program and we did away with many of the traditional practices of searching, keeping doors locked, etc. We utilized many community agencies and brought volunteers into the institution thus keeping the institution and the community closely associated. This program as well as others have demonstrated beyond any doubt that keeping the patient at home does make a significant difference in how he responds to the definitive treatment offered him and even more importantly, how well he stays at home.

The impact of the comprehensive community mental health centers making treatment available to any aggregate population of 75,000 or more is indeed staggering. It is my firm, sincere judgment that the far sighted thinking on the part of the National Institute of Mental Health in instituting this program will be by far and away the most significant of all of the three revolutions. Although it will in no way eliminate mental illness any more than general hospitals eliminate physical illness, it will alleviate much of the suffering, the agony, and the despondency to which only those who have had mental illness can testify. Ladies and gentlemen, as a professional person with the responsibility of caring for the mentally ill of a State, I would urge you to consider at all costs not only the extension of the present program, but a large expansion of it. To do less would be more than foolhardy and would potentially endanger the lives and the emotional health of every one of us here.

Dr. GLASS. I would like to follow with my statement. I have a prepared statement. I will not read it because I feel that Dr. Donohue has a story to tell and does not have a prepared statement.

I should like to summarize my remarks by pointing out that you have heard of the decade of effort to obtain this community program, going from the studies that Dr. Ewalt had in the Joint Commission on Mental Illness and Health and you know about Public Law 88-164 which launched the community mental health center program.

It not only launched a construction program but a whole new way of doing this, not new techniques, but a new operation, how to use people, how to treat people as outpatients, how to treat them in alternatives to hospitalization.

So that the program launched not just construction but a new way of handling the problem. Now it is almost as if the military medical services, and I am an old military psychiatrist, confined their operations only to base hospitals and didn't have followup field service to support troops in the field.

This is what the new program did. Necessarily it took time to get started. It had to be written. It had to be understood.

Enthusiasm had to be stimulated and we have gone through the first 3 years of this. Now we are moving. We have a momentum going. There are only 128 construction grants and 72 staffing grants as of April 1.

Now, many of these are complementary. Our one grant which Dr. Donohue will talk about is both staffing and construction. If we at this time fail to renew this program we have broken faith with everything that we have tried to do in stimulating it.

For example, this would stop a whole decade of progress. We are on our way now. We are getting more and more interest. More and more people are exploring this idea and understanding it. I don't know how much time I spent in Oklahoma explaining what a community health center was.

It was always mixed up with a clinic. The substance and spirit of this law strongly indicates that a continuing program was contemplated, not only President Kennedy's 2,000 centers.

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For example, there is the insistence that the State plan shall provide for adequate community mental health centers for all of the people in the State-not a few of them-and it shall set forth a program for construction of seven community mental health centers based on a statewide inventory and I am quoting from the law.

It should be evident that if we don't fully renew the center program, we will be discriminating against those regions and communities in which approved applications have not yet been completed or are on their way. Often this delay is due to a shortage of mental health people in this community and often those communities need the mental health care the most.

For example, failure to review this legislation would do the following in Oklahoma: we have three grants, two approved, one in the process. Those three grants will use up most of the money available under the present 3-year program.

Yet, when completed they will supply services to less than a fourth of the population, to 600,000 which is less than one-fourth of our population.

This is what I mean. Yet, this excellent beginning has stimulated Muskogee, has stimulated Ardmore and other places to get going on this project. If we fail to renew it we block all of the efforts that we have done all these 3 years.

With that, I would like to turn this over, unless you have questions at this time, to Dr. Donohue, who will show you what a center looks like, at least from planning and somewhat from an operational stage. (Prepared statement of Dr. Glass follows:)

STATEMENT OF ALBERT J. GLASS, M.D., DIRECTOR DEPARTMENT OF MENTAL HEALTH, STATE OF OKLAHOMA

Mr. Chairman, I am Dr. Albert Glass, Director of the Oklahoma State Department of Mental Health and a member of the Board of the National Association of State Mental Health Program Directors. I represent these Directors of the state programs for the mentally ill in the 50 states and several territories.

As administrators for the vast majority of metnal health services in the United States, the State Mental Health Directors have a vital concern in the proposed Mental Health Amendments of 1967 and unanimously urge its passage. This act will make possible a continuation of the nationwide movement to improve and increase the availability of treatment resources for mental disorders, which was launched in 1963.

PROPOSED AMENDMENTS

1. Renewal of the Centers Program for an additional 5 years.

(a) Extends the community mental health construction program through Fiscal 1972. Authorizes $50 million for Fiscal 1968 and such sums as necessary for Fiscal 1969-1972.

