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13 million man-hours per year of psychological effort, primarily teaching and research, related to mental health. This total of 26 million man-hours compares, for example, to an estimated 27 million man-hours per year contributed by psychiatrists. The latter contribute a considerably higher proportion of their time to direct clinical service, particularly in private practice settings.

It is interesting and relevant to note that psychology is primarily a public service profession for approximately 85 percent of all psychologists are employed in non-profit organizations and only 5 or 6 percent are in private practice; the remaining 9 or 10 percent are employed in business and industry. Thus psychologists are especially likely to be interested in community mental health center programs and, in keeping with their public service tradition, are likely to be a crucial source of manpower particularly if they have free and open access to positions of responsibility and leadership on the basis of individual competence equally with other mental health professions. We believe that manpower will be the critical element in mounting effective community health programs.

In March 1966, the American Psychological Association adopted an official position paper titled "The Community and the Community Mental Health Center" offering guidelines and discussion addressed to "community leaders who face the problem of deciding how their communities should respond to the opportunities that are opened by the new Federal and state programs”. Because of the widespread public interest this paper has attracted and because of its relevance to the legislation, H.R. 6431, which is the subject of these hearings, I respectfully request that it be made a part of the official hearings record.

As it did in formal testimony in 1963 and again in 1965, the American Psychological Association supports the goals of the community mental health centers legislation.

The first priority of the community mental health centers program is to make hospital beds and care readily available in settings close to home to people whose disturbed behavior either incapacitates them or causes concern to themselves, their family, their friends and employers, and the community at large. Thus the basic care facilities of the formerly geographically-remote state mental hospital are now in the process of being located in local and regional population centers. More beds and, hopefully, more care will become available as this program develops. The psychotic and the acutely disturbed members of the community will find help near at hand. The achievement of this limited but important objective will be a considerable accomplishment.

The community mental health centers program seeks also to make more readily available in communities throughout the nation forms of care and treatment which heretofore have been tried out on a more limited basis or in a relatively few places. Thus provisions are being made to incorporate day care programs, halfway houses, suicide centers, emergency or "walk-in” services, and the like into the community center programs. These already existing practices and procedures for dealing with the acutely and severely disturbed may thus become more generally available.

However, the most significant and exciting challenge and opportunity for the community mental health centers program does not revolve around this medically traditional inpatient-outpatient care program. The boldness and the promise of the enabling and supporting legislation passed by the Congress in 1963 and 1965, resides in its potential for obtaining a breadth and depth of local community involvement that would get to the crux of behavior disorder. For mental disorder is neither the private misery of the individual nor a personal problem solely of his making; it frequently has its roots, as well as its effects, in the social relationships and the social settings or systems of which the individual is a part.

On this view, the community mental health center's major undertaking will be to strengthen the totality of the community's investment in the human effectiveness of its members. The schools, the courts, the churches, business and industry are among the major social arenas in which the special perspective and special competencies of the center should find expression. For the disturbed or troubled person, the goal of community mental health programs should be to help him and the social systems of which he is a member to function together as harmoniously and productively as possible. And as we gain new knowledge bearing on the design of human environments for effective human functioning we eventually will be able to come to terms with the basic problem of prevention. But, beyond that, our ultimate goal, in a viable democracy, must be no less than to provide for the discovery, development, and wise utilization of all our human resources. Meet

ing the immediate needs of the severely disturbed is prologue to the achievement of this national goal.

The other great opportunity and challenge is to devote a necessary and substantial share of the total community mental health effort to children and youth. They are our resources for the future-our potentially productive contributors to the quality of American life—our major responsibility for the present. They must not be overlooked.

If we settle simply for a “mopping-up” or “picking up the pieces” operation in our community mental health programs, we settle for too little.

So it is the promise and the prospect, the anticipation of things to come, that especially commands our interest and mobilizes our efforts as psychologists. The beginning has been made, the effort is underway. To sustain its gathering momentum, we endorse and support the provisions of H.R. 6431. Thank you for the opportunity to appear here today.

