each psychiatrist, and at least half the number of clinical psychologists. If the psychiatrists in that region were in short supply, a great deal of the work that the psychiatrist does can be done by properly trained social workers, psychologists or nurses, under the supervision of the psychiatrist. Therefore, the numbers might be changed around proportionately. I have made no estimate of the number of nurses because this would vary tremendously, depending on the proportion of in-patient and out-patient activities carried on, and how much the nurses made home visits. Again let me emphasize that these are educated guesses at best. I think one will find that the number of persons required in centers in different parts of the country may vary substantially, and one major variant will be the kind of treatment the people there want; that is, do they want predominantly medications and group supportive therapy, or do they want long-term intensive therapy, etc. It will also vary with the amount of use made of psychiatric aides, new categories of mental health workers, etc. However, as far as I can tell the above figures will do for a start. Sincerely, Mr. ROGERS. Would the gentleman yield? JACK R. EWALT, M.D., Mr. ROGERS. What would you say is the population area that you serve? Dr. EWALT. As of the first of April or March 28, our new mental health plan went into effect and I was given a so-called catchment area and it has 225,000 people in it. I was given this area because of our relatively large staff and the fact that this hospital was set up to serve the whole State as a teaching and research hospital and the buildings and facilities and staff are there and so we will continue to do this. Now, it is our estimate that our admission rate to the hospital will be about 300 a year from our catchment area, leaving us roughly 600 a year whom we will continue to serve from less well-sponsored areas of the States. The clinic breakdown I don't have yet. It is hard to count individuals in the clinic. We run about 47,000 clinic visits a year. This is a guess and let the record plainly show that it is a guess. Probably there are not more than about 20,000 visits a year; that is the person coming to see the doctor or the social worker from our particular catchment area. Mr. ROGERS. I wonder about this: When the mental health center was projected it was about 100,000 up to 200,000, 20 psychiatrists and a little over. Dr. EWALT. That was the figure I gave him off the top of my head. We have 200 beds. Mr. GORMAN. He is modest. He has the oldest center in the country and does more business than any patient center. Mr. SATTERFIELD. Mr. Gorman, I have just one question to direct to you. In answer to one of Mr. Rogers' questions, you indicated that we should accelerate more rapidly than you think has been indicated, maybe to the extent of doubling what you think has been indicated. I am sure that this suggestion will get due consideration and I would be interested in knowing whether or not you feel that we have enough properly trained personnel to permit that kind of acceleration. In other words, are there sufficient personnel to justify acceleration of the kind you suggest? Mr. GORMAN. I am delighted, sir, that you asked me that question because in the 5 years I have served on the advisory council the basic problem has been how you get the manpower. We have it in the State hospitals. As Dr. Ewalt correctly points out, it is awfully tough to get them to work in State hospitals. More than 45 percent of the doctors in the State hospitals are foreign-born physicians, in Florida quite a few Cubans and in New York State more than 50 percent are foreign born. We don't seem to be able to attract the young American doctor except in the new hospitals. Let me say that in 1945 there were 3,000 psychiatrists. Today, there are 18,000. It has become a very strong specialty. Last year more postgraduate courses were offered in psychiatry than in any other single specialty. We have come from a very small band into a very broad specialty. The same is true with psychiatric nurses, social workers, and others. I have been to see a few of these centers under the staffing grants. It seems to me that there are millions of people who lead empty lives, unproductive lives, housewives who are getting tired of playing bridge or being beaten at canasta, who would like to work in a center as a mental health worker. I think the hand-to-hand relationship, the help one gives to a child who is disturbed indicates that you don't have to have five degrees on the wall. I have seen this in the foster grandparents program. I have seen mothers working on the wards with children. I have heard doctors say, "This is the most effective person we have in the entire hospital." We haven't begun to tap the manpower. I think it has been proven in VISTA, foster grandparents, and other programs that we can use these people effectively. They are the first meaningful contact some of these kids have ever had with another person. I talked to one of these foster grandparents who had a stroke, who sat at home for 4 years. He said he was useless, retired from business, had a barber come in and