Testimony of Francis J. Braceland, M. D., Sc~ D, representing the American Psychiatric Association and The National Association for Mental Health in support of appropriations for the NATIONAL INSTITUTE OF MENTAL HEALTH before the HOUSE APPROPRIATIONS SUB-COMMITTEE ON LABOR, HEALTH, EDUCATION AND WELFARE Representative John E. Fogarty, Chairman April 2, 1963 Mr. Chairman; Members of tb.e Cour11i tt;(e~:; ~ There is no need t"o:r' xwe to recomit for you the rn:miJJe;r of yea.rs I have been coming bet"ore this C©mm.:ttt,ee :tn behal,f <ot" the mentally ill; some­ times I think it has been sio regularly a.nd frequently that I may ha~ worn out illlY' welcome$ This year, howe,rer, in etddi'tic:ri "to re'Presenting the .Ameri­ can Psychia,trfLc Associ,atiJLco 1t:1=-the oldest of t,ur mi,tional medical societies-­ I am also professional representa.t:tve of tha,t great group of citi.zens who comprise the iiatioirlal A,EHS,,'-»cdation jt\or Men.tal Heal"tho These responsibilities are great.. One gr(ru:p is m~:t{le up of th~~ n:a:ti4:;mi;s more than 13.,000 psychia­ trists who have been accui:rt;,,):med tt'iJ sp e8,k f'or legi.ons of' d'istressed pati,ents 1 down through the agc~s 1rih,e1n n© t;Jn,e ela;e ,seemed to care.. :r.1he other consists o:f a valiant group err ci,tizf,',1lrltJJ 1:ra:o.d.ed, together, w:iLth a history o:f more than 50 years of wonderful work .,.. ,.,,:..,.•,.v-,,·.• -,. s,11:sv'la.t.ing 'the plight of people 'Who were sick and more often than n:r)t n~2!glec·ted.,, F'ortuna.tely, in representing the citizens' group I have the hor1J:»:rt· iO)t'll be:iJlg a~1sociated wt"th one of the NA:MH's distinguished officers, Mr. I:1ta.zer CheS:t,r.»no My first pleasarrt duty :is to respectfully salute you and your Com­ mittee, Mr. Chairman, for it i~ thi.s:1, Conmiittee and its coun.terpart in the Senate -which have steadfastly stood by the efforts of those groups which have sought to raise the level of psychi.atric practice and to bring the hu­ mane care of the mentally ill ·to its present high level.., We have recently acquired a lot of new friends, Mro Chairman, and we are extremely grateful for them, but you gentlemen are (,,;ld friends; you have been so down. through the yearso In. fact, you fought for sti.pends to educate mental health per­ sonnel., for research fuxids to help find the causes of mental illness, and for comm.unity funds to try new approaches, t4::» "the problemo These efforts are now coming to fruition; the Comm:ittee -worked hard, oft;en against great odds. You gentlemen need no encomi~~s from me but I have repeatedly said in public and in private what I would like to repeat here-...wi.thout ·the help of this Com­ mi.ttee and Mr. Hill's Co:mm:il:ttee in the Senate, our situation in me11tal hos­ pitals and in our overall fight against mental disease might well be in chaos. In an appearance before you about four years ago we mentioned that we were probably w-rong 1n looking for a dramatic breakthrough against mental disorder, for, as we were doing so, the specialty of psychiatry was advanc­ ing slowly and steadily, though undramatically. Today it is almost incredible to see the interest 1 the aa:vances and the results of concentrated efforts to control this scourge. M.Y colleague, Mike Gol"m8.n, and I asked you at that time to bear with us f(or a.no)ther decade, for certainly great things were in the offing and, while we kuew well tba.t you had no intention o±"' deserting, neither you nor we expected ·'th:l.:ngs tc» ha,ppen ae, quickly as they did. I don't think any of us expected to hear a President of the United States say in our time what our present distinguished President said as he announced a veritable crusade: 911 This situat:ion has been t(()lerated :ear too longo It has troubled our national conscience 'but only as a problem unpleasant to mention, easy to postpone and despairing of solution. v~ The objectives the President mentioned, as you know, were~ First, seeking the causes of' the illnesses--this :means research. Second, strengtben:lng the skilled manpower pool necessary to sustain the attack.......this means the train­ ing stipends and the funds f'or teachers and courses and the preparation of those who are dedicated to preparing personnel for a concerted attack on the mental disease problem. Third, strengthening and improving programs and facilities serving the mentally ill and the retarded; this includes many of the projects which you have endorsed--the clinical centers, the new concepts under Title V/) and ,~~ri©us othc't 'projects for which y())u earli.er prepared the groundworko As to the present situation.9 as I see it from my vantage piednt, so much has happened tha.t tt is hard to get it all in proper perspectiveo General and private mental hospi.tals now are reporting a much shorter stay....., some as low as 3 or 4 ~:t;ks--for psychiatric patientso Think of what this means tc families» to frienc1El;, to the economy, to industry 51 to the nation, to the patients themselves.; A whole new philosophy seems to be springing up; people are now expected 't;c> get well 1 and they- seem to meet thi.s expectationo ~e attitudes :in tr:e better rnental hospitals have changed im= measurably. People are conf"ideimt ly expected to recover and return to their homes and their jtibs as quir~kly a,s possibleo Ot)le phenomenon has appeared which I 1-rould like to comme:nt upor::o Iii general :medicine 9 when a patient is affecd:;,ed with d:i.abetes P the doctor tri.es t(OJ adjust his blood sugar while keeping him e,t, h001e or; bett,er yet.9 on the j,obo Fa.iling in this the indivi­ dual is admi.tted to ·the ho,s1,i:ttal :!''or a short period and attemP'ts a:t adjust... ment o}f his bloc;d chemistry are ms,de o But ·the patient does not have to stay in the hospital for an. i.n·terminable period,. This :ts i:n contr~.st to the way things used to be handled in emotional disordero Let the person have one upset, which distressed his family, friends or society in general, and away he would go to a mental bospital--and the period of his absence was usually an extended one. This routine is changing now, fortunatelyo Attempts are bei.ng made to treat the mental patient early and intensively and, if at all possible, to keep him out of hospitals altogethero A sizeable number of these patients wi.11 have recurrences and will come back==but that is all :dght; so does the di.abet::Lc come backo In the meanti.me, however P they will have been home and perhape, "Will have been at work.v a11d this is a great step in the right directiono Perhaps you will hear the complaintJ :made by t;he ultra=conservatives in our field~ Yes, the patients ~nt bomep but they sti.11 have the illnesseso Well.l' the diabe·ti,c still has his illneas 7 also, but he is functionin,gjand he is not in a chrc>nic dise,::'~se hospita.l.9 and he is not a public chargeo I am sure that; ytJU gentlemen know1 as we do J two i:mportant corol­ laries of this situati<tm~ (1,) Mo ma.tter -what we do, there will always bci:: a num.ber of sick pe,ople 1.d1c>se illn,ess will drag on over a long period and some of them will not get well at all o These folks ,,ill htit,Ye to be placed in 1nsti'tutions intended f'or t;he: chronically :i.lL (2) 'Tl1ere are so>me 111.... nesses which, bees.use oi:f the iriberent danger imrolved in themi "Will require attention in the seeu.rtty (if"" Bta.te hospitals o In other 'W'Ord:s 9 gentlemen, no matter how inter1sive our treatmeu,t efforts, there will al-ways be a type of state bospital req:ui,:red a ! believe fi:r.mly .9 however 9 that wlth the fruition of present plans we d.efir.i.i:b::'.!ly e:a.r1 preven·t chronicity t:r1 a large number of cases and, we ca,,n cut t;he state hc:vs:pi tal. population in half within the next decade.. I beH.Enre: a,1sf)) 8\1'.)methtng 't;,ha.t i~ SR.. id more frequently now, namely that within several decades the old type of state hospital as we know it can be made to disappearo May I intro(ject at this point one explanatory statemento In mak­ ing the above rema.rks I in no ~,y intend to cast aspersions upon those fine people who work in state hospitals and who have through the years dedicated themselves to a most d.ifficult task, usu.ally against great odds o T.hese hos­ pitals contain many fine professional people who have stayed on their jobs and taken abuse because they knew they were needed and, because they were hel.d there by thei.r soc:ial consciences o !be abuses in state hospitals may fairly be placed at the door of the citizens--all of us==we got 'What we paid for an4 we allowed things ttl deteriorate because we did not insist that state legislators correct themo Well» e.t present citizens are aroused, communities are en·thused, psychiatry is moving closer to medicine 3 and thin.gs are better in generalo ifb.e family doctor is interested and. J fortunately j) is playing a larger role in the alleviation of emotional illnesses; he is the first 11.ne of defense against it o T:b.ere i.si still some feeling about people wi.th mental disorder P but much of it is covert and i·t is only infrequently expressed openlyo T.b.is feeling 9 this mi.ld fear and antipathy is a remnant of the past, it is a carry-overo It ::l.s as if ther,e -were some moral connotations connected rlth mental illness o It is a feeling o~en unexpressed that P iij:if he had been a better man, he wrould ll]A:;;t be sicko i 11 In other words~ i"If' he were like me, he would not have gcrtten this illness c i1 ihis is Phariseeism of the worst sort; it is the Pharisee standing afar off and thanking God he i.s not as one of' these o As a matter of taet, it usually i.s not the g~ad guy'i who becomes ill; his conscience is made of gutta perchao It is more often the good and dedicated person who becomes sick because he has suffered in some fashion at the hands of otherso Gentlemen, I hope you will forgive me these preliminary remarks; they are the mu.sings of a cliniciano You have heard by now from many people-­ some of' them experts, all of them in earnest--and I shall take but little more of your ·time., I desire only to aecentuate a few of the things you al­ ready have heard and perhaps to add one additional professional slant to them. There is little need to recall that there are still more than a half million people in our state hospitals. Forty per cent of them have been hos­ pitalized for more than 10 years and more than one third of them are over 65 years of age. ::rllere are now 17 million people in the nation over 65 years of age and it is estimated that there n l l be 20 million in that age group in the next decade. In oth~<r words, while we are thinking of the contemplated wonderful new imrtitu:tions of"' the future, we cannot forget that we have these large nu:mbers still. in state hospitals and we must keep at them and never give up in ,m.r eff'o:rts to themo We cannot let them dow. I am sure "that you have heard that every day a s:mall number of people (between 5 and 10 of , who have been hospitalized for more than 20 years, are leavirig the J.)l,,..,,~,JJ'"'o!b and taking their places in the comm.un­ ity. True enough, the number is small, but it bas an important lesson for you and for me. fact tha:t they do get well after such a long time means that all the while must have had that potentiality for recovery. It is up to us, each in our way, to enable all others who have similar potentiali­ ties to realize the:m. Just one more statement, if you please, gentlemen, about some of the legislation comtemplated for the future and before I get down to the several points I would like to make regarding the present budget. You are thoroughly familiar with the concept of the comprehensive mental health center a.nd what it entails in the future. Among its manifold tasks will be the prevention of the :return of people to state hospitals. You know how many of them now leave these hospitals under medication and then fail to continue to receive it or take the medication while they are out. Also you know that families are not alw.ys overjoyed to see these patients cane back and employers are 11ot alWS'.,YS in a hu.rcy- to hire tbemo Hence their gravi­ tation back to state hospitals, and hence the excellent reasons for trying to keep them out of these ho:spitals in the f'irst place., They need treat­ ment quickly, thoroughly and close to hom,e so they do not lose contact with jobs or with loved one.so This si'tua:tio:u lie,d ::tts counterpart in the military serviceo In World Wa..r II a great ma1:cy men 'Were lost to the service by reason of' invalid­ ing those wi.th emotional upset from the area of combat into hospitals remote from their u.11:its& Once :tn hospitals and with no respons:1,bi.lity, many lost their m.oti vati,o:n f.,o:r re·tt:trn:lng to di:fficul·t combat situations and could not be returned 'to duty. La.ter Colonel Glass :made particular note of 'this fact and, as a consequenc;e J) i.tt the K(Jrean ci<omlic·t those 'Who broke emotionally were treated quickly a:c.d wi.t:td.J:J "tib5: combat area with remarkably better re­ sults., '!:he sa.rrli;:. will surely h,:,ld true in. civilizn life o Treatment in the area and in the commur1.:tty ·thus is medically and psychiatrically sound and :it has been proven ·to 'be SGo Hospitalization is no longer the si.ngle and inevitable m.Erthod or locus of 'treatmen·t; it is only one of several po)ssi­ bilities and it is not neccooarily the beat. In regard to the budget for this presen.t fiscal year 9 ·we would like to address ourselves to you regarding the personnel situation. In spite of the advent of new drugs and of changed environment in hospitals and in view of all of the contempla·ted advances, there looms before us a severe personnel shortage. Even now there is still insuf'ficient personnel to utiliz,e and apply all of. the techniques which are known to us. The au­ thorities in one foreign country reasoned that with new drugs and tech­ niques available they crou.ld cut down on the numbers of personnel involved, but thi.s wa.s a misera/ble f11,ilu.re a.ind the opposite proved ·to be 'the case. There :i.s still an urgent neeat for trai.ned tnd.i vidua.ls t·o eli.minat,e some of the obvious deficiencies lxi1, the carre (i)f psychiatri.c pa.ti.ents. 1 The ri.se in populati.on and. t;he inten.Ed.fi,cation o:f' treatment ef'forts spell the need for an urgen:t ine:re?,se in the recru:i.t,ment and training of' \rorkers of different skills to carey out th~; ·v:~r::tous required p:rocedu:r\~~s,:, Several years a.gt) t;be ~Joint Ccmxmission report presented a rather grim picture f»f· mt:ntal ht"·a,1th man:powr tre11ds 0 Things ha;,re improved very little si.n.ce the:rio At; :pretV"::tJ:t tihert~ are a.pprox:tmately 13,000 psy,chiatr::tsts i.n the United. States and it ·1 :0 co:aserv"a.tively esti.m.a.ted tha·t we :nreed trice that number 4' The shor..ta.gr2.:s of; t;:ra:lned c'.lintca,1 psychologis'ta1 and psychia­ tric social wurk.erB a.re almJ dJ.rrt:r"~ss:ingly obvi.ous 11> 'rhe shcirtage of° nurses is common knowledge :i.:n all but, it i,s parti.cularly obirious in psy- chiatry. .Albee:• s report 'W'B.S: J,ublished. 1.1ea.rly four years ago and. at tha·t time he coI:i.t~luded 'that, ·a.ril.ess ·~re are i.ndustrious in continuing ou.r recru.it­ men't, and training of" inct.i.vid'ct21.l$ ·in ,all C>f' these so-called ~ore :psychiatric fields, we wi.11 s,lowly lc)se grciund i.n. ·the next sever.al decades 11>, You ca.n well imagine wba.t the situat;ion would no1rr be if you had not turned your e.t·tention to the problem over ·the past decade I.I> Due largely to the help of NIMH stipends a,::id training grants, the numbers of indivi­ duals in the :fo11r discipli.nes which make up the col'e .:mental health profes­ s:tons have~ increased. ·twir, and. a half times in 11. years" This speaks volttmes for the effectivene:i3s tC)f the ·traini,ng grant programs and accentuates the need for continual int;erest in that direction. We need t;o begin right now to train, m(lJ:: e people f'or the contemplated work to be done in the years to 0 come 0 Comprehensive: mental. health «::enters will be of little use W'ithout trained personnel to run them. It is rrr:, expe:I"i.e11ce t;ha,t there a.re m·et11;y mcJre indiYiduals apply:tng for training 1.n psychiatry tJb.a.n 'there are stipends to cir:,yer t;he1m.. This is tru.e also of the situa:tlrem. with ge.neral practitioner grants. This year we had three times as many bona f'i.de appli.cants for these grants a,s Tre could accommodate(> (?his is a s,::i' :1rce of never end.:lng wc,tAderment to me e 1 I once thought that,aft(er t:he :f.lr6,t f'lurry,interest i.n thi,s general practit:loners • program. would dle: ou:t, hut, inst;ea.d. it has increased. & r:rh. 1.S: reason :f'1c»r inter­ esrt in i't is obviout-.\, tlv~~ p:r:·'&:tct~i't:l{m.er tS,ee:s such need f1or underfita.nding of emotional prol,l.ems o He (::?51.c(:,unters them f"requentl.y, 1w:1.s91u.erading as physi.­ cal d.iseaf.tes ~ I need say m,t:r.dng t,;,:J y~)u a'b::mt research 'tra:lni.ng or training in fiel.ds othe:r than :p:sych:itatry_f who are experts JJl t;he:m@ 1: w<ietld or.J.y respectfully suggest that this year the training gr:a.nts fo.c f}ener:a1 :pra.cti:ti,orJ.ers be ra:ised. to 11 million dol- eertf1:inly, one tii:t the Ili!::glected areas tn tfhe care of' patients is ·tha"t of recrui-tlng and improving the: quality c1f sub-prof"essional and tech­ nical manpower personnel4> These are) the people often closest ·to the men­ tally ill pa't:ients--they st;a,y 'With the,m for the longes·t periods of ·time-­ and yet most of 'them have had, no ·training or, at best, their training is skin:q;,y. Thus far there has, been 11ttle incentive :f'crr ·these individuals to undertake wor·k in mental hospita.ls. Most of' their jobs lead up a dea.d, end street. For many of them t,o bee an attendant or an ai.de today means that they wtll be aides next year and 10 years f'rom now with little hope of ad­ vancement<» In the light l»:i~ t;b.1,ngs to come in the mental health field and keep­ ing in mind present unern:ployment figures and the li.k.ely effects Q;f automation on future employment, I wuld. suggest :much more attent:i,,n be pai"d to train­ ing and retrain:i.ng in th~~t:ie groups--perhaps pa.rt:1.cularly :1.n thee training of aides and. in attempti.ng t,D inc:rease thei.r levels of competenc,e. Toward this eff'ort I -would sugg,:u2rt.; r:i~:,ifB'.b.:,.g also -the i.n-serv:tce appropria.ti.on for tra.in­ ing from 3 mil,11.on, three 1:,:i..:indr,e:d four ·thc1usand ttJ six million, three hundred four thousand; it :la vel:1 juf1ttf'ied and :it mlght help solve several problemsfl The Department of Labor ,might ·br~ int,eirrested in this partkula.r facet of' ·the problem. I would li,k.e parti.cularly t~)) endorse the Prestdent 's reques·t :t,or 12 million dolls.rs f~)r hr:ispi.t;.il i:mp.rorve:ment gra.10:t~;; ~ A lot will come from ·this effort, I am sure. I:n I know of one s'tate 1d:dch ha.. s already experimented wi.t:b. an imJ)rovemcm·t grant to a few hosp:ttals for seYeral wards in ord.er to move the 1,;id~:il~n-ts (f(lft more quickly I> ~1:lLs 11 ijsneak previevi'i was an unqualified suc,~~ess; xw·t 01nCly wrere patients :moved out tw:i.ce as fast, but the excitement the efi"ort c:rea;t,ea, i..n ·the hospi:tal was electri.c:"' I't ra.iseid the tone o:f' the 1:'.rtl'.1er w,rds ·wtli.ch set out to compete with the segments of' the hospital which they thought had been favored (rver thei.r owf> One thing I see :i.n the offing which needs you.r· especial attention, if you. please, gentlemen, is the over-all picture of the st;ate control pro­ grams. Thie funds wbi,ch ycm have allocated to the states in the past have 11 acted as se:ed 1110neyw~ a]'ld many o:f the states have responded to your prompt­ ing by alloeat:i.ng funds for clinics for adults a.nd .children$ This area. i.s extremely i.m:porta.nt :lf w-e are to prevent ch1•oni.c illness or to prevent hos­ pitalizati.on at a.11. He:re ls one of the early warning systems, an early defense I areas and o:f the repay of' time., I be this I cf ntnesseso In crea.:ses.-. I more :for Th.e need. come I in jects; iri the I have of these abled several beforehand cou.rse variOU12l I I the il" dL htuui.l:1.- ated and I the int,o a,bout and. a:moru1t o:f dread about "these and aroused cd.tizens Suggest.rt:::d. Increases in Pro-poised 1964. Budge't Presid.entis Budget Suggested Budget Training *lljOOOjOOO In..,service Training .3s 304.,ooo 6,304.,ooo St.ate Control Program Gra:rrts to stat1es cc, 6,750:,000 10;¥75oflooo e:l:tnics 3 et.co Research Title V ~?,l, 190,000 Clinical Research Cerrte:cB 3,000,000 Total Request,:; F1.sca1 1964 1 190$0969000 206.'i/346~000 STATEMENT BY FRANCIS J. BRACELAND, M. D. BEFORE THE SUBCOMMITTEE OF THE SENATE APPROPRIATIONS COMMITTEE IN SUPPORT OF THE PRESIDENT'S BUDGET FOR THE NATIONAL INSTITUTE OF MENTAL HEALTH, NATIONAL INSTITUTES OF HEALTH, PUBLIC HEALTH SERVICE. May 16, 1963 -000- Presented on behalf of The American Psychiatric Association ~- ~ the National Association for Mental Health I am Francis J. Braceland and 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 psy-. chiatric 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 Pennsylvania Hospital until 1941 when I was appointed Professor of Psy­ chiatry 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 am a Rear Admiral, Medical Corps, USNR-Retired. 1946-51 - Head of the Section of· Psycniatry, M'ayo 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 Psychi­ atry, 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; P-resident, Association for Research in Nervous and Mental Disease, 1957; Chairman, American Medical Association Section on Nervous and Mental Disease, 1956; Chairman, Na­ tional Health Forum, 1958; President, Board of Ex:aminers for Certification of Mental Hospital Superintendents, 1955; Vice-President, World Psychiatric Associ­ ation, 1961. I have served as a member of the Advisory Council to the National Institute of Mental Health. Mr. Chairman, members of the Committee, I am happy to appear before you once more to represent the ~4..merican Psychiatric Association and the professional 2 - aspects of the National Association for Mental Health in behalf of the Presi­ dent's budget for the National Institute of Mental Health. As you know, the professional organization I represent has a membership of 13,000 psychiatrists -- most of the physicians in the country practicing psy­ chiatry in institutional settings of all kinds, in community mental health pro­ grams of all kinds., and in private practice; the voluntary organizations I repre­ sent, with a membership of tens of thousands of persons, has, over more than fifty years of its existence, relied heavily upon its professional members to efforts to improve the plight of the mentally ill, und to improve the mental health of our citizens. My first pleasant duty is to transmit to you., Mr. Chairman, and to the members of your con:mittee, the greetings of my colleagues in both organizations. I wish, too, to communicate to you their heartfelt thanks, for it is this com­ mittee and its counterpart in the House which have steadfastly stood by the ef­ forts of the APA and the NAlv.lH to raise the level of psychiatric practice, and to ensure that the mentally ill and the mentally retarded receive the best care that modern psychiatric medicine can provide. We think of you gentlemen as our friends, for so you have proved yourself to be down through the years as you staunchly supported for goals for which we stand: for the promotion of the mental health of the citizens of this wonderful country of ours; for the prevention of the psychiatric disorders whenever pos­ sible; for the prompt and effective treatment of the psychiatric disorders when they do occur; for the rehabilitation and the reintegration into society of those who have suffered from these disorders; for the compassionate and hopeful care of those unfortunates whose illnesses lead to lifelong, and several disabilities. We are grateful to you, as psychiatrists, for your concern for our pa­ tients. But we are, perhaps, more grateful to you as citizens who are committed 3 to improving the lots of millions of our fellow citizens who are today -- or perhaps tomorrow -- undergoing the anguish that accompanies the mental illnesses. You have fought valiantly for years, and often against great odds, for research funds to help find the causes of the mental illnesses, and how they may be prevented and cured; for training funds to ensure that there be a sufficient number of adequately trained personnel to care for the mentally ill, and that the helping persons within our communities our teachers, our clergymen, those working in social agencies and others -- understand how to promote the mental health of our citizens; for grant-in-aid funds to stimulate the growth of commun­ ity mental health programs in our various states; for project funds designed to test and evaluate new methods of caring for the mentally ill. Though you gentlemen need no encominums from me, I would like to repeat here what I have repeatedly said in public and in private -- without the help of this committee and ¥.Jr. Fogarty's committee in the House, our situation in mental hospitals and in our overall fight against mental disease might well be in chaos. The efforts of' the past are coming to frui.tion -- and the fruit is good, though the tree which bears it is yet too small to provide for all our needs. Four years ago, when we appeared before you, we mentioned that we were probably wrong in looking for a dramatic breakthrough against mental disorder, for the specialty of psychiatry was advancing slowly and steadily, though un­ dramatically. Gentlemen, we were wrong in our expectations, for in the past two years, since the Joint Cormnission on Mental Illness and Health, which was author­ ized by Congress, submitted its Final Report to you, we have witnessed a break­ through of major proportions. We have broken through the walls of general indifference towards the fate of the mentally ill which sometimes made it appear that those concerned with controlling this scourge were few in number, and iso­ lated from their fellows. 4 - The nature of this breakthrough was presented to us in unmistakably dramatic terms on February the fifth of this year, when the President of the United States, for the first time in the history of our country, proposed to the Congress that a wholly new national approach to the twin probleins of mental illness and mental retardation be adopted. As he said then: 11 I am convinced that, if we apply our medical knowledge and social in­ sights fully, all but a small portion of the mentally ill can eventually achieve a wholesome and constructive social adtjustment • • • It is clear that a concerted national attack on mental disorders is now both possible and practical • • • • 11 11 If we launch a broad new mental health program now, it will be possible within a decade or two to reduce the nurnber of patients now under custodial care by 50 percent or more. 11 Gentlemen, the American Psychiatric Association and the NAMH which I represent today wholeheartedly support all the specific proposals contained in this Presidential message. We consider the adoption by Congress of each specific proposal to be essential to the successful development of each and of all of the other specific proposals, and to the effectiveness of the total program as an integrated attaclt upon the problems of mental illness and mental retardation. The progra.111 is designed to meet the needs of many di.fferent types of patients the mildly and severely mentally ill, the acutely and the chronically ill. The President in his message proposed essentially a five-point program. Provisions 'for implementing the first four points of this program were as you know made in the budget which you are now considering. The five essential points in his message are: 1. The provision of Federal a3:::dstance through planning grants for the development of comprehensive mental health programs by the States. 5 - 2. The expansion and extension of efforts to increase the supply of and improve the utilization of trained manpower. 3. The support of expanded research in order to "push back the frontiers of kn01Tledge in basic and applied research into the mental processes, in therapy, and in other phases of research with a bearing upon mental illness." 