{ä ĸɛ w ɝœĜĬƒVƓ¼7ł ɝ%Ǘɝ 6 ɝĭ ' Ɣ¹!ɝ ȃÙɝŃÈńǘɝ ȝ ÚɝƫǠɝ ƕ ƺ ɝɆ: /Ȏ Ĺɜ ǥ ɝ `Ûɝ Hɝ Ȅ ɝ ɝ« ƖɋƗ ɝ 3 "ɝeȅŅ ȼ :Ⱦɝā ɝS Į¬ Ƙ +ɝ ǙÄ 0 ɝ ōɝȰ ɝ nj p¤Vfɝ Ƭ£ǂɝ ɝ ɝƯ ƙƻ°ɝ ɝǫ ƚ @ɝ JÜɝ ƛ ɝ .^ɝ Ƽ + ɝ) ÁT ?ÝɝǍ ɓɝ ɝC ɝ " ɝ ƽ fɝ 5 ɇM ɝ ɝ Ȟhɝ o ɝ ȆĘ½ ɝ Ŏɝ¸R ɝ É ɝ ŖȐ ɝ Ɯ Ɲ¾. ƞ ǚ/Yɝ ȿɝ ' ±!ɝ ) ȇ ɝ ªǬ ] ɝ b ɝ E ɝ ȟƾ ƟǛ4ɝ ĥ cŨɝ ǜɝ ȱ ɝ ē Ơ |ɝ nµ ȲņȠɝ ĺɝ ¿ ɝ Ĕ Gɝ ċ, " éɝ Ď UÊÞɝ 5 ɝ ď fę£ɝ ƨ ǃŇş ɝ -ŏɝč®ɔį ơ ¿ȈƢȡȳȢɝ
ÁZ Á ti½Á [u!4Á Á ¡S ¢Á£T5Á" v#5 ¤Á PÁ$ 6Á QÁ¥U7Áo5x¬ nj¾Á-\ .8 93Á º]Y^wÁ ¦V:Á % qp±x_§¿Á ;& s<Á '(= ¨>/Á k`)ÀÁ Á W?Á ² @ ³Ay©Á 05·Km q5x®Á S Á BCzÁ ´{D¸E|Á }1Á 2B*a b ~ Á X ¹FÁ GHxÁ ¯ gI Á J3Á r BÁµ Ác ª¶f«d |Á° Á h »lB3RK Á L M +U Á 3Á5¼ B eN|,O Á
ĒO ɝ© 8ɝ ȉ ȴ6ɝ ŐɝdQ ɝ ȵ[ % ȹɝǭ^ T2 ɝ őɝ; ɕ $ƣÌ qA !ɝ "Å , 4ɝ 5 ɝV & ɝ ɝ 3 Ļ ȣɝ ũ ?ɝĦ ɝ F ªr zɝuɖɝ Ⱥů ɝ Ȥc IƤƿDɝ ǝİ ¯ƥ +ɝ~ Æ W = ɝ ŒɝǮ@ɗ P ěaȊ )ɝ . % ɝ, ɝŠ ȋĚ¢ɝ Ū ǯƦ / ɝƧ ɝȶ# ɝ ¦ ÊêɝĂDŽ . ßɝ Å ŔǦ BɈ Dž!àɝ ȷū ɝ > ɝ Àƭdž¤ɝ 9 ǞËɝ 9 ǟÀ LJËɝ Ʈ¥Wɝ # ɝ š-ɝ ɉ "ƨrM ȥ ļɝ :Ľɝ Ȍ ı ƩɌ ɝ ǣɝ
Ȋ ĭ Ȋ ƥ S ŽǍ ƦĮǰ Ȋ þȊ & 9 5ǎ7 Ȋ Ǐ k įV; Ȋ ĕ,"Ȋ %Ȋ DZÔ VDz xFȊ Ƨ Ȋ ǐ Ȋ Ė Ȋ o Ǥ Ȋ ƙ ÚǑİ ¯Ȋ Ä > 3Ȋ 2[Ȋı 8 ǩJ YȊ MȊ ūš Ȋ 3F IJ BDŽ Ȋ Ȋ v 9 Ȋ )YȊ ǒ Ȋ 3Ŵ ž Ȋ ÿȊ &n Ȋ8 7 %ǫ ȊĒD+ ij ſIŢȊ= 0 =p[]ȊĴ Ȋ Ȋr 8 K}ǓȊ Ȋf ƻŻĵ Ȋ ĀȊ k 5&Ķ+Ȋ É% $ ŵ {[Ȋ Ȋǔė Ȋ ] ƚ' ȊgB $% X ¶Ȋ Ȋ+ (Ȋ iȊ @ cķţ Ǖ7/TȊ Ȋc Û Ŷ Ȋ Ȋ Ƥ5bȊ8) ǖ Ȋ PǗ?