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Thank you very much.

(Dr. Ewalt's prepared statement follows:) STATEMENT BY JACK R. EWALT, M.D., PAST PRESIDENT, AMERICAN PSYCHIATRIC ASSOCIATION, PRESENTED ON BEHALF OF THE AMERICAN PSYCHIATRIC ASSOCIATION

Mr. Chairman and mmbers of the committee, I am honored to appear once again before a distinguished committee of the Congress on behalf of the American Psychiatric Association to urge legislation which, if passed, will mark another milestone in the nation's struggle against the mental illnesses.

The issue confronting us here today is simply stated. Before the end of this fiscal year upwards of 200 community mental health centers will be under development throughout our country as the result of the Community Mental Health Centers Act. Our national goal is to achieve 500 of these centers by 1970 and 2000 by 1975 in the service of some 200 million Americans. Thus, we have run well in the first few miles of the marathon that started with President Kennedy's wholly new approach to mental illness and mental retardation, an approach that would bring the mentally ill out of the large public mental hospitals back into the main stream of medicine in their own communities. But the final goal is not yet in sight and the hardest miles are ahead. Are we going to drop out or forge ahead? That is the issue.

Speaking for our Association and its 15,000 physician members who specialize in the treatment of the mentally ill, I would leave no doubt in your mind that the extension of the community mental health center construction and staffing program is of absolutely critical importance at this stage in the history of the mentally ill in our country. In all conscience, no other course is open to us. Let me explain why I think so, for we are not dealing here with a mere matter of erecting some new buildings. It is rather a matter of whether we are to fol. low through on a wholly new concept of how we shall relate to the mentally ill and how we may nurture a mentally healthier nation.

It is an exhilarating observation that we as a people have made more progress against the mental illnesses in the past twenty years than in all the millenia that went before. Nor is it difficult to demonstrate that it has been the federal government, responding to the will of the people, that has provided the foundation stones for that progress.

One thinks back on the tremendous advances in psychiatric care generated by the Veterans Administration after World War II. There was the passage of the National Mental Health Act in 1946. In 1955, during President Eisenhower's Administration, Congress approved the Mental Health Study Act which led to the work of the Joint Commission on Mental Illness and Health. Later the stirring report of that Commission (Action for Mental Health) led directly to President Kennedy's special mental health message to the Congress in 1963. Then you appropriated funds to help the states make longrange plans for participating in a new national mental health program and concurrently offered to share with the states the expense of constructing and staffing comprehensive community health centers. More recently, the Congress made provision for extending mental health care to the elderly mentally ill in the Medicare legislation.

What has happened as a result of this stimulatory leadership at the federal level? If we were to state it in a sentence we might simply say that we have found out that most of the mentally ill can be treated in the community, providing that the community will supply an adequate range of comprehensive services for them. But we discovered this in a kind of helter-skelter way.

There were the new drugs, for example, that came our way in the 1950s. It was the first time that psychiatrists ever had some really good pills just like other doctors. These pills would cheer the depressed and calm the manics. With them we could treat many highly disturbed patients in our offices without resorting to long-term hospitalization.

At the same time we experimented successfully with new forms of psychological therapies both in hospital settings and in private practice, such as milieu therapy, group therapy, and family therapy. The idea was to get away from always treating a single patient at a time for the better part of an hour and, whenever possible and effective, deal with several patients at once in a group.

Particularly significant in the 1950s was the development of the day and night hospital idea, or part-time hospitalization. It has long since been demonstrated

that many patients can hold a job while they are treated at night, or that they can be treated during the day and return to their homes at night.

Most heartening of all, however, was the growth of short-term psychiatric care in community general hospitals. It is a striking fact that about 500 community general hospitals in our country now have psychiatric departments which admit and treat about 400,000 patients a year, about twice as many as are admitted to public mental hospitals. Many other general hospitals without separate departments also treat many mental patients, and it is probably safe to say that a halfmillion patients all told are treated yearly in these community hospitals. Moreover, a very substantial percentage of these patients have the greater part of their bills paid by some form of health insurance.

All of these developments, combined, are responsible for the fact that our public mental hospital population has declined by about 20 percent over the past decade and this in the face of a growing population and rising admission rate.

Concurrently with these auspicious changes came a gradual modification of public attitudes towards the mentally ill by way of an acceptance of their afilictions and support of a realistic national program to help them. Had we expounded the community mental health center idea twenty years ago, our words would have fallen on deaf ears. Even our brethren in other fields of medicine would not have listened. But now it is different.

Another gratifying by-product of this broad movement to bring the mentally ill back into the community and into the medical mainstream has been its effect in quickening the interest of nonpsychiatrist physicians in joining the battle against the mental illnesses. It is a striking fact that about 15,000 general practitioners or family physicians, in the past ten years, have been motivated to take postgraduate courses in psychiatry to enhance their understanding of the patients they see in everyday practice. Indeed, many of them have gone on to specialize in psychiatry. This never could have happened twenty years ago when psychiatry was so largely isolated in public mental hospitals. Psychiatry had to get back into the community where the action is. And, incidentally, every medical school in the nation today sees to it that all of its students acquire basic training in psychiatry.

