I ‘ - __ X \C‘? 1;! \z “91‘ * .r' ,i . i , i ? _/.- Report of lhe Surgeon General’s Ad “00 Committee on Plamling for Mental Health Facilities @Adfiffl Va rum g C, .12: M IQ}: 3 r -_ 1V R-Lbi “1,. iii . ' " 0 0 ' .- g 9;” 2.»?24'423. Plamung 01 Famlluesém 11W? ‘5 ‘f fixiisugfiff Wufifia fi’ixéu-W’ifa ”I‘m-.30" ‘”- ‘* mwmx. nu 7&3qu- by; for Mental Health Services Gmlls Prinviples Action ('5. DEPAR'I‘HEN'I‘ (H9 lll-IAL'I'II. I?Il)l'('..\'l‘lU.'\'. AND \\ ELI-1U”) Public Health Svrviu- _.o« x“ as “9‘ Recommendations in Brief . . . GOALS ' To provide proper facilities for early diagnosis, intensive and continued treatment, and rehabilitation programs designed to restore the individual to his fullest mental, physical, social, and vocational abilities. 'To encourage the establishment of small community or regional facilities which eventually would replace the traditional large mental institutions. PRINCIPLES In planning for mental health facilities it is necessary to: ' Develop a comprehensive plan for providing mental health services throughout the State. ' Coordinate facility planning with other health planning programs. ' Collect data on current needs and available resources. ' Evaluate structural and functional adequacy of existing facilities. ' Develop a coordinated pattern of facilities and services. ° Use facilities at peak efliciency. ACTION In developing and implementing its Statewide plan, the State planning body should: ° Determine levels of overall need; survey avail- able resources; examine State population patterns and movement; establish logical service areas; and estimate remaining need. ' Evaluate existing legislation and administrative procedures and initiate steps to bring about con- formance with latest concepts. ‘ Develop a construction program for new facilities and the modernization of existing facilities. In programing needed mental health services, emphasis should be placed on: ' Prevention, early treatment, rehabilitation, and aftercare. ' Continuity of treatment and care. ' Multiple services at one location. ' Specialized services as well as generalized care. ° Inpatient care in small flexible units. ' Psychiatric services in general hospitals. ° Rehabilitation for the mentally retarded. ' Proximity to the population to be served. ' Research and training. ° Develop a priority system designed to provide needed facilities. ° Consult local planning groups and secure their participation in assessing community needs and in implementing the plan. ' Make determinations concerning the construc- tion of specific facilities in terms of operating program, proposed location, design, and cost. ° Initiate action programs to stimulate support for mental health programs and facilities. Report of theISurgeon General’s Ad Hoc Committee on Planning for Mental Health Facilitifl/ Planning of Facilities for {Mental Health Services/j l "l \ BET \ Ti pnl' I APR 10 1961 JNVRW (+111 _1.rrpr 1:1 JANUARY 1961 US. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE . Public Health Service AN AD 1100 COMMITTEE on planning for mental health facilities was named in August 1959 in response to a recommendation adopted at the 1959 conference of the Surgeon General with State and Territorial Mental Health authorities. The recommendation follows: That the Public Health Service be encouraged to establish an ad hoc committee of State Mental Health and H ill-Burton authorities to work with the Public Health Service during the next year in formulating treatment and administrative guidelines which could be utilized by State agencies in developing a statewide plan for mental health facilities. PUBLIC HEALTH SERVICE PUBLICATION NO. 808 For sale by the Superintendent of Documents, U.S. Government Printing Oflice, Washington 25, DC. Price 40 cents. Pt} 7% The Surgeon General’s ' 7 Ad Hoc Committee on Planning for Mental Health Facilities Us" r7913 HYBUC HEALTH UR? I v J AGK C. HALDEMAN, M.D., CHAIRMAN Assistant Surgeon General Chief, Division of Hospital and Medical Facilities Public Health Service JOHN J. BOURKE, M.D. Assistant Commissioner Division of Hospital Review and Planning New York State Department of Health BERNARD BUCOVE, M.D. Director of Health Washington State Department of Health DALE C. CAMERON, M.D. Assistant Superintendent Saint Elizabeth’s Hospital Washington, DC. TERREL O. CARVER, M.D. Administrator of Health Idaho Department of Health R. L. CLEERE, M.D. Director of Public Health Colorado State Department of Public Health HIRAM W. DAVIS, M.D. Commissioner Virginia State Department of Mental Hygiene and Hospitals HERBERT G. FRITZ Chief Division of Hospitals Maryland State Department of Health STEWART T. G‘INSEERG, M.D. Commissioner Division of Mental Health Indiana State Department of Health ROBERT T. HEWITT, M.D. Chief Hospital Consultant Services Community Services Branch National Institute of Mental Health Public Health Service MRS. LOUISE W. MASTERS Director Division of Hospital Facilities New Mexico Department of Public Health HAROLD L. McPHEETERs, M.D. Commissioner Kentucky State Department of Mental Health Contributing Stafl DIVISION OF HOSPITAL AND MEDICAL FACILITIES John D. Thewlis J.J.Ozog Betty Watt Brooks Gruine Robinson NATIONAL INSTITUTE OF MENTAL HEALTH Edward J. Flynn 431 ACKNOWLEDGMENT The committee wishes to gratefully acknowledge the invaluable contribution to this report made by State Hospital and Medical Facilities (Hill-Burton) Authorities, State Mental Health Authorities, and representatives of the eight Public Health Service regional offices. At a joint conference of these groups held in Washington on January 5, 1961, it was agreed that the report would serve as a useful guide for developing more adequate mental health facilities. At the same time, however, a number of constructive suggestions were offered regarding certain modifications which would strengthen the report and make it more universally applicable. These were carefully considered by the committee and a number of alterations were made to the original text. The committee feels it was indeed fortunate that a review of this nature was made possible prior to the official publication of the report. Because of the progress made in recent years in coping with the problems of mental illness, it is of utmost importance that these advances be further extended through the combined efforts of those particularly knowledgeable in the fields of hospital facilities and mental health. Leroy E. Burney, MD. The Surgeon General Public Health Service Dear Dr. Burney: Transmitted herewith is the report “Planning of Facilities for Mental Health Services” prepared at your request by the especially—designated ad hoc committee appointed to develop principles for meeting the Nation’s growing need for more adequate mental health facilities. The committee, in examining the reported mental bed shortages through- out the country, finds that the solution to the problem does not simply lie in providing additional beds. Instead, an overall examination must be given to the changing concepts in the treatment and care of the mentally ill so that facilities may be planned in such a manner that they will provide an appropriate setting in which to best execute the latest treatment methods. Major recommendations of the committee include: 1. That community-based mental health facilities be established as part of a coordinated system of statewide health services. The ultimate objective would be to provide proper facilities for early diagnosis, intensive and con- tinued treatment, and rehabilitation programs designed to restore the individual to his fullest mental, physical, social, and vocational abilities. Construction and expansion of large mental institutions should be strongly discouraged, and State activities should be directed toward replacement of existing institutions of this type by smaller community or regional facilities offering a wide spectrum of services. 2. That each Governor consider taking whatever steps are necessary to stimulate the development of a comprehensive plan for mental health facilities. He may wish to designate an existing agency or appoint a planning body comprised of representatives of professional and lay groups concerned with the many-faceted problems of mental health. 3. That States enact enabling legislation and provide additional financial support to stimulate the construction, equipment, and maintenance of needed mental health facilities approved by the planning body. The committee hopes that, after consideration has been given these rec- ommendations as well as other proposals in the report, necessary steps will be taken to encourage all public and private agencies concerned to combine forces in an attempt to meet the Nation’s mental health facility needs. Sincerely yours, CW JACK C. HALDEMAN, M.D., Chairman. January 1961 Contents Acknowledgment ............... Transmittal Letter .............. -------- ........ ........ Chapter I. Current Problems and Treatment Trends ...... Adult Mentally Ill ............... Extent of the Problem ........... Trends in Care, Treatment, and Rehabilitation Emotionally Disturbed and Psychotic Children . . Extent of the Problem ........... Mentally Retarded Children and Adults . ..... Extent of the Problem ........... Trends in Care, Treatment, and Rehabilitation Related Social Problem Areas . . . . . ..... Alcoholism .............. Extent of the Problem ........... Treatment Programs ...... . ..... Drug Addiction ............ . . . . . Extent of the Problem ........... Treatment Programs Juvenile Delinquency . ...... . . . . . . . Extent of the Problem Treatment Programs ...... Aging .............. . . Extent of the Problem ...... Trends in Treatment ......... Related Aspects of the Problem . . . . . . . Available Facilities . . . ....... . . . . . ........ ........ Chapter II. Principles for Developing a Statewide Plan ..... The Planning Group ...... . . . . . . . . Planning Principles ............ . . . Planning Procedures .............. Page iv coax: \I 14 14 14 15 15 16 18 18 18 19 19 19 19 19 19 20 20 20 21 21 22 25 26 30 viii Chapter III. Factors Impeding Effective Implementation of the Plan . . . .................... Legal and Administrative Considerations Financial Problems. . . . . . . . ....... Personnel and Staff. . . . . . . . . . . ..... Social Attitudes Chapter IV. Implementing the State Plan Stimulating Interest Financial Basis for Implementing the Plan Legislative and Administrative Program . Appendix Tables . References . Table Tables Number 1. Psychiatric Hospitals and Institutions for Mentally Deficient, by Type of Ownership, United States and Territories, 1959. . 2. Number of Psychiatric Hospitals and Beds, by Size of Hospitals, United States and Territories, 1959 ..... . . . . .. 3. Number of Institutions and Beds for Mentally Deficient, by Size of Institutions, United States and Territmies, 1959 . . . . . . 4. Number of Psychiatric Hospitals and Beds, by Size of Community, United States and Territories, 1959.. . . . . . . ...... 5. Number of Institutions and Beds for Mentally Deficient, by Size of Community, United States and Territories, 1959 . . . ...... 6. Mental Beds in General Hospitals, by Ownership, United States and Territories, 1959 . ...................... 7. Mental Beds in General Hospitals, by Size of Hospitals, United States and Territories, 1959 . . . . . . . . . . . . 8. Mental Beds in General Hospitals, by Size of Community, United States and Territories, 1959 . . ..... . . . . . . . . . . . 9. Existing Acceptable Mental Hospital Beds in Each State and Pos- session, and Beds per 1,000 Population, 1959 Page 35 36 38 39 41 41 42 43 45 55 46 47 47 48 48 49 50 51 53 Summary and Conclusions THIS REPORT presents the findings of an ad hoc committee appointed by the Surgeon General to develop a basis for improved planning of mental health facilities throughout the Nation, As a backdrop for its deliberations, the committee was particularly mind- ful of the inadequacy of many existing State facilities as well as the lack of long-needed community-based programs and services. The committee observed that in spite of recent dramatic advances in the treatment of mental illness, little progress has been made in providing the various types of facilities which would offer the most appropriate environment for carrying out the latest treatment methods. The inadequacy of present facilities is considered one of the primary impediments to more rapid progress in the treatment of mental illness—one of the Nation’s major public health problems. PURPOSE OF REPORT The primary purpose of this report is to offer a guide to States in developing adequate mental health facilities.* While the committee fully recognizes that facility planning cannot be carried out in a vacuum, no attempt is made here to answer all questions in all areas of mental health programs and services. The report, however, does strongly emphasize the need to consider all facets of mental health services and programs including treatment, care, and rehabilitation before embarking on a construction program. It also stresses the need to develop a plan which is comprehensive and is coordinated with other health planning programs in the State. In addition, recognition should be given to the fact that community mental health services provide an excellent training ground for professional and ancillary personnel. ROLES MUST BE CLARIFIED The committee recognizes that each State must approach its planning in- dividually. To accomplish this, clarification must be made of the respective roles and responsibilities of local, State, and national agencies and groupsf (both voluntary and governmental) for planning, administration, and financ- ing of community mental health facilities and services. Because of the wide divergence of health facility problems and the media through which necessary *These refer to the entire spectrum of facilities for all mental disorders, including mental retardation. TWherever local, State and Federal agencies or groups are mentioned in this report, both voluntary and official organizations are implied. 583652—61—2 action may be achieved in the different States, the priniciples and methods of procedure proposed in the report are intended to be sufficiently flexible to meet a variety of different and changing patterns. INCREASED COMMUNITY RESPONSIBILITY In reviewing current treatment trends, the committee noted that during recent years there has been an increasing tendency for communities to assume the responsibility for the care, treatment, and rehabilitation of the mentally ill. This trend has indicated the need for a wide spectrum of community services with increasing emphasis on the prevention of mental illness and the promo- tion of mental health. The various services must be flexible enough to be adapted to new concepts of prevention, care, treatment, rehabilitation, and aftercare related to many types of patient problems. A continuing need exists for expanded research, increased training, and the exploration of new methods for improving services in the areas of diag- nosis, care, treatment, and rehabilitation and in the prevention of mental ill- ness and the promotion of sound mental health. As improved community facilities and services become available more personnel skilled in psychiatric care will be needed for these programs. The mental health problems of the aged, because of the continuing in— crease in the number of people 65 years of age and older, must be given special consideration in the development of an adequate program for mental health facilities and services. These needs should not be separated from overall community planning for this age group. MUST DETERMINE GAPS What are some of the steps which must be taken if more adequate facilities are to be provided for the mentally ill? In attempting to answer this question, the committee first examined the scope of the problem, latest concepts in treating the mentally ill, and the ex- isting gaps from the standpoint of facilities. These findings are presented in chapter I. The remaining chapters of the report present guidelines which may be followed in developing a statewide plan, removing existing barriers, and im- plementing the plan. The committee, in determining the steps to be followed, emphasized that in attempting to rectify the mental health facility problem, activity must be carried out on many fronts simultaneously. Some functions which require continuing attention include the evaluation of existing facilities and activities involving the stimulation of health education programs and the revision of legislation where needed. The State plan itself should be sufficiently flexible to be amenable to changing conditions. Although this report is intended as a guide for developing more effective mental health facility planning, it should be emphasized that as scientific ——fl knowledge in the field of mental health increases and as more experience is accumulated, these plans may be subject to modification. RECOMMENDATIONS Establish authoritative planning body As the initial step in developing a statewide plan and program the committee recommends that the Governor of each State consider taking Whatever steps are necessary to stimulate the development of a comprehensive plan for mental health facilities. He may wish to designate an existing agency or appoint a planning board, broadly representative of professional and lay groups con- cerned with mental health, to develop and implement the plan. The function of this agency or planning board would be of a continuing nature. Special funds would be required so that suflicient staff may be maintained to assist the State agency or planning board in carrying out its activities. The agency or planning board should establish liaison with other State, local, and areawide planning bodies in order to coordinate planning activities. Planning principles A prerequisite of sound planning is the establishment of guidelines or prin- ciples so that action to be taken will lead to the accomplishment of overall objectives. Some of these major principles (see chapter II) include: 1. Planning activity should encompass the entire complex of mental health facilities and services required for the State. Consideration must be given all existing and proposed services and facilities, both public and private. 