Mr. ROGERS. Thank you, Mr. Chairman.

Mr. JARMAN. Mr. Carter.

Mr. CARTER. Thank you, Mr. Chairman.

Thank you, gentlemen, for your excellent presentation. Certainly, I appreciate the dedication that you have to this great problem that faces all of us, mental health.

Of course, I further agree with you that not only should we pay adequate attention to mental health, but also air pollution and water pollution, which are great problems to us at this time.

I think regardless of the war we must pay attention to our internal problems. This problem should be solved, war or no, or it might some time affect our internal security.

Another thing, any home may well be involved. Young children as you say are often involved. I have seen this many times. It is heartrending to see a youngster of 14 talking incoherently and it is extremely gratifying to see these minds find themselves. I think you have a wonderful program and I certainly want to do my part. Dr. EWALT. Thank you.

Mr. GORMAN. Thank you, Dr. Carter.

Mr. JARMAN. Mr. Satterfield?

Mr. SATTERFIELD. Thank you, Mr. Chairman.

Dr. Ewalt, I haven't had a chance to study your statement as I certainly will because I am sure that it will be important and interesting if for no other reason than your experience in this area.

Was I correct in interpreting that you treated 9,000 patients in your center last year?

Dr. EWALT. It would be just under 6,000, I believe, sir.

Mr. SATTERFIELD. The reason I make this point is that I think it might be interesting to this committee and to the record if we might have from you a breakdown of your pattern of staffing during this period of time. I don't know whether you have it at hand now or if you can submit it.

Dr. EWALT. I can tell you but it isn't a fair one. Our institution has three functions and the budget and staffing for the research efforts and the training efforts-it is an integral part of Harvard Medical School-equal that for patient service. I have 70 young doctors in training there in psychiatric residencies plus four under a special program of private funds from Asia to try and introduce methods

there.

It takes a vast number of senior doctors to supervise their work if we are to keep them out of trouble. Harvard Medical School has a very intensive educational program. I have the figures right in my head but I think to say that this is what you would need, say, out in western Massachusetts at Pittsfield is not correct.

I will give you them. I have 70 residents. I have 35 senior psychiatrists that are full-time and 35 that work from a half day to a day a week. I will even go further. If you came to our place you would find that our medical program is good and the place is filthy.

I have 22 psychoanalysts and 19 janitors so that our medical program is better than our housekeeping. The Massachusetts Legislature will give me doctors and Harvard will give me doctors but nobody will hire a porter for me. I figured this out once and I could send the figures of what I could run the place on if I didn't have a

teaching or training thing and I think I could handle the thing on about 20 psychiatrists and that many psychologists and 60 social workers but I will send you those figures.

Mr. SATTERFIELD. If it is not too much trouble.
Dr. EWALT. It is no trouble at all.
Mr. SATTERFIELD. Thank you, sir.
(Information requested follows:)

MASSACHUSETTS MENTAL HEALTH CENTER,
DEPARTMENT OF MENTAL HEALTH,
Boston, Mass., April 7, 1967.

Rep. DAVID SATTERFIELD,
Congress of the United States,
Washington, D.C.

DEAR REPRESENTATIVE SATTERFIELD: You asked about the number of staff I would estimate it would take to run a community mental health center for about 100,000 people. I believe the estimate usually kicked around is for about ten psychiatrists and appropriate numbers of other supporting personnel. I have played around with these figures some for our own hospital as I testified. Our experience requires a little free estimation because we have been serving the entire state but not on a giving service to everyone's basis. Further, because we have large numbers of persons here, including myself, who do a fair amount of one-to-one or individual psychotherapy or psychoanalysis, we use up more manpower than may be required in many of the community mental health centers. Also, most of my time for example is spent either in teaching or supervising research projects. By these maneuvers, having warned you that these figures are educated guesses at best, I will proceed.

Our hospital on any day has about 200 to 220 in-patients, about 125 of whom are on a 24 hour care basis and the remainder on a day or night basis. There is a considerable shifting of patients between the above categories as they improve or have temporary relapses. Each patient is seen briefly every day by his physician and has from one to three prolonged interviews or psychotherapy each week. The out-patient department and the emergency service see about 5,000 different persons a year. The hospital admits approximately 900 persons per year. The number of persons coming to the out-patient department means little as the work load depends on the number of patient visits. If one person comes ten times, he uses up more manpower than five persons who come once each. Therefore, most clinics count their case load in terms of "patient visits", that is, each time a person comes to see his doctor he is counted as one. Thus one patient who comes twice a week for a year might account for a hundred patient visits in a year, and another person who comes only three times and then needs no further care would only count as three, etc. Our clinic runs about 47,000 patients visits per year. Again I would emphasize that our patients all have some type of individual therapy as well as some type of group therapy. Because we are a teaching and research institution, this type of approach may be more intensive than is needed-I think we just don't know for sure.

