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Governor Ellington was invited to be with us this morning and could not because the legislature was in session but he has asked me to express his regrets, and let me say as commissioner of mental health that he has #. overwhelming .. for our program and has given us the highest increase in our budget, hopefully which will be approved at any time, in the history of our department. What I have done in my statement is to briefly outline the three revolutions that I have seen occurring in F. the first being the advent of Dr. Freud, the second revolution which is the tranquilizer in 1954, and third the comprehensive mental health center and I really see this as the most significant of all and I would like to confine my verbal testimony to my experience as the superintendent of Moccasin Bend Hospital, a small State hospital which opened 2 years prior to the comprehensive centers but which was run similar to the centers and just briefly outline our experience there because I think it is relative to the staffing questions which have been asked. Mr. JARMAN. §. it would be appropriate to say that the Chair has announced that we will try to finish the hearing by 12 o'clock. Apparently we cannot do so. So, our intent is, in fairness to the witnesses who have come to the hearing, some from outside the Washington area, to ask for permission to sit this afternoon at 2 o'clock to conclude the hearing if we don't finish this morning. Dr. WINSTON. Moccasin Bend Hospital, as I say, opened in 1961 actually. The results that we had there with this type of program similar to the comprehensive center we feel are almost miraculous. We cut the average first stay from 6 months to 5 weeks in the first year of operation. We started new programs that were not capable of being started previously because of the small comprehensive concept that we envisioned and that is now in operation elsewhere, too. We did this, I might add, with only one other psychiatrist serving an area of some 600,000 people. Let me make the remark that we rely heavily—in fact, solely, I should say—on the aid staff and the use of tranquilizers and not one patient there received the sort of treatment that I as a psychiatrist was trained to give; that is, the 1-to-1 psychotherapy relationship. Yet we got these patients out, we kept them out and they are continuing to give what I think is a real testimony to the value of how these comprehensive centers can work without necessarily the staffing pattern that we have been accustomed to in the past and would like to haye but cannot apparently have in light of short staff. Let me read my concluding paragraph. The impact of the comprehensive community mental health centers making treatment available to any aggregate population of 75,000 or more is indeed staggering. It is my firm, sincere judgment that the farsighted thinking on the part of the National Institute of Mental Health in instituting this program will be by far and away the most significant of all of the three revolutions. Although it will in no way eliminate mental illness any more than general hospitals eliminate physical illness, it will alleviate much of the suffering, the agony, and the despondency to which only those who have had mental illness can testify.

I urge this committee to consider not only the extension of the present program but a large expansion of it. (Dr. Winston's prepared statement follows:)

STATEMENT OF DR. NAT T. WINSTON, JR., CoMMISSIONER OF MENTAL HEALTH, STATE OF TENNESSEE

I am Dr. Nat T. Winston, Jr., Commissioner of Mental Health for the State of Tennessee. Governor Buford Ellington of our State was invited to participate at this committee hearing, but because of pressing legislative matters currently under consideration in the General Assembly of Tennessee, he is unable to come. He has asked me to express regret that he could not be here and may I say as commissioner of mental health, that his interest in our problems and in our overall program has been overwhelmingly positive. He has asked the current legislature for a greater increase in our budget than anytime in the history of the department and has given his wholehearted endorsement and support to our program. I shall make my remarks quite brief in urging you to consider the extension of the Community Mental Health Centers Construction and Staffing Act (H.R. 6431). In my judgment, there have been three revolutions in psychiatry. The first occurred around the turn of the century with the advent of the theories of the development of mental illness first advanced by Dr. Sigmund Freud, the father of modern day psychiatry. The original postulates of Dr. Freud have been altered somewhat, but his most significant contribution was his pointed observation that there were causal factors in childhood resulting in adult disturbed behavior. This meant that no longer could we complacently sit back and place patients in “insane asylums” and wash our hands of the matter. We would now have to look for methods of treatment of a definitive nature. The second revolution occurred in 1954 with the advent of the first true tranquilizer. Although we had methods of physical treatment prior to 1954 and although we had drugs which would produce sedation, we had no drugs which would produce tranquilization without crippling side effects. These miraculous drugs do not cure in the strict sense of the word, but merely control symptoms thus altering many age-old concepts we have had about the mentally ill. They have, for example, permitted new ideas in design and architecture for mental hospitals. They have completely modified and changed our programs for the mentally ill by permitting a freedom and versatility of programs never before possible. They have led in my opinion directly to the third revolution. This revolution came about because of you, the legislative body of the United States. You appointed in 1955, a five year study group to look at the problems of the mentally ill. The famous “action” report released by this group in 1961 held as its primary recommendation that the mentally ill, if he was to receive the best chance for recovery and to remain well, must be treated at home in small intensive treatment units just as we treat physical illness in our many local general hospitals. The report held that it was just as absurd to congregate patients in large regional mental hospitals as it was to send the average case of pneumonia or appendicitis to the university hospital 200 miles away. In backing up this recommendation, you then passed in 1963 the Comprehensive Community Mental Health Centers Act, which in my way of thinking has revolutionized our entire approach. It has placed the mentally ill back where they belong—in the community. It has done much already to reduce the stigma and the fallacious thinking of individuals about mental illness. It was my privilege to have opened, as the first superintendent, the Moccasin Bend Psychiatric Hospital in Chattanooga in 1960. This small, intensive treatment unit is operated much as the comprehensive centers are being operated following 1963. Here we had the chance to see what new ideas coupled with tranquilizers could do for the patient who was treated right at home in his own environment. The results were almost miraculous. We cut the average length of stay for a first admission acute case in the State of Tennessee down from six months to five weeks in our first year of operation. We started new programs never before conceived of in mental institutions such as 24-hour around the clock visiting, sending patients home who were still presenting symptoms for weekend visits, but who with the confidence that they would not be separated from their families returned readily and improved more rapidly. We utilized every recreational facility of the city of Chattanooga itself in our recreational

