How do I tell these people about a Bureau of the Budget stretchout? I don't know how to tell them. Will they really understand?

I worry about children, because I have a few myself. The American Psychiatric Association estimates that there are about 4 million children who are in need of some kind of psychiatric help because of emotional difficulties. Of this number, anywhere from a half million to a million children are so seriously disturbed that they require immediate psychiatric treatment.

Very few of these children are getting the treatment which they need. More than 300,000 children were seen in mental health outpatient clinics last year-in most cases the "treatment" consisted of a single diagnostic interview followed by the admission that there were no facilities in the particular area for prolonged treatment. And I have heard it hundreds and hundreds of times, and parents are told that there are no facilities for long-term treatment. How about the other 3,700,000 children who seek treatment? I am just talking about people. Maybe people are out of style, but I am kind of partial to people. I think they are still in style and worth preserving.

I worry about 18,000 children who are still confined this very day in State mental institutions. I may be in the minority, but I don't think one child should be in a State mental institution. I have said this for 22 years and every time 'I walk through a ward and see a child in a ward with grownups, I say, "There, but for the grace of God, would be my child," and it worries me to this day.

Mr. Chairman, I have lived through the era of the snakepits and no one is more pleased with the fact that we are improving our State hospitals and that through increased personnel and drugs we have succeeded in reducing our State mental hospital population by more than 100,000 over the past decade. I am very happy about it but it is nowhere near President Kennedy's goal. He said that by 1963 we should reduce our population from 500,000 to 250,000, but our present census is 450,000, not 250,000.

However, I would remind the committee of this fact. The State mental institution is no longer the primary source of psychiatric treatment. It is very important, but not the primary resource. Twenty years ago, State institutions handled three out of every four mental patients; in 1965, they cared for only one in every five persons.

There is undeniable evidence that the American people are demanding that the mentally ill be treated in the community in the same way in which the psysically ill are. When asked what we want for the mentally ill, I put it simply: We want equal time with the physically ill. That is all we want, equal time.

The average per capita expenditure for the mentally ill in a State hospital is $7 a day for all care. The average cost in the general hospital is $47.19. Is there that much difference between a physically ill and mentally ill patient? I would refer that question to the distinguished doctor from Kentucky. The American Medical Association says that mental illness is America's most pressing and complex problem. If it is, why in something or other don't we spend an equal amount of money on these people. when there are 6 million people in this country who are being treated for mental illness?

We cannot build this network of mental health centers on the cheap.

I don't want to delude you. We cannot do it with 1-year estimates and "such sums as may be required over the next 4 years.'

This was the trouble with the State mental hospital. We never had plans for it. When I was a reporter back in the forties when Mr. Jarman served in the State legislature and was so helpful to us in that program, they never had a long-range plan.

The total per diem cost then in Oklahoma and in Chattahoochee, that garden spot, Mr. Rogers, in Florida, was less than $1 a day. They were just trying to survive and keep their heads above water with thousands of patients and skeleton staffs.

It is a little better today.

Mr. Chairman, may I say this: I believe with all my heart that if we are to meet the promises we made to the American people in 1963, when we asked 30,000 citizens to cover this country and plan for a new era for the mentally ill and they did and they surveyed the State hospitals and they interviewed people and developed the plans and every State has submitted a plan and 30,000 citizens were involved in it, we must renew this legislation for at least 5 years at a cost in the neighborhood of $500 million.

That to me is a minimum figure. We are operating now at a level of $50 million a year and we have built less than 200 centers.

We have to at least double that. I am being conservative. I realize that there is a war going on.

I read the newspapers, too, but so do the American people. I saw in the Washington Post on Monday of this week, and I don't know if the members of the committee saw this, the Harris survey which polled the American people on our domestic programs.

I always hear stories about how the American people want a big space program and want to spend $30 billion to get us to the moon but nobody asks the people.

Lou Harris asked them and the answer was this: They wanted a lot of domestic programs cut, including aid to cities and I don't disagree or agree with this.

This is not my province, but the Harris survey of Monday said that they wanted to cut back aid to cities, cut back aid to welfare and relief programs and cut back the space program and so on but the three most popular programs which they wanted to increase are all within the purview of this committee; air pollution, water pollution, and running No. 3, mental health clinics or centers.

If you want to go to the people and see what they think about it I think that a poll is very eloquent indication of it. Now. I conclude with this statement. This is no luxury item we are talking about. This is no matter of rifles and ruffles as the distinguished House minority leader puts it.

Since when is the mental health of any human being a "ruffle" which we can dispense with at will in wartime or in peacetime. We are talking about what the American Medical Association has described as our most pressing and complex problem and I say finally that I hope to God that all of us here in this room, both members of this committee and all of us here, have the wisdom to act in commensurate fashion.

Thank you very much.

