Has this been expanded? Is this being brought to the attention of people in this field?

Dr. WINSTON. This is the case.

Mr. ROGERS. Has your experience been brought to the attention of people?

Dr. WINSTON. Well, it was in Reader's Digest, I don't know if you call that necessarily brought to the attention of everyone. What I say by traditional patterning is that we don't have this in most state hospitals because we don't have the staffs available and it wasn't out of choice that we had the patterning.

It was out of the necessity. When we opened the new hospital, I had only one other psychiatrist that I could employ, but this did not keep us from getting the patients out through the selection of tranquilizers, et cetera, and the aids who had the feel for people.

Mr. ROGERS. I am talking about the psychiatric society, the mental health association.

Dr. WINSTON. Yes, sir. This is not the unique experience by any

means.

Dr. GLASS. Mr. Rogers, there is no traditional pattern. Everyone is experimenting and moving with various kinds of mental health workers, social workers, using their scarce psychiatrists much more in a supervisory relationship than in a one-to-one relationship.

When you say, "Is there a trend in this direction", that is the trend entirely in the direction.

Mr. ROGERS. The reason I asked the question is when the testimony was presented to us when we passed the bill, it was that they envisioned a center of 8 psychiatrists, or it was 10, for 100,000 population.

Now, Dr. Winston tells me it was 75,000 and he treats the popula tion in the area with two. This is quite a change from basic thinking even just a few years ago.

Dr. GLASS. I don't think it was thinking. I think these were guesstimates.

Mr. ROGERS. I would think guesstimates are based on what they felt was necessary. I hope they wouldn't tell us they need 10 psychiatrists for every mental health center and it is going to cost a tremendous sums of money to provide the staffing down to 35 unless it was needed.

I heard of these new ideas coming up but I don't know that they are being actually acted upon by people here in trying to encourage a new approach or think it is easier to say, "I get more money if I say I need 10, although that may not be what I need."

Dr. DONOHUE. We went over this with the National Institute of Mental Health and discussed it at length. The American Psychiatric Association is extremely interested in this and we have the Journal on Hospitals and Community Psychiatry which produces articles constantly on this as do the programs of the American Psychiatric Association but also the people in the National Institute of Mental Health whom I have dealt with. We have worked to come up with new answers and one thing would be what is your caseload, where are you, where are you located.

For instance, this will affect your staffing patterns, too, whether you have a lot of poverty and a low educational area, distances into your hospital, the type of structures you have, how many psycholo

gists, social workers, and others you have to throw into the fray, but I don't know that there is any real set standard.

At least the National Institute of Mental Health didn't present me with one. They wanted me to prove that I could treat the number of patients that I estimated with what I was asking for the money

for.

Mr. ROGERS I presume there would be a minimum?

Dr. DONOHUE. Yes, sir, I think there would be a minimum but I would think this would vary with your proposed caseload and the type of things you could handle.

We are going to take all comers in Oklahoma so that it is going to be different than if you didn't take alcoholics or psychotics or this or that.

We are going to use our hospitals and the National Institute of Mental Health has encouraged that we use our hospitals and as back up services so that these centers don't get filled up.

We are 12 to 16 days on our inpatient stay. If we would extend that and keep the patients there longer, we will fill these up like they have done in other countries so that we wouldn't be able to operate. It is according to what your back up is going to be: are you going to use full-time psychiatrists and psychologists or have part-time coming in?

There are many factors that will affect your staffing pattern.

Mr. ROGERS. I was thinking of the minimum required and presented to us in the testimony on this whole subject. The figures given which I won't go into on page 101 of our hearings were 10 psychiatrists for a population of 100,000, 8 psychologists, 8 social workers, 19 nurses and so forth.

Dr. DONOHUE. They didn't stick me with that minimum anyway. because I couldn't have found that many and I don't think I needed that many now.

