FOR RELEASE

UPON DELIVERY

THE NEW MENTAL HEALTH CHALLENGE FOR ALL AMERICANS
Speech at
First Legislative Conference, Massachusetts Association for Mental Health
8 PM Monday, February 3, 1964
Sheraton-Plaza Hotel, Boston, Mass.
by

MIKE GORMAN, Washington, D. C.
Executive Director, NATIONAL COMMITTEE AGAINST MENTAL ILLNESS
Member, NATIONAL ADVISORY MENTAL HEALTH COUNCIL, U.S.P.H.S.

Governor Peabody, Dr. Solomon, Members of the Legislature, Guests:

The gauntlet was thrown down by our martyred President less than a year ago
when he sent to the Congress the first message on mental health and mental retardation
ever submitted by a Chief Executive of this nation. In that message, he said:

"This situation has been tolerated far too long. It has troubled our national

conscience -- but only as a problem unpleasant to mention, easy to postpone

and despairing of solution. . . The time has come for a bold new approach."

The Congress responded to the challenge and enacted into law a bill providing
federal matching funds for the construction of mental health and mental retardation
centers in the heart of the community. In affixing his signature to this legislation
on October 31, 1963, former President Kennedy noted:

"The nation owes a debt of gratitude to all who have made this legislation

possible, It was said, in an earlier age, that the mind of man is a far

country which can neither be approached nor explored. But, today, under

present conditions of scientific achievement, it will be possible for a

nation as rich in human and material resources as ours to make the remote

reaches of the mind accessible. The mentally ill and the mentally retarded
need no longer be alien to our affections or beyond the help of our communities."
page two

There is really no way in which I can adequately convey to you the historic,
precedent-shattering importance of this legislation. In very simple terms, it repudiates
two centuries of isolation and custodial confinement of the mentally ill, and it pro-
claims their inalienable right to skilled and compassionate treatment in the milieu
in which they live, love, work and aspire.

Describing this legislation as "one of the boldest programs in the field of mental
health in the history of the world", Senator Hubert Humphrey told the annual convention
of the National Association of Mental Health last November that if the first session
of the 88th Congress had achieved nothing more than the passage of President Kennedy's
mental health program, it could lay justifiable claim to a memorable record,

[me task before all of us now, here in Massachusetts and throughout the nation,
is to translate these new concepts for the care of the mentally ill from broad gener-
alities into specific programs.

In the words of Ralph Waldo Emerson: "Go put your creed into your deed,"

Let us remember that we must honor a solemn commitment to the Congress and to the
American people in putting this community mental health concept into effect.

As a first step you are engaged here, as are your sister states throughout the
country, in comprehensive planning designed to develop solid foundations for new mental
health services tailored to meet the specific needs of each community. SUTSTNS ET om
the-tens¥ Sid THTSHSTEY-of-the~penel-discussion.sarlier-todey-on-progeess—to date in
these phenning..offoses, You are well on your way to a new and exciting blueprint for

mental health services in this Commonwealth,
page three

This is a precious opportunity which must not be missed. Noting that this is
the first time such a total planning effort has been made in any health area, Dr.
Robert Felix observed recent ly that "the mental health field, which for so long lagged
behind other health areas, has an opportunity to demonstrate on a national scale the
value of comprehensive, long-term planning in a broad medical~social problem area."

Hundreds of professional workers will be involved in hammering out these plans
over the next several years, but they must be augmented and guided by thousands upon
thousands of citizens who care so deeply that they will insist upon a clean break with

the custodial past.

First and foremost, we must realize that this is a long, uphill fight. Equally
important, we must abandon the mendicant, somewhat apologetic approach we take when we
ask for a few crumbs from our national bounty. Our stance must be vigorous, aggressive
and unwavering in our continued efforts to shape a new and enlightened national policy
for the care and treatment of the mentally ill.