(Dr. Ewalt's prepared statement follows:)

STATEMENT BY JACK R. EWALT, M.D., PAST PRESIDENT, AMERICAN PSYCHIATRIC ASSOCIATION, PRESENTED ON BEHALF OF THE AMERICAN PSYCHIATRIC ASSOCIATION

Mr. Chairman and mmbers of the committee, I am honored to appear once again before a distinguished committee of the Congress on behalf of the American Psychiatric Association to urge legislation which, if passed, will mark another milestone in the nation's struggle against the mental illnesses.

The issue confronting us here today is simply stated. Before the end of this fiscal year upwards of 200 community mental health centers will be under development throughout our country as the result of the Community Mental Health Centers Act. Our national goal is to achieve 500 of these centers by 1970 and 2000 by 1975 in the service of some 200 million Americans. Thus, we have run well in the first few miles of the marathon that started with President Kennedy's wholly new approach to mental illness and mental retardation, an approach that would bring the mentally ill out of the large public mental hospitals back into the main stream of medicine in their own communities. But the final goal is not yet in sight and the hardest miles are ahead. Are we going to drop out or forge ahead? That is the issue.

Speaking for our Association and its 15,000 physician members who specialize in the treatment of the mentally ill, I would leave no doubt in your mind that the extension of the community mental health center construction and staffing program is of absolutely critical importance at this stage in the history of the mentally ill in our country. In all conscience, no other course is open to us. Let me explain why I think so, for we are not dealing here with a mere matter of erecting some new buildings. It is rather a matter of whether we are to follow through on a wholly new concept of how we shall relate to the mentally ill and how we may nurture a mentally healthier nation.

It is an exhilarating observation that we as a people have made more progress against the mental illnesses in the past twenty years than in all the millenia that went before. Nor is it difficult to demonstrate that it has been the federal government, responding to the will of the people, that has provided the foundation stones for that progress. One thinks back on the tremendous advances in psychiatric care generated by the Veterans Administration after World War II. There was the passage of the National Mental Health Act in 1946. In 1955, during President Eisenhower's Administration, Congress approved the Mental Health Study Act which led to the work of the Joint Commission on Mental Illness and Health. Later the stirring report of that Commission (Action for Mental Health) led directly to President Kennedy's special mental health message to the Congress in 1963. Then you appropriated funds to help the states make longrange plans for participating in a new national mental health program and concurrently offered to share with the states the expense of constructing and staffing comprehensive community health centers. More recently, the Congress made provision for extending mental health care to the elderly mentally ill in the Medicare legislation.

What has happened as a result of this stimulatory leadership at the federal level? If we were to state it in a sentence we might simply say that we have found out that most of the mentally ill can be treated in the community, providing that the community will supply an adequate range of comprehensive services for them. But we discovered this in a kind of helter-skelter way.

There were the new drugs, for example, that came our way in the 1950s. It was the first time that psychiatrists ever had some really good pills just like other doctors. These pills would cheer the depressed and calm the manics. With them we could treat many highly disturbed patients in our offices without resorting to long-term hospitalization.

At the same time we experimented successfully with new forms of psychological therapies both in hospital settings and in private practice, such as milieu therapy, group therapy, and family therapy. The idea was to get away from always treating a single patient at a time for the better part of an hour and, whenever possible and effective, deal with several patients at once in a group. Particularly significant in the 1950s was the development of the day and night hospital idea, or part-time hospitalization. It has long since been demonstrated

that many patients can hold a job while they are treated at night, or that they can be treated during the day and return to their homes at night.

Most heartening of all, however, was the growth of short-term psychiatric care in community general hospitals. It is a striking fact that about 500 community general hospitals in our country now have psychiatric departments which admit and treat about 400,000 patients a year, about twice as many as are admitted to public mental hospitals. Many other general hospitals without separate departments also treat many mental patients, and it is probably safe to say that a halfmillion patients all told are treated yearly in these community hospitals. Moreover, a very substantial percentage of these patients have the greater part of their bills paid by some form of health insurance.

All of these developments, combined, are responsible for the fact that our public mental hospital population has declined by about 20 percent over the past decade and this in the face of a growing population and rising admission rate. Concurrently with these auspicious changes came a gradual modification of public attitudes towards the mentally ill by way of an acceptance of their afflictions and support of a realistic national program to help them. Had we expounded the community mental health center idea twenty years ago, our words would have fallen on deaf ears. Even our brethren in other fields of medicine would not have listened. But now it is different.

Another gratifying by-product of this broad movement to bring the mentally ill back into the community and into the medical mainstream has been its effect in quickening the interest of nonpsychiatrist physicians in joining the battle against the mental illnesses. It is a striking fact that about 15,000 general practitioners or family physicians, in the past ten years, have been motivated to take postgraduate courses in psychiatry to enhance their understanding of the patients they see in everyday practice. Indeed, many of them have gone on to specialize in psychiatry. This never could have happened twenty years ago when psychiatry was so largely isolated in public mental hospitals. Psychiatry had to get back into the community where the action is. And, incidentally, every medical school in the nation today sees to it that all of its students acquire basic training in psychiatry.