4. The provision of special grants for demonstration projects to assist State mental hospitals to improve the quality of care, and to provide in-service training for personnel manning these institutions. This will permit the hospi­ tals to perform a valuable transitional role, through the strengthening of their therapeutic services., and by becoming open instj.tutions serving their local communities. 5. The establisrJnent of comprehensive community mental health centers through the provision of Federal support on a sharing basis for construction and early year operation. Gentlemen, last week it was my great pleasure to attend the one hundred and nineteenth Annual Meeting of the American Psychiatric Association. Approxi­ mately three thousand of the nation ts psychiatrists -- and many professional persons who work closely with psychiatrists -- gathered in St. Louis, ~lissouri, to report scientific developments, and to discuss .matters of mutual concern. You may be sure that much of the tall centered around the President's proposals. Many of the psychiatrists present there have devoted their entire professional lives to the care and treatment of the mentally ill and mentally retarded in public institutions. They care for the destinies of over 700,000 persons. With their viewpoints fresh in my mind, I would like to discuss with you, first, the role of the public institutions, and its bearing upon the budget you are now considering. First, the atmosphere in the better mental hospitals has changed immea­ surably. People are confidently expected to recover and return to their homes - 6 and their jobs as quickly as possible. One phenomenon has appeared which I would like to comment upon. In general medicine, when a patient is affected with diabetes, the doctor tries to adjust his blood sugar while keepj_ng him at home or, better yet, on the job. Failing in this the individual is admitted to the hospital for a short period and attempts at adjustment of his blood chemistry are made. But the patient does not have to stay in the hospital for an indeter­ minable period. This is in contrast to the way things used to be handled in emotional disorders. Let the person have one upset, which distres3ed his :family, friends, or society in general., and away he would go to a mental hospital -- and the period of his absence was usually an extended one. This routine is changing now, fortunately. Attempts are being made to treat the mental patient early and intensively and, if at all possible, to keep him out of hospitals altogether. A sizable number of these patients will have recurrences and will come back -- but that is all right; so does the diabetk come back. In the meantime, however, they will have been home and perhaps will have been at work, and this is a great step in the right direction. I am sure that you gentlemen know, as we do, two important corollaries of' this situation: (1) No matter what we do, there will always be a number of sick people whose illness will drag on over a long period of time and some of them will not get well at all. The appropriate treatment for these foLks has been, and continues to be, available in our public institutions. (2) A very small minority of the mentally ill have illnesses which make them a society over rather extended periods of time -- these require the security offered by the State hospitals. In other words, gentlemen, however successful intensive treatment in the community may be, for the foreseeable future we must realistically anticipate that some patients will continue to need longer term treatment in public mental 7 - hospitals. We have every evidence to expect the patient load in these hospitals to be dramatically reduced but not eliminated in its entirety. llie important factor is, of course., that so...called longer term treatment shall be genu:i.ne treatment and not simple custody. llius I have been distressed in recent months to learn that, in some instances, the President's plea to launch a concerted drive to reduce the number of patients now under custodial care by 50 percent or more within the next decade or two has been interpreted to mean that the proposed new program has no place within it for the public mental institution. Moreover., I have been somewhat f'earful that, in my previous testimony on the budget before the House Subconmiittee on Appropriations and in the testimony I presented on Ma.rch 6 in support of Senate Bills 755 and 756, I may have slight­ ed a number of important points and in so doing lent credence to this interpre­ tation of the President's program. Let me therefore take this occasion to state forthrightly the concerns of the two associations I represent today vis-a-vis this aspect of the proposed program. First, we are well aware of the burdens under which the public mental institutions of this country have struggled for many decades. From their own personal reminiscences my colleagues could supply ten thousand pages of testimony to this connnittee -- testimony detailing the inadequacies inherent in our present system of caring for the mentally ill in state hospitals with inadequate budgets, outmoded buildings, and sparse personnel. This is an old story, and a heartrending one to them. 'Iheir lives have been spent in making medical and moral decisions which no physician, and no per­ son dedicated to serving the spirit of mankind should be called upon to make. They have had to decide on which ward to place one physician, when ten physicians are needed. They have had to decide which patients are to receive active - 8 - treatment, when all patients could benefit from more intensive therapeutic efforts. Among my colleagues, gentlemen, there is no quarrel with the President's statement that the number of patients under custodial care should be sharply re­ duced. For them, a patient lost to the state institution is a patient saved for a life in the community. Second, my colleagues and I, while aware of present inadequacies in state institutions, are also aware that for many patients, treatment in a state insti­ tution ts the treatment of cho:I.ce -- if the state institution is equipped to do :Lts job, is properly staffed with trained personnel, and is imbued with the spirit of hopefulness that is the proper reflection of our current state of knowledge. Let me tell you the story of one state hospital, which became imbued with this spj_ri t of hopefulness some few years ago, and which was given proper equipment with which to work. In the space of a few years, the resident patient population of Worcester State Hospital, M9.ssachusetts, has decreased from 2,600 to 1,600, a decrease of 38%. Worcester State Hospital is the oldest state hospital in Massachusetts, having been established in 1833. Until a few years ago, the original building was still in use as an administration building. This was replaced by the 560-bed Bryan building, named after a well-known administrator-psychiatrist, which com­ bined, under one roof, an admission center, a surgical-medical unit, and an in­ tensive treatment unit. For a time, the major push within the hoE_:;pital was to utilize the new building to the fullest extent possible. Wnen this was accomplished, a major effort was made to meet the needs of the chronic patients who had remained in the back wards. 9 - To accomplish this, the Superintendent and Assistant superintendent took over the management of some of the chronic wards themselves, and functioned as ward physicians. It didn't take them very long to discover that some of the patients could be released -- and this was done. Since then, the discharge of patients to the connnunity -- to their own homes, foster homes, nursing homes, etc. -- has accelerated. While the happenings at Worcester are particularly dramatic, many differ­ ent state hospitals throughout the country report considerable success in re­ ducing the number of patients under custodial care by the use of modern treatment methods. And now, gentlemen., we come to the major point of my plea before you today. The President's budget for 1964. contains a request for $12 million to provide for the first phase of a three-phase progrrun to upgrade the quality of care j_n State institutions for the mentally ill and for the mentally retarded. This would make possible the awarding of grants up to one-third of the State institutions for the mentally ill and the mentally retarded, at amounts of up to $100,000. It is my understanding that in 1965 and 1966, funds will be re­ quested to permit funding of projects in the other two-thirds of the institutions. These projects, as required by law for all mental health project grants, must be reviewed by the National Advisory Mental Health Council and recommended favorably as a basis for support. Until the marvelous new community mental health services of the future are more widely developed, the mental health project grant (under authority of title V) offers an ideal mechanism for stimulating and encotrraging the State hospitals to strengthen their therapeutic programs through the undertaking of demonstration projects. Active treatment-oriented programs, particularly those interwoven with an active prevention and treatment-oriented program in the - 10 - community are especially desirable and provide an excellent transitional device to bridge the gap between ti.½e present State hospital and the emerging community mental health programs in which the State hospital of the future will have a new role. I can hardly express to you my dismay when I learned that no provision for this portion of the President's budget request was included in the budget for the NIMH as reported by the House ~@ornsUriu:_. In the name of the more than 700,000 persons who reside in our public institutions for the mentally ill and the mentally retarded, and of the tens of thousands of persons who care for these unfortunates, I urge that this cut in the President's budget be restored to the full amount requested. Now I would like to address you regarding the personnel situation. In spite of the advent of new drugs and of changed environment in hospitals, there looms before us a severe personnel shortage. The rise in population and the in­ tensification of treatment efforts spell the need for an urgent increase in the recruitment and training of workers of different skills to carry out the various required procedures. We have 13,000 psychiatrists in the United States, and it is conservatively estimated that we need twice that number. The shortages of trained clinical psychologists and psychiatric social workers are also distres­ singly obvlous. The shortage of nurses is connnon knowledge in all fields, 1Jut it is certainly obvious in psychiatry, and was commented on by Mr. Gorman. You can imagine what the situation would now be if you had not turned your attention to the problem of personnel over the past decade. Due largely to the help of Niif{ stipends and training grants, the numbers of individuals in the four disciplines which make up the core mental health professions have i.ncreased 2½ times in 11 years. This speaks volumes for the effectiveness of the training grant programs and accentuates the need for continual interest in that direction. 11 - It is my experience that there are many more individuals applying for training in psychiatry than there are stipends to cover them. 'Ihis is true also of the situation with general practitioner grants. T.his year we had three times as many bona fide applicants for these grants as we could acco:mmodate. I would therefore respectfully suggest that this year the training grants for general practitioners be raised to ~511 million. There is an urgent need for this. Certainly one of the neglected areas in the care of patients is that of recruiting and :improving the quality of subprofessional and technkal manpower personnel. These are the people often closest to the mentally ill patients they stay with them for the longest periods of time -- and yet most of them have had no training, or at best their training is skimpy. Therefore I would suggest that much more attention be paid to training and retraining these groups -- per­ haps particularly in the training of aides and in attempting to increase their levels of competence. Toward this effort I would suggest raising also the in­ service appropriation for training from $3,301+,000 to ~,304,000: it is well justified and it might help solve several problems. The Department of Labor migb.t be interested in this particular facet of the problem. One thing I see in the offing which needs your special attention, if you please, gentlemen, is the overall picture of the State control programs. The funds which you have allocated to the States in the past have acted as "seed money" and many of the States have respond.ed to your prompting by allocating funds for cornrmmity programs. This area is eJ;:tremely important if we are to prevent chronic illness or to prevent hospitalization at all; I therefore have no hesitation in requesting that you think of raising the present projected budget from $6,750,000 to $10,750,00Q. I fear that I am taking too long and since, in general, we in the pro­ fession are happy ·with the President's budget, there are only two other areas in - 12 .,. which we would suggest increases. I would increase the funds for Clinical Re­ search Centers by $1,250,000 over the President's budget. The need for these centers and their potentialities for good are obvious; it is out of these centers that new and vital information certainly must come and I commend them to you highly. Also, the title V project grants hold possibilj_tfos for advance in knowledge in the field. It is unnecessary for me to spell out these projects. I have personal knowledge of several of these and I am highly imprec;:~ed by what they can accomplish. One that is fresh in my mind enabled several autistic children to enter regular nursery school, whereas beforehand they had been con­ demned almost surely to lifetime custodial care. These protjects could well use an additional $6 million over the $15,190,000 already requested in the 1964 budget. I would like to discuss at length l1k1.ny aspects of the budget and the proposed National Mental Health Program but it is not fair to take your time .. If I have seemed a little intense in my statement, I would ask your indulgence. Please remember that I have watched this situat:i.on for over 30 years.and I know, by heart, the inadequacies of our present system of caring for the mentally ill. 11 And when it seems that now is the time., in our field, that There is a tide in the affairs of men, which, taken at the flood, leads on to fortune," it would be injudicious for me to ask for less than a great deal for the mentally ill of this country. For this flood of interest in their plight, which is already washing away the outmoded aspects of our present system of psychiatric care, must not be allowed to recede until -- to mix a metaphor -- the foundations of the new system of care are firmly laid. I know that this committee will not allow that to happen. Thank you, gentlemen, for allowing me to come before you. * * * SUGGESTED INCREASE IN PROPOSED !_26~ BUDGET TRAINING President's Budget Suggested Budget General Practitioner 9,000,000 11,000,000 Program Inservice Training 3,304,000 6,304,000 STATE CONTROL PROGRAM Grants to States for Clinics, etc. 6,750,000 10,750,000 RESEARCH Title V 15,190,000 21,190,000 Clinical Research Centers 1,750,000 3,000.,000 TOTAL REQUESTS FOR FISCAL 1964 190,096,000 206,346,000 * * * Testimony of Francis J. Braceland, M.Do, Sc.D. representing the American Psychiatric Association and National Association for Mental Health in support of appropriations for the NATIONAL INSTITUTE OF MENTAL HEALffl HOUSE APPROPRIATIONS SUB-cOMMI!TEE ON LABOR, HEALTH, EDUCATION AND WELFARE Representative John Eo Fogarty, Chairman March 11, 1961+ I am Frqc~s Jo B:taceland and I have b~tiu a psychiatrist for over ,30 yea:rso I graduated from Jefferson Medical College in 1930'-.d was mi intern and Chief Resident at Jefferson Hospital until November, 1932, whel\\ I began my psychiatric fellowship training at the old Pe~nsylvania H~apit•l in Philadelphiao I was then a Rockefeller Fellow _in Psychiatry in Zuriph 9 at the National Hospital, Queen Square in London~ r·re- -,, - Clinica"l Director at the Pennsylvania Hospital until 1941 whell. I was appointed Professor of Psychiatry and Dean of the School of Medi- ,, I -ave since occupied the following positions: time Chief of the Psychiatric Sectiono I am a Rear Admiral, Medical Corps, USNR=Retiredo j 1946-51..., Head of the Section of Psychiat~, Ma.yo Clinic, and Professor Psychiatry, Graduate School, University of Minnesota. 19.51 until present 1 b. Psyehiatrist=in....Chief, The Institute of Living, Hartford, ~onnecticut, and Clinical Professor of Psychiatry, ,~ Yale University; since 1951 Lecturer on Psyehia1ry, Harvard Medical SchooL, I have been in the past: Preside•t, American Boa.?"d of Psychiatry and Neurology, 1953. President, American Psychiatric Association, 19.5W7o President, Association for Resea.?"ch in Nervous and Mental Disease, 1957. Chairman, American Medical Association, Section on Nervous and Mental Disease, 19560 Chairman, National Health Forum, 19580 President, Board of Examiners for Certification of Mental Hospital Sup~intendents 9 19550 Vice-President, World Psychiatric Association 9 1961- I have served as a member of the Advisory Council to the ~ational Institute of Mental Healtho Mro Chairman qd Members of the CommittMg I am appreciative of the privilege of appearing before you and with my co'J,leagues diecuseing the citnzens 9 ~ t as presented by Hr" Hikt Gorman and of ,; giving professional testimony to substantiate the need for the requests which he makes of youo On previous occasions here I have represented several dedicated groups of citizens; today 9 along with Dro Ewalt 9 I represent the American Psychiatric Association 9 which is made up of 14 9 000 psychiatrists who ax>e oecupied in the various segments of psychiatric practiceo I respectfully ask permission to enter a state= ment for the record and time to comment briefly upon the present mental illness and mental health situation hereo It is written that Pericles remained persona grata with the Athen~ ian people because they only heard him occasionallyo I can only hoJ>t that my regular appearance here does not j•opa'rdize my most pleasant relationship with youo As a representative of a band of dedica*d c~i..:. ·:;,.. leagues, I appear here as a hardy perennial 9 but alw~a enco~ged by the knowledge that you know our cause is a serious and worthy oaeo You have been patient and farE;Jighted and 9 while understandably pr1trt.ti v, of the taxpayers' funds 9 you have at the same time and with the help of your colleagues in the Senate 9 kept the situation of the u&.lly ill in this country from becoming chaotico Had you not seen over tht past decade and even beyond that that this problem goes toll~he very root of the n.ati.on 9 a fibre CJ we would not have nearly advanced to the point that we have reached todayo It is true'J there is a frighte:ainf amo'1D.t of work still to be done 9 but we have the framework now and Mro Gorman has told you of the lowered census in our hospitalso What he did not emphasize enough~ although he helped mightily to bring it about, was the widespread hope that people now have that we will make i~roads upoa mental illness and learn to institute preventive measures in our commu,nitieso He has told you of the great strides forward w~ica have been taken and none of us has ey heait.tion in pr esying·tluit ,,,. in the future 9 w.tU.1 your continued help and assis~.anoe, even greater / advances will be brought about to the advantage of patient'iJ family, conmnmi.ty and nationo I hav~ no intention of taking up, yom" time witll. our past, none too happy or humane history'iJ but I must observe that ill my 33 years as a psychiatrist I have never been quite so hopeful or so edified at tlte' . ·/} signs of progress which I see now., When I began iB tkis, t••· ' l1llpOJU- I that was a sedative 9 there were no physical treatme:atte except llydro~. therapy and i.t.a related and admittedly somewhat oem±o approaclle·so· Tae outlook •~ arcy-thin.g but brighto Hospitals-were locked tightly; it wu di!fi,cul t to get in or get out; and tl\e public knew JUd:ld.n.g .of t:a.. dis­ trese"d people they hou.aedac-and they seemed to care lesao le were .. j c~:,mpletely alien and isolated from the profeasioa ad t1le comm.un.itu"o Fortunately 9 all of thi,s has changed ud you have helped to cllallge it and it i.s about these c1ulllges tJaat I wot1ld like to talk !irst. The most,remarkable change of all ie to 1'• found in the marked u.d steadily increasing intertJst tliat the community is displaying ia the cause of mental health and mental illness" Th.e public now, bt o al- it most incredible tu:rnox,abou.t, is becoming patently anxious u.c:I 'llfilliJlg ,'l to help m,willing to take direction u.d impatt.ent to get OB ~~• the : 00 jobo Understandably, that particular attitude wu given a kealtlly tranafus:i.qi1 by the unpre~edented Mental Health Message adt by tke lf.t• President t,:, ~ongr~s5 in February 1 1963 9 but evea so ~ere is more ot a ground swell th.an we ever were justified i:a expectin.go Fortuaately, you had laid the groUBdwork for this reaction by the programs you n­ couraged and auppc>rted over tll.e past decade di) so we have not been taken entirely tm.awareso The psychiatrist who is invited to address com­ munity groups now is more frequently than not asked to come prepared to advise what steps the community can take to help with tile plight of its sick fellow ~itizens and •at it ©U. do by way of preventiono This reao'tion is extremely gratifying because it is in the last analysis the commun.ity which will decide upon the s t ~ of the inatitutioas and the workers in the field and iJ is they who will deMIJ.iM through their reprpsentati ve legisle:tqra the calibre and the support which our hospita.ls and clinics will receiveo Actually\) this community interest is rtitl.ag 1 proper and well juatified 9 for there is a bond between the community and the families which go to make it upo It is becoming more and more apparent that the communityi the larger family to which we belong, often can be a potent source of help and correction by giving professional support 9 advice and assistance in times of needo The family, sharing in and contributin.g to the activities and gfneral ne•ds of the communij7, should in tul"n look to the community to pro,r:t;de support when a catastrophe, such. as mental illness'i' strains its financial and emotiom.al resourceao To allow the mental health of an entire family to be 'Ulldermined by the illness of one sick member is too high a price for either the family or the conuntmit~ to payo Just as the family tries to protect ' ' its individual membersi $0 doees the community have the reapo:aeibility of preserving the health of the individual family and its members 9 for they are the segments which go to make it upo It is the community 9 therefore 9 through its many resources-and agencies that should provide help and guidance for the mentally ill patient and his familye ijeretofore 9 however~ the reactions of all of us have been 'lto quickly get the patient out of the wey--to warehouse him~ as i.t were--for earlier the custom has been to reject those people who were a:ick. men'tally and 'Whose t::ocial 'bfthavior was unpredictable., Yet 9 the mind of mans sick or well, has such limitless possibilities for growth and creativenessj or trouble and destructivenees 9 that neglect If we wo:r·k marble 9 .it will. perisho If we work '1pon"' brass 9 'time will ef!aoe it~ ' If we rear temp1Aa 9 they 'will crt1.mble t;o dust., But 9 if we work upon me~i s -immortal minds1i if we imbue t,h,em ·with high principles 9 with the just fear of God~ w:ith love of their fellow men 9 we engrave on those table'l:;s Homething which no time can effac~- 8.llld which 4tll1 brighten an.d b:righten to all eternity o It i.s appa1"ent from this and numerous other comparable observationst that effort put into th~ maintenance of mental health and the prevention of merrt~.il i11nfl~ss l:ue>~, lasting values for the community and for mankind far The communi t:y has taker2 inridly to the concept of the Comprehensive Ct;:rmnun.H~y Ment.;al H~alth denters 9 as outlined in the Presidential Mental Health Mt1ss,ag,t10 Th~,y are not quite clear on what ia entailed as yet 9 but they are a.ware of ·the fact that there is a desperate effort ne~ded to decentralize psychiatric treatment and regard the ha~pital, not a, t•e pivotal point in the program, but rather as only one of the several posaibili:ties for help an.d a la.te resort for '•the more serious and longer lasting problems., They know that treatment could be furnished closer to home cJ.nd, to loved ones and jobs and that hospitals are not made better' by being isola:ted <Xf' overcrowdedo I have no critical remarks to make about tht;;se iustitution.s hereo They are what we 9 as citizena 9 have made thtHll :C:s'1.ty fault we have to find about them is fault found with ourselvea 9 ;fur' citizens get wba.t ·they are interested in finucing and :i.n e:ncou.rag:ingo Tla.e President's message emphasized that the centers should,nfoous community resources and provide better community facilities for all as- pects of men.tal careot~ Finally~ a.:n.d of extreme importance~- .the centers should aim at prtnrentiono "Prevention rill require both selected, spe­ cific programs directed especially at known causes 9 and the general strengthening of our fun.damental community social welfare and educa"" tional programso" Thus, it is clear that these centers are proposed as single •lements 9 ioeo coordinating elements or focal points ot a network of mental :health services and 9 important though it may be 9 it will be only o:ne of the components of the compreheneive mental health program for- a geographical regio:rt~ through wllich two reeults are sougat ~ (1) Quicker and, i.f poeeible 9 bet·ter diagnosi.s 9 treatment~ re= - ~ h.abili.tation and consultationo (2) Creation of a positive m~ntal health action with preventive valueo As ,,e visualize it presently~ a conceptual model of compreh.ensive mental health services may ·tie prC?sented a,s a single entity witlt three dimen- ' sionsg (1) The mental hospital dimension (intra-mural services) wkere tke problem essentially would be that of upgrading serviceec (2) The extra...,mural dimen,sion 11 or outpatient services, broadly de­ fined11 where t~e most urgent problem is a very considerable ex­ pansion of services for very large numbers who need help and have none now available to theme (3) A new d.im,ension 9 des~ribed as "Comprehensive/' which develops I out of 'the :rt:ffort to focus all community resourc~s and better •., coOl!l.dinate a.11 efforts in order to improve treatment results of more and more i:a to of so11ec,n.e would 'M'll"~W,,£',.17'.~<j..,,& a :no more to mem­ of I ~ere is indeed an urgent need :for additional psyclrl.atric mu­ power9 not only to staff these cottemplated new centere 9 but also to cury out the dutie.a wh;eh are already facing uso Ta.e Presj,dent has asked for 73 million 9 213 thousand dollars :for this aspect of the over­ all program; I would urgently ask you to increase this amount to tlle 83 million d.1:.,llars which, President Kennedy foresaw would be aeeded for fiscal 19650 It takes a loug time to prepare i:m.dividuals for the demanding work required of them in the mental illness, mental health disciplia•Bo Their availability wi.11 determine how fast we cu. expand our programa and carry out the urgently needed functiomwhick all of us know need to be doneo No matter wb.at advances we ma.keg no matter what :new drugs are found~ we ca.11 do nothing without the manpower which will adminis­ ter the treatment and supervise -the over-all care of sick peopleo Unless we implement the programs which have been :i;ro jected by prepar­ ing men for the 150 new mental health centers wl:tlon are t~_be .~u~lt with feder·al matching fundsil we will get nowhere" Our mental b.oepitala in some of the states' are still i.n the same precarious condition tkey h.ave been in for many years. They are consta.atly plagued with person­ nel shortageeo Were it not for the large n~tera of foreign pllyeicia11.s aesisting in most state hospitals, we would be in serious troubleo T.nis cannot go on forever, we do ne®d a cadre of physicians wllo will work part or full time i1f it;hese insti tutioBso Tile need-the urgent need==the sick people in thousand4 are realities which must · be faced and your a,ssistano~ here will pay dividends in the future_, I confe,ssif",·d. ·to you earlier that I was one of the ones who was not too convinced ~,'bout the general practitioner training programso I I u.i be ................. ,' uawera. geJt6?'