2. Facility planning should be coordinated with other planning programs in the field of public health and mental health. This is necessary in order to avoid possible divergent planning or unnecessary duplication of services. 3. Inpatient psychiatric care should be provided in small, flexible units. Construction and expansion of large mental institutions should be strongly discouraged* and State activities should be directed toward replacement of existing institutions of this type by smaller community or regional facilities offering a wide spectrum of services. These include activities such as out- patient and emergency services through hospital clinics or mental health centers, increased use of general hospitals for the treatment of psychiatric patients, half-way houses, day and night hospitals, and nursing homes. The existing large mental institutions, however, should not be allowed to deteri- orate. So long as these large institutions must be continued, vigorous measures should be taken to alter their administration to allow for the maximum possible implementation of modern concepts of treatment and care. Consideration should be given to the development of alternate uses, to the extent feasible, as the need for domiciliary care in these institutions decreases. 4. Facility planning should incorporate the concepts of progressive pa- ‘New psychiatric hospitals should not exceed 600 beds. tient care,* flexibility of design to permit easy conversion of space to other uses, and proximity to a general medical facility or medical complex as well as the population being served. Provision should be made for early diagnosis, intensive treatment, long-term care, and rehabilitation. 5. Communities with general hospitals should be encouraged to develop psychiatric services. Ideally, every community with a general hospital should have at least minimal psychiatric services. Developing a statewide plan The State plan should be based upon a comprehensive survey of existing facili- ties and services, and the determination of remaining need. In determining need, factors which must be given special consideration include newly proposed community mental health activities, traditional mental health services, State population patterns and movement, and logical service areas. Reliance should no longer be placed on reported mental bed shortages based on bed-population ratios which may no longer be realistic. Other steps which should be taken in developing a State plan include: Evaluate existing legislation and administrative procedures and take ac- tion to bring them in conformance with latest concepts of treatment and care. Develop a construction program for new facilities and the modernization of existing facilities. (This should be coordinated with the State Hill-Burton agency to assure its incorporation in the official State plan of that agency.) Develop a priority system designed to provide facilities in order of greatest need. Consult local planning groups and secure their participation in assessing community needs and in implementing the plan. Make determinations concerning the construction of specific facilities in terms of operating program, proposed location, design, and cost. Initiate action programs to stimulate support for mental health programs and facilities. Proposed construction which does not conform with provisions of the State plan should be actively discouraged. Removing existing barriers The State’s designated planning authority should appraise political, social and economic factors relating to mental health and determine the feasibility of eliminating any barriers which might impede implementation. Factors to be considered include outdated legislation and administrative procedures, financ- ing, availability of qualified personnel, and professional and social acceptance of the proposed program. 1. Legislation and administrative procedures.—Areas requiring careful scrutiny include the possible need for modernization of admission and dis- charge requirements; means for stimulating local responsibility for community mental health programs and facilities; the need for more appropriate facilities 'In keeping with this concept, patients are grouped according to their degree of illness and the need for care. Progressive patient care is frequently described as “the tailoring of hospital services to meet the patient’s needs.” and services for the mentally retarded and the aged; and the possibility of coordinating existing specialized community programs under an authoritative local planning body. 2. Financing—The various sources of financial assistance which might best stimulate the needed construction or modernization of mental health facilities must be evaluated. Emphasis should be placed upon developing a cooperative system of voluntary and official local-State-Federal financing of construction costs, and upon the enactment of appropriate community mental health service legislation to provide State assistance in constructing and oper- ating community-based facilities. The possibility of increased assistance to the mentally ill under State welfare laws should be explored. As for Federal action, the committee recommends that the Department of Health, Education, and Welfare give consideration to the proposal to Congress of the following: a. Modification of Hill-Burton legislation to provide a categorical grant to States to further assist in implementing the program. b. Modification of existing Public Assistance provisions of the Social Se- curity Act so they do not discriminate against persons with any type of illness, mental or physical. (The State Mental Health Authorities approved a similar recommendation at their annual conference in January 1961.) 3. Personnel—The proposed program should provide for a practicable method of assuring the availability of adequate and competent personnel. Experience in the Hill-Burton program has shown that the availability of adequate facilities has attracted vitally needed physicians and board-qualified specialists to rural areas. 4. Social acceptance—An evaluation should be made of the readiness of the community to accept the programs being developed and a continuing education program should be undertaken to keep the public informed of the activities of the State and local planning bodies. A concerted effort should be made through health education and publicity methods to acquaint the public with the problems of mental illness and the most effective methods for coping with these problems. Implementing State plan Programs to implement the State plan will vary, depending on the indi- vidual problems and needs in each State. Some of the activities which all States would have in common would be aimed at (1) stimulating public interest, (2) providing adequate financing to stimulate construction where needed, and finding means of financing the cost of services, including third- party payment systems, (3) obtaining and training specialized personnel, and (4) developing an adequate legislative program covering such areas as admis- sion and discharge procedures, the transfer of patient records, the care of the mentally retarded and the senile aged, and State and local assistance to community mental health facilities and services. The committee presents this report with the hope that it will provide a basis to the States for developing more adequate long-range planning for the care of the mentally ill. Chapter I Current Problems and Treatment Trends MENTAL ILLNESS, when Viewed from the per— spective of community needs, presents a prob- lem of staggering proportions in terms of the numbers of people affected and the costs of services. If the problem is to be reduced, it is imperative that efforts be directed toward the promotion of sound mental health and the pre- vention of mental disorders. In addition, em- phasis must be placed on expanded research, increased training of personnel, and continued exploration of new methods of prevention as well as care, treatment, and rehabilitation. An adequate program for the promotion of mental health and the prevention of mental illness should involve activities to increase pub- lic understanding of factors which affect the well-being of individuals of all ages. Attention should be directed to the removal of conditions that produce excessive stress, frustration, or de— privation. Emphasis also should be placed on personality development in the child and the strengthening of emotional resources in dealing with day-to-day problems. The program should be carried out through many services including prenatal clinics, pre- school clinics, schools, industries, and private and public community agencies and institu- tions. Among those participating in these pro- grams would be physicians, clergymen, teachers, social workers, and other persons in a position to advise, guide, or influence the adjustment of the individual to his daily life situation. Research is now underway to determine ways in which these services can be more effec- tive in prevention, early identification, treat- ment programs, and more efficient utilization of personnel. Mental illness can be categorized into sev- eral broad general classifications. Described in this chapter are (1) the adult mentally ill; (2) emotionally disturbed and psychotic children; (3) the mentally retarded, both children and adults; (4) related social problems including alcoholism, drug addiction, and juvenile delin- quency; and (5) aging as it relates to the need for special mental health services. In each category the scope of the problem is reviewed along with its mental health compo- nents and trends in treatment that have impli- cations for the future planning of mental health facilities. The kinds of service applicable to several categories will be described briefly under the programs for the adult mentally ill and reference will be made to them later when they are applicable to planning for other categories. ADULT MEN TALLY ILL Extent of the Problem The resident population in public mental hos- pitals in 1959 totaled 542,721, approximately the same as the number of patients in all gen- eral hospitals. During that same year main- tenance expenditures for mental hospitals reached $854 million. Since 1956 there has been a slight downward trend in the number of resident patients in public mental hospitals at the end of each year. In 1959, for example, there were 2,100 fewer patients, or a decrease of 0.4 percent from the 1958 total.1 Nora—A11 references appear on p. 55. This development has come about even though there has been a steady increase in admissions to public mental hospitals since the mid 1940’s. For example, total admissions in— creased by 6.7 percent between 1958—59. The number of deaths in such hospitals has fluctu— ated over a period of time indicating a 3.3 per- cent decrease betWeen 1958—59, while between 1957 ~58 there was a 9.5 percent increase and an 8.4 percent increase in 1959—60. Thus, the drop in the number of resident patients in hospitals must be interpreted in terms of the combined effects of admissions, net releases, and deaths. The extent of the problem of adult mental illness is not restricted to those patients served by public mental hospitals. Estimates pro- jected from sample studies indicate that ap- proximately 17 million people need some type of psychiatric care. As services and facilities become available, more needs become evident; thus, it has been found that geographic vari- ations in reported rates of illness are often merely a reflection of the extent of services available and utilized in different areas. The Joint Commission on Mental Illness and Health estimates the direct costs of mental illness to the American economy to be in excess of $1.7 billion a year.2 In addition, there are many indirect costs associated with loss of in- come and productivity as well as human suf- fering, not only for the individual, but for his family and other associates. The rates of admissions to public mental hospitals by States during 1959 ranged from a high of 196.3 per 100,000 population to a low of 59.9.1 These rates are influenced by such fac- tors as policies regarding admission, the avail- ability of hospital facilities, the existence of other resources, community attitudes and the level of tolerance within families and commu- nities, public education, the age ratios in the population, and certain cultural, economic and social patterns. There seems to be no valid basis for assuming that the need for psychi- atric services indicates any Wide variation by geographic area; rather, studies have shown high consistency in the rates of specific cate- gories of mental illness throughout the general population. Admission rates tend to increase 8 with the number of beds available for the care of psychiatric patients. Similarly, the annual cost of care for a patient in a mental hospital as reported by the States for the year 1959 varies from a high of $1,799 to a low of $460. This is related to methods of accounting and has little validity in terms of cost evaluation. It has even less value when related to concepts of care, treat- ment, and rehabilitation. Unfortunately, data are not available on the cost of care per indi- vidual as related to time in residence and com- pared with the costs of treatment in different settings. Any cost-of-care evaluation is signifi- cant only as related to total case cost and the probability of successful treatment. Trends in Care, Treatment, and Rehabilitation The burden for the care, treatment, and re- habilitation of the mentally ill has been tradi- tionally borne by the States; however, in recent years, the local communities have begun to ac- cept this responsibility. As a result, local community mental health boards have been es- tablished either through legislative or admin- istrative action. These boards are concerned with the development of local mental health programs encompassing prevention, commu- nity education, early diagnosis and treatment, care of the acute and chronically ill, and after- care services for those requiring temporary hospitalization. In this perspective the tradi- tional mental hospital becomes only one of the resources needed. To fulfill its increasing number of functions most adequately, the hos- pital must be an integrated part of a coordi- nated program of facilities and services. The acceptance by the community of re- sponsibility in the area of mental health has resulted in the development of concepts centered on the desirability of a multiple number of services to meet the varying needs of individuals. Realistic planning must incorporate such fact- ors as the population characteristics, economic support, local cultural patterns, and the avail- ability of professional staff. The same services probably cannot be made as readily available in some types of com- munities as in others, and some types of serv- ices will of necessity be located outside the community. In all instances, however, the needed services should be based as close to the population to be served as practicable. In this way the patient has the benefit of all the re- sources of the community as well as the thera- peutic value of the community itself in terms of the ease of maintaining family contacts and the constructive use of as much community freedom and activity as he is able to use effectively. Isolation is not just a question of physical distance but is related to the entire concept of community-hospital coordination in meeting the needs of the individual patient. In some areas and for some services a patient can travel to and effectively utilize services that are re- moved from his immediate physical environ- ment. These facilities and services, however, should be integrated with local facilities and services to ensure their most effective use in a comprehensive pattern of care related to the needs of the patient. One method of integrating local services with those at distant locations is by providing the family physician with greater opportunity for experience and training in psychiatric