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a willingness to minimize presumed prerogatives, professional people and lay board members can find ways of distributing responsibility that will substantially increase the effectiveness of a center's program. The tradition, of course, is that the director of a mental health center must be a psychiatrist. This is often the best solution, but other solutions may often be equally sensible or more so. A social worker, a psychologist, a pediatrician, a nurse, a public health administrator might be a more competent di ctor for a particular center.
The issue of clinical responsibility is more complex but the principle is the same: competence rather than professional identification should be the governing concern. The administration of drugs is clearly a competence-linked responsibility of a physician. Diagnostic testing is normally a competence-linked responsibility of a psychologist ; however, there may be situations in which a psychiatrist or a social worker may have the competence to get the job done well. Responsibility for psychotherapy may be assumed by a social worker, psychiatrist, psychologist, or other trained person. The director of training or of research could reasonably come from one of a number of disciplines. The responsible community member, to whom these guidelines are addressed, should assure himself that there is a functional relationship in each instance between individual competence and the job to be done:
This issue has been given explicit and responsible attention by the Congress of the United States in its debates and hearings on the bill that authorizes funds for staffing community mental health centers. The intent of Congress is clear. As the Senate Committee on Labor and Public Welfare states in its report on the bill (Rept. No. 366, to accompany H.R. 2985, submitted June 24, 1965) :
There is no intent in any way in this bill to discriminate against any mental health professional group from carrying out its full potential within the realm of its recognized competence. Even further it is hoped that new and innovative tasks and roles will evolve from the broadly based concept of the community mental health services. Specifically, overall leadership of a community mental health center program may be carried out by any one of the major mental health professions. Many professions have vital roles to play in the prevention, treatment and rehabilitation of patients with
mental illnesses. Similar legislative intent was established in the debate on the measure in the House of Representatives.
Community members responsible for mental health centers should not countenance absentee directorships by which the fiction of responsibility is sustained while actual responsibility and initiative are dissipated. This is a device for the serving of professions, not of people.
The comprehensive community mental health center should provide a formal training program. The need for centers to innovate in the development or reallocation of professional and subprofessional roles, which has been stressed above in line with Congressional intent, requires in every center an active and imaginative training program in which staff members can gain competence in their new roles.
The larger centers will also have the self-interested obligation to participate in the training of other professionals. Well-supervised professional trainees not only contribute to the services of a center; their presence and the center's training responsibilities to them promote a desirable atmosphere of selfexamination and openness to new ideas.
There should be a director of training who would be responsible for: (a) inservice training of the staff of the center, in the minimum case; and, in the larger centers, (b) center-sponsored training programs for a range of professional groups, including internships, field placements, po ctoral fellow ps, and partial or complete residency programs; and (c) university-sponsored training programs that require the facilities of the center to give their students practical experience. Between 5% and 10% of the center's budget should be explicitly allocated to training.
PROGRAM EVALUATION AND RESEARCH
The comprehensive community mental health center should devote an explicit portion of its less budget to program evaluation. All centers should inculcate in their staff attention to and respect for research findings; the larger centers have
an obligation to set a high priority on basic research and to give formal recognition to research as a legitimate part of the duties of staff members. In the 11 "model" community programs that have been cited previously, both program evaluation and basic research are rarities; staff members are commonly overburdened by their service obligations. That their mental health services continue to emphasize one-to-one psychotherapy with middle-class adults may partly result from the small attention that their programs give to the evaluative study of program effectiveness. The programs of social agencies are seldom evaluated systematically and tend to continue in operation simply because they exist and no one has data to demonstrate whether they are useful or not. In this respect the model programs seem to be no better.
The whole burden of the preceding recommendations, with their emphasis on innovation and experimentation, cries out for substantial investment in program evaluation. Only through explicit appraisal of program effects can worthy approaches be retained and refined, ineffective ones dropped. Evaluative monitoring of program achievements may vary, of course, from the relatively informal to the systematic and quantitative, depending on the importance of the issue, the availability of resources, and the willingness of those responsible to take the risks of substituting informed judgment for evidence.
One approach to program evaluation that has been much neglected is hardheaded cost analysis. Alternative programs should be compared not only in terms of their effects, but of what they cost. Since almost any approach to service is likely to produce some good effects, mental health professionals may be too prone to use methods that they find most satisfying rather than those that yield the greatest return per dollar.
All community mental health centers need to plan for program evaluation; the larger ones should also engage in basic research on the nature and causes of mental disorder and on the processes of diagnosis, treatment, and prevention. The center that is fully integrated with its community setting will have unique opportunities to study aspects of these problems that elude investigaion in traditional clinic and hospital settings. That a major investment be made in basic research on mental health problems was the recommendation to which the Joint Commission on Mental Illness and Health gave topmost priority.
The demands of service and of research are bound to be competitive. Because research skills, too, are scarce, it is not realistic to expect every community mental health center to have a staff equipped to undertake basic research. At the very least, however, the leadership in each center should incorporate in its training program an attitude of attentiveness to research findings and of readiness to use them to innovate and change the center's practices.