(Additional material submitted by the American Psychological Association may be found in the committee files.)

Mr. JARMAN. This concludes our hearings on the bill and we appreciate all of you appearing before us.

Thank you.
(The following material was submitted for the record :)
THE AMERICAN PUBLIC HEALTH ASSOCIATION, INC.,

New York, N.Y., April 7, 1967.
Hon. HARLEY O. STAGGERS,
Chairman, House Committee on Interstate and Foreign Commerce,
Rayburn Office Building,
Washington, D.O.

DEAR MR. CHAIRMAN : The American Public Health Association is privileged to support the principles and objectives included in H.R. 6431, which you have introduced, and which would extend the authority of the Community Mental Health Centers Act. As stated in our testimony to your Committee in 1963, the motives and objectives of this Act, which at that time was a legislative proposal, merited the full support of everyone who was interested in or concerned about the problems of mental health. We stated then that the proportions and scope of the problems involved in the treatment and cure of mental disorders made it apparent that there is a continuing need for a redirection of efforts relative to the control of mental disorders. We are convinced that effective treatment of the mentally ill is facilitated when patients are removed from the huge and impersonal mental hospital. Mental health services should be made a part of the total medical capabilities of communities.

The bill H.R. 6431 is basically an extension of the authority originally granted. Those features of the bill which are administrative in nature we will not comment upon. Is is our considered judgment that experience since the enactment of the Community Mental Health Centers Act has provided ample evidence of the validity of this endeavor. The progress to date, as might well be expected, is not as comprehensive nor far-reaching as could be hoped but it most certainly is headed in the proper direction. This this nation in an enilghtened age could not continue to countenance a system of treatment that was medieval in concept has been proven, even if to a limited degree, during the few short years of experience under the Community Mental Health Centers Act. We are convinced that even greater potentials remains to be realized. The statement of your Committee contained in the Committee's report dated August 21, 1963, which related to the previously accepted method of providing what had been termed as "care for the mentally ill," was most eloquent. In this context the report stated, “Either we must develop the quantity and quality of community services which will ultimately replace these institutions, or we will have to undertake a massive program to strengthen State mental hospitals.” It was further stated that your Committee was of the opinion that there was a need to develop new methods of treatment, that there was a lessening in our disposition to reject and isolate the sufferers of mental illness, and that all of these factors argued strongly for the

treatment of mental illness in the community. Evidence that this would require a major effort seemed apparent ; for example, only $1 was being spent on Community Mental Health Services for every $10 being spent for care in State institutions.

The American Public Health Association was and is in complete agreement with your Committee's conviction that there must be established for the citizen who needs it the capability to obtain through a single point of contact the full range of diagnostic, therapeutic and rehabilitative services, whether in-patient or out-patient, for the mental illness from which he may suffer. We are not convinced, however, that this concept has been accepted by some involved in programs of mental health. We hope your Committee will continue every effort to bring about the desired change of emphasis from the large institutionalized facility to the community-centered mental health program.

We urge, therefore, that the basic elements of the Community Mental Health Services Act be extended as is proposed in H.R. 6431. Would you please make this statement a part of the record of hearings on H.R. 6431? Sincerely yours,

BERWYN F. MATTISON, M.D.,

E.cecutive Director.

AMERICAN HOSPITAL ASSOCIATION,

Washington, D.C., April 6, 1967. Hon. JOHN JARMAN, Chairman, Subcommittee on Health, Interstate and Foreign Commerce Commit

tee, Rayburn House Office Building, Washington, D.C. DEAR CONGRESSMAN JARMAN: This statement is sent to you to express the views of the American Hospital Association in respect to H.R. 6431, a bill "to amend the public health laws relating to mental health to extend, expand, and improve them, and for other purposes."