.a.L. alu)litioa,; . viol••~•• tlte u- ut mu:.11 I to it "'"'""i/'':a)'i!"ai,\\"!Jl<\!11 ··of ca.re are are in time work al­ The to lt:a:urt or that kave to order of and explain abriormal thi:nking~r we must acquire more exact knowl•!ls• of normal thought processeso FttndameD.tal knowledge of n.ormal meta• bolism and biochemistry of the brain is estsential to compreltensioJ>. t1 of the ,ur::1s ill which tllese pro9esses may be defective in. a sckiz4 , ' ... phrenic disordero sciences warrant optimiamo We are acquiring and aco~lating cial experiences determiae o in,dividual 9 a level ot adaptationtt Research is a gamble 9 like the Bank at Monte Carlo; one cun.ot guar$lltee a kit od one must pay keavily for wro:ag gqeeses.;· But schizdpltrenic illaeeeee have challenged the best of scientific minds for centurie s an.d 9 tlterefore 9 is a wortlly foema, 1 pd every avenue of approach. to its caueatio• must be followed cloaelyo ' . I shall not take yo-ur time discussing tlle problems atte:ada:at upon th$ in.crease of older perso:ae. i:a our society€i I lta:ve been. sur­ prised to learn tltat a much h.igller number of patiots in tke .aear 65 age group is suffering from acute brain syndromes tlta:a I llad ex­ pectedo T.aere is a need 9 therefor•, fo.r more adeq~te facilities to deal witk the pkeyical illnesses wkiclt produce bekavioral symptomso bone report of 600 perso:as livug i:a a commu:aity a researck study indicated that qme-seveatk of them were psychologically impairedo Careful consideration of all of tu researck programs concer:a­ ing youllg a:ad old and those i:a-betwee:a presents a ratll.er definite indication tkat an additional 10 million dollars will be required, .J a l over tke 73,millions ~o~lara which tke fresident llas requested i~ ' i his budget. It will require 83 million to coJitu:ue I tke programs =12- I coimn~tn't on one particular piase of r◄••~ck pri~st:~1:mtg at t:U ~ t ia. order to demoastrate . conceru to a large Ei\:mlber of peoplee I for wlrl.ck 11 million President ad fo~ wkich, I believe, is required. You remarkable effect of drugs im. aiding inpatient cem.sus in our hospitals, despite A drop, of 9o 7 per ce;at since 1956,, i;a. is not to be paased off lightly" t-~ Net doubled between 1955 bd 1963 f:rom 126,498 to --·~-·~--~•H to all of this, a number of patients ""'®§.:.1.1.'Y,~ of 'kospitals oa ml4ieat,iou--botk ant;i-depressots-ad it is about tke latter tut I would to a of depression in the midgle a:ad older age groups~~··-~· and it is being recopized muck more often tho it was covered by physical eompl,.aiats of vari- ous more often t:.b.an not its real import was missed 9 but now ev:rei:»sl.Ol'l.m are bei:m.g recognized more readily ud tke ph.ysioio act reaso:m.ably quickly nd effectively to lift over the depressive periodo a tke meutime the ad dynamic factors goes oa. Ta.is is tieklisk patients are suieidalo Tlie drug givea t11.em reasonably rapid actimgo So~_of tke u.ti-depreaeu.ta i• use toda;;y appue~rtiy do work ud me:n and women are beiag sustained -d kept i;n tlte·1eo~ity with:_,,__ ! their helpo I meationed tae a6ed for a drug wldca would act quickly--- ~: ud we ~ one-""'u.d. we 1tad numei-ous patieats taking i.t ud a luge number of people were taking it in various parts of tae eouatry ud were being sustained at llloaeo About ten days ago tke J"c,D.Ao ordered ,the drug wi:thdran from tlae marketo Some deatu mad been reported from its usea Now we knew that this drug had to be cuefully coatrolled; but over the years it ku been avai~able ud ia use we h.ad little or l'lq trouble witll it, for we 11Stayed wit.kin th.e dose range advised by the manufacturer, kept careful wa~ch. o:m. tke patien:ts, amd •ere ready to move at the first siga of t:rouble., Had tae <rug not been valuable" we would Jlot kave gone to all th.is botae.r. Well, u I result of this sudden stoppage and our inability to b\gin uotker anti-depressant for oae week, lest th.ere be serious ;rouble, a number of patients 11.ave kad difficulties and some of tllem ad to be kospitalizedo ~• drug is called Panaateo Now, lilly do I go into all of th.is witk you aere? Simply to impress you with tke gr•at need t.o coD.tinue to ,aupport researck in. payclloph.armacology. file President kas asked for 11 million; n need at the very least 13 aillioa to co~tiaue our work with th.ese A drugs~ Out in clinical practice we ratker play ior keeps. Tlle u.ti• depressants llelp people to keep going ad.keep some.of tkem ~om suici.d.eo The pllenothiazi11.ea kelp us get u.d keep people out of mem.­ tal hospi.tahs:~ Tkeee are adj~cte to tke overall treatment, min.d you 9 but t1tey :are :Lmportut adjwacteo Th.ey kelped to reduce tlle l '; load tkat we already commented upOD.o so=called inhibitors; i,t nd to be re- moved from in country because of its ·toxicityo is a drug; ad it is $till be~:ag pre~ good resultso vv~~~~0 up the fact that 1• must support resea:rcll its fullest exteDt; it will pay off i:a results far we expend to make potent drugs safe research items in the budget--the llospital improveme~t projects, the m.ental agree my colleaguee·j they are in yo'Ul" Tll.e Title 5 projects gruts have sup­ new and bold approach to the problems posed by Ill it is probable that they have beem the march wkick is now culmiD.atin.g ia tke co:a;.. H-lth Progruso Tlaey have been tke ad­ forth matching fU11ds from states a:ad be more calls for these projects now, cut dowm the size of our big hospital populationso will to be tried to satisfa'?torily take institutio•s, ,so tllat they too may better triea1:mtint approacheso I agree -eartily witi rq colleagues there is an u~,~~~IT meed for a six millio• ao11«J fncr,ase over Mro Cuirmu.'j I •••d take :ao more of yol.U" time ia explaiaiq' tllliaga you al.re•~ b.ow,all too ••1lo ·le-.apap.ra in. ever:, par\et;l t~ country dai.I,' pr•e•~t coacrete ,vii••c• of tke •~•d of dia'­ treesed people for traiaed profeasiou.l kelp~, -EY:,17 -upect at \lte aeatal :i.ealtlt problem •••d• coati•ui.•g atten.ticao It wu ••~ lected f'or gen.eratioae ud we are reapiag tae fruit of tut neg­ lect~ I know tllat you W:,.11 aot allow it to slide q•ckward for lack of ••cesaa.ry funds .•ow tut we 11.a.v•·come tkia faro NIMH FISCAL 1965 BUDGET INCREASES PROPOSED BY C:rfiZENS 1965 ~965 President's Citizens Bu t Budget $26,112,000 $26,112,.000 119000,000 13,000,000 17,000,000 23,000,000 3,2.50,000 3,250,000 5,222,000 5,222,000 1./1509000 3,7.50,000 .J.2., 000, 000 12,000,000· 161 000 161.,000., 95,000 #86,4959000 $.1+9, 163, 000_ i55,163,000 - 8,000,000 8,000,000 10,000,000 .12, 000 ,000 6,0009000 7,,000,000 50,000 ··50,000 , $'73, 213,000 182,213,000 I 6,750,000 I 6,750,000 124,402,000 124,402,000 $188,917 ,ooo- - $209,917,000 121,000,00Q STATEMENT by FRANCIS J. BRACELAND, M. D. before the HOUSE APPROPRlA TIONS SUBCOMMITTEE ON LABOR, HEALTH, EDUCATION AND WELFARE Representative John E. Fogarty, Chairman In support o! appropriatione for the NATIONAL INSTITUTE OF MENTAL HEALTH March 15, 1965 Presented on behalf of The An1erican Psychiatric Association I am Francis J. Braceland and I have been a psychiatrist for over 30 years. I graduated fron1 Jefferson Medical College in 1930 and was an intern and Chief Resident at Jefferson Hospital until November 1932, when I began my psy­ chiatric fellowship training at the old Pennsylvania Hospital in Philadelphia. I was then a Rockefeller Fellow in P:3ychiatry in Zurich, ':;witzerland, and at the National Hospital, Queen Square, London. I returned to be Clinical Director at the Penn­ sylvania Hospital until 19H, when I was appointed Professor of Psychiatry and Dean of the School of Medicine, Loyola University. I have since occupied the following positions: 194-2-46 - Special Assistant to the Surgeon General, U. S. Navy, and war-time Chief of the Psychiatric Section. I am a Rear Adm.iral, MeiHcal Corps, USNR, Retired. 1916-51 - Head of the Section of Psychiatry, Mayo Clinic, and Professor of Psy­ chiatry, Graduate School, University of ~Ennesota. 1951 until present - Psychiatrist-in-Chief, The Institute of Living, Hartford, Connecticut, and Clinical Professor of Psychiatry, Yale University; since 1960 1.recturer on Psychiatry, Ifarvard Medical School. I have been in the past: President, American Board of Psychiatry and Neurology, 1953. President, American Psychiatric Association, 19 56-57. President, Association for Research in Nervous and Mental Disease, 1957. Chairn1an, American Medical Association, Section on Nervous and Mental Disease, 1956. Chairman, National Health Forum, 1958. President, Board of Examiners for Certification of Mental Hospital Superintendents, 1955. Vice-President, World Psychiatric Absociation, 1961- I have served as a rnember of the Advisory Council to the National Institute of Mental Health. Mr. Chairman and members of the Committee, I appreciate this opportunity to appear before you on behalf of the American Psychiatric Association and to express our support of the citizens' budget for the National Institute of Mental Health a11 proposed by the capable Executive Director of the National Committee Against Mental Illness, Mr. Mike Gorn-,an. I appear here as a hardy perennial but. as always, I am encouraged by the recognition that you consider our cause a worthy one. In fact, your intereet in and support of the cause of the mentally ill of thie nation has brought us to the point we have now reached. Never in my 33 years '" ae a psychiatrist have I been quite so hopeful or so encouraged by the signs of progress I see everywhere ae I am today. The community mental health center concept, of course, ie the m.ost striking sign of progress. But coincidental with the emergenc~ of this concept are changing patterns of hospital care for the mentally ill, changing methods of treatment, chang­ ing goab which now include more emphasis on prevention and adjuatment without absolute "cure," and changing public attitudes and beliefs which have helped remove stereotyped misconceptions and stigmas in regard to mental illness. My ~olleagues and I are disceeaing in enlightened communities through-- out the land a quickening of interest in mental health problem•. By an almost incredible turn-about there can now be sensed in sorr1e quarters a willingness to help, a willingness to accept direction, an impatience to get on with the job. The m.ental health professional invited to speak to community groups now is not faced with the necesaity of convincing people of the importance of his mission; he is expected to give advice as to how the community can help with the plight of its sick adulte and children and how preventive measures may be established. Just a few atatistics will indicate the extent to which patterns of care are changing, thus giving rise to the new optimism about community- based programs we see everywhere. In 1964 the average daily resident population in atate and county mental hospitals dropped to below 500,000 for the first time in 15 years. Net live relea1ee from the hoapitals have n1oee than doubled in the last 10 years. The number of outpatient psychiatric clinics increased from about 1, 200 in l 954 to about 1, 800 in 1963. The number of patients under care in these clinics increased in that same period from 379,000 to 862,000. Twenty years ago only 48 general hospitals were known to admit mental pati.ents. In 1964 there were 1,005 general hospitals admitting an estimated 413, 000 psychiatric patients. Facilities for partial ho•pitalization have increased rapidly. In March 1964 there were 1,:12 day-night units in the United State• in which a psychia .. trist assumed medical responsibility for all patients. This was an increase of ZS units compared with the previous year; prior to 1960 there we:re only 37 day or night unite in the United State•. -3- Yes, as Mr. Gorman has pointed out, the state hospital, once the major resource of psychiatric treatment for m.ost Americans, now no longer fills that role. Furthermore, the 24-hour bed baa lost itl primacy and today two out of every three mental patients receive treatment on a partial hospitalization or outpatient badll. So, I feel we have good reason for our optimiam. The great need for a. relo.cation and a revitalisation of this nation• s mental health services became rnanifeat in 1961 and 1962, partly as a result of the work of the Joint Commilsion on Mental Illness and Health, established by eongress to evaluate and analyze the need• of the mentally ill in the United States and the resources for their care. In 1963 Presi .. dent Kennedy delivered his historic Special Message on Mental Illness and Mental Retardation, in which he called for "a new type of health facility, one which will return mental health care to the mainstream of American rr1ecHc:ine and at the aame time upgrade mental health aervices. tt That same year the Congress responded by passing the Mental Retardation Facilitiea anc1 Community Mental Health Centers Construction Act of 1963. In 1964 the components and the mechani.ce of a community mental health centers program were established. Thus, the need which crystallized in 1961 and 1962 has become the challenge which mu•t be met in 1965 and beyond. In meeting it all of us have a share- -the Congre••• the Administration, professional aaeocia­ tions such as the one I repreeent here today, and citizens' groups. As I reflect on thie challenge, it is obvioue that two problema are uppermost--manpower and money. The National Inetitute of Mental Health, charged by the Congresa with administering the programmatic aapectll of the community mental liealth center• program, as well aa a myriad of other responsibilities in the areas of research and training, needs a great deal of money to do ita job. I am mindful that you must be protective of the taxpayer•' funda, but at the same time I am mindful that the task facing ue is a large, dilfieult, and expensive one. I believe that the citizene• budget as outlined to you by Mr. Gorman comes closer to meeting the need than does the official one which was earlier presented to you. I would like to turn my attention first to the area of manpower and training. All of us are acutely aware of both the manpower shortage• in all the mental health professions and the unequal distribution of thia man ... power throughout the country. When I ponder the manpower problem, I am reminded of a quotation from Abraham Lincoln. L:ncoln aaid: "The dogmae of the quiet past are inadequate to the ,tormy present. The occa­ sion is piled high with diffi.culty and we must riae with the occaaion. As our case is new. so we must think anew, and act anew. 11 While training programs in the core mental health disciplines are in­ creaeing i.n number and capacity, their total output continues to fall short of dem.and, even for the limited n1ental health facilities now in operation. J'ou have heard, gentlemen, that by 1970 we will require at least 87, 000 workers in the core professi.ons of psychiatry, clinical psychology. -5- psychiatric social work, and psychiatric nursing. About 22,000 of them will be needed to staff the community mental health centers we hope to see built by then. It is obvious that we will not be able to provide the men­ tal health personnel we will need in the next decade- -or even in the next two decades--unhtss we can greatly increase existing training programs for which NIMH is the major source of support. A lack of yearly increaees in training appropriations for NIMH can seriously hamper the efforts to reach the projected manpower goal. While the Congreee increased the training funds for the Institute by eight million dollars for fiscal 1965, the increase was ten million dollars lees than the amount anticipated sor this year in the 10-year NIMH projectione. Translated into actual manpower, the loss of that ten million dollars means the loss of one year's training for about l, ·425 people and produces a shortage almost impossible to make up. It also can have a profound effect upon the quality and stability of training centers, which are forced to re­ consider their goals if funds are not forthcoming at the national level. The impact on persona needing treatment is greate•t of all. According to recent calculations, a shortage of l, 000 professionala make• it impos­ sible to poovide direct clinical service, to about 100,000 patients. A los.s of 1,000 trainees for one year would mean that about 39 con1munity mental health centers could not be staffed and that services would not be available to nearly four million people in areas the centers are designed to serve. Another crucial factorraffecting manpower is the level of stipend sup­ port lor training. Increases in mental health stipends are long overdue, since the last general increaae occurred in 1960. Both the National Science Foundation and the National Institutes of Health have increased levels for predoctoral stipends, leaving a great gap between the level of NIH fellowships and NIMH trainee stipende- ..a gap that increaae• the dif­ ficulty of attracting the highest quality personnel into the mental health professions. I understand that last year, due to a ehortase of funds, the National Advisory Mental Health Council had to reject a,~plications for training /':;/"''' stipends which would have a.mounted to tew1n.illion dollars; and it is ex- pected that in 1965 the Council could recommend award of more than twelve million dollars than i8 available. I hope that the Cong res• will find it ap­ propriate to correct this situation aa it considers the 1966 budget for NIMH. The official budget presented to you earlier asked for a total of 83. 2. million dollars to carry out the NIMH training program for fiecal year 1966; I would respectfully ask you to appropriate 95. 2 million dollars for thh purpoae. which will come closer to meeting the demands. There are one or two special aspects of the training program to which I would like to pay particular attention. The first is the general practitioner program• which I did not enthuse about ae much ae I might have originally, but of which I have since becom.e a strong supporter. Like many ol my psychiatric colleagues, I was afraid that this program would not at~act the highest quality applicants. I have recanted a number of times, /rwe have found that the applicants have been capable men who are turning their psy­ chiatric training to very good use indeed.. As you know, there are three .. 1 ... typee of training available under this program.: a three-year residency program for non-psychiatric phy•icians, so that they m~y become fully qualified psychiatrists; short--term training, usually in the evening, de .. signed to im.prove the psychiatric skills of the non-psychiatric physician while he continues in his regular practice; and full-time psychiatric train­ ing for 6 to 12 months for non.psychiatric physicians who want more in­ t~nsive training than can be offered in a par~-time or short refresher course but who intend to remain in non-psychiatric practice. The kind of general practitioner training that I know the most about b the short-term courses given in the evening. In th~ Hartford area, where I live, not only are the courses regularly filled, but additional courses have had. to be organized to m.eet the demand. And the results are already apparent in the increasing interest with which phyeicians in our area are regarding the emotional problems which patients present. I feel that for the three general practitioner progran1• the sUJn of 12 m.illion dollars mentioned in the citizens' budget comes clotter to meet­ ing the need than the 1O. 5 million dollar• in the official budget. Another kind of training that I think is very important is training in comm.unity psychiatry for psychiatric residents and other mental health personnel. NIMH is now supporting ... --among others - ... training in com­ munity psychiatry at Columbia, Yale, and Johns Ho pkine Universities, and at the State Department of Mental Hygiene in California.. Last yea:r our Ai•ociation, in cooperation with the National As aocia­ tion for Mental Health. made a eurvey of existing community mental health centers across the country. The Psychiatry Department of Columbia University and the American Medical Asaociation participated in this project. In addition to identifying Z34 mental health facilities which had some of the elements of a community rr1ental health center, it was de ... cided to do a more intensive study of 11 programs which came close to meeting the goal of comprehensive comn1unity-based facilities. Some interesting findings came out of this intensive study, which I think have implicatione for the kind of research and training progran1e, supported by NIMH funds, that we are talking about today. The 11 centers chosen for intenaive study were not necessarily the best com.munity mental health centers in the country but there ie no ques­ tion but what they were i,epresentative of son1e of the best work going on in thia new and exciting field. And yet, as Dr. Walter Be.rton, Medical Director of the American Psychiatric Association, pointed out in hie introduction to the book des.,. cribing the centers, most of the centers are lacking in adequate facilities for special groups, such as children, the aged, the m.entally retarded, and alcoholics. I am afraid that, despite our best efforts, peychiatry has found it difficult to treat these groups succeesfully. This, of course, points to the need for more research and I an1 happy to see that the NlMH has sup­ ported a number of reaearch efforte which may point to new and promising approaches to these difficult problems. I could mention just briefly the Cooperative Commission on Alcoholism, which !or four years has been carrying on a large-scale study with NIMH support and is expected to is sue a report by the end of 196 5. In addition, 16 other alcoholism projects are being supported by NIMH funds in the current fiscal year. The problem of mentally disturbed children and adolescents is also an extrem.ely serious one, as indicated by the fact that the hospitalization rate for children and adolescents continues to clin-ib alarmingly, even though ra.tea for other age groups have level«l. off or even decreased. In fiscal year 1964 NIMH spent a total of 20 rnillion dollars for research in child and adolescent mental health, including juvenile delinquency and mental retardation. About half of this was for basic research and about half for research under the Mental Health Project& Grants program, which supports pilot projects, demonstration•, and operational and evaluative atal.dies. One of the long-tern1 etudies under a, Mental Health Project Grant 11 11 that I have watched with interest is Project Re-Ed, which ie training so-called "teacher counselors" at the George Peabody College for Teachers In Nashville, Tennesaee, to work with emotionally disturbed children. The project, under the direction of Dr Nicholas Hobbs, also operates two schools for such children, one in Nashville and the other in Durham, North Carolina. This research project still has four yea.rs to run but early experience sug­ gests that the teacher-counselors, who are teachers with a year of special graduate training, can, with the conaultation of mental health professionals such as psychiatrists and psychologists, deal effectively with children with serious e1notional disturbance. This kind oi program is considerably le6 s expenaive to operate than the more conventional residential treab:nent for diaturbed youngsters and the children have been staying at the Re ... Ed schools about six months instead of the usual stay of about two years in the resi.dential treatment centera. Thia kind of research, I ,Ug8•st, gentlemen, will eventuaJly result in our being better able to come to grip• with some of our most serious problems. Another NIMH activity that I think is bringing encoura,ging progress is the Hospital hnprovement Program, authorized by Congress in 1963 to provide for the immediate improvement of treatment of patients now resid•nt in state mental hospitals an.d institutions for the retarded. By providing funds Congress is making it possible for the state hospitals to raise the level of patient care through demonstration projects. The funds are being used in a variety of ways but I was very pleased to learn of the projects that are developing specialized treatment programs for the spe­ cific groups I have just been talking about, such as the aged, mentally ill children, and the retarded. Many of the Hospital hnprovement Project grants are directed at the older chronic patients who have been on the back wards of state hospitals for years without any special attention being paid to them. By means of therapy and activity programs many of these patients improve to a point where they can be discharged,if a suitable home can be found for them,and outpatient services are n1ade available after the patient's discharge. I am also im.pressed with the work being done for the mentally re­ tarded· by means of the Hospital hnprovement Program; 46 such projects -11 ... are now underway in 31 states. To show the kind of thing that is being done I could cite a self-car~ training program at a ho8pital in Texas for totally dependent crib cases. Six months after the project began all theee very severely retarded children were ambulatory and dreseing themselves and mo~t were feeding them selves and were toilet trained. I feel that the Hospital hnprovement Program is not only extremely valuable in itself, but is going to give us some dues on how to handle some of our special problem group8 in community mental health centers, as well as in hospital or institutional eettings. The 18 million dollars recommend~d in the Pre si,dent• s budget and in the citizens' budget for this purpose will be money well spent. An aspect of research that I feel especially etrongly about has to do with discovering techniques of p~ychiatric intervention that will be effective with groupg at all levels of socieey. Again I would like to quote Dr. Walter Barton from his introduction to the book, THE COMMUNITY MENTAL HEALTH CENTER., AN ANALYSIS OF EXISTING MODELS. Dr. Barton, like most of his other psychiatric colleagues, recognizes the essentlality of psycho­ therapy in the treatment of emotional problems but abo sees the impossi­ bility of effecting it in many of the problems which the com.munity mental health centers will encounter. He writes: "The psychiatric disorders of the blue collar worker and of the m.edically indigent are the hard-core prob­ lem. The community mental health program was designed to aseume much ol the responsibility for treatment, particularly of acute illnesses, hereto .. fore delegated to the public mental hospital. To effect such a drastic change -12- requires an eclectic approach, with great emphasis on group and milieu therapy, as well as chemotherapy. n Since this is a subject that is also dear to my heart, I was pleased to read last year that NlMH had awarded a Mental Health Project Grant to the Sidney Hillm.an Health Center in New York City which, am.ong other things, will identify new case-finding techniques am.ong union members and ex­ periment with new methods of provirling mental health services for blue collar workers and their families. There a.re many other kinds of mental health research that l wish I had time to mention- -the clinical research centers, the psychopharmacology program, research into schizophrenia, and many othere.. I feel that we must support research efforts to the fullest possible extent and that the results will be worth many times the dollar expenditure. Therefore, my colleagues and I agree that there is an urgent need for the 11 million dol- lar increase asked for in the citizens' budget over the amount requested in the official budget for the total NlMH research effort. Before I finish there are two other budget iten1 s I would like to speak about briefly; both are included under the amount requested for Direct Operati.ons. Included in the President' e budget are fund a for 25 more positions in. the Institute' s regional officee and corr1munity services pro­ grams. I have already menti.oned the important work being doee through the mechanism of the Hospital Improvement Program, the Mental Health Projects Grant program, as well as the new program. for the construction of com.munity mental health centers. Their success depends in part on the -13- quality of the application• •ubmitted and in the preparation and review of the applications, regional office ataf! play a key role. I have found in my own experience as adm iniatrator of psychiatric programs in and out of govermnent that economizing on staff ia usually false economy. A program ie only as good as the quality of the staff that directs it and I reapectfully euggeet that the imp•etant programs being administered by NIMH require high-quality staff in sufficient nu:rnbere to do the job. The other item pertains to the National Clearinghouse for Mental Health Information. Whan I wae beginning my practice of p1ychiatry 3 3 years a.go, it was not yery difficult to keep up with the literature in the field. We all know about the information explosion since that time; a physician cannot hope to be fully informed with regard to research and other development.. even if he spends two or three hours a day reading his professional journale. There is need now for highly refined--and expensive--com.puter techniques to acquire, proce•s, store, and make available information of uee to mental health profeaaionala and program people. One of the iteme in the Direct Operations budget ha• to do with increased funds for a new stage in the development of the Clearinghouse, calling for the use and refinement of computer techniques unique to the needs of the Clearinghouse. I feel thie expense ie justified. Earlier in my statement I remarked that the mental health need which crystallized in 1961 and 1962 has become the challenge which must be faced in 1965 and beyond. I noted that the challenge must be shared by the Congress, the Adn1inistration~ citizens' groups, and profeaaional -14- associations such aa the one I represent here today. As I close I w-ould like to tell you very briefly how n1-y profession of psychiatry is preparing to play its role in meeting the new challenge. Last Septen1ber our Council had a special three-day meeting to con­ sider the question: Is the American Psychiatric Association organized to play its appropriate role in dealing with existing problems and pressures which confront the profession of psychiatry as a whole an<l, if not, what changes are indicded? We were unanimous in recognizing that changes were needed. Among other things we agreed that psychiatric services must be a.vailable to all citizens and that we will bend every effort to recruit, train, and make better use of all mental health personnel; that we will support adequa,ae budgets for all existing psychiatric facilities and the new ones that are needed; that we will sea.rch for broader rc>les for other disciplines and helpers in all mental health services; that we will urge our n1em.bers to redirect their skills to more active consulting and service roles in the new community facilities. I think you will agree that fresh winds art:! blowing on the mental health front. It is therefore of prime importance to give adequate support to training, research and other programs that will bring us closer to our goal of having good mental health services aYailable to a.11 citizens. TESTIMONY BEFORE HOUSE APPROPRIATIONS SUB-COMMITTEE on Labor, Health, Education and Welfare Representative John E. Fogarty, Chairman on FISCAL 1967 BUDGET for the NATIONAL INSTITUTE OF MENTAL HEALTH by Francis J. Braceland, M.D. Presented on behalf of The American Psychiatric Association March 21, 1966 I am Francis J. Braceland and I have been a psychiatrist for nearly 35 years. I graduated from Jefferson Medical College in 1930 and was an intern and Chief Resident at Jefferson Hospital. I began my psychiatric fellowship training at the old Pennsylvania Hospital in Philadelphia in 1932. I was then a Rockefeller Fellow in Psychiatry in Zurich, Switzerland, and at the National Hospital, Queen Square, London. I returned tribe Clinical Director at the Pennsylvania 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 am 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. 