program and we did away with many of the traditional practices of searching, keeping doors locked, etc. We utilized many community agencies and brought volunteers into the institution thus keeping the institution and the community closely associated. This program as well as others have demonstrated beyond any doubt that keeping the patient at home does make a significant difference in how he responds to the definitive treatment offered him and even more im

portantly, how well he stays at home. The impact of the comprehensive community mental health centers making

treatment available to any aggregate population of 75,000 or more is indeed staggering. It is my firm, sincere judgment that the far sighted thinking on the part of the National Institute of Mental Health in instituting this program will be by far and away the most significant of all of the three revolutions. Although it will in no way eliminate mental illness any more than general hospitals eliminate physical illness, it will alleviate much of the suffering, the agony, and the despondency to which only those who have had mental illness can testify. Ladies and gentlemen, as a professional person with the responsibility of caring for the mentally ill of a State, I would urge you to consider at all costs not only the extension of the present program, but a large expansion of it. To do less would be more than foolhardy and would potentially endanger the lives and the emotional health of every one of us here. Dr. GLAss. I would like to follow with my statement. I have a prepared statement. I will not read it because I feel that Dr. Donohue has a story to tell and does not have a prepared statement. I should like to summarize my remarks by pointing out that you have heard of the decade of effort to obtain this community program, going from the studies that Dr. Ewalt had in the Joint Commission on Mental Illness and Health and you know about Public Law 88–164 which launched the community mental health center program. It not only launched a construction program but a whole new way of doing this, not new techniques, but a new operation, how to use people, how to treat people as outpatients, how to treat them in alternatives to hospitalization. So that the program launched not just construction but a new way of handling the problem. Now it is almost as if the military medical services, and I am an old military psychiatrist, confined their operations only to base hospitals and o have followup field service to support troops in the field. This is what the new program did. Necessarily it took time to get started. It had to be written. It had to be understood. Enthusiasm had to be stimulated and we have gone through the first 3 years of this. Now we are moving. We have a momentum going. o are only 128 construction grants and 72 staffing grants as of April 1. ow, many of these are complementary. Our one grant which Dr. Donohue will talk about is both st and construction. If we at this time fail to renew this program we have broken faith with everything that we have tried to do in stimulating it. For example, this would stop a whole decade of progress. We are on our way now. We are getting more and more interest. More and nore ple are exploring this idea and understanding it. I don't know how much time I spent in Oklahoma explaining what a community health center was. It was always mixed up with a clinic. The substance and spirit of this law strongly indicates that a continuing program was contemplated, not only President Kennedy's 2,000 centers.

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For example, there is the insistence that the State plan shall provide for adequate community mental health centers for all of the people in the State—not a few of them—and it shall set forth a E. for construction of seven community mental health centers based on a state

wide inventory and I am quoting from the law. It should be evident that if we don't fully renew the center proam, we will be discriminating against those regions and communities

in which approved applications have not yet been completed or are on

their way. Often this o is due to a shortage of mental health ople in this community and often those communities need the mental

ealth care the most. - - - - For example, failure to review this legislation would do the follow

ing in Oklahoma: we have three grants, two approved, one in the process. Those three grants will use up most of the money available

under the present 3-year program. Yet, when completed they will supply services to less than a fourth of the population, to 600,000 which is less than one-fourth of our

population. - - This is what I mean. Yet, this excellent beginning has stimulated

Muskogee, has stimulated Ardmore and other places to get going on this project. If we fail to renew it we block all of the efforts that

we have done all these 3 years. With that, I would like to turn this over, unless you have questions

at this time, to Dr. Donohue, who will show you what a center looks

like, at least from planning and somewhat from an operational stage. (Prepared statement of Dr. Glass follows:)

STATEMENT OF ALBERT J. GLASS, M.D., DIRECTOR DEPARTMENT OF MENTAL HEALTH, STATE OF OKLAHOMA

Mr. Chairman, I am Dr. Albert Glass, Director of the Oklahoma State Department of Mental Health and a member of the Board of the National Association of State Mental Health Program Directors. I represent these Directors of the state programs for the mentally ill in the 50 states and several territories.

