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support such an extension to a State with economic and professional problems such as ours, this program has been an absolute lifesaver. Through the stimulation provided by P.L. 88–161 and P.L. 89-105 we have touched off a real revolution in the provision of mental health services in this State. Without it, there is serious doubt that any substantial progress in community mental health would have been obtained. We are now in a position of moving forward, which can either be greatly assisted by the continuation of the program, or seriously retarded by its abrupt termination.

A bond issue which provided only 1.2 millions of dollars for assistance to communities for construction has rewarded us with a Federal share utilization (either projected or certified) of 100 percent in mental retardation thru 1968 and 100 percent in mental health thru 1966. Four construction projects in mental retardation and four in mental health have been approved at the State level, and of these three have already received Federal approval; the others are now being reviewed.

In addition, thru provisions of P.L. 89-105, we have been able to obtain full utilization of our 1966 monies and have pending an additional ten staffing grants which hopefully will obtain any unused monies from other States to the extent of about 1.2 millions in Federal assistance.

These programs have stimulated community interest and community cordination of planning beyond our fondest hopes. We have been able to initiate programs which have recruited people into the State of Kentucky and which we presume will continue to operate.

Plans to insure continuation of the programs once initiated is essential in this program as Federal funds are withdrawn. However, continuation of the initial Federal staffing assistance is needed if the remaining regions in Kentucky are to ge started. I am sorely afraid that these nine other regions of the State will find the cupboard bare, if there is not a continuation of this remarkable program.

This State and others like it, without the benefit of large metropolitan populations and strong State tax bases, have found the initial assistance given by these programs to be invaluable; I again urge that the Congress continue to assist us in provision of a totally new concept in the care of the mentally ill and the mentally retarded. In order not to belabor this, may I say that this department stands ready to forward to you any specific details which you might care to have relative to our development. O.S. text will be sent to you in letter form.

DALE FARABEE, M.D., Commissioner.

[Telegram]

JEFFERSON CITY, Mo.,

April 4, 1967. Congressman HARLEY STAGGERS, Chairman, Interstate and Foreign Commerce Committee, House of Representatives, Washington, D.C.:

Have learned that your committee is holding hearings on H.R. 6431, to extend authorization of staffing and construction of community mental health centers. This is to advise that we in Missouri wholeheartedly endorse this step and urge support by your committee.

The reasons for continuation are: (1) many States did not have sufficient time to develop administrative staff and procedures to implement fully P.L. 88–164 and P.L. 89–105; (2) community representatives have required considerable time to organize and raise funds in order to apply for Federal matching monies to build centers; (3) as centers are developed there is an impetus to other communities to build mental health centers, thus an extension would make it possible to construct and staff additional facilities; (4) some States are without mental health service acts and thus have no financial resources to match with local funds to build and staff centers.

GEORGE A. ULETT, M.D.,

Director, Missouri Division of Mental Diseases.

[Telegram]

AUSTIN, TEX., April 12, 1967. Congressman HARLEY STAGGERS, Chairman, Interstate and Foreign Commerce Committee, House of Representatives, Washington, D.C.:

The Texas Department of Mental Health and Mental Retardation of the State of Texas is vitally interested in passage of H.R. 6431 which would extend for five years authorization for construction and staffing of community mental health centers. Texas has recently undertaken a comprehensive community mental health centers program and the financial assistance afforded by this measure would be of inestimable value.

JOHN KINROSS-WRIGHT, M.D.,

Commissioner.

[Telegram]

BATON ROUGE, LA., March 31, 1967. Congressman HARLEY STAGGERS, Chairman, Interstate and Foreign Commerce Committee, House of Representatives, Washington, D.C.:

I heartily endorse the bill, H.R. 6431, extending for five years the existing programs for construction and staffing of community mental health centers. Louisiana has 14 projects scheduled for construction, however, Federal funds will only permit 7 centers to be built. In addition the 1967 Louisiana State plan recommends the construction of 15 new centers and additions to 6 existing centers.

WILLIAM P. ADDISON, M.D., Louisiana Commissioner of Mental Health.

[Telegram]

COLUMBIA, S.C., April 3, 1967. Congressman HARLEY STAGGERS, Chairman, Interstate and Foreign Commerce Committee, House of Representatives, Washington, D.C.

Extension of the Community Mental Health Center programs, as proposed in H.R. 6431 and S. 1132, would be most welcome in South Carolina. This State's comprehensive mental health plan leans heavily on the community center concept. Three applications for construction grants have been approved and two others are being processed, along with one staffing grant application from a sixth area which will submit a construction application later. It appears that virtually all, if not all, of this State's construction grant allocations will be used. All matching funds are being supplied by local communities, giving evidence of grassroots support.