1951-65 - Psychiatrist-in-Chief, The Institute of Living, Hartford, Connecticut; since 1965 Senior Consultant in that institution and Clinical Professor of Psychiatry, Yale University; since 1960, 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 & Mental Disease, 1957 President, Board of Examiners for Certification of Mental Hospital Superintendents, 1955 Chairman, American Medical Association, Section on Nervous & Mental Disease, 1956 Chairman, National Health Forum, 1958 Vice-President, World Psychiatric Association, 1961 - I am now Editor of The American Journal of Psychiatry, the official organ of American Psychiatry and am a psychiatric consultant to the Surgeons General of the Army, Navy, and Public Health. ~ Mr. Chairman and Members of the Committee. I appreciate this opportunity to appear before you on behalf of the American Psychiatric Association, an organization which numbers approximately 17,000 psychi- atrists on its rolls, and to express the support of that official organization for the citizens' budget for the National Institute of Mental Health as just elaborated by my colleague and friend, Mr. Mike Gorman. I began to appear before this Committee 20 years ago and with few exceptions I have had the privilege of appearing before you every year since then, so you can see that I am a hardy perennial. However, Mr. Chairman, we are appearing today in a different psychiatric world than the one in which we began our testimony 20 or even 10 years ago and I hasten to add that much of the progress which we have made over that period was aided, abetted, encouraged, and financed by the assistance given us by you gentlemen and your counterpart in the Senate. Apropos of this fact the March issue of T~:~rri~r.-~':c1t1!?urnal of Psychiatry, which I have the honor to edit, has a special section of 10 papers on community psychiatry and an editorial by Dr. Robert H. Felix, which is entitled "Community Mental Health, A Great and Significant Movement." I quote two short statements taken from Dr. Felix's com- mentary, for I know that you know he played an important part in our mental health advances. He said: (1) It is not a dream but a reality. More progress has been made in psychiatry in the last 30 years than in all the span of recorded medical history before that time. 2. (2) Now mental illnesses and their prevention have become in fact the community concern we have said for so long they should be. Mere words cannot express the great debt the American people and, in fact, people everywhere owe to the late President Kennedy and the Congress of the United States for translating the findings and recommendations of the Joint Commission on Mental Illness and Health into law, thus making possible action at the community level. Here today I need not add that this Committee played an important part in the formulation and financing of the Joint Commission; incidentally, this is the fifth anniversary of the publication of its report, Action for Mental Health. I said recently in a review of 1965 psychiatric advances in the Medical World News that psychiatry has been influenced more by happenings outside of its field than those events which took place in it. In that you are acutely aware of and have been the obstetricians of many of those external happenings, I would ask your permission to examine for you the professional aspects and background of those urgent requests which Mr. Gorman made of__ you here today. The figures which he gave you are dramatic in their impact: ''The unpreceden- ted reduction in state mental hospital populations has saved the states an esti- mated two billion dollars in patient care costs and four billion dollars in con- struction costs over the ten year period. 11 He then called your attention to the fact that, even with these savings, the goals of the martyred President have not been met. The average annual reduction in the state hospitalized patients has been only 1.5 percent and the President had hoped the census of these institutions would be reduced by 50 percent in one or at most two decades. He expressed the opinion that we are failing because budgetary allocations to accomplish this had not been forthcoming. I have lived in mental hospitals for over 30 years, gentlemen, and I am acutely conscious of the number of sick people they house. Despite our advances, 3. those institutions still house 475,000 souls and some of them are hardly proper place£ in which to expect people to get well. Even if we attain our goals and gradually reduce their populations, these institutions will be with us for a long time to come. In the past we have investigated them, exposed them, condemned them, excoriated them, and abolished them numerous times but they are still with us. Actually, the talk of abolishing them is far-fetched -- sheer demands of economics of space and long-term illness require them. Besides, we do not want to abolish them, we only want to abolish the old image they cast. We must improve them,however, and make them habitable, decent, and functional. Most of these hospitals were built in the last century. They are large struc­ tures and some of them are grim. Earlier they simply warehoused human beings. Most of them are much better now but they need to be kept up and in good repair, for proper surroundings are an aid to convalescence, and the road back to home and loved ones is a hard one, which needs all the help and encouragement which can be given. Therefore, the Hospital Improvement Program is an exceedingly important one. It has to do with the surroundings and the dignity of sick people. It cannot be · shor·t-changed., for these . . people have few understanding . friends • It. is our opinion professionally that the sum of twenty-four million dollars is needed to do this job properly. Admittedly, this is six million dollars more than is asked for in·the President's budget but this is necessary if the 70 institutions which have asked for help will not be turned down. In that problems do not arise singly, the mention of hospitals brings up another serious situation, namely, manpower. Without proper staffing at all levels, hospitals simply become shelters. My colleague, Dr. Daniel Blain, who is well known to you, has recently been chairman of a Commission on Manpower of the American Psychiatric Association. He was charged with thoroughly investigating this 4. important problem and his group made a thorough examination of the situation and has recently completed a report on the subject. Fortunately, he is here today and pre­ pared, in case you would care to ask him questions on the subject. To avoid repeti­ tion and conserve time, I forbear to anticipate what he will say. However, there are six important new elements which will drain precious manpower of all types away from hospitals, clinics, schools, and communities which at present are only sparsely covered. Please note that most of these are due to conditions outside the discipline of psychiatry and some are due to government regulations, some to changing times. The first new element is the government regulations which concern patients 65 and over. These will profoundly influence this age group and necessarily greatly increase the number of older people utilizing psychiatric facilities. This trend will require additional personnel. The second is the already mentioned community centers. These will require sufficient personnel to make their existence justifiable. From whence are they to come? Essential as these new centers will be in the new plans to make sick people, heretofore isolated and in some instances lost, return to home and loved ones, they will need capable personnel in all of the four core disciplines to help them on their road to recovery. Thirdly, we might keep in mind the physician draft. Essential as it is to provide physicians for the care of our fighting men, this promises to wreak havoc with the production of new psychiatrists, junior medical and psychiatric staffs, as well as nurses and male aides. Just as the rain falls on the just and the unjust alike, physicians will have to hesitate, as they did in the Korean war, before taking residencies in psychiatry or jobs after they have completed them, lest their draft 5. numbers come up. In like manner, employers will be hesitant about hiring them. Fourth, and extremely important as far as personnel is concerned, will be the carrying out of the resolve made by Surgeon General Stewart of HEW and enunciated at the White House Conference, that the best of health services must be made avail­ able to all who need them. This will require a number of psychiatrists, for it is known that many people express their anxieties and depressive reactions by means of physical symptoms and large numbers of psychiatrists will be needed to help in the nation's clinics. Fifth, it should be noted that there are ten new medical schools in the making and they will be ready in a few years. Where are they to get staff personnel? Undoubtedly they will require full-time clinicians and teachers of psychiatry, amon3 other personnel. Unless we can train more individuals to replace those who aspire to academic life, we are in trouble. Thus far all that is left to deans of the new schools is the ancient and not so honorable art of pirating the help they need, but that is often an exhibition of the law of diminishing returns; they can't all steal staff fromaneanotherfor long. Sixth, and not to be neglected, is the increasing trend to the opening of new psychiatric wards in general hospitals and new Day Hospitals and the search for men to man them. This trend will surely increase as hospital staffs throughout the country learn that human beings have a psyche which is completely intertwined with their bodies and one cannot get out of order without affecting the other. Hereto­ fore some of these folks looked upon the psyche as only an unfortunate append.age which got in the way of their making physical diagnoses. Fortunately, that is rapidly changing. 6. Gentlemen, we can only meet these situations by the training of more personnel, I had the honor of writing the mental health section of the Second Hoover Commission Report some years ago and I said then and repeat it now: Had not the Congress empowered the NIMH to train men for our discipline, things would be in utter chaos and we would be back to warehousing a large number of sick human beings. A survey in 1963 indicated that almost 30 percent of the psychiatrists and 16 percent of the psychologists are providing services in more than one institution, moonlighting if you will, and the proportion of psychiatrists working in outpatient departments who have multiple jobs is 46.l percent for psychiatry, and for psychology 23.8 per­ cent, nursing 22.4 percent, and social work 13.5 percent. Unless additional per­ sonnel is provided for, therefore, the psychiatric aspects of Medicare, community centers, psychiatric wards in general hosptials, even psychiatrists to serve the armed forces, will be in a sorry state. It is none too satisfactory even now. I have publicly done penance a number of times in the past for not backing · General PractitionersLTraining more enthusiasticallywhen the idea was first introduced. But I make amends for that now. I thought at first we would not attract the men, but we have done so, and, gentlemen, those whom I have helped train are in general good doctors in every sense of the word. They have done excellent work, many of them returning to the communities in which they formerly practiced, and, armed with their new skills, they are eagerly awaited by the colleagues who knew them. I note in my own hospital this year that, while we have additional applicants for this program, that poignant little note which says: "Your program is approved but there are not sufficient funds to pay for it.", has again appeared. 7. For a number of years now we as a hospital and our local Branch Society as a unit have conducted classes for non-psychiatric physicians. These are remarkable exhibitions of the willingness of these men to learn new skills. They arrive at 8:00 P.M. and at some phase of their program bring psychiatric problems from their own practices with them. It is hard to get them to go home at 11:00 P.M. This all redounds to improved care of people and is a remarkably good program. Profes­ sionally we have no hesitation at all in requesting an increase of two million dollars over the limit set by the administration, so that this plan can be spread and that the physicians outside of the psychiatric discipline be helped to care for the emotional problems of their patients, problems which present themselves in many disguises. For the overall Graduate Training Programs, which encompass psychologists, nurses, social workers, and other mental health personnel, in addition to psychi­ atrists, we recommend the addition of twelve million dollars to the Administration Budget. The case for In-service Training for those who are closest to the patients andwith -them constantly, theaides, . . practical -nurses,. housetnothe:t'S, . . e-t:~., . . hc1s. been eloquently presented by Mr. Gorman and we endorse his stand and his suggested budget, as we do his suggestions for staffing Mental Health Centers. Without a satisfactory budget they will simply be additional tax-free buildings on the landscape. Research As to the present state of psychiatric research, a number of exciting things are happening -- nothing particularly melodramatic, but certainly a slow steady advance in our understanding of the distressing conditions which we encounter. Each year we have hoped to come before you with some dramatic break-through but 8. this we know now may not be fated to happen, though we may continue to hope. We can work and strive for some breath-taking discovery but, actually, what happens is usually a slow making of inroads upon the illnesses which we treat. As to the basic sciences, research in them is slowly contributing its leaven. The study of brain metabolism is proceeding in a much more sophisticated manner than ever before. All of the reports of advances need careful checking and replication before we can get excitied about their potentialities for treatment. For instance, work was reported last year which postulated the possible transfer of learned information from one animal to another and from one species to another in the form of RNA extracted from the brains of animals trained in particular tests,. Next month, however, an investigator from my own hospital will report his inability to replicate this work in The American Journal of Psychiatry. Others will pro­ bably confirm this negative report. Thus the need for many investigators to examine the same leads. The psychophysiologists have continued their interest in so-called Biologic Clocks· andtheir preHminar·y data·indicate that there is a correlate between disturbed behavior in experimental animals and the deterioration of the ability of these clocks to keep accurate time. They tend to go slower or lose time as behav­ ior becomes increasingly disturbed. However, the administration of some of the newer psychoactive drugs reduces the disturbed behavior and with it comes an improvement in the time kept by the monkey's inner clock. Has all of this any possible value as far as humans are concerned? Well, one cannot say for sure as yet; the cause and effect relationship in this association of disturbed behavior, drugs, and biologic clocks as physiologic correlates is not conclusive. However, it is not improbable that further investigation will indicate that there is an 9. optimum time for the administration of drugs of various classes for various types of illness. This would be an advance, indeed, for it would make the action of drugs much more effective. Before getting into a consideration of the psychoses, I would like to comment briefly on the unfortunate increase in the number of young patients who are emotionally disturbed. From 1950 to 1960 the first admission rates in state and county mental hospitals for children under 15 rose from 10.4 per 100,000 population to 21.5. The rates for youths between 15 and 24 rose from 58.8 per 100,000 to 79.3. Private psychiatric hospitals have a plethora of these patients; they constitute from one-third to one-half of their population and more often than not they present difficult problems. One sad by-product of all of this is that there is an interference with the education of these patients, some of whom are excep­ tionally bright and have fine potentialities. It has always distressed me that we as a nation are so intent upon and will spend so much money upon the education of young people and yet, if they falter and come down with emotional problems, we are prone to abandon them and fail to provide educational facilities for them. The greatest impact upon this problem will come from work already under way through grants from NIMH, already in action or programmed. And it will be the availability of treatment services and preventive efforts of the new mental health centers that will aid in keeping these young folks out of mental hospitals and close to their homes and their schools. Research efforts with these groups must continue and increase and the reduction in present funds or failure to grant additional funds to finance these efforts would be tragic. You have already heard of the need for special help in dealing with the estimated 60,000 narcotic addicts who are to be found most frequently in the major 10. metropolitan areas. Not only are they in a fair way to be lost but their efforts to get funds for the illegal purchase of drugs by criminal action or, saddest of all, by involving younger people are extremely serious accompaniments of their illnesses. Coupled with narcotic addiction, there is an abuse of sedatives, barbiturates, and addicting drugs of various classes. Occasionally now young patients appear who have been experimenting with drugs of the type of LSD and find their way into mental hospitals. This problem may increase. As to alcoholism, there is no need to tell you of its ravages. There are over five million chronic alcoholics and probably five million more trying hard to earn that title. No particular class or group is involved; it goes through the population from those economically deprived to those economically privileged. Again, the seeds of this are being sown too freely in the young and strangely perhaps not so strangely -- in men in middle life, many of them in prominent positions. The causes in these variant groups are different but the results are the same -- heartache and suffering for the more than 25 million people they encounter or are related to in some fashion. To handle drug and alcohol and other addicting problems it is essential (1) to foster a wide range of research efforts; (2) to coordinate and stimulate epidemiologic studies; (3) to learn to use the knowledge we already have; (4) to provide leadership in the development of inservice training and a continuation of postgraduate training for use of new knowledge. Fortunately, a center is con­ templated within the NIMH to coordinate all program activities in drug and alcohol areas. It is probable that the idea of this center was stimulated by this Commit­ tee. 11. As to suicide, one is surprised to learn that it is the tenth leading cause of death in the United States -- it outranks stroke. It even outranks the toll of traffic accidents in Los Angeles. What interests me most is the suicide rate in students -- it ranks third in the cause of death in this group and, if the truth were known, it is probably second. An unknown number of accidents which occur are really carefully planned and then too, for many diverse reasons, some suicides are deliberately not reported as such. While the total given nationally is 20,000, the true number is much higher and the number of suicide attempts is ten times the number of successes. Fortunately, a number of cities now are developing suicide prevention services and the Los Angeles center, which has been operating more than six years and which is outstanding, has developed the basic knowledge, methods and techniques for a nationwide prevention program -- but increased funds will be required to continue research and to distribute widely the information which has been acquired. The suicides of college students bother me very much. Although I am con­ vinced, after 35 years experience, that one cannot with any certainty prevent a person from destroying himself when he is intent and bound to do so, we must make sure that we do all we can to detect early signs of that intent and take steps to protect the individual who is inclined to self-destruction. One way to do this is through the health services of the institutions of learning, for psychiatrists in these services can detect the early signs of depression which, left untreated, might well result in serious consequences. Farnsworth, who probably is more know­ ledgeable in the field of emotional problems in college students than anyone else, notes that a number of these individuals can be recognized in college health 12. centers. Some institutions have psychiatrists in their health departments; otherij do not for various reasons -- some financial, some because of lack of psychiatric assistance in the area; others seem to feel that this is not the concern of educators and I often wonder what these officials say to parents whose sons have hat an emotional break. It must be difficult; maybe one has to have physical symptoms to attain respectability. Maybe, too, I am unfair in these statements. As to the psychoses, of course the greatest interest is probably exhibited in that congeries of symptoms known under the catch-all title of schizophrenia, a group of symptoms which has defied the efforts of some of the world's most brilliant men to arrive at its solution. It is probable that, when a solution of the problem is arrived at, it will encompass many other basic research ideas over and above the schizophrenic problem itself. Major investigators are of the opinion that the most promising evidence fo~ a biochemical abnormality lies in the area of transmethylation. One recent study compatible with this idea was the demonstration of an abnormal catecholamine metabolite in the urine of some schizophrenics. The evidence is still preliminary that this substance is produced within the body and is not a component of the diet. There is no direct evidence that this material produces schizophrenic symptoms. Interest in a protein constituent of the blood of schizophrenics continued strong; it also is apparently in the blood of some schizophrenics and it is capable of producing certain behavioral metabolic or cellular changes in experimental animals. There are a number of such studies and, fortunately, no wild claims are being made regarding the. That has been our trouble in the past and has led to quizzical attitudes toward them. We seem to be playing around the edges research-wise and as 13. yet cannot get things together. There is apparently a fatty acid compound found exclusively in the sweat of schizophrenics; what its significance is we do not know. Brain studies made by means of new instruments measure the electrical activity of the brain of schizophrenic patients through the intact scalp. This may lead to a demonstration of significant differences in the brain function between the mentally ill and the normals. No door can be left unopened and every lead must be followed. The social, psychological, and cultural factors of the illness are being investigated. One does not know how these factors and basic research findings can be gotten together to produce their devastating effects, but in some way they do. It is simply further evidence, however, that schizophrenia is not an isolated dis­ ease, but rather a combination of mental and emotional malfunctionings. It is easier for the economically better situated and the more highly educated psychotic patients to stay out of hospitals and, if hospitalized, to get out of them. It is not clear as yet whether the improved prognosis for the first group isdue to greater clinical. improvement or to the greater supportLveness .. of the environment available to them outside. Though they seem to be free of major psychiatric symptoms one year later, their community adjustment leaves something to be desired. As to treatment, phenothiazine drugs seem to be the treatment of choice. Symptoms can be controlled by this means. Studies show that a number of patients who earlier would have had to be hospitalized now can be maintained at home by drugs and a cooperative family. There is some evidence that those who improve on different drugs have different pretreatment symptoms and background histories. If these results hold up, they would provide a basis for assigning patients to 14. that drug on which they are most likely to improve. As to depression, research on its causes may be becoming more fruitful. Studies underline the involvement of norepinephrine in the mechanism of action of both major classes of anti-depressant drugs and it is evident now that two quite different drugs used to treat hypertension occasionally produce defressive illnesses; both groups cause a dramatic drop in the brain levels of norepinephrine. This evidence needs careful study and exhaustive research. From Europe, and to a lesser extent from American studies, comes evidence now of electrolyte abnormalities in depression, and of the response to mania and possibly recurrent depression to treatment with an electrolyte, lithium ion. All of this, however, is in its earliest stages and we would do well to contain our enthusiasm about it. I could go on and on, Mr. Chairman, but your time is valuable. At the end of the innumerable examples of research leads I would give, I would speak of the things we would urgently hope for, things which might be brought to pass if we continue our efforts. I would not imply that we could buy advances but I would suggest that now that so many fine research men are interested in our field we ha7e higher hopes of accomplishment than ever before. All of this would add up to one thing, however, and that is crystal clear-~ a cut in the research budget of $2,374,000., as proposed by the administration, is unthinkable. Actually, the budget should be increased and we recommend the modest increase of $626,000 over the 1966 budget, or a total of $40,756,000. We have already considered the Demonstration Projects (Title V) and we agre~ heartily with Mr. Gorman that the important projects under this heading merit greater support or they will die of inanition. We recommend an additional two 15. million dollars be appropriated to aid the alcohol, drug, and suicide projects for the reasons I gave above. This would mean a total of $20,357,000. rather than the $18,357,000. in the official budget. I think I need not comment on other aspects of the budget; that has been done very well by my colleague. I am aware of your dedicated interest, as you are of ours. I am aware, too, of the ncmerous calls upon the Congress for funds. I can only hope that now that we have finally started to get our patients out from behind forbidding large stone walls that we will not be slowed down or brought to a halt. Mental patients have had a bad time of it for a number of years. Lack of space, of personnel, of funds have dogged them always; theirs is not a popular cause and they have little appeal to the public at large. We can only depend upon you ge~tlemen for help. Down through the ages the public has come to believe that our patients are a government responsibility and in the main the citizens have failed to see the necessity for taking care of them, even as they do patients with physical illness. It is-probable that···as long·as·man lives·hewill have emotions and.,i:fhe has emotions, they will get out of order and emotional disorder will never be popular or command sympathy or understanding in our culture. Man cannot go on his way unemotionally; God reserved that mood for cows. Therefore, when he gets upset, we must take care of him; hence this urgent appeal to you. Thank you for your courtesy and attention. 