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The latter profession contributes a consderably higher proportion of its time to direct clinical service, particularly in private practice settings.
It is interesting and relevant to note that psychology is primarily a public service profession, for approximately 85 percent of all psychologists are employed in nonprofit organizations and only 5 or 6 percent are in private practice; the remaining 9 or 10 percent are employed in business and industry.
Thus psychologists are especially likely to be interested in community mental health center programs and, in keeping with their public service tradition, are likely to be a crucial source of manpower particularly if they have free and open access to positions of responsibility and leadership on the basis of individual competence equally with other mental health professions. We believe that manpower will be the critical element in mounting effective community mental health programs.
Mr. Chairman, along the line the questioning took this morning, that is, with respect to manpower, I would like for a minute to extend extemporaneously my remarks about the manpower problem. We in psychology believe this is the critical element. We believe this morning's questioning was highly relevant directly to the point.
The best discussion of this that I have seen is a brilliant and incisive analysis by Mike Gorman in a speech he made in Seattle in December of this past year entitled "Critical Need for Additional Mental Health Manpower, and with your permission I should like to enter it in the record at this point.
Mr. JARMAN. That will be done.
THE CRITICAL NEED FOR ADDITIONAL MENTAL HEALTH MANPOWER
(Speech at State of Washington Conference on Mental Health Training Needs,
December 3, 1966, Seattle, Wash., by Mike Gorman, Washington, D.C., Executive Director, National Committee Against Mental Illness)
I want to emphasize here today that the severe shortages of all kinds of psychiatric personnel are the most serious roadblock in our determined efforts to bring intensive psychiatric care to all who need it. Last year, close to four million Americans received treatment for mental illness in state hospitals, general hospitals, outpatient clinics and in tbe offices of private practitioners, but another two million were turned away because we lacked the treatment personnel to handle them.
Despite the fact that the National Institute of Mental Health has supported the training of 30,000 professionals in the four core disciplines--psychiatry, psychology, social work and nursing-since 1948, we have never been able to catch up with the increasing demand for these people.
For example, approximately 25% of budgeted positions for staff psychiatrists in both state mental hospitals and schools for the mentally retarded still remain unfilled. Many of the filled positions are held by foreign doctors—in a number of states as high as 50% of the total psychiatric complement is made up of foreign born physicians.
According to a recent survey published by the National Institute of Mental Health, 21 state hospitals are without a single psychiatrist, and 91 state hospitals have only one to four psychiatrists.
In "Psychiatric News”, the monthly publication of the American Psychiatric Association, an average of 150 positions for psychiatrists are offered each month. Some of these vacancies go unfilled for a year or more.
There is an increasing trend toward the opening of psychiatric units in general hospitals. Last year, a record number of 600,000 psychiatric patients were ad
mitted to general hospitals. Despite this trend, a recent pilot study made by the NIMH staff disclosed that approximately half of the hospitalized patients in general hospitals have a primary or secondary diagnosis of mental illness, yet only six percent of all physicians and three percent of all nurses in these hospitals have had any psychiatric training.
The next few years will see a fantastic acceleration in the demand for psychiatric personnel.
The Medicare legislation, whose major provisions went into effect on July 1st of this year, authorizes psychiatric services for people over 65 in general hospitals, state hospitals, and private institutions; it also provides, under Part B of Title 18 of the Social Security Act, for psychiatric out-patient services up to $250 a year for the millions of elderly people who have already elected to participate in this phase of the program.
Labor, through the bargaining process, is winning sizeable psychiatric benefits for union members. For example, the contract negotiated by the United Auto Workers, which went into effect on September 1st of this year, covers two and a half million workers and their dependents in 77 major cities for extensive inpatient care and up to $400 a year in out-patient psychiatric services.
However, the greatest demand for mental health professionals is already manifesting itself as new community mental health centers are built under the 1963 Kennedy legislation. The announced goal of that legislation is 2,000 centers by 1975; this will generate a tremendous pressure for additional trained professionals in all disciplines.
