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psychiatrists a year. We are importing quite a number also and now we question whether the brain drain is a good thing but it is a good thing for us.

Also, the psychologists group has expanded, the social workers, nurses, and so forth, so that we are producing more manpower but I think even more important we are learning more about how to use the manpower so that sometimes in my own place, for example, we have one program where the psychiatrists rarely see patients at all.

They spend their time in consultation working with social workers, indigenous coinmunity mental health workers, recreational, rehabilitation, and other paramedical personnel.

They spend time answering their questions, consulting about problems that have come up; so that we are learning to use our trained manpower much more effectively than we did before.

Mr. ROGERS. Could you give us for the record any study that has been made or any projection as to needs of manpower?

Mr. GORMAN. They have been made. The National Institute of Mental Health just made a study in November 1965 and we can supply it for the committee.

It is a very optimistic projection.
Mr. Rogers. What is the basic finding of that study?

Mr. GORMAN. It is that under Federal and other programs we have added more than 100,000 mental health personnel in the last 15 years but the only problem is we have built a better mousetrap. More people are seeking the treatment than ever before so that we have to keep running to catch up with everybody.

That is the problem. We have increased enormously.

Mr. ROGERS. I wonder about not necessarily the increase but what is the lack of personnel presently? What is the problem?

Mr. GORMAN. It still depends on from what viewpoint. If you take the center one fellow says he needs 10 psychiatrists and the other says he can get along with four.

Mr. ROGERS. Surely the psychiatric study made some recommendation.

Dr. EwALT. There is such a figure. We can send it to you. (The information requested follows:)



Boston, Mass., April 6, 1967. Representative PAUL ROGERS, Congress of the United States, Washington, D.C.

DEAR REPRESENTATIVE ROGERS: At our hearing you asked a number of excellent questions and also asked for additional information. I will try and furnish this. If I have overlooked something you wanted or if something else occurs to you, would you have one of your staff contact me by letter or phone and I will try and find it for you.

You will recall you were particularly interested in what role the American Psychiatric Association was playing in stimulating interest in teaching and providing leadership for sub-professional persons who might be recruited to work in the mental health field. This type of activity runs in about three groups: (1) Volunteers, that is persons who are otherwise emyployed or are housewives who give some time each day a week to the care of mentally ill persons. The American Psychiatric Association has worked with this group for a long time and has a standing committee on volunteers. We have also

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worked closely with the National Association for Mental Health who have felt that the program for volunteers is one of their major operations. I am enclosing a book. You will note that while the conference was sponsored by the Massachusetts Association for Mental Health a lot of the participation was by psychiatrists and other socalled mental health professionals, and with a good representation from the laity. This was and should continue to be a very important activity. I won't go into the detail here, but the mere fact that people will take time from their busy lives to work with mental health problems does a great deal for the morale of the professionals as well as for the patients.

The second large category consists of the sub-professionals who work in our hospitals. These are the socalled aides, attendants, etc. who work with the nurses, the occupational therapists, the rehabilitation group, the social workers, psychologists, etc. The basic purpose is to expand and extend the effectiveness of the trained personnel in psychiatry.

The American Psychiatric Association has a Commission on Allied Service Personnel, headed by Philip B. Reed, a psychiatrist in private practice in Indianapolis. The purpose of this group is to provide leadership for the subprofessional personnel, helping them with funds for further training, further recognition as important allies in the treatment and rehabilitation of patients, etc. The American Psychiatric Association publishes a special little magazine for them called Staff. This is distributed free to state hospitals and other mental health institutions and is directly aimed at improving the morale through recognition and training of this very important group. This latter group actually provides the bulk of care of patients in the large state hospitals, and we are most concerned that they carry over and function in the new mental health centers, particularly as workers in the community. The National Institute of Mental Health has helped a great deal with the further improvement of the technical skills of this group by making hospital improvement grants and in-service training grants to most of the large state hospitals and some of the smaller mental health centers such as the Massachusett Mental Health Center.

The third group overlap somewhat with the preceding one. I separated it out because the preceding group always works under the direction of professional persons. Some of us have thought for some time that in some categories of activity sub-professional persons, properly trained in specific and perhaps rather narrow areas of function, can work with a minimum of supervision. Experiments with using attendants or aides as group therapy leaders, experiments with using people from the community as community leaders, community assistants and community counselors have proven effective in many areas including Massachusetts, some areas in Florida, and in a large delinquency program in New York City.