In doing this, we must adhere to a boldly proclaimed set of minimum standards short
of which we will not compromise under any circumstances,

In testifying before a Congressional committee last year, I said that in the same
manner as we talk of the right of a child to a good public education, we must talk of
the right of every individual who needs it to early psychiatric treatment designed to
make him a happier and more effective individual. Dr. B. H. McNeel, Commissioner of
Mental Hospitals of Ontario in Canada, summed up this minimum medical demand concisely

when he said recently:
page four

“Adequate treatment should be available for all psychiatric patients as early

as possible, as continuously as possible, with as little dislocation as

possible, and with as much social restoration as possible, Treatment should

be available on the job, but if that is not possible, with the patient still

living at home, and if that is not possible, it should be done in the community,

and if that is not possible, then without breaking the ties which commit the
patient to his community."

As a statement of our national objectives in the mental health field, I commend to
you the words of Dr. Felix, who told the Congress last year that "public mental hospi-
tals as we know them today can disappear in 25 years’ if all levels of government and
the public at large unite in this great endeavor.

In his historic mental health message of February 5th, 1963 to the Congress,
President Kennedy predicted that the number of patients in state mental hospitals could
be halved in the next decade or two if we intensified our treatment efforts both in
these hospitals and in the community.

The constitutional pessimists have already attacked this as an impossible goal.
These are the same self-appointed guardians of the past who, when the first significant
reductions in state mental hospital populations occurred in the 1950's as a result of
the introduction of the new drugs, cried out that this was a "flash in the pan™ - it
couldn't last because the "inevitable" trend since 1773 had been an annual rise in the
number of hospitalized patients.

I hate to pull the rug out from under these erring prophets who seem to have an
emotional stake in human misery, but figures recently released by the National Institute
of Mental Health show a truly remarkable reduction of 54,000 patients in our state
mental hospitals over the past eight years - from 558,000 in 1955 to 504,000 in 1963.

This historic reduction of almost 10 percent in the populations of these human

warehouses is not only far in excess of what those of us who were attacked as "irres-~

ponsible optimists" predicted years ago in Congressional testimony, but has been achieved
page five

in the face of a constantly rising flood of new admissions. Furthermore, instead of
a tapering off of this downward trend in the size of institutional populations, there
has been a marked acceleration - the drop of 12,000 patients in 1963 set a new record,
breaking the previous record drop of 11,000 in 1962,

Apart from such obvious dividends as a reduction in over-crowding and the freeing
of scarce psychiatric personnel for more intensive work with acute cases, this heart-
ening trend has resulted in enormous economic savings to the states. Above and beyond
the fact that a higher per diem expenditure can now be concentrated on fewer patients
with a resulting increase in discharges, the dramatic reversal of the seemingly inevitable
annual rise in number of hospital patients has eliminated the necessity for two billion
dollars of planned hospital construction costs during the past decade.

All of you have earned these savings by your dedicated efforts, and you must per-
suade your state legislature that these projected capital construction funds be trans-~
ferred to the building of community mental health centers,

We must devote particular attention to the several millions of Americans who need
psychiatric treatment, but cannot get it today because it is too expensive. There is
no point in establishing a chain of community mental health centers designed to apply
psychiatric band-aids to neurotics from middle-income and upper-income groups. We must
first of all guarantee treatment in depth to those who are seriously ill.

We have been much too gentle in calling health insurance plans to task on this
point. Many health insurance plans still discriminate against the hospitalized mentally
ill. Furthermore, as we move out into the community, we face a real challenge in con-

vincing these health insurance plans that it is wiser and far less expensive to cover the
page six

patient on a short-term ambulatory basis than in an expensive hospital bed. In a long
and somewhat wearying experience dealing with executives of these plans, I am convinced
that they will take no forward steps of this kind unless the public pressure is intense.

We must supply that pressure.