A carefully documented 1965 NIMH survey indicates that we will need between 120,000 and 125,000 professionals in the four core disciplines by 1975. We have about 65,000 of these professionals now.
Those of us who were members of the Congressionally-appointed Joint Commission on Mental Illness and Health from 1955 to 1961, and those of us who had the privilege during the ensuing period of participating actively in the drafting of the Kennedy legislation, are absolutely determined that our nation will achieve the aforementioned goals.
Granted the overwhelming need for additional mental health manpower, what do we do about it?
Over the past decade and more, I have listened to scores of speeches and pored through a veritable cascade of articles dealing in the most general terms with the need for innovation and imagination in developing new minds of mental health personnel. I submit that the time for speech-making is over and that, in the words of the late Father Divine, we stop generalizing and begin to "tangibilitate."
Some of this hard thinking and planning has been going on within the various advisory training subcommitees of the National Institute of Mental Health since 1964. These efforts resulted in a document prepared in October of this year by a coordinating panel representing all the mental health training subcommittees which serve the National Institute of Mental Health. In the amount of time at my disposal I cannot present all of the thoughtful, practical recommendations of that panel, but I would like to highlight a few of them because they are highly relevant to the manpower situation here in the state of Washington.
1. There was a clear recognition on the part of the panel that resistances to any changes in current jurisdictional control over mental health manpower training were both fierce and formidible. It was the overwhelming consensus of the members of the NIMH panel that mental health professionals, most of whom are wedded to the status quo, offer little promise in developing and experimenting with new kinds of manpower. For example, leaders of the extant mental health professions frequently restrict their discussions to suggestions for additional categories of sub-professionals—in other words, lower forms of the human species who will be subservient to the professionals and who will, at the same time, increase the status of these professionals.
Noting that “a certain academic atmosphere of reprisal against change in discipline patterns for services and training existed", the coordinating panel recommended substantial research support to projects designed to delineate and propose solutions to the manifold barriers to innovation in training,
2. There was much discussion in the document of the feasibility of establishing a National Mental Health Training Service Center which would concentrate upon both the research necessary to define new manpower roles and upon the support of specific training projects for these people. It was suggested that this
center might be developed along the lines of the Foreign Service Academy, and that the setting of the center or institute might well be within a consortium arrangement of universities. In a further radical departure, the panel proposed that such a center train all categories of mental health personnel together, with the training programs geared to the broadest possible conceptualization of community mental health. In such an experimental, inter-disciplinary center, people in unions, housing, the poverty program, Alcoholics Anonymous, etc., would be brought together to learn and to exchange information as to ways in which people cope with severe stresses without professional help.
3. Support the work of, and do research on the job spectrum of selected individuals such as directors of small town community mental health centers in areas where very little orthodox professional help is available.
4. Integrate mental health training with such broad programs as Manpower Development and Training, Project Head Start, the Office of Economic Opportunity and countless others which are providing limited, directive training so that previously unskilled people can be of service to those in need.
5. Establish career development awards for outstanding individuals who would devote full time and attention to exploiting and expl ng innovative ideas related to training.
6. Develop a procedure to promote innovation by establishing a flexible financial pool to provide risk capital for certain types of broad-scale innovation. This recommendation stemmed directly out of the panel's belief that the present rigid mechanisms of support tend to inhibit individuals with creative ideas from applying for grants. It was further suggested that a good deal of mental health training could be done outside of the university setting and that by doing so, one could bypass sterile curricula and academic jurisdictional empires.
