ST,ATEMENT DR~ FRANCIS BRA representing the AMERICAN PSYCHIATRIC A in support of the 1960 of the NATIONAL INSTITUTE OF MENTli LTE .l\.sking for money·~ no matter for whorn or whatp has always been a bit difficult for me and I an1 never very good at iL But when I lot)k back at the situatitm, when I testified in favor of the National l\1e:ntal Health Act 9 12 years agoi and co:r:npare conditions then and nowi I feel not the slightest hesitancy in corning befor1.~ you requesting funds for extending the program eif the NationaJ. Institute of 1vienta 1 Hea ltl1o :F'or th.ere is evidence on every hand that the money invested in :rnental health efforts 1s yielding results. Bcd;h in a:nd ot:i.t of r:rie:n.tal hospitals~ th.ere has been great progress. Ntrw treatrnent 1:neti1Qc.::ts have b~:~e:n introduced and old {):nes improved. More patients are being released fror:t, hospitals after shorter stays. Community rnental health. facilities h.rve incret::ised in nu.mber and effectiveness◊ There is a i:rr.·0·1.ving public av;,.arene~:;s of the natu.re of mental illness 9 a los~ of the hopelessness whi(:h used t>t) zurr,n.:nid itp and a general realization that son1e­ t.hing can be don.e about it. There is vddespread and growing interest in pn:,moting goQd mental hf:a1.i:h at thl't~ co:rnrnunity level and in overcoming such public mental health proble:ms as alcoholism and juvenile delinquency o More people are being trained. as rnental health specialists" And roost important of allg a great reseax'ch effort has been rnc:ibilized to study~ from many dif­ ferent an.gles:1 a. great variety of problems related to mental illness and health., We have :reac:b.ed a point~ in fact~ where we can 1t afford to slow down or stand still, lest wel lose the 1rnomentum gained in these fir st fruit­ ful years of i:n.-vi:!:Sb:1nenL l"fo'W Needs Develop with :.Progress Though \Ve have '.irnade great progrE,ss, we still have a long way to go,, Viewed f:torn a national 9 O'vera.11 standpoint 9 Ute r-rH::;ntal health effort is just getting well 1..:m.t~l.e1;1"way. There are still en.orrnou.s needs to be r.netp even more., perhaps, than when the program started. We still have the old problems with us, and a lot of new ones, too& For progress is dynamic and new needs are bound to develop along with our gains. The program is growing and should have the support it needs to continue to grow. And that means mo1·e funds than last year, because the same amount it p.ad last year is not enough to cover its normal growthq Training and research programs are ongoing activities and comrnitments have already been made for them. They cannot be permitted to grind to a halt. Likewise, there are other areas where marked progress is evident but where problems are coml)ounded with new developments and thes~ in particular need additional support. Progress iJ:1. Mental Hospitals Since my work is in the mental hospital area, I have been impressed most by the progress in the care and treatrnent of the mentally ill in the lZ years since the Mental Health Act was passedo There is recognizable evi­ dence of this progress in the statistical fact that last year for the third straight year there were fewer patients in mental hospitals at the end of the year than at the beginning,, This occurred in spite of the fact that first adm.issions to mental hospitals were up from the preceding year. It is thought by some that this downward swing in hospital populations is due mostly to the advent of the tranquilizing drugs, but this is only one of the ,factors reaponsible for the improvement. Actually, there was already note­ worthy improvement evident as much as a year and a half before the first of the tranquilizers was introduced in 1953. Even more important than the drugsjl in my opinion, has been the basic change that has taken place in the philosophy of treatment for the mentally ill since the Mental Health .Act was passed~ The goal of t~eatment has clearly become to rehabilitate the patient so that he is able to return to community living$ This philosophy also includes the be ,ef that the hospital itself must provide a therapeutic environment in which tl:H:, patient will natur­ ally improve. More attention is being given to the hospital nd.lieu~-the physical, psychological an.d social environment in. which, th'f': pt;tien,t lives from day to day. The concept of the open. hospitalv so succ 1i~ssful in some British communities II has taken hold in. the United State:~; in modified form, with strikingly beneficial results in some places,. T~ere are also refinements in our older methods of treatment which we cannot yet afford to discard. New techniques in shock tl eatment-­ 0 the use of sedatives ar:td muscle relaxation ahead of the treatment-ilt.\ve taken away much of the patient's fear of this method which has proved so effective in some types of mental illness. Such techniques as group therapy, psychodrama and occupational therapy are being used more and more in both State-supported and private hospitals. While Federal funds have not been spent directly for improvement in mental hospitals. much of the progress I have noted can be ascribed to the focusing of public attention on conditions in mental hospitals prior to ~ the passage of the Mental Health Act and to public education by mental health personnel in developing the NIMH program. Much of the improve­ ment also rests on understanding gai:Q.ed throt1gh NIMH research and pilot investigations. Mental Health Project Grants Mental hospitals stand to profit directly from the NIMH program of Mental Health Project Gra.nts for which Congress passed enabling legis­ lation in 19560 These grants provide public and p:rivat e agenciesv institutions 1 and individuals improved methods taUy UL studies memi,tal h.itgspitals 9 a.s wen as iTI:11 fadUties be tried.. They to study the setting or the use or that very leaves otherwise sent those Westerm, states chiat:rk ing physicians medium televisfon. tialities it has to My (Q)WIDl. who ii.re ties Cou1mseU1:mg Board combines the old -5- counseling.. It offers the help of a woman judge, an attorney, and a clergy­ man of the denomination to which the person involved subscribes. If he , needs emotional assistance* he is referred to the clinic. He is given legal help if he needs that, and is provided also with a spiritual adviser. The agency 1 s service thus cuts across the fields of law, psychiatry and social work. The project is designed to explore the potentials of such an arrange­ ment to bring these professions together to work ~ooperatively for the wel ... fare of the patient or client rather than at cross purposes as so often is tru.e in such cases. From the examples I have given you, you can see that this recently created grants program offers great possibilities for initiating improve­ ments, fostering progress, and overcoming difficulties in many different areas & There were 65 projects approved for support last year which was the first year of operation for this program. Most of them are continuing projects involving two to five years of support, which means it will take almost the full amount of money allocated last year to keep them running this year., In the meantime, interest and new ideas a.re developing and the Institute expects an in<;:reasing number of new applications next year. I should, therefore, urgently recommend to you that next year's allocation for Mental Health Project Grants be doubled over what it was last year. Drug Research Needed A good example of how progress brings new needs and new prob­ lems is the advent of the psychoactive drugs in the treatment of mental illness which we have already mentioned. The rapid development of this type of therapy has opened up a whole new area of research that needs at­ tention and support- Dr,. Morton Kramer 1 chief of the Bic»metrics Branch of the National Institute of Mental Health, has written a monograph on the need for more psychopharrnacological research. In it, he points out. ~so e of the important implications involved in the widespread use of tranquil~,7:,1ng (:I.rugs. Among the many as yet unanswered questionswhich he raises arf,~ Basically how safe are these agents for tl1e pa ti z:,)J.t '? Authoritatively, what are their imrnediate a::s: wed.1 as their long­ range effects? What really are the psychological effects of the drugs? Do they actually produce depressive reactions or other psychQtic symptoms? Is it safe to permit persons to drive automobiles while on these drugs? Is it safe to use these drugs for childreri? What effect do they have on the lea:r.nin.g p:rocess? And so on. These questions and many others need. to be answered for each of the new drugs that are coming into common use, There were more than 40 of them on the market the last time I counted them. There are probably many more by now and even more in the process of development. All poten­ tial psychiatric drugs need thorough clinical and preclinical testing and thorough evaluation--not only for their effectiveness and safety, but also to determine conditions under which they will be most usefuL We need to know the different effects of different drugs on different types of psycholo­ gical disturbances and physical symptoms .. The psychiatric drugs not only hold great promise as treatment tools, but they also can be utilized as extrer:nely valuable tools for learning more about the basic structure and functioning of the brain and central ner­ vous system, both u1 health and in illness. This opens up a second area in ·-7- which both basic and clinical research is need.e:d to ta,kt; ad\1antag e of the 1 great potentialities of the psychoactive drugs, The NIMH Psychopharmacological Service Cen. ;;:;et up in I 956 to encourage and coordinate research in thi~; field" ha tensive program with 132, laboratories and stuc!.::,r center:~~, ,.xu.ctiI:lg grant- supported research. This is a most valuable service tinued support, fen:- the '\1vork is being done in medical ./i a.n.d in other established research centertL Within the past yf:ar" the Institute has also set ?JP it:s own CHnica.1 Neuropharmacological Resea.rch Center at Saint Elizab(e:ths J-I·:) 0;pital/J \.vith 0 the Hospital cooperating in an exte;o.:sive pr:)gran1 of bod::-. ha.sic :fand clinical research, Saint Elizabethsp as you. krH)Vi/ 9 has a b.\:tge poptilation from which the Center can. draw for its cHnica.1 st:uud5.