As for general public attitudes about the mentally ill, there can be no doubt about citizen receptivity to the wholly new approach. I have just recently read the manuscript, soon to be published, of a scholarly survey of public attitudes among adult residents of New York City.* The survey was conducted by Columbia University in cooperation with the New York City Community Mental Health Board. The investigators found that the public was much more optimistic about the treatability of mental illness than formerly. Seven out of ten adults said that they would be willing to have former mental patients as co-workers or neighbors. Nine out of ten think that government should be spending more for mental health services, and there is widespread support for community services, especially emergency services. Interestingly, however, three out of five adults in New York City could not name a hospital that accepted mental patients and three-quarters could not name a clinic where they could go for prompt service. This suggests again how far we have to go in extending community services and educating the public as to their availability.

Moreover, this same twenty-year period has witnessed a quickened interest in psychiatric consultation from industry, the clergy, the courts, schools and colleges, social agencies and all of the others who have a special role in dealing with the troubled people of our times.

Also, twenty-seven states have enacted community mental health services acts to facilitate the development of comprehensive services at the local level.

To sum it all up, let us suppose that twenty years ago someone dear to us had developed a mental illness? What recourse did we have? If we were rich and the illness not too serious, we could look for help from the private psychiatrist or the private hospital. If the illness were severe and we were of modest to poor means, we were almost forced to turn to the public mental hospital, and with the sickening thought that it might well prove to be the end of the road for our loved one.

Now it is different. If we are affluent we can still purchase the very best in psychiatric care. But millions more of us can obtain a comparable quality

*The Public Image of Mental Health Services, Jack Elinson, Ph. D., Elena Padilla, Ph. D., and Marvin E. Parkins, M.D., Mental Health Materials Center, New York City, May 1967, 300 pp.

of care in general hospitals, and increasingly in day and night hospitals, outpatient clinics, half way houses, rehabilitation facilities, nursing homes, and the like. We can do this because more and more of these facilities are becoming available and more and more of the cost of such care is borne by third-party payments.

What I have been talking about, of course, is the community mental health center idea and how it evolved, bit by bit, over the years. If we do not appreciate that the community mental health center is not so much a building as an organization of services, then we cannot truly grasp the import of extending the construction and staffing legislation. Hence I have tried to place the whole development in its historical context.

As you know, to qualify for federal assistance every center project must incorporate five essential services an inpatient service, an outpatient service, part-time hospitalization, emergency service, and consultation service, and these services should be geared to accommodate from 75,000 to 200,000 persons. None of these services represent new ideas, as I have sought to demonstrate. What is new about the community center idea is the pulling together of these elements into a manageable, coordinated continuum of services in a particular community or segment of a community. If it makes no sense for a patient with pneumonia to be seen by a dozen different doctors and treated in several different facilities, neither does it make any sense for a mental patient to be shunted from a social agency to a clinic to a hospital to another social agency, ad infinitum, seeing different professionals and filling out fresh forms at every stop along the way. The principle of the center operation is that by drawing together the five essential services into a single administrative unit any patient eligible for treatment in any part of it will be eligible for treatment in any other part of it.

Very rarely would a community need to construct a mental health center with all of the essential services from the ground up. It is the stated position of our Association, for example, that wherever possible the inpatient component of a center should be provided by the community general hospital. On the other hand, a new building might be needed to house the other four essential services, or any part of them. In a word, the important consideration is not to duplicate existing services but to fill in the gaps and harness all together in a coordinated system to meet individual needs within the same system. For example, in the West Philadelphia area there are six major hospitals and a host of social and community agencies all of whom must share responsibility in providing comprehensive services for that area. If they were to plan independently, the result would be chaos. In 1965, however, they got together in a joint planning effort under the aegis of the University of Pennsylvania and formed what they call the West Philadelphia Mental Health Consortium. This Consortium has just recently submitted a staffing grant application which proposes to use all of these facilities in providing the five essential services for the area.

I hope I have helped to make it clear why the extension of this legislation comes at such a critical time in our history. We are just getting started. Millions of Americans remain outside of the wholly new approach. The states have had less than two years to develop their plans, submit their applications for assistance, and get their new centers under way. It is of no small significance that as of the end of the first fiscal year (June 30, 1966) 93 center projects in 43 states and Puerto Rico had been funded through this program. Ninetythree percent of the construction monies and 80 percent of the staffing funds had been obligated. Has any other bold new program launched by the Congress ever been seized upon more avidly? I doubt it. But the people on the firing line in your state and mine have scarecly had time to catch their breath. We cannot yet, in all fairnes, select out a single center any where and say, in confidence, “this is the way to do it.” One does not achieve massive social change in a trice. But we can point with pride to the enormous progress I have highlighted and the promise of quickening our efforts to further the purposes of the community mental health center.

In closing I am reminded of Mr. Winston Churchill's comment after the British had defeated General Rommel in North Africa to the effect that one could not speak of it as the end, or even as the beginning of the end, but it was, he said, perhaps the end of the beginning. I hope, gentlemen, that you will approach this legislation in Mr. Churchill's spirit and that you will pass this legislation with the same degree of unanimity that you approved the original propositions which it will now extend.