Dr. Henry Brosin, Professor of Psychiatry at the University of Pittsburgh, who will become President of the American Psychiatric Association at its May meeting, is very much interested in developing new knowledge and a new category of persons known as mental health workers. It is hoped that some of the above group of aides and other non-trained persons might, through the cooperation of junior colleges or other similar educational institutions, receive some more formal type of training that would enable them to function even more effectively than the rather naturally occurring skills that some of these people have. We need to know a good deal more about this than we do now. Experience here shows that if these persons are to be effective they must have access to a skilled psychiatrist or at least to a social worker or psychologist with whom they can consult, discuss some of their troublesome problems, etc.

It is my belief and, with your encouragement I will continue to push for it, that the American Psychiatric Association program will probably embark on a rather extensive program in this area.

If I have overlooked some of the points you had in mind would you please let me know as it will be my pleasure to communicate with you further. Sincerely,


Superintendent. Dr. Ewalt. The problem is not in staffing these new mental health centers. The problem is still in staffing the old ongoing chronic diseases or long-term hospitals that are perhaps not as desirable. Wherever they have created these new center programs the people have been

interested and they have been able to recruit people somewhat to the dertiment of these other institutions.

Mr. ROGERS. Let me ask you one other question: Have there been any major breakthroughs in the treatment of mental health that your association is encouraging use of?

Dr. EwALT. Certainly the major breakthrough has been the development of these drugs, the tranquilizing drugs, the antidepressant drugs. We are just now beginning to realize that there is another drug and it is so cheap it is a commodity and not really a drug, lithium, used in the manic-depressive diseases and apparently quite specific, and it may even be used as a prophylactic or preventive.

It is lithium carbonate. You remember some of the old health resorts used to have lithia water. Some people drank too much and it killed them and it was taken off the market. It is used, people tell me, for putting the polish on fine china but in proper doses and with proper laboratory control of the level it is a very effective drug in manic-depressive diseases and even more spectacular in that disorder than the tranquilizers have been in schizophrenia.

Mr. ROGERS. Did the tranquilizer knowledge come out of the National Institutes of Health?

Dr. Ewalt. I think the testing and learning more about how to use them did. The first use of the drug itself came from our colleagues in Europe. Whether that was on one of our foreign grants or not I don't know.

Mr. GORMAN. We developed several of the antidepressants here in America.

Mr. Rogers. In the Institutes!
Mr. GORMAN. Institute grantees, yes.

Dr. EWALT. The first tranquilizers were not as effective as some of the newer ones, all of which were developed by the industry here, some under grants.

Mr. GORMAN. We have the finest screening for drugs in the world. We put them through a very fast and rapid screening.

Mr. Rogers. Your figures that you suggest to this committee would be what?

Mr. GORMAN. My curbstone figures are roughly that we double the program so that would mean $500 million over the next 5 years.

I saw original figures last fall which indicated that we would reach that level. I understand the budgetary process sometimes better than I understand my own checkbook and I know what happened between November and this month.

But I honestly feel, and I think the commissioners from the various States who are here today will testify to the fact that if we keep it at this low level, the $50 million a year or something like that, because my understanding is that the administration figure which will be submitted—and I want to be careful again but I can't be, my personality is against me—will run about $60 million in the next fiscal year and about $70 million in the next year.

I think the "haves" will get it all. The ones ready with the applications and the ones who are experts in grantsmanship will get it, but the poor guy in the rural area who has to work up the application is going to wait. He is not going to get it because he does not have enough

carbon paper.

Mr. Rogers. Thank you, Mr. Chairman.
Mr. JARMAN. Mr. Carter.
Mr. CARTER. Thank you, Mr. Chairman.

Thank you, gentlemen, for your excellent presentation. Certainly, I appreciate the dedication that you have to this great problem that faces all of us, mental health.

Of course, I further agree with you that not only should we pay adequate attention to mental health, but also air pollution and water pollution, which are great problems to us at this time.

I think regardless of the war we must pay attention to our internal problems. This problem should be solved, war or no, or it might some time affect our internal security.

Another thing, any home may well be involved. Young children as you say are often involved. I have seen this many times. It is heartrending to see a youngster of 14 talking incoherently and it is extremely gratifying to see these minds find themselves. I think you have a wonderful program and I certainly want to do my part.

Dr. EWALT. Thank you.
Mr. GORMAN. Thank you, Dr. Carter.
Mr. JARMAN. Mr. Satterfield?
Mr. SATTERFIELD. Thank you, Mr. Chairman.

Dr. Ewalt, I haven't had a chance to study your statement as I certainly will because I am sure that it will be important and interesting if for no other reason than your experience in this area.