16. NIMH FISCAL 1967 BUDGET INCREASES PROPOSED BY CITIZENS Mental Health Activities 1966 1967 1967 Budget President's Budget Citizens' Budge~ Research: Regular $40,130,000 $37,756,000 $40,756,000 Demonstration 17,985,000 18,357,000 20,357,000 (Title V) Hospital Improvement 18,000,000 18,000,000 24,000,000 Clinica 1 Res. Centers 1,750,000 1,750,000 1,750,000 Gen. Research Support 5,839,000 6,313,000 6,313,000 Research Cost Sharing 811,000 2,100,000 2,100,000 Children's Commission 500,000 500,000 500,000 Scientific Evaluation 215,000 225,000 225,000 TOTAL RESEARCH $85,230~000 $85,001~000 $96,001,000 Research Fellowships $ 8,364,000 $ 9,133,000 $ 9,133,000 Training: Undergraduate $ 8, 300;000 · $ 8,500,000 $ 8,500,000 Graduate 59,811,000 62,948,000 74,948,000 General Praet. ll;OO0,ooo. 11,000,000 13,000,000 Inservice 6,850,000 6,850,000 9,000,000 Scientific Evaluation 120,000 150,000 150,000 TOTAL TRAINING $86,08L000 $89~448,000 $105,598.000 Mental Health Staffing $18,899,000 $33,907,000 $40,000,000 Eta te Control $ 6,750,000 $ 6,750,000 $ 6,750,000 Direct Operations $ 27,326,C00 $28,876,000 $29,876,000 TOTAL REQUEST $232,650,000 $253,115.000 $287,358.000 Total Increase Requested - Citizens' Budget $34,243,000 Construction of Community Mental Health Centers $50,000,000 $50,000,000 $65,000,000 Increase for Community Mental Health Centers $15,000,000 TESTIMONY BEFORE SENATE APPROPRIATIONS SUB-COMMITTEE on Labor, Health, Education and Welfare Senator Lister Hill, Chairman on FISCAL 1968 BUDGET for the NATIONAL INSTITUTE OF MENTAL HEALTH by Francis J. Braceland, M. D. Presented on behalf of The American Psychiatric Association June 6, 1967 I am Francis J. Braceland and I have been a psychiatrist for nearly 36 years. I graduated from Jefferson Medical College in 1930 and was an intern and Chief Resident at Jefferson Hospital. I began my psychiatric fellowship training at the old Pennsylvania Hospital in Philadelphia in 1932.. I was then a Rockefeller Fellow in Psychiatry in Zurich, Switzerland, and at the National Hospital, Queen Square, London.. I returned to fre Clinical Director at the Pennsylvania 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 am a Rear Admiral, Medical Corp·s, USNR, Retired. 1946- 51 - Head of the Section of Psychiatry, Mayo Clinic, and Pro­ Gradua.1:e School, University of Minnesota. 1951-65 - Psychiatrist-in- Chief, The Institute of Living, Hartford 9 Connecticut; since 1965 Senior Consultant in that institu­ tion; also Clinical Professor of Psychiatry, Yale Univer­ sity; since 1960, 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. President, Board of Examiners for Certification of Mental Hospital Superintendents, 19 55. Chairman, American Medical Association, Section on Nervous and Mental Disease, 1956. Chairman, National Health Forum, l 958e Vice-President, World Psychiatric Association, 1961-66. I am now Editor of The American Journal of Psychiatry, the official organ of American Psychiatry, and am a psychiatric consultant to the Surgeons General of the Army, Navy, and Public Health. Mr. and Members of the Committee: I am appreciative of your willingness to hear me. I appear before you as a representative of the American Psychiatric Association; the official body of American psychiatry which numbers approximately 17,000 psy- chiatrists. I am here to express support of that association for the citizens t budget for the National Institute of Mental Health, the budget detailed for you by my dedicated colleague and worker for the betterment of the condition of mentally sick people -- Mr. Mike Gorman. There is no need for me to recall to you the number of times I have appeared before this distinguished committee. I am a hardy perennial having appeared first in a navy uniform as Chief of Navy Psychiatry in World War II, fresh from first-hand knowledge of the havoc wrought by emotional and mental disorders in our nation's youth detected as we mobilized for war. Dis orders which led to hundreds of thousands of re - jections for m:iTffary service and an equal number of psychiatric casualties abroad and on the home front. You may recall that so serious was this situation that at one time General Marshall complained that we were sending more men home with psychiatric diagnoses than we were sending abroad to fight the enemy. Each year as we come before this committee., we have hopes of bring­ ing ~o you information regarding some remarkable breakthrough in our work which., like polio vaccine., will solve many of our problems. But, the mental and emotional make -up of man is much too complex to allow for a - 2 - sin1plistic advance such as this. Fortunately there has been, however, a slov, steady advance in our knowledge due largely to the research and training funded by this committee and its counterpart in the House, both of which have consistently recognized our problems and many times have helped us even to the point of markedly increasing the budget recommended by the administration in so doing. Though neither the NIMH nor psychiatry are brash enough to claim credit for it, there is at least one bit of good news out of the Vietnam conflict, namely, the reduction of losses from the military service due to psychiatric causes. A number of factors have combined to make this highly desirable situation possible. I shall not take your time to expand upon these factors but, certainly, psychiatric insight. gleaned from two world wide holocausts contributed to this welcome turn of events. To be rejected by, or surveyed out of military service for psychiatric reasons, is a traumatic event which has deleterious effects which even reach into a man's life in his civilian capacity. This says nothing of the effect of the serious drain upon the nation's military manpower supply. I have been a psychiatrist for 36 years, a clinician and a teacher who has lived mostly in the mental hospital milieu and it is my hope that I may address you on one or two clinical aspects of mental illness, for that is my only competence. Some of the things I say here today have been said befo:t;e but they seem even more pertinent here and now. One of those - 3 - is to note that I had the privilege of writing the mental health portion of the Hoover Commission Report. I said then and want to repeat now that, were it not for the foresight of this committee and its counterpart in the senate in furnishing the NIMH with sufficient funds and the wisdom and skill of the NIMH officials in distributing them for training and research, the mental hospital and psychiatric picture in this nation would be in chaos. However, Mr. Chairman, we are appearing today in a different psychiatric world than the one in which we began our testimony 20 or even 10 years ago and I repeat that much of the progress which we have made over that period was aided, abetted, encouraged, and financed by your assistance. Apropos of this fact, the March 1966 issue of The American Journal of Psychiatry, which I have the honor to edit, had a special section of 10 papers on community psychiatry and an editorial by Dr. Robert H. Felix, which is entitled "Community Mental Health, A Great and Significant Movement. 11 I quote two short statements taken from Dr. Felix 1 s commentary, for I know that you know he played an important part in our mental health advances. He said: ( 1) It is not a dream, but a reality. More progress has been made in psychiatry in the last 30 years than in all the span of recorded medical history before that time. - 4 - (2) Now mental illnesses and their prevention have become in fact the community concern we have said for so long they should be. Mere words cannot express the great debt the American people and, in fact, people everywhere owe to the late President Kennedy and the Congress of the United States for translating the findings and recommendations of the Joint Commission on Mental Illness and Health into law thus making possible action at the community j level.. When the martyred president expressed the hope that our state hospital population might be halved within a decade, I was one of those who did not believe it could be done, but, gentlemen, it is beginning to look like it might be done., The Joint Commission he spoke about, you will remember, was made up of representatives of numerous and varied national organizations. You sponsored that group and it, after a careful study of the mental health situation in the nation - - a study extending over five years -- is sued a report, the now famous Action for Mental Health, which has been called the magna earta·····ofthementaHyiH;.; The figures Mr Q Gorman has given you regarding mental hospital statistics are dramatic indeed; they are worthy of careful study. Prior to the new lease on life which the advent of new concepts and new drugs gave us in the middle of the last decadej we were in a fair way to have to continue to build new mental hospitals and continue to increase the size of those already extant. With the more than 700, 000 patients in state hospitals that he mentioned, plus nearly an equally large number in private hospitals, general hospitals, and combined institutions, we would have been in serious trouble as the population continued to expand. - 5 - Instead, today these institutions house only half the number who might have been incarcerated, but that is still too many. With 452,000 individuals in these institutions at present, some of them in places hardly conducive to recovery or rehabilitation, it is obvious that our 1 work is far from being completed.. Therefore, though I shall in the interest of time only touch upon certain aspects of the overall program, we in the profession heartily endorse the request in the citizens 1 budget that $45 million dollars be added to the administration's budget request, for a total of $293, 860, 000. 00, in order that good work already started may continue .. It is probable that in no year but this present one has the progress of the national mental health program been so specific., nor has there been an immediate future in which the decisions of the Congress will be more crucial in making possible a continuity of effort on the part of all concerned toward solving what has been called the nation's No., 1 health problem .. The money which Congress has appropriated thus far., in addition to its prime purpose, also has acted as seed money and called forth appropriations by the various states far in excess of those provided by the federal govern­ ment.. An article in one of the journals published by the American Psychiatric Association notes the progress made by one state in meeting its problem. Undoubtedly., seed money for training and research spurred the initiation of this work and the resourcefulness of its citizens and community interest - 6 - carried to fruition. Since 1946 the resident state hospital population in Iowa has dropped 75%, from more than 6, 600 in that year to 1, 683 in October 1966. , This notable change is due largely to Iowa's effort to get the patients out of large institutions., to decentralize and treat sick people in clinics, half-way houses, mental health centers and institutes. The active workers in the mental health field give a large number of people credit for this change -- governors, state senators and representatives, U. S. congress­ men, county supervisors., clerks, auditors., psychiatrists, family doctors, clergymen and others. The citizens in all states are not quite so fortunate., however., and it will be a long time before some of them will be able to leave the grim fortresses which house them. Plans were made in 1963 to improve these institutions in all of the states and., hopefully, this year was to see a budget of $36 million dollars to accomplish this., You have before you the ' . " ' ,, .. , , - , , . , ,............ ,f? administration 1 s budget and know that the hopes for bettering the lot of these patients vanishes.. It is our hope that an additional $6 million dollars will be added to the administration's request in order to continue good work already begun and start in some hospitals which are badly in need .. For nearly two years now the grant support program in aid of both construction and staffing of community mental health centers has been in full operation.. As a result, more than 120 centers' grants have been funded. - 7 - The year 1967 marks the turning point at which the concept of high quality care and treatment of sick people changes before our eyes from a hope to a reality for hundreds of thousands of our fellow citizens. When the plans were made originally, Congress authorized $65 million dollars for construction of these centers for fiscal 1967 and fiscal 1968. It is a severe blow, therefore, to note that the $15 million dollars cut from last year 1 s budget is again recommended for this year. Thus, the national fervor which was worked up with the hope that people would re - cei"'!e treatment near their homes and loved ones, is to end in disappoint- ment. It is in these centers that various agencies, clergymen, family doctors and mental health personnel were to labor, and in them the blue collar worker was to receive treatment instead of being shipped off to a distant institution. We urge that the $65 million dollars originally authorized by Congress for the construction of comprehensive community mental health programs be appropriated in the FY 1968 budget. The proposal to extend the provisions of the Community Mental Health Centers Act certainly is a wise one. Dr. Yolles has announced that should Congress extend construction and staff aid for centers, community health centers will be available to about one-half the nation's population in the next five years. Grants have already been made to centers in 44 states and territories and Federal aid has encouraged communities to marshall their own resources. The new ways and new and expanded mental health services are being brought to a variety of populations. - 8 - It was reported to Congress last year that the progress being made by Institute in its continuing efforts to improve the mental health of American people is, indeed, impressive. That progress must be ace in 1968, in my opinion, if we are to maintain our momentum. Therefore, my initial request is urgent; it concerns manpower. There continues to be a critical shortage of trained manpower in the mental health fields. This has been said time and again; but we can now add something else to this statement. In the past two or three years, the potential of universities and other training facilities has grown to the point that knowledgeable men in this field believe that manpower can be trained in sufficient quality and quantity to meet the public demand for services - - i_Lsufficient funds in support of training are made available immediately. All of us are acutely aware of both the manpower shortages in all the mental health professions and the unequal distribution of this man­ power throughout the country. When I ponder the manpower problem today 9 I am reminded of a quotation from Abraham Lincoln. Lincoln said: 11 The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty and we must rise with the occasion. As our case is new, so we must think anew, and act anew." While training programs in the core mental health disciplines are increasing in number and capacity, their total output continues to fall short of demand, even for the limited mental health facilities now in operation. - 9 - It is estimated, gentlemen, that by 1970 we will require at least 87,000 workers in the core professions of psychiatry, clinical psychology, psychiatric social work, and psychiatric nursing. About 22, 000 of them will be needed to staff the community mental health centers we hope to see built by then. ( It is obvious that we will not be able to provide the mental health personnel we will need in the next decade -- or even in the next two decades -- unless we can greatly increase existing training programs for which NIMH is the major source of support. A lack of yearly increases in training appropria- tions for NIMH can seriously hamper the efforts to reach the projected manpower goal. The President• s budget, now before you, includes $100. 7 million for the training program of the NIMH. This is an increase over last year's training appropriation which totaled $94. 5 million. But it is still some $8 million short of the $15 million annual increase in training funds pre­ viously accepted by the Congress, at the outset of this program, as a minimum requirement to meet the projected goals of the nation's mental health program. In fact, due to increases in costs, the NIMH will be able to award even fewer training grants than in this pre sent year .. That $15 million annual increase is not a mythical figure, I submit. It was arrived at thoughtfully and accepted generally. But only in FY 1963 was it actually appropriated. I would sincerely hope, Mr. Chairman, that the FY 1968 budget could be increased by this amount and I would like to present to you some of the reasons why it is vital this year. - 10 - Translated into actual manpower, the loss of even ten million dollars means the loss of one year's training for about 1,425 people and produces a shortage almost impossible to make up. It also can have a profound effect upon the quality and stability of training centers which are forced to reconsider their goals if funds are not forthcoming at the national level. The impact on persons needing treatment is greatest of all. Accord­ ing to recent calculations, a shortage of 1, 000 professionals makes it impossible to provide direct clinical services to about 100,000 patients. A loss of 1,000 trainees for one year would mean that about 39 community mental health centers could not be staffed and that services would not be available to nearly four million people in areas the centers are designed to serve. The health legislation of the recent past gives us an opportunity to establish new, experimental and special training programs to provide mental health services for the peopleo The profession of psychiatry is rapidly accepting and practicing the precepts of treatment within the community and treatment based on public health methods. To work with psychiatrists, we must train more persons as allied health personnel, to meet new needs and to carry out new treatment methods. It is time, now, to introduce training programs of this type even in the junior colleges of our land and to support their initial efforts. - 11 - In today's complex world, mental health professionals must also have available opportunities to continue their education. For a number of years now, the Institute has established as a solid base for its Continuing Education Program, the means of providing postgraduate f training in psychiatry for general medical practitioners and other medical specialists. All the other mental health professions are now in need of similar programs and a Continuing Education Branch has recently been established within the Institute to support these activities. Thus far 11 1 000 non-psychiatric physicians have received short term training in psychiatry. Professionals and non-professionals alike can update their skills with this sort of federal support. Any public or private non-profit institution, including hospitals, community mental health centers, professional organizations, state and local agenciesj and universities and colleges can request aid in establishing such programs. But the amount of aid to be forthcoming will depend explicitly on the amount of funds available. In 1968, I feel that funds for continuing education should have an exceedingly high priority. Of course, the major portion of funds in support of training will be expended to continue expansion in the core professions of mental health~ - 12 - But we now know that the number of professionals must be augmented by allied personnel. If the nation does not provide for this kind of team approach to mental illness and its proliferating problems of poverty and s tr<r s s, funds expended to train professionals will not be spent to maximum effectiveness. A survey done in 1963 indicated that almost 30 per cent of the psychiatrists and 16 per cent of the psychologists are providing services in more than one institution, moonlighting if you will, and the proportion of psychiatrists working in out-patient departments who have multiple jobs is 46.1 per cent for psychiatry, 23. 8 per cent for psychology, 22. 