again in 1965 in support of the Community Mental Health Centers Amendments to provide funds for the initial staffing of mental health centers. We appear again today because of our continuing interest in this vital and exciting program. The people of the Nation are indeed indebted to the late President Kennedy for his imaginative recommendations which formed the basis for the mental health program, the extension of which this committee now has under consideration. Mental health is indeed America's number one health problem. One out of every 12 Americans is now being hospitalized for mental illness at some time during his life. By providing early diagnosis and early treatment on an out-patient basis through the Community Mental Health Centers, this frightful toll can be substantially reduced. About one-half of the hospital beds in this country are used in treatment of the mentally ill. Through early diagnosis and treatment, many people who would otherwise require hospitalization can be kept on their feet, on their jobs, and in their families and in their communities.

Available evidence indicates early diagnosis and treatment on an out-patient basis can greatly reduce hospitalization for mental illness. The experience of the Massachusetts Mental Health Center, one of our older out-patient programs, is an example. In 1940, only 700 of the 3,171 patients were admitted as out-patients before the emphasis was placed on out-patient treatment. In 1961, this ratio was reversed: only 700 of 3,700 patients needed hospitalization and only 40 of the 700 had to be committed to State mental institutions.

We, in the AFL-CIO, have a very direct interest in this program. Up until the passage of this legislation, workers suffering from mental illness have very rarely received any kind of treatment-good, bad, or indifferent. This has been true, because the overwhelming bulk of our mentally ill have simply been institutionalized, many of them in city and State hospitals where they received mainly custodial care rather than a program of active therapy. Out-patient services have generally been limited to the upper and upper-middle income groups which could afford treatment on a face-to-face basis with a private psychiatrist or psychoanalyst.

This situation is currently changing, and new therapeutic techniques such as drug therapy, group and family therapy, role playing, work therapy, and so forth, show great promise of providing effective treatment for more people at reasonable cost. Our experience with mental health programs that have been negotiated by some of our affiliates clearly illustrates the need to make provision for out-patient facilities. Negotiating money to pay for treatment is not enough. The treatment a member may elect to purchase may not be appropriate or may be prohibitively expensive, such as face-to-face therapy by a private psychologist. We wish, therefore, to emphasize that the initial contact the person needing treatment should make should be with the community mental health center where his condition can be diagnosed and a course of treatment outlined from among a wide range of therapeutic procedures.

Such a program is that of the Retail Clerks in Los Angeles, where psychiatric care is rendered at several centers which are open day and night. The union's welfare fund contracts for the service on a prepaid basis and the membership is encouraged to use the plan

through the union's official journal and through their educational programs.

The Retail Clerks mental health program is built upon four basic principles: (1) immediate service (no waiting lists); (2) continuity of care; (3) flexibility of treatment approaches and methods; (4) comprehensiveness of care. Face-to-face therapy is provided when deemed appropriate, but by stressing early treatment the more expensive therapeutic methods have been minimized. The important thing is that such a full range of services can only be made available through a unified clinical and administrative program. This comprehensive mental health program is financed by a 2 cents per hour employer contribution to the health and welfare fund and by a $2 per-visit fee.

The great promise of the Community Mental Health Centers Act, in our opinion, is that it will enable our affiliates to bargain with employers for similar programs wherever there is a mental health center which could provide the necessary services.

The Community Mental Health Centers Act, as amended, holds great promise for the future, but the program is only in its infancy. As of March 1967, grants totaling about $66 million had been made to approximately 160 mental health centers in 46 jurisdictions to serve a population of some 27 million. H.R. 6431 extends through fiscal 1972 authorization for facilities and staffing of the community health centers. For fiscal year 1968, $50 million is authorized for facilities as compared to $65 million for 1967. The authorization for staffing is $30 million. We believe both amounts should be increased. We should accelerate the program toward the goal of having as many mental health centers as are necessary in order that every person in the United States could have access to a mental health center by 1975. Thank you, Mr. Chairman.

Mr. JARMAN. Thank you very much, Mr. Seidman.