The American Hospital Association strongly supported the legislation developed in 1963 which resulted in the Community Mental Health Centers Act. We further supported the amendments to the Act developed in 1965 which had the primary purpose of providing assistance in meeting certain costs of professional and technical personnel utilized within comprehensive mental health centers.

At the time the Congress was considering the professional and technical personnel assistance amendments of 1965, we stressed our belief that the costs involved in mental health care were such that the government would likely have to be involved on a continuing basis. We further strongly urged that the matter of such financing be approached on a long range basis. We suggested that such a continuing financing program to be sound should require more than short-term federal monies but should provide a basis for continuing grants with state and local participation.

It was our belief that once a mental health center was developed and in operation, there was no evidence to substantiate any decreasing need for financial support. As we have observed the program in its development, our beliefs have been confirmed by reports we have received from throughout the field. A good many hospitals have not undertaken to participate in the program because of the uncertainties of continued financial support. Boards of trustees are fearful of becoming involved in major mental health developments when they can foresee no continuing assurances as to their ability to finance the projects.

Therefore, we urge once again that this committee approach the problem on a long-range basis and amend the law so as to require continued federal financing with state and local participation.

We wish to comment also on the over-all operation of the mental health program. On the basis of all evidence then available, we expressed our beliefs at the time the legislation was being developed that basically it was essential to develop the program so that mental health care would be developed within the main stream of the communities' over-all health programs. One obvious means for such an accomplishment was to utilize fully the potential of community general hospitals and, of course, the medical staffs of such hospitals.

We are concerned that the program in its development to date is failing to utilize the full potential of existing health facilities throughout the country.

We have had repeated statements from around the country that a basic problem is the rigidity with which the state mental health commissioners have administered the program. By and large, it is our impression that they have had too little interest in seeing community general hospitals participate; and, in fact, the statements are made that attempts on the part of general hospitals ito participate are often frustrated.

It is the contention of general hospitals that there is real danger of mental health moving back into the old pattern of its devolpment outside the general medical care community and within separate mental care institutions. We believe this would be an unfortunate continuation of past practices and policies.

As we have viewed these problems it has seemed to us that in part the present total emphasis on the comprehensiveness of the program may be at fault. There are undoubtedly large medical complexes where it is entirely fitting that a truly comprehensive approach to mental health be developed. However, it is obvious that such situations are relatively few in number when we view the country as a whole. It is strongly suggested that this legislation should be amended so as to make possible the full contribution of general hospitals and the medical care community without the necessity of in every instance insisting that only a totally comprehensive program will be approved.

It is our feeling that this desirable result could be accomplished by amending the law so as to permit the Surgeon General to approve less than totally comprehensive programs in areas of the country where it is demonstrated that such comprehensiveness is not feasible and yet where it can be demonstrated that an important service can be provided on less than a comprehensive basis and in such a way that we are thus taking advantage of all potential resources.

Another hindering aspect of the present mental health program is the high priority given to patients residing in what is defined as "catchment" areas. This suggests a geographic approach to the definition of areas which can be served. Such a definition is totally contrary to the concept of the normal health service areas. The larger community hospitals, and particularly all those which are teaching hospitals, do not draw patients from any specific geographic area. Patients come from widely divergent areas not circumscribed by any set boundaries. We suggest that mentally ill patients can best be served by developing programs for those patients who are normally attracted to a given medical center. This appears especially necessary since it will be a very long period of time before the country is likely to be blanketed by community mental health programs.

The hospitals of the nation as represented by this Association are keenly aware of the enormity of the problems involved in developing adequate health care programs for the mentally ill. We applaud the demonstrated desire of the federal government to stimulate and encourage local community action. This statement is in no wise intended to be simply critical of the past performance of the program. On the contrary, we express our strong belief that it is essential that the full potential of individual communities and the nation's health resources be utilized in an approach to the problems involved. We are fearful that at the present time we are failing to develop programs in such a way as to maximize such full potential and so that such a result will be achieved.