{;:;rs" T':his rnakes it possible also to observe and evaluate diffe"1:e:n,t types of drug therapy and their ef­ fects on diffe:r<:m.t kinds of psychotic: ;;yn1ptou;•s," .Dr, Joel .Elkes:., an ,:mt= standing pharmacologist and psyd.d,:?l t:rist frotn Birn:in.gharn ,; EnglandD who heads the project!) is inten'::sted to(0 i:n making r;:;cientifl.c. sb.1<.cU•e;s on. how the 1 use of the drugs affects the attitudes t:")f bc)t!1 pati(ents and st:afI :rnembe:rs and how much such changes in the hospital milieu have to do ·with the imp:rcove­ rnent in patient recovery~ Laboratories for basic research on the drugs themselves and on the biological and psychological. reactions they cause have been installed in one of the buildings at Saint .EH:~abeths!l ·which also serves as a center for clinical studies o This ne,;v Center v cornbining NIMH and Saint Elizabeths 1"'esources~ strikes rrH?: as a most p:rm-.nl:sing p1·oject in this important field of :r·esearchv and oru~ worthy of aU the; financial support it takes to get it off to a good :start and keep it going◊ Though you appropriated $6)1 000,. 000 fn:c the su.pport of research projects and prograrr1s in psychopharmacology la.st ye:011 do not k11.-ow how much of it was used for this purposeu as too.li:n.g r,.p iti tficult task.. I do know that, having la.unched a tho:n.1ugh sea1·ch foJ:' the JL. tio:n needed to use these new therapeutic to()ls safely and inteUigen.t1y-i) t~ can. be :no qu.e stion no'vv as to the ".JV isdon1 of pr ovid.ing en.ough ,r_:,:c,. rry the sear ch on through~ It is ou:c btdief that this vrnrk will requir unly the full Broadsc:ale :R,,eseare:h Pro While I ha·ve :singlr.:!d out psychoph,::.Ltn1acology because it is rH::\N and of irnn.1ediate interest,, I ..;vcCHJ.kt :not ·vvant to overernptv::11,iz,e it in relation to the trerrH:Yruicvus over·-all research effort the T--Jx'lti(;.n.al I:n.stitute of Mental pu:rpcise f:r.om y,,ear to year the Institute has LH::.er; .,:,,ble to direct the efforts of literally hu:ndreds of scientists into avem.1.i:fi r ~.~i'~ e:a:rch related to mental illne;ss and health,, :Be~1ides the important studii·s .NIJvU-1 is conducting in its a great ~lar.iety of basic and c:1in.ical rret,earch pr-ojects in u:ni.ve:r·ed.t.ies~ hos- pita ls j'/ clinics and la bo:ratorief5 tl1roughout the c1..nn1t:r·y" Sdentis ts are study­ ing the problems of rn ental illness an.d. hea 1th, frorn evf,ry pc s\7dble angle and~ 1 while th,;!SC p:t·oblems are far tot) r:na:ny and tor.i <>ornplicated to expect major breakthroughs ,of dramatic causes or curt:~sv tl::1e rtJsearch is constantly yield­ ing knowledge and understanding th.at makes for pr,ogreS!L It would be sacrificing rnuch of tlit~ investrnemt aLt•1e,ady i-nade if the scientists f~:nHsted in the N[MH reseai~ch program failed t,, push for·\JtJard in their s~arch for scientific knc:rv,lledge {Jn which to base tr·eatrt1e.nt an.d preven­ tive r:neasure;;, It is a trernt!mdous undertaking and onie ·\l\rhich v,liH have to be extended indefinitely and at increasing cost, if it is to produce even a portion of the knowledge we need to grapple with the complicated problems we face in th.is field* As one who has watched this nationwide research effort grow from almost nothing to its present impres proportions, I urge increased support, to the extent of 50 per cent, for this inval.uable program* Without extensive research, there could be no valid progress in ov.e:rcoming mental illness, for ·unless we have knowledge O:Q. which to base our efforts, those efforts are likely to be wasted, and may even prove harmfql. Rehabilitative Services I have my OWil definition of what it takes to rehabilitate a person who enters a mental hospital for treatment and it involves not only what hap• pens to while he is in the hospital, but also what happens in 'the commun· ity to which he returns. Rehabilitation of a mental patient, as I see it, consists of five parts. Th,e· first thi~g required. is treatment of the situation, which the patient pre· sents$ That's what he came for and he would.n 1t be there if he did not need 'treatment~ The second essential is that the patient receive some educcltion while he is recovering--that he is learning and doing something constructive each day4 Idleness is demoralizing. Nothing could be worse for mental" patients than Just having to sit or wander around with nothing special to do. Some patients learn skills and increase their efficiency while in the hospi­ tal and thi:1>, in turn, helps them to get employment when they are abl~ to The third factor in rehabilitation is the socialization of the patient. His trouble frequently Hes in his inability to get along with others. People don't get sick in a vacuum. It is in their dealings with other people, th.eir close personal re1ationshipsjl that they get "all fouled up, "to use the -10- vernacular" They can 1t ge:t 'INt1:;JJ with.ou:t learni-ng emotional reactions to other peopleo The fourth thing that must ·be <ion.E:: is tc 1 rr:.· pare the patient for a return to the community and his family,, Jt 1::; por,;:::.iJ:Jte for us to help the patient a great deal in the neutral suxr of our hospital but we nmst prepare hhri for the problems wh.ic.h. h(:.'. ':JU. ·n1e•~t, .., vhen he goes out. The fiftb. necessity is the preparatie:t;, of fh~"' farnily and the cornnn1nity for the retur:n of the patient, There is: no ·uJ.se preparing patients by the best of rehabilitative procedures if the :fa-r:,·,rly or' tr.1.e community will not receive therr1 ·wh.en they recover o With the help of new therapies v nH)r e pa tie:r:i.ts "'n ever before recover enough to leave the hospitaL But the hospital is not as simple as it sQunds" Under some cir CE:t"" more likely to regress if they are released fr they stay" Some are better off in the hospHa 1h,Pi::. Others have no home to which tJhey can ret.urno So<:'•i ;J.b~:.~d. continu.ed treatment but are able to ~"'vork or spend part of their day at homeo Even those who are completely able to return to tlrn community a:,re bound to have difficulfyin readjusting unless the community is prepared to help them. Thusp a variety of rehabilitative faci.l.iti·es is called for~ halfway- houses» foster home carev day ax1d night hospital care.9 sheltered wo:rkshops 11 outpatient clinics» and~ above all~ people and places \,Vithin the community where they can turn for help when they need it. Preventive :tvfeasures Communities should ·oe ,Nell equipped with services and facilities that would help keep people ~~:!:.. of mental hospitals, E·rnc:cgency treatment, for mental illness should be made available either in outpatient clinics or in general hospitals, Treatr.oent at the ti:n:H.~ an illness fixst becomes appar­ ent1 before the psychcitic cJmdition becomes deeply ingrained~ can often pre- vent a serious long··"tern1 illness., Peonle should not be sent to mental hos-- .L pitals unless they need :rni~ntal h,ospital treatrnenL One ri~ason why hospitals ·,;_ .J • . are crowded is because peopte a e ;2;ent there '1.vhen they· can 1t get care any- where else. For examplev the1·e are hundreds of older people in mental hos­ pitals who ~1vould be rriuch better off if they could be cared for elsewhere'.· Cornrnu.nit:i.es should prov·ide services a:nd facilities that would enable older citizens to stayi, and h;;::ve their n.eed.s rnet:, ~T, their own community.· Public health. services should inc.Au.de prcr.d.:sion fo:r ~:h,e treatment of alcoholism within the con1munity o Schools and sheltered '\,verkshops should be provided for the mentally retardei.:L There ~:;hould be rnore child guidance clinics and more ri:isidential tr-eatn;H:::nt centers fen~ emotionally disturbed children. it takes a lot of inoney,) and :a lot of dedicated effort by profession­ ally trained ·people to set up comrnunity mental health programs and keep tht:.:m l"lmtiing •. But. witll the help of .F'ederal grants~-in-aid every Stafe in. the Uni.on-has bt:fe:1· abl:e tit) at tea st make a :start on establishing this sort of a 'program,. Some ()f th.e..·more densely populated and wealthier States have made . " :rea 11y rn1p:ress1ve progress, But even such States as California a"nd New York do not have· a;ny\,;1J1er.e .near the services that are neededo In rural areas, ·.particularly» ther.,e:<ha£; bee;n scant progres~L Most of the clinics arid other fac'.Hi:tles are 1.ocated in. cities)) an.d there are many rural areas where·no help whateve-r i~Hpr{5vided in the mentail health, mental welfare field~ The Biometrics Branch of N:U./!H has reported that only 9 per cent of the pro­ fessional clinical servic•:ss are in rural areas i:n 'which 0. per cent of the population l.iveso I ag:ree· heartily ·with the: rf::solution passed foz:t v,:;;;ar by the National Association fer Mental Health» in "'lv\lhich the ..A ssociati011 a that Congress v this year, a.ppropriate at f.e;.Hrt 8 n:iiUio:n dollars for co:nnccunity mental health s~rviceso 1.tfoney ,3pent in thjs ''V"/ay is seed rnorieyo COTff1.nunities won't» and often can 'tp go ahead on tJieir own initiative to set up clinics and services~ but once such service::S axe et:.d:abiished through the help of Federal funds» the communities that have thern vvoukl.n 1t h1ow ho\xJ to do wit1:H)u..t then, o Technical .As si:stance Projects Scarcity of 1rno:rney is not the only reason that comrnunities fail to initiate rnental he?rb:ih progra:r:ns, 'They he .:fate because they do not know how to go about setting up an.ct conducti:ng such p:rogr::.:1·rns O To help overcome this difficulty the Na tiion,a l In:stHute of Mental He2: I.th has made cons ulta ti.on and technical .assistanCf'; available tlu"ough the R.egio:na1 Offices of the Public Health Service, . As an ext-ffnsio:n of thL6 cr . ,. lice." the Institute provides support for Technical Assist;.ince Projects, ThBse are special conferences primarily focused on a particular :rne.ntal he.a Uh proble:tn '\Nith. which the State calling the conference is conce:rnecL For exarnplev Wyoming had a project to c,on­ side1~ tb.e nutilizatiox1 of Corn:rnunity Res0u:rces in Merital HeaHJ1 Programs. n Another» in 1\.fassachus:.ett:G;) l0Gk1ed into 11 .1',/fental BeaH11 Aspects of Alcohol 11 Educafron; South Carolin.a he]d one on nThe Volun.teer Resource Person in Community :~,/fe:ntal Beal.th,, 11 Last year 15 States took ad.vantage of this type of grant support,. to th::t"eI:th out .scHTi(e of tl:ie troublesorne questions they con­ fronted in th.eir eJ:forts to develop r.1evv programs or revitalize ongoing ones. -13- These Technical .Assistance Projects have pro·ved very helpful» I am told 9 and continlH~ to be more and more in demandu I ho·pe earnestly that Con­ gress will see fit to provide a budget large enough to cove:t a fa:r more sizeable sum for this purpose tl1an the $66» 000 that was spent last year~ Manpower P:r·oblem Obviouslyj it takes a gr eat number of highly trained~ qualified people to organize and carry on. a broad scale program of :research and action such a:s that which it?.i