4 per cent for nursing. Unless additional core personnel to cover the psychiatric aspects of Medicare, community centers, psychiatric wards in general hospitals and psychiatrists for other burgeoning needs are provided, the mental health situation will be in a sorry state. Due to the cle:rnc.tllds oftli~tirnef:;, the once m~glected medical discipline which I represent, has slowly come from behind hospital walls and spread its influence and attracted the interest and help of the community. It now makes contributions to its sister medical disciplines, to military medicine, to industrial medicine, to religious counseling and to education and these demands are bound to continue to increase as new services are demanded of this already overworked medical specialty. - 13 - As to psychiatry's growing importance in education, let me quote a few statistics for you. Federal figures indicate that in 1966 six million students were enrolled in our colleges and universities, 68% of them in publicly controlled institutions. It is to these students that the nation I will look for its future leaders. Yet Farnsworth, Harvard's Director of Student Health, one of the most knowledgeable and experienced of college psychiatrists, points out that surveys indicate that for every 10,000. students, 1, 000 will have emotional conflicts of sufficient severity to warrant some professional help. Three to four hundred will have depression severe enough to impair their efficiency, and of the five to twenty who will attempt suicide, one to three will succeed. Fifteen to twenty of these students will become ill enough to require treatment in mental hospitals~ These statistics have serious connotations and one of the wisest and most understanding comments on the subject that I have heard was made by Harvard's Dean of Freshmen, Dr. F. S. von Stade, who said: nwhen so many capable youngsters are on the beach, it makes good sense to have expert lifeguards when some of them go beyond their 11 depth. This, gentlemen, is one of the important roles of the college psychia­ trist and this is only one of the services performed by one group of men who are trained by means of government funds. - 14 - This committee, last year, communicated to the House its concern that mental health research efforts continue to expand. I concur in that concern and I sincerely hope that research funds will be appropriated for :FY 1968 in an amount not only necessary but as generous as possible. The light shed by research can be illusive and flickering. There are periods in which that light seems shadowed and uncertain. But mental health research is today providing some exciting and hopeful findings. It would be catastrophic to tell the research investigators to hold still, or at best to tread water. Service., training and research must proceed simultaneously, benefiting one from the other. With your permission., I shall not go into detail regarding overall mental health research here but, rather, will comment upon that mental illness known as depression which has fascinated me since my advent into the profession. I gay~ one ofthe scientific pap~rso11 clepressioninMadrid, .thatMr. Gorman mentioned, and in fact was chairman of that section of the World Psychiatric Congress" Also I was a member of the NIMH Ad Hoc Committee appointed to investigate this illness and it is true that depression is one of the most painful and tragic diseases known to man. Strangely., too, it often seems to be an accompaniment of greatness. Many great men in world history and in our own nation's history were depressed and some lost their lives during periods of depression. I am sure you can recall the sad histories of some of them. - 15 - Presently in our own nation approximately 20., 000 deaths by suicide are reported annually., but that is only part of the story for there are many accidents which are well thought out and contrived and basically are 1 suicidal acts. Most of these individuals are depressed; a number of them psychotically depressed. Approximately 200., 000 individuals in this country were treated last year for depression and there were equally as many depressed people treated under other diagnoses because of accompanying physical symptoms. The illness occurs in individuals of both sexes., all ages., all income levels and in all parts of the country. The predominating., and often all envelop- ing feeling in these patients., is one of despair., often so intense that it leads to suicide.. Strangely., now it is the psychiatric diagnosis most often made and, strangely too., it often is found in men in middle life good, conscientious., hard working individuals .. In earlier years., depressJ011: in rniddle Ji£~ was thought to be the exclusive property of the female; now it is known that it affects many men particularly those in their fifties in the so-called prime of life.. In this period., there is a lessened ability to tolerate loss., frustration., or disappointment as one notes the beginnings of declining physical powers and personal resources .. It should be noted that even the man of achievement in middle life may - also suffer severe depression. The statesman., the editor., the business - 16 - executive., the professional man, all are prey to the onslaughts of this illness.. You can recall instances well known to you I am sure, and you know that in these periods society loses worthwhile and capable individuals. Occasionally a man in this age group goes through a so-called ttsuccess" depression, a feeling of being pushed beyond his powers, a frightened look-down from a high position from which there is always a danger of falling. Severe depressions occuring in women at the time of middle life, when youth is fading., family leaving home, and husband preoccupied with work., have long been known and are well documented. Finally., severe depressions often occur in the older age groups. Some of these people make suicidal attempts; some succeed. Often these illnesses appear to be due to senile change, but closer inspection reveals that they are due to depression and., if the illness is caught in time, it will respond to treatment. The impact and urgency of this problem is better understood when one realizes that over the next five years in the range of one million people will be seriously affected by feelings of depression and despair., much more than the ordinary attack of hives., and that more than one hundred thousand Americans, most of whom are depressed., will take their lives in the same span of time. The issue ·of suicide is even more distressing in that it is the fourth mo~t frequent cause of death in the productive ages of 18 to 45. It is said to be the third but it is more likely the second cause of death in - 17 - college students. Serious depression., unrecognized or untreated., has a high risk of suicide and in a real sense is a malignant disease that kills. Depression and suicide are inexorably linked together. The toll of depression in our society., however., goes far beyond the malignant illness we have just mentioned. It is often an intermittent and recurrent disease; many individuals suffer from it and are unable to function., or function at a minimal level during the depressed period. Within a given year 3 150., 000 individuals are hospitalized for psychotic or psychoneurotic depressions in the United States. Another serious concomitant result of depression is the psychological impact of the illness on the family of the individual sufferer., particularly if the illness cul­ minates in tragedy. The toll of depression in our society is further reflected in time lost from work and in students who drop out of high school or college. Some of the well known loss of interest and apathy in students, so frequently reported, is due to depression.. There is also repeated evidence suggesting a close relationship of depression with other medical problems such as alcoholism and drug addiction. I have no desire to dwell at length upon further clinical aspects of this / or other illnes ses 3 nor can I presume further on your time.. The fact is that now 1 with careful planning 3 intelligent utilization of resources and recently developed methods and hypotheses., it is possible for the first time to launch an attack on this illness and to make inroads upon it and the quiet desperation and suffering that accompany it. Three bodies of - 18 - data in the basic sciences, the areas of catecholamines, the electrolytes and steroid metabolism, have progressed to a point where they may. be immediately applicable to the understanding of the biochemical abnormalities in depression. I would like to urge, therefore, that a special NIMH laboratory for the study of depression be created and that the Ad Hoc Committee 1 s recommendations regarding it be followed. They have already been presented to you. This laboratory could be the center for the collection of all information extant upon this subject. It will have intra-mural and extra-mural components and will coordinate all research material upon the subject, in addition to training necessary personnel. I would strongly urge this committee to add $4 million dollars to the present research budget in order that this important project may be gotten under way. As an instance of the possibilities of advances in the immediate future, on Friday, March 31, 1967, the NIMH published a bulletin outlining a potentially effective drug tr~atment for manic-depressive psychoses. This drug is thought to control the recurrence of this devastating illness and a mechanism is now suggested as to the manner in which lithium salts may act in the treatment of mania, a problem which has plagued doctors and patients alike for more than a hundred years. Apparently it checks the intense manic excitement, and overactive patients are said to become calm under its influence. More importantly, it seems to act as a preventive of both manic and· depressive attacks. Heretofore we have been able to treat and wait out individual attacks of this illness but we were never able to prevent recurrences, - 19 - and patients and their families lived in dread of their reappearance. The drug is lithium carbonate. It is no miracle drug. It requires expert care in its administration and in the handling of the patient. It needs much more research. It has promising possibilities; it is a prototype of the drugs which are in the offing which hold hope for greater relief of emotional disorders and for the possibility of treating patients without having to hospitalize them. I shall say nothing about alcoholism 3 narcotic addiction., or drug abuse; they have been covered by Dr., Yolles and Mr. Gorman. I, too., urge that an additional $13 million dollars over the administrationts budget be added to finance research needs against these destroyers of men. There are numerous other aspects of the program I would like to discuss with you, but it is not fair to take up your time. You have heard Dr. Yolles and Mr. Gorman and we all agree on the needs. If I seem a bit enthusiastic orinte11se in. my statements or efforts., I would ask your indulgence. Please remember that I have watched this situation for over 35 years and I have seen people neglected, humiliated and otherwise badly treated, and now with the present new enthusiasm and community interest., we may be pardoned for wanting their lot to improve. We live in dread that the clock will strike 12 and the royal coach which has carried our Cinderella of medicine to its present knowledgeable heights ~ will turn into a pumpkin. I know that this committee will not allow that to happen. - 20 - In back of the various jokes about psychiatrists., mental hospitals and sick people, and beneath the cartoons in which couches and men with beards are prominent, there is still a certain amount of dread about these illnesses. In the present partnership of the professions)j the government and aroused citizens., we are sure we can remove most of that. It is our sincere hope that we can do so soon. Thank you., gentlemen., for allowing me to come before you. NIMH FISCAL 1968 BUDGET INCREASES PROPOSED BY CITIZENS 1968 President 1 s Budget Citizens Budget RESEARCH $ 76,477,000 $ 89,477,000 HOSPITAL IMPROVEMENT 10,610,000 L6,610,000 TRAINING 100,762,000 114, 150, 000 RES. FELLOWSHIPS 9,859,000 11,859,000 DIRECT OPERATIONS 50,764,000 61,764,000 TOTAL $248,472,000 $293,860,000 TOTAL INCREASE REQUESTED - CITIZENS BUDGET $45,388,000 COMMUNITY MENTAL HEALTH SERVICES Construction Grants $ 50,000,000 $65,000,000 Center Staffing 46,168,000 46,168,000 Narcotic Facilities 4,000,000 4,000,000 TOTAL - Community Resources $100,168,000 $115, 168,; 000 INCREASE FOR COMMUNITY MENTAL HEALTH SERVICES - $15,000,000 TESTIMONY BEFORE HOUSE APPROPRIATIONS SUB-COMMITTEE on Labor, Health, Education and Welfare Representative Daniel J. Flood, Chairman on FISCAL 1969 BUDGET for the NATIONAL INSTITUTE OF MENTAL HEALTH by Francie J. Braceland, M. D. Preaented on behall of The American Paychlatrlc A••ociation April 25, 1968 I am Francie J. Braceland and I have been a peychiatrilt for nearly 36 yeare.. I graduated from Jeffereon Medical College in 1930 and wa1 an intern and Chief Reaident at Jefferson Hoepital. I began my paychiatric fellowship trainin1 at the old Pennaylvania Hoapital in Philadelphia in 1932.. I was then a. Rockefeller Fellow in Paychiatry in Zurich, Switzerland. and at the National Ho1pital, Queen Square, London. I returned to be Clinical Director at the Penneylvania Hospital until 1941, when I was appointed Profee,or of Psychiatry and Dean of the School of Medicine, Loyola University. I have aince occupied the followina po•itiona: 1942-46 - Special Aaaietant to the Sur1eon General, U. S. Navy, and war-time Chief of the Psychiatric Section. I am a Rear P..dmiral, Medical Corpe, USNR, Retired. 19-46-51 - Head of the Section of P•ychiatry. Mayo Clinic, and Profe11or of Psychiatry, Graduate School, Univer•ity of Minne1ota. U)Sl-65 - Paychlatriet-in-Chief, The Inatitute of Living, Hartford, Connecticut; •ince 1965 Senior Conaultant in that inltitution; aleo Clinical Profeaaor of Psychiatry. Ya.le Univer1ity; since 1960. Lecturer on Psychiatry, Ha.rvard Medical School. I have been in the pa.et: President, American Board of P•ychiatry and Neurology, 1953. Pre1ident, American Paychiatric Aa1ociation, 1956 ... 57. Pre•ident, .Aasociation for Re•earcb in Nervou• and Mental Dileaee, 1957. Preaident, Board of Examiner• for Certification of Mental Hoapital Superintendent•, 1955. Chairman, .American Medical A1aociation, Section on Nervoua and Mental Di1ease, 1956. Chairman, National Health. Forum, 1958. Vice-President, World Peychiatric A••ociation., 1961-66. I am now Editor of The J\merican Journal of Paychiatry, the official oraan of American Paychiatry, and am • psychiatric conaultant to the Sur aeon• General of the Army, Navy, and Public Health. Mr. Chairman and Members of the Committee: I am appreciative of your willingne•s to hear me. I appear before you as a repreeentative of the American Peychiatric A••ociation; the official body of Amel"ican Psychiatry which number a nearly 18, 000 paychiatrists. I am here to express the support of that aeaociation for the citben•• budget for the National Institute of Mental Health, the budget juat detailed for you by my respected colleague, Mr. Mike Gorman. A• a hardy perennial in appearance before you, I have risked boring you by repeating anatchee from our early teatimony epanning a period of. twenty yeare. There are two main point• I would like to emphasize in that regard. The first ia that our initial appearance• here followed rather closely upon the end of World War II and the early beainning• of the National Institute of Mental Health. This repetition ia important thie year for the reason that the fund• which you appropriated in thoee early year• have paid off hand•omely insofar as psychiatric caaualties in modern warfare are concerned. In World War II, the .muJnber of psychiatric casualties was alarming, and the cause of great concern. Now, due to careful research and observation, the number of psychiatric casualties from the Viet Nam war ie remarkably 1mall. The aecond point I would like to empbaeize i• that when we came before you twenty yeara ago, an l't:1®::c,:o;_ns,dr:o"'llraJh1 jarge number of our fellow citizen• were con.fined to larae state hoapitala, and the proapect was that this number would increaae markedly a• the population increased. 2. Now, aaain due in great part to your help in eupplying re•earch and manpower fund•, the appropriation• have paid off and the number which was expected to be over 700,000 i• down to 4Z6, 000. Fortunately, it even dropped by 26,000 in the pa•t year. I am e1pecially pleased to bring theae reports to you. In thoae early yeara of our reporting to you, and for aome time• after­ ward• 11 the attention of our medical •pecialty was foeuaed eharply upon individual emotional problem• and mental lllne••e• and, mo1tly, upon hoepita lized patient•. Our appeal to you encompaased an apoloaia and an explanation that our work wae with eome wonderful people who were ill temporarily and recovery wa• possible if the per•on wa• not i•olated and forgotten. .And we •aid, in fact, that if the person wa• properly and •kill.fully treated, recovery would be ma.de by a larae proportion of them. our the1es was that the•e good people were really repreaentatives of ourselves under different circumatance• and the di!ference• between u• were thoae of degree, rather than of kind. We were actually aaying to ouraelve• and to others, with Lowell: "Conaole youraelf, dear ma.11 and brother; whatever we may be •ure of, be aure at lea1t of tbil: That we are dreadfully like other people. Human nature ha• a much greater genius for eamene•• than originality. " Thi• is •till true. The difference between u• and sick people i•: :i,ne of degree rather than of kind. Fortunately, however, you are aware of the fact that the aituation ha• chanaed markedly lince tho•e early day•. Not only hae the mental health picture itaelf changed but, al•o• our approach to it ha.a changed. Steady advance• have been made due to reaearch and more enli1hteaed attitude• and alao we have moved out from behind large ,tone wall• and into th. community at juat about the right time to be of help with the general unre•t which ia evident all around u•. Federal tun.de have helped brin1 thia desirable lituation about. My only competence la that of a clinician, a peychlatriat for thirty--,s ix" year• and, with your persniaaion I will coaflne my remark• to the nation'• mental health aa a clinician ••e• it today. touchin1 upon important •ea­ ment• with which the clinician deala. aDd accentiq finally the wideapread anxiety and depreasio». which b•••t• the population at the pre•ent time. Our aituation of 1eneral unre•t la not alto1ether unique or unprecedented. There have been other tlme1 like thia but, ill my opinion, the aatlon baa not witne• aed a time like the preeent with lta wideapread rioting, draft re•i•ta:nce, and violence, •inc• that time more than one hundred year• a10 when the nation wa• at war with ltaelf. Ba•ically, what i• common to •uch period•, Dr. Geor1e Ro•en eay1, la that "They are time• when •ocietle• and their culture, or aegment• within them, are cbansiat ~o aomething el••: when the accu•tom.ed ttructure of order, power, belief•, aJad meanin1, dlaintearate and man confront• the iaecrutable future not knowin1 what l• to come." Well, there i• no need for me to tell you a•ntlemen that the old order la cbaqing rapidly and the new direction• are not clear •• yet. So people will react to the unprecedented change• in • fashion dependln1 on their background• and the weight ol. out•ide pre11ure• upon them. Pre,eat day anxieties and turmoil will be uaed constructively by •ome people, and they will eet about to do what they can to be of help to other•- Other people will be overwhelmed by the rapidity of change and tome will become eick and depree1ed. Another 1roup will become angry and pre­ judiced. Still other• will take matter• into th.eir own hand• and be moved to violence. Each pereon will handle hi• anxietiee in bl• own faahlon. It ie obvioue to ua now aa clinlclana that societal factore. •uch a• poverty. urban overcrowdi , lack of education and all factor• which lead to de•pair and peraonal futility, are a• important iD populating mental hoapitab aa are the phyaieal and emotional di1order• which we heretofore have •tudied 10 carefully. A• yet there ia no couen•u• on how violent behavior ca.a be atopped. The only thin.a we can aaree on 1• that it mu•t be prevented. To para ... phrate the late President Kennedy'• apt phraae reaarding war, and •ub1titutin1 the word "violence 0 for it, we might •ay that: ,.Mankind mu1t eliminate violence or violence will eliminate mankind. .. The NIMH baa been involved bi reaearch effort• to develop underatancUna of the force• of violence aa they relate to behavioral •ciencea, but much more need• to be done, particularly re1earch in. the behavioral ecience• and in mental health effort, to under•tand the factor• which cause violence. Behavioral reaearch has already provided us with a relevant body of knowledge on motivation, emotion, attitude, and on individual 1roup and social proces ees. This information can be collected and refined, but we need to know much more. Today we are face to face with variou• aspect• of general tlllreat, including ita ineatal health implication•. At the level of prevention, there 1• already aignifica.nt and ueeful informa­ tion about the nature of the ay•tem which stimulate• •ocial disquiet and lead• to ma•• violence. Some of this material wa• furni,hed to the Kerner Commieaion. The commi11ion reque•ted the data available from behavioral acience re•earch which might be of aid to them, and a ataff paper was prepared in answer to that requeet. Thi, material was •••embled from variou• project• in univefaitie• and other diver1e department, being funded by NIMH grant•. What ie being doae i• to •upport the training of individuals to etudy and deal with the ii •ue• and problem• thought to be related to riota. Thu•, eocial inatitutiona, economic fore••~ urban planning, human relation•, family life, diacrimination, cultural forces and other factors affecting the live• of the poor and minority group•, all are receiving increased attention by mental health and related prof•• don.all. At t.hie point I ahould interject a note of caution. I, by no mean• in.tend to imply that p•ychiatrl•t• are 1r.0•thaayer1 or, indeed, that they know how to aettle the problem• which be11et iu, unsettled nation•.. No one pretend• that thi• ii 10. What I do intend to imply ia that psychiatry and it• co-worker• do 6. po••••• a body of knowledge gleaned from reeearch and experience wh.ich might be utilized. among other thbi1•, in tryin1 to understand what i• going on. The Director of NIMH •aid on one occaaion: "Much of thl• material i• dbperaed. It need• to be collected and refined and put in contest with other lindiaga, and then judged on the ba1i1 of field trialt." One of th• problem• h that the acientlfic community appear• to be talking to it•elf, aince neither the public or the policy maker• act very often a• though the word h&d 1otten through to them. The point here i• that thle i• not the time for budget• to be cut, eepecially tho•• connected with manpower, reaearch, community and beha'Vioral aciencea. Rather, it i• a time to increa•e them markedly and to •ncouraae effort• to correlate all available material,for the mental health of the nation i• involved. I am cognizant ol the heavy demand• for funds belna made upon the Congr•••• and aware of aome of the dilemma• you face. I have confidence in your wiado:m in meeting the•• problem•• however, and I know too that you will keep b1 mind the importance of aouad mental health in communitiee, and know that there are la.rae number• of eick and diatre••ed ind.ivlduale who c:amtot epea.k for them1elve1 in thls reaa.rd. The mentally di•W~';ed. th. addicta I the alcoholics, all of them are poorly understood and, 1ometime•, they are badly treated. When you helped to briag u• out of iaolated mental hoapitala I into the community, neither you. nor we kaew the extent of the demand• which would be made upon \H for aervice• atul for •••htance. The old point of view 7. that mental illness wae chronic and refractory to treatment is gone. The new point of view i• that moat mental illnes, •erves ite purpose and dieappeara, and it doe• ao more rapidly and completely when it ia well understood and skillfully dealt with. We see patient• now, Karl Menninger say•, not as much ae persons afflicted with certain disea•e•, but •• human beings obliged to make awkward and ex.pensive maneuver• to maintain themselves, Isolated from their fellows, harassed by faulty living techniques, their reaction, are intended to make the beat of a bad bargain, and at the 1ame time to fore•tall a worse one. In other words to in.aure survival even at the coat of •uffering and 1ocial dieaater. While social change in the paat was mea1ured in term• of hi1torical epoch•, centuri•• or generation,, the rate• of economic /J aocial and technological change move so quickly today as to impose a perpetual pree•ure upon every individual. Change• in the nature and distribution of the population of the nation• have inteaaified the problems of mental health and have created a general awareneaa of concern about them. ·rhe diaappearance of frontiers and the rapid shift from rural to urban living have reduced the opportunities for dlaaffected or non-conforming pereon• to escape cloae scrutiny. There i• no longer a eatisfactory place for them to migrate. The increaaing trend toward crowded dwelling units in cities baa concentrated more people in situation• which tend to intensify stres•, and at the eame time reduces both individual and aocial tolerance for the 8. inevitable dieturbin1 behavior which ari•e•. We all know of the major aocial conditions which have atrealful effect• upon people'• mental health. They are reported re1ularly, sometime a traaically, in our news media. In mentioning theee event•, pleaae underatand again that p1ychiatri1t1 do not pose a1 oracle•.. We cannot change tbeae social condition•, but we can make effort. to prevent illneesea ari1in1 from them and we muet take care of the people who become diaturbed aa a reeult of them. Like Spinoza, we make ceaeele• e effort• not to ridicule, bewail, or •corn human action•, but to understand them. We point out that har1h treatment, the feeling of being unloved, quarrels and ineecurity, all brin1 out hoatility and atrengthen anti-eocial inclination• in individuals and group•. Emotional deprivation in child­ hood account• for later anti-aocial and 1ometime1 criminal behavior, a1 well a• as sorted kind• of mental di• order•,, Ho1tility and reaentment may 1bow up in defiance of parent• and all authority -- fathere, teacher,, police, military officer•, jud1e1, God. It can remain covered up for a long time and emer1• later tragically. In. familie1 where there ia acute tendon, children feel iaolated and displaced and deformed character, can en•ue which will be evidenced later a• anti-aocial or emotionally di•tree sed individual•. Juet how do we propoae to 10 about helping with these problem•? By movina further into the community with the community mental health center• which you funded and which you have heard •o much about. We will go into 1torefront clinic• in underprivileged neighborhood• 9. wherever necee aary to really get to people who need help. Realize, if you plea1e, that the fund• which you appropriate for reeearch and for paychiatric manpower have va1t implication• for mental health far beyond the usea made of them in the purely mental health field. Thil once neglected diecipline ha• now apread ita influence and slowly attracted the help and the demand !or help from the community. It began to make contribution• to ite aiater medical apecialtiea and to military and industrial medicine, shortly after World War II. Its help ha• a.ho been 1olicited by educational and religioua institution•, and the ■ e contribution• are slated to increaee.. ! would Ju•t like to mention briefly our contribution• to these varied diacipUne•. Thi• will tell you of the company we keep, give you an account of our stewardship, and inform you of the wideapread effect of the fund• which you are asked to appropriate here • .A• to the present day application• of our findings to general medicine. the work of paychoaomatic re•earch ia well known. · Though we have not aatiafactorily solved the age old body-mind problem, our finding• are con1tantly becoming more important. Everything from the diurnal rhythm of our bodie•, our eo--called "biologic clock•, '* the optimal time to administer drug•, the influence of rapidly changing time zonea upon fiyer• and travelers, the phenomena of eleep. the varioua chemical and biological phenomena which underlie depresdon• -- all of theee have paychological and physiological component•. The1e, plu• the remarkable contributione of the socioloailt• and anthropologi•t• regardina man•• behavior. hold exciting proapecta for future reaearcb in man'• mental well-beln1 and in hi• behavior. A• to the contribution• made by paychiatric clinical obaervation and ba•ic reaearch to military paychiatry already mentioned, they are remarkable a• evidenced by the fact that in the Viet Nam conflict thu• far there ia a remarkably low number of paychlatrlc caaualtiee. Thia ii due to a number of factors, the most important of which are a more careful selection of men, and a more efficient and immediate treatment of emotional upaet• at the front and close to the man•• own unit. The knowled1e which we have gained from our reaearch&IJ a.110 ha• helped u• to be of aaliatance in lnduatry. Paychiatry can make noteworthy contribution•, and hi. •ome inatance• i• already doin1 eo. lt• role i• conaultative and preventive.. It can pinpoint cau••• of time loat and reaaon• for turnover of per•onnel. Obviouely it ie not the function of buaiae•• or indu•try to act a• nuraemald or paychlatric clinic, but it doee seem wile in tbeae days of manpower ahortaae• to ellmiaate road block• to emotional aatilfaction and to con•erve ekillful personnel wherever poeeible. Thi• utilisation of 1kl1led peyehiatric help in tnduetry will arow. Unfortunately, however, at preaent there are not enou1h con•ultante to 10 around. A• to the contribution• to education, with the peraonnel aided by fund• from NIMH, I went into detail laet year on the type of the problema encoW1tered and their incidence. I ehall not take up your time repeatin1 tho•• remark.a. You know, however, of the importance of the•e youna 11. people in high •chool and in college. From them will come tomorrow•• leader•. Fortunately many of their problem• are minor and tranlient. In general, the•• are baeically admirable young•tere, even if they are occadonally difficult. Twice in the month of March 1967, our military leaders in Viet Nam a poke of thoae young men whom they had encountered ...... mostly drafted men. They 1aid of them, "Let me tell you, they are the bravest, 1marteat aoldiers we have •een in twenty-six year• in the military. They are re•ourceful on a battlefield. They are 1iving of their all and doina a fantastic job." It i• evident that once committed, these young people acquit themeelve• creditably. The problem, of couree, lie• in the question,how to in1pire tbemf More help in adviaing them and careful attention to the mental health of the1e young people i1 e••ential. They repreaent the nation•• hope for the future • .All of thia ie by way of report to you and thi• fanta•tic array o{ need• and of effort•, of work being done in the mental health field i• being offered to you in juatificatlon of the budget which Mr. Oorman ha• Ju•t preaented to you. The preventive pos aibilitie1 are evident. The•e bud1et• are not dmply for mental hoapitala thou1h they, too, benefit from all that ia going on in the field. Mental health re•earch and mental health work•r• were obvioualy needed to fill the breech in a number of preaaing eituation•. So true i• thi• that peychiatry. one of the major di1cipline1 called upon for a1eiatanc:e, ia having an identity criab of tu own. It mu•t be careful not to •pread itaelf too thinly 12. in an effort to be all thing• to all people. Ba.aically it ba• a medical mia•ion. It did not •••k these other taau. They evolved aa the apeclalty evolved in it• modern drea •. It cannot, however, under any cireuxn•tance•, fall to re a pond to the call of the community for mental health ia an ab•olute nece••lty to it. Your committee baa in the pa.It cornmwdcated to the Houee it• concern that mental health reaearch effort• continue to expand. Thl1 1• eeeen.tlal in theee pw•••nt tim•• of areat national unreat. We are in a period ae brilliant and a• violent•• that which aurrounded the period of the French Revolution. Memal Health reaearch today i• providia1 aome exciting I 1 ftndln1• which portend hope for the future.. To interrupt lnve•tiaatprs, , to aak them to tread water and ••• their reaearch team• diaintearate and diaappear, would be calainatou• in thi• period of sreat anxiety. I would ura• you, therefore, to condnue and lacr•••• the aupport of reeearch fund• bc;,th for internal and external NlMH program, and. like the Bau of Moa.te Carlo, one cannot auarantee a payoff, but when oae occur• it le areat in it• extent. Wlth your permi• don, I eball not 10 in.to further detail regarding overall mental health re•earch here, nor comment further on the dire reault1 of any cut-back in research fund•. That ha• been ably taken care of by my coll..,pe. Rather, I would lib to comment upon ,everal eituatiom which are in need of. coo.tinued and expanded attention. 