As for general public attitudes about the mentally ill, there can be no doubt about citizen receptivity to the wholly new approach. I have just recently read the manuscript, soon to be published, of a scholarly survey of public attitudes among adult residents of New York City.* The survey was conducted by Columbia University in cooperation with the New York City Community Mental Health Board. The investigators found that the public was much more optimistic about the treatability of mental illness than formerly. Seven out of ten adults said that they would be willing to have former mental patients as co-workers or neighbors. Nine out of ten think that government should be spending more for mental health services, and there is widespread support for community services, especially emergency services. Interestingly, however, three out of five adults in New York City could not name a hospital that accepted mental patients and three-quarters could not name a clinic where they could go for prompt service. This suggests again how far we have to go in extending community services and educating the public as to their availability.

Moreover, this same twenty-year period has witnessed a quickened interest in psychiatric consultation from industry, the clergy, the courts, schools and colleges, social agencies and all of the others who have a special role in dealing with the troubled people of our times.

Also, twenty-seven states have enacted community mental health services acts to facilitate the development of comprehensive services at the local level. To sum it all up, let us suppose that twenty years ago someone dear to us had developed a mental illness? What recourse did we have? If we were rich and the illness not too serious, we could look for help from the private psychiatrist or the private hospital. If the illness were severe and we were of modest to poor means, we were almost forced to turn to the public mental hospital, and with the sickening thought that it might well prove to be the end of the road for our loved one.

Now it is different. If we are affluent we can still purchase the very best in psychiatric care. But millions more of us can obtain a comparable quality

*The Public Image of Mental Health Services, Jack Elinson, Ph. D., Elena Padilla, Ph. D., and Marvin E. Parkins, M.D., Mental Health Materials Center, New York City, May 1967, 300 pp.

of care in general hospitals, and increasingly in day and night hospitals, outpatient clinics, half way houses, rehabilitation facilities, nursing homes, and the like. We can do this because more and more of these facilities are becoming available and more and more of the cost of such care is borne by third-party payments.

What I have been talking about, of course, is the community mental health center idea and how it evolved, bit by bit, over the years. If we do not appreciate that the community mental health center is not so much a building as an organization of services, then we cannot truly grasp the import of extending the construction and staffing legislation. Hence I have tried to place the whole development in its historical context.

As you know, to qualify for federal assistance every center project must incorporate five essential services-an inpatient service, an outpatient service, part-time hospitalization, emergency service, and consultation service, and these services should be geared to accommodate from 75,000 to 200,000 persons. None of these services represent new ideas, as I have sought to demonstrate. What is new about the community center idea is the pulling together of these elements into a manageable, coordinated continuum of services in a particular community or segment of a community. If it makes no sense for a patient with pneumonia to be seen by a dozen different doctors and treated in several different facilities, neither does it make any sense for a mental patient to be shunted from a social agency to a clinic to a hospital to another social agency, ad infinitum, seeing different professionals and filling out fresh forms at every stop along the way. The principle of the center operation is that by drawing together the five essential services into a single administrative unit any patient eligible for treatment in any part of it will be eligible for treatment in any other part of it.

Very rarely would a community need to construct a mental health center with all of the essential services from the ground up. It is the stated position of our Association, for example, that wherever possible the inpatient component of a center should be provided by the community general hospital. On the other hand, a new building might be needed to house the other four essential services, or any part of them. In a word, the important consideration is not to duplicate existing services but to fill in the gaps and harness all together in a coordinated system to meet individual needs within the same system. For example, in the West Philadelphia area there are six major hospitals and a host of social and community agencies all of whom must share responsibility in providing comprehensive services for that area. If they were to plan independently, the result would be chaos. In 1965, however, they got together in a joint planning effort under the aegis of the University of Pennsylvania and formed what they call the West Philadelphia Mental Health Consortium. This Consortium has just recently submitted a staffing grant application which proposes to use all of these facilities in providing the five essential services for the area.

I hope I have helped to make it clear why the extension of this legislation comes at such a critical time in our history. We are just getting started.. Millions of Americans remain outside of the wholly new approach. The states have had less than two years to develop their plans, submit their applications for assistance, and get their new centers under way. It is of no small significance that as of the end of the first fiscal year (June 30, 1966) 93 center projects in 43 states and Puerto Rico had been funded through this program. Ninetythree percent of the construction monies and 80 percent of the staffing funds had been obligated. Has any other bold new program launched by the Congress ever been seized upon more avidly? I doubt it. But the people on the firing line in your state and mine have scarecly had time to catch their breath. cannot yet, in all fairnes, select out a single center any where and say, in confidence, "this is the way to do it." One does not achieve massive social change in a trice. But we can point with pride to the enormous progress I have highlighted and the promise of quickening our efforts to further the purposes of the community mental health center.

In closing I am reminded of Mr. Winston Churchill's comment after the British had defeated General Rommel in North Africa to the effect that one could not speak of it as the end, or even as the beginning of the end, but it was, he said, perhaps the end of the beginning. I hope, gentlemen, that you will approach this legislation in Mr. Churchill's spirit and that you will pass this legislation with the same degree of unanimity that you approved the original propositions which it will now extend.