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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. We 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.

Mr. JARMAN. Thank you both for a very good presentation and for advocacy of what you see as the problem here. The problem certainly is before us as a Nation. I think we can take heart in the comment in Dr. Ewalt's statement that developments so far are responsible for the fact that the population of our mental institutions has declined by about 20 percent over the past decade and this has been done in the face of a growing population and growing admission rates,

Mr. Rogers?
Mr. ROGERS. Thank you, Mr. Chairman.

That was a very impressive statement. I have read Dr. Ewalt's statement. I think your testimony is very helpful in pointing up problems that do exist. We were told by the Department, I believe, that there were some 286 centers.

Mr. GORMAN. That was the anticipated figure by June 1967.
Mr. ROGERS. I thought these were committed.
Mr. GORMAN. No; I am on the council and we just had a meeting.
Mr. ROGERS. Those were not correct.

Mr. GORMAN. If you check the record, I think the Department said that this 286 was their projected figure by June 30 of this year. That is in Mr. Cohen's testimony. They would hope to staff and construct that amount. The present number is 173.

Mr. ROGERS. I thought just for construction alone it was 286.

Mr. GORMAN. That is not correct. I am sure of that because we just had a meeting on it.

Mr. ROGERS. Now, I understand that about the time we passed this legislation it was anticipated or projected that the requirement for beds for mental patients had that trend continued would be up to some 700,000.

Mr. GORMAN. That is correct, sir.

Mr. ROGERS. But that since that time it has come down to some 400,000.

Mr. GORMAN. 452,000.

Mr. ROGERS. Who are actually in beds in mental hospitals. Has that relieved the problem of the construction program at all?

Mr. GORMAx. If I might say this, sir, or would Dr. Ewalt comment first?

Dr. Ewalt. I think it has relieved the problem of creating custodial or long-term chronic disease construction. I think it does not cut down on the number of active treatment community mental health center types of programs we need. These are not so much beds. There are beds in them but the other thing needed is all kinds of services for day care, rehabilitation treatment, educational programs and things of this sort so that State appropriations for construction of chronic disease beds has undoubtedly been decreased.

I some places they are tearing down buildings; others are relieving crowded institutions by creating buildings, but in terms of the center grants since they are to be away from these big centralized institutions and all out through the community particularly the smaller towns and cities, it has not decreased that and I think the program is projected of needing 2,000 of these by the time the population reaches 200 million is still an accurate projection.

Mr. ROGERS. You feel that that is a correct figure?
Dr. EwALT. Yes, I do.

Mr. ROGERS. Then you were quoting from the State hospitals as to this reduction in beds, not from local communities.

Dr. Ewalt. I wouldn't think so. These 2,000 mental health centers if they had an average of 50 beds apiece, which I don't think they will because some will have 200 and some 25, will be no more beds than that, but they will be quite different in their distribution.

Mr. GORMAN. Could I make one comment, Mr. Rogers? I think the thing that I pointed out in my testimony, that 20 years ago the State mental hospital was really the only resource and the fact that today four out of five people seek treatment elsewhere is a great tribute to the State hospitals because the fact that they are discharging two or three times the number of people means that the people go to the community resources.

But factually 2 million Americans last year sought and were unable to find treatment in the community; not enough clinics, not enough psychiatrists, this is the answer. We have more clients than we are able to handle.

Mr. ROGERS. I believe you said that 10 percent only of the ongoing program was a contribution of the Federal Government.

Mr. GORMAN. In 1965, sir.

Mr. ROGERS. That ratio doesn't necessarily follow in this particular program, does it?

Mr. GORMAN. No, sir. This was a total of all kinds of expenditures for community mental health services.

Mr. ROGERS. I notice that the amount of contribution of Federal funds in the construction program varies from State to State. What is your feeling about that?

Mr. GORMAN. I feel that it is really based as you know, Mr. Rogers, in the record of the 1963 and 1965 hearings, upon the Hill-Burton formula; roughly that you allow for low per capita income so that the poorer States are asked for only $1 of matching for $2 in Federal matching and New York State gets $1 in Federal matching for $2 in New York State matching.

This is the theory. I don't know that I have either the wisdom or lack of caution to comment on it. I think we will have to see how it works out. The Hill-Burton formula is kind of sacrosanct. We always use it in connection with construction programs.

I am glad the States have the option within the State not to take the flat formula. They have done this in Florida, used a variable formula. I don't know. I know people in Delaware who are very unhappy because they get only $1 in Federal money for every $2 expended, I think, because the Du Pont Co. is there.

Mr. ROGERS. What is your viewpoint on the manpower problem as to psychiatrists aids? What is our lack of needed personnel, would yoù estimate, now as to psychiatrists and for technical people to help them?

Dr. EwALT. Well, there certainly is a shortage. When you try to give an exact figure it depends on how they use them. I think we have to move forward on two fronts. I believe we are making progress on both.

First, in the actual expansion of training facilities and this has been done. For example, the schools are now producing about 2,000

psychiatrists a year. We are importing quite a number also and now we question whether the brain drain is a good thing but it is a good thing for us.

Also, the psychologists group has expanded, the social workers, nurses, and so forth, so that we are producing more manpower but I think even more important we are learning more about how to use the manpower so that sometimes in my own place, for example, we have one program where the psychiatrists rarely see patients at all.