skills. Such training would make it possible for the physician to treat some cases of mental ill- ness effectively at community level and to cos ordinate his services with other needs of the patient. The family physician can participate in management of psychiatric emergencies, pre- admission services, and follow-up care. Trends in the treatment and care of the mentally ill indicate the need for a wide spec- trum of public and private services and facili- ties. These should be designed to provide pre- vention, early diagnosis and treatment, outpatient care, part—time or short-term hospital care, long-term treatment in a specialized men- tal hospital with a modernized program, and community-based programs of rehabilitation and aftercare. Special emphasis should be placed on flexibility as related to both present and future use. 583652—61—3 Mental Hospitals In programing for mental health services, pro- vision should be made for continuity of care based upon meeting the individual needs of patients at various stages of illness. The men- tal hospital must be coordinated with other com- ponents of the community program such as clinics, aftercare, and allied services for the patient and his family. These community serv- ices should be focused on prevention and treat- ment of mental illness and the return of the patient to his home or a community—based re- source as soon as such return is medically feasible. A more cheerful and hopeful atmosphere exists in mental hospitals today than ever be- fore in history. Although admissions are in- creasing, the total number of patients resident in State mental hospitals has been decreasing slowly in the last few years. The full meaning of these decreases is not known since both dis- charges and deaths have increased. Efforts have been renewed to discharge patients as soon as possible and to design re- habilitation programs within the hospital for patients who require a longer period of treat- ment. A recognized first step in producing a ther- apeutic environment in the hospital is to ascer- tain whether anything of an antitherapeutic nature exists. Most authorities here and abroad feel that the large mental hospital is apt to be antitherapeutic. While in many instances eco- nomic considerations preclude the immediate elimination of these hospitals, additional con- struction of such facilities should not be pro- gramed. Existing hospitals will, of necessity, provide an essential service for many years. Efforts should be made, however, to alter their administration to allow for the maximum pos- sible implementation of modern concepts of treatment and care. Establishment of small treatment units, providing closer relationship and understanding between personnel and patients, has already been undertaken in many hospitals. The increased emphasis on the therapeutic use of personnel and other treatment innova- tions, including the tranquilizing drugs, has 9 made a great difference in the care of the so— called disturbed patients. Episodes of dis- turbed behavior occur but are treated more effectively. The old “disturbed” ward is al- most gone. In hospitals of the future, security will be a minor issue as compared with what it has been in the past. With the increased emphasis on social psy- chiatry, the philosophy that patients are able to respond positively to greater freedom has resulted in unlocking more wards throughout the country. Protagonists of the open hospital theory contend that it reduces administrative problems, and improves the attitudes of patients and personnel, and provides a better therapeutic setting. In addition, locking up patients is con- sidered inhumane and the cause of considerable disturbance and chronicity. If patients are al- lowed more freedom it becomes imperative to provide activities for them. These needs must be considered in developing hospital design. The open hospital concept involves much more than the unlocking of doors. It requires intensive programing and realignment of staff duties to offer the patient a variety of activities and services structured to meet his individual needs and his capacity to handle increasing amounts of freedom of movement in progress- ing toward treatment goals. Programing fre— quently involves an increase in occupational and recreational therapy, educational planning, group therapy, and other constructive activi- ties within the hospital setting and in the community. General Hospitals Traditionally, there has been a wide separation in the treatment of the mentally ill and the physically ill patient. Twenty years ago only 48 general hospitals in the United States were admitting psychiatric patients. In 1957 some 515 general hospitals were known to admit mentally ill patients for diagnosis or treatment regardless of whether they maintained separate units for such patients. Reports from 381 of these 515 general hospitals indicate that during that year approximately 183,000 patients were 10 admitted for psychiatric treatment.3 In 1959, 269 non-Federal general hospitals had psychi- atric units of at least ten beds and provided a total of 15,306 psychiatric treatment beds. This expansion has been both a cause and a result of more psychiatrists moving into prac- tice in communities and obtaining staff appoint- ments in general hospitals. Factors in this trend of greater hospital utilization have been the improvement in treatment techniques, the increased experience and confidence of psy- chiatrists and other physicians that patients can be treated in general hospitals, and the in- creased understanding and leadership of hos- pital boards and administrators. The length of hospitalization is usually short and no com— mitment is involved, so that there is less social disruption for patients and their families. Pa- tients are often more amenable to being ad- mitted to a general hospital than to a mental hospital, and their attitude is frequently more favorable for treatment. Early diagnosis and intensive therapy at the general hospital may eliminate the need for many patients to be transferred to large State mental hospitals. Several States are experimenting with subsidizing the diagnosis and treatment of patients in general hospitals with psychiatric services. Other ex- periments include the admission of all mentally ill persons from a specific area to a diagnostic psychiatric service to determine the feasibility of local care for all mentally ill. There is already abundant evidence that psychiatric services should be encouraged in general hospitals. Such services can contribute substantially to the entire program of the hos- pital for all patients and provide improved integration of staff and services in many aspects of hospital planning for improved patient care. The advisability of integrating care and treatment of the physically and mentally ill is still being studied. Some hospitals have already begun experimenting in this connection. Day Hospitals, Night Hospitals The conventional outpatient treatment of one hour in a day, successful with many mental patients, is often not enough for the psychotic patient and for many neurotic patients. The needs of these patients may be met by the day or night hospital which can be operated as a part of the program of a general hospital, a community mental health center, or in conjunc- tion with other community facilities. Patients are in these hospitals for a varying number of hours during the day or night and then return to their home or place of employment for the remainder of the 24 hours. Diagnosis, treat- ment, and rehabilitation are functions of the day or night hospital. Various kinds of ther- apeutic activities may be included. The program of the day or night hospital can be extremely flexible in services offered and the amount and intensity of patient care. Some patients may have daily appointments and some may come only when they feel the need. Ex- perience has indicated that day or night hos- pitals can effectively sustain some mental pa- tients in the community as an alternative to full- time hospitalization. Halfway Houses The trend toward expediting the return of the patient to the community has necessitated the development of improved aftercare programs. An outstanding example in this area is the halfway house. There are many variations of programs included in this category. In gen— eral, however, they are planned as transitional programs for persons who no longer require hospitalization but are not yet ready to resume independent living. Residents live with other patients under some supervision in this transi— tional dwelling, moving back into the commu- nity gradually by reestablishing relationships through employment, social and family activ- ities, and recreation. In practice, halfway houses vary consider- ably in organization, programs, and auspices. For example, one halfway house is established specifically to find work for patients. Another provides not only supervision and social activi- ties but also psychiatric treatment. Halfway houses in the community may be organized under official or voluntary auspices. Some are developed under the supervision of the mental hospital and may even be located in a ward of the hospital. In such instances the hospital regulations are liberalized with regard to this ward. Patients are placed more on their own responsibility with regard to movement in and out of the hospital and their activities within the hospital. Definite rehabilitation programs are organized for the patients and they are en- couraged to become a part of community life. Case Work, Family Nursing Service, Foster Care, F amily Care Increased emphasis is being placed on pro- grams and services focused on retaining the mentally ill or emotionally disturbed patient in a home situation when this is indicated as desirable for the patient. As stated previously, many therapeutic factors exist in the home and community which can favorably affect the pa- tient’s potential for recovery. Planning for the individual should in- volve close coordination and communication between those providing psychiatric treatment and the agency sponsoring the home care as- pects of service. There must be careful evalu- ation of the family situation and the patient’s needs. The family may require help in under— standing the patient and his needs. Further- more, the family may also need help in provid- ing the services required by the patient. Several situations may arise in which either foster care or homemaker services are feasible in patient planning. These services may be provided for (1) children and other family members while the mother is receiving treatment during an acute phase of illness or during periods of extended hospitalization, (2) the mentally ill patient as a part of home care, (3) the discharged patients who Will need as- sistance in returning to their homes and resum- ing their responsibilities as homemakers, and (4) the senile patients requiring a certain de- gree of psychiatric supervision and care in their homes. Community health and social agencies often offer services to patients and families be- fore, during, and after hospitalization. These 11 services should be coordinated with those pro- vided by the hospital staif, local physicians, and employment, educational, and vocational rehabilitation agencies. Social workers on the hospital staif and in local public and private agencies, public health nurses, and visiting nurses are the usual sources of these needed services. Sometimes more than one community agency may be in- volved. To ensure continuity of care and to avoid unnecessary duplication, these services should always be carried out on a coordinated and cooperative basis. Nursing Homes Increasing use is being made of nursing homes as a resource to retain the less disturbed patient in the community or to expedite his return to the community after hospitalization. Services in these facilities range from complete bed nursing care to a variety of programs for the ambulatory patient who requires less super- vision and care. In many instances there is little difference between the patient population in nursing homes and that of State hospitals. Frequent review of the patient popula- tion is necessary to establish the level of need of those being served in the nursing home. It is imperative to avoid the possibility of the nurs- ing home patient being overlooked and retained in a facility not appropriate for his individual situation. Nursing homes should be planned to pro- vide facilities and programs ranging from day care service for ambulatory patients to com- plete 24-hour bed care. In some States and areas, it is practical to consider specialized psy- chiatric nursing homes equipped and staffed to provide intensive care for the mentally ill. In other situations it may be feasible to provide additional services to generalized nursing homes to better enable them to meet the needs of the mildly disturbed patient who otherwise would need to be transferred to a specialized nursing home. The nursing home located near the patient’s home and community resources can be a very valuable segment of the spectrum of community services needed to provide con- tinuity of patient care. 12 Outpatient Clinics Clinical facilities or mental health centers pro- vide services which enable the mental patient to remain in the community while receiving care on an outpatient basis. During recent years such services have been increasing at a rapid rate and have demonstrated their effec- tiveness in the area of diagnosis, care, treat- ment, and rehabilitation. When service is requested in outpatient facilities, the patient should be seen immediately along with his family, if possible. Since many problems can be solved more eflicaciously if attacked when acute, the situation and its psychological and social ramifications should be evaluated and action taken as quickly as pos- sible. In many instances long-term psycho- therapy is not required nor desirable; instead, individual and group counseling, physical treatment, or environmental manipulation may be more effective. Emergency Treatment Service Exploratory work is now underway to deter- mine the feasibility of establishing treatment teams which would be available at any time to go out into the community. Patients with an emotional disorder would be seen as soon as a crisis arises. Such a service would not only provide treatment early in the patient’s illness but would permit better assessment of the pa- tient’s surroundings and their possible efi’ect on his condition. The emergency service team may be based in a mental hospital, a general hospital, a mental health clinic or a local health depart- ment. Recommendations may be made or ac- tion taken which may involve referral to a social welfare agency; referral for treatment to a physician, an outpatient service or a psychiatric service at a general hospital; or further diag- nostic study by the emergency team. Social Ulubs for Era-patients Social clubs may be organized and supervised either by professional workers or by eX-patients themselves. In addition to providing social ac- tivities, the groups ofi'er consultation and advice as to sources of help—social, medical, and voca- tional. Some halfway houses are actually so- cial clubs rather than residential facilities. These may be organized under the auspices of public or private agencies or individuals in the community and may be an integrated part of a broader program of services. Rehabilitation Workshops Rehabilitation workshops have been designed to provide a sheltered working experience for handicapped persons. Although such work- shops have been available for patients with chronic physical disabilities for some time, they have more recently been extended to include the mentally ill. They may offer the opportunity for learning new skills, or regaining compe- tence in old ones. For some, they may be a stepping stone for gainful employment in in- dustry or business; for others, these workshops may represent the highest level of rehabilita- tion potential. The therapeutic value of the work and the need for individualized “prescrip- tions” are as important in these programs as in the rehabilitation work assignments made dur- ing the patient’s hospitalization. Community Mental Health Centers Community mental health centers should be planned as facilities where all mental health services can be centralized. These services in- clude prevention, promotion of mental health, consultation, treatment, and aftercare. Ex- perimentation with these centers has occurred mostly in urban areas. They can be planned to provide diagnostic services, outpatient care, day and night hospitalization, 24-hour hospital- ization, and transitional and aftercare facilities. These centers should be constructed as a part of or in proximity to general health facili- ties such as public health centers and general hospitals. Factors such as population density, geographic distances, or economic consideration occasionally may make it necessary to consider the construction of separate facilities covering various segments of the program. Even in such instances the facility should be an integral part of an overall plan for a complete spectrum of health services. Such consideration is necessary to prevent unnecessary duplication of facilities and services and to make possible the best utili- zation of specialized personnel, a higher quality of care, economy of operation, and a compre- hensive program of services. Coordination of Services Mental illness is often precipitated by a crisis in the family, on the job, or elsewhere. Appro- priate treatment given in an appropriate man— ner and at the appropriate time will often restore the patient to equilibrium, though not necessarily cure his basic personality problems. Commitment and hospitalization may be un- necessary and may make the total problem worse by disrupting the social and family situation. On the other hand, the nature of the illness may make hospitalization, even for long periods, the treatment of choice. Hospital programs can be planned so that even the long-term patient is helped to reach his maximum func- tioning level. If social and family ties are not to be weakened, the patient should be treated as near home as possible, even if hospitalized. Also, if the patient is to avoid chronicity and relapse, rehabilitation and aftercare are necessary. Since facilities should be constructed in keeping with programs to be offered, it is essen- tial that program planning precede facility planning (see chapter II). The isolation of mental hospitals from physical care facilities, training sources, and community health and welfare agencies, both physically and psycholo- gically, has impeded the development of mental health programs. All of these factors make it imperative that there be coordinated planning for mental health facilities. 