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Washington, D.C. The subcommittee met at 10 a.m., pursuant to recess, in room 2123, Rayburn House Office Building, Hon. John Jarman (chairman of the subcommittee) presiding.

Mr. JARMAN. The subcommittee will come to order. We will continue the hearings on H.R. 6431. I think the only comment that the Chair would make at the beginning of the hearings this morning is, that we do have seven witnesses. We do intend to try to finish the hearings this morning. So that, I hope that both witnesses and members of the subcommittee will take note of that time limitation that we have.

Our first witness this morning is Mr. Bert Seidman, director of Social Security Department, AFL-CIO.



My name is Bert Seidman. I am director of the Social Security Department of the AFL-CIO, and I am very pleased to have the opportunity to testify here this morning on behalf of the AFL-CIO on the amendments to the Community Mental Health Centers Act, H.R. 6431. With me is Mr. Richard E. Shoemaker, who is assistant director of the AFL-CIO Social Security Department.

We appear here this morning in support of the amendments proposed by the distinguished chairman of the full committee, Congressman Staggers, in H.R. 6431, which extends authorization to continue Federal financial support for the construction and staffing of community mental health centers. H.R. 6431 also includes authority for grant recipients to use funds for the acquisition of existing buildings

rather than just the expansion, remodeling, and alteration of such structures. We also support the amendments which would authorize project grants to Federal institutions and the provision for the establishment of a contingency account to meet unforeseen needs.

Mr. Chairman, the AFL-CIO appeared in 1963 in support of the Community Mental Health Centers Act (Public Law 88–164) and



again in 1965 in support of the Community Mental Health Centers Amendments to provide funds for the initial staffing of mental health centers. We appear again today because of our continuing interest in this vital and exciting program. The people of the Nation are indeed indebted to the late President Kennedy for his imaginative recommendations which formed the basis for the mental health program, the extension of which this committee now has under consideration.

Mental health is indeed America's number one health problem. One out of every 12 Americans is now being hospitalized for mental illness at some time during his life. By providing early diagnosis and early treatment on an out-patient basis through the Community Mental Health Centers, this frightful toll can be substantially reduced. About one-half of the hospital beds in this country are used in treatment of the mentally ill. Through early diagnosis and treatment, many people who would otherwise require hospitalization can be kept on their feet, on their jobs, and in their families and in their communities.

Available evidence indicates early diagnosis and treatment on an out-patient basis can greatly reduce hospitalization for mental illness. The experience of the Massachusetts Mental Health Center, one of our older out-patient programs, is an example. In 1940, only 700 of the 3,171 patients were admitted as out-patients before the emphasis was placed on out-patient treatment. In 1961, this ratio was reversed: only 700 of 3,700 patients needed hospitalization and only 40 of the 700 had to be committed to State mental institutions.

We, in the AFL-CIO, have a very direct interest in this program. Up until the passage of this legislation, workers suffering from mental illness have very rarely received any kind of treatment-good, bad, or indifferent. This has been true, because the overwhelming bulk of our mentally ill have simply been institutionalized, many of them in city and State hospitals where they received mainly custodial care rather than a program of active therapy. Out-patient services have generally been limited to the upper and upper-middle income groups which could afford treatment on a face-to-face basis with a private psychiatrist or psychoanalyst.

This situation is currently changing, and new therapeutic techniques such as drug therapy, group and family therapy, role playing, work therapy, and so forth, show great promise of providing effective treatment for more people at reasonable cost. Our experience with mental health programs that have been negotiated by some of our affiliates clearly illustrates the need to make provision for out-patient facilities. Negotiating money to pay for treatment is not enough. The treatment a member may elect to purchase may not be appropriate or may be prohibitively expensive, such as face-to-face therapy by a private psychologist. We wish, therefore, to emphasize that the initial contact the person needing treatment should make should be with the community mental health center where his condition can be diagnosed and a course of treatment outlined from among a wide range of therapeutic procedures.

Such a program is that of the Retail Clerks in Los Angeles, where psychiatric care is rendered at several centers which are open day and night. The union's welfare fund contracts for the service on a prepaid basis and the membership is encouraged to use the plan

through the union's official journal and through their educational programs.

The Retail Clerks mental health program is built upon four basic principles: (1) immediate service (no waiting lists) ; (2) continuity of care; (3) flexibility of treatment approaches and methods; (4) comprehensiveness of care. Face-to-face therapy is provided when deemed appropriate, but by stressing early treatment the more expensive therapeutic methods have been minimized. The important thing is that such a full range of services can only be made available through a unified clinical and administrative program. This comprehensive mental health program is financed by a 2 cents per hour employer contribution to the health and welfare fund and by a $2 per-visit fee.