(b) Permits construction grant recipients to use the funds for acquisition of existing buildings instead of only new construction, remodeling, alteration, expansion, etc.

(c) Provides for enforcement after 1969, in state plans, of maintenance and operation standards.

2. Renewal of Staffing Program.

Extends funding of staffing program for community mental health centers through fiscal 1972; also provides authority to continue making grants through fiscal 1976 to centers already receiving grants. 3. Contingency Fund.

Establishes "contingency fund" for the Secretary of H.E.W. Secretary would have control of $50 million of expiring unobligated funds out of various HEW grant programs. Has no direct bearing on mental health

centers program.

BACKGROUND

In order to appreciate the importance and need for the proposed Mental Health Amendments Act of 1967 it is necesary to review the origin and present status of the Community Mental Health Centers program.

Over a decade ago the Joint Commission on Mental Illness and Health was established by Congress to study and make recommendations on this most common and most disabling health problem of the nation. As a result of the Commission's findings and report in 1961 and the rising awareness of the increasing dimensions of mental disorder by many prominent lay and professional citizens, PL 88-164, the "Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963" was enacted by the 88th Congress. In essence, this Act authorized funds to begin the construction of community based facilities for the mentally ill and the mentally retarded. It should be recognized that, at this time and even today, the majority of mental disorders were either neglected or because of the absence of an alternative to hospitalization are referred to state mental hospitals, many of whom were located at some distance from the community. This lack of local mental health facilities is in sharp contrast to surgical, medical, and other non-psychiatric medical services which were present mainly in or near the community. In effect it is as if military medical services were provided mainly in base hospitals with little or no facilities to follow and render prompt medical support to troops living and fighting in the field.

While the 1963 act seemingly only provided for the construction of community mental health facilities, in actuality it introduced new concepts and programs for the management and treatment of mental disorders. Since new methodology and concepts require considerable time for understanding and acceptance and because of the scarcity of mental health personnel similar to the general shortage of health personnel, initially, implementation of the Community Mental Health Centers Construction Act proceeded slowly. But with time and effort there came more and more awareness and increasing appreciation of the "Centers" concept. This program was given considerable impetus in 1965 by passage of the Amendments of Public Law 88-164 which authorized financial assistance toward meeting the cost of technical and professional personnel serving community mental health centers during the first 51 months of their operation. With this assurance of staffing support more community and public agencies moved to explore ways and means of establishing centers and submit feasible applications for their operation and construction.

In the several years of its operation, PL 88-164 has encountered inevitable problems in its regulations and administration which have been or are being resolved. For example, initially regulations and attitudes due to the anxiety and effort to stimulate "center" applications unwittingly fostered the impression of a rivalry between community mental health centers and state mental hospitals. It seemed that a dicotomy was being established between these two systems of mental health care. Indeed it was "rumored" that community mental health centers would do away with state mental hospitals. However, with time and experience it has become clearly and widely evident that comprehensive mental health care requires the integration of services between community centers and state mental hospitals. Further, that Community Mental Health Centers, must be supported by facilities of state mental hospitals, else cases requiring prolonged care will absorb the energies of the Center and prevent its function as a flexible facility which can promptly respond to local problems and needs. It has become recognized that state mental hospitals can and should provide community mental health services either alone or in concert with local community agencies for citizens residing in its environs. This more flexible use of state mental hospitals is of particlar pertinence in view of the shortages of the mental health professional manpower which are even more scarce in rural areas where many state mental hospitals are located.

The overall events and experiences of the past several years has produced increasing implementation of the Community Mental Health Centers Act until at this time (1 April 1967) 121 construction grants have been made along with 73 staffing grants.

RENEWAL OF THE CENTERS AND STAFFING PROGRAM

1. Failure to renew the Centers and Staffing program at this time would be disastrous to a decade of progress that has been made in community psychiatry.

It should be recognized throughout the country that there are many applications in various stages of preparation. The withdrawal of federal support at this time would make it virtually impossible to reestablish such favorable climate and interest in providing services for the mentally ill.

2. The substance and spirit of PL 88-164 strongly indicates that a continuing program was contemplated. For example, there is the insistance that the state plan "shall provide for adequate community mental health centers for people residing in the state" and shall "set forth a program for the construction of community mental health centers (A) which is based on a state-wide inventory of existing facilities and survey of needs."