13. We mentioned that in one major preventive approach to the general •ocial unrest which is so evident nationa.lly, the NIMH l• supporting the development of community mental health centere throughout the land. When the concept of these center• wa• evolved, they were thought of primarily as a means of group mental health service• -- mostly for the deprived -- but, in general, aa place• that patient• could be treated in their own communitie•. Now, however, they loom in addition to be centers with poaeibilities for reeeareh and training facilities for program• quite directly related to civil disorders, social unre•t and violence: becauae, on the finding• of this re search and on our ability to train worker a who can under1tand and influence deprived people, will rest our ability to glwe them the 1ervice1 they need in the places where they live. Some 260 of these center• have received Federal grant• to help finance construction and initial staffing, and a1mo•t 100 of them are operating today. Their etaf!e are treating mental illness and emotional disturbance but they are al10 beginning to meet many more need• in their communities than they originally expected to do. Communities are looking to •et up and expand the u1e of these centers and it 1s certain that their preventive and consultative aervicee will contribute toward aocial change• that can ea.ae the preseure• and 1tre1a underlyin1 violence. Thie will not be done by mental health worker• alone. Rather. it will be a baae where phyeiclane, clergymen. and other capable profee eional• will pool their knowled1e and apply their competence to the problems which are preaently diaturblna communities. 14. To neglect to expand the number of these centera, to cut budget• now, to fail to help bring these concept• to a broad fair trial, would be tragic. One !ears a return of our dispirited g:rou.p to isolated hoepitab lf we fail in our efforts to help broaden the base of community centers .. The capable Director of NIMH baa told you, I am eure, of hi• plan• to implement President Johnson's •tatement that one of the immediate objectives of his adminietration will be to develop 0 a child health program; to provide for families unable to afford it, ace es• to health aervic•• from pre-natal care of the mother through the child'• fir•t year." I •hall not go into detail regarding the program• which have been worked out -- in the interest ot'time -- suf!ice it to eay they are, indeed, well conceived and they merit your •trong eupport. I would like to diacu• a many more important cllnical a,pect• of problem• which face ue, but I realize that your patiellee •hould not be tried. I would certainly talk about alcoholiam and urge you to markedly increa1e the budget for reaearch and traintn1 to help with that 1courge. It attack• the high and the low, breaks up families, and di•tre••e• children in untold numbers.. I would reiterate what I said to you la•t year, and earneetly eeek your help in eetabliahtng laboratorie• to further the under•tandln1 of the phenomenon of depreesion, one of the moat painful congerie• of •ymptom• known to us. I say thie becauee uaually there i• no viaible aymptom which account.I for the per•on.• • diltre• •, and that make• under1tandin1 more difficult and the tllnea, harder to bear. 15. Melancholy ia a phenomenon a• old•• man. The queation hae been aaked why so many great men have been melancholy. Some have loat their live• durin& period• of depre• aion. I am •ure you can recall the ead hbtorie• of • ome of them. Of all of the emotional illll•• ••• treated by paychiatriete in the preaent culture, depreasive phenomena are in the forefront. Depre••ion is the paychiatric diagnoeia made moet frequently today. The Medical World Newa, in a March ieaue, aurvey• th• eubject under the apt title 0 New Face• of Depreasion," and a aub-tltle, "An Old Syndrone with a 1968 Look. u The article begin• with a quotation from the Greek biographer, Plutarch: "When a man i• depreaaed, every little evil i• ma1nified by the epectre• of hie anxiety. tt Plutarch'• observation la aa apt today ae when. he made it 2000 year• aao. 1 think we are juetified in brin1ing thi• eubject to your attention agab1 for aeveral important rea.aon•: 1. The incidence of depreaaive phenomena. 2. The bade 1cienti•t• have 1one far in the paet aeveral year• in determinin1 many of the chemical and phyaiolo1ical accompaniment• of the illn•••· 3.. The condition ia eminently t:reatabl• today. Often ••11- limited, the condition can be alleviated by drugs and other modern method• of treatment. Feeling• of aadnes,, hopel•••ne•• or de1pondency, may ariae due to adver1e external circumatancea in which the individual find• himself. Whether the conditiona be really overwhelming or whether for aome reaaon the individual find• himaelf inadequate to deal with them, the r••ulting deprea,ion ie the aame. 16. Fortunately for moat of us, our depreseive feeling• are only transitory and either disappear apontaneously or alter we have worked out some type of positiive solutions to the problem reepouible.. These depreaaions are obvious and easily recognized, but there are 0th.era which are masked to the point where no one but an expert can detect their presence until a full-blown deep depreasion appears. Here the situation ie much more seriou,, the depreeeed nlood become• longer la1ting. and the attitude of dejection and the train of syn1ptoms which follow in its wake render the individual ineffectual. These depressions are the illne•sea moat difficult to bear, for unlike medical or surgical illnes aes, there are no vieible physical .t ymptoma apparent to the euUerer• or to others that might explain hie distre a a. Theae depreeeive episodes mu•t be differentiated from grief, a normal phenomenon, and should not be confuaed with it. In grief the losa is personal, objective, external, and readily underltandable. The reapon1e it calle forth i1 realiatic and proportionate to what baa been loat. Grief, which i• the normal expre11ion of aorrow and bereavement which follows the loss of a loved one, i• •elf-limited and gradually subsides. Psychotherapist• call attention to the great effort expended by theee lndividua.la who fttel that they do not deaerve anything in their own right, but must continue to atrive and achieve 1f they are to get someone to love them or to continue to love them. It hae long been recognized that the1e good people are extremely vulnerable to lo•• of po1ition or statue or the lo•• of material poa•easion•. They are vulnerable. too, to the decline of phylical abilltle• •••ential to their continued achievement or even with 17. advancing age the lo•• of certain future poaaibilitiea of achievement. Examples of theae •ituation• are plentiful today in our period of merge•, atrict rule& for retirement, and the pre,aure• of our economic aituation. Children and adoleacents may become depreaeed and some of their deetructive behavior may mask a mild depre••ion a• they aearch for meaningful relatioaahips. They are not our concern here, but we •hould mention that much of the apathy, boredom, and willillgne•• to enliat in ahno•t any cauae except atudy in college student• ia of the aame genre. The complaint• that they don't know what they want to do, the lack of intere•t in education in general, the feeling of the uaelea ane11 of it all, and the couplin1 of education and attainment with the older generation• from whom they are aeparated, all may be due to uade:rlying mild deprea1lona. It i1 no longer eaay for them to take a moratorium and drop out of college for a while to catch up with themaelve•, for the draft mu.at be kept ln mind. Some of the student• deliberately arrange to fail, which fact diatre1ee1 their parents and bring• their pli1ht sharply into focus. Under these 1ituationa, the attractiven••• ol trying drug• in aome form l• apparent. They have heard of the pleaeure of attaining a "hlghtt and they are influenced to try it by the pre1aure• of their peer,. If they are fortunate, the experience will b• diaappoint1n1 or acary: if it prove• attractive, they will have 1ome aerioue decilion• to make. While it i• true that •o•called ttpot" ia not addletlna in the physical ••n••• •• are the narcotic drug•, 18. neverthele••• there ia a paychological attractiveneaa to it and it ia not at all the harmless aubatance that enthuela•t• make it out to be. We have talked aeveral time• about depre1eione of middle life and earlier thought to be the excluaive property of women and due to the change of life. W • decried both of theae a••umption• and noted the occurrence of depreeelon in. men a decade later, and au11••ted that the only relation to change which was preeent waa the individual'• inability to change in accor•nce with the aurroundln.1 chanaee which faced their age group in the preaent culture. We noted, too, that pereona who were rigid, comcientioue, and inclined to perfectioniam, were vulnerable to depreaeion in thi• p•riod. They were not ea1ily influenced e•en though circumstance• around them were changing rapidly. The•e are ueually fine people bot their ri1idity become• a hazard when their external circumatance• call for marked change and they are unable to comply. As to the reaction• of older people to the pre1ent aeneral unrest and rapidly chan1ing cultural and economic environment. they are underatandable. In the preaent era, with youth in the center of attention and in "children's e ruaa.dea u in politic• and the •earch for young people to occupy executive and top poaitiona, men. in the older age group• are underatandably in1ecure. with Very often they find tbem1elve1 unable or unwilling to keep up 1 td1r the pace and they withdraw, react in a depre••lve manner and become chronically ill. 19 .. Mr. Chairman, if I have become too clinical in thi• preaentatton again, I asaure you that it ia my only competence. I cho1e thia method of preeenta- t ion to you rather than repeat line for line the budget need• which ha• been done so ably by my colleague, Mr. Gorman. l do want to emphadze heartily, however, our agreement with him. The mental health field baa opened up. It ha• great po••ibilitie1, and I know that you and your committee member• will inalst that it continue it• activitie•.. The mental health of the community depend• upon the health of it• individual,, and the mental health of the nation depend• upon the health of itl communitiee. TESTIMONY BEFORE SENATE APPROPRIATIONS SUB - COMMITTEE on Labor, Health, Education and Welfare Senator Lister Hill, Chairman on FISCAL 1969 BUDGET for the NATIONAL INSTITUTE OF MENTAL HEALTH By Francis J. Braceland, M. D. Presented on behalf of· The American Psychiatric Association June 25, 1968 I am Francis J. Braceland and I have been a psychiatrist for nearly 36 years. I graduated from Jefferson Medical College in 1930 and was an intern and Chief Resident at Jefferson Hospital. I began my psychiatric fellowship training at the old Pennsylvania Hospital in Philadelphia in 1932. I was then a Rockefeller Fellow in Psychiatry in Zurich, Switzerland, and at the National Hospital, Queen Square, London. I returned to be Clinical Director at the Pennsylvania Hospital until 1941 1 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 am 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 Minnesotao 1951-65 - Psychiatrist-in-Chief, The Institute of Living, Hartford, Connecticut; since 1965 Senior Consultant in that institution; also Clinical Professor of Psychiatry, Yale University; since 1960, Lecturer on Psychiatry, Harvard Medical School. I have been in the past: President, American Boc1;rd of Psychiatry and Neurology, 1953. President, American Psychiatric Association, 1956..:57. President, Association for Research in Nervous and Mental Disease, 1957. President, Board of Examiners for Certification of Mental Hospital Superintendents, 19 5 5. Chairman, American Medical Association, Section on Nervous and Mental Disease, 1956 .. Chairman, National Health Forum, 1958 .. Vice -President, World Psychiatric Association, 19 61-66. I am now Editor of The American Journal of Psychiatry, the official organ of American Psychiatry, and am a psychiatric consultant to the Surgeons General of the Army, Navy, and Public Health. Mr. Chairman and Members of the Committee: I am appreciative of your willingness to hear me. I appear before you as a representative of the American Psychiatric Association; the official body of American Psychiatry which numbers nearly 18, 000 psychiatrists. I am here to express the support of that association for the citizens t budget for the National Institute of Mental Health, the budget just detailed for you by my respected colleague, Mr. Mike Gorman. As a hardy perennial in appearance before you, I have risked boring you by repeating snatches from our early testimony spanning a period of twenty years. There are two main points I would like to emphasize in that regard. The first is that our initial appearances here followed rather closely upon the end of World War II and the early beginnings of the National Institute of Mental Health. This repetition is important this year for the reason that the funds which you appropriated in those early years have paid off handsomely insofar as psychiatric casualties in modern warfare are concerned .. In World War II, the number of psychiatric casualties was alarming 3 and the cause of great concern. Now, due to careful research and observation, the number of psychiatric casualties from the Viet Nam war is remarkably small.. The second point I would like to emphasize is that when we came before you twenty years ago, an unconscionablylarge number of our fellow citizens were confined to large state hospitals, and the prospect was that this numb~r would increase markedly as the population increased. 2. Now, again due in great part to your help in supplying research and manpower funds, the appropriations have paid off and the number which was expected to be over 700., 000 is down to 426,000. Fortunately, it even dropped by 26., 000 in the past year. I am especially pleased to bring these reports to you. In those early years of our reporting to you, and for some times after- wards, the attention of our medical specialty was focused sharply upon individual emotional problems and mental illnesses and., mostly., upon hospitalized patients. Our appeal to you encompassed an apologia and an explanation that our work was with some wonderful people who were ill temporarily and recovery was possible if the person was not isolated and forgotten. And we said, in fact, that if the person was properly and skillfully treated, recovery would be made by a large proportion of them .. our theses was that these good people were really representatives of ourselves under different circumstances and the differences between us were those of degree, rather than of kind.. We were actually saying to ourselves and to others., with Lowell: "Console yourself, dear man and brother; whatever we may be sure of, be sure at least of this: That we are dreadfully like other people. Ht!-man nature 11 has a much greater genius for sameness than originality,. This is still true.. The difference between us and sick people is one of degree rather than of kind.. Fortunately, however, you are aware of the fact that the situation has changed markedly since those early days .. 3. Not only has the mental health picture itself changed but, also, our approach to it has changed. Steady advances have been made due to research and more enlightened attitudes and also we have moved out from behind large stone walls and into the community at just about the right time to be of help with the general unrest which is evident all around us. Federal funds have helped bring this desirable situation about .. My only competence is that of a clinician; a psychiatrist for thirty-. six years and, with your per•mission I will confine my remarks to the nationts mental health as a clinician sees it today, touching upon important seg­ ments with which the clinician deals, and accenting finally the widespread anxiety and depression which besets the population at the present time .. Our situation of general unrest is not altogether unique or unprecedented.. There have been other times like this but, in my opinion, the nation has not witnessed a time like the present with its widespread rioting, draft resistance, and violence, since that time more than one hundred years ago when the nation was at war with itself.. Basically, what is common to such periods, Dr. George Rosen says, is that "They are times when societies and their culture, or segments within them, are changing to something else; when the accustomed structure of order, power, beliefs, and meaning, disintegrate and man confronts the inscrutable future not knowing what is to come .. 11 Well, there is no need for me to tell you gentlemen that the old order is changing rapidly and the new directions are not clear as yet. So people 4. will react to the unprecedented changes in a fashion depending on their backgrounds and the weight of outside pressures upon them. Present day anxieties and turmoil will be used constructively by some people, and they will set about to do what they can to be of help to others. Other people will be overwhelmed by the rapidity of change and some will become sick and depressed. Another group will become angry and pre­ judiced., Still others will take matters into their own hands and be moved to violence. Each person will handle his anxieties in his own fashion. It is obvious to us now as clinicians that societal factors, such as poverty, urban overcrowding, lack of education and all factors which lead to despair and personal futility, are as important in populating mental hospitals as are the physical and emotional dis orders which we heretofore have studied so carefully& As yet there is no consensus on how violent behavior can be stopped. The only thing we can agree on is that it must be prevented. To para­ phrase the late President Kennedy 1 s apt phrase regarding war, and substituting the word "violence 11 for it, we might say that: "Mankind 11 must eliminate violence or violence will eliminate mankind. The NIMH has been involved in research efforts to develop understanding of the forces of violence as they relate to behavioral sciences, but much more needs to be done, particularly research in the behavioral sciences and in mental health efforts to understand the factors which cause violence .. 5. Behavioral research has already provided us with a relevant body of knowledge on motivation, emotion, attitude, and on individual group and social processes. This inf~Hmation can be collected and refined, but we need to know much more. Today we are face to face with various aspects of general unrest, including its mental health implications .. At the level of prevention, there is already significant and useful informa­ tion about the nature of the system which stimulates social disquiet and leads to mass violence. Some of this material was furnished to the Kerner Commission. The commission requested the data available from behavioral science research which might be of aid to them, and a staff paper was prepared in answer to that request. This material was assembled from various projects in universities and other diverse departments being funded by NIMH grants., What is being done is to support the training of individuals to study and deal with the is sues and problems thought to be related to riots. Thus., social institutions, economic forces., urban planning, human relations, family life., discrimination, cultural forces and other factors affecting the lives of the poor and minority groups, all are receiving increased attention by mental health and related professionals .. At this point I should interject a note of caution.. I, by no means intend to imply that psychiatrists are soothsayers or., indeed, that they know how to settle the problems which bes et an unsettled nations.. No one pretends that this is so. What I do intend to imply is that psychiatry and its co-workers do 6. possess a body of knowledge gleaned from research and experience which might be utilized, among other things, in trying to understand what is going on. The Director of NIMH said on one occasion: "Much of this material is dispersed. It needs to be collected and refined and put in context with other findings, and then judged on the bas is of field trials.'' One of the problems is that the ~cientific community appears to be talking to itself:, since neither the public or the policy makers act very often as though the word had gotten through to them,. The point here is that this is not the time for budgets to be cut, especially those connected with manpower, research, community and behavioral sciences. Rather, it is a time to increase them markedly and to encourage efforts to correlate all available material,for the mental health of the nation is involved., I am cognizant of the heavy demands for funds being made upon the Congress, and aware of some of the dilemmas you face. I have confidence in your wisdom in meeting these problems, however, and I know too that you will keep in mind the importance of sound mental health in communities, and know that there are large numbers of sick and distressed individuals who cannot speak for themselves in this regard., The mentally disturbed, the addicts, the alcoholics j all of them are poorly understood and, sometimes, they are badly treated .. When you helped to bring us out of isolated mental hospitals :1 into the community, neither you nor we knew the extent of the demands which would be made upon us for services and for assistance. The old point of view 7. that mental illness was chronic and refractory to treatment is gone. The new point of view is that most mental illness serves its purpose and disappears, and it does so more rapidly and completely when it is well understood and skillfully dealt with. We see patients now, Karl Menninger says, not as much as persons afflicted with certain diseases, but as human beings obliged to make awkward and expensi_ve maneuvers to maintain themselves, Isolated from their fellows, harassed by faulty living techniques, their reactions are intended to make the best of a bad bargain, and at the same time to forestall a worse one. In other words to insure survival even at the cost of suffering and social disaster. While social change in the past was m·easured in terms of historical epochs, centuries or generations, the rates of economic, social and technological change move so quickly today as to impose a perpetual pressure upon every individual. Changes in the nature and distribution of the population of the nations have intensified the problems of mental health and have created a general awareness of concern ab.out them.. The disappearance of frontiers and the rapid shift from rural to urban living have reduced the opportunities for disaffected or non-conforming persons to escape close scrutiny. There is no longer a satisfactory place for them to migrate .. The increasing trend toward crowded dwelling units in cities has concentrated more people in situations which tend to intensify stress, and at the same time reduces both individual and social tolerance for the 8. inevitable disturbing behavior which arises. We all know of the major social conditions which have stressful effects upon people's mental health. They are reported regularly, sometimes tragically, in our news media. In mentioning these events., please understand again that psychiatrists do not pose as oraclesQ We cannot change these social conditions, but we can make efforts to prevent illnesses arising from them and we must take care of the people who become disturbed as a result of them. Like Spinoza, we make ceaseless efforts not to ridicule, bewail, or scorn human actions, but to understand them. We point out that harsh treatment, the feeling of being unloved, quarrels and insecurity, all bring out hostility and strengthen anti-social inclinations in individuals and groups. Emotional deprivation in child­ hood accounts for later anti-social and sometimes criminal behavior, as well as assorted kinds of mental disorders .. Hostility and resentment may show up in defiance of parents and all authority -- fathers, teachers, police, military officers, judges, God., It can remain covered up for a long time and emerge later tragically. In families where there is acute tension, children feel isolated and displaced and deformed characters can ensue which will be evidenced later as anti-social or emotionally distressed individuals Q Just how do we pr~pose to go about helping with these problems? By moving further into the community with the community mental health centers which you funded and which you have heard so much about. We will go into storefront clinics in underprivileged neighborhoods 9. wherever necessary to really get to people who need help. Realize, if you please, that the funds which you appropriate for research and for psychiatric manpower have vast implications for mental health far beyond the uses made of them in the. purely mental health field. This once neglected discipline has now spread its influence and slowly attracted the help and the demand for help from the community. It began to make contributions to its sister medical specialties and to military and industrial medicine, shortly after World War IL Its help has also been solicited by educational and religious institutions, and these contributions are slated to increase.. I would just like to mention briefly our contributions to these varied disciplines,. This will tell you of the company we keep, give you an account of our stewardship, and inform you of the widespread effect of the funds which you are asked to appropriate here. As to the present day applications of our findings to general medicinei1 the work of psychosomatic research is well known.. Though we have not satisfactorily solved the age old body-mind problem, our findings are constantly becoming more important.. Everything from the diurnal rhythm 0 0 of our bodies, our so -called biologic clocks, the optimal time to administer drugs, the influence of rapidly changing time zones upon flyers and travelers, the phenomena of sleep, the various chemical and biological phenomena which underlie depressions - - all of these have psychological and physiological components. These, plus the remarkable contributions of the sociologists and anthropologists regarding man 1 s behavior, hold 10. exciting prospects for future research in man's mental well-being and in his behavior. As to the contributions made by psychiatric clinical observation and basic research to military psychiatry already mentioned, they are remarkable as evidenced by the fact that in the Viet Nam conflict thus far there is a remarkably low number of psychiatric casualties.. This is due to a number of factors, the most important of which are a more careful selection of men, and a more efficient and immediate treatment of emotional upsets at the front and close to the mants own unit. The knowledge which we have gained from our researches also has helped us to be of assistance in industry .. Psychiatry can make noteworthy contributions, and in some instances is already doing so. Its role is consultative and preventive.. It can pinpoint causes of time lost and reasons for turnover of personnel. Obviously it is not the function of business or industry to act as nursemaid or psychiatric clinic, but it does seem wise in these days of manpower shortages to eliminate road blocks to emotional satisfaction and to conserve skillful personnel wherever possible .. This utilization of skilled psychiatric help in industry will grow.. Unfortunately, however, at present there are not enough consultants to go around. As to the contributions to education, with the personnel aided by funds from NIMH., I went into detail last year on the type of the problems encountered and their incidence.. I shall not take up your time repeating those remarks~ You know, however, of the importance of these young 11. people in high school and in college. From them will come tomorrow's leaders. Fortunately many of their problems are minor and transient. In general, these are basically admirable youngsters, even if they are occasionally difficult. Twice in the month of March 1967, our military leaders in Viet Nam spoke of those young men whom they had encountered mostly drafted men. They said of them, "Let me tell you, they are the bravest, smartest soldiers we have seen in twenty-six years in the military. They are resourceful on a battlefield. They are giving of their all and 11 doing a fantastic job. It is evident that once committed, these young people acquit themselves creditably.. The problem, of course, lies in the question,how to inspire them? More help in advising them and careful attention to the mental health of these young people is essential. They represent the nation1 s hope for the future. All of this is by way of report to you and this fantastic array of needs and o.f eHol'Ls, o.f work being done in the n1enial health .field is being oHe.re<l to you in justification of the budget which Mr. Gorman has just presented to you.. The preventive pas sibilities are evident. These budgets are not simply for mental hospitals though they, too, benefit from all that is going on in the field. Mental health research and mental health workers were obviously needed to fill the breech in a number of pressing situations. So true is this that psychiatry, one of the major disciplines called upon for assistance, is having an identity crisis of its own. It must be careful not to spread itself too thinly 12. in an effort to be all things to all people. Basically it has a medical mission. It did not seek these other tasks. They evolved as the specialty evolved in its modern dress. It cannot, however, under any circumstances, fail to respond to the call of the community for mental health is an absolute necessity to it. Your committee has in the past communicated to the House its concern that mental health research efforts continue to expand. This is essential in these present times of.great national unrest. We are in a period as brilliant and as violent as that which surrounded the period of the French Revolution.. Mental Health research today is providing some exciting findings which portend hope for the future. To interrupt investigatDrs, to ask them to tread water and see their research teams disintegrate and disappear, would be calamatous in this period of great anxiety., I would urge you, therefore, to continue and increase the support of research funds both for internal and external NIMH programs and, like the Bank of Monte Carlo, one cannot guarantee a payoff, but when one occui·s it is great in its extentQ With your permission, I shall not go into further detail regarding overall mental health research here, nor comment further on the dire results of any cut-back in research funds. That has been ably taken care of by my colleague. Rather, I would like to comm_ent upon several situations which are in need of continued and expanded attention. 