We face an exciting challenge in praviding psychiatric services for emotionally
disturbed children. Here again, we have often settled for the bare minimum -- a
separately designated ward in an overcrowded state hospital or, infrequently, a ten to
twenty bed unit which is almost immediately over-loaded with a backlog of cases. |

spat shar ace-paeeeto-aa-eretry were ehe-enaicce-orreeci St
abandoned,

Several months ns ag0,..1-apent~e-day-wieiting. the Massachusette-Meatal jiealth Center
acento co
here in Boston. Its buildings are not very. prepossessing,, but- its-serviees.tg, suffering

sib ERTIES Fy 8
eats ye pera ene
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hankind are magnificent. With a fulltime. stag£.of-l4-psychiateists,..plus..59~psychiatric
residents, it handles 4,000. patients a year. its doors are. open to all, yet.it has no
long waiting List.” In its emergency walk-in. clinic, it handles. more..than.2,000 patients
a year, It assigns. patients to its various services -« -the-24-hour ‘Hospi fat;~the day
hospital, the night hospital, or the-emergency clinic. .--.on-the bagis.of psychiatric
need, and not on the basis of ability to pay-or the comfort-sf the staff.

[is we go about the task of bui lding a nationwide chain of community mental health
centers, we will run up against the negativisce who argue that the goals we set are
impossible because we do not have the manpower,

In 1947, the National Institute of Mental Health was allocated $1 million to

inaugurate a training program in the various psychiatric disciplines. In that first
page eight

We have impressive documentation to the effect that early, intensive treatment,
while more expensive on a day-to-day basis, is considerably cheaper per patient than
long-term custody at supposedly ‘economical" rates

Our critics may grant us the point that early, intensive treatment pays off in
human and economic terms, but they then will argue that taxes are already too high --
that this democracy cannot bear this further financial burden.

I am willing to grant the point that these community mental health centers will be
relatively expensive to operate, and that we do not have detailed cost statistics from
every state in the Union. Suppose the average cost is $20 a bed -- this is still $15
a bed under the comparable cost for care of physical illness in our general hospitals.

Because of the nature of our affluent society, many of us who have testified before
federal and state legislative bodies for increased financing of intensive treatment
services have been forced on many an occasion to restrict our case to the economic savings
which accrue from support of such services, Over the years, a very good case has been
made against the unimaginative construction of huge state mental hospitals which eat up
tax dollars at a staggering rate.

However, I would like to submit the proposition that the issue of economic savings
has a relatively low priority in the field of mental health.

The over-riding consideration is the treatment and return to society of thousands
upon thousands of sick individuals. This is the true measure of our worth as a society.

Dr. Kenneth Appel, that great psychiatrist and humanitarian who sparked the forma-
tion of the Joint Commission on Mental Illness and Health, recently described the great
challenge facing this democracy in putting the unused talents of people to work in the

service of their suffering brethren in these moving words:
page nine

"Tt is an irony that the silent people, the helpless people in our mental

hospitals and in our communities need human contacts; and the thousands,

yes millions of the unemployed or retired need useful work to do. Yet our

human and social engineering, our economic engineering, has not developed

ways and means of bringing these two great needs together to supplement

each other."

However, when we talk about increased financing of mental health services so that
thousands upon thousands of mental patients can be returned to productive living, we
run up against the hoary argument that public taxation has reached a confiscatory level
and that the individual citizen is groaning under a tax burden which he is increasingly
unable to handle.

Have we indeed, as a people been increasing our expenditure for public services
at a rate which is too burdensonmefor the individual taxpayer?

In his beautifully documented study "The Question of Government Spending", Francis
M. Bator notes that in the years from 1929 to 1959, non-defense spending as a percentage
share of the non-defense output of our economy rose only slightly:

"We have been committing in the post-war period only a slightly larger

fraction to such communal uses as schools, roads, sanitation, urban renewal,

etc. than we did in 1929 and a smaller share than in 1939 and 1940."

When we consider the rapid rise in our population -- a record growth of three
million people in a year -~ added to a sharp jump in individual personal income, we cannot
but conclude that the so-called heavy burden of increased taxes for public services is
an undocumented myth.

