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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.

You hear a lot about the Harvard College kids getting into trouble but 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.

Mr. ROGERS. I am not suggesting that you work at counter purposes but simply to have some leadership that they can follow. I think it has to have some professional acceptance before it will go anywhere.

Mr. GORMAN. But many of the psychiatrists are attending these conferences.

Mr. ROGERS. I would hope that this would be followed.
Dr. Ewalt. I will let you know, sir.
Mr. JARMAN. Mr. Kuykendall.

Mr. KUYKENDALL. Thank you, Mr. Chairman, for your courtesy. I am not a member of the subcommittee but I have a few questions to direct to Mr. Gorman.

I am going to ask for some statistics which I would like to have sent to me.

Dr. Carter, my colleague from Kentucky, suggested that the family situation for the mentally ill children is important and I think this is something that we all recognize that a factor is the social situation at home.

However, if you have a correlation between the economic status of the families who produce mentally ill children and the social status correlation, I would like to have it.

The social disturbance from home certainly applies to everyone.

Mr. GORMAN. Before turning it over to Dr. Ewalt, in the RedlichHollingshead study, the highest percentage of schizophrenics comes from the lowest educational and income groups.

Mr. KUYKENDALL. May I have a copy of your studies!
Mr. GORMAN. Yes, sir.
(The information requested follows:)

MASSACHUSETTS MENTAL HEALTH CENTER,

DEPARTMENT OF MENTAL HEALTH,

Boston, Mass., April 6, 1967. Hon. DAN KUYKENDALL, Congress of the United States, Washington, D.O.

DEAR REPRESENTATIVE KUYKENDALL: At the April 5 hearings on community mental health centers, the Redlich-Hollingshead Study was mentioned by Mr. Gorman. I remembered some more recent ones. In 1964 there was a conference on delinquency at the Menninger Foundation in Topeka, subsidized by the Maurice Falk Medical Fund. The results have recently been published by Gibbons and Ahrenfeldt, two Britishers, in Tavistock Publications, 1966, page 201. While this conference attempted to cover too much in too short a time, it did tend to bring out the fact that, in spite of the many variables, delinquency, mental disease, etc. in children and adults was associated with poor education and poor socio-economic status—this irrespective of the general economic level of the community in which the person lived—i.e. the poor in the rich countries and the poor n the poor countries were both worse off than the well-to-do in either country. Another one also occurs in Tavistock Publications, 1966, page 208 called Troublesome Children by D. H. Stott. This is a very elaborate study of children, mostly Scottish. While he is attempting to show that these problems are due to what he calls primary neuroticism, which one gathers he thinks is genetic, the book contains a large amount of data to show that most people would feel that it was associated in his cases with poor socio-economic status and the stress which goes with poverty and the very strict Scottish homes in the cases of some of the children.

The most scientific study is by Harold Skeels. Twenty some years ago he participated in a research program in which twenty-three children were studied in a home for the retarded. It was a typical under-privileged, snakepit type home. They divide them into two groups but some were lost so they ended up with ten in the control series and eleven in the experimental series. Briefly, the

control series were left in the home. The experimental series were removed into a new school where there was a great deal more stimulation in terms of attention, experience in training, learning, etc. Over the first three or four years there was a rapid increase in the I.Q. and performance level of the experimental group, while the control group remained unchanged-in fact, the experimental group improved so much that they were all placed in adoptive or foster homes where they received a lot of love and attention in these specially selected homes. Some twenty odd years later the experimental group members are without exception achieving at an average level. Most are working, many have completed their education and most are married. The members of the control group on the other hand were all in institutions of one sort or another, and had been throughout the experimental period except for one who died of some infection. While this is not directly related to socio-economic factors, it is the most carefully done series to show the effect of the kinds of environment that go with better socio-economic circumstances in homes, etc. Sincerely,

JACK R. EWALT, M.D.,

Superintendent. Mr. JARMAN. Thank you very much, Mr. Gorman and Dr. Ewalt. We here on the committee appreciate very much your fine testimony this morning.

Mr. GORMAN. Thank you, Mr. Chairman.
Dr. EWALT. Thank you.

Mr. JARMAN. Our next witness is Mr. George J. Otlowski of the National Association of Counties.

STATEMENT OF GEORGE J. OTLOWSKI, REPRESENTING THE

NATIONAL ASSOCIATION OF COUNTIES

Mr. OTLOWSKI. Mr. Chairman and members of the committee, I was extremely impressed as an elected county official by the testimony that just preceded mine. I think that the members of this committee were undoubtedly impressed as I was.

Frankly, the problem as presented by these two gentlemen was not only dramatized here this morning, but I think pinpointed in the fact that we are going to have to get more and more community involvement in this whole program aside from the professional direction and guidance.

We are going to have to involve all people in the community, the older people, the younger people, on a voluntary basis, on a nonprofessional basis, under the proper guidance and supervision of the professional people if we are going to be able to cope with this gigantic problem that confronts us.

I would like to point out that I am an elected county official of Middlesex County and I am representing the National Association of Counties, and, of course, the national association is supporting H.R. 6131 which extends Public Laws 88-164 and 89-105, providing Federal assistance for the construction and initial operation of community mental health programs is well-known by the Congress and the Federal administrative agencies.

We have long supported, in principle and in fact, treatment of the mentally ill close to their homes.

The recent flowering of the community" treatment concept is an exciting innovation to some. But it has been a reality with county government in the United States for many years. So, Mr. Chairman,

it is an understatement for us to say we "support" a concept which we in the counties virtually initiated in this country.

For example, 2 years before the enactment of Public Law 88-164 in 1963, the county governments were operating 392 community mental health treatment clinics—or "centers”-in 36 States.

It is true that these 392 county facilities did not provide "comprehensive” treatment services. The were principally "out-patient” clinics. But they were in the community and part of the community, and we welcomed-in 1963—the chance to upgrade them into “comprehensive treatment centers” by adding "in-patient" and other essential services.

The Congress gave us that chance with Public Laws 88–164 and 89– 105. However, even before Public Law 88-164, the counties in some States were operating comprehensive mental health treatment programs, including in-patient care.

In my own State of New Jersey, six counties have been operating comprehensive treatment mental hospitals since the beginning of the century.

Let me say this about my own State, one of the greatly gratifying things that should be of interest to the committee: the States and the counties are vitally interested in this program, they are spending the money, they are willing to spend the money, they know the money has to be spent in this area.

For example, at this very moment, the New Jersey Assembly, the lower house, unanimously passed a bill, and the Governor has indicated that he is going to sign it, which would provide $712 million for contributions for construction, $71/2 million unanimously passed by the lower house without one dissenting vote.

I think this is the kind of indication that you want that indicates that States and counties want to spend this kind of money.

These hospitals today have a resident population of 6,500 patients. This means that county government in my State of New Jersey operates community mental health treatment programs larger than the mental hospital programs of 30 States.

In the State of Wisconsin, since 1881, the counties have operated their own local mental hospitals. Today in Wisconsin there are 35 county mental hospitals, serving 71 counties and covering 84 percent of the State's population.

In Iowa, the counties run 84 after-care facilities for aged ex-mental patients, and at present there are almost 3,000 patients in the Iowa county facilities. Also, in Iowa, the counties pay full cost of treatment of county residents who are committed to Iowa State mental hospitals.

Here, I think, that you can see that counties, and I am going to show more specifically, are becoming more engaged in this problem, more and more willing to pay the moneys that have to be spent here and, as has been indicated by the testimony that was given by my distinguished predecessors, frankly, the Federal Government has not been spending the kind of money that it should be spending in this area and the time has arrived now for a real partnership between the Federal Government, the States, and county governments in this area of mental health.

Thus, we see a clear record of interest on the part of the American county government in the treatment of the mentally ill in, or close to, their own communities. This is important, so very important, in their own communities. There is a big difference between a mentally ill person going to a State institution and going to his neighborhood community center the moment there is an indication of mental illness because he doesn't go to a State institution 9 times out of 10 until he is committed, until the mental illness is so progressive that, as the testimony indicated, after that it is a matter of years before he comes back to the community.

I would just like to point out this to the committee: I have been in this business for 12 years. I have had the good fortune to serve as chairman of the welfare committee in my county for 12 years and I distinctly remember when I first came on the board in my county and I started to advocate mental health clinics.

Most of my colleagues on the board 12 years ago thought I was talking about some kind of proposed retreat for retired politicians. They had no concept of what the mental clinics would serve in the county.

The amazing thing after 12 years in my county, which has 600,000 urban and suburban people, is that today the mental health clinics in that county vary in their concept of diagnosis and treatment for children and adults including additional alcoholic treatment centers, narcotic treatment clinics, crises intervention clinics, after-care clinics, and companion houses.

In 12 years, this has been accomplished in my county. The fantastic change that has taken place is not only amazing but pleasing, and here again is an example where Federal, State and county governments can form an effective partnership in the expansion of this kind of a program, and here again, we are talking about this bill that we are testifying about today because this is the beginning of that partnership.

This is the beginning of getting into the home, getting into the neighborhood, reaching out into the families. The great tragedy, Mr. Chairman, and members of the committee, with these clinics that we have established in my own community, is the wail and cry of the people who are on the waiting lists and cannot be treated. That is the great tragedy, when you sit there as an elected official and you have great big lists of people who are breaking the doors down to get into the clinics and you cannot take them because the clinics are not sufficiently comprehensive or sufficient in number to take care of the great needs that exist.

In 1963 and 1965 the National Association of Counties came before this committee in support of the proposed community mental health construction and staffing legislation.

In 1963 the administration proposal called for a 5-year program of $330 million starting on a 75-percent matching basis. The proposal was cut by 2 years and $180 million, with the matching formula reduced.

Now, we come back with 3 years of good, practical experience behind us and we ask for an extension of the program to get it moving at a pace originally envisioned.

Thirty-one county mental health centers are now underway. At this point, Mr. Chairman, I ask that a list of the 31 county projects be made a part of the hearing record. I am going to submit that.

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