3. It should be evident that the non-renewal of the Centers program would be discriminatory for those regions or communities in which approved applications for community mental health centers have not been completed. Often such a delay is due to the shortage of mental health professional manpower which frequently occurs in communities where there are the greatest needs for "Centers." In effect, only certain communities would enjoy federal support for their mental health programs, whereas other areas of need would be denied.

4. An example of what would occur in the event of failure to renew the "Centers" program can be envisioned in Oklahoma. In Oklahoma, three approved or current applications for Community Mental Health Centers Construction will absorb most of the federal funds made available to the state under PL 88-164. However, these three centers will serve less than 1/4 of the state's population. But this excellent beginning has stimulated other communities who are now exploring ways and means of making application for community mental health centers. A denial of the "Centers" program at this time would not only eliminate planning, but also any future efforts to establish community psychiatry.

In summary, the state directors of mental health programs who are in daily and intimate contact with the mental health problems of the country strongly urge pasage of the Mental Health Amendments of 1967. Failure to enact this legislation will impede a decade of progress in establishing improved and modern mental health care.

Mr. JARMAN. Doctor, I think it would be well if you go ahead with your part of the presentation and then perhaps there will be some questions.

Dr. DONOHUE. This is a community mental health center. These are the essential services that are offered. As you may know, a community mental health center includes outpatient, inpatient, partial hospitalization emergencies, consultation and education services. These are the required. These are the ones that are recommended and in addition, diagnostic precare and aftercare, rehabilitative, research evaluation, and training.

These are the services that we have in the center which we will show you that we have now in actual operation. We began operation a month ago. We have both a staffing and construction grant and at this time I want to show the reason for the need for this.

Somebody asked a while ago about the number of patients. This yellow line shows the admission rate into the central State hospital in Norman, Okla., which serves a million population in density. 24 counties in central Oklahoma, but reflects what happens not only in Oklahoma but in most other States.

In 1953 and 1954 as Congressman Jarman is well aware, we were admitting about 1,000 patients. We were kind of in the snakepit area in 6 or so years after Mike Gorman but we started coming up and as you can see this is the way it is all over. Our number of patients in the hospitals is dropping down but this has only decreased the overcrowded and other things because if we had not decreased the census look at that admission rate which is now going up.

We started with 1,000 admissions a year and are now over 4,000. Personnelwise, in order to take care of these custodial patients we were using 880 some employees on a 48-hour workweek and now we have a 17-percent increase but they are professional people who came in to do this job.

Incidentally, we are estimating that the center now that we are operating is going to serve one section of this area which has 256,000 people in it. We estimate that out of that 256,000 that we will admit the same as we admitted out of this million. Why? Because we are there where these people can come and get this treatment and get it when they need it immediately.

The don't have to drive 40 or 50 or 100 miles.

This is a cross-section of the proposed new mental health center. The plans are up here now and I was talking to the National Institute of Mental Health yesterday and we are ready to break dirt. This shows the whole new philosophy, not the old type mental hospital building.

This has all the latest things. This is, of course, showing the new type. These cupolas, for instance, are towers so that the patients know immediately where they are located in relation to these buildings.

If you notice, they are built in pairs and we will show you why. This is the in-patient division. Notice that instead of having the great mammoth wards that you have in the mental hospitals throughout the country these are based on 16-patient units.

There are two patients to a room with a bath instead of having 40 or 50 sharing one bath if you were that lucky. When I went into Oklahoma we had 100 and maybe more to one bathroom. This has the facilities for emergency care and treatment. It has the lounge in here if you will notice.

There are no great massive areas. Incidentally, working with the National Institute of Mental Health, this is a 6-foot corridor instead. of 8, which saved millions of dollars for the Government and us because we were able to design these things differently.

This has wall-to-wall carpeting to keep the sound levels down, and give you a softness in relation to your patients. It has a fireplace. It doesn't cost much more but it gives you a warmth and feeling for these people.

This is the new idea, a little privacy in their own little section for every 16 patients and a visiting room. In the old days in the mental hospitals the last thing they wanted was visiting.

Now here it is very important because we are doing family therapy. We are treating the whole family. So we want the visitors in. We have 24-hour-a-day services in the offices. In the old days of mental hospitals there were no offices.

This is the gymnasium in which we can do psychodrama. These are music listening areas. This can be used as an auditorium but it is actually a gymnasium. You move the chairs and you have a gymnasium.

Here is the lounge where people can go. There is a fireplace here again. This is, as you can see, a place where patients can rest as in a lounge in a hospital. It has a warmth, and incidentally, there are no shadows in here. This is all top lighted with skylights and fluorescent lighting so that there are no shadows to frighten the patient.