called for by the Natio:nal }Ae:n.tal Health Act. Moreover» most of the required personnel mu.st be drawn from professions which are still new and i:n which there has beenv and still isr; an acute short­ age of manpower. At the time the .Act was passed there we:re very few people trained in the four most needed professions*·-,psychiatryi, clinical psychology, psychiatric nursing and psychiatric ;~ociall ,.vork,. And what was more funda­ mentalv there was little opportunity for people to acquire the highly special­ ized and expensive training required to entier 1:he6e fields. The Natiorial Institute of M~en.tal H,ealth has made a great effort to remedy this situation through its wen organized and well received training program.. With funds aHocated by Congressv the Institute has provided finan­ cial assistance to many medical schools 9 hospitalsli and other training cen­ ters to help thern expand and improve their facilities so that more and better training would be a·vailable in these four disciplineso It has also provided some 5i1 000 traineeships to help promising individuals take this trainingo In spite of these fruitful effortsv there still ren:iains a tremendous shortage of personnel trained in the mental health disciplineso According to Dr .. George W. Albeev Director of the Task Force on Man.power for the Joint Commission on Mental Illness and I-Iealthv ther,e is one psychiatrist for every 19, 000 people in the United States; there is one psychologist to each 11, 000 people; there is one trained psychiatric social worker to every 78» 000 people. This shortage of trained people is acutely felt in. the mental hospi­ tals all over the country~ as well as in the NIMH effort tc get the people it needs for its program. 'To give you an examplev a sur,1ey :recently made in some of the Western States brought out the fact that in one of the State hos­ pitals studied, ther<:; were only 18 psychiatrists where thf:y should have 44 to :meet APA standards; t.here 'Were only 5 psychologists '>l✓ here there should have been 12; 44 graduate nurses where there should hs-ve been 150; one occupational therapist where there should have been 12; and two social workers where there should have been 75 ❖ Psychiatric Training for Mo D.s In my capacity as a r.nember of the NIMH Advisory Board 9 I note that the Institute is still working hard to provide training and encourage people to train for the four major mental he;;dth ~;~pecialtieso In the mean­ while9 several other types of training prograrns have been started which will help relieve the manpower shortage and also make more psychiatric knowledge available to people in key positions for implementing the over-all mental hea 1th effort. One of the most promising of these new training programs and on~ which the .t\merican Psychiatric .Association heartily endorses~ is the one that offers residency traineeships and support of post-graduate courses in psychiatry to practicing physicians o Since the general. practitioner training program was launched~ just I ,.. , d{~ months ago~,, the National Institute of Mental Health has received more t..11.an. l 00 applications for traineeships and post··gradua te courses. Within a month there were applications for more than 900 9 000 of the original appropriation of 1.3 million dollar so . A nd applicatio:ns co:ntinue to pour in» attesting to the widespread interest among rr::edical pr::.:,r· ;_,:,oners in the psy- chiatric approach to healing and public health◊ Another training progran1 airned at getting ps i.c principles into general medical practice is the one giving grant psychiatric training of medical students at the undergraduate levet, i:t:, program is already well established. 'Ihere are active grants» tc for teaching costs in 86 rnedical ~chools and schools Hon to teaching grants 0 :schoQ h.a:ve been offered $600 stlxdent stipends for extra-,cur:ricular clinical or rr~search training in psychiatr f:~r rnedical stu- dents,, ·:~·b:is program fJ L::i.iHated in the sur:rrrrier of J 95 r ha,.s had enfrmsiastic acceptance and 737 stipend units have bee:c. av.Jarded duri.u.g Lh current year. Here is a farsighted venture which eventuaU should help to relieve our short­ age of clinicians. training for rnedical stu­ dents will be activated in 1960 . Its purpose ir:: to pTctnote a·.mong :rnedical students~ an understanding c,f hu:rnan beh..avior a:nd its irnportan.ce in health and illness. Grants are offered to rnedical schools in support of training programs in the basic sciences of hurnan behavior. While this program is not expected to take hold. as rapidly as that for p3ychiatric training» several pilot projects have demonstrated tht:; feasibility of this type of training in medical schools and there is a real need for this prograrr1o i\pplications have already been received fron"'l close to 50 medical schools o Some of the new programs also offer support for psychiatric training for nurses and welfare specialists" -16- Training for Research The :research fellow ship progran, set up i:n. 1947 has helped hundreds of individual workers in the biological,9 medical and social science areas to :receive training while they v.;orked on research projects,, .Ferr rnore :mature scientistsv the career investigator program has offered support for ad,vanced study and experience. These programs should be continued and expandedo But they do not meet the need for specialized training for people to do re­ search on problems related. to mental illness and healt:h, To help meet this needv the Institute i:nit.iated in fit,ca.1. year 1959 a new program of support at the doctoral level to train r e.searc'h personnel in 1 various fields of psychology--child psychologyp social psychology" ,f:xperimen-· tal psychologyp etc. The purpose of this program is to develop r~;se:a:rch per­ sonnel to un,rfertake work in such mental health problem area as retardation9 juvenile delinquencyv alcoholism" and agingo Another j.::-r.p1,n·'tant new research training program is the one designed to supplement the \:.:raditi.onal training in other related fieldsv so that each researcher can br to bea. r a :n 11:rn ber of interdisciplinary research skills in ·working on mental heal''.J:i. problems. Under this programr behavioral scientistsv biological scientists~ epidemiologists and social scientists will be able to receive doctoral and pastoral training in mental health fields. Psychiatristsii psychologistsv psychiatric social workers and psychiatric nurses~ on the other handr will be able to receive postdoctoral training in the research skills a.mi techniques of the biological and social sciences~ .For the most part these research training programs are new. But a great many applications have been received from institutions that are equipped to gi':e training for mental health research and a number of grants have been award.edo The Institute has taken the right approach to the -manpower problem by directing its efforts towards providing more opportuni tD train for work in ·the mental health field. We cannot hope to accomplish wh.at needs to be done unless our universities~ hospitals and other training centers graduate enough people with the proper training to do the job. I hesitate to think of the condition psychiatry would be in today were it not for ihe help of this Institute in training personnelp particularly psychiatrists, I r:nentioned this in writing up the report of the Mental Health Section of the Hoover ReporL Conditions would be absolutely chaotic without the assistance of that large number of workers provided for by stipends from the National Institute of Mental l!ealth. The N. I. l\,,f.H, needs nine million dollars more than it ~had last year tc continue its training program p to pay for normal expansion and growth of the older ones O and to encourage the beginning of ne,,;v programs o The training of competent personnel is the very founda th>:n upon which the whole mental health effort restso I particularly urge that you give the No L Mol-L training progra:rn all the support it can useo Additional Funds Needed As the country moves forward toward objectives set by the Congress in the Mental Health Act!) as the program broadens in its scope~ and as new needs and new problems arise 0 the cost of financing further progress is un­ avoidably high. We need additional funds to protect the investment we have already maae and to make further progress possible in an area so vital to our national well-beingo There is little point in pouring billions of dollars into the sky­ rocketing science of the physical universe unless we match it with what is needed to achieve and maintain a population of people sound enough in mind -18- and body to cope successfuly with the problems brought about by the sudden sweeping changes affecting t.he world in which we livec. more than ever ep wt1 need to give attention tci the mental health of nation. For these reasons, Mr., Chairman» I feels tht'. t the funds for the mental health program should be substantially increased this year" To hold the line is to retreat at the very time that we are beginning to see lighto I would like to see at least 75 million dollars for mental health activities in 1960. With these funds the Institute could push forward in research in all of the areas outlined abo-..re 9 all of which are essential. 9 and I know t you gentlemen will do what you can to see that our advance$ so recently started, will not be handicapped now. I a:r(l Dro .F'ra:n,cX.s Jo B:rac hncL I aTn a psychiatrist and have been in the px-actice of psycb.iatry for app:roxirf':at1:>ly :~8 r:;arso iH present I alTi the Psychiatrist=in ..·Chief of the Institute of Living, an old nH.mtal hospital in Hartford, Con.necticu.L Fiere today I :r,epr,.:;s1:;x1t fhe nearly 11 r 000 mernbers of the Arnerican Psycl1iatric Associatic.n 9 the old.est of the national medical s<>cieties. " a r:nong them the presi- dency of tb.e AnH.:.ricaL P:10;::~:r.