shave him, wouldn't go out, and so on. Now he goes to Children's Hospital every day. I said, "Why do you do that, sir?" He said, "Mr. Gorman, there are six children who depend on me getting there every day so I get up and shave myself and get there every morning at 9 o'clock." He doesn't have any degrees. He is a successful businessman. Now he shaves himself. The barber has less work. Mr. SATTERFIELD. That is all the questions I have. Mr. JARMAN. Thank you, gentlemen, for your contribution. I, too, have observed this foster grandparent program in the mentally retarded program in Florida. It is very successful. Some of the children never expressed themselves and are beginning to now. They say it has been very successful. I wonder if your association has gone into this problem to the extent that you could recommend the use of people in psychiatric centers. I think there is going to have to be some knowledge and some leadership and guidance given before they would bring in people like this to use them. I think there is a hesitancy. Mr. GORMAN. Exactly. Dr. EWALT. I agree with you, sir, but there has been a lot of work done in this. I believe our fellow association, the National Association for Mental Health, has really taken the leadership as a lay organization, working with lay people. Our association has certainly helped. If you would like, I will send you a book on volunteers in mental hospitals which my good wife edited for the Massachusetts Association for Mental Health and which prescribes programs around the country. You hear a lot about the Harvard College kids getting into trouble but you don't hear about the several hundred under the program working in hospitals giving aid to psychiatrists and we are even using high school youngsters. We have taken some leadership but mostly it goes in cooperation with the Association for Mental Health. Mr. ROGERS. I was hoping you would give consideration to having your association actually put forth a plan of this type to get this information out. Mr. GORMAN. We have, Mr. Rogers. Mr. ROGERS. The psychiatric association, itself? Mr. GORMAN. The National Institute of mental Health is directly concerned with manpower. We spend $100,000,000 a year on training programs which you give us through appropriations. We have called conferences for what we call the middle level mental health worker. Our best source is the junior colleges. We have found a number of junior colleges that will train the 2-year workers. The Southern Regional Education Board has done a terrific job. Dr. McPheeters, who used to be the mental health director in Kentucky, is now the Associate Director for Mental Health. I am supposed to attend a conference on what helpers you can use, whether you can train them in junior college, in Atlanta next week. Mr. ROGERS. I think that is excellent. I think there is going to have to be more recognition by the doctors themselves to get acceptance. Mr. GORMAN. We are bringing them into the conferences? Mr. ROGERS. Of these nonprofessional people. Mr. GORMAN. It is a big problem. Dr. EWALT. I would agree with you, sir. The thing, however, is that it is being done, not perhaps as much as it should be, and it is growing. Mr. ROGERS. Shouldn't you have a committee go into this problem? Dr. EWALT. By seeming to pause, I am trying to think. The American Psychiatric Association, I think, has 70 committees and I am not sure whether we have one on this particular problem. We have one on working with physicians and working with the volunteers. I will look into this. Mr. ROGERS. I would be very anxious to follow up on this. As you say, I think the use of the elderly people, perhaps in this program with short courses through the junior colleges would be helpful. Dr. EWALT. The thing one has to be careful in the professional business is staying out of the other fellow's backyard. If the National Association for Mental Health has a big program, we would tend to help and work with it. Mr. ROGERS. I am not suggesting that you work at counter purposes but simply to have some leadership that they can follow. I think it has to have some professional acceptance before it will go anywhere. Mr. GORMAN. But many of the psychiatrists are attending these conferences. Mr. ROGERS. I would hope that this would be followed. Dr. EWALT. I will let you know, sir. Mr. JARMAN. Mr. Kuykendall. Mr. KUYKENDALL. Thank you, Mr. Chairman, for your courtesy. I am not a member of the subcommittee but I have a few questions to direct to Mr. Gorman. I am going to ask for some statistics which I would like to have sent to me. Dr. Carter, my colleague from Kentucky, suggested that the family situation for the mentally ill children is important and I think this is something that we all recognize that a factor is the social situation at home. However, if you have a correlation between the economic status of the families who produce mentally ill children and the social status correlation, I would like to have it. The social disturbance from home certainly applies to everyone. Mr. GORMAN. Before turning it over to Dr. Ewalt, in the RedlichHollingshead study, the highest percentage of schizophrenics comes from the lowest