Individual psychotherapy through talk-the favored method in most mental health programs-is best suited to adults. What to do with an enraged child on a playground is not normally included in curricula for training mental health specialists. It would seem that our plans and programs are shaped more by our methods and predilections than by the problems to be solved.

Yet an analysis of the age profile of most communities-in conjunction with this relative neglect-would call for a radically different allocation of money, facilities, and mental health professionals. We do not know that early intervention with childhood problems can reduce later mental disorder, but it is a reasonable hypothesis, and we do know that the problems of children are receiving scant attention. Sound strategy would concentrate our innovative efforts upon the young, in programs for children and youth, for parents, and for teachers and others who work directly with children.

The less than encouraging experience of the child guidance clinic movement a generation and more ago should be a stimulus to new effort, not an occasion for turning away from services to children. The old clinics were small ventures, middle-class oriented, suffering from most of the deficiencies of therapeutic approach and out-reach that have been touched upon above. A fresh approach to the problems of children is urgently needed.

We feel that fully half of our mental health resources-money, facilities, people should be invested in programs for children and youth, for parents of young children, and for teachers and others who work directly with children. This would be the preferable course even if the remaining 50% would permit only a holding action with respect to problems of adults. But our resources are such that, if we care enough, we can move forward on both fronts simultaneously. The proposal to place the major investment of our mental health resources in programs for children will be resisted, however much sense it may make, for it will require a thoroughgoing reorientation of the mental health establishment. New facilities, new skills, new kinds of professional people, new patterns for the development of manpower will be required. And new and more effective ways must be found to reach and help children where they are in families and schools and to assist these critically important social systems in fostering the good development of children and in coming to the child's support when the developmental course goes astray. This is one reason why community leaders and other nonprofessionals concerned with the welfare and development of people should be centrally involved in establishing the goals of community mental health centers. They can and should demand that the character of the new centers be determined not by the present habits and skills of professional people but by the nature of the problem to be solved and the full range of resources available for its solution.

PLANNING FOR PROBLEM GROUPS THAT NOBODY WANTS

As a focus for community planning for mental health, the comprehensive center should assure that provision is made to deal with the mental health component in the problems of various difficult groups that are likely to fall between the stools of current programs. Just as good community programming for mental health requires continuity of concern for the troubled individual across the many agencies and services that are involved with him, so good programing also requires that no problem groups be excluded from attention just because their problems do not fit neatly into prevalent categories of professional interest, or because they are hard to treat.

There are a number of such groups of people, among whom problems of human ineffectiveness are obivous, yet whose difficulties cannot accurately or helpfully be described as mainly psychological: for example, addicts, alcoholics, the aging, delinquents, the mentally retarded. It would be presumptuous folly for mental health professionals to claim responsibility for solving the difficult social and biological problems that are implicated in these types of ineffectiveness. it would also be irresponsible on the part of persons who are planning community mental health programs not to give explicit attention to the adequacy of services being provided to these difficult groups and to the adequacy of the attack that the community is making on those aspects of their problems that are accessible to community action.

Recently, and belatedly, national attention has been focussed on the mentally retarded. This substantial handicapped group is likely to be provided for outside the framework of the mental health program as such, but a good community

mental health plan should assure that adequate provision is in fact made for them, and the comprehensive center should accept responsibility for serving the mental health needs of the retarded and their families.

Some of the other problem groups just mentioned-e.g., the addicts and alcoholics-tend to get left out partly because treatment by psychiatric or psychological methods has been relatively unproductive. Naturally, the comprehensive center cannot be expected to achieve magical solutions where other agencies have failed. But if it takes the approach advocated here that of focusing on the social systems in which problem behavior is embedded-it has an opportunity to contribute toward a rational attack on these problems. The skills that are required may be more those of the social scientist and community change agent than those of the clinician or therapist.

In planning its role with respect to such difficult groups, the staff of the center might bear two considerations in mind: in the network of community agencies, is humanly decent care being provided under one or another set of auspices? and does the system-focused approach of the center have a distinctive contribution to make toward collaborative community action on the underlying problems?

MANPOWER

The present and future shortage of trained mental health professionals requires experimentation with new approaches to mental health services and with new divisions of labor in providing these services. The national effort to improve the quality of life for every individual-to alleviate poverty, to improve educational opportunities, to combat mental disorders-will tax our resources of professional manpower to the limit. In spite of expanded training efforts, mental health programs will face growing shortages of social workers, nurses, psychiatrists, psychologists, and other specialists. The new legislation to provide Federal assistance for the staffing of community mental health centers will not increase the supply of manpower but perhaps may result in some minor redistribution of personnel. If adequate pay and opportunities for part-time participation are provided, it is possible that some psychiatrists and psychologists now in private practice may join the public effort, adding to the services available to people without reference to their economic resources.

The manpower shortage must be faced realistically and with readiness for invention, for creative solutions. Officially recommended staffing patterns for community mental health centers (which projected nationally would require far more professionals than are being trained) should not be taken as setting rigid limitations. Pediatricians, general medical practitioners, social workers other than psychiatric ones, and psychological and other technicians at nondoctoral levels should be drawn into the work of the center. Specific tasks sometimes assigned to highly trained professionals (such as administrative duties, follow-up contacts, or tutoring for a disturbed child) may be assigned to carefully selected adults with little or no technical training. Effective communication across barriers of education, social class, and race can be aided by the creation of new roles for specially talented members of deprived groups. New and important roles must be found for teachers, recreation workers, lawyers, clergymen. Consultation, in-service training, staff conferences, and supervision are all devices that can be used to extend resources without sacrificing the quality of service.

Mental health centers should find ways of using responsible, paid volunteers, with limited or extended periods of service. There is a great reservoir of human talent among educated Americans who want to contribute their time and efforts to a significant enterprise. The Peace Corps, the Vista program, Project Head-Start have demonstrated to a previously skeptical public that high level, dependable service can be rendered by this new-style volunteer. The contributions of unpaid volunteers-students, housewives, the retired-can be put to effective use as well.

PROFESSIONAL RESPONSIBILITY

Responsibility in the comprehensive community mental health center should depend upon competence in the jobs to be done. The issue of who is to be responsible for mental health programs is complex and is not to be solved in the context of professional rivalries. The broad conception of mental health to which we have committed ourselves in America requires that responsibility for mental health programs be broadly shared. With good will, intelligence, and

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 A social worker, a psychologist, a pediatrician, a nurse, a public health administrator might be a more competent director 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.

TRAINING

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, postdoctoral fellowships, 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 substantial 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, wide 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. BRAYFIELD. I appreciate that, you can't help it.

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. 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