13 EMOTIONALLY DISTURBED AND PSYCHOTIC CHILDREN Extent of the Problem Statistics relating to the number of children in need of psychatric services because of mental illness or emotional disurbance are extremely elusive and fragmentary. A 1956 study by the Department of Psychiatry of Columbia University indicated that an estimated 10 per- cent of public school children in the United States are emotionally disturbed and need mental guidance. Yet the majority of schools do not have sufficient trained personnel nor ade- quate facilities in the community to aid these disturbed children. Of the 493,387 patients residing in public prolonged care hospitals for mental disease in the United States at the end of 1957, some 2,752 were under 15 years of age. Of the 118,393 first admissions during the year, 2,226 were un- der 15 years of age.3 A recent study entitled “First National Re- port on Patients of Mental Health Clinics’” estimates that 379,000 individuals were clinic patients during 1955; of these, 197,000, or 52 percent, were under 18 years of age. Various studies of the resident populations of institutions for retarded children have indi- cated that psychotic children frequently are hos- pitalized as retarded because of inadequate diagnosis. In addition, facilities for the psy- chotic and the mentally retarded child are in— adequate. Many retarded children have con- current problems of emotional disturbance which complicate attempts to measure the ex- tent of the problem. As more facilities for early diagnosis be— come available, more children are being identi- fied as needing psychiatric service. Similarly, there is an increasing demand for services and facilities to provide appropriate treatment. Efl'orts, therefore, should be directed toward programs of sound mental health focused on the prevention of mental illness and emotional disturbance. Furthermore, services should be provided for early identification, care, treat— ment, and rehabilitation. 14 Trends in Care, Treatment, and Rehabilitation Many of the services and facilities required in treating the psychotic or emotionally disturbed child are, with certain modifications, similar to those described for the adult mentally ill. Particularly pertinent are programs of day hospitals, day care centers, outpatient services, foster homes, and homemaker services. These programs should be focused on the educational needs of the children as well as on the psy- chological and other medical aspects of their illness. Vital links with the family and com- munity should be maintained and the family situation should receive consideration in both temporary and long-range plans for the child. Where the home situation is not a con- tributing factor to the child’s maladjustment, home care programs offer the advantage of re- taining the child in familiar surroundings. If permanent residence in the home is not possible, a day care facility can plan a program for the child where as much family contact as practi- cable is retained. Under such a program the child would spend nights and weekends with the family. Any treatment program for disturbed chil- dren must have an educational focus. Going to school is the occupation of children and learning situations are essential for their de- velopment. The child must have the oppor- tunity to work within a structured group. Consideration of children’s emotional problems by teachers and other adults Who play a signifi- cant role in their lives can prevent or alleviate many situations that produce excessive stress and frustration. Diagnostic Centers To provide appropriate services to meet the particular needs of the disturbed child, a com- prehensive diagnostic service must be utilized. The diagnostic center can be a part of the service offered at a general hospital, a mental health center, or a public health clinic. In many instances extended observation will be an essential part of the diagnostic process. Early Identification and Prevention Preventive programs in departments of public health, welfare departments, and school systems are of special significance. These programs offer a positive approach to mental health through the early identification of children with special problems. Public health programs re- lated to prenatal and well—baby clinics should be encouraged. School programs at the elemen- tary and pre-school level can strengthen activi- ties conducive to good mental health and elimi- nate those conducive to poor mental health. They can be designed to identify those children who exhibit a need for special help related to emotional disturbance or retardation. A com- prehensive program within the schools should present a combined approach encompassing educational and social therapy. Such a pro- gram, which focuses on those adults who play an important role in the child’s life, includes observation, testing, home visiting, and parent education. Residential Treatment Centers for Children Increased emphasis is being placed on the de- velopment of residential treatment centers for emotionally disturbed children. These centers are directed toward creating a therapeutic milieu with program emphasis on education, group living, and group therapy supplemented by clinical services. Many modifications of residential care are possible through utilizing the concept of the day care or the day hospital where the program focus can be similar but where family involvement is more extensive. Residential treatment centers must be adequately staffed with skilled personnel for comprehensive services and continued coverage if they are to be an effective resource for dis- turbed children. Programs and patients must be periodically reviewed so that the center will not become a dumping ground for difficult children. Opinions differ as to the kind of child who can be treated in residential centers with a peer group. Differences also exist in regard to what is considered the most suitable size, staff— ing pattern, and architecture. Where residen- tial centers are developed it is essential to plan for extensive family involvement and return to the community as soon as feasible. Many resi- dential treatment centers utilize public school facilities for their child population so that the individual retains contact with community ac- tivity. Frequent home visits are included in the individual planning when this is appropri- ate to the needs of the child. Hospital Care Approximately one-third of the States provide specifically designated facilities or programs to serve the mentally ill or emotionally disturbed child in some of their public mental hospitals. Studies are now being conducted to determine whether adolescents may be treated more ef- fectively on adult wards than on wards specif- ically focused on an age grouping. Special attention is being given to the needs of the adolescent in the areas of education and voca— tional training. Preadolescent children in hospitals re— quire special units, programing, and staffing to meet their particular situation. MENTALLY RETARDED CHILDREN AND ADULTS Extent of the Problem Mental retardation has been defined as “a chronic condition present from birth or early childhood and characterized by impaired intel- lectual functioning as measured by standardized tests. It manifests itself in impaired adapta- tion to the daily demands of the individual’s own social environment.” 5 While a number of 15 other definitions have been advanced, they ap- pear to differ primarily in the degree to which emphasis is placed on “social adequacy” or “social incompetence,” or in attempts to estab- lish a distinction between retardation and mental deficiency. In the United States, mental retardation has been defined most commonly in terms of achievement on standardized intelligence tests. The usual procedure is to ascribe intellectual retardation to an individual whose intelligence quotient score is 70 or less. While additional diagnostic data are obviously necessary, this concept has the advantage of providing a reli- able technique of developing prevalence data as well as a means of determining classifications in terms of the degree of intellectual deficiency. Although intellectual deficiency is easier to measure, treatment programs must also be re- lated to physical and emotional development and social adequacy. On the basis of the measure cited above, approximately 3 percent of the population of this country is estimated to be mentally re- tarded, with numerical estimates ranging from 4.8 to 5 million people. The distribution of this group, in terms of levels of deficiency as measured by psychometric tests, follows : 5 I 0 Estimated Percent Classification range number of total Severely retarded (Totally dependent) ______________ 0—19 180, 000 3% Moderately retarded (Tram- able) ___________________ 20—49 540, 000 11 Mildly retarded (Educable)- 50—69 4, 280, 000 85 The trend today is toward caring for as many of the retarded as possible outside of institutions. General endorsement of this de- velopment has resulted in changing the em- phasis in institutional programs. Except for the severely retarded, children are not institu- tionalized solely because of retardation, but because of complicating physical, emotional, behavioral, and social problems. Thus the in- stitution which cares for these children must be, in large measure, a hospital in order to provide the kind of care and treatment required. On the other hand, such institutions must also pro- vide educational and training programs and 16 other activities as do residential treatment cen- ters primarily designed for emotionally dis- turbed children. The need for institutional care usually de- pends upon the degree of retardation. The mildly retarded seldom require institutional care. However, a greater number of the mod- erately retarded and almost all of the severely retarded ultimately require care in a facility such as that described in the preceding paragraph. Statistics regarding the incidence of mental retardation are complicated by many factors. . Even the retarded child may be performing at a level far below his capacity because of con- current emotional complications. The incidence of problems relating to retardation tends to rise sharply during the years of compulsory educa- tion and then drops oflz' sharply. As the midly retarded reach chronological adulthood many seem to do quite well. As they grow older, how- ever, factors such as competition in the labor market, public attitudes, and emotional diffi- culties produce a problem of adult retardation that merges into aging retardation. Of the approximately 5 million mentally retarded, it is estimated that more than 1.5 mil- lion, or almost one-third, are under 20 years of age.8 Further retardation studies indicate a variation in the rates at different age levels. Thus, the estimated prevalence rate for children under 5 years of age is only 2.1 per 1,000 popu- lation in that age group, while the estimated rate for children 10 to 14 years ranges from 20 to 80 per 1,000 population, depending on the study quoted.7 Trends in Care, Treatment, and Rehabilitation The problem of mental retardation requires a high level of professional skills and coordina- tion of professional endeavors. Pediatricians, psychiatrists, psychlogists, special teachers, nurses, social workers, occupational therapists, and rehabilitation counselors must be among those who work together with parents to give the child a chance for his optimum development. Traditionally, State institutions have sought to ——‘—__fi provide care, treatment, training, and education for the mentally retarded, either in prepara- tion for return to the community or as the basis for a happy and useful life within the institu- tion. Even after adequate community facilities have been provided for the educable and train- able retarded, there still will be a relatively large number with emotional and physical de- fects requiring hospital care. Programs for retarded children should be aimed at helping them to function as well as possible at their own level of intelligence and ability. These programs should be planned for a wide range of degrees of deficiency, including long-term life span plans for some. It is essen— tial, therefore, that careful consideration be given to the treatment and protection of retarded individuals on the basis of individual need. Community training centers are being developed by parent groups throughout the country and are being expanded to include rehabilitation, vocational, and day-care facilities. An overall program should have as its major aspects: (1) early identification or diag- nosis, (2) treatment, (3) education and train- ing, and (4) placement and guidance. Once the problem of mental retardation is identified and treatment begins, the other steps of the program should follow according to the level of intelligence and the ability of the individual. Hospitals have been called upon increas- ingly to provide care and protection for greater numbers of severely mentally handicapped persons, many of whom have gross physical deformities. Concurrent with the improve- ments in medical techniques, the chances for survival of infants and children with severe developmental abnormalities have increased markedly. At the same time the life expect- ancy of these severe cases has lengthened. These developments, concomitant with the large number of births in the years following World War II, have proportionately increased the demands on institutions for the care of re- tarded children. The result has \been severe overcrowding in all institutions throughout the country. There is a concurrent trend of in- creased programing in the school system and 583652—61—4 in the development of other community re- sources which makes it feasible to sustain greater numbers of the less severely retarded in the community. Institutions Although institutions for the prolonged care of the mentally retarded must he basically hos- pitals, other kinds of community facilities and training and rehabilitation programs should be established for the moderately and mildly retarded. Many types of facilities and services discussed under the adult mentally ill may, with modifications, provide needed services for the mentally retarded. Day Gare 0enters Special programs in a modified day hospital or mental health center directed toward training, education, self—care, vocational training, and parental counseling can be helpful in serving a segment of the retarded group. Outpatient care and group therapy sessions with both chil- dren and parents may be incorporated in the program. Sheltered Workshops Employment opportunities in sheltered work- shops for purposes of training and for long- term sustaining opportunities are essential for many retarded individuals if they are to re- main in community life. Diagnostic and E valuation Centers Diagnostic and evaluation centers provide for short, inpatient stay as well as outpatient study. These services are necessary if a careful diag- nostic workup is to be made of the child before he is assigned to a program. These centers also provide an excellent opportunity for research. Foster Care and Homemaker Services Foster care and homemaker services offer the same functions provided for the emotionally disturbed child. 