My estimate as figured out on man hours, with appropriate time for vacations, etc., is that it would require about 25 full time people to man the clinics if they did nothing but care for patients. It would take about 15 to man the house or hospital if they did nothing but take care of patients.

These figures are for our present operation. The best estimate I can make at this time for the demands on us from our catchment area is that about 65 percent of the above hours and patient days will be used up by patients from our catchment area which has 225,000 people in it. Thus as we operate I could get by with approximately 10 in the hospital and 16 or so in the clinic for 225,000 people. If we divided this again by half for a catchment area of 100,000 we would then come out with about 13 psychiatrists necessary to operate such a center, that is, psychiatrists or persons working under a psychiatrist doing essentially what they do. Some institutions would operate with a smaller number of psychiatrists and a larger number of social workers or clinical psychologists. Because we are a medical center we tend to use more of the medical personnel and less of the social workers or psychologists. In an ordinary center, however, I would assume they would have approximately two to three social workers for

each psychiatrist, and at least half the number of clinical psychologists. If the psychiatrists in that region were in short supply, a great deal of the work that the psychiatrist does can be done by properly trained social workers, psychologists or nurses, under the supervision of the psychiatrist. Therefore, the numbers might be changed around proportionately.

I have made no estimate of the number of nurses because this would vary tremendously, depending on the proportion of in-patient and out-patient activities carried on, and how much the nurses made home visits.

Again let me emphasize that these are educated guesses at best. I think one will find that the number of persons required in centers in different parts of the country may vary substantially, and one major variant will be the kind of treatment the people there want; that is, do they want predominantly medications and group supportive therapy, or do they want long-term intensive therapy, etc. It will also vary with the amount of use made of psychiatric aides, new categories of mental health workers, etc. However, as far as I can tell the above figures will do for a start.

Sincerely,

Mr. ROGERS. Would the gentleman yield?
Mr. SATTERFIELD. I yield.

JACK R. EWALT, M.D.,
Superintendent.

Mr. ROGERS. What would you say is the population area that serve?

you

Dr. EWALT. As of the first of April or March 28, our new mental health plan went into effect and I was given a so-called catchment area and it has 225,000 people in it.

I was given this area because of our relatively large staff and the fact that this hospital was set up to serve the whole State as a teaching and research hospital and the buildings and facilities and staff are there and so we will continue to do this.

Now, it is our estimate that our admission rate to the hospital will be about 300 a year from our catchment area, leaving us roughly 600 a year whom we will continue to serve from less well-sponsored areas of the States.

The clinic breakdown I don't have yet. It is hard to count individuals in the clinic. We run about 47,000 clinic visits a year.

This is a guess and let the record plainly show that it is a guess. Probably there are not more than about 20,000 visits a year; that is the person coming to see the doctor or the social worker from our particular catchment area.

Mr. ROGERS. I wonder about this: When the mental health center was projected it was about 100,000 up to 200,000, 20 psychiatrists and a little over.

Dr. EWALT. That was the figure I gave him off the top of my head. We have 200 beds.

Mr. GORMAN. He is modest. He has the oldest center in the country and does more business than any patient center.

Mr. SATTERFIELD. Mr. Gorman, I have just one question to direct to you. In answer to one of Mr. Rogers' questions, you indicated that we should accelerate more rapidly than you think has been indicated, maybe to the extent of doubling what you think has been indicated.

I am sure that this suggestion will get due consideration and I would be interested in knowing whether or not you feel that we have enough properly trained personnel to permit that kind of acceleration.

In other words, are there sufficient personnel to justify acceleration of the kind you suggest?

Mr. GORMAN. I am delighted, sir, that you asked me that question because in the 5 years I have served on the advisory council the basic problem has been how you get the manpower.

We have it in the State hospitals. As Dr. Ewalt correctly points out, it is awfully tough to get them to work in State hospitals. More than 45 percent of the doctors in the State hospitals are foreign-born physicians, in Florida quite a few Cubans and in New York State more than 50 percent are foreign born.

We don't seem to be able to attract the young American doctor except in the new hospitals.