13. We mentioned that in one major preventive approach to the general social unrest which is so evident nationally, the NIMH is supporting the development of community mental health centers throughout the land. When the concept of these centers was evolved, they were thought of primarily as a means of group mental health services -- mostly for the deprived - - but, in general, as places that patients could be treated in their own communities,.. Now, however., they loom in addition to be centers with possibilities for research and, training facilities for programs quite directly related to civil disorders., social unrest and violence; because, on the findings of this research and on our ability to train workers who can understand and influence deprived people, will rest our ability to give them the services they need in the places where they live. Some 260 of these centers have received Federal grants to help finance construction and initial staffing, and almost 100 of them are operating today. Their staffs are treating mental illness and emotional disturbance but they are also beginning to meet many more needs in their communities than they originally expected to do. Communities are looking to set up and expand the use of these centers and it is certain that their preventive and consultative services will contribute toward social changes that can ease the pressures and stress underlying violence. This will not be done by mental health workers alone. Rather., it will be a base where physicians., clergymen., and other capable professionals will pool their knowledge and apply their competence to the problems which are presently disturbing communities. 14. To neglect to expand the number of these centers, to cut budgets now, to fail to help bring these concepts to a broad fair trial, would be tragic. One fears a return of our dispirited group to isolated hospitals if we fail in our efforts to help broaden the base of community centers. The capable Director of NIMH has told you, I am sure, of his plans to implement President Johnson 1 s statement that one of the immediate objectives of his administration will be to develop 11 a child health program; to provide for families unable to afford it, access to health services from pre-natal care of the mother through the child 1 s first year. 11 I shall not go into detail regarding the programs which have been worked out - - in the interest of time -- suffice it to say they are, indeed, well conceived and they merit your strong support .. I would like to discuss many more important clinical aspects of problems which face us, but I realize that your patience should not be tried. I would certainly talk about alcoholism and urge you to markedly increase the budget for research and training to help with that scourge.. It attacks the high and the low, breaks up families, and distresses children in untold numbers., I would reiterate what I said to you last year, and earnestly seek your help in establishing laboratories to further the understanding of the phenomenon of depression, one of the most painful congeries of symptoms known to us.. I say this because usually there is no visible symptom which accounts for the pers on 1 s distress, and that makes understanding more difficult and the illness harder to bear. 15. Melancholy is a phenomenon as old as man. The question has been asked why so many great men have been melancholy. Some have lost their lives during periods of depression. I am sure you can recall the sad histories of some of them. Of all of the emotional illnesses treated by psychiatrists in the present culture, depressive phenomena are in the forefront. Depression 1s the psychiatric diagnosis made most frequently today .. The Medical World News, in a March issue, surveys the subject under the apt title 11 New Faces of Depression," and a sub-title, "An Old Syndrone with a 1968 Look. 11 The article begins with a quotation from the Greek biographer, Plutarch: "When a man is depressed, every little evil is magnified by the spectres of his anxiety. 11 Plutarch1 s observation is as apt today as when he made it 2000 years ago .. I think we are justified in bringing this subject to your attention again for several i~portant reasons: 1. The incidence of depressive phenomena. 2,. The basic scientists have gone far in the past several years in determining many of the chemical and physiological accompaniments of the illness,. 3.. The condition is eminently treatable today. Often self­ limited, the condition can be alleviated by drugs and other modern methods of treatment. Feelings of sadness, hopelessness or despondency., may arise due to adverse external circumstances in which the individual finds himself .. Whether the conditions be really overwhelming or whether for some reason the individual finds himself inadequate to deal with them, the resulting depression is the same. 16. Fortunately for most of us, our depressive feelings are only transitory and either disappear spontaneously or after we have worked out some type of positiive solutions to the problem responsible. These depressions are obvious and easily recognized, but there are others which are masked to the point where no one but an expert can detect their presence until a full-blown deep depression appears.. Here the situation is much more serious, the depressed mood becomes longer lasting, and the attitude of dejection and the train of symptoms which follow in its wake render the individual ineffectual. These depressions are the illnesses most difficult to bear, for unlike medical or surgical illnesses, there are no visible physical symptoms apparent to the sufferers or to others that might explain his distress. These depressive episodes must be differentiated from grief, a normal phenomenon,· and should not be confused with it. In grief the loss is personal, objective, external, and readily understandable.. The response it calls forth is realistic and proportionate to what has been lost.. Grief., which is the normal expression of sorrow and bereavement which follows the loss of a loved one, is self-limited and gradually subsides .. Psychotherapists call attention to the great effort expended by these individuals who feel that they do not deserve anything in their own right, but must continue to strive and achieve if they are to get someone to love them or to continue to love them. It has long been recognized that these good people are extremely vulnerable to loss of position or status or the loss of material possessions. They are vulnerable, too, to the decline of physical abilities essential to their continued achievement or even with 17. advancing age the loss of certain future possibilities of achievement. Examples of these situations are plentiful today in our period of merges, strict rules for retirement, and the pressures of our economic situation .. Children and adolescents may become depressed and some of their destructive behavior may mask a mild depression as they search for meaningful relationships. They are not our concern here., but we should mention that much of the apathy, boredom, and willingness to enlist in almost any cause except study in college students is of the same genre. The complaints that they don't know what they want to do, the lack of j interest in education in general, the feeling of the uselessness of it all, and the coupling of education and attainment with the older generations from whom they are separated, all may be due to underlying mild depressions. It is no longer easy for them to take a moratorium and drop out of college for a while to catch up with themselves, for the draft must be kept in mind_, Some of the students deliberately arrange to fail, which fact distresses their parents and brings their plight sharply into focus. Under these situations, the attractiveness of trying drugs in some form is apparent. They have heard of the pleasure of attaining a ''high" and they are influenced to try it by the pressures of their peers. If they are fortunate 1 the experience will be disappointing or scary; if it proves attractive, they will have some serious decisions to make. While it is true that so-called "pot 1 ' is n?t addicting in the physical sense, as are the narcotic drugs, 18. nevertheless, there is a psychological attractiveness to it and it is not at all the harmless substance that enthusiasts make it out to be. We have talked several times about depressions of middle life and earlier thought to be the _exclusive property of wo men and due to the 1 change of life. We decried both of these assumptio~s and noted the occurrence of depression in men a decade later, and suggested that the only relation to change which was present was the individual's inability to change in accordance with the surrounding changes which faced their age group in the present culture. We noted, too, that persons who were rigid, conscientious, and inclined to perfectionism, were vulnerable to depression in this period. They were not easily influenced even though circumstances around them were changing rapidly. These are usually fine people but their rigidity becomes a hazard when their external circumstances call for marked change and they are unable to comply. As to the reactions of older people to the present general unrest and rapidly changing cultural and economic environment, they are understandable. In the present era., with youth in the center of attention and in "children's crusades" in politics and the search for young people to occupy executive and top positions, men in the older age groups are understandably insecure. with Very often they find themselves unable or unwilling to keep up the pace and they withdraw, react in a depressive manner and become chronically ill. ,I 19. Mr. Chairman, if I have become too clinical in this presentation again, I assure you that it is my only competence. I chose this method of presenta- tion to you rather than repeat line for line the budget needs which has been done so ably by my colleague, Mr. Gorman. I do want to emphasize heartily, however, our agreement with him.. The mental health field has opened up.. It has great possibi,lities, and I know that you and your committee members will insist that it continue its activities.. The mental health of the community depends upon the health of its individuals, and the mental health of the nation depends upon the health of its communities. ADDENDA TO TESTIMONY Since this testimony was written, the United States Supreme Court ruled by a 5-4 decision that criminal punishment of a chronic alcoholic did not constitute a violation of the Eighth Amendment prohibiting cruel and unusual punishment. The decision strongly reenforces the importance of NIMH activities in the field of alcoholism. All nine Justices expressed dissatisfaction with the present criminal system of handling alcoholics., The majority ( 5 Justices) stated that, 11 The picture of the penniless drunk propelled aimlessly and endlessly through the law's 'revolving door' of arrest, incarceration, release and re-arrest is not a pretty one. 11 The minority (4 Justices) stated, "It is entirely clear that the jailing of chronic alcoholics is punishment. It is not defended as therapeutic, nor is there any basis for claiming that it is therapeutic ( or indeed a deterrent). The alcoholic offender is caught in a "revolving door" leading from arrest on the street through a brief unprofitable sojourn in jail back to the street and, eventually, another arrest. 11 These comments from the highest court in the U. S. further re enforce a major goal of the NIMH alcoholism activities, i.e. to develop appropriate social-medical alternatives to the present inhumane and ineffective system of dealing with homeless chronic alcoholics~ The growing number of community mental health centers present an unusual opportunity to assist communities throughout the country in establishing the network of services needed for the care and treatment of alcoholics. Addenda pg. 2 An important argument in the majority opinion is that current information about alcoholism and its treatment still is rather limited. Justice Marshall, speaking for the majority, describes the state of knowledge on the subject as "comparatively primitive. 11 This argues strongly for the expanding of current NIMH research activities dealing with the nature, causes and treatment of alcoholism. Another important argument of the majority is that facilities for the "treatment of alcoholics are woefully lacking throughout the country." This is cited by the justices as a reason for continuing reliance on the criminal system for handling chronic alcoholics Q Clearly the development of more adequate care and treatment services through the expansion of the community mental health centers program and other medical-social services - - is a major means of overcoming this lack. All nine of the Justices agree that alcoholism is a major medical-social problem. The majority opinion states that the "destructive use of alcoholic 11 beverages is one of our principal social and public health problems .. 11 11 The other four Justices describe alcoholism as a major medical problem. The importance of strengthening and expanding NIMH training programs 11 is emphasized by the majority's statement that there is an almost complete 11 absence of ... 9 manpower for the implementation of a rehabilitation program. While only a minority of the Court was willing, on constitutional grounds, to bar the criminal incarceration of chronic alcoholics for the offense of public drunkenness j all of the Justices agree~ that: Addenda pg. 3. 1). Alcoholism is a major medical-social problem. 2). Current criminal procedures are ineffective. 3). Current facilities for the treatment of alcoholism are inadequate .. 4). Further research is urgently needed on the nature, causes and treatment of alcoholism. 5). There is a severe shortage of personnel trained to work in this area. Nlr~{ FISCAL 1969 BUDGET INCREASES PROPOSED BY CITIZENS 1969 President's Citizens Bud~et Bud&£!._ $ 81.,159,000 $ 91,659,000 HOSPITAL IMPROVE'J:viENT 10,610,000 16,610,000 TRAINit~G 109,046,000 133,200,000 10,641,000 11,641,000 EJ\.RLY CHTLD CARE PROJECTS 14,500,000 14,500,000 DIRECT OPERATIONS 52,875,000 59,875,000 $327,4852000 TOTAL INCREASE REgUESTED - CITIZENS BUDGET $4-8 1654 2 000 cm1l•fUNITY l¼,.ENTAL HEALTH RESOURCE SUPPORT Construction Grants $ 15,000,000 $ 60,000,000 Center Staffing 64,300,000 70,300,000 Narcotic Facilities 8,000,000 8,000,000 TOTAL - CONMUNITY RESOURCES $ 87,300,000 INCREPhSE FOR co~~IDNITY RESOURCES $51,000,000 TESTIHOHY :BEFORE PUBLIC HEALTH SUBCOlJHTTJ1E or TIDTI :SILL H. :R. 2550, CITED AS THE tt2-:-ATI01TA1 ?]TtJROPSYCHIA 1I1RIC IIJSTITUTE ACT 11 Co;,_?tain Frnncis tT. Bra,celancl (l'IC), USFR Chief, IT erLTOJ?S?chiD,tr ic 3ran.ch Professional Division J3uronn of Eec1ici:1e .'.'\nCl Surcerzr ancl Lt. Oomclr. Eoua:rcl P. Rone (IIC), USJ.,TR Asst. Chief., Feurops;rchin:bric :Branch Profossion~l Division J3nreau of iiedicine r1,ncl Sm~ 6 er;,,r The opuuons nnc1 asrrnrtions con kdnocl heroin are the ·)rivo,te ones of the rn,.thors e,nc1. aro not to 'be con­ strued as official or reflecting the views of the :-:-av:r Do:r;nrt:rnnt or the r·ri,Yal Ser,rice as c, u1:-cole. There is little q_uestion of the merit of a :program which 0 )romises an all-out attack on the problems of 11ental illness and human behavior. These, as ·wel_l as others of our ·9ost-war :problens, have a cornnon denominator--the h1J1nan factor which req_uires r1uch stud;s, ancl constructive effort. Accelerated research ancl the ra1)id. acbrances which have co:---1e about in the fields of :,_1hysics, conmerce, an.cl chenistr:'" will oe of little good if l"<-11lJredictaole hu:.Ja11 :)ehavior is allov1ed re,;:ieatedl:r to lay waste our civilization. U~_) to noi:r the job of Psychiatry· has been to a~9:ply scientific t ech:aiq_ues ancl methods to the :wo7Jlems of nental illness and human behavior. Its task has been not only the reco{;n.i tion ancl treat:-1ent of the ;·Jentall:T sick l)l1.t also the cliscovery of 7Jetter ways ancl ueans to -:1revent these illnesses. Again and again the war has clemonstratecl that in orc.ler to uncl.erstand mental illness, ·1:1hat is first rec1uirecl is an u~1clerstancling of :--1en; how they live, ;,.,hat the;v 1:!ant from life, where they have cone from, and uhat tlleir lJackgro1mcls have oeen. llen clo not r;et Dentally sick flout of the blue 11 so to si-:>eak:; in a large neasure, t::i.eir illness or uell bej_ng cle·,:1encls u1on their relations to other nen. The ,,-rar I s smashing clinD.X a,t Riroshiua and Fagasaki hammered in to the consciousness of all men one irrefutalJle fact: More than ever before, ::1an I s very existence is clependent uqon his f ello1-rm1en. This reali zatio:1, :~;:ceat though it .is, is aot enough. Ways ancl neans have to be er eat ea. for better w1.clerstancling hi..tJa11 7Jehavior 2,nd doing sonething .::•,~Jout its training. It is tragically significtmt that our civilization founcl it easier to s·()li t an atom than it has to join nan 1Ji th man. - 2 - The ul tinate benefits of an increased unc1erstanding are iErJlicit in a progran as comprehensive as this. It is imperative that a central foundation be established tnon ·v,hich each acldi tional 'bloc~;: of knot:lec1ge can be laid. Ad11i ttecllzr the final goal is a long way off, l)1J.t it is well to rer..wm7Jer that there is no end without a beginning. There are some imnecliate and tangible retrards to be gained.. 3L1.t oefore i•re can hOJ?e to acco::::J1lish a full and corn1lete tLnc1ersta:1c1ing of tlie larc;er issu.es at staJrn, we ha7ire to a·,J1;raise our 1)resent statns. s -•·.I.. »·- There is a consicleralJle bloc}: of 01.u-- JO\mlr,.tion vrhich cloes not enjo;r nental health. This Oomr:ittee, in these sessions, ·will have -Jeen given clD-ta which will anpl~r testify to this in.dis~:?uta1)le fnct. ::Dae::.:. analysis which has ~Jeen mac1e clearl3r incl.icD,tes that rrnntal c1isease is. not restricted to any one group or any ~:?articular level in the nation. Still further, it is a-marent that nental clisease itself is onl;;r ~Jart of the ::1ental heal th \)roblern. The eJ<..1Jeriences of the Arnea. Forces show that 90<'~ of the \)S:.rchiatric problem is concerned uith nental disorders other tl1an insanity. Des~)i te the fact that as a gro1..y;, the Arr11ed Forces a:i.~e the most fit of the yoang adults of the nation, every branch of the Services has had its qu.ota of the m1stable, the enotional13r disord.ered ai1d the nentally ill. The psychiatric prolJlem ·:JGrvacles every as)ect of onr national life. a2.1d collectively these c1isorclers constitute the lnrc;est single 1;1edical pro7Jlen itrhich confronts the nation. The inven tor:r of the heal th of the nation I s man:')Otrer, which has -been made b:r the Selective Service System ancl the Medical Deparktent s of the Arnecl Forces, leaves no cloubt th2,t hoal th is a national resource - 3 - Li.Ore vital to our econon~r than coal or oil or chemical reserves. .AI1cl. yet it nust also 1Je recog:'J.ized that we have done little to conserire it. Ue have s·)8nt far less on mental hoal th research than vrn have in t}1e j_~esearch '."rhich led to the cl.evelo·}1r10nt of high octane gasoline, for instance. We haYe clo:-:i.e less on a national scale for the ·,Jrev.ention of ~]on tal illness than we have to Jrevent soil erosion a;1cl the wastage of our lmJ7Jer reserves. We have less coordinD,tion on a no:tional scale as coDcorns mental health than ·1:-re have in the mining and c1istriht1tion of coal. Tho analoc;ies and comparisons Di 6 ht be oxtencled. Dos:)ito tb.e excellent 7Jeginninc;s r.1ade 7Jy isolated ,?rivate gro1J~9s ancl agond.es anc1 even in smne instances, connnni ties, roal ·progress toward the goal of ncntal l--..oaltb. 1'12,S not 7JeeD. acco/rqlished "because of the li:~1itocl. scale ancl the lack: of coorcU- nation. of their endeavors. et10rnons ·)rofi t in )?Oolecl ~rrocluction ancl research. Funclo.montal rese[1,rch Partic11larl;s: in r:1atters as COJF;lex a..ncl- as far-roaching as rnontal :10.o.1tl1 is it c1osiraiJle to have tl10 aclvantagos of a colloctivo o::>1Jroe,1,ch ·by r.12.ny Jcrson.s an.d 1::;r01..1;1,?S~ The scalo on ul1ich this has °1Joen ·1ossiblo horoto- fo1~e has 'oeen lir.c1itocl. Fo,:,r tf any teaching institu.tions or COLETt.-::.1:i.ties or ·)hilanthropic forn1cl2.. tions havo been in a ·>osi tion to ei thor afforcl or cot1uancl. the :personnel ancl facili t;y- resources necessary for snch a:1 rn1d.ertaking. Pilot Btri_dies have givm loacls ul1ich indica;be the VD,lno of tho ::.rnro oxtensi ve roles 1Ji th ,.Lich ·;_)sztchiatry has to 7Je concornocl ootll insic1-o ancl.. outsic1e of the j'.1ei1tal hos-,)itals. Tho at1vancing ~1 rocro~rn of scio:n tific ueclicine has nade us a nation of 01a_or peo:!?l o--snl) ,ject to tJ.1e cliseases Elna. c1.isa1Jilities of olcl.or life. This chance in ovonts Tucnty or tvroi1t:r-fivo ~,oars ago by ancL larc;o nontol clisoaso wns ro;::;..},:rclocl as a problem of adolosconco. At tho prosent time, because.of the uar>::od s}1ift i:11 the ago char,:"1.,cteristics of tho concl"al ·)o- )ulntion, 1 J;he RolatiYel;y li ttlo research h2s oeon do:10 on tLis aspect uhich ::)T'o:·_1ii3os to ~)e a :1.ost i:1~,)ortant 11 ro:Jlom toj1 or fi:ftoon y02.,1"'s hon.co. The acloq_nacy of nontC1l ins ti tl1.tionalizatio11 for all ,:10:rtally cl.iscasocl :).::',tionts has to bo invosti~ated. Tho 6_cvolo~yu1ont of fostor hoDo care 2Dcl tb.o ~:iossi1JL1_ity of extra-institutional colonization. liavc to bo consiclol"ocl The on.tire natter of the 1_)rophylactic noasuros w:.dch can ·bo v.socl to ~,)rovont LJ.O:tl.tal illnoss brint;s to tho fore a nost Lroorta.nt )hPoso. Ps:rchiatry in tho f .J.tuJ:o uill not con.tent itsolf iJith tho 1 cLisoaso. The jol) of to:,-Jorrow 1s I's~rcl:.iatry is lar 6 o-scn,lo prove:1tion. testify- to t.'·ds) dicl not co:,'.10 DJ)out u:i1til thoro voro snch ncasu.ros as vaccination and ii:11:11.mizn,tion. In tho s2x10 :,·10..t E1or in \rhich lictLici:10 h1:ts '- 5 - vrill )Y ovont nnch rn1nocossary u.. :n.ha·-r::dnos s. Ho 7Jolievo tho:t, tho t ochTii quo o:f :•1.oro successful livinc::~ c2,11 7Jo tar:.[;>,.t. ,.-m11lcl nocossaril;;r have to 1Je comprohonsi vo. Aclul t c.1-11d cllilcl ,c;u.icLJnce ciin.ics, con::1sellin 6 n,ncl \)Tofossional e}rnistr1nce to tl10 con:rts, D..'}Cl conr.:l'J.l tc1,tion clLdcs 2or tho ·,-rn.blic schools 2.re sono of t:10 s1- .os:i.c1iar:t 1 Jrojocts ~1ich cone to mind. s;,cJ.1i~\tr:r trill requ.ire coorcli:1atimi ancl :,Joolccl rosom"cos,. ·mt t:::1.0 noods. Withont tr.0,inocl ,)oo·,;lo to clo tho job, t}1cso ·)lcX1S tb.is c"Lofici t uill ~Jo ovorco::-to. ion.ts 1 i:.1 ,., - b - is attribt. .talJlo too, faih;_ro of this first lino clofo::iso. 0 T~wro is ;1ocd. for consic:Lo1~c:::'v~Jlo rosoLtrch in toD,ching tochn.iqnos trhich vrill ovorco:10 this clofj_cioncy ,c'rhic:.1 is t:;ontJrallzr rococ;nizocl. T::10 u.se of trcinin~ ~otion ~icturos J.. s an o:::wxr) 1 o or ~ 0110 iTrorovecl. :.rnthocl ,.i:d.. ch deserves ox)loitntion. E):.:istinc trn,ininc; faciJ.itios are not acloq_1-.,-,. c1,to to T.10ot those L-,.:.1cc~i ,,to if wo ovor ho~o to ~rogross to a sol~tion. Ps:,c:.1iatric oclu.c,1,tion cannot lJe con.tent to con:fi:10 itself to or follow. Ps:rc}\iD,tric od.nc2,tion has to i:1.cluclo tl.:.o ,J1-1.1Jlic c\t lt:tr{;o. :1oocl. to lc10 1:r SLQlO ·basic ·;s;rc:.1.iatric fu.ncladcnta1s if they ,1,ro to :Jc I t i s :f ch 1 o t o io:.1s c..:to sick ·Jeo?1le, ont also tho/c a lar:::;e :oerco;1.tc.7,ge recover. llo as a, sorvicos o/ the tOff)Oraril:r cl.irrnblecl rn1d OVffl in s0:10 inf3tttncos the a :.:.igh ::)orcontngo of - 7 - tivo attit1.1clo 1;-rhich c OTJi1ntl.i tz;r scale. We havo no d.esire to ~:)rolon:; thir:i cl..ir.,cussio:1., t:io issu.oG r>,,t c::,,:,-1J_ corrcln:t o t:.10 in.c1i vich.1.r1l contri 7YJ.tions of i;:wln/cccl crou:)s 2,;1cl incli- Toso1..1.rcos. Tho scientific ~-Jototitio1itios of coorclin.r,,ted ri,ction in strc:.ttoa. in 0tJ.10r fiolcls; tho i):F)o-tus 1:.r:-.d.ch is 110,-:;clocl Li tho fiolcl of In order to bogin to solve tho rm:; oar ch on all l o-:rol s; 0-i::.;o:1.cios in ti:lCir uorthvrhile onclo,,1·-vors ii-,_ this i:'iolcl; con nccrue; su.ccossfcl cn,rr~r:i,1~ 011 of this uork vrill cl.ovalvo-­ tb.o tonchors. - 8 - To quote a stat011ont L1 tho 19L2:LJ: Rcr)ort of t:1~G Rockofollor Fo1..,1.:.1.cl.2,t ion: 11 It is not too Hu.ch to assort tlw,t in its nctnal ri,ncl ·1oto.11tial con.tTibution to General ::wdicino, to ocfo.cntion, to socioloQr, indeed to tho conoral business of livi~~,