17 N ursz'ng H omes Nursing homes are used to provide care for many retarded persons, particularly those with severe brain damage. School Programs Special classes within the educational system provide a better opportunity for the develop- ment of a child’s maximum potential. Expan- sion of these classes would make it possible for a greater proportion of the mildly mentally re— tarded to adjust more adequately to community living. Research Programs Research in mental retardation has tended to lag behind studies in other areas of medicine. Institutions and universities should therefore be stimulated to carry on long-needed research in this field. Additional investigations, partic- ularly in the physiological and biochemical fields, are needed to develop leads to prevention programs and guides to reduction of incidence by increased knowledge of causations. Among the problems which should be given increased emphasis are those of premature births, impli- cations of infection of mother during preg- nancy, dietary controls, and genetic metabolic defects. Further methodological research is also needed to determine how best to use diag- nostic and evaluative data in developing pro- grams of treatment for the mentally retarded child. Related Aspects of the Problem Programing for the mentally retarded is fre- quently complicated by problems of concurrent disabilities such as emotional disturbance, de- linquency, and physical disability, as well as by problems of school failure, community atti- tudes, lack of employment opportunities, and allied family disruptions. The existence of these correlative problems emphasizes the need for comprehensive diagnosis and individual study as a basis for planning treatment programs. RELATED SOCIAL PROBLEM AREAS Alcoholism, drug addiction, and juvenile delin- quency are among the social problems which frequently have a relationship to mental or emo- tional illness. Treatment for individuals in any of these categories must be based upon proper diagnoses and evaluation of the extent to which the mental health component is involved. Segments of the population in each of the related social problem areas may be benefited by programs similar to those described under fore- going sections. Certain modifications will be necessary, of course, for the programs in each area. ALCOHOLISM Extent of the Problem Alcoholism as defined by the World Health Or- ganization includes “those excessive drinkers 18 whose dependence upon alcohol has attained such a degree that it shows a noticeable mental disturbance, or an interference with their bodily or mental health, their interpersonal rela- tions, and their smooth social and economic functioning.” 3 Since 1940 the number of persons identified as alcoholics has increased tremendously. The World Health Organization estimates that there are more than 4.5 million alcoholics in the United States. Reliable data on the incidence and preva- lence of alcoholism are not available because of the lack of (1) a uniformly applied definition and (2) adequate reporting. In addition, the diagnosis of this condition is often complicated by the existence of other emotional ills. Police arrest data indicate that chronic alcoholics are frequent inhabitants of workhouses and penal institutions, yet these statistics are not always reported. The actual extent of the problem is further complicated by the lack of facilities and of professional interest in this area. The alcoholic is not accepted for treatment by many general practitioners, clinics, or social agencies, nor by many general hospitals. Treatment Programs A comprehensive treatment program for the alcoholic should include consideration of his family and his immediate social environ- ment. A total framework of community care utilizes such resources as the general prac- titioner, clinics, general hospitals, public health services, courts, correctional institutions, and facilities for acute and long—term treatment. Programs include case finding, diagnosis, treat- ment, and followup care. Attention should also be directed toward aspects of nutritional deficiency and reeducation. Among the facilities and programs which have proved particularly effective are outpa- tient services in clinics, day and night hospital programs, halfway houses, vocational counsel- ing and rehabilitation services, group therapy programs, and followup care by public health nurses. The skid row population is a segment of the problem of alcoholism closely associated With mental illness, mental retardation, and social and economic failure. Special com- munity services must be developed to aid this group. DRUG ADDICTION Extent of the Problem A recent estimate of the Interdepartmental Committee on Narcotics of the US. Govern- ment placed the number of narcotic addicts in the United States at approximately 45,000 as of December 31, 1959. The problem tends to center in large urban areas and is not of acute concern in most States. Treatment Programs Public Health Service Hospitals at Lexington, Kentucky, and Fort Worth, Texas, provide comprehensive programs of treatment and re- habilitation for drug addicts. Because of the limited scope of the problem no special pro- longed care facilities are indicated for most areas. For the most part, drug addicts are treated in special institutions and public mental hospitals; however, general hospitals are be- ginning to be used as treatment sources. In treating drug addicts, careful supervi- sion and security are required during the period of withdrawal. A comprehensive program of education for prevention is necessary, as well as a community program to modify attitudes, develop employment possibilities, and make the services of community agencies and facilities available to the addict. Rehabilitation pro- grams should include vocational education and counseling, group therapy, and follow-up serv- ice by probation officers and other social agen- c1es. JUVENILE DELINQUENCY Extent of the Problem Valid statistical data concerning delinquency is difficult to obtain because of variation in the law and age limitations established in different jurisdictions. In a recent report (1960) pre- pared for a Subcommittee of the Committee on Appropriations of the House of Representa- tives by the National Institute of Mental Health and the Children’s Bureau, the follow- ing current trends were indicated : “The total population of children in the age group 10 to 1’7 years has increased almost 50 percent in the last decade and is expected to increase another 50 percent by 1.980. The na- tional rate of reported juvenile delinquency has doubled in the decade from 1948—58. Careful analysis of the data suggests that the increases are not artifacts of better reporting or more eflicient law enforcement, but are real. 19 “In 1058 between 1.5 million and 2 million youngsters under 18 were dealt with by the po- lice for misbehavior. Over 600,000 different children came before the juvenile courts be- cause of illegal delinquent behavior, including traflt‘c ofienses. Even if the 1958 rate remains static, a total of 4—5 million diflerent children will be referred to the juvenile courts within the neat decade for delinquent acts.” 9 The number of children known to the police and juvenile courts has shown a per- centage increase during each of the last nine consecutive years that has been greater than the percentage increase of the child population. It is obvious, therefore, that the problem of law violating behavior by children and youth is increasing to a degree that is of great public concern. Treatment Programs The extent to which mental and emotional dis- orders contribute to delinquency and the treat- ment required can be determined only on the basis of comprehensive diagnosis. In many instances there is a relationship between de— linquency and mental illness, emotional disturb- ance, or mental retardation. To treat this aspect of delinquency, the programs and facili- ties previously discussed can be modified to meet individual needs. Outpatient clinics, day hospitals, day care centers, and general hos- pitals should be utilized for treatment. The pro- gram is usually focused on educational and social needs, individual and group therapy, vocational guidance and training, and recrea— tional opportunities. The treatment should include work with the families since the pro- gram should remain child-centered and com- munity-oriented with as little disruption of a normal environmental situation as possible. ~ There has been a trend toward the develop- ment of residential treatment centers for de- linquents with major emotional problems. In addition, special services have been introduced in correctional institutions. The residential treatment centers are usually located in or near the home community, are limited in size, provide 20 a therapeutic group living experience, and in- clude appropriate provision for education, rec- reation, vocational training, and both individual and group therapy. The same programs and philosophy of individual treatment should be incorporated into all State or local training schools. Since the delinquent child is handled by the police and juvenile courts, well—trained personnel and special detention facilities can provide a constructive approach and can pre- vent a destructive traumatic experience for the individual. Foster homes, group boarding houses, and follow-up services are among the programs and facilities of particular significance. Most factors contributing to delinquency are socioeconomic and cultural rather than psychiatric, though psychiatric problems are common. Thus, it is important that the agencies with responsibility and interest in these areas have an orientation toward positive mental health. AGING Extent of the Problem The number of persons over age 65 in the gen- eral population is growing rapidly and is cur- rently estimated at more than 15,000,000 with an increase of approximately 400,000 a year.” Mental illness in this age group has many facets which should be examined before facility plan- ning is undertaken. A review of first admissions to public pro- longed care hospitals for mental illness in the United States in 1957 indicates that more than 31,000 were persons over 65 years of age— approximately 25 percent of all first admis- sions.a The diagnostic categories into which this group of patients was classified were pri- marily cerebral arteriosclerosis (approximately 15,000), and senile brain disease (approxi- mately 10,000); however, all types of illness were represented. The mortality among these aged patients tends to be high so that they rep- , 7————_fi resented only approximately 10 percent of the total resident population in mental hospitals at the end of 1957 (46,000 of a total population of 493,000) .8 The number of aged patients in mental hos- pitals is, however, only one segment of the problem of the aging. There are many more aged persons with serious problems of adjust- ment who are living in their own homes, with families, or in other facilities. Also, many age persons in mental hospitals may be there onl because of the lack of appropriate facilities to provide more adequate care. Trends in Treatment The problems of aging are related to many so- cial, economic, and cultural factors. Mental health services are designed to provide for bet- ter adjustment through programs of prevention and early treatment. Coordination of all com- munity services is necessary to meet the medical, economic, and social needs of the aged popula- tion, to prepare them to accept their limitations, and to provide motivation for the constructive use of their time and resources. A program of prevention focused on sound mental health con- cepts can help to alleviate many of the problems of adjustment for the aged. To receive maxi- mum benefits under such a program, individuals should begin preparing for their old age many years prior to their retirement—and no later than at the age of 45. The implementation of a comprehensive program of care for the aged requires the coop- eration of physicians, nutritionists, nurses, pub- lic health agencies, social agencies, housing and recreation agencies, clinics, general hospitals, nursing homes, and other facilities for the care of acute or chronic illness. A good mental health program, including the services of a psychiatrist, should be available to these groups when needed. Among the programs and facili— ties needed are variations of many of those previously mentioned. Homemaker Services Many of the aged can function adequately in their own homes if provision is made for lim- ited assistance in housekeeping and for help- ing the individual to carry on limited com— munity activities and to utilize community re- sources. Properly directed and supervised volunteers can frequently be used successfully in home programs for the aged. Foster Homes The use of foster homes for aged persons has been demonstrated as an effective method of retaining the individual in the community in a family setting structured to meet his indi- vidual needs. Group homes are also an alter- native that may provide an appropriate facility for some individuals. Nursing Homes Nursing homes provide a variety of services ranging from a minimum of supervision directed toward ambulatory care with con- siderable involvement in community life to complete bed nursing care with psychiatric services when indicated. Each nursing home should have staff and program designed and structured to meet the needs of the patient population it serves. There is a trend toward the movement of {i aged patients from mental hospitals to nursing 7’ homes. In the implementation of such a pro-‘ gram it is important to ascertain whether the nursing homes are adequately prepared to meet the individual needs of the patients. Day Care Centers Numerous programs for the aged have de- veloped in day care centers where the individ- ual has an opportunity for social contacts and activities designed to meet his needs and interests. Related Aspects of the Problem Problems of aging are frequently complicated by varying degrees of physical disability which necessitate a program of comprehensive 21 medical and dental care. The services of the general practitioner should be used in dealing with a range of medical problems, many of which will have psychiatric components. To the degree feasible, the aged population should have the advantage of a Wide range of facilities and services designed and programed to provide a satisfactory home and community life con- sistent with the patient’s physical, mental, and emotional capacities. As a more positive ap proach to mental health, the aged also should be assisted in mobilizing their own resources to develop their ingenuity, skills, and individual capacity. AVAILABLE FACILITIES Data compiled by the Division of Hospital and Medical Facilities of the Public Health Serv- ice 11 indicate that in 1959 there was a total of 503,301 beds in 620 non-Federal psychiatric hospitals. In addition, 42 psychiatric hospitals operated by the Federal Government provided 64,932 beds, mainly through the 41 Veterans Administration mental hospitals located throughout the country. Approximately 46 percent of these non— Federal psychiatric hospitals were publicly- owned, either by State, county, or local govern- ments; 42 percent were classified as proprietary facilities; and the remaining 12 percent were operated under a nonprofit form of organiza— tion. In general, however, facilities under the two latter types of sponsorship tend to be rela- tively small. As shown in the table below, of 27 9 psychiatric hospitals with less than 100 beds, 259 were either nonprofit or proprietary. On the other hand, of the 208 hospitals with 500 or more beds, 204 were publicly owned. NON-FEDERAL PSYCHIATRIC HOSPITALS, BY SIZE AND OWNERSHIP, 1959 Type 0/ ownership Non- Publldy profit 0- sze oflwapltal owned agency prietary Total Less than 100 beds _______ 20 48 211 279 100—299 beds ____________ 47 22 38 107 300-499 beds ____________ 13 4 3 20 500 beds and over _______ 204 2 2 208 Unknown _______________ 1 _ _ _ _ 5 6 Total _____________ 285 76 259 620 As shown in the following table, the great- est proportion of the non-Federal psychiatric 22 beds is provided in State mental institutions. Of the 503,301 non-Federal beds reported, 91.4 percent were in hospitals owned and operated by the States or Territories. An additional 3.4 percent of the total were located in county- or city—sponsored facilities. In contrast, non- profit and proprietary facilities, respectively, provided only 1.9 and 3.3 percent of the non- Federal psychiatric beds in the country. NON-FEDERAL PSYCHIATRIC HOSPITALS, BY OWNERSHIP, NUMBER or BEDS AND AVERAGE DAILY CENSUS, 1959 Number of beds Average daily census Ownership Number Percent Number Percent Publicly owned--- 447, 358 94. 8 528, 100 97. 0 State or Territory" 459, 949 91. 4 507, 414 93. 2 County or City--__ 17, 409 3. 4 20, 686‘ 3. 8 Nonprofit ________ 9, 322 1. 9 7, 172 1. 3 PrOprietary ______ 16, 621 3. 3 9, 129 1. 7 Total _____ 503, 301 100. 0 544, 401 100. 