At the end of your statement you indicate that you think amounts in the bill should be increased. Of course, in the bill there is an openend provision setting out "and such sums as may be necessary for the next 4 fiscal years." The committee will be interested in any concrete and definite recommendations that might be made to it as to what the figures should be, because there is certainly thinking on the committee that the amounts should be pinpointed in detail rather than leaving it as an open-end provision.

So that any evidence that you might care to furnish us on what you think the authorization should be would be considered by the committee.

Mr. SEIDMAN. Mr. Chairman, of course, we are not in a position to give you a pinpointed figure as to what this might be.

Mr. JARMAN. I might say that I didn't have in mind necessarily that you do so this morning; but if you have evidence to submit on that, submit it to the committee.

Mr. SEIDMAN. I could be very brief in stating what our recommendation would be. Our feeling is, that the original goal of 2,000 mental health centers throughout the country is one which should be reached by 1975, and we think therefore that the amount which is set forth in this bill for 1968 is inadequate. We have no recommendation as to the precise additional amount, but we think it should be

substantially greater not only in fiscal year 1968, but even more so in the years ahead. Because we think that the tooling up phase of this program will have been completed by that time, and that the necessary preparations and construction of centers can go forward more rapidly in the ensuing years.

Mr. JARMAN. Thank you very much.

Mr. Satterfield.

Mr. SATTERFIELD. No questions, Mr. Chairman.

Mr. JARMAN. Mr. Springer.

Mr. SPRINGER. No questions.
Mr. JARMAN. Dr. Carter.

Mr. CARTER. No questions.

Mr. JARMAN. Thank you very much for contributing to the hearing. Our next witness this morning is Dr. Jack Ewalt, of the American Psychiatric Association; accompanied by Mr. Mike Gorman, of the National Committee Against Mental Illness.

I would like to comment that Mr. Gorman is a longtime friend, dating back to Oklahoma days when he was active in newspaper work and did a very comprehensive study of mental illness in our part of the country.

STATEMENT OF DR. JACK EWALT, AMERICAN PSYCHIATRIC ASSOCIATION; ACCOMPANIED BY MIKE GORMAN, EXECUTIVE DIRECTOR, NATIONAL COMMITTEE AGAINST MENTAL ILLNESS

Mr. GORMAN. I thank the Chairman.

Dr. EWALT. It is an honor, sir, to appear before the committee in support of H.R. 6431. I have a prepared statement which I shall not read. I will try to talk very briefly, at least for a psychiatrist, and try to answer any questions.

Mr. JARMAN. Dr. Ewalt, I also would like to mention the fact that you have served very efficiently as staff director for the Joint Commission on Mental Illness and Health.

Dr. EWALT. Thank you.

Currently we have less than 200 of these mental health centers under construction across the country. If we are to give adequate service of a minimal sort to our 200 million citizens by 1975, we will have to have about 2,000 of these. It takes time and effort to plan these things and raise the local funds which represent about $3 for every Federal dollar expended. It takes time to make the plans that will meet the Federal criteria. The program should accelerate so that by 1970 we will be able to have about 500 of these centers and then double that number in the following 5 years, if we can get adequate support.

In the past years, we have made a great deal of progress. We have the Joint Commission Study, which was authorized under the Eisenhower administration and completed under the Kennedy administration. We have the Kennedy Mental Health Plan, and the States have made a lot of plans.

We have made much progress in the ways we treat patients. You have heard a lot about milieu therapy, the importance of the surroundings to patients; about the flexibility of care-not making them stay

all day or night if they only need part of the day or night to be cared for; the use of group therapy and the use of other professionals as well as psychiatrists.

I will just list one or two highlights. I think it is significant that now more patients are admitted to general hospitals than to all other hospitals combined. The number of mental patients admitted each year increases, but the number discharged also increases. So that over the last 10 years we have reduced the population of these hospitals by about 20 percent by the application of these new methods. That is a very significant figure, because if the hospitals had continued to grow at the rate they had before, rather than decreasing in population, figuring the construction costs of $20,000 a bed, it would have been $412 billion spent on brick and mortar that we are not spending today. Mr. Seidman mentioned the Massachusetts Mental Health Center where I make my living. Last year in this hospital (where we admit about 900 a year to the hospital and between 4,000 and 5,000 a year to the clinic, and take the very acute, difficult patients as they come off the street) we certainly didn't "cure" everybody, but we only sent on for long-term hospitalization 1.7 percent of the patients we admitted. We were proud in years past that we have only committed 20 percent of our patients. So we have made a lot of progress in how to do our jobs better, and I don't think there is anything we do that could not be replicated by any well-staffed and well-run mental health center anywhere in the country.