What are we spending our money on these days? A 1962 Bureau of Labor Statistics
survey reports that our gains in income have far outstripped our basic living costs

since 1947; we now spend a smaller share of our income on the basic necessities -- food,

clothing and shelter.
page ten

In 1961, for example, we spent $20 billion on recreation; $11 billion for alcoholic
beverages; more than $7 billion for tobacco products, and $3% billion for TV sets,
radios and phonographs. We also managed in that same affluent year to spend $323 million
for chewing gum. Over and above these and many other expenditures, we managed to accu-
mulate the record sum of $78 billion in savings and in durable assets.

Now, and much more to the point, how much of our booming personal income did we
spend on these onerous state taxes about which we hear so much talk? In 1961 we spent,
measured in constant dollars, 4% of our personal income for state taxes as against 3.7%
in 1948. In other words, in a period of 13 years there was a rise of only three-tenths
of one percent in the portion of our individual incomes which went to state government
in the form of taxes,

Zeroing in on the target, how much did we spend on mental hospitals as a percentage
of our personal incomes? In 1961 we spent eighteen-hundreths of a percent of our per-
sonal income on mental hospitals, as against seventeen-hundreths of a percent in 1948,
In very simple terms, in thirteen years we devoted only an additional one-hundredth of
a percent of our personal incomes to the support of mental hospitals.

How about state mental hospital operating expenditures as a percentage of total
general state expenditures? According to a survey jointly conducted by the American
Psychiatric Association and the National Association for Mental Health, less than 3%
of general state funds went to mental hospitals in 1961, a significant drop from the
three and a third percent which was devoted to these facilities in 1956,

Is this a fair proportion of state expenditures? By way of contrast, state govern-

ments in 1961 devoted 28% of their funds to highways. In that year, as a nation, we
page eleven

spent $10 billion for highways. Furthermore, the Department of Commerce recently
estimated that the accelerated national highway program inaugurated in 1957 would,
upon completion in 1972, cost the American people $55 billion.

I know that you fought a prolonged battle over the financing of mental health
services here in Massachusetts during the 1963 session of the General Court, so that
I shall confine myself to just a couple of comments which bear some relation to the
problem.

While a higher percentage of your state budget goes to mental health activities
than in most other states, it is pertinent to note that this percentage is drawn from
a much narrower tax base than in most of your sister states. For example, although you
are the tenth wealthiest state in the country in terms of per capita income, you are
twenty-eighth in the amount of money spent per person on state government, and forty-
first in per capita state taxes as a percentage of individual personal income.

Rather than document this assertion from outside sources, I quote the following
from an official publication entitled "The Massachusetts State Budget in Brief";

"Massachusetts is one of the wealthiest states in the nation. The income of

Massachusetts citizens continues to rise and taxes imposed by the state

government are relatively moderate when compared with other states...

Massachusetts citizens, at the present time, have roughly twice as much money

left over after taxes as in 1945."

Without going into a detailed discussion of the budget of the Department of Mental
Health, which is responsible for more than 27,000 patients scattered among 18 different
institutions, I submit that your per diem of $6.00 a day is far from sufficient to supply

adequate staff, decent housing, and wholesome food to those unfortunates who are wards

of the Commonwealth.
page twelve

I submit the further proposition that your investment in mental health services is
hardly commensurate with the extraordinary leadership you have provided over a century
and more to the mental health movement. The first President of the American Psychiatric
Association was from Massachusetts, as is the current President. In the last decade
alone, you have given the American Psychiatric Assocation three of its most outstanding
Presidents -- Dr. Harry Solomon, Dr. Walter Barton and Dr. Jack Ewalt. You can still
draw upon the wisdom of Solomon and the kinetic energy of Ewalt, but we in Washington
are fortunate these days in being able to tap the long experience of Barton.

During his tenure as President of the APA in 1957-58, Dr. Solomon focused his
major attention upon the inadequacies of the big state mental hospital.

"The large mental hospital is antiquated, outmoded and rapidly becoming

obsolete", he declared in his Presidential address in 1958. "We can still

build them, but we cannot staff them; and therefore we cannot make true

hospitals of them."