The larger centers, especially those that can establish affiliation with universities, have an obligation to contribute to fundamental knowledge in the area of their program operations. Such centers will normally have a director of research and a sub tantial budget allocation in support of research, to be supplemented by grants from foundations and governmental agencies. By encouraging their staff members to engage in basic studies (and they must be sedulously protected from encroaching service obligations if they are to do so), these centers can make an appropriate return to the common fund of scientific and professional knowledge upon which they draw; they also serve their own more immediate interests in attracting and retaining top-quality staff and in maintaining an atmosphere in which creativeness can thrive. As a rough yardstick, every center should devote between 5% and 10% of its budget to program evaluation and research,
VARIETY, FLEXIBILITY, AND REALISM Since the plan for a comprehensive community mental health center must allocate scarce resources according to carefully considered priorities tailored to the unique situation of the particular community, iride variation among plans is to be expected and is desirable. Since decisions are fallible and community needs and oportunities change, provision should be made for flexibility and change in programs, including periodic review of policies and operations. In spite of the stress in these guidelines on ideal requirements as touchstones against which particular plans can be appraised. no single comprehensive center can be all things to all men. Planning must be done in a realistic context of limited resources and imperfect human talent as well as of carefully evaluated community needs, and many hard decisions will have to be made in setting priorities.
In rural areas, especially, major alterations in the current blueprint would seem to be called for if needed services are to be provided. As a result, the comprehensive community mental health centers that emerge should be as unique as the communities to whose needs and opportunities they are responsive. This is all to the good, for as it has been repeatedly emphasized, there is no well-tested and prefabricated model to put into automatic operation. Variety among centers is required for suitability to local situations; it is desirable also for the richer experience that it should yield for the guidance of future programing.
The need for innovation has been stressed; the other side of the same coin is the need for adaptability to the lessons of experience and to changing requirements of the community. Flexibility and adaptiveness as a characteristic of social agencies does not just happen; it must be planned for. The natural course of events is for organizations to maintain themselves with as little change as possible, and there is no one more conservative than the proponent of an established, once-radical departure. Plans for the new centers should therefore provide for the periodic self-review of policies and operations, with participation by staff at all levels, and by outside consultants if possible. To the extent that active program evaluation is built intrinsically into the functioning of the center, the review process should be facilitated, and intelligent flexibility of policy promoted. Self-review by the center staff should feed into general review by the responsible board of community leaders, in which the board satisfies itself concerning the adequacy with which the policies that it has set have been carried out.
This final recommendation returns once more to the theme, introduced at the outset, that has been implicit in the entire discussion: the responsibility of the community for the quality and adequacy of the mental health services that it gets. The opportunities are now open for communities to employ the mechanism of the comprehensive mental health center to take major strides toward more intelligent, humane, and effective provision for their people. If communities rise to this opportunity, the implications for the national problem of mental health and for the quality of American life are immense.
Mr. JARMAN. Doctor, we are going to have to halt.
Mr. BRAYFIELD. Let me terminate my testimony right now and thank you very much for the opportunity, and I will file my additional remarks for the record tomorrow.
Mr. JARMAN. We appreciate your statement very much and appreciate your being with us.
I am sorry about the time element.
Mr. JARMAN. You can add to your testimony in the record and certainly we will be studying it before the committee acts.
Mr. BRAYFIELD. Thank you, Mr. Chairman. (Dr. Brayfield's prepared statement follows:) STATEMENT OF DR. ARTHUR H, BRAYFIELD, EXECUTIVE OFFICER, AMERICAN
PSYCHOLOGICAL ASSOCIATION Mr. Chairman and Members of the Subcommittee: My name is Dr. Arthur H. Brayfield. I am Executive Officer of the American Psychological Association, the national organization of psychologists with 26,000 members, which has its headquarters at 1200 17th Street, N.W., Washington, D.C. I am accompanied by Dr. John J. McMillan, Administrative Officer for Professional Affairs. I welcome the opportunity to testify before this Subcommittee today in support of H.R. 6431. Psychology and psychologists are deeply involved in mental health services and programs. As a behavioral science discipline, psychology provides the fundamental basis for the work of all mental health professionals-psychiatrists, social workers and nurses, as well as psychologists. As a behavioral science profession, psychology contributes a significant share of the manpower available to the field of mental health. Based on data from the National Register of Scientific and Professional Personnel and from NIMH studies, we estimate that in 1964 approximately 8,000 psychologists provided some 13 million man-hours per year of direct clinical services, primarily the diagnosis and treatment of mental disorders, and another 7,500 psychologists spent another
13 million man-hours per year of psychological effort, primarily teaching and research, related to mental health. This total of 26 million man-hours compares, for example, to an estimated 27 million man-hours per year contributed by psychiatrists. The latter contribute a considerably higher proportion of their 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 non-profit 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 health programs.