Five other area mental health boards have expressed interest in expanding clinics into comprehensive centers but cannot meet current program deadlines. Two other clinics just getting underway would be prospects for centers later, as would one other area not now having a clinic.

If the program is terminated as scheduled, less than half of the need will have been met in South Carolina and the neediest areas, by and large, will be the ones left untouched.

Extension of the staffing grants is most important. The original deadlines for staffing applications were too close to the construction grant deadlines, so that many centers being constructed under current authorizations will not be completed in time to obtain a staffing grant. If construction grant legislation is extended, the need to extend the staffing grants will be even more imperative since many communities will not project centers without initial staffing aid.

WILLIAM S. HALL, M.D..

South Carolina Commissioner of Mental Health. Dr. Glass. Our first witness will be Dr. Winston.

Dr. WINSTON. I am Dr. Winston and I will briefly go over my written statement.

Governor Ellington was invited to be with us this morning and could not because the legislature was in session but he has asked me to express his regrets, and let me say as commissioner of mental health that he has given overwhelming support for our program and has given us the highest increase in our budget, hopefully which will be approved at any time, in the history of our department.

What I have done in my statement is to briefly outline the three revolutions that I have seen occurring in psychiatry, the first being the advent of Dr. Freud, the second revolution which is the tranquilizer in 1954, and third the comprehensive mental health center and I really see this as the most significant of all and I would like to confine my verbal testimony to my experience as the superintendent of Moccasin Bend Hospital, a small State hospital which opened 2 years prior to the comprehensive centers but which was run similar to the centers and just briefly outline our experience there because I think it is relative to the staffing questions which have been asked.

Mr. JARMAN. I think it would be appropriate to say that the Chair has announced that we will try to finish the hearing by 12 o'clock. Apparently we cannot do so. So, our intent is, in fairness to the witnesses who have come to the hearing, some from outside the Washington area, to ask for permission to sit this afternoon at 2 o'clock to conclude the hearing if we don't finish this morning.

Dr. WINSTON. Moccasin Bend Hospital, as I say, opened in 1961 actually. The results that we had there with this type of program similar to the comprehensive center we feel are almost miraculous. We cut the average first stay from 6 months to 5 weeks in the first year of operation.

We started new programs that were not capable of being started previously because of the small comprehensive concept that we envisioned and that is now in operation elsewhere, too.

We did this, I might add, with only one other psychiatrist serving an area of some 600,000 people. Let me make the remark that we rely heavily—in fact, solely, I should say—on the aid staff and the use of tranquilizers and not one patient there received the sort of treatment that I as a psychiatrist was trained to give; that is, the 1-to-1 psychotherapy relationship.

Yet we got these patients out, we kept them out and they are continuing to give what I think is a real testimony to the value of how these comprehensive centers can work without necessarily the staffing pattern that we have been accustomed to in the past and would like to have but cannot apparently have in light of short staff.

Let me read my concluding paragraph.

The impact of the comprehensive community mental health centers making treatment available to any aggregate population of 75,000 or more is indeed staggering.

It is my firm, sincere judgment that the farsighted thinking on the part of the National Institute of Mental Health in instituting this program will be by far and away the most significant of all of the three revolutions.

Although it will in no way eliminate mental illness any more than general hospitals eliminate physical illness, it will alleviate much of the suffering, the agony, and the despondency to which only those who have had mental illness can testify.

I urge this committee to consider not only the extension of the present program but a large expansion of it.

(Dr. Winston's prepared statement follows:)

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STATEMENT OF DR. NAT T. WINSTON, JR., COMMISSIONER OF MENTAL HEALTH,

STATE OF TENNESSEE
I am Dr. Nat T. Winston, Jr., Commissioner of Mental Health for the State

Governor Buford Ellington of our State was invited to participate at this committee hearing, but because of pressing legislative matters currently under consideration in the General Assembly of Tennessee, he is unable to come. He has asked me to express regret that he could not be here and may I say as commissioner of mental health, that his interest in our problems and in our overall program has been overwhelmingly positive. He has asked the current legislature for a greater increase in our budget than anytime in the history of the department and has given his wholehearted endorsement and support to our program,

I shall make my remarks quite brief in urging you to consider the extension of the Community Mental Health Centers Construction and Staffing Act (H.R.

In my judgment, there have been three revolutions in psychiatry. The first occurred around the turn of the century with the advent of the theories of the development of mental illness first advanced by Dr. Sigmund Freud, the father of modern day psychiatry. The original postulates of Dr. Freud have been altered somewhat, but his most significant contribution was his pointed observation that there were causal factors in childhood resulting in adult disturbed behavior. This meant that no longer could we complacently sit back and place patients in "insane asylums” and wash our hands of the matter. We would now have to look for methods of treatment of a definitive nature.