educational and income groups. Mr. KUYKENDALL. May I have a copy of your studies? Mr. GORMAN. Yes, sir. (The information requested follows:) MASSACHUSETTS MENTAL HEALTH CENTER, DEPARTMENT OF MENTAL HEALTH, Hon. DAN KUYKENDALL, DEAR REPRESENTATIVE KUYKENDALL: At the April 5 hearings on community mental health centers, the Redlich-Hollingshead Study was mentioned by Mr. Gorman. I remembered some more recent ones. In 1964 there was a conference on delinquency at the Menninger Foundation in Topeka, subsidized by the Maurice Falk Medical Fund. The results have recently been published by Gibbons and Ahrenfeldt, two Britishers, in Tavistock Publications, 1966, page 201. While this conference attempted to cover too much in too short a time, it did tend to bring out the fact that, in spite of the many variables, delinquency, mental disease, etc. in children and adults was associated with poor education and poor socio-economic status-this irrespective of the general economic level of the community in which the person lived-i.e. the poor in the rich countries and the poor n the poor countries were both worse off than the well-to-do in either country. Another one also occurs in Tavistock Publications, 1966, page 208 called Troublesome Children by D. H. Stott. This is a very elaborate study of children, mostly Scottish. While he is attempting to show that these prob. lems are due to what he calls primary neuroticism, which one gathers he thinks is genetic, the book contains a large amount of data to show that most people would feel that it was associated in his cases with poor socio-economic status and the stress which goes with poverty and the very strict Scottish homes in the cases of some of the children. The most scientific study is by Harold Skeels. Twenty some years ago he participated in a research program in which twenty-three children were studied in a home for the retarded. It was a typical under-privileged, snakepit type home. They divide them into two groups but some were lost so they ended up with ten in the control series and eleven in the experimental series. Briefly, the control series were left in the home. The experimental series were removed into a new school where there was a great deal more stimulation in terms of attention, experience in training, learning, etc. Over the first three or four years there was a rapid increase in the I.Q. and performance level of the experimental group, while the control group remained unchanged-in fact, the experimental group improved so much that they were all placed in adoptive or foster homes where they received a lot of love and attention in these specially selected homes. Some twenty odd years later the experimental group members are without exception achieving at an average level. Most are working, many have completed their education and most are married. The members of the control group on the other hand were all in institutions of one sort or another. and had been throughout the experimental period except for one who died of some infection. While this is not directly related to socio-economic factors, it is the most carefully done series to show the effect of the kinds of environment that go with better socio-economic circumstances in homes, etc. Sincerely, JACK R. EWALT, M.D., Mr. JARMAN. Thank you very much, Mr. Gorman and Dr. Ewalt. We here on the committee appreciate very much your fine testimony this morning. Mr. GORMAN. Thank you, Mr. Chairman. Dr. EWALT. Thank you. Mr. JARMAN. Our next witness is Mr. George J. Otlowski of the National Association of Counties. STATEMENT OF GEORGE J. OTLOWSKI, REPRESENTING THE NATIONAL ASSOCIATION OF COUNTIES Mr. OTLOWSKI. Mr. Chairman and members of the committee, I was extremely impressed as an elected county official by the testimony that just preceded mine. I think that the members of this committee were undoubtedly impressed as I was. Frankly, the problem as presented by these two gentlemen was not only dramatized here this morning, but I think pinpointed in the fact that we are going to have to get more and more community involvement in this whole program aside from the professional direction and guidance. We are going to have to involve all people in the community, the older people, the younger people, on a voluntary basis, on a nonprofessional basis, under the proper guidance and supervision of the professional people if we are going to be able to cope with this gigantic problem that confronts us. I would like to point out that I am an elected county official of Middlesex County and I am representing the National Association of Counties, and, of course, the national association is supporting H.R. 6431 which extends Public Laws 88-164 and 89-105, providing Federal assistance for the construction and initial operation of community mental health programs is well-known by the Congress and the Federal administrative agencies. We have long supported, in principle and in fact, treatment of the mentally ill close to their homes. The recent flowering of the "community" treatment concept is an exciting innovation to some. But it has been a reality with county government in the United States for many years. So, Mr. Chairman, |