Mr. JARMAN. Thank you both for a very good presentation and for advocacy of what you see as the problem here. The problem certainly is before us as a Nation. I think we can take heart in the comment in Dr. Ewalt's statement that developments so far are responsible for the fact that the population of our mental institutions has declined by about 20 percent over the past decade and this has been done in the face of a growing population and growing admission rates.

Mr. Rogers!
Mr. Rogers. Thank you, Mr. Chairman.

That was a very impressive statement. I have read Dr. Ewalt's statement. I think your testimony is very helpful in pointing up problems that do exist. We were told by the Department, I believe, that there were some 286 centers.

Mr. GORMAN. That was the anticipated figure by June 1967.
Mr. ROGERS. I thought these were committed,
Mr. GORMAN. No; I am on the council and we just had a meeting.
Mr. ROGERS. Those were not correct.

Mr. GORMAN. If you check the record, I think the Department said that this 286 was their projected figure by June 30 of this year. That is in Mr. Cohen's testimony. They would hope to staff and construct that amount. The present number is 173.

Mr. ROGERS. I thought just for construction alone it was 286.

Mr. GORMAN. That is not correct. I am sure of that because we just had a meeting on it.

Mr. ROGERS. Now, I understand that about the time we passed this legislation it was anticipated or projected that the requirement for beds for mental patients had that trend continued would be up to some 700,000.

Mr. GORMAN. That is correct, sir.

Mr. ROGERS. But that since that time it has come down to some 400,000.

Mr. GORMAN. 452,000.

Mr. ROGERS. Who are actually in beds in mental hospitals. Has that relieved the problem of the construction program at all?

Mr. GORMAN. If I might say this, sir, or would Dr. Ewalt comment first?

Dr. Ewalt. I think it has relieved the problem of creating custodial or long-term chronic disease construction. I think it does not cut down on the number of active treatment community mental health center types of programs we need. These are not so much beds. There are beds in them but the other thing needed is all kinds of services for day care, rehabilitation treatment, educational programs and things of this sort so that State appropriations for construction of chronic disease beds has undoubtedly been decreased.

I some places they are tearing down buildings; others are relieving crowded institutions by creating buildings, but in terms of the center grants since they are to be away from these big centralized institutions and all out through the community particularly the smaller towns and cities, it has not decreased that and I think the program is projected of needing 2,000 of these by the time the population reaches 200 million is still an accurate projection.

Mr. ROGERS. You feel that that is a correct figure?
Dr. EWALT. Yes, I do.

Mr. ROGERS. Then you were quoting from the State hospitals as to this reduction in beds, not from local communities.

Dr. EWALT. I wouldn't think so. These 2,000 mental health centers if they had an average of 50 beds apiece, which I don't think they will because some will have 200 and some 25, will be no more beds than that, but they will be quite different in their distribution.

Mr. GORMAN. Could I make one comment, Mr. Rogers? I think the thing that I pointed out in my testimony, that 20 years ago the State mental hospital was really the only resource and the fact that today four out of five people seek treatment elsewhere is a great tribute to the State hospitals because the fact that they are discharging two or three times the number of people means that the people go to the community resources.

But factually 2 million Americans last year sought and were unable to find treatment in the community; not enough clinics, not enough psychiatrists, this is the answer. We have more clients than we are able to handle.

Mr. ROGERS. I believe you said that 10 percent only of the ongoing program was a contribution of the Federal Government.

Mr. GORMAN. In 1965, sir.

Mr. ROGERS. That ratio doesn't necessarily follow in this particular program, does it?

Mr. GÓRMAN. No, sir. This was a total of all kinds of expenditures for community mental health services.

Mr. ROGERS. I notice that the amount of contribution of Federal funds in the construction program varies from State to State. What is your feeling about that?

Mr. GORMAN. I feel that it is really based as you know, Mr. Rogers, in the record of the 1963 and 1965 hearings, upon the Hill-Burton formula; roughly that you allow for low per capita income so that the poorer States are asked for only $1 of matching for $2 in Federal matching and New York State gets $1 in Federal matching for $2 in New York State matching.

This is the theory. I don't know that I have either the wisdom or lack of caution to comment on it. I think we will have to see how it works out. The Hill-Burton formula is kind of sacrosanct. We always use it in connection with construction programs.

I am glad the States have the option within the State not to take the flat formula. They have done this in Florida, used a variable formula. I don't know. I know people in Delaware who are very unhappy because they get only $1 in Federal money for every $2 expended, I think, because the Du Pont Co. is there.

Mr. ROGERS. What is your viewpoint on the manpower problem as to psychiatrists aids? What is our lack of needed personnel, would you estimate, now as to psychiatrists and for technical people to help them?

Dr. EwALT. Well, there certainly is a shortage. When you try to give an exact figure it depends on how they use them. I think we have to move forward on two fronts. I believe we are making progress on both.

First, in the actual expansion of training facilities and this has been done. For example, the schools are now producing about 2,000

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