At a meeting in November of this year, the National Advisory Mental Health Council devoted an entire day to a discussion of the crisis in mental health manpower, with particular emphasis upon the recommendations of the aforementioned coordinating panel on training. It appointed a subcommittee of three members, and since your own Dr. Charles Strother and I comprised two-thirds of the subcommittee, we came forth with a very strong policy declaration which the Council unanimously adopted :
"In light of the documented need and enormous demand for mental health seryices, and the momentum of the community mental health centers program, there also is an immediate requirement for strengthening and enlarging the mental health manpower pool through innovative and imaginative development of new manpower sources. This includes the possibility of new types of mental health workers, and the utilization of all educational resources including high schools, junior colleges, universities, technical schools, and graduate programs.
"In order to enlarge the manpower pool, emphasis must be placed on the following: (a) the definition and development of patterns of service that will make optimal use of new types of personnel ; (b) the development and financial support of appropriate educational programs for such personnel ; (c) the development of methods of supervision that will insure maintenance of adequate professional standards."
I am aware that you have been giving considerable attention to the mental health manpower situation here in Washington. I have recently re-read the texts of the papers of your November, 1963 Discussion in Depth Conference on Mental Health Manpower; I am more impressed today than I was a couple of years ago with the pioneering nature of the thinking at that conference. For example, Dr. Robert Hewitt, then Director of the Western Interstate Commission on Higher Education mental health program, pegged his whole presentation around the point that the existing mental health disciplines excluded thousands of people who could be trained to work with the mentally ill. He proposed a new personnel yardstick: "What are the vital things to do to restore people to the community"? He suggested that we develop new job descriptions which would conform to these realistic needs rather than to an academic delineation of professional and sub-professional roles.
Even more radical and innovative in its thinking was the paper delivered by Dr. Garrett Heyns, then your distinguished Director of the Department of Institutions and now the Executive Director of the Joint Commission on Correctional Manpower and Training. Appropriately entitled “Training for What?”', the
Heyns presentation pointed out a number of mental health areas where no training curriculum existed. As as example, he cited the fact that no college curriculum existed to prepare students to function as full time directors of volunteers in either hospital or other mental health settings. In the burgeoning field of industrial therapy, he noted the existence of only one college curriculum, and for recreational leaders only six college curricula. Stressing the vital role of inservice manpower education, he wondered "why there has not been the development of curricula in graduate programs which would more specifically prepare persons to work as directors and instructors in inservice education programs."
Concluding his talk, he suggested that university faculties come out of the ivory tower, visit mental health institutions and agencies to find out what kinds of people were needed, and then work with these agencies in formulating job descriptions and in developing new training curricula.
I am fully aware of the fact that there are a few places in the country where new kinds of personnel are being trained and used quite effectively. In Washington, D.C., where I live, we are using trained housewives whose own children have completed school in key roles in well baby clinics, in our Children's Hospital, etc. In several states in the country-notably Illinois, Indiana and Kansaschild care workers who have had a formal junior college course, or merely intensive on-the-job training, are being used with great success. In New York City, expediters are being used as a personnel bridge between a mental hospital, several neighborhood mental health centers and the ethnic minorities served by these facilities. Arizona is about to launch a program under which it will place hospital-community respresentatives in various parts of the state to serve as a bridge between its one mental hospital and the patients and their families. Several state hospitals are beginning to train and use expediters who will be assigned a specific number of ward patients and will be responsible for interpreting their treatment and other needs to the now remote central administration of the hospital.
These state and local efforts are heartening, but I submit that there is a broad need for a national effort in planning for the recruitment, training and utilization of many new kinds of mental health personnel. At this point in time, very little thinking has gone into this staggering but exciting challenge. However, the Southern Regional Education Board, a compact of 15 Southern states, has not only held an exciting conference on the cooperative regional training of new kinds of mental health personnel, but is also developing hard data on the people being served in the various components of the community mental health program, what specific jobs the helping professions carry out in these centers, and what additional kinds of people are needed to serve present and future patient needs. Later this month, the SREB will hold a conference on the role of the community mental health center in teaching people how to work in community mental health.
In concluding this paper, I would like to share with you some of the challenging new ideas and suggestions which have been developed out of these various conferences within the past year.