Mr. ROGERS. But this is the point I wanted to develop, that unless we do go into a new approach rather than a set minimum

Dr. DONOHUE. Mr. Rogers, the National Institute of Mental Health in my dealing with the people and I have seen a lot of them because they have been real interested and we were one of the first off the ground, have been very considerate in going over in detail what we are going to be and have never held me to anything.

I think they have made me prove that I was going to realistically handle these things. I think they are doing a good job.

Mr. ROGERS. What amount of money do you think we should authorize to be appropriated for the continuation of this program?

Dr. DONOHUE. I am not at that level of operation any more but we will have to accelerate it. I know you are going to have to accelerate it because you are going to keep adding to it.

All us guys in business are already in business and then you are going to have to accelerate these new ones coming in.

Dr. GLASS. It is the considered opinion of the National Association involved in this and which has most knowledge about the plans that there needs to be an increase because more centers are coming aboard and we would support the statements that are made that it may well be doubled as to the present 1968 amount of money.

Mr. ROGERS. Should the Hill-Burton law require a psychiatric unit in every hospital?

Dr. GLASS. I think that one of the problems of Hill-Burton is this: For example, let's say there is a 25-bed hospital in a certain area that needs one. If you require them to have a psychiatric unit they may not be able to operate it so you are already requiring something that is functionless to them.

So one would hate to have this legislation restrictive on particularly small hospitals.

Mr. ROGERS. It might not in a 25-bed hospital.

Dr. GLASS. You would have to have a larger hospital.

Dr. WINSTON. I think this new program does away with this.
Mr. ROGERS. To have psychiatric from the hospital?

Dr. WINSTON. From 1963 on. The community mental health center does away with this need for a new Hill-Burton facility, let's say, is my feeling.

Dr. GLASS. The hospital by merging in a number of the services of the community can become the inpatient facility but these negotiations should be left to the community to do. There may be several hospitals that would want to do it, one a Catholic and one a community hospital and so forth, so that I don't believe that we should take every hospital and say, "You must do thus and so.”

I think we wouldn't be wise if one hospital wants to specialize in a lot of surgery and someone else does something else. I think it would be unwise to insist that they build a certain number of beds and work to operate a certain number of beds.

Mr. ROGERS. You don't think the problem is such that general hospitals of a reasonable size should have psychiatric beds or treatment? Dr. GLASS. I think they should be encouraged to and a lot are doing it spontaneously.

Mr. ROGERS. Why should it not be required?

Dr. GLASS. When you require something you have to lay a yardstick against circumstances which we absolutely don't know. There may be three hospitals in an area. One of them has a good psychiatric service which all the psychiatrists logically use. That doesn't mean the one a block away should have the same thing.

Mr. ROGERS. Suppose there is no hospital that has the good psychiatric department.

Dr. GLASS. Then we will have to plan which areas.

Mr. ROGERS. Is this duplicating our program to say we have to build community health centers when it can be incorporated in the hospitals which are going to be built and must be built?

Dr. GLASS. There are hospitals which are going to be renovated. There are a number of areas. For example, you are talking about inpatient services but to our minds the inpatient service is the smallest element.

Mr. ROGERS. I will agree. This may be so but I am saying should that be incorporated. It may not be the largest. It may not need but 25 beds. I don't know.

Dr. GLASS. True, but it may not be the appropriate place to have it. Mr. ROGERS. Should we just completely disregard the mental health problem in building community hospitals?

Dr. GLASS. On the contrary, I don't think we should disregard it but now community hospitals are entering, as you know, into this program very heavily so we are not disregarding them.

We are inviting them. For example, St. Anthony's Hospital in Oklahoma City has an approved mental health center and are entering into it voluntarily. That doesn't mean that Mercy Hospital three blocks away has to do it.

Dr. DONOHUE. There ought to be some private beds in addition to the community part.

Mr. JARMAN. Mr. Brown.

Mr. BROWN. If you can properly separate treatment of mental illness in community hospitals into prevention which means outpatient care and treatment which means inpaitent care and then, incarceration, definite assignment of a mentally ill patient to a hospital because there is no hope of treatment, what kind of breakdown do you get on that basis, percentage-wise? Where is your need greatest?