In March 1966, the American Psychological Association adopted an official position paper titled "The Community and the Community Mental Health Center' offering guidelines and discussion 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". Because of the widespread public interest this paper has attracted and because of its relevance to the legislation, H.R. 6431, which is the subject of these hearings, I respectfully request that it be made a part of the official hearings record.
As it did in formal testimony in 1963 and again in 1965, the American Psychological Association supports the goals of the community mental health cen. ters legislation.
The first priority of the community mental health centers program is to make hospital beds and care readily available in settings close to home to people whose disturbed behavior either incapacitates them or causes concern to themselves, their family, their friends and employers, and the community at large. Thus the basic care facilities of the formerly geographically-remote state mental hospital are now in the process of being located in local and regional population centers. More beds and, hopefully, more care will become available as this program develops. The psychotic and the acutely disturbed members of the community will find help near at hand. The achievement of this limited but important objective will be a considerable accomplishment.
The community mental health centers program seeks also to make more readily available in communities throughout the nation forms of care and treatment which heretofore have been tried out on a more limited basis or in a relatively few places. Thus provisions are being made to incorporate day care programs, halfway houses, suicide centers, emergency or "walk-in” services, and the like into the community center programs. These already existing practices and procedures for dealing with the acutely and severely disturbed may thus become more generally available.
However, the most significant and exciting challenge and opportunity for the community mental health centers program does not revolve around this medically traditional inpatient-outpatient care program. The boldness and the promise of the enabling and supporting legislation passed by the Congress in 1963 and 1965, resides in its potential for obtaining a breadth and depth of local community involvement that would get to the crux of behavior disorder. For mental disorder is neither the private misery of the individual nor a personal problem solely of bis making; it frequently has its roots, as well as its effects, in the social relationships and the social settings or systems of which the individual is a part.
On this view, the community mental health center's major undertaking will be to strengthen the totality of the community's investment in the human effectiveness of its members. The schools, the courts, the churches, business and industry are among the major social arenas in which the special perspective and special competencies of the center should find expression. For the disturbed or troubled 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. And as we gain new knowledge bearing on the design of human environments for effective human functioning we eventually will be able to come to terms with the basic problem of prevention. But, beyond that, our ultimate goal, in a viable democracy, must be no less than to provide for the discovery, development, and wise utilization of all our human resources. Meet
ing the immediate needs of the severely disturbed is prologue to the achievement of this national goal.
The other great opportunity and challenge is to devote a necessary and substantial share of the total community mental health effort to children and youth. They are our resources for the future--our potentially productive contributors to the quality of American life-our major responsibility for the present. They must not be overlooked.
If we settle simply for a "mopping-up" or "picking up the pieces" operation in our community mental health programs, we settle for too little.
So it is the promise and the prospect, the anticipation of things to come, that especially commands our interest and mobilizes our efforts as psychologists. The beginning has been made, the effort is underway. To sustain its gathering momentum, we endorse and support the provisions of H.R. 6431.
Thank you for the opportunity to appear here today.
(Additional material submitted by the American Psychological Association may be found in the committee files.)
Mr. JARMAN. This concludes our hearings on the bill and we appreciate all of you appearing before us.
New York, N.Y., April 7, 1967.
DEAR MR. CHAIRMAN : The American Public Health Association is privileged to support the principles and objectives included in H.R. 6431, which you have introduced, and which would extend the authority of the Community Mental Health Centers Act. As stated in our testimony to your Committee in 1963, the motives and objectives of this Act, which at that time was a legislative proposal, merited the full support of everyone who was interested in or concerned about the problems of mental health. We stated then that the proportions and scope of the problems involved in the treatment and cure of mental disorders made it apparent that there is a continuing need for a redirection of efforts relative to the control of mental disorders. We are convinced that effective treatment of the mentally ill is facilitated when patients are removed from the huge and impersonal mental hospital. Mental health services should be made a part of the total medical capabilities of communities.
The bill H.R. 6431 is basically an extension of the authority originally granted. Those features of the bill which are administrative in nature we will not comment upon. Is is our considered judgment that experience since the enactment of the Community Mental Health Centers Act has provided ample evidence of the validity of this endeavor. The progress to date, as might well be expected, is not as comprehensive nor far-reaching as could be hoped but it most certainly is headed in the proper direction. This this nation in an enilghtened age could not continue to countenance a system of treatment that was medieval in concept has been proven, even if to a limited degree, during the few short years of experience under the Community Mental Health Centers Act. We are convinced that even greater potentials remains to be realized. The statement of your Committee contained in the Committee's report dated August 21, 1963, which related to the previously accepted method of providing what had been termed as "care for the mentally ill," was most eloquent. In this context the report stated, "Either we must develop the quantity and quality of community services which will ultimately replace these institutions, or we will have to undertake a massive program to strengthen State mental hospitals.” It was further stated that your Committee was of the opinion that there was a need to develop new methods of treatment, that there was a lessening in our disposition to reject and isolate the sufferers of mental illness, and that all of these factors argued strongly for the