The most heartening development has been the formulation of an increasingly precise articulation of what we are looking for when we talk of new kinds of mental health personnel. There is a growing recognition that individuals possessing less than complete professional training can serve an important role in helping persons who are experiencing emotional distress or mental disabilities. In other words, individuals with differing levels of training can provide important services to people in need of help.
At the aforementioned SREB conference, a fairly sophisticated group of more than 60 people involved in training generally agreed that what we are looking for is a middle level mental health worker who can perform many of the tasks now done by professionals. It was pointed out that the concept of the middle level worker had been accepted quite widely in the field of physical medicine over the past decade; the associate nurse, the practical nurse, medical and dental technicians, office assistants, X-ray technicians and other para-medical workers were cited as examples.
Three broad categories of mental health workers were identified by the conference delegates :
1. Innovative roles and functions, i.e. new occupations.
2. Generalists (“Human Services Technicians” was suggested as a possible definition.)
The designation "sub-professional" is perjorative and condescending in its status implications, and I am most happy that the SREB conference delegates concentrated their major hopes upon the innovative and generalist areas. The fact that these two types of workers are not identified with any single professional group is, to my way of thinking, an enormous virture. Innovation is always difficult; I am fully aware that job descriptions for new types of middle level mental health workers will require a lot of work and experimentation. But, as one conference delegate pointed out, we are not engaged in formulating à description of an all-purpose mental health worker, but rather designing specifications for particular kinds of workers—child care specialists, therapy workers, counsellors of alcoholics, interviewers, data gatherers, nursery school aides, research assistants, and so on.
We are not exactly walking in the wilderness in this area. A questionnaire gent to Mental Health Workers in Florida, VISTA full time workers in West Virginia and assorted workers in other mental health programs revealed the kinds of mental health duties actually being performed now by people who think of themselves as community mental health workers. The training of these people ranges from a high school diploma only to a Master's Degree in a specialty. It is illustrative to list some of the tasks these workers currently perform :
1. Does individual counselling.
families after hospitalization.
portation to clinics, for living needs, for medication, etc. 7. Assists patients to find living accommodations, homemaker services, etc. 8. Assists patients with legal restoration procedures. 9. Makes case investigations for county judge. 10. Serves as liaison with physicians and county health officers regarding
admissions and releases. 11. Does home investigations for hospital staff. 12. Serves as liaison with ministers, welfare officers, employers, vocational
counsellors regarding restoration of patients. 13. Works with school staffs—teachers, principals, guidance counsellors
regarding problem children. 14. Serves as liaison between clinic and outlying counties, other agències,
etc. During the past year, there has been much discussion of the role of the junior or community college in providing training for middle level mental health work
There are approximately 500 junior colleges in the country now, with a total enrollment of a million and a quarter students. The junior college move. ment is growing so rapidly that by 1972 it is predicted that more than two million students will be enrolled in these colleges. Furthermore, many junior colleges are adding a wide variety of occupational training programs to their curricula. For example, 180 colleges now offer a two-year Associate Degree in Nursing program; thousands of graduates have already been placed in hospitals throughout the country.
Providing the training is only the first step in this massive effort. A number of training directors at the SREB conference pointed out that until mental health agencies provided positions with sufficient status and adequate salaries, recruitment would continue to be difficult. For example, Dr. John E. True, Associate Director of the Purdue University experimental two-year program for mental health workers, pointed out that his program had not been flooded with applicants.
A number of conference delegates emphasized the necessity for a more aggressive recruitment program among married women, domestic workers, the unskilled and the educational drop-outs. Poverty and juvenile delinquency programs in various parts of the nation use many of these people to excellent advantage, but the mental health field is still too rigid and stuffy to seek converts from these groups.
Finally, for the purpose of further discussion at this meeting, I submit for your attention a shopping list of steps which must be taken in the next few years if we are to recruit the thousands of mental health workers we need in our vastly expanding mental health programs: