for local communities, and cities and States, to do something on their own? They need a sort of spark plug to set off the movement, so to speak. Is that not your opinion?

Miss LEVINE. Yes; I think that is very true.

Mr. PRIEST. So leaving out entirely the question of the ability of the State or city to pay for it-and I agree with Mr. Brown, I believe the State or the city of New York is able to furnish the necessary facilities-they haven't done so up to this time, and it has not been done anywhere else in the country as it should have been done, and that is one of my main desires in this sort of legislation, to give an impetus to local communities and States to do that job.

Miss LEVINE. Yes.

Mr BROWN Will the gentleman yield at this point, so that I may be fair to the State of New York?

Mr PRIEST. Yes.

Mr. BROWN. I see in table 2 that Dr. Felix has included the estimated necessary clinical service and medical service now available, and from that I notice that the State of Massachusetts stands first with 78.3 percent of the estimated necessary clinical service being available at this time, and that the little State of Delaware stands next with 64.3 percent, then the District of Columbia, the Federal Government, more or less, with 49.6 percent, and the great State of New York stands fourth, with 46.8 percent, so evidently you do have approximately 50 percent of your estimated needs for clinical services in the State of New York, according to the Public Health Service. Miss LEVINE. Yes.

Mr. PRIEST. All right; you may proceed.

Miss LEVINE. This may help explain, only in a partial way, why New York City has not been able to do more than it has. According to such available data as we had as of August 1, 1945, 426 psychiatrists in New York City were in private practice or in psychiatric clinical work. If these psychiatrists were to work only with the rejected and discharged with whom this study is concerned, they would need to be seeing only 20 patients for 2 hours a week each, 8,520 men. That is only about half of the group in New York.

Another aspect of the problem of treatment is in the distribution of psychiatric term between private practice and clinical service. In the out-patient clinics treating adults in New York City there are 130 psychiatrists, some of whom work full time in the clinics, but most of whom work from 2 to 4 hours a week. The total number of hours of psychiatric clinic time available to the rejected and discharged who need and want help is approximately 792 hours a week, and this time must be shared by all adults in the city who receive out-patient psychiatric clinical care.

The recommendations that have grown out of this study are: First, that additional free and low-cost psychiatric clinic service, especially prepared to give clinical treatment for psychoneuroses be established with evening hours available;

That privately sponsored services can never adequately meet the needs in psychiatric rehabilitation must be recognized, and public services should prepare now for a greatly expanded program of treatment and prevention in the field of mental hygiene. However, until resources and personnel can be mobilized under governmental auspices, the exigencies of the present needs demand that services be set up

under a variety of auspices. Hospitals having some clinical service must expand them, new clinical services must be inaugurated under any auspices that can provide professionally qualified personnel and a program of training of additional personnel must be started immediately.

Second, the training of additional personnel for psychiatric clinics: The figures given on available personnel dramatically demonstrate that even if all the psychiatrists in New York City were to treat only the psychiatric rejectees and nonservice-connected dischargees who currently need and want treatment only about one-half the men could be given immediate help. The training of additional personnel. therefore, becomes an urgent necessity. The number of persons needed, and the complexities of recruiting and training such personnel are so great that only under the Federal governmental project could such a program be adequately planned. It is not the function of this study to recommend the details of such a program, but it must point to the urgency for the need of training personnel for work in psychotherapy. Such personnel includes not only psychiatry, but the adjunctive services of psychology and psychiatric social work which constitute, combined with psychiatry, the professional psychotherapeutic team. The program of training included in the proposed Federal legislation in the Priest bill is of the type necessary to meet the large demand for professional training in mental hygiene in this country.

New York City, however, should not and must not wait upon a Federal program to begin training for psychiatric treatment. Medical schools and professional organizations having a training program should combine to give special training to physicians, who have the required background in treatment of the neuroses. The establishment of special clinical services for treatment of neuroses should provide the organization for treatment and training. A special training course for those psychiatrists, whose experience has been limited to in-patient work with the hospitalized mentally ill would be a quick and effective means of making qualified personnel available for treatment of the neuroses.

Third, the effective use of clinical services: Merely increasing the capacity of psychiatric clinics as they are now operating is not the entire solution to the problem of providing psychiatric treatment for those who need it. In studying the experience of psychiatric clinics, accepting rejectees and dischargees, it was discovered that there was an extensive waste of clinical time, particularly in those clinics whose primary function was conceived as treatment. Most clinics are operated on an appointment schedule and broken appointments cannot easily be filled by other patients.

Effectiveness of the clinic's treatment work could be said to be effective in only 36 percent of the number of cases referred. This represents too great a waste of clinic time. Responsibility for improper referrals and for men who go to the clinics not understanding the nature of the clinic or the nature of the psychiatric help are clearly placed on the referral forces. Proper preparation for referral includes the determination of suitability for out-patient psychiatric care, the preparation of the patient for the services at the clinic, and the preparation of pertinent history or diagnostic material for the use of the clinic. Agencies and individuals referring patients to

clinics should be meticulous in the screening and preparation of patients for clinic referral, so that the inadequate time available may be used effectively.

Clinic procedures, too, must be examined in view of the necessity to use each clinic hour in effective service.

We went on to describe in some detail the criteria for screening outpatients properly for psychiatric care and preparing them adequately for psychiatric treatment.

In connection with what might be an obstacle actually in the inherent set up of some of the clinics and the current practice in clinics would account for a good part of the waste in psychiatric time is the matter of the mechanical features and the steps through which these patients must go before they can even get to a psychiatrist, and they generally characterize that as red tape, and we feel that must be eliminated in order to get a patient to treatment as quickly as possible and to reduce the discouragement he feels when he is given that kind of run-around.

We also recommend, in addition to the training of psychiatric personnel for actually functioning in psychiatric clinics, the training of psychiatrists, and as well psychiatric adjuncts-that is the psychiatric orientation for allied professional groups, such as private physicians, general practioners and social workers, in various community agencies and so forth, who deal with problems of psychiatric disorder, and many of whom do not recognize what a psychiatric problem is, and do not handle it properly.

We also feel the urgent need for the development of a better program of mental health consultation service. In this service one of the most glaring deficiencies found was the basic unfamiliarity of the men studied with the nature and meaning of emotional illness and psychiatric disorders, and also on the part of the personnel in social agencies and general practitioners who deal with these problems. There are many concepts that are widespread about what a psychiatric disturbance is, and how it should be treated. A prevalent one is that these difficulties can be overcome through will power or character, and that the problems presented in adjustment are related to physical condition. In the psychoneurotic these fallacious ideas often aggravate the condition and rarely is the individual able to bring himself back to a state of healthy functioning through such efforts. That more resources for giving aid to people in mental health problems in the early stages of their development are urgently needed is again emphasized by this study. Of the men who wanted help but were without it, only 7 percent had ever had contact with a psychiatrist. Most of the men had sought some help from the medical or social services, but few had been in contact with a service equipped to aid them in their psychiatric problems.

The educational as well as therapeutic value of easily available diagnostic and treatment services has been demonstrated in tuberculosis, venereal disease, and cancer. Treatment services in the field of mental hygiene could be of great value in the early detection and treatment of personality problems, and in providing an additional opportunity for people to learn more about behavior.

The development of mental health consultation services in New York City health centers is recommended as an essential part of an adequate preventive and treatment program in mental hygiene.

The consultation service here recommended is one in which the services of the full psychotherapeutic team-psychiatrist, psychologist, and psychiatric social worker-would be available. Persons with any type of psychiatric or mental health problems could come for advice. Prolonged, intensive treatment would not be given in the consultation centers but cases requiring this type of care would be referred to the psychiatric services specializing in treatment. Such a service could be an effective means of screening cases for the treatment

services.

Consultation service would give short service to a great number of people who need advice and help on minor problems. Mothers would be given help with their children, young people would have a resource for help with their many problems, and professional workers in the area might seek the psychiatric advice of the service on the problems which confront them.

This recommendation, obviously, is geared to the preventive aspects of psychiatric illness.

Mr. PRIEST. Does that conclude your statement?

Miss LEVINE. Yes.

Mr. PRIEST. We certainly appreciate your appearance here. That is a very interesting study, as I have followed it. It will be very helpful. Do you think the passage of this legislation is advisable? Do you favor its passage?

Miss LEVINE. Yes; indeed.

I would like to have this part of the report which deals with psychiatric rehabilitation and its needs, which is a summary of the findings and recommendations, written into the record.

Mr. PRIEST. Without objection, we will see that that is done. (The material referred to is as follows:)

NEEDS IN PSYCHIATRIC REHABILITATION IN NEW YORK CITY (A report by the New York City Committee on Mental Hygiene of the State Charities Aid Association of a study made by the committee under a grant from the Commonwealth fund, September 1945)

SUMMARY OF SIGNIFICANT FINDINGS AND RECOMMENDATIONS When this study was undertaken it was hoped that recommendations for an adequate program of rehabilitation for men who had been identified as having psychiatric problems severe enough to warrant their rejection or discharge from the armed services, could be made. However, the number so identified are so great that adequate treatment by the available personnel is impossible. By June 30, 1944, in New York City approximately 78,500 men had been rejected and 31,500 discharged during training because of neuropsychiatric handicaps. The findings of this study show in the opinion of the staff of the study that 82 percent of these men need psychiatric help but only 21 percent of them are sufficiently aware of the nature of the problems, or of the fact that there is help for their conditions, to want to receive help immediately.

From these findings the assumption can be made that in New York City, 19,000 men need and want psychiatric help immediately. Of these, approximately 14,000 need and want psychotherapy, 1,000 psychiatric examination, and 4,000 psychiatric case work. Of those who need psychotherapy 61 percent will require free service. Of the other 39 percent few can meet the costs of extended treatment by private psychiatrists.

According to the best data available there were as of August 1, 1945, 1,426 psychiatrists in New York City who were in private practice and in psychiatric. clinical work. This number was obtained from membership lists of professional psychiatric societies and medical associations. If these psychiatrists were to work only with the rejected and discharged with whom this study is concerned, they could treat, seeing 20 patients for 2 hours a week each, 8,520 patients.

Another aspect of the problem of treatment is in the distribution of psychiatric time between private practice and clinical service. In the outpatient clinics treating adults in New York City, there are 130 psychiatrists some of whom work full time in the clinics but most of whom work from 2 to 4 hours a week. The total number of hours of psychiatric clinic time available to the rejected and discharged who need and want help is approximately 792 hours a week and this time must be shared by all adults in the city who receive outpatient psychiatric clincial care.

The types of psychiatric problems for which these men need and want help influences the character of the clinical services required. Since the bulk of those for whom therapy is indicated are psychoneurotics (67 percent) special skills in treatment of neuroses are indicated. The next largest group (14 percent) indicated as needing treatment are diagnosed psychopathic personality inadequate but presumably have some mixed symptoms of psychoneurosis and were thought by the study staff to be amenable to current treatment methods. Since many of the existing psychiatric clinics are so organized and staffed that their major work is in diagnostic study, a different kind of orientation is needed for effective treatment.

One other factor affecting the kind of clinical service indicated should be noted. Only one-fifth of the men who need and want help were unemployed at the time of the interview, and this number will probably decrease as recently discharged men are absorbed into jobs. Most of the men, therefore, will need to have treatment time made available to them outside of their working hours. Evening clinical service is therefore needed.

The figures on needs for psychiatric services from this study do not include the services needed by veterans who have service-incurred or service-aggravated psychiatric disabilities. Already this community has felt the impact of the treatment needs of men returned because of combat neuroses and other service-incurred psychiatric disabilities. The Veterans' Administration is turning to civilian clinics for the outpatient care of these men and the present inadequacy of psychiatric clinical services will become increasingly apparent as efforts are made to obtain help for that group which has an undisputed priority for treatment.

I. ADDITIONAL PSYCHIATRIC CLINICAL SERVICES

The first recommendation to come from this study is that additional free and low-cost psychiatric clinical services especially prepared to give treatment for psychoneuroses, be established with evening hours available.

That privately sponsored services can never adequately meet the needs in psychiatric rehabilitation must be recognized and public services should prepare now for a greatly expanded program of treatment and prevention in the field of mental hygiene. However, until resources and personnel can be mobilized under governmental auspices, the exigencies of the present needs demand that services be set up under a variety of auspices. Hospitals having some clinical service must expand them, new clinical services must be inaugurated under any auspices which can provide professionally qualified personnel and a program of training of additional personnel must be started immediately.

II. THE TRAINING OF ADDITIONAL PERSONNEL FOR PSYCHIATRIC CLINICS

The figures given on available personnel dramatically demonstrate that even if all the psychiatrists in New York City were to treat only the psychiatric rejectees and non-service-connected dischargees who currently need and want treatment, only about one-half the men could be given immediate help.

The training of additional personnel, therefore, becomes an urgent necessity. The numbers of persons needed and the complexities of recruiting and training such personnel are so great that only under a Federal Government project could such a program be adequately planned. It is not the function of this study to recommend the details of such a program but it must point to the urgency of the need for training personnel for work in psychotherapy. Such personnel includes not only psychiatry but the adjunctive services of psychology and psychiatric social work which combine with psychiatry to form the professional psychotherapeutic team. The program of training included in the proposed Federal legislation of the Priest bill (H. R. 2550) is of the type necessary to meet the large demand for professional training in mental hygiene in this country.

New York City, however, should not and must not wait upon a Federal program to begin training for psychiatric treatment. Medical schools and professional organizations having a training program should combine to give special training