A the end of June 1966 there were 93 centers in 43 States underway. We had spent most of the money made available. I think there are 125 centers under construction. We can't possibly go forward if we don't have authorization for the extension of these programs.

Mind you, the expansion will have to accelerate as the years go on, and we are not magicians, but with expansion I think we can very shortly cut down on the number of people cared for. And these people, of course, in some percentage, will become productive citizens and taxpayers rather than consumers of services.

I think at this time I would like to again emphasize that the money that we get from the Federal Government is really pump-priming money and it is essential. So far 1 Federal dollar has mobilized about 3 private dollars, and not all of this money has come from the States. Mr. Gorman has the figures, but I think about 40 percent of the matching funds comes from non-Government or private sources.

This is, indeed, a very important piece of legislation for the public welfare. I think I will stop at this point. I have submitted the written statement, and I will be prepared to answer questions. Mr. Gorman might want to say something.

Mr. GORMAN. Mr. Chairman, I thank you for that gracious introduction. Mr. Springer, Mr. Satterfield, and Dr. Carter, after listening to yesterday's testimony by the administration on H.R. 6431, introduced by Mr. Staggers and others, I have decided to testify in an attempt to bring to this committee some sense of urgency concerning the legislation before it.

I want to address myself to your question about the moneys where the administration is vague about "such sums as may be required over the next 4 years." I have some fairly precise ideas. I serve currently

as a member of the National Mental Health Advisory Council. This is the second time I have been appointed to that job. I don't know why. I was originally recommended by President Kennedy, and then by President Johnson. I would like to bring to this committee, if I may, our idea of the financial needs and potential of this program. Now I speak from a background, if I may say so, of 22 years, going back to the sovereign State of Oklahoma when you and I were youngand you look young now, and I feel old, Mr. Jarman. I testified before this very distinguished committee as a newspaper reporter, in 1946, before Percy Priest on behalf of the legislation which created the National Institute of Mental Health:

1. The administration bill proposes $50 million for construction of mental health centers in the coming year and "such sums as may be necessary during the following 4 years." When asked for the actual sum necessary to implement the program during the subsequent 4 years, the administration witnesses promised to supply figures to the committee at a later date. Under Secretary Cohen so testified yesterday. I know the reason for this. I have been in Washington 17 years, so that I have a suspicion that the Bureau of the Budget has put a clamp on these figures, and I understand the restraints under which Mr. Cohen had to testify yesterday and I sympathize. I am delighted that I don't have the same restraints.

Mr. Chairman, I don't see any point in coming before this distinguished committee with a 5-year bill which includes figures for only the first year. I submit that this is not being fully frank with the members of this committee, who want the fullest information. I am again not criticizing the administration, but I think, sir, I am stating a fact.

Let me recite a brief history of this legislation which you of course know, but I can recapitulate. All of you were members of the committee going back to 1963, when we first passed the legislation, except the gentleman from Kentucky.

In 1963 President Kennedy proposed a 5-year program for construction of mental health centers costing a total of $330 million. The funds were to be allotted as follows: $35 million in the first year; $50 million in the second year: $65 million in the third year: $80 million in the fourth year; and $100 million in the last year. These are the exact figures which he recommended. The Senate in 1963 passed a bill authorizing $230 million for centers construction, eliminating the fifth year of the program.

A few months later, the House passed a bill for 3 years eliminating both the fourth and fifth years. The final bill provided only $150 million over a 3-year period for construction of centers. I am not going into the staffing, because it is too complicated. I use construction as an example-$35 million for the first year, $50 million the second year, and $65 million the third year. These were the authorized figures under the 1963 legislation.

In actual fact, however, we have not even achieved the $150 million level. For example, although the Congress had authorized $65 million for the third year (fiscal 1967), the current year which we are now in, the administration asked for only $50 million and that is all we got.