Was I correct in interpreting that you treated 9,000 patients in your center last year?

Dr. Ewalt. It would be just under 6,000, I believe, sir.

Mr. SATTERFIELD. The reason I make this point is that I think it might be interesting to this committee and to the record if we might have from you a breakdown of your pattern of staffing during this period of time. I don't know whether you have it at hand now or if you can submit it.

Dr. EwALT. I can tell you but it isn't a fair one. Our institution has three functions and the budget and staffing for the research efforts and the training efforts—it is an integral part of Harvard Medical School-equal that for patient service. I have 70 young doctors in training there in psychiatric residencies plus four under a special program of private funds from Asia to try and introduce methods there.

It takes a vast number of senior doctors to supervise their work if we are to keep them out of trouble. Harvard Medical School has a very intensive educational program. I have the figures right in my head but I think to say that this is what you would need, say, out in western Massachusetts at Pittsfield is not correct.

I will give you them. I have 70 residents. I have 35 senior psychiatrists that are full-time and 35 that work from a half day to a day a week. I will even go further. If you came to our place you would find that our medical program is good and the place is filthy.

I have 22 psychoanalysts and 19 janitors so that our medical program is better than our housekeeping. The Massachusetts Legislature will give me doctors and Harvard will give me doctors but nobody will hire a porter for me. I figured this out once and I could send the figures of what I could run the place on if I didn't have a

teaching or training thing and I think I could handle the thing on about 20 psychiatrists and that many psychologists and 60 social workers but I will send you those figures.

Mr. SATTERFIELD. If it is not too much trouble.
Dr. EWALT. It is no trouble at all.
Mr. SATTERFIELD. Thank you, sir.
(Information requested follows:)



Boston, Mass., April 7, 1967. Rep. DAVID SATTERFIELD, Congress of the United States, Washington, D.C.

DEAR REPRESENTATIVE SATTERFIELD: You asked about the number of staff I would estimate it would take to run a community mental health center for about 100,000 people. I believe the estimate usually kicked around is for about ten psychiatrists and appropriate numbers of other supporting personnel. I have played around with these figures some for our own hospital as I testified. Our experience requires a little free estimation because we have been serving the entire state but not on a giving service to everyone's basis. Further, because we have large numbers of persons here, including myself, who do a fair amount of one-to-one or individual psychotherapy or psychoanalysis, we use up more manpower than may be required in many of the community mental health centers. Also, most of my time for example is spent either in teaching or supervising research projects. By these maneuvers, having warned you that these figures are educated guesses at best, I will proceed.

Our hospital on any day has about 200 to 220 in-patients, about 125 of whom are on a 24 hour care basis and the remainder on a day or night basis. There is a considerable shifting of patients between the above categories as they improve or have temporary relapses. Each patient is seen briefly every day by his physician and has from one to three prolonged interviews or psychotherapy each week. The out-patient department and the emergency service see about 5,000 different persons a year. The hospital admits approximately 900 persons per year. The number of persons coming to the out-patient department means little as the work load depends on the number of patient visits. If one person comes ten times, he uses up more manpower than five persons who come once each. Therefore, most clinics count their case load in terms of "patient visits”, that is, each time a person comes to see his doctor he is counted as one. Thus one patient who comes twice a week for a year might account for a hundred patient visits in a year, and another person who comes only three times and then needs no further care would only count as three, etc. Our clinic runs about 47,000 patients visits per year. Again I would emphasize that our patients all have some type of individual therapy as well as some type of group therapy. Because we are a teaching and research institution, this type of approach may be more intensive than is needed—I think we just don't know for sure.

My estimate as figured out on man hours, with appropriate time for vacations, etc., is that it would require about 25 full time people to man the clinics if they did nothing but care for patients. It would take about 15 to man the house or hospital if they did nothing but take care of patients.

These figures are for our present operation. The best estimate I can make at this time for the demands on us from our catchment area is that about 65 percent of the above hours and patient days will be used up by patients from our catchment area which has 225,000 people in it. Thus as we operate I could get by with approximately 10 in the hospital and 16 or so in the clinic for 225,000 people. If we divided this again by half for a catchment area of 100,000 we would then come out with about 13 psychiatrists necessary to operate such a center, that is, psychiatrists or persons working under a psychiatrist doing essentially what they do. Some institutions would operate with a smaller number of psychiatrists and a larger number of social workers or clinical psychologists. Because we are a medical center we tend to use more of the medical personnel and less of the social workers or psychologists. In an ordinary center, however, I would assume they would have approximately two to three social workers for

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