We appreciate the opportunity of expressing these views and request the statement be made a part of the published record of the hearings. Sincerely yours,

KENNETH WILLIAMSON,

Associate Director.

AMERICAN NURSES' ASSOCIATION, INC.,

New York, N.Y., April 3, 1967. Hon. HARLEY O. STAGGERS, Chairman, Committee on Interstate and Foreign Commerce, U.S. House of Representatives, Washington, D.O.

DEAR MR. STAGGERS: The American Nurses' Association, the professional organization of registered nurses, wishes to record its support of H.R. 6431, which proposes to extend, expand and improve the public health laws relating to mental health.

The American Nurses' Association supported enactment of Public Law 88–164 which provided assistance for construction of mental health centers and Public

Law 89–105, which authorized financial assistance to help the centers meet the cost of professional and technical personnel.

We supported the legislation because we were aware that the treatment of the mentally ill in state hospitals was handicapped because of the size, location and staffing patterns of these institutions. Too frequently care has been custodial rather than therapeutic largely due to the lack of professional personnel. This resulted in frequent, long, or permanent hospitalizations. Additionally, the isolated location of most state hospitals deprived patients of close, supportive contacts with family, friends, and community life. This situation also made recruitment of qualified personnel more difficult.

The establishment of community mental health centers is a relatively new approach to the prevention and treatment of the mentally ill. Many communities already have available diagnostic and treatment facilities, inpatient and outpatient psychiatric services, and provisions for emergency care and rehabilitation. In most instances these are not coordinated to the extent that continuing supervision of patients is provided from the onset of symptoms through to complete rehabilitation. One important function of the community mental health center was to stimulate coordinating of these various efforts to improve services to patients and families.

The availability of services in localities where people live can result in early recognition of illness and intervention at a time when treatment is likely to be more successful and lastng. For patients who may still require hospitalization away from their homes, the community mental health center is a resource for providing follow-up care and rehabilitative services. The hospital stay would, therefore, be shorter enabling the individual more quickly to resume his proper role in society.

In addition to providing direct services to patients and families, the mental health center also has an educational function in the community. Because of lack of knowledge and understanding of the pathological process by members of the family and community, the mentally ill were all too frequently rejected. The support and understanding of relatives is vital to full recovery. Because hospitals for the mentally ill are generally in isolated areas, an effective sustained plan for interpreting mental illness and the patient's needs to his family is frequently impossible.

Closer collaboration is necessary between mental health personnel and other health workers in public and private community agencies, and with practicing physicians, nurses and social workers. Although their major function may not be directly related to mental health and mental illness, they too have a responsibility in prevention, in follow-up care, and in rehabilitation. The staff of the community mental health center becomes a resource for helping these allied professional groups broaden their understanding and knowledge of mental health and therefore, provide more effective service. The centers provide clinical facilities where doctors, nurses, psychologists and social workers can gain first hand experience in working with psychiatric patients and their families. In addition, consultant service is made available to those coping with the behavior problems of the child and adolescent.

The success of programs to combat mental illness depends in large measure on the availability of well-qualified professional manpower. We have stated repeatedly that buildings alone cannot constitute a program. They provide only facilities for treatment. The provision of treatment and the quality of care is dependent on personnel. We, therefore, urge your Committee to approve the extension of the provision for meeting the costs for staffing mental health centers.

Your bill H.R. 6431 will continue the assistance to states to help them deal effectively with the problem of mental illness and further relieve them of the tremendous financial burden they carried so long. Establishment of the mental health centers is providing a means, not only for helping patients in their own communities, but also for developing new types of programs that are less costly than the traditional confinement in a longterm institution.

We urge the favorable consideration of H.R. 6431 and request that this communication be made a part of your Committee's record of hearings. Sincerely yours,

JUDITH G. WHITAKER, R.N.,

Executive Director,

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