Dr. GLASS. Let's say this: We can't agree with your definition because we have treatment as outpatient and treatment as inpatient and day care, but nevertheless, I understand what you mean that if you consider those cases that require prolonged care, institutional care, if you are talking about psychiatric patients and get away from the physically disabled the older patient who needs a supervised living enviroment like a nursing home, if we exclude those and talk about physically able but menatlly ill patients who have to be kept in an institution for a prolonged period, we don't feel it is more than 1 to 2 percent of admissions.

Experience indicates that 1 to 2 percent of admissions would reach such severity as to be kept for that long.

Mr. BROWN. Let me pursue this question just a step further. There is in crime control and prevention a trend away from incarceration and into treatment so to speak, the social approach and now perhaps a trend into prevention.

We are doing this in welfare to some extent. Is there a Federal involvment here in the prevention of mental illness that we are overlooking and merely spending all our funds on treatment?

Dr. DONOHUE. No, all your poverty programs-I was on the discussion of Ozarkia today which crosses some of our area and these things are being well considered. If you are going into the prevention of mental illness you get into a real complicated area, getting into poverty, education, pre-school.

Mr. BROWN. Alcoholism, drugs.

Dr. DONOHUE. You are getting into a cross structure of family relationships, sociological relationships in families and many things which under the present programs are ongoing.

I don't know whether there are letters for them but in general the poverty programs, the Appalachia-Ozarkia type things where we are really going into the redevelopment of our cities and things like this, these in the final analysis would be preventive programs in the mental health field.

You get into the outpatient and actual care and treatment to prevent the individual from getting sicker. Yes, we are doing that. In the Oklahoma Medical Association, for instance, to show you the interest in

this in the State of Oklahoma, we have had two conferences in which the medical association financed a conference to bring in the people who were interested and we had 1,000 come in who work in these various areas in Oklahoma who came in because there is this much interest. We had one for doctors and had over 200 doctors. There is a marked interest and the American Psychiatric Association working with another grant is training physicians to understand more about psychiatry. We have Thursday afternoon programs on those because when I went through medical school it was a hit and a lick. So we are shifting this whole thing. You see, there are actually 7 levels in the mental health field. You start down here with 42 percent according to the Joint Commission Report of people going to ministers before they go anywhere.

So, you start with the minister, the police officer, the schoolteacher, and another layer of counsellors, court counsellors and public health nurses and the layer of general physicians who see these people alone and mental hygienic clinics and advisory clinics.

Then you have psychiatrists and then here comes this new mental health center and then you have the State hospital. We have a compendium of service already structured. I agree we need to train the people.

For instance, in Oklahoma now we have a school for police officers. The police officers from Oklahoma City come and spend 2 days working and taking courses in the state hospital, in this area and we also have 14 hours of courses in psychology for them and things like that. The other day I was talking to them about subsequently having these guys in these cars that make rounds

Dr. GLASS. I would like to pursue your question. That part of the community mental health center that deals with preventions, the consultation and education, is one of the essential services.

Now, the actual prevention is really indistinguishable from what goes on with all the other programs under welfare and poverty and so forth.

The consultation and education arm of the center meets with those people, police, judges, welfare workers, and others to bring the contribution of the mental health center to them.

Mr. BROWN. Thank you.

Mr. JARMAN. Thank you again, gentlemen, for being with us and for your testimony.

A roll call is in progress so that we will ask for permission to sit again at 1:30 here in this room to conclude the hearing.

The Committee will stand in recess until 1:30 p.m.

(Whereupon, at 12:40 p.m. the hearing recessed to reconvene at 1:30 p.m. the same day.)

AFTER RECESS

(The subcommittee reconvened at 1:30 p.m., Hon. John Jarman, chairman of the subcommittee, presiding.)

Mr. JARMAN. The subcommittee will please come to order.

The House is in session, but we have secured permission to continue hearings during general debate on the bills on the floor of the House