They spend their time in consultation working with social workers, indigenous coinmunity mental health workers, recreational, rehabilitation, and other paramedical personnel.

They spend time answering their questions, consulting about problems that have come up; so that we are learning to use our trained manpower much more effectively than we did before.

Mr. ROGERS. Could you give us for the record any study that has been made or any projection as to needs of manpower?

Mr. GORMAN. They have been made. The National Institute of Mental Health just made a study in November 1965 and we can supply it for the committee.

It is a very optimistic projection.
Mr. Rogers. What is the basic finding of that study?

Mr. GORMAN. It is that under Federal and other programs we have added more than 100,000 mental health personnel in the last 15 years but the only problem is we have built a better mousetrap. More people are seeking the treatment than ever before so that we have to keep running to catch up with everybody.

That is the problem. We have increased enormously.

Mr. ROGERS. I wonder about not necessarily the increase but what is the lack of personnel presently? What is the problem?

Mr. GORMAN. It still depends on from what viewpoint. If you take the center one fellow says he needs 10 psychiatrists and the other says he can get along with four.

Mr. ROGERS. Surely the psychiatric study made some recommendation.

Dr. Ewant. There is such a figure. We can send it to you. (The information requested follows:)

MASSACHUSETTS MENTAL HEALTH CENTER,

DEPARTMENT OF MENTAL HEALTH,

Boston, Mass., April 6, 1967. Representative Paul ROGERS, Congress of the United States, Washington, D.O.

DEAR REPRESENTATIVE ROGERS: At our hearing you asked a number of excellent questions and also asked for additional information. I will try and furnish this. If I have overlooked something you wanted or if something else occurs to you, would you have one of your staff contact me by letter or phone and I will try and find it for you.

You will recall you were particularly interested in what role the American Psychiatric Association was playing in stimulating interest in teaching and providing leadership for sub-professional persons who might be recruited to work in the mental health field. This type of activity runs in about three groups: (1) Volunteers, that is persons who are otherwise emyployed or are housewives who give some time each day a week to the care of mentally ill persons. The American Psychiatric Association has worked with this group for a long time and has a standing committee on volunteers. We have also

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worked closely with the National Association for Mental Health who have felt that the program for volunteers is one of their major operations. I am enclosing a book. You will note that while the conference was sponsored by the Massachusetts Association for Mental Health a lot of the participation was by psychiatrists and other socalled mental health professionals, and with a good representation from the laity. This was and should continue to be a very important activity. I won't go into the detail here, but the mere fact that people will take time from their busy lives to work with mental health problems does a great deal for the morale of the professionals as well as for the patients. The second large category consists of the sub-professionals who work in our hospitals. These are the socalled aides, attendants, etc. who work with the nurses, the occupational therapists, the rehabilitation group, the social workers, psychologists, etc. The basic purpose is to expand and extend the effectiveness of the trained personnel in psychiatry. The American Psychiatric Association has a Commission on Allied Service Personnel, headed by Philip B. Reed, a psychiatrist in private practice in Indianapolis. The purpose of this group is to provide leadership for the subprofessional personnel, helping them with funds for further training, further recognition as important allies in the treatment and rehabilitation of patients, etc. The American Psychiatric Association publishes a special little magazine for them called Staff. This is distributed free to state hospitals and other mental health institutions and is directly aimed at improving the morale through recognition and training of this very important group. This latter group actually provides the bulk of care of patients in the large state hospitals, and we are most concerned that they carry over and function in the new mental health centers, particularly as workers in the community. The National Institute of Mental Health has helped a great deal with the further improvement of the technical skills of this group by making hospital improvement grants and in-service training grants to most of the large state hospitals and some of the smaller mental health centers such as the Massachusett Mental Health Center. The third group overlap somewhat with the preceding one. I separated it out because the preceding group always works under the direction of professional persons. Some of us have thought for some time that in some categories of activity sub-professional persons, properly trained in specific and perhaps rather narrow areas of function, can work with a minimum of supervision. Experiments with using attendants or aides as group therapy leaders, experiments with using people from the community as community leaders, community assistants and community counselors have proven effective in many areas including Massachusetts, some areas in Florida, and in a large delinquency program in New York City. Dr. Henry Brosin, Professor of Psychiatry at the University of Pittsburgh, who will become President of the American Psychiatric Association at its May meeting, is very much interested in developing new knowledge and a new category of persons known as mental health workers. It is hoped that some of the above group of aides and other non-trained persons might, through the cooperation of junior colleges or other similar educational institutions, receive some more formal type of training that would enable them to function even more effectively than the rather naturally occurring skills that some of these people have. We need to know a good deal more about this than we do now. Experience here shows that if these persons are to be effective they must have access to a skilled psychiatrist or at least to a social worker or psychologist with whom they can consult, discuss some of their troublesome problems, etc. It is my belief and, with your encouragement I will continue to push for it, that the American Psychiatric Association program will probably embark on a rather extensive program in this area. If I have overlooked some of the points you had in mind would you please let me know as it will be my pleasure to communicate with you further. Sincerely, JACK R. EwALT, M.D., Superintendent.

Dr. EwALt. The problem is not in staffing these new mental health centers. The problem is still in staffing the old ongoing chronic diseases or long-term hospitals that are perhaps not as desirable. Wherever they have created these new center programs the people have been

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