Let me say that in 1945 there were 3,000 psychiatrists. Today, there are 18,000. It has become a very strong specialty. Last year more postgraduate courses were offered in psychiatry than in any other single specialty. We have come from a very small band into a very broad specialty. The same is true with psychiatric nurses, social workers, and others.

I have been to see a few of these centers under the staffing grants. It seems to me that there are millions of people who lead empty lives, unproductive lives, housewives who are getting tired of playing bridge or being beaten at canasta, who would like to work in a center as a mental health worker.

I think the hand-to-hand relationship, the help one gives to a child who is disturbed indicates that you don't have to have five degrees on the wall. I have seen this in the foster grandparents program.

I have seen mothers working on the wards with children. I have heard doctors say, "This is the most effective person we have in the entire hospital."

We haven't begun to tap the manpower.

I think it has been proven in VISTA, foster grandparents, and other programs that we can use these people effectively. They are the first meaningful contact some of these kids have ever had with another person. I talked to one of these foster grandparents who had a stroke, who sat at home for 4 years. He said he was useless, retired from business, had a barber come in and shave him, wouldn't go out, and so on.

Now he goes to Children's Hospital every day. I said, "Why do you do that, sir?" He said, "Mr. Gorman, there are six children who depend on me getting there every day so I get up and shave myself and get there every morning at 9 o'clock."

He doesn't have any degrees. He is a successful businessman. Now he shaves himself. The barber has less work.

Mr. SATTERFIELD. That is all the questions I have.

Mr. JARMAN. Thank you, gentlemen, for your contribution.
Mr. ROGERS. May I ask just one question before you leave?

I, too, have observed this foster grandparent program in the mentally retarded program in Florida. It is very successful. Some of the children never expressed themselves and are beginning to now. They say it has been very successful. I wonder if your association has gone into this problem to the extent that you could recommend the use of people in psychiatric centers. I think there is going to have to be some knowledge and some leadership and guidance given before they would bring in people like this to use them. I think there is a hesitancy.

Mr. GORMAN. Exactly.

Dr. EWALT. I agree with you, sir, but there has been a lot of work done in this. I believe our fellow association, the National Association for Mental Health, has really taken the leadership as a lay organization, working with lay people.

Our association has certainly helped. If you would like, I will send you a book on volunteers in mental hospitals which my good wife edited for the Massachusetts Association for Mental Health and which prescribes programs around the country.

but

You hear a lot about the Harvard College kids getting into trouble you don't hear about the several hundred under the program working in hospitals giving aid to psychiatrists and we are even using high school youngsters.

We have taken some leadership but mostly it goes in cooperation with the Association for Mental Health.

Mr. ROGERS. I was hoping you would give consideration to having your association actually put forth a plan of this type to get this information out.

Mr. GORMAN. We have, Mr. Rogers.

Mr. ROGERS. The psychiatric association, itself?

Mr. GORMAN. The National Institute of mental Health is directly concerned with manpower. We spend $100,000,000 a year on training programs which you give us through appropriations.

We have called conferences for what we call the middle level mental health worker. Our best source is the junior colleges. We have found a number of junior colleges that will train the 2-year workers.

The Southern Regional Education Board has done a terrific job. Dr. McPheeters, who used to be the mental health director in Kentucky, is now the Associate Director for Mental Health. I am supposed to attend a conference on what helpers you can use, whether you can train them in junior college, in Atlanta next week.

Mr. ROGERS. I think that is excellent. I think there is going to have to be more recognition by the doctors themselves to get acceptance. Mr. GORMAN. We are bringing them into the conferences?

Mr. ROGERS. Of these nonprofessional people.

Mr. GORMAN. It is a big problem.

Dr. EWALT. I would agree with you, sir. The thing, however, is that it is being done, not perhaps as much as it should be, and it is growing.

Mr. ROGERS. Shouldn't you have a committee go into this problem? Dr. EWALT. By seeming to pause, I am trying to think. The American Psychiatric Association, I think, has 70 committees and I am not sure whether we have one on this particular problem.

We have one on working with physicians and working with the volunteers. I will look into this.

Mr. ROGERS. I would be very anxious to follow up on this.

As you say, I think the use of the elderly people, perhaps in this program with short courses through the junior colleges would be helpful.

Dr. EWALT. The thing one has to be careful in the professional business is staying out of the other fellow's backyard. If the National Association for Mental Health has a big program, we would tend to help and work with it.