0 The predominant role of State governments in providing care of the mentally ill is illus- trated further by comparing the average daily census data reported for the variously spon- sored facilities. For the year 1959, the aver- age daily census of all non-Federal psychiatric hospitals in the country was 544,401. Of this total, 93.2 percent represents the average daily census of patients hospitalized in State and Territorial psychiatric hospitals in that year, as contrasted to 3.8 percent in county and city hospitals, and only 3 percent in both nonprofit and proprietary hospitals. Classification of these hospitals by size of community indicates that almost one-half of the publicly-owned hospitals and slightly more ,,_________fi than one-half of the public beds are located in communities of less than 10,000 population. Only 17 percent of the hospitals in this group and 15 percent of the beds were located in com— munities of 100,000 or more. A slightly greater tendency to locate in centers of higher population concentration is noted for both non- profit and proprietary facilities. The availability of suitable mental hospital beds in the United States is indicated by a recent survey of Hill-Burton State plans. Beds considered to be unsuitable because of fire or health hazards, obsolescence, etc., were excluded. For the country as a whole, the survey showed a ratio of only 2.58 suitable mental hospital beds per 1,000 population. Study of the data on the individual States and Territories indicated that only 3 States have a ratio of more than 4 beds per 1,000 popu- lation; 10 States fall in the range of 3.00 to 3.99; 21 between 2.00 and 2.99; 17 between 1.00 and 1.99; and 2 States have less than 1 bed per 1,000 population. Changing emphases in methods of treat- ment and the development of alternative pat- terns of care can be expected to reduce the need for beds in mental hospitals. The concept of bed—population ratios should be reevaluated for future planning purposes. Psychiatric Units in General Hospitals In 1959, 269 non-Federal general hospitals had psychiatric units of at least ten beds and pro- vided a total of 15,306 psychiatric treatment beds. Of this number, 6,133 were in voluntary institutions and 9,143 were in publicly-owned facilities. Only two proprietary hospitals re- ported having psychiatric units, with a com- bined total of 30 beds. The majority (61 percent) of the general hospitals with psychiatric units were located in communities with a population of 100,000 or more. An additional 17 percent were located in communities of 50,000—100,000 population. Institutions for the Mentally Deficient The Master Register of Hospitals 11 indicated that in 1959 the Nation’s 264 institutions for the mentally deficient provided a total of 93,287 beds. While only 87 of these institutions were State-owned and operated, they provided 92.8 percent of the total number of beds. Propri- etary facilities in the field, while more numer- ous, tend to be smaller; 169 proprietary insti- tutions contained a total of 5,389 beds. Under all types of ownership, the great majority of the facilities for the mentally deficient were located in communities of small population and in rural areas. Hospitals and Beds for Alcoholics, E pileptics and Narcotic Addicts Because of variations in designation and in reporting of services, data on the availability of facilities and beds for treatment and care of alcoholics are not reliable. Few specialized treatment centers are available. Those which can be identified are relatively small and are predominantly under proprietary and nonprofit auspices. .. In recent years, the: number of hospitals specializing in the treatment of epileptics has been decreasing. Throughout the country, only six facilities are still specially designated as hospitals for epileptics, and even those are treating other types of patients. Of the six reported, four are State—sponsored and two are proprietary. The two hospitals for narcotic addicts op- erated by the US. Public Health Service make available a combined total of 1,805 beds. The only other specialized hospital in the country— a city-operated facility of 140 beds in a large eastern metropolitan area—is now planning to close, and its activities will be transferred to units in selected general hospitals. Chapter II Principles for Developing a Statewide Plan THE DIMENSIONS of the problems of mental ill- ness, the changing trends in the treatment and care of the mentally ill, and the nature of the available resources emphasize the need for de— veloping comprehensive plans and programs for mental health facilities and services on a statewide basis. These programs should have as an ultimate objective the provision of ade- quate facilities for early diagnosis, intensive and continued treatment, and rehabilitation programs designed to restore the individual to his fullest mental, physical, social, and voca- tional capabilities. In working toward this goal it will be necessary for each State to es- tablish the individual objectives which it hopes to accomplish through the planning process, and to establish action programs based on the provisions of the statewide plan. One of the major long-range objectives of all statewide plans should be the ultimate elimi- nation of large State mental institutions as they now exist. Need for this action stems from increasing evidence of the antitherapeutic effects of large mental institutions and of the greater effectiveness of community-based mental health programs. While several decades may be required to accomplish this objective, the plan should provide for progressive replace- ment of these large institutions by smaller more flexible facilities, readily available to the popu- lation, and either incorporated in or in the proximity of a medical center or complex. In a number of States action has already been taken to remodel their large institutions so they will provide several small units. A more immediate objective toward which the State plan should be directed is the involve- ment of State and local public agencies and private groups in formulating programs and providing mental health facilities and services in line with newer concepts. The cooperation, assistance, and financial support of these agen- cies and groups are essential to the successful execution of an effective program. One method of accomplishing this objective would be through establishing a planning body at the State level which is broadly representative of public agencies, professional, private, and civic groups active in the field, as well as the general public. THE PLANNING GROUP As the first step in developing a plan and pro- gram, the committee recommends that in each State, the Governor take necessary action to initiate the development of a comprehensive statewide plan for mental health facilities. Al- though this may be accomplished in a number of ways, the following methods may be con- sidered: (1) the designation of an existing State Agency to which appropriate authority and re- sponsibility would be delegated. Under this plan, an advisory group would be appointed to work in collaboration with the State agency. Members of this group would be broadly repre- sentative of the principal public and private agencies and organizations concerned with the promotion of mental health and referral, care, and treatment of the mentally ill. Among those 25 who should be included, unless designated as the planning agency, are the State Mental Health Authority, the State Health Department, the State Hill—Burton Agency where it is not a part of the State Health Department, mental hospi- tal authorities, the State director of programs for mentally retarded in those States having separate authority for this responsibility, as well as educational and welfare authorities and local mental health authorities. The committee feels that no more than half of the total mem— bership should represent professional groups in the health field. The others might include rep- resentatives from education, the court system, the providers of funds for capital investment, the State legislature, opinion-molding groups, and community leaders. (2) The establishment of an especially or- ganized planning board. The composition of this board should be similar to that suggested for the advisory group to the State Agency. As in the case of the advisory group, it is rec— ommended that no more than half of the total membership of the planning board should rep- resent professionnal groups in the health field. The remainder should be drawn from other public and private sources. Whether the planning body is designated in accordance with either of the proposals noted above or in accordance with some other plan, an expert pool of professional judgment should be maintanied either within the membership it- self or by the maintenance of appropriate tech- nical advisory committees. These committees would furnish consultation and advice in spe- cific areas such as publicity, legislation, and coordination of planning with other health groups. Specific and adequate authority must be delegated to the planning body to permit effec- tive execution of assigned responsibilities. In addition to the survey and planning functions, this authority must include the development of appropriate liaison and working relationships between the planning body and those agencies responsible for implementing the hospital and community aspects of the mental health pro- gram. The Committee further recommends that sufficient funds be provided, on a continuing basis, to assure the retention of a full—time staff and the continuity of the planning functions from year to year. PLANNING PRINCIPLES Within the context of the established objectives, the development of a comprehensive statewide plan and program for adequate mental health facilities and services by the planning group should be based on consideration of the follow- ing principles: 1. Planning activity should encompass the en- tire complex of mental health facilities and services required for the State. A prerequisite to the formulation of the plan for the construction of facilities is the ex- istence of a comprehensive statewide plan and program for the care and treatment of the men- tally ill. This overall plan should make pro- visions for all existing and proposed services 26 and facilities, both public and private. 2. Facility planning should be coordinated with other planning program. Plans for the development of mental health facilities will affect and be affected by the ac- tivities of other planning programs in the fields of public health and mental health. To mini- mize the possibility of divergent or contradic- tory planning, procedures should be established for effective liaison with the official State health agencies, areawide planning groups, and other local or regional planning bodies. Co- ordination of planning with these groups is essential, particularly in respect to long-term mental care facilities, since the actual need for mental beds in an area will depend to a con- siderable degree upon the number of suitable mental beds in general hospitals as well as in nursing homes or other long-term facilities. 3. Adequate planning data should be developed. A comprehensive survey is essential to de- velop factual information on existing condi- tions. This should include: (a) the prevalence of mental illness; (b) the location, physical con- dition, and utilization of existing facilities; (0) the availability of services; and (d) the adequacy of personnel and staff. To the extent appropriate, data should be projected to reflect anticipated changes in population concentra- tion and characteristics, patterns of treatment and care, and the availability of trained personnel. 4. Existing facilities should be evaluated in terms of structural and functional adequacy for continued use. The survey of existing mental health facil- ities will provide the data necessary to evaluate the functional and structural adequacy of such facilities and their location for purposes of developing a coordinated system of facilities and services. On the basis of this evaluation, decisions may be made as to their acceptability for continued use, the need for and feasibility of modernization or improvement, and the need for additional facilities. In the case of facil- ities found to be structurally or functionally inadequate, or poorly located, serious consider- ation should be given to the advisability of abandonment or transfer to other use. Should replacement be desirable, the type and location of the new facility should conform to the principles and objectives of the statewide plan. 5. Facilities and services should be functionally coordinated. In developing a coordinated program of treatment and care for all types of mental dis- orders, provision must be made for an inter- related network of facilities and services de- signed to meet the varying levels of medical, nursing, and other needs of the patient. In- cluded among the needed facilities and services are those for early diagnosis, intensive treat- ment, long-term care and treatment, rehabili- tation and aftercare, and guidance. A state- ment of the purpose and objectives of each facility should be developed prior to specific programing as a part of the coordinated system. 6. Facilities and services should be programed for use at mamimum eyficiencg. In planning a program of coordinated serv- ices, consideration must be given to the utiliza- tion of facilities at their highest level of efficiency. In keeping with this objective, exist- ing facilities must be evaluated in terms of (1) their current or intended role in the proposed pattern of treatment, and (2) changes or modi- fications in the facility or its purpose to achieve the highest possible levels of efficiency, consist- ent with size, location, and anticipated caseload. The same goal would, of course, be equally ap- plicable in planning and programing new facilities. 7'. Facilities should be organized to provide continuity in care and treatment. The concept of isolated, segmentalized treatment of the mentally ill should be dis— carded and replaced by a concept of continuous treatment and assistance from the time of initial diagnosis until return to social and physical well-being. A progressive gradation of levels of treatment should be planned within and be- tween facilities in a coordinated system. Avail- ability of the particular type of treatment or rehabilitation best suited to an individual’s needs at any particular stage of his illness would permit increased social contacts and a gradual refitting for either full return to society or to such modified activity as his condition permits. 8. Facilities should be located in or adjacent to a community hospital or health center. Related to the principle of providing care suitable to patient need is the desirability of programing both short-term and long-term mental health facilities as a part of or in close proximity to a general hospital or other com- munity health facilities. The advantages accruing from this arrangement—mutual avail- 27 ability of specialized services, avoidance of duplication of facilities, and the sharing of scarce professional personnel and equipment—— can readily be envisioned, in terms of economy, efficient use of skilled personnel, and more effec- tive treatment of the patient. .9. Facilities should be readily accessible to the population to be served. Emphasis in planning facilities should be placed upon provision of treatment and rehabil- itative services readily accessible to patients. Location of these facilities should be guided by the desirability of causing as little disturbance of family and community relationships as is consistent with effective treatment. The essential functions of local units would be early detection and treatment, prevention of chronicity, early return to society and preven- tion of relapse. Application of this principle would lessen the need for programing addi- tional beds and facilities for long-term custo- dial care. 10. Facilities should be oriented toward early treatment and rehabilitation. Emphasis in planning should be placed on facilities which will provide early diagnosis, intensive treatment, and an active program of rehabilitation designed to restore the individ- ual to his fullest mental, social, and vocational capabilities. Proposals for construction of new or additional long-stay facilities should be carefully evaluated in terms of the possibility of alternative construction designed for inten- sive treatment and early return to community life. 11. Facilities should be designed to provide multiple services. To the extent possible, various types of mental health services and programs should be brought together into a single complex. Result- ing advantages include economy of operation, coordination of programs, and the effective utilization of space and staff. The programing of mental care and treatment facilities should include such possible applications of this prin- 28 ciple as (1) incorporation of mental health diagnostic and treatment clinics as parts of a psychiatric hospital, (2) utilization of the same space for diagnosis and treatment of various types of illness at different times, and (3) pro- vision of acute and chronic treatment and re- habilitaton Within the same facility or complex. 