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1. A more incisive analysis of the total personnel needs in mental health is required for a clearer understanding of the specific contributions which can be made by middle level mental health workers.
2. A great deal of further work is needed in sharpening the role definition and specific competencies of the mental health worker. This is particularly necessary for the generalist, or "people worker", as he was described at the SREB conference.
3. The problem of establishing uniform standards of training and licensing or certification of the graduate must be squarely faced. Rigid Civil Service and personnel standards must be opened to new job classifications.
4. A major task involves improving the image of the mental health worker. Dr. Norman C. Harris, Professor of Technical Education at the University of Michigan, remarked recently that despite the great national need for semiprofessional and technical workers, these occupations were still down-graded in our society. As he said :
“This lack of status exacerbates the problem and even where community colleges have provided excellent facilities and instrumental programs, enrollments are seldom up to expectations."
It has been suggested that voluntary agencies such as the National Association for Mental Health take steps to correct the distorted and out-dated images the general public has of people working in a mental health setting. One specific proposal which deserves serious consideration is that a sampling survey of high school students and their families be made to determine their attitudes toward these potential mental health worker jobs.
Accomplishing the aforementioned bill of particulars will not be easy, but it can and it must be done. Dr. Kenneth Skaggs, a specialist in occupational curriculums with the American Association of Junior Colleges, summed up our present position and our future potential very nicely in a recent address to training leaders :
“We have no place to go but forward. We cannot go back and I think that we all need to realize that as the needs of society begin to crystallize, somebody is going to do the job, and God forbit that inappropriate people do the job. And unless we in the professions and we in education, the appropriate people do it, somebody else will and we will probably not like the results. We have no place to go but in the positive implementation of these things we have been talking about." .,
Mr. BRAYFIELD. Mr. Gorman, in that speech, set out the dimensions of the problem and recommended fundamental changes in approach. One of the things that interested us most was that he was critical, highly critical, I might say, in the matter of conservative professional leadership. He pointed to jurisdictional disputes and pointed to the fact that training programs in universities had been slow to change and in general he said that the professions were not meeting adequately their responsibilities.
We were so impressed by the statement we sent it out to more than 200 graduate departments of psychology. There have been jurisdictional disputes. In 1963, for example, it was necessary for psychologists to wrestle with NIMH over regulations for the 1963 legislation because they did not make possible for other nonpsychiatric mental health professionals to have leadership responsibilities in that program.
Fortunately, the picture is changing and the 1965 legislation in its legislative history explicitly recognized that positions of leadership should be filled on the basis of competence, not the basis of professional discipline.
I was interested in Dr. Donohue's presentation because he and I have had the pleasure of working together over the last several years. I remember our first exchange after serving on a committee for some time, he said, “You don't talk like a psychiatrist.”. I was pleased to be able to say to him, “You don't talk like a psychiatrist."
This is a development that is taking place.
I also note that staffing patterns advocated by Mr. Jones on behalf of HEW in 1963 in the hearing record of that time have gone by the boards as some of the testimony today indicated. But manpower is indeed in its conventional dimensions a critical problem. Psychologists, for example. We produce about 1,000 Ph. D's a year. Over the next 10 years our best estimate is it will require all of these Ph. D. psychologists simply to staff the teaching and research positions in the institutions of higher education.
This certainly means that in psychology we may not be able to make the kind of contribution that we will be expected to make. Community mental health centers do not present the only mental health professional personnel service needs. For example, the VA needs about 100 or 200 psychologists each year and the State hospitals are miserably staffed in the sense of having adequate numbers, and special clinics report the same thing, and I think the important thing to note, as questioning by Mr. Brown indicated earlier, is that there are other areas of human service that are draining off manpower:
I was down in Texas recently and the State education authority there had just issued a call for one year for 1,200 school psychologists to be added in that State. School psychology is the most rapidly growing area of psychology. You can't begin to fill the needs.
Correctional psychology, work with children, the recent Gibbon's bill calling for training of 50,000 additional child development school personnel, all indicate to us that as far as psychology is concerned we do indeed have a major manpower problem which would lead me to recommend that the NIMH training support stipend program in psychology be increased by at least a factor of five, and this is on the basis of some considered study of their present program and needs for the future.
We have an interest in new programs. In Florida, for example, Dr. Louis Cohen at the University of Florida has recently started a program for the training of mental health workers with bachelor's degrees. We have also coming up this month a jointly sponsored conference with the National Association of Social Workers which is devoted entirely to use of nonprofessional indigenous personnel in mental health capacities.
Our concern with the community mental health program has been evidenced, for example, by the adoption of the association's official position paper entitled, “The Community and the Community Mental Health Center," which is widely distributed and attracts great public interest and which I thought, in preparing this testimony, was perhaps quite relevant to the legislation under consideration and after hearing the questions of the last 2 days I would say not only is it relevant but extremely important because we have really been hearing about a quite conservatively oriented community health program and I am pleased to say I believe our approach is considerably more progressive than what is represented to date.
With your permission, Mr. Chairman, I would respectfully request that our paper be made a part of the official hearing record.