·d of F\sychi.atry and N,0u:rology~ the .American Diseases t,f th the l'fa tiona l H ea 1th tx-!lc Sectio:n of the::: Bureau of J\ 1!edicine t,;) the Su:rgeon Ciex1eral~ lJ" S" N"av·y an.d U. So Ar:cny, an.d a rnembe::r of the e:n.L I was also a mem- The A.roerica.:n tric: i\.f:L£~ociation is appreciative of the oppor-~ tunity to testify befo:r e through the wisd~Jrr1 an_c.t fo,r ight of yolrr (:>DtYTrnittee ;:.;:;nd the courage and. dedication of your distingtdshi~;d Cha1rrnan~ in co.rnpa.ny ,with Senator Hill; that tT' ists of thre rta ti,on a1nd. rnany nthe·r s of our conf:rerest ·we v-..;c1:ld like t<:) ackno".;vle,d.ge to yo1.1 the in.debtedness of those whose ta :sk it is to ca.rf:: £01~ th,ese: sii.::ls:. a.nd :rnisu11derstorc)d patients o The following is a detailed budget Psychiatric Association for the fiscal year of the Nati.onal Institute of Mental Health FISCAL 1959 RECOMMENDED GRANTS APPROPRIATION Research Projects 18i834g000 ,100(:/)000 Research Fellowships 1,39611000 2,.,0000000 Trainh1g 18~213,000 0000000 State Control. Programs 4,0001,000 0000000 DIRECT OPERATIO!:e Research 6,921,000 1)000©000 Review and Approval 863,000 1v200 9 000 Training Activi.ties 100,000 l00:)000 Professional and Technical Assistance 1,73ot)ooo 2. s200 .,000 Adm5.nistration 162,000 TOTAL 52,419,000 1,000,000 1 r 'I?esti:mony of i:n I ffe of to in I in of' the you are to set tba.nlt."3 for of' the to there ha.ve you the been t:ruly hospltals for ou.r the end of one a M:Ost of o.f ca:use of i:ri were 'Without ef:eort,....... indicated. :tn of' :most of them,, I where with home centers; of t.;he sociologic as well as econo:m::tc; increase nutriber of' these in the count:cy such k:tnd usually For example, see in the priva;te he who and i:n I '!JlJW krmw to I the as of in 111 d<J the the both if he f':lnd.s then there :ts the a in the vork of' the its this '.mDve the degree of we and a I O'-)(t0000-◊0000000000(J GOO Testimony of t.he Ameri.can :in HOUSE LABOR, at I have been the I ha,re :tl'!.&dt~ me t.o I Q :for Durl:r..\g the o:f th~ I been, I come and to my It has become even mor{:: obv:ious since last I ap,Peared before you. t.b.at mar:ik:ind. is upon what 1,till be gt"eatest perfod o:f change th.at has e·ver been kn01,n1., se<-.:m}.S to be happen:ing» u de Chardin the :Freneh the ·,rrhole: striJ.ctu.1',:'.; of' human consciousness and a fresh kind. of' life In the f'.ace of thit:1 one car1 remain indifferent." 1I:he recent t:r:i:p of' a brave a.na. modest m.an :into outer space seerns to bear 01t t th:i.s o:f' advances, the result of vast effo:rt;s w-h:ir:h almost beggar o:f JJ1.ed.:tc tne an.d. of element in t;ion. When all People and their men.tal d.:i.sord.er :in its va:r:lou.s phases and. varicru.r1 a.ura.td,0nso that a n8,t::Lon lUre ortrs which displays a huro.an:it.ar:ian i..:nterest in :ind::tv:i.d:uaJ.s ao.d whteh :ts r1f.,ht.ly the best ed:u.cat:lo:i:1 :f'o:r ea.eh :person, is wi.lling to withd.raw its i._uterest a1most entirely on::~e that person has displayed_ any evidence of emotional o::c men.tal diBE:!a.se., It :ls almost confir.m.ation of Chest;erton f H that men ea;n see r;;)u.blin:Jl.e volume, Actio:n :for M~ntal He,\?,l.lt~h 9 an,d, I know 'too that it played a large part in provi.ding the fu1.I1ds and la:u:nch:ing th,at proje<;t so I 8h,all not dwell up011 it for too long bu:t I w01ulrl LiJ1:e to merely touch upon a :few salient points which a:re to be found in the Fir~,i,l Report before discussing such nmnda.:ne burt admittedly 1.mporta.ut t;h:ings as budgeto Among others, the Report quotes Alan Gregg who hall a fil:3/:dlit;y for putting problem.~ in proper perspective o In 19J~4 he aa.id~ No other spe cd,al ty of :med:icd11e h,11,s had a 1 history so rrtx·snge rM.:rr ,a, 1·elat:ion to l:1t11n.an, thought so :i,:;1t;:ima,te as psychiatryo The t:hre,&'; r110,s·t :powerful tra(Lit:lons or histor:lc;al heri,tages of psychiatry a1~e st:ill as they haYe been f'I"C>m 't:tme :bmnem.or'ial.,. the hox"t'or w:h:i,,;,~h mental d.iisea,:se 1ru~:ptres, the power anil tb1e ,sr!:11:rtlet;y w:tth whieh psych:ia:'L:t"fo symptoms 1nf'llten(ce lm.1:na:r:11 reila, f;ion,a; -::;;11d t.he tend.enc:y of mar.1 to thi:r1.k of' sp.i:rtt as ?1ot se:pa,rable bu.t already ,se:parate f:rom. body. Th.eS';E➔ tibe i.nevi t.a:ble and l.rrvete:riti.,t;e h.a.rl.d,:icaps o:f ps::r\•. i:.Iata"y. been waged, with patien.t hei:roi.sm 51 none the less ad.m.:i.:rable for be:lng at t:im.es perha;ps d,espond.e:r1t .rmd. bewild.ered_j he :foun(l It a ba,tt.le tl.ot yert All of tJ.1est:; things may still be said toda,y an.d although, those of us who hiP.J:ve been 1:11 cl:tni.cal pre.c't:ice and in mental hospi'tals for more than a qi1a,rter o:f a CR:n;tury have noticed a gen,eral so:fte:r.d.ng of. contend, this tn:tere~t ls only a beginning awakentng and we are now i.n about. the same position as our medi.cal confreres were about forty years ago., The sad fa,c-t re,main.s that there is still a Cind.e:rella cast to our professional features and although we look much better tha:n we did in 1946 ·,}.rhen the mental he~1,J:t;h act; was passed, wb.at good S{pparel we have would. d:tsappear were ::tt.; n:ot :for the su,pport a,~f:ford.ed us by the Fed.t~ral Govern­ me:o:t; ·through the 1mderstand.i:ng and assistanee of' th:is Committee and its counterpart in the :faC;t, also remains that the support of the to the psychiatric assistance in this research program.s o:f many throu,gh federal funds that the 'the increase o Ou.r knowledge lu?1s .a,dvan,ced a:ncl r1ew tc) be a boon but; now This mistake was made in France of' were a:vailable a saving could be made 111 'Ln cat,as t,rophe for without special:ized the to general practit:ioners lles:i.::rouis i.t was ·thought.; by some o:f u.r$ I was among them) that when the :fi,rst rush was over that; the :for ·this of would fall o:ff rapidly. Ins.t.e,"'9.d o:f that the on and there are many more applica, n:ts ;for tJ1effie thw:1 there a:re stipends t.o g:ive them. From personal o~f these men I mn ot the opin:ion that ba.t.tle .against mental of :f:i:nished products educated under this prograrn are out :now a.ud i t :ls :fair to say that t.bey -wi,11 surely justify the effort au«:l funds ·which hav·e been expended upon them. some of these men I can better of:f had. but :t"elt ha,,d status :for 'too who f:r.om the :ur.rt only a :f:teld .. in of we huave from for wh:lc;h you a,pprop::r.:iated practi.ces o These a:_pp:rcnred. h~:v-e totaled for only fou:r th:is; year the Preside:n:t ns men whose int.he fieLtl ... health an.a. me:ntal w.hi,ch are the ba.ckbone of the whole psychiatric progri:3.rc1 o this field remain.s to repeat aga:in that training :ln we will be to r~tu.r.n no idea of how dependent ,Since the war, most o:f' the your1,g of childrer1, welcome into practice unless o:f the men who were trlJ,:t:r:..ed through the me;d,:ium, o:f :from hhese sc:holarships :in the f·ield. and are that it yea:r. tt ~ppears as though there will be over twelve m:illfou dollars worth o:f appl:ica:tions which will fall the <) are c1xmu.lat:i.ve. There is also a of funds for programs tn. nu.rs i.ng psychology and :involved here. The field is ready to train, the ,and, tJr.1,e students bu·t e..11 too their programs are this ,and wonders how long these groups will be to w,ii; before t.hey get d,is!::ouraged i l and t.ur:n their atten:tion more, W''ith its fellow mlllion dollars for this extremely whieh been a scourge need f'or man the need for other mental health a dou:bl:ing next five toward th:ts and unable to newr at;t:i:tudes an,d new e::x:ist at; all levels over us and -valuable :fi.eld o Mo:n.eys gi:ven to a d.oez :.n.ot about the It is :i:ndeed shame to ,a"Wake:n the ::tnte:r;;::is t o:f men only to let them. doitJ11 at, to u.nders ta11d which he;ve been as ou,r nw.nber one health ealls :for &1 allocat:io:n for these e.as:i.ly be doubled and 000 wouJil Bef'o:re of the you my admira;tiou fo:r tbP \-r;ormJJ1,:\L men are :i:t, d:if:f:L;;;l:JJ.lt to select them that you. have heard. me failk. o:f' yrnio To idea,s w:h:ich a.re emerging are :fascinating.;; ev~n :new a~d :it :is more or circle--rather :tt moYes o:n,e rung higher. Today, with your QJ.totations, d.ef:ini tely echo my sen:t.J..men:tfi. a :form of have to tr.1e The analogy let u.s :l.t; more No don.or of funds can be ,rlll co:nt;inu.e gt-ving money ex;pe:t":i.ence soon shows that sooner or infectfa:n.--1:,{;':i,s ·I~J,h~: 1::~u:m tb.i'~,t, 1rras need.ed" to br:ing suJilhan.ilaniide to the attention the wnrlrl~ ffsl mfl:filOO'lts""3w'Q~Q»a.:w.lQQ-~-~.--·cni 1 The rt:.t1E~r~:trJJCe of 1v1eil:i(•.:.t:ii,l -8- The drug had the in etce, is larger :for the My second the la.at issue attack upon tbe research the :lt points ou.t they occupy :most to m.an md. are of ·to t;o l.11 the same :for our :first o:f ....,,.,,....,......,~..,,...., ~from Rffln, s kidney for the cu.l t::tva;t;ion will g::tsow on but that even more applicable to crippled: those art:ifici.al mothers" seem :for a. time to be noxmal have st:ill an.other ad.vantage as research subjects, 2 to 3 and can be kept in controlled -to ,~•...1..c;i,,.""'iw"s;;;,'""· e~er:iments. Studies of' this k:tnd .,,,1,,1,4,.,_.,. beh!Jivior that cou1d be obtained :in no .asks . w:b.ether the cr::ttics suggest we carry out Or perhaps ·th.ink :r.t unimportant to Or, dangerous to study ...9.,,. are I woulil like "'co recall is at the present •.!6.'U!,,,.., .!..,'t,i/J\.A.vY. those one were to would be these th~t o:r the :for w:tll 1:le: bef"ore us to he work may be carried. o:no will be :ls m:y belle.r bu't surely coming o:f agee "L~,1 s·tudy and I used to properly ~•,k•~~,..~'-1:'A~.. ~ ..k~fu·•~l,E,, drugso the e:ixiellen:t stud:les wel,l eontrolled. carr:i,ed out the is one knmiiru for marked e:f'fe c:t 1 a.:rt ,etc. ,,<,;;..,,~,,."'"·""""' wi.ll be In able to raise eome :from w:i.thin and c:li,nic,~lly depressed M.d SUiC(J~::i8!:%~'J::'lj been long,erlristi,ng. I am carify the n1"lr'>'n1~l"'l·:1 this will indeed, must that none of these is all of them are still in need of caref\tl It; be boon to ~ind if t.hey can be the atot.1k :tn trade of many middle age ;z;,:rt:.:n.:t1:)1J 'tIDO to ·treat the.m. w:h:Ue w:ill be wo:rtJJ:wh:ile which will I It it and I w.h:ich you, the be I :from :field, of· in :per man than ~ to le.!t''J'e for ::L~clud..c1rl ·w:hi,c;h. obt;a:ln,ed. :ln 1949. ~rn.ese ad,raniees to to cai·ry on thir.s work~ :present day namely, the of ( mo:re co1m11xm.it:ies This program is a, logical to help to will It will all hs:ve to when the earlie:r the I:f state and, local mental for direct The or of the state a:oil a;ttac~hed to ge-..neral and be system and the for who have n.ot ·oe some who cannot 'be the too of' to ret;urn homee Ur1less there is one wh:kh by revolution!), The .,,.,,... ,.. .,.,..,.., out some time ago that the .,...,.,.,.,.,..,n uxctts :in a,:re 'too e,q:>ected to confom. t~o w:ith the :patients i:n moder.a, It general hospitals t;o ~,?.A,<,;,i,11,.