12. Inpatient psychiatric care should be pro- vided in small, flexible units. In the past, the need for additional in- patient psychiatric care has usually been met by the expansion of existing tax-supported mental hospitals. The resulting development of large institutional structures has been re- flected in less personal care and treatment of the individual patient and has tended to pro- mote chronicity rather than early recovery and return to society. Further expansion of existing large mental institutions should be discouraged. These fa- cilities should be surveyed for possible reorgan- ization into smaller, more specialized units, more adaptable to individualized patient care and treatment. New psychiatric hospitals should be situ- ated close to the population to be served and should not exceed 600 beds. Where need exists for the provision of a larger number of beds, consideration should be given to construction of small multiple units or branches which would provide greater flexibility for possible future conversion to other uses. 13. New psychiatric services should be de- signed to provide specialized treatment. Flaming and construction of new psy- chiatric facilities should be oriented toward the provision of highly specialized services and techniques required for effective diagnosis, treatment, and rehabilitation of the more in- volved psychiatric illnesses. Since much of mental illness results from and leads to social disability, programs of patient treatment should include both medical therapy and op- portunities for social interaction. Accord- ingly, facilities should be designed to provide space for group therapy, recreational and oc- cupational therapy, dining areas, private con- sultation, and social services. Consideration should also be given to the need for privacy, maintenance of personal dignity, and the de- velopment of as personal and homelike an atmosphere as possible. 14. Communities with general hospitals should be encouraged to develop psychiatric seroices. The advantages of early local treatment are such that, in the opinion of the committee, every community which has a general hospital should have available at least minimal psy- chiatric services. Provision of these services within the hospital would make available a means for early investigation and local treat- ment of psychiatric disturbances, and would furnish a referral point for patients requiring more intensive treatment and extended periods of care. With proper evaluation and an ade- quate program of psychiatric services, mental patients may be intermingled with other pa- tients in the hospital, with the resulting advan- tages of social interactions in a more normal situation and the avoidance of the stigma asso— ciated with segregated treatment. Where staffing and anticipated caseload warrant, an organized psychiatric service may be developed under the direction of a psychi- atrist or a physician with training in the treat- ment of emotional disorders. If not available in the community, psychiatrists from nearby areas may be called upon as consultants to local physicians who have assumed the care. of psy- chiatric patients. The requirements for spe- cialized space would depend upon the objectives of the local hospital unit. In hospitals with a psychiatric caseload of more than 15 patients, space should be provided for such specialized services as occupational, recreational, and group therapy. In such hospitals, patients could still be placed on other services, with joint use of nursing and treatment areas as in- dicated by the individual’s treatment program. In larger hospitals having a greater number of psychiatric patients, usually 25 or more, con- sideration may be given to the advantages of a separate psychiatric section. From the standpoint of efi'ective therapeutic nursing service, the optimum size of each nursing unit is considered to be between 20 and 25 beds; proposed nursing units exceeding 25 beds should be carefully evaluated with a view to possible subdivision into more manageable pro- portions. Such a psychiatric section should provide special facilities for consultation rooms, recreation, occupational therapy, social service, dining space, etc. Some psychiatric sections in general hos- pitals have from 200 to 300 beds. When prop- erly staffed and programed, such facilities may serve as auxiliary psychiatric hospitals pro- vidin g long-term care. 15. Facilities and services for aftercare should be established. Comprehensive planning requires that con- sideration be given to facilities for aftercare of patients who no longer need active psychiat- ric treatment or who need a transitional setting prior to return to the community. The nature of these facilities depends upon the needs of the patients to be served. Followup services may be provided by family physicians, public health nurses, community-based social workers, or through full- or part—time clinics, frequently operating as parts of the hospital’s outpatient department. Transitional facilities range from the halfway house, organized to assist the indi- vidual in his readaptation to social living, to the more permanent type of care made avail- able through boarding or foster homes, con- gregate types of domiciliary facilities, and nursing homes providing psychiatric nursing service under adequate psychiatric supervision. A definitive study of the treatment status of individuals in existing institutions and the feasibility, on the basis of individual prognosis, of assignment to the type of aftercare facility best suited to the individual’s needs will pro- vide a basis for determining the type, size, and location of the facilities needed. 16. Facilities for mentally retarded should be designed to include active programs of reha- bilitation. The success of recent efforts in the rehabili- tation of mentally retarded children and adults points up the desirability of a stronger shift in 29 emphasis from custodial care to positive efforts at rehabilitation of the individual and develop- ment of self-supporting status. In accordance with this more purposeful objective, the com- mittee recommends that construction of new facilities for the mentally retarded, or remodel— ing of existing structures, be planned in terms of units of not more than 600 beds, and de— signed for an active rehabilitation program as opposed to custodial care. PLANNING PROCEDURES A comprehensive plan for mental health facil- ities should be directed toward provision of adequate care and treatment for all persons Within the State in need of such services. To accomplish this objective, all existing services and facilities should be evaluated. Where needs exist, additional facilities should be pro- gramed as a part of the overall plan. Planning activity should be a continuing process. Since it should be oriented toward both short-term and long—range goals, the plan for construction of mental health facilities must be conceived and developed as a continuing document. It must be amenable to periodic revision in response to changes in concepts of treatment or in the characteristics and needs of the population to be served. In consideration of the need for a compre- hensive and flexible plan, the committee recom- mends the following planning procedures: 1. Develop indices of need. Effective planning of psychiatric facilities and services requires basic data which reflect, as completely and reliably as possible, the num- bers and types of cases needing psychiatric care. Only on the basis of such information can a realistic evaluation be made of (a) the actual effectiveness of the facilities and services al- ready in existence, (b) the need for providing new or additional facilities and services, and (c) the nature and location of such facilities for maximum benefit to the population of the area to be served. In the past, health authorities have at- tempted to estimate facility needs on a formula basis. Previously used indices of need such as ratios of mental hospital beds to population 30 served are no longer believed to be realistic be- cause of the constant changes brought about by such factors as new developments in treatment methods, the increased numbers of the aged, and improved social and economic status of the population. These factors complicate the plan- ning process, making it unfeasible to plan by merely applying a mechanical ratio of beds per thousand population. In some instances the changes (i.e., new treatment methods) would reflect a need for fewer beds, whereas other variables (i.e., aging population and improved economic status) would mean an even greater number of beds might be needed. Because of the wide variety of factors which must be con- sidered before embarking on long-range medical facility planning, the committee feels that additional experience will be required before sound formulas can be recommended. In the meantime, it will be necessary for each commu- nity to make a determination of the greatest gaps in its current program and direct initial efforts toward meeting the most urgent needs in both community services and mental hospital facilities. Communities, in developing their own in- dices of need, should determine not only the role of the mental health facilities but of other health facilities and their possible interrelation- ships. As an example, consideration should be given to the possible use of other types of facil- ities which might care for the aged. Ideally, joint planning should be carried out by those providing facilities for the care of the chronic- ally mentally ill and those concerned with plan- ning facilities for other types of long—term ill— nesses. If suitable programs can be developed, there may be less need for mental hospital beds since many patients currently hospitalized would be more properly cared for in other types of facilities. 2. Survey available recources. A comprehensive and continuing survey of all available resources which are essential to the development of a statewide plan and program should include: (a) An inventory of all public and private facilities in the State, which actually provide service in the fields of mental diagnosis, treatment and/or care. For proper evaluation of these facilities, the types of data listed below would be desirable. Development and analysis of these data should take into consider- ation the different problems and objectives applicable to both long-term care and short-term treatment, and the effect these ditferences would have upon determina- tions of the adequacy of program, space, and staffing. Examples of the type of information to be obtained follow: (1) Name of facility and location. (2) Type of ownership or control. (3) Designation of facility as currently used (long- term care; intensive psychiatric treatment; out- patient departments of hospitals; day care hospital; night care hospital; halfway house; psychiatric unit (or service) of a general, tuber- culosis, or chronic disease hospital; diagnostic and treatment clinic; nursing home; sheltered workshop; home for mentally retarded; child guidance center; residential treatment center for emotionally disturbed children). (4) Number of patients treated by level of care required. (5) Types of services provided (diagnosis, short-term treatment, long-term treatment, rehabilitation services, i.e., occupational therapy, neurological services, etc.). (6) Number of inpatient beds, by type of service (admitting, intensive treatment, custodial, convalescent) . (7) Inpatient utilization (patient days per year, num- ber of new admissions, number of readmissions, rate of occupancy). (8) Number of outpatients and number of outpa- tient visits. (9) Source of patients (by residence and referral agency). (10) Number of dispositions (discharge, death, trans- fer to other service, referral to other institution by type of institution to which referred). (11) Classification of structure (suitable, replaceable, unsuitable). (12) Programed stafling and current vacancies. (13) The per patient cost of treatment and care (over- all and by type of patient). (14) Source and patterns of financing the services and facilities. (b) An inventory and evaluation of the effectiveness of all mental health and related programs and serv- ices in the State, including the location and the spe- cific nature of the program services available. Included in this inventory should be the number of personnel by professional classification available for providing the services, the estimated caseload, and the service area covered. (c) Information on any operational relationships which currently exist among facilities and the various programs and services, in terms of referral patterns, joint use of personnel, etc. 3. Survey State population patterns and movement. Evaluation of the degree to which existing facilities meet the actual need for psychiatric services and the determination of need for ad- ditional facilities, require a knowledge of the composition, distribution and movement pat- terns of the population to be served. As a basis for efi'ective planning, study of the State and its political subdivisions should be directed toward the development of data on such population characteristics as relative density throughout the State; significant differences in economic and social status as they may effect the demand for services; ease of transporta- tion; and the existence of established travel patterns, as reflected in retail trading areas, use of educational, religious and recreational facilities, and the utilization of hospital and medical services. 4. Delineate service areas. On the basis of the population findings, the State can be divided into logical commu- nity service areas. Delineation of service area boundaries should take into consideration such factors as population dispersion, potential availability of personnel, travel patterns and travel time, and the location and adequacy of existing facilities. In many States, the sys- tem of general hospital service areas already developed in connection with the Hill-Burton program may provide a ready-made pattern 31 for programing community-oriented facilities. Also, depending upon the anticipated sponsor- ship and operation of proposed psychiatric fa- cilities, consideration should be given to the possible advantages of defining service and regional areas along the boundaries of political subdivisions or combinations thereof. From this basic pattern of service areas, a regional pattern of organization can be developed for provision of more highly specialized psy- chiatric services, economically feasible only through support from larger groupings of the population. 5. Determine remaining need. With the division of the State population into logical service areas, the need-criteria pre- viously developed for each type of psychiatric facility may tentatively be used to determine the nature and size of the facilities required to provide adequate service to the area popula- tion. Determination of need should be based on evaluation of the existing utilization pat— tern, efl'ectiveness of existing units, proper utilization of stafl’, and other judgmental factors. 6‘. Evaluate existing legislation and adminis- trative procedures. Current legislation and administrative re— quirements which may affect the nature or con- duct of the proposed statewide program of mental care and treatment should be reviewed and evaluated. Factors which may restrict the development of a desirable pattern of services and facilities should be carefully examined and suitable action initiated for their revision or removal. Where necessary, a positive program of legislative action directed toward enactment of appropriate community mental health serv- ices legislation should be instituted. 7'. Program to meet the need. A long—range construction program to pro- vide new facilities where needed and to modern- ize existing facilities or convert them to more effective use should be developed and incorpo- rated in the overall plan. In developing this program, consideration should be given to both 32 the long-range as well as immediate need for construction in each area, the ability of the area or combination of areas to support the type of facility needed, and the proper location of the facility. In this connection, the need for addi- tional facilities should be considered in light of the long-range goal of eventually replacing large State mental hospitals with other types of facilities. The program so developed should be reviewed from the standpoint of complete- ness of coverage and the desired coordination of services, both existing and proposed, into an integrated statewide pattern of psychiatric care. 8. Develop priorities for assistance. The statewide plan should include a pri— ority system for construction purposes. The system should be based on principles designed to assure the development of needed facilities in the order of greatest relative need between areas and types of facilities, with particular emphasis on psychiatric services and units in community general hospitals and on other community facilities. For each category of facility, priority ranking may be established on the basis of the calculated percentage of need which has been met. This procedure alone, however, will not provide an adequate basis for selection between projects of equal rank, or for projects of differ- ent categorical status. Additional factors which may be used as bases to supplement the need-met criteria include: (a) The size of the population group to be served. (b) Comprehensiveness of the proposed program; provision of a broad spectrum of service. (c) Inclusion in or formal afliliation with a large medical center. ((1) Participation in an approved training program. (e) Coordination or consolidation of activities with other mental health facilities or programs. (f) Formal afl‘iliation with a general hospital. (g) Program emphasis on prevention, early diagnosis and treatment. (h) Provision of a wide range of clinic services. (i) Relative need for service as compared to other categories of mental facilities. Selection of the specific priority factors to be included in the statewide plan will depend upon the particular needs of the State, as dem— onstrated by the survey of existing resources and the objectives of the statewide mental health program. .9. U tilize local planning groups. There is increasing evidence of local com- munity interest in programs for the prevention of mental illness, early treatment, short-term care, and the readaptation of the individual to society.