(The material referred to follows:)
THE COMMUNITY AND THE COMMUNITY MENTAL HEALTH CENTER
By M. BREWSTER SMITH' and NICHOLAS HOBBS
(This statement was adopted on March 12, 1966, by the Council of Representa
tives as an official position paper of the American Psychological Association)
Throughout the country, state and communities are readying themselves to try the "bold new approach" called for by President John F. Kennedy to help the mentally ill and, hopefully, to reduce frequency of mental disorders. The core of the plan is this: to move the care and treatment of the mentally ill back into the community so as to avoid the needless disruption of normal patterns of living, and the estrangement from these patterns, that often come from distant and prolonged hospitalization; to make the full range of help that the community has to offer readily available to the person in trouble; to increase the likelihood that trouble can be spotted and help provide early when it can do the most good; and to strengthen the resources of the community for the prevention of mental disorder.
The community-based approach to mental illness and health attracted national attention as a result of the findings of the Joint Commission on Mental Illness and Health that was established by Congress under the Mental Health Study Act of 1955. After 5 years of careful study of the nation's problems of mental illness, the Commission recommended that an end be put to the construction of large mental hospitals and that a flexible array of services be provided for the mentally ill in settings that disrupt as little as possible the patient's social relations in his community. The idea of the comprehensive community mental health center was a logical sequel.
In 1962, Congress appropriated funds to assist states in studying their needs and resources as a basis for developing comprehensive plans for mental health programs. Subsequently, in 1963, it authorized a a substantial Federal contribution toward the cost of constructing community mental health centers proposed within the framework of state mental health plans. It appropriated $35 million for use during fiscal year 1965. The authorization for 1966 is $50 million and for 1967; $65 million. Recently, in 1965, it passed legislation to pay part of the cost of staffing the centers for an initial period of 5 years. In the meantime, 50 states and three territories have been drafting programs to meet the challenge of this imaginative sequence of Federal legislation.
In all the states and territories, psychologists have joined with other professionals, and with nonprofessional people concerned with mental health, to work out plans that hold promise of mitigating the serious national problems in the area of human well-being and effectiveness. In their participation in this planning, psychologists have contributed to the medley of ideas and proposals for translating the concept of comprehensive community mental health centers into specific programs. Some of the proposals seem likely to repeat past mistakes. Others are fresh, creative, stimulating innovations that exemplify the "bold new approach" that is needed.
Since the meaning of a comprehensive community mental health center is far from self-evident, the responsible citizen needs some guidelines or principles to help him assess the adequacy of the planning that may be under way in his own community, and in which he may perhaps participate. The guidelines and discussion that are offered here are addressed to community leaders who face the problem of deciding how their communities should respond to the opportunities that are opened by the new Federal and state programs. In drafting what follows, many sources have been drawn upon: the monographs and final report of the Joint Commission, testimony presented to Congress during the consideration of relevant legislation, official brochures of the National Institute of Mental Health, publications of the American Psychiatric Association, and recommenda
1 M. Brewster Smith, Ph. D., is Professor of Psychology and Director of the Institute of Human Development at the University of California, Berkeley. He was Vice President of the Joint Commission on Mental Iness and Health and was formerly President of the Society for the Psychological Study of Social Issues and editor of the Journal of Abnormai and Social Psychology.
2 Nicholas Hobbs, Ph. D., is Provost of Vanderbilt University and Director of the John F. Kennedy Center for Research on Education and Human Development at Peabody College. He was Vice Chairman of the Board of Trustees of the Joint Commission on Mental Miness and Health and is currently President of the American Psychological Association and Vice President of the Joint Commission on Mental Health of Children.
tions from members of the American Psychological Association who have been involved in planning at local, state, and national levels.
The community mental health center, 1966 model, cannot be looked to for a unique or final solution to mental health problems : varied patterns will need to be tried, plans revised in the light of evaluated experience, rigidities avoided. Even as plans are being drawn for the first comprehensive centers under the present Federal legislation, still other bold approaches to the fostering of human effectiveness are being promulgated under the aegis of education and of economic opportunity programs. A single blueprint is bound to be inadequate and out of date at the moment it is sketched. The general approach underlying these guidelines may, it is hoped, have somewhat more enduring relevance.
Throughout, the comprehensive community mental health center is considered from the point of view of members of a community who are seeking good programs and are ultimately responsible for the kind of programs they get. The mental health professions are not to be regarded as guardians of mental health, but as agents of the community-among others—in developing and conserving its human resources and in restoring to more effective functioning people whose performance has been impaired. Professional people are valuable allies in the community's quest for the health and well-being of its members, but the responsibility for setting goals and major policies cannot be wisely delegated.
COMMUNITY INVOLVEMENT AND COMMUNITY CONTROL
For the comprehensive community mental health center to become an effective agency of the community, community control of center policy is essential. The comprehensive community mental health center represents a fundamental shift in strategy in handling mental disorders. Historically, and still too much today, the preferred solution has been to separate the mentally ill person from society, to put him out of sight and mind, until, if he is lucky, he is restored to normal functioning. According to the old way, the community abandoned its responsibility for the mental patient to the distant mental hospital. According to the new way, the community accepts responsibility to come to the aid of the citizen who is in trouble. In the proposed new pattern, the person would remain in his own community, often not even leaving his home, close to family, to friends, and to the array of professional people he needs to help him. Nor would the center wait for serious psychological problems to develop and be referred. Its program of prevention, detection, and early intervention would involve it in many aspects of community life and in many institutions not normally considered as mental health agencies: the schools, churches, playgrounds, welfare agencies, the police, industry, the courts, and community councils.