The courageous observations of Dr. Solomon received detailed confirmation in the
final report of the Joint Commission on Mental Illness and Health, This Commission,
located here in Boston and brilliantly led by Dr. Ewalt, proclaimed the need for a
chain of community psychiatric facilities throughout the length and breadth of this land.

You are deeply engaged in this endeavor at the current moment in Massachusetts. In
addition to major centers planned for Lowell, Fall River and Springfield, you contemplate
several additional centers in this city. It is also gratifying that the Legislature,
after a momentary indiscretion, followed the leadership of Governor Peabody in providing
for an expansion of your famous Massachusetts Mental Health Center. I followed some of
the debate over this matter in the Boston papers, and was truly astounded to find

several members of the Massachusetts Medical Society quoted as branding this desparately

needed expansion as "Socialism". This sort of verbal witchcraft is most inappropriate
page thirteen

to a factual discussion of the need for additional physical facilities to care for
suffering people, particularly emotionally disturbed children, the mentally retarded
and the aged.

As one who has been critical of the actions of some state legislatures but, since
my days as a political reporter, cognizant of and sympathetic to the trials and tribu-
lations of the individual state legislator, permit me to pay my respects to the General
Court of the Commonwealth of Massachusetts. I know that everyone in this room is
grateful to the legislature for its vital action in raising the salaries of both pro-
fessional and non-professional workers in the Department of Mental Health. These
salary increases will permit Dr. Solomon to compete on more equal terms with his fellow
Commissioners in acquiring additional psychiatric personnel.

You are also engaged in a comprehensive, two-year planning effort to determine just
where and when you will locate additional mental health centers throughout the state.
In eventually supplanting the large mental hospitals, I hope that you will give careful
attention to Dr. Solomon's oft-repeated recommendation that moderate-sized facilities
in the form of colonies or homes be used to care for those chronically ill individuals
for whom, at the present time, we have no effective treatment. As the English have
proved over the past decade, these colonies or hostels. can be run with a minimum of
staff and a maximum of compassion if they are kept small enough.

Time does not permit an adequate expression of the extent of the debt all of us in
the mental health field owe to you here in Massachusetts for your many experiments in
new ways of handling mental illness. I am particularly impressed with the success of
the pilot projects at Boston State Hospital and at the Massachusetts Mental Health Center

in the prevention of hospitalization through the use of improved screening techniques
page fourteen

combined with home treatment services. Here in America, where all the family, legal
and medical pressures seem to unite in a conspiracy to force the patient into the
hospital, there is a tremendous lesson to be learned in your demonstration of the many
family and community strengths which can be drawn upon to keep the patient functioning
outside the hospital. Furthermore, you tear down the veil which has shrouded public
psychiatry in an atmosphere of fear, mystery and isolation when you provide for home
visits by medical students and residents and when you work closely with family physicians
in joint therapeutic efforts.
The 40-bed, all-purpose center for intensive treatment is an appealing concept.

[ naybe through these centers we can rekindle some of the warmth between staff and patients
which Charles Dickens described in 1842 after a visit to what is now the Boston State
Mental Hospital:

"Every patient in this asylum sits down to dinner every day with a knife and
fork; and in the midst of them sits the gentleman (the Superintendent) ."

Isn't this personal contact the essence of what we are trying to create when we
talk of a chain of small, well-staffed, community centers? |

The tasks facing you are many, and foremost among them is the job of convincing the
people and their elected representatives that additional mental health expenditures are
both desirable and warranted. I like what John Powers, your State Senate President,
told the delegates to the Governor's Conference on Action for Mental Health here in
this city in May of 1962:

"Tell the people your story as you have told it to me", he urged them. "Tell

them of the hundreds of thousands of pitiable human beings whom their money
can restore to dignity."
page fifteen

Neboreor

jm his magnificent Inaugural Address in January, 1961, our late President told us
ft,

that the road would not be easy:

"A11 this will not be finished in the first one hundred days. Nor will it be
finished in the first one thousand days, nor in the life of this Administration,
nor even perhaps in our lifetime on this planet. But let us begin."

Here in Massachusetts and throughout this great land, let us continue. |

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