* This increasing interest on the part of local communities should be encouraged by the State planning group and efforts should be made to secure the participation of appropri— ate local groups in assessing community needs and in implementing the plan at the community level. A number of community or areawide plan- ning groups are already in existence in the country, primarily in metropolitan areas. In these instances, the State planning body should work with the local groups in developing plans and programs for mental health facilities and services in the community or area. Thus, the local program would conform to the overall statewide plan and program. In addition, it would ensure that the local program for these facilities would be an integral part of the total complex of medical facilities and services of all types proposed for the area. In those areas where a planning group does not already exist but appears to be justified because of population concentration or signifi- cant local planning problems, the State plan- ning agency, with the assistance of key inter- ests in a community, should encourage the de- velopment of a local planning and advisory group. Such a group, comprised of representa- tives of the agencies and interests in the com- munity concerned with the prevention, care, and treatment of mental illness, could, with proper ‘Increasing amounts of money are being spent for com- munity mental health services designed to keep patients within the community. In 1957, the States alone spent an estimated $27 million in support of these services as compared with only $5.9 million in 1952. Community Mental Health Services Acts are already in operation in no less than ten States with, in two States at least, joint financing of certain locally oper- ated facilities and services. guidance and staff assistance from the State agency, serve as an advisory and operational affiliate of the State planning agency. The local planning and advisory group, be- cause of the competencies and interests it rep- resents, will be able to provide the more detailed knowledge of local conditions necessary for planning purposes and for implementing the community program. The types of informa- tion which could be developed and analyzed by this group include: (a) More precise information than might be obtained from a State survey on the extent to which local needs are now being met. Information could be obtained on the number and kinds of mental patients from the area who are under treatment in hospitals, nursing homes, or clinics, or on waiting lists of these facilities. Also, estimates could be obtained from local health and wel- fare agencies and schools of the number of residents of the community who would be referred for treatment if facilities were available. (b) A detailed analysis of the facilities and programs, both public and private, now operating in the com- munity. The analysis should include the types of pa- tients served, the services being made available to the patients, the present patient load, historical trends in patient load, type and availability of staff, admission policies, cooperative relationships with other agencies and programs, and referral procedures to other services both within and outside the area. 10. Review programs for construction. Decision as to the acceptability of a pro- gram for inclusion in the overall State plan should be based upon formal review and con- sideration by the State planning agency. Proposals for construction of specific facilities should be reviewed in terms of their operating program, proposed location, design, and cost. Analysis of the operating program should in- clude such items as: (a) The types of patients to be served and the specific services to be provided. (b) The area which the proposed facility can serve. (c) The extent to which the proposed services will be integrated with other closely related programs of treatment. Care should be taken not to lose any of the efiectiveness of already established programs and services.” ((1) The extent to which the services will be coordi- nated with other community programs and services. Consideration should be given to establishing opera- 33 tional relationships with hospitals, health and welfare agencies, service associations, schools, courts, general practitioners, etc. (e) Provision for follow—up and aftercare of the pa- tients to be treated. (f) The operation. stafl‘ing pattern required for effective (g) The current availability and anticipated sources of financial support for the construction of the required facility, and for maintenance and operational costs of the service program. The location of the proposed facility should be carefully reviewed in terms of the ready availability of its services to the population, 34 and of its physical relationship or proximity to a general hospital or other medical service cen— ter. Finally, consideration should be given to the size of the facility, the adequacy of design for the proposed program of operation, and such factors as flexibility and feasibility of use for multiple purposes. Proposed construction with funds over which the State government has no control should be reviewed by the appropriate State agency, and those projects which are not in conformance with the State plan should be ac- tively discouraged. Chapter III Factors Impeding Effective Implementation of the Plan POLITICAL, ECONOMIC, and social factors which have evolved as a result of past attitudes toward mental illness will directly influence the nature and development of a plan for a comprehensive system of mental health facilities. Recognition of these factors and the problems they pose, and the development of positive programs for ef- fecting necessary changes are essential to the development of the plan and to its implementa- tion. Most of these factors involve legal and ad- ministrative considerations, financing, ade- quate stafling with trained personnel, and pro- fessional endorsement and social acceptance. LEGAL AND ADMINISTRATIVE CONSIDERATIONS Care and support of the mentally ill for many years have been considered to be primarily a re- sponsibility of State government. Assumption of this responsibility by the State has resulted in the formation of a rigid structure of law and regulatory procedure through which the ac- cepted programs of treatment and care are implemented. Any proposal to modify current methods of handling the problem of mental ill- ness must take into consideration the need for, impact of, and possible resistance to changes in pertinent legislation and administrative practices. Modernization of Admission and Discharge Procedures Commitment procedures, with their emphasis on curtailment of individual rights and segre— gation of the patient from society, have not been conducive to public acceptance of a mental hos- pital as a place of treatment. The difficulties of discharge inherent in the process add to the public impression of the finality of admission to a mental hospital and have undoubtedly been instrumental in discouraging voluntary admis- sions and the free use of these facilities. To promote more effective use of existing mental hospital facilities in a coordinated pattern of service, procedures are urgently needed to guarantee the patient early and informal ad- mission for treatment. Legal barriers to treat— ment, such as outmoded or restrictive commit- ment procedures, should be eliminated so that the right of the patient for early treatment may be preserved. Joint State-Local Responsibility Changing concepts of diagnosis, treatment, and care of mental patients have brought about a reevaluation of the relative roles and responsi- bilities of the State and local governments in providing and supporting mental health serv- ices. Recognition of the values of preventive activities, early diagnosis, and intensive treat— ment in a local setting has led a number of States to provide for joint State and local re- sponsibility and support of such community activities as mental health clinics, psychiatric services in community-operated hospitals, and consultative services to local health and wel- 35 fare agencies, educational systems, and law en- forcement agencies.* Some States have ac- complished this by Community Mental Health Services Acts. Whether by legislation or by administrative decision, arrangements of this type may develop a sense of community and family responsibility for providing and sup- porting local mental health services. Further- more, the availability of financial assistance for local facilities would encourage their devel- opment and use and would minimize existing tendencies on the part of local agencies to rele- gate patients to State-supported institutions primarily because of economic considerations. Coordination of Local Services In many communities a number of difi'erent agencies such as local health departments, schools, courts, and industrial organizations, provide some elements of a mental health pro- gram. While these isolated programs fulfill a part of the community needs, they may lack a unified purpose and deter the development of an effective community—wide program. The authority of the appropriate State agency should be such as to enlist the cooperation of these agencies in the development of a coordi- nated program. Personnel Standards The practice of direct staff appointment by executive or administrative authority, rather than through the merit system process, is still being applied in some States. This practice ‘For additional information, see Fact Sheet Number 8, January 1959, “Highlights of Recent Community \Mental Health Legislation,” issued by the Joint In- formation Service of the American Psychiatric Asso- ciation and National Association for Mental Health. adversely affects the development of high standards of hospital operation and adminis- tration. In the interest of better patient care, this policy should be abandoned and the selec- tion and appointment of all staff personnel for public mental health facilities should be made on a merit basis, under standards and proce- dures set forth in a statewide system of per— sonnel administration. Legislative Recognition of Needs of Mentally Retarded and Senile Aged Until recently, the problems of mental retarda— tion and care of the senile aged have been viewed almost entirely in terms of the provision of custodial-type care. To permit more effec- tive planning, these conditions should be recog- nized in any legislative action as related to the overall problem of mental care and treatment. Legislative restrictions which prevent more adequate treatment should be removed so that these groups may receive equal status in an overall plan for developing, constructing, and financing needed facilities. This planning should be done in collaboration with other bodies which would be involved with planning other types of long-term care facilities. Continuity of Records Attempts to develop a program of progressive care and treatment in accordance with the changing needs of the patient will be seriously hampered by current difficulties in obtaining records of previous treatment. Implementa- tion of the concept of continuity of patient care requires that appropriate legal or administra- tive changes he made to provide for continuity and easy transfer of the patients’ records. FINANCIAL PROBLEMS In past years, mental health facility construc- tion has been directed primarily toward the 36 development of large central institutions, owned and operated by the States. Changing concepts of treatment and care point to the need for redirecting construction activity in the field and emphasizing the necessity of provid- ing funds for community—based facilities. Costs of Construction The cost of new construction and the conversion of existing facilities to new uses preferably should be shared jointly under a cooperative system of Federal-State-local financing, operat- ing Within a framework of defined need and a pattern of priorities set forth in the statewide plan. Heretofore, funds allocated to the States under the Hill-Burton program have been used primarily for the construction of needed general hospitals. Slightly less than 5 percent of the total Hill-Burton funds has been utilized to assist in constructing mental health facilities. The possibility of alloting a greater proportion of these funds to this area should be investi- gated in each State. Also, the Department of Health, Education, and Welfare is urged to consider the feasibility of modifying the Hill- Burton legislation to assure additional assist- ance in constructing and equipping mental health facilities, particularly those in local communities. Serious consideration should be given to the development of a State grant-in-aid pro- gram for financial assistance in establishing and operating communityebased facilities. Such a program would encourage local communities to accept the responsibility of providing needed facilities and services and would decrease the demands on the State institutions. Costs of Operation The development of a. network of coordinated facilities is severely handicapped unless there is some assurance that ' reasonably adequate financial resources will be available for their support at an effective level of operation. Re- liance on individual resources for this support is unrealistic. A recent study 1“ indicates that a mere 10 percent of the population, at the present time, can really afford to buy psychiatric care on a private basis. In this era of high construction, maintenance and staffing costs, adequate mental care and treatment must come through the pooling principles implicit in in- surance or through the cost—spread principle of support through public tax funds. Most health insurance and other prepay- ment plans have not provided coverage for patients with mental illness. Recent removal of this restriction by some plans, at least in part, and with little or no increase in subscription rates, is encouraging. As experience accumu- lates, and in recognition of the increasing de- mand for insurance services in this field, it may be expected that costs of diagnosis and early treatment, at least, will increasingly be covered by a prepayment technique. Means of expand- ing prepayment benefits to such other services as day hospitals, nursing homes, and rehabilita- tion activities need to be developed. The major portion of the cost of mental care and treatment will, in all probability, con- tinue to be met from public funds. Current approaches to the problem, however, in terms of its recognition and appropriation of adequate financial support, leave much to be desired. Average per patient maintenance expenditures in public non—Federal mental hospitals were only $4.06 per day in 1958. In contrast, the ex- pense for a patient in a short-term general hos- pital in 1958 was reported as over $28 per day. On the other hand, the average national per capita expenditures for community mental health programs showed an encouraging in- crease in the period 1955 to 1958. While still small in comparison to the average national per capita expenditures for State mental hospitals, the combined Federal, State, local and private expenditures for community-based programs almost tripled during the three-year period. A continuation of this trend would provide a firmer basis for developing a comprehensive program of community health services. The “feast or famine” atmosphere which has too frequently influenced the provision of financial support to State mental health pro- grams has been detrimental to the development of an effective approach to the problem. The need for an adequate and continuing level of 37 treatment of the mentally ill must be recognized by legislative bodies and must be given contin- ued and adequate support. More Widespread adoption by the States of appropriate commu- nity mental health legislation, providing State assistance on a more permanent basis for ac- ceptable local programs and facilities, should be encouraged. The possibility of increased as- sistance to the mentally