The second revolution occurred in 1954 with the advent of the first true tranquilizer. Although we had methods of physical treatment prior to 1954 and although we had drugs which would produce sedation, we had no drugs which would produce tranquilization without crippling side effects. These miraculous drugs do not cure in the strict sense of the word, but merely control symptoms thus altering many age-old concepts we have had about the mentally ill. They have, for example, permitted new ideas in design and architecture for mental hospitals. They have completely modified and changed our programs for the mentally ill by permitting a freedom and versatility of programs never before possible. They have led in my opinion directly to the third revolution.

This revolution came about because of you, the legislative body of the United States. You appointed in 1955, a five year study group to look at the problems of the mentally ill. The famous "action" report released by this group in 1961 held as its primary recommendation that the mentally ill, if he was to receive the best chance for recovery and to remain well, must be treated at home in small intensive treatment units just as we treat physical illness in our many local general hospitals. The report held that it was just as absurd to congregate patients in large regional mental hospitals as it was to send the average case of pneumonia or appendicitis to the university hospital 200 miles away.

In backing up this recommendation, you then passed in 1963 the Comprehensive Community Mental Health Centers Act, which in my way of thinking has revolutionized our entire approach. It has placed the mentally ill back where they belong-in the community. It has done much already to reduce the stigma and the fallacious thinking of individuals about mental illness.

It was my privilege to have opened, as the first superintendent, the Moccasin Bend Psychiatric Hospital in Chattanooga in 1960. This small, intensive treatment unit is operated much as the comprehensive centers are being operated following 1963. Here we had the chance to see what new ideas coupled with tranquilizers could do for the patient who was treated right at home in his own environment. The results were almost miraculous. We cut the average length of stay for a first admission acute case in the State of Tennessee down from six months to five weeks in our first year of operation. We started new programs never before conceived of in mental institutions such as 24-hour around the clock visiting, sending patients home who were still presenting symptoms for weekend visits, but who with the confidence that they would not be separated from their families returned readily and improved more rapidly. We utilized every recreational facility of the city of Chattanooga itself in our recreational

program and we did away with many of the traditional practices of searching, keeping doors locked, etc. We utilized many community agencies and brought volunteers into the institution thus keeping the institution and the community closely associated. This program as well as others have demonstrated beyond any doubt that keeping the patient at home does make a significant difference in how he responds to the definitive treatment offered him and even more importantly, how well he stays at home.

The impact of the comprehensive community mental health centers making treatment available to any aggregate population of 75,000 or more is indeed staggering. It is my firm, sincere judgment that the far sighted thinking on the part of the National Institute of Mental Health in instituting this program will be by far and away the most significant of all of the three revolutions. though it will in no way eliminate mental illness any more than general hospitals eliminate physical illness, it will alleviate much of the suffering, the agony, and the despondency to which only those who have had mental illness can testify.

Ladies and gentlemen, as a professional person with the responsibility of caring for the mentally ill of a State, I would urge you to consider at all costs not only the extension of the present program, but a large expansion of it. To do less would be more than foolhardy and would potentially endanger the lives and the emotional health of every one of us here.

Dr. Glass. I would like to follow with my statement. I have a prepared statement. I will not read it because I feel that Dr. Donohue has a story to tell and does not have a prepared statement.

I should like to summarize my remarks by pointing out that you have heard of the decade of effort to obtain this community program, going from the studies that Dr. Ewalt had in the Joint Commission on Mental Illness and Health and you know about Public Law 88–164 which launched the community mental health center program.

It not only launched a construction program but a whole new way of doing this, not new techniques, but a new operation, how to use people, how to treat people as outpatients, how to treat them in alternatives to hospitalization.

So that the program launched not just construction but a new way of handling the problem. Now it is almost as if the military medical services, and I am an old military psychiatrist, confined their operations only to base hospitals and didn't have followup field service to support troops in the field.

This is what the new program did. Necessarily it took time to get started. It had to be written. It had to be understood.

Enthusiasm had to be stimulated and we have gone through the first 3 years of this. Now we are moving. We have a momentum going. There are only 128 construction grants and 72 staffing grants as of April 1.

Now, many of these are complementary. Our one grant which Dr. Donohue will talk about is both staffing and construction. If we at this time fail to renew this program we have broken faith with everything that we have tried to do in stimulating it.

For example, this would stop a whole decade of progress. We are on our way now. We are getting more and more interest. More and more people are exploring this idea and understanding it. I don't know how much time I spent in Oklahoma explaining what a community health center was.

It was always mixed up with a clinic. The substance and spirit of this law strongly indicates that a continuing program was contemplated, not only President Kennedy's 2,000 centers.

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