The great promise of the Community Mental Health Centers Act, in our opinion, is that it will enable our affiliates to bargain with employers for similar programs wherever there is a mental health center which could provide the necessary services.

The Community Mental Health Centers Act, as amended, holds great promise for the future, but the program is only in its infancy. As of March 1967, grants totaling about $66 million had been made to approximately 160 mental health centers in 46 jurisdictions to serve a population of some 27 million. H.R. 6431 extends through fiscal 1972 authorization for facilities and staffing of the community health centers. For fiscal year 1968, $50 million is authorized for facilities is compared to $65 million for 1967. The authorization for staffing is $30 million. We believe both amounts should be increased. We should accelerate the program toward the goal of having as many mental health centers as are necessary in order that every person in the United States could have access to a mental health center by 1975.

Mr. Chairman.
Mr. JARMAN. Thank you very much, Mr. Seidman.

At the end of your statement you indicate that you think amounts in the bill should be increased. Of course, in the bill there is an openend provision setting out “and such sums as may be necessary for the next 4 fiscal years." The committee will be interested in any concrete and definite recommendations that might be made to it as to what the figures should be, because there is certainly thinking on the committee that the amounts should be pinpointed in detail rather than leaving it as an open-end provision.

So that any evidence that you might care to furnish us on what you think the authorization should be would be considered by the committee.

Mr. SEIDMAN. Mr. Chairman, of course, we are not in a position to give you a pinpointed figure as to what this might be.

Mr. JARMAN. I might say that I didn't have in mind necessarily that you do so this morning; but if you have evidence to submit on that, submit it to the committee.

Mr. SEIDMAN. I could be very brief in stating what our recommendation would be. Our feeling is, that the original goal of 2,000 mental health centers throughout the country is one which should be reached by 1975, and we think therefore that the amount which is set forth in this bill for 1968 is inadequate. We have no recommendation as to the precise additional amount, but we think it should be

Thank you,

substantially greater not only in fiscal year 1968, but even more so in the years ahead. Because we think that the tooling up phase of this program will have been completed by that time, and that the necessary preparations and construction of centers can go forward more rapidly in the ensuing years.

Mr. JARMAN. Thank you very much.
Mr. Satterfield.
Mr. SATTERFIELD. No questions, Mr. Chairman.
Mr. JARMAN. Mr. Springer.
Mr. SPRINGER. No questions.
Mr. JARMAN. Dr. Carter.
Mr. CARTER. No questions,
Mr. JARMAN. Thank you very much for contributing to the hearing.

Our next witness this morning is Dr. Jack Ewalt, of the American Psychiatric Association; accompanied by Mr. Mike Gorman, of the National Committee Against Mental Illness.

I would like to comment that Mr. Gorman is a longtime friend, dating back to Oklahoma days when he was active in newspaper work and did a very comprehensive study of mental illness in our part of the country. STATEMENT OF DR. JACK EWALT, AMERICAN PSYCHIATRIC ASSO

Mr. GORMAN. I thank the Chairman.

Dr. EwALT. It is an honor, sir, to appear before the committee in support of H.R. 6431. I have a prepared statement which I shall not read. I will try to talk very briefly, at least for a psychiatrist, and try to answer any questions.

Mr. JARMAN. Dr. Ewalt, I also would like to mention the fact that you have served very efficiently as staff director for the Joint Commission on Mental Illness and Health.

Dr. EwALT. Thank you.

Currently we have less than 200 of these mental health centers under construction across the country. If we are to give adequate service of a minimal sort to our 200 million citizens by 1975, we will have to have about 2,000 of these. It takes time and effort to plan these things and raise the local funds which represent about $3 for every Federal dollar expended. It takes time to make the plans that will meet the Federal criteria. The program should accelerate so that by 1970 we will be able to have about 500 of these centers and then double that number in the following 5 years, if we can get adequate support.

In the past years, we have made a great deal of progress. We have the Joint Commission Study, which was authorized under the Eisenhower administration and completed under the Kennedy administration. We have the Kennedy Mental Health Plan, and the States have made a lot of plans.

We have made much progress in the ways we treat patients. You have heard a lot about milieu therapy, the importance of the surroundings to patients; about the flexibility of care—not making them stay

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