Ȋ @ 'Ȋ āȊ +; Ȋ !ż ~ `Ȋ Æ> Ȋ <H¿¹Ȋ 0 $W Ȋ ? Ȋ KůŤ ïȊ I ôU Q UȊ /Ȋ ǘĘ Ȋ ĸŷƛ ǭ Ȋ LȊX Ĺ dzxǥ5ƨÊťȊ čÜǙ Ʃ1Ȋĺ Ȋ ī Ȋ ďDĻ ļ ƀ Ȋ e ƪ Ȋ Ȋ ǁ õ ( Ɓ Ȋ ĂȊ Ƃ'bȊpŬŭ ,: )|Ȋ q Ȋ &ȊĽ Ȋ 2 ľÑŲų Ȋ - Ȋ ǚȊ Ɯ 1 }4Ȋ ę Ȋ GȊ 2GÝO. 7 Ȋ J Ȋ ĈÓ ÞĿz Ȋ ÕȄȊ 4@ Ȋ 1 ß : -:Ȋ ƐMȊÖŀ Ŧ NŁ ÐŰȊ Dž l ËǛ °Ȋ Å2"àmł ǜƫ. dž¡Ȋ Ńƃ - _Ȋ @ Ǿ,Ȋ ö ^ # #Ȋ!Ě ń ȊÒ :LJȊ Ȋ Ņ CǴ Ȋ Ȋ 6D. ņ Ȋ4> ǝȊ .w Ƅ, 2¢Ȋ P Ȋ ½ƅ$ C Ȋ ' £Ȋ Ň Ȋ ǽŧ]Ȋ Ȋ×ň Ȇdě áBKvȊ0? Ɔ ,%/ ±Ȋ ·XȊȀ÷Ȋ 00Ƭ r Ȋ d ;Ƈʼn "Ȋ "â Ŋ WFȊ #Ȋ uȊ ǦƔ W#ȊQǧnjȊ ċǻƼƕ ¤Ȋ Ȋ e ƈȊ Ȋ Z Ȋ 5$ĜȊ 3 ŋ 9. Z1Ȋ * Ȋ Y Ȋ ĝ fȊ ǵ%ƽ ) ŝ 'B=Ȋ ȃ +Ǭ Ş 3Ȋ LȊ ȊºHÀ<Ȋ ƾ N Ȋ &ȅȊG ƭ Ȋ 6 ¥Ȋ Ȋ Ʈ ē * Ȋ E Ư ŮyȊ 1Ȋ Ø Đ Ȋã \ GȊ Ɲ ĞŌ Z ²Ȋ Çğ Ȋ Ǟ ō Ȋ ăȊ8 " Ġo ( 7 ȊäÌư-Ȋs Ǩ/Ȋ Ȋ ;{Ŏ "Ȋȁ Ȋ Ȋ ø hȊ ǶT4 E ŏwt NȊĉƖ å Ȋ Ȋ ġ Ȋ ƞ P æ ¦Ȋ Ƒ Ȋ!Ģ Ȋ Ȋģ % _Ȋ ĄȊ Ɵ "çm Ɖ Ũ" s2Ȋ ðȊC 6® SȊ ąđ Ȋ&9 S Ȋ*Ə §Ȋ Ȋ! Ȋ Ǯ Ʊ¨Ȋ iȊ \ A RȊè*Ʋ Ȋǟ a!Ȋ ĆǠ DȊ hȊ Ȋ(Ĥ ȊLjƒ+Ő ȊÙ Š Ȃ Ȋ g / Ȋ Ȋ őéŒǃ³Ȋ
< Ƿ œ' Ȋ 1Fê A ©Ȋ Ĭ Ȋ »Ɠ ƊA4 Ȋ Ãù 4* Ȋ Á J ǡĥȊ E Ȉ - !ªȊ Ƌ Ȋ (O Ȋ ¼HÂ<Ȋ Ơ $Ƴ Ȋ > ǿ Ȋ ĦIñȊ ÍȊ ş Ȋ QŸ0 ë Ȋ /UȊ # Ȋ¸ Ŕ Ȋ 3 lŕ Ǣ `Ȋ ¾ Ȋ! ȊòŖljħú !ûƎt $Ȋ ~ Ȋ y^ RǸ ŗ 6Ȋ Ď Ȋ LȊ(Ĩ Ȋ Ȋ V\ ü Ȋ ćȊ Ȋ ì ǂ Ȋ &)u Ȋ TȊ Ř ȉ ơ ƴ az Ȋ ƌȊ Ȋ q Ȋ ĩ Ȋ Ȋ= ǹ ř Î Ȋ( R, ´Ȋ ÈýȊí îC5ó «Ȋ n Ƶ ĊƗ ¬Ȋ A'ĪȊ : E Ȋƶ . NJȊ # Ʒ #Ȋjǀ ŹȊ ;9Ȋ ^ Ƣ Ƹ ŚNjÏũȊjƘƹȊǯ-Ȋ 6 śȇ Ŝ |Ȋ MȊČǼ Ǻƺ Ȋź ƍǪ)ŪȊO *űǣ?Ȋƣƿ Ĕ µȊ