&,ll,;,rg who are grossly risks o To tJ:rts may be tne one acutely ill inbo the symptomatic treatment .a,na. with h:im. with no some o:f these :into bet.ween. the eaeh othero (1) (l :~~:ange of UM:m:t;:lo:tto A gra1];t seed t,hem a:ml :rrom th.Ls who would. attained :from an.d pilot efforts work a.t'f:1 im::o:r.porated become effort the state and Local health groups 0 I kt:tOW that, some of the :interested in menta.l which is beirig enth1.1s :iasm mil,lio:n d.ollars :for aid, mill:to:n of' the various suggest excee(l:ingly worthwh1J,e on the part of have and. w:lll of coverage in tems of areas of' th:ls year approximately were awarded One brie:ad th. and number of varied w:lth most that; I ca~u see on the concerned with of you,:..11.g minds, many of "them. a,nd, aS1S!l..lr~nc:e that increased t;he 'Y,!!S.,riou,s f,~ctors i,n the When th:ts we w:ill be able ·to make still :ln ou:r treatment of it0 maile :bi great part by the o;f comb:ined e:f:forts more w:ho men:t;a,l NA1rIONAL INSTITUTE OF ME:tfl:llL HEALTH ,= PROPOSED FISCAL 1963 BUDGET RESEARCH GRANTS PRESID:ENTuS BUDGET CITIZENS REQUES1r Regular Programs $33,000,000 Psycb.opha.:rma,c:;ology 11,385,000 15,000,000 Title V 9.v516,ooo ll,c1000,000 General Research Support 3,900.1 OC{) 5.s ooo, 000 Cli.nfoal Research Centers 1.~000:, 000 6,000,000 TOT.AL-RESEARCH GRANTS !12b '➔JL.QQQ. l. $70, 000 .~ 000 RESEARCH FELLOWSHIPS $ 7.1000,000 '!¥RAINING GRAJiTS Regular P:r'ogram,s $4;5 ,i 000:, 000 General Practi.t:ioner 9Jooc."ooo Research Train.iug 3JBOO,:,,OOO 7JOOO;i000 4>61,000?000 STATE CONTROL PROt1RAMS DIRECT OPERATIONS $18~170:)000 $22,150~000 TOTAL REQUEST-FISCAL 1963 $175,150,000 1 - Adm.ini.strat:i.on total for Res,earch Grants :lnclu,d.es $45.~ 000 :for sci.e:nti:fi.c evalua,tion and planning grants o I I ! TESTIMONY ON.HE3688 AND,HR3689 l (Facilities for tbe Mentally Ill and the Mentally Retarded) ' Presented to tbe Subcommittee on Public Health and Safety of the Hous·e Committee on Interstate and. Foreign Commerce March 27, 1963 on behalf of The American Psychiatric Association by Francis J. Braceland, M.D., Sc.D. I am Francis J. Braceland end I have been a psychiatrist for over 30 years .. I graduated from Jefferson Medical College in 1930 and was an intern and Chief Resident at Jefferson Hospital until November, 1932, when I began my psychiatric fellowship training at the old Pennsylvania Hospital in Philadelphia. I was then a Rockefeller Fellow in Psychiatry in Zurich, Switzerland, and at the National Hospital, Queens Square in London .. I returned to be Clinical Director at the Pennsylva.nia Hospital until 1941 when I was appointed Professor of' Psychiatry and Dean of the School of Medicine, Loyola University. I have since occupied the following positions: 1942-46 - Special Assistant to the Surgeon General, U.. S., Navy and war-time Chief of the Psychiatric Section, I run a Rear Admiral, Medical Corps, USNR-Retired. 1946-51 - Head of the Section of Psychiatry, Mayo Clinic, and Professor of Psychiatry, Graduate School, University of Minnesota. 1951 until present - Psychiatrist-in-Chief, the Institute of Living, Hartford, Connecticut, and Clinical Professor of Psychiatry, Yale University. Since 1959 Lecturer on Psychiatry, Harvard Medical School.. I have been in the past: President, American Board of Psychiatry and Neurology, 1953; President, American Psychiatric Association, 1956-57; President, Association for Research in Nervous and Mental Disease, 1957; Chairman, American Medical Association Section on Nervous and Mental Disease, 1956; Cbainnan, National Health Forum, 1958; President, Board of Examiners for Certifies- tion of Mental Hospital Superintendents, 1955; Vice-President, World Psychiatric Association, 1961 - . I have served as a member of the Advisory Council to the :Mational Institute of Mental Health. Mr.. Cha.irman and Members of' the Committee: I appear here today as a representative of the American Psychiatric Association and I bring you the respectful greetings of its President, Dr. C.H. Hardin Branch, its officers and its members. In their names I am asked to register approval of House Bills HR3688 and HR3689. Our organization, the oldest professional medical society in the nation, has been accustomed to speak also for legions of patients ~,__c--,,,,,·-"', whom its members~ bas cared for down through the years, during periods when no one else seemed to bother® Therefore to say simply that we approve/ seems mild and },/ not expressive enough. We feel much more strongly than that. We regard these bills as milestones in the progress of humane and scientific care and treatment of the mentally ill and the mentally retarded. Before I continue my testimony, there is one observation that I would like to make, even though it might be considered gratuitous.. You will hear a great deal of testimony, but none of it, especially mine, will be half so eloquent, so concise, so perceptive or so convincing a.n endorsement of these bills as the Special Message of February 5, 1963, from the President of the United States Relative to Mental Illness and Mental Retardation. I am not dissembling ... neither he nor you need encomiums from me - but the message did encompass the whole situation and showed deep understanding of the plight of our patients and the difficulties we ha,ve faced in trying to treat them. I shall not try to embellish his message but rather simply to emphasize from a professional standpoint some facts pertinent to these bills. BACKGROUND It was 17 years ago that my colleagues and I appeared before this Senate Committee to tell of the suffering, the distress and the terrible waste of manpower we had encountered in the military services and which was occasioned by mental and nervous disorders in service personnel in World War IL I remember that we were hesitant about telling tbe whole story; for we feared that if we did, some~ might think the problem so vast and overwhelming that they would want to invest in something more hopeful and amenable to treatment. We had just learned the hard way in wartime that a man disabled by mental or emotional disorder was just as much a loss to his country as if be ha.d been seriously wounded .. This was not a pleasant bit of knowledge .. It was, however, C reality. We had .learned also that there was pr~ious little that we knew about effective treatment for these sick men and that there were pitifully few of us to carry out what we did know. You responded to the urgent requests of the u. s.. Public Hee.1th Service, the military, the profess:Lonsl societies, and other citizens by passing the National Mental Hea.ltb Act, the manifold benefits of which will :never be completely estimated.. Without this act or something akin to it, the whole problem of mental illness and the ca.re of distressed people in this nation would have been in chaos for another decade .. By means of this legislation we were enabled to train professional and auxiliary personnel; to begin some and to enla.rge other research efforts; and in general to raise the knowledge of our profession and the level of treatment of sick and distressed people to their present high planes .. RECENT ADVANCES Things have moved rapidly since those early days; the situation, while by no means near solution, is markedly better.. There has been an arrest in the climb of the state hospital census, despite the nation's population increase .. Some mental illnesses have been conquered. We have attracted to our specialty some bright young men and women from the fields of medicine and nursing, and an aura of hope pervades the whole psychiatric discipline, probably more than ever before in its history. Numerous research projects are under way, and among the people working on them are brilliant scientists from other fields, who have become interested in ourproblems and in the predicament of our patients .. Family doctors have become much more involved in helping · to care for emotional problems, for they have realized for some time that a large segment of their practice is concerned with emotional disorders masked by physical symptoms. To help prepare these physicians and to impart to them some of the knowledge which we have acquired, numerous courses have been set up for them in various parts of the country, subsidized by grants from the National Institute of Mental Health. - 3 - Attitudes inside of mental hospitals also have changed; people are now expected to get well, and, encouraged to do so, they are prone to respond. But even with all of the improvement~-and it is an accepted fact that mental hospitals have markedly improved-- there are still far too many of these institutions which remain custodial in nature. The Joint Commission on Mental Illness and Health notes that only 20 percen!·of them are real therapeutic centers and implies that, for one reason or another, the others have not taken advantage of new knowledge which is available. In recounting our advances, I find no need to spend too much time discussing the new drugs--the tranquilizers and the anti-depressants. You have heard a great dea.l about them, I am sure, and you will hear even more about them and their successors in the future, for chemistry and pharmacology will surely continue to contribute more of their leaven--the fruits of their constant research. Actually these drugs have been a Godsend and are probably the most important single element in our recent progress. THE NEXT PHASE Our appearance here today, therefore, is in one sense a return visit to tell you that a portion of the mission which we set out upon with your blessing and your help seventeen years ago has been accomplished, and it is now time for the next move forward .. Fnrtunately, the initial element in that next step is embodied in the two bills which are before us today for consideration. They are the beginnings of the implementa.tion - 4- of the President's plan for the relief of mental illness and for a serious attack upon the problems of mental retardation, conditions which have been neglected and problems which are fra.ugbt with emotional distress., HOW WE GOT OUT OF THE COMMUNITY I know that you have little time to listen to past history, but please let me mention briefly a period in our history when construction/of institutions for mental ---~ patients was a serious consideration., In the middle of the last century Dorothea Dix was busy importuning legislatures to build state hospitals to care for the patients whom she was laboriously collecting from cellars, garrets, jails and run-down municipal asylums. She reasoned that the state--a larger segment of government--would provide better care for these patients .. The legislatures responded and did build state hospitals--big and strong, and grim and destined to last--and, wbateYer else they have done, gentlemen, they have lasted and patients are still being cared for in many of them. The communities were willing, perhaps even glad., to have these patients moved, for neither they nor the doctors knew what to do for distressed, retarded and ill people., If the pa.tients were quiet and tractable, they were allowed to romn at large in the towns but, if they were not, they