As administrators for the vast majority of metnal health services in the United States, the State Mental Health Directors have a vital concern in the proposed Mental Health Amendments of 1967 and unanimously urge its passage. This act will make possible a continuation of the nationwide movement to improve and increase the availability of treatment resources for mental disorders, which

was launched in 1963.
Proposed AMEnd MENTS

1. Renewal of the Centers Program for an additional 5 years. (a) Extends the community mental health construction program through Fiscal 1972. Authorizes $50 million for Fiscal 1968 and such sums as necessary for Fiscal 1969–1972. (b) Permits construction grant recipients to use the funds for acquisition of existing buildings instead of only new construction, remodeling, alteration, expansion, etc. (c) Provides for enforcement after 1969, in state plans, of maintenance and operation standards. 2. Renewal of Staffing Program. Extends funding of staffing program for community mental health centers through fiscal 1972; also provides authority to continue making grants through fiscal 1976 to centers already receiving grants. 3. Contingency Fund. Establishes “contingency fund” for the Secretary of H.E.W. Secretary would have control of $50 million of expiring unobligated funds out of various HEW grant programs. Has no direct bearing on mental health centers program.

BACrground

In order to appreciate the importance and need for the proposed Mental Health Amendments Act of 1967 it is necesary to review the origin and present status of the Community Mental Health Centers program.

Over a decade ago the Joint Commission on Mental Illness and Health was established by Congress to study and make recommendations on this most common and most disabling health problem of the nation. As a result of the Commission's findings and report in 1961 and the rising awareness of the increasing dimensions of mental disorder by many prominent lay and professional citizens, P.L. 88–164, the “Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963” was enacted by the 88th Congress,

In essence, this Act authorized funds to begin the construction of community based facilities for the mentally ill and the mentally retarded. It should be recognized that, at this time and even today, the majority of mental disorders were either neglected or because of the absence of an alternative to hospitalization are referred to state mental hospitals, many of whom were located at some distance from the community. This lack of local mental health facilities is in sharp contrast to surgical, medical, and other non-psychiatric medical services which were present mainly in or near the community. In effect it is as if military medical services were provided mainly in base hospitals with little or no facilities to follow and render prompt medical support to troops living and fighting in the field.

While the 1963 act seemingly only provided for the construction of community mental health facilities, in actuality it introduced new concepts and programs for the management and treatment of mental disorders. Since new methodology and concepts require considerable time for understanding and acceptance and because of the scarcity of mental health personnel similar to the general shortage of health personnel, initially, implementation of the Community Mental Health Centers Construction Act proceeded slowly. But with time and effort there came more and more awareness and increasing appreciation of the “Centers” concept. This program was given considerable impetus in 1965 by passage of the Amendments of Public Law 88–164 which authorized financial assistance toward meeting the cost of technical and professional personnel serving community mental health centers during the first 51 months of their operation. With this assurance of staffing support more community and public agencies moved to explore ways and means of establishing centers and submit feasible applications for their operation and construction.

In the several years of its operation, P.L. 88–164 has encountered inevitable problems in its regulations and administration which have been or are being resolved. For example, initially regulations and attitudes due to the anxiety and effort to stimulate “center” applications unwittingly fostered the impression of a rivalry between community mental health centers and state mental hospitals. It seemed that a dicotomy was being established between these two systems of mental health care. Indeed it was “rumored” that community mental health centers would do away with state mental hospitals. However, with time and experience it has become clearly and widely evident that comprehensive mental health care requires the integration of services between community centers and state mental hospitals. Further, that Community Mental Health Centers, must be supported by facilities of state mental hospitals, else cases requiring prolonged care will absorb the energies of the Center and prevent its function as a flexible facility which can promptly respond to local problems and needs. It has become recognized that state mental hospitals can and should provide community mental health services either alone or in concert with local community agencies for citizens residing in its environs. This more flexible use of state mental hospitals is of particlar pertinence in view of the shortages of the mental health professional manpower which are even more scarce in rural areas where many state mental hospitals are located.

The overall events and experiences of the past several years has produced increasing implementation of the Community Mental Health Centers Act until at this time (1 April 1967) 121 construction grants have been made along with 73 staffing grants.

RENEWAL OF THE CENTERs AND STAFFING PROGRAM

1, Failure to renew the Centers and Staffing program at this time would be disastrous to a decade of progress that has been made in community psychiatry.

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