This spread of professional commitment reflects in part a new conception of what constitutes mental illness. The new concept questions the appropriateness of the term “illness" in this context, in spite of recognition that much was gained from a humanitarian viewpoint in adopting the term. Mental disorders are in significant ways different from physical illnesses. Certainly mental disorder is not the private misery of an individual; it often grows out of and usually contributes to the breakdown of normal sources of social support and understanding, especially the family. It is not just an individual who has faltered; the social systems in which he is embedded through family, school, or job, through religious affiliation or through friendship, have failed to sustain him as an effective participant.
From this view of mental disorder as rooted in the social systems in which the troubled person participates, it follows that the objective of the center staff should be to help the various social systems of which the community is composed to function in ways that develop and sustain the effectiveness of the individuals who take part in them, and to help these community systems regroup their forces to support the person who runs into trouble. The community is not just a catchment area from which patients are drawn; the task of a community mental health center goes far beyond that of purveying professional services to disordered people on a local basis.
The more closely the proposed centers become integrated with the life and institutions of their communities, the less the community can afford to turn over to mental health professionals its responsibility for guiding the center's policies. Professional standards need to be established for the centers by Federal and state authorities, but goals and basic policies are a matter for local control. A broadly based responsible board of informed leaders should help to ensure that the center serves in deed, not just in name, as a focus of the Com
munity's varied efforts on behalf of the gerater effectiveness and fulfillment of all its residents.
RANGE OF SERVICES The community mental health center is "comprehensive" in the sense that it offers, probably not under one roof, a wide range of services, including both direct care of troubled people and consultative, educational, and preventive services to the community. According to the administrative regulations issued by the United States Public Health Service, a center must offer five essential services to qualify for Federal funds under the Community Mental Health Centers Act of 1963: (a) inpatient care for people who need intensive care or treatment around the clock; (6) outpatient care for adults, children, and families; (c) partial hospitalization: at least day care and treatment for patients able to return home evenings and weekends; perhaps also night care for patients able to work but needing limited support or lacking suitable home arrangement; (d) emergency care on a 24-hour basis by one of the three services just listed; and (e) consultation and education to community agencies and professional personnel. The regulations also specify five additional services which, together with the five essential ones, “complete" the comprehensive community mental health program: (f) diagnostic service; (g) rehabilitative service including both social and vocational rehabilitation; (h) precare and aftercare, including screening of patients prior to hospital admission and home visiting or halfway houses after hospitalization; (i) training for all types of mental health personnel ; and (i) research and evaluation concerning the effectivenes of programs and the problems of mental illness and its treatment.
That the five essential services revolve around the medically traditional inpatient-outpatient core may emphasize the more traditional component of the comprehensive center idea somewhat at the expense of full justice to the new conceptions of what is crucial in community mental health. Partial hospitalization and emergency care represent highly desirable, indeed essential, extensions of the traditional clinical services in the direction of greater flexibility and less disruption in patterns of living. Yet the newer approach to community mental health through the social systems in which people are embedded (family, school, neighborhood, factory, etc.) has further implications. For the disturbed person, the goal of community mental health programs should be to help him and the social systems of which he is a member to function together as harmoniously and productively as possible. Such a goal is more practical, and more readily specified, than the elusive concept of cure, which misses the point that for much mental disorder the trouble lies not within the skin of the individual but in the interpersonal systems through which he is related to others. The emphasis in the regulations upon consultation and public education goes beyond the extension of direct patient services to open wide vistas for imaginatve experimentation,
The vanguard of the community approach to mental health seeks ways in which aspects of people's social environment can be changed in order to improve mental health significantly through impact on large groups. Just as a modern police or fire department tries to prevent the problems it must cure, so a good mental health center would look for ways of reducing the strains and troubles out of which much disorder arises. The center might conduct surveys and studies to locate the sources of these strains; it might conduct training programs for managers, for teachers, for ministers to help them deal with the problems that come to light. By providing consultation on mental health to the governing agencies of the community, to schools, courts, churches, to business and industry, the staff of the center can bring their special knowledge to bear in improving the quality of community and family life for all citizens. Consultation can also be provided to the state mental hospitals to which the community sends patients, to assist these relics of the older dispensation in finding a constructive place in the new approach to mental health. Preferably, revitalized state hospitals will become integral parts of the comprehensive service to nearby communities.
In performing this important and difficult consultative role, the mental health professionals of the center staff do not make the presumptuous and foolish claim that they know best how the institutions of a community should operate. Rather, they contribute a special perspective and special competencies that can help the agencies and institutions of community life—the agencies and institutions through which people normally sustain and realize themselves--find ways in which to perform their functions more adequately. In this endeavor, the center state needs to work in close cooperation with other key agencies that share a concern