were incarcerated--and all too often, when they were incarcerated, they were forgotten. Once these individuals were out of sight and safely stored in hospitals, they were, more often than not, also out of - 5 - mind,. To make matters worse, when this transfer had been accomplished, the citizens voted for economy and, as the state hospital census went up, its staff and personnel ratios went down, with results which are too well kno~m to you to elaborate here. rrhese patients were then, as they are now, the last to benefit in good times and the first to suffer in bad times. I have no intention, gentlemen, to denigrate the state hospital system. There have been, and are, good ones and bad ones. There is now, and always have been, a large number of men--physicians particularly--wi~Jstrong social consciences who perform.ea dedicated work in these institutions, often against frustrating odds. Basically, the community has been at fault. We, the citizens, have gotten what we paid for. NEED FOR RETURN TO THE COMMUNITY It is time, high time, to change all of these things, however, There is urgent need to bring the patients back to the community. We know much more about them now. We know they can be belped--not all of them unfortunately, but most of them--and that efforts can be made to prevent the illnesses of the others from becoming chronic. Unhappily, a number of sick people will go on, and will become chronics, despite all efforts to prevent it. Even then, however, ihere is no need to give up. If time pennitted, I would tell you many interesting stories of people who have left chronic disease hospitals a.nd taken their places in the connnunity long after hope that they - 6 - might do so ha.d been abandoned. Another thing has happened in the past several decades which indicates that the time is ripe for the return of our mentally ill people to the community. This is the growing rapprochement between psychiatry and medicine .. This is an important--in fact, an essential and determining--in:fluence in any change in the direction and location of treatment efforts. To meet the mental health needs of an advancing social order it bas become obvious that there must be a sustained cooperative effort to return psychiatric patients to the connnunity medical field. Changes in the practice of medicine, like changes in the practice of psychiatry, have made this possibility much more feasible and workable. Actually, a large pa.rt of medical practice has emotional overtones, and the new interest and willingness of the community doctors to partake actively in the care of mentally ill and retarded patier:ta augurs well for the future of all concerned., It is axiomatic that one cannot be emotionally ill without some physical involvement, and one cannot be physically ill without his emotions being involved, for man is one, whole and entire, and a.ny fragmentation of his treatment is artificial.. It is reasonable for us to visualize a.n important part of future psychiatric effort to render proper diagnostic service and alleviate emotional distress as being community based.. This ba.se should be in a center which offers a variety of treatment possibilities. It could be in a private group practice with necessary facilities, a private mental hospitel which had the «:rnsentials required to carry out the - 7 - mission, a general hospital or medical center, or indeed a state or federal complex which was available and properly staffed and functional. It has been said frequently in the pe.st that too much dependence bas been placed upon hospital psychiatry. This is partially true, but it was often so because of the low frustration tolerance of people in the connnunity. A man might have any type of physical illness and be sure of getting both treatment and understanding in the community. But let there be any hint of mental symptoms, and there would surely be a strong suggestion that he be rapidly hospitalized .. Also, it should be men- tioned that for a long t:i.me hospitalization was all that we had to offer these •· ~ J patients. One accusation that was often made was that too large a portiontof state i hospital budgets had to be spent for maintenance and general ca.re of patients rather than for active treatment. This, unfortunately, was often true. The construction and staf:fing of' tbe comprehensive connnunity centers should alleviate most of that difficulty, however, and put hospital psychiatry into its proper place as simply one of several possibilities for the care or sick people., TIMJL"'LINESS OF THE BILLS Nationwide, there is at present a growing a.ppreciation of the need for more connnunity clinics, guidance centers and outpatient as well as inpatient facilities. The provision of these services will be a. major factor in the avoidance of long-tenn bospitalization and the chroni.ci ty of mental disorders. For many yea.rs psychiatry has emphasized the value of early recognition and early treatment of mental disease. With further public education and with the provision of community facilities such as those we discuss here today, and with early treatment and a variety of treatment facilUies in a community center, families will be more inclined to seek help early rather than late. Despite the fact that some patients with long-standing illnesses are recovering under modern treatment methods, sometimes to the point of social remission, it is really in the early stages of illness that the most effective treatment can be given and there is the best outlook for future stability. The old Adagia of Erasmus still i' holds good: It is better to treat at the beginning than at the end. Brief hospitalize- tion is desirable for many reasons other than economy, and certainly the humanitarian aspects of the early return of a loved one to the family need not be elaborated upon here .. It is reasonable to believe that the construction of these centers in the com- munity will lead to a closer identification of the townspeople with the problem and a much more re.a.dy acceptance of responsibility for fellow citizens who become ilL Close proximity to family, family doctor, and to consultants who know the pa.tient will in many instances make unnecessary the expensive duplication of treatment and surgical facilities, and certainly will prevent the dissipation of psychia.tric ef- fort on medical problems which ought to be handled by other physicians. It is hardly necessary to add, however, that, while all of these new efforts are being made, we will have to keep in mind those patients who remain in state hospitals and not let up in our efforts to restore them to family and job., As important parts of the comprehensive mental health center, one can readily visualize the value of day and night hospitals. Only when the patient cannot be handled on an outpatient level with the help of day care would it be necessary to resort to 24-hour hospitalization. There is no doubt but that there will be a fair number of these patients; some few will even go on to longer illnesses, but not nearly in the numbers we ba.ve been accustomed to expect. The idea is to treat patients early and vigorously and so prevent chronicity. PRESSING NEED FOR FOLLOW-UP CARE The comprehensive connn.unity centers would also be available to patients after discharge from mental hospitals; this is particularly/important,. In most states the i ·l readmission rates of discharged schizophrenic patients presently is 30 to 4o percent, which is much too high,. The patient returns home; there is no one to direct him to take his medication; he slips backward a bit and bas trouble getting a job; and bef'ore long the poor fellow, discouraged, gravitates back to the state hospital.. It is the only place where he is comforta.ble and feels be is being cared :for. - 10 - The policy of treatment in outpatient departments or of brief hospitalization cannot be expected to pay off unless the patient is able to maintain his gains in the community. It is essential, therefore, that be keep in contact with f'amily and friends and be prepared during his hospitalization for the problems he will meet when be goes out .. Equally important is the preparation of the family and community for the pa.tient 's return. There is little use in giving the patient the advantages of the best in treatment and rehabilitative procedure if the family or community will not receive him when he recovers .. Hence the pressing need for connnunity centers with their variety of inpatient-outpatient care, day centers and rehabilita- tion facilities and places within or near them where patients can turn for help when they need it. ESSENTIALS OF COMPREHENSIVE COMMUNITY MENTAL HEALTH CENTERS The essential components of a comprehensive mental health center would be inpatient and outpatient care, the day hospital and the diagnostic clinic .. No matter what else is available, these elements are necessary.. Emergency service could be provided from the clinic through the person' ';)family physician if be has one or through any clinician in practice .. It will get the doctors in the community into the act, as it were .. It will include them in the care of the mentally ill; they will be able to make rounds in the center and in various parts of it to take care of their pat-ients .. - 11 - Treatment at the moment of crisis often is more effectual than at any ti.me thereafter; it might be crucial and might indeed prevent long-term illness.. The psychiatric clinic itself should be made :flexible enough to handle emergencies as they arise on a 24-hour basis and, certa.inly, flexible enough to permit follow-up care so that the essential doctor-patient relationship may be maintained, even if briefly and intermittently. Many patterns of professional practice will emerge in the establish- ment of these centers and many events will transpire which will unify and coordinate the community's efforts, which now are widely scattered. Certainly, the cause which these bills advocate is just and the purpose of these centers praiseworthy. The intent is to furnish an early defense against chronic illness. It is essential that all efforts be made to help restore patients to their families and to their fullest mental, physical, social and vocational capabilities. We have here an excellent opportunity to utilize skills, which heretofore have been dormant, for the alleviation of conditions which have too long been neglected. Prevention, mental health consultation,treatment where necessary, and after care-- these are the essential duties of the personnel of the center. Diagnostic services, day and night hospitalization, 24-hour hospitalization, and transitional a.fter care-- ! all are added aids to the !solution of the problems which, the President noted, "Occur /---~ more frequently, affect more people, require more prolonged treatment, cause more - 12 - suffering by the families of the afflicted, waste more of our human resources and constitute more of a financial drain upon both the Public Treasury and the personal 11 finances of the individual families than any other single condition .. SOME POSSIBLE ROAD BLOCKS While mass education, it is devoutly hoped, will finally erase certain misconcep- tions which hamper progress, that utopian time ha.s not yet arrived.. People still have erroneous ideas about mental illness.. They tend not to consider a.s mentally i.11 a person who shows no violent or bizarre behavior though he may be suffering from a condition which if untreated would lead to disabling cbronicity, suicide or horn.icide.. People do not link up the human tragedies featured daily in the newspaper-- premature deaths, suicide, brawls, alcoholism, etc., with emotional disorder. They do 11 11 think in terms of fate~ or of crackpotsll, or rrpeople who should be locked up 11 ., All of this is an indication of widespread unwillingness to understand that some of these persons, though not ell, are sick. The e~uticnal set of a segment of the community toward mental illness bas deep historical roots .. It is still equated by many people with the mysterious and tbe uncanny and by some with that which is evil and shameful.. The logical outcome of this is the thinking by some tha.t mental illness is something of which the patient himself is "guilty ft.. Hence the tendency to bide mental ~ptoms and be adjudged "not guil ti 1 .. Thus one misses out on hospitalization early, when treatment is most - 13 - effectual.. The antiquated laws on bospita.lization and confinement in some parts of the country have done little to improve this situation.. These are truths which psychia.­ trists have contended with for generations but still the lesson has not been learned., All too often precious time is lost before a psychiatric disturbance becomes florid enough to bring action, and damage is done not only to the patient but also to the family and sometimes to the community. Therefore a major job of public education needs to be undertaken if these units are to be used effectively. Once the community understands that effective psychiatric treatments have been developed and that they a.re most ef:fectual if applied early, this stumbling block should be eliminated .. With general acceptance will come community interest and pa.rticipa.tion, which a.re the basic ingredients of social progress .. One thing w:i.11 have to be made clear and spread broadcast.. The mere building and operation o:f a comprehensive mental health center will not eliminate mental disease in the community. Nor will the mental hospitals empty out quickly. There has always been mental disease and as far a.s can be determined now, there always will be. The feasibUity of reducing the present patient load in state hospitals, however, is not a figment of the imagination. It probably can be done within a decade.. Early treatment in the community with an emphasis on reha.bilitation will materially cut down the state hospital admission rates.. Aftercare in community - 14 - clinics will materially reduce re-admissions., Hal:f"Way houses, day centers, nursing homes for older patients--all of these outlets for sick people who do not require intense supervisfon--will help to reduce the census of these institutions .. Added to this there is the undoubted fact that a number of chronic patients who have been hospitalized for long periods do get well, whether under some particular drug or activation program.. This i.s a most encouraging prospect .. A problem will probably arise in attempting to coordinate the various isolated services in co:mmunities and bring them under one aegis in order that they be able to function more efficiently. While some reluctance to give up long-held privilege and to work in close cooperation with other groups will be encountered, this difficulty should be gradually overcome., Some differences will probably never be bridged, but they will be taken care of by time and attrition .. All of this indicates the necessity for laying down ground rules early in the planning of the comprehensive centers and thus forestalling many problems before they disrupt a much-needed addition to the fight against mental illness, Questions will be asked regarding these centers., Is the concept medically sound? The answer to that question can be given without hesitation. The concept is not only medically and psychiatric~lly sound but it is a highly desirable step forward which in the long run will mark a great advance in treatment.. It is simply the advocacy of a change in the locus of treatment, a change in the right direction - 15 - and one which will prevent a patient from being alienated from his family. 11 The next question has already been asked: Who is going to pay for all of this?n The answer is that we already are paying, according to the President's message, $2 .. 4 billion a year in direct public outlays for service--a.bout $L8 billion for mental illness a.nd $600 million for mental retardation.. This is exclusive of the many indirect costs in anguish, wastage, etc .. ; the cost of these factors cannot be estimated., Here again will be a change of locus of payment and in this change I believe a much better chance of preventing long-tenn illness. I do not pose as an economist and m:y financial prognostic ability leaves much to be desired, but in m:y judgment this cannot prove to be a costly mistake. People are going to need treatment and if they can get it early and in the community they not only have a better chance of recovery but they also tve a better chance of paying for service either individually or by means of ·"' one of the various insurance plans which must surely and hopefully become interested in these worthwhile efforts. You will notice that I have confined most of my testimony to the cause of the mentally ill, the field which has occupied me most in my professional career. None- theless I would like to espouse the cause of the mentally retarded most heartily. This group has long been neglected, and it is with all sincerity tha.t the members of the American Psychiatric .Association endorse legislation which will react to the benefit of this group. - 16 - There bas been a conspiracy of' silence regarding both of these afflictions .. This silence has been due to misunderstanding and feare Behind tbe jokes about these patients and the cartoons about psychiatrists there is wonderment and dread .. These sick people are not a race apart, they a:re--under certain circumstances-- you and I, and they and their families cry out for help . You have in your power to make the initial step toward giving that help by passing these bills .. - END - STATEMENT OF FRANCIS J. BR.ACELAND, M. D. PAST PRESIDENT OF AMERICAN PSYCHIATRIC ASSOCIATION AND MEDICAL DIRECTOR. OF INSTITUTE OF LIVING AND CLINICAL PROFESSOR OF PSYCl-ilATRY AT YALE AND LECTURER. AT HARVARD Dr. Braceland. Thank you very much, Mr. Chairman. I am glad to be here, and aek your permiaaion to put the •ta.te• ment in the record and to comment upon it briefly. Mr. Roberta. Let it be included in the record. (The atatement of Dr. Bracelana ia aa followa:) 258 Dr • .Bracelano.: Thank yo.J. air. There is a page or two in the front of my atatement trying to explain me, but I have been at this for 30 y':;ars.. ln order that Mr. Neleen not be alone and that he has a repreaentative here today. l would liKe to tell him that I was the firet psychiatrist a.t the Mayo Clinic, and waa a.lso a profesaor at the University of Minnesota .. We appeared before the Committee or the coanterpart of it for the first time seventeen years ago, lvJr .. Priest in the Houae { and Senator Pepper in the Senate. We were .mifrorn. Dr. Felix wa.• one, Dr. lv... enninger and l were the others. We were re• preaentating the service• advocating sincerely the paaeage o.f the National Mental Health Act. We bad been through a great deal. I waa the Chief of Psychiatry in the Navy, Dr. Felix in Public H.ealth, and Dr. Menninger in the Army. And we saw the waste of a great many men at a time when the nation nt:eded them. At that time we had no one to turn to and we had k> make a lot of 90 day Wo... nders to care for these men. We were continually worried about what would happen to our patients in the foture. Well, it waa the National Mental Health Act which ha• enabled ua to riee to the standard• that we have reached today. Through the training of men, thro,1gh the bacKing of research, and by reason of the knowledge and the level of the profea•ional treatment that we have attained, we have made our speciality into a \;.,j' ,~J, ·--7 a much rr1ore effective px-of1;;ssion. There was an aree•t in the rise of the boapital ce.naua beginning. I believe in 1956, and by that time aome of the mental illne1aea had been conquerea, and some others prevented from becoming chronic. There were cou.rae• ior general practitiiomera set up and subsidized in part by the NllvlH, a.nd in general there was a ntore optimistic atmosphere in mental hospitals. Before that it wa• aa if there were a sign on the gate nAll ye who enter here leave all hope behind. 11 But when it wa• seen that the cenaua did no·t haYe to conti.nue to riae yearly ... (this waa at the time of the advent of new drug• and various methods of treatmt:ntl .... then people t.001, h.eart, they were expected to get well, and many of them did get well. But still there are too many of theee inatitutiona which are cu•todia.l in natu.re. The Joint Commiasion noted that really only 2.0 percent of the state hoapita.b were really therapeutic centers. I agree with my colleague, Dr. Ewalt; however, (1 wae on the Commhaion with hiln) that thia bill ie aatiafactory the way it is; it is not something to be tampered with. by every iroup which ha• some •c>ecia.l cause in mind. Wt! like the bill the way t,rou have it, gentlemen, it will take early care of the mentally ill. One bas only to go back 30 yeare and realize what aome of theee places were and to aee what we are correcting. I agree with Dr. Ewalt aleo in that l wouldn't denigrate my colleaiiue• who ran theae ho•pitale. 'rhe public got what it paid £or, and many dedlcated men •tayed a.t work in them juat becauee they had aocial conaciouene•s which kept them on the job. they could have done n1uch better outside. We completed the first pha•e of our taak rea.•onahly­ well, gentlemen, if you please. And it ia time for the next atep. We return to you therefore, eeeking help for the next phaae. Now it la time that many of the community effort• be coordinated and worked out together. These resources are apread out at the present tiine, and thi• i• wa•teful of funda and of personnel. The two bill• under consideration here a.re indeed timely for implementation of the Preaident• • plan. and in addition to being a further advance toward mental health· we are glad to note there ia to be a. ••rioue attack on mental retardation. We have mentioned that we would like to bring our patients ba.ck to the community. You ma.y 1ay to me, "Well, how did you get out of the community in the fir st place? n Well, a hundred year a ago ...... and I am not going to regale you with hbtory .... when Dorothea Dix •tarted to collect theee people from the municipal aayluma. which were alao alma houses, and from garrets and jails and basements, she thought that if •he could get them into the etate inetitutiona that being in a larger government institution they would get better care. Well, the people were glad to see them go, and the doctor a were glad a.lso , for no one knew 111bat,:to do a.hout them. But, when they got them out of the state, howts.ve;-, they ala() were out of mind, the cneeue enlarged, the staff leaeened, and we aoon had the situation that we are bewailing today. It is time therefore to bring these patient• bacK to the community to ma.Ke a start first at preventing illneaf!l, then at treating it q,.iicKly when it appear.a becau•e A.t hae been known aince the time of Eraemue; that the time to atart treatment ie early rather then when the illne1u hae already become chronic. Now, family doctors and phyaiciane in general hospitals are willing to be of help. That was not alwa fa ao. But it ia axiomatic that one can't be ill phyeica.lly without emotion• being involved. and it is just as true that one can•t be aick mentally without some phyeical aapecte of the problem manifesting themselves. This relates ua aolidly to medicine. The important part of our effort for the future. then, ia to render a diagno•tic aervice quicKly to treat the patient in the community. not to let him get away for too long where he ie forgotten by hie family, where the wUe get, a job, the children grow up and perhape become ashamed of hirn. where no one want• to hire him, and the only place the poor fellow will be comfortai>le ie back in a mental ho apital. We need a center that offers a variety of treatment possibilities. close to general ~1pitals, out not necessarily adjacent to them. They can also be near private non-profit institution• or even government facilities. The1·e are many other aapects of the problem, which will have to be wor.Ked out Dy the •ta.te authority which i• con• trolling the program. The fact that private practitioners of medicine are becoming vitally intere•ted in the program delights us. It augurs well for the futl1re. Private mental ho•pitala are intere•ted .... 1 run one of them. We have 48 full time physician,, many of them in varioa1 atagea of their training. Theae new center• ahoulli help to put hoapit.al paychiatry in its proper perapective ae just one of the elementa in tr~atment and not the only element. Heretofore, whenever a. per•on ehowed even one mental ayn1ptor.n, away he would be ,.umt. If he had diabeteffl and needed regulation, thia could be done in the home or in the hospital for a abort period. But let a poor fellow have one hallucination or delusion and off he went, and usually his banishment for a long time .. We have aai.d that t.heae bill• are tbnely. They come at a time when we .<;now what to do for people who are becoming ill. We can be of help to a great many of them. 'The situation ia very much better than we ever suspected it could be at this time. We never thought that we would live to aee so much intereet in this problem. It waa neglected for so long. There ie an incentive !or people now to accept help earlier. Here• tofo:re they have been fearful that they might be stigmatized. The con•truction of theae centers therefore ia UKely to lead to clo•er identification with the townspeople. ln 1955, J. told the American Ho•pita.l Aeeociation that we longed for the day WLen the community would adopt mental patie nte and mental hoepitals like they did the general hoapitala. They are proud of their general ho•pitals and consider them their own. Not so the mental hospitals •• they are out•ide oi the pale. All the while we are making new improvement•• however, we can't forget the people who remain in the etate ho•pltala. There will alway• have to be a place for people who•e illneae will take a long time to heal. There ie a pre•eing need now for follow-up care and theee centers ehould meet that need. Some patient• leave state hoapitala; fail to take their medicine•• and where there ii nobody to care for them, they neglect thcmeelves and gravitate back to the hoepital. There is n.o use of treatini patients expertly and then caating them off. Sorneone muat follow them in order to help him main• tain what they have gained. You have bfien told, gentlemen .... though you already knew them very well -- the essentails of the requisites d. tbe~e centera. It is Y•~)ur hope I am au.re aa it is ours that varioua typea of insttuitione will colloborate in these new efforts. In patients, out patient•• diagnostic centers, day and night hospitals are the essential elements for the center•. Oue can add to theee but without the four element• mentioned the ce:nter would not be complete. There are some road blocks that will be sure to arise to complicate n'.latters. The questio11 will ariae, is thie idea medically and paychiatrically sound? We can say unheaitatingly it is medically and psychiatrically sound. Who is going to pay for it? We are paying .fo it now, to the tune of about three billion dollars. If you donlt hold m.e to closely to it, 1 will say I believe that the situation in New York is not quite as expeneive as was indicated and there are not aa many a.s 130 thousand patients. I th.ink there are 100,000 ·patients, and that include• a number of retarded too. The bills for all of this in a state li~'\'.f: New Yo1·k come close to atout $300 rn.Ulion; So we are paying for it now. We would liKe to catch the Ulneeees early, and put theae people back into the cornmunity faster. Will v.~ be able to gather together theae var'?ltlt i•olated center• and atop the wastage of personnel? 1 think ,,,. I would like to mention one word also in behalf 0£ Title 11 of the bill, which helps to train the doctors and the various types of personnel needed in the centera. Now, with automation, putting people out of work, it ought to be poaeible for ua to retrain many of them and to perhaps reduce the peraonnel ehortage which ha• hamp~red us !or so long. You have been very good to listen to me and 1 am appreciative. I would be glad to answer any que•tione that I am able to anawer. ( The etatemexit of Dr. Braceland follow a:) Mr. Roberta. Doctor, l wae just remarKing to one of my colleagues that we on thia aubcommittee feel that we are highly privileged to have men of your caliber and your training and experience to come and tell the 1tory of this problem. We appreciate the fact that you gentlemen are important people in the nation and in your cc,mmunity, and that you ta,,,e time from your busy lives to come to Waahington and try to help us work out what we believe to be very uaeful legislation. And l just want to aay tba.t you •nd the other witne11ee today have the thank.a of our subcommittee. I haven•t any questions except that I wouldDliKtLto congratulate you on a fitie statement. Dr. Braceland. Thank you, air. Mr. RiJberts. The gentlemen from New York. Mr. O'Brien: Just one queation. I take it, Doctor, that you feel that in New York if we take the $300 million cost figure -- I don 1 t know how exact1:hat i•• it might be $400 million ...... that we have an opportunity through theee ~· bills to reinvest a subatantial part of that in a way that would do u.a more good, ia that correct? Dr. Braceland. Yes, Mr. Congreaaman. And I think you have had a little aample of it already. I think that in one or two places you have te•ted two or three wards which would bnitat• what we are trying to do to aee whether it would work, and it not only work• and the patients get out much quicker, but it influence• the reat of the hoapital, and the ward upatair• will H.y, well, they are not beUer than we are, and it lif ta up the tone and the morale of the whole institution•. 1 think you have been eampling a little bit of your own up there and have proven that thia will work. ?v'ir. O'Brien. Thank you. Mr. Roberta. The gentlemen from Minnesota. Mr. Nehen. I was curioua, years ago in Minne•ota I think an operation waa performed, lobotomy. Dr. Braceland, Yea. Mr. Nelaen. Ia that atill practiced to any degree? Dr. Braceland. No, not to any degree Mr. Nelsen, be• cauee once you cut thoae fibres in the brain you can't tie them together with pink ribbona. Now, it happen• occaaionally in one or two type• of illness, bu.t very, very rarely, and we are reluctant to do it. I may have •aid thia earlier. Mr. Nelaen, but I am getting along in yeara and as my body get• shorter my anecdotee get longer ... • l wa1 Chariman of that committee of Governor Youngdahl•• advi aory • ... Mr. Neleen. I wae in the legielature at that time. Dr. Braeela.nd. And 1 remember we had a great deal to do about all thi9. Mr. Nehen. Another point l would like to touch on, I think we all recognize, and. 1 think all the committee• have recognized, that the main impetue come e from the states. And in your judgment, this bill which ia intended to provide that incentive to get thingt moving, in your judgment, does thi• protect adeqltately ao that we dontt lean too much on the Federal Governmeut in the future, but it sta:rts our states moving. and then we will do a bette?' job? Do you think there i• adequate protection in thia bill to guard againat the po••ibility that too much will be expected from the Federal Government on a long range ba1ia in the future? Dr. Braceland, I think that the committee ha• it nicely built into the bill. There i8 a certain percentage for the conatruction, and only a certain tirne allotted for helping with the etaffin&• And 1 think alao that it ha.• been proven, becauee I am afraid to have to tell you. 1 have been coming down for a number of year• looking for funde for the NlMH ....... this money aeede the eta.tea, the 1tates now have come out •o mu.ch further than we ever thought they would, and the eeed money ha.a come from the feed monet that hae been put in. And I think it ia well protected. 1-'ir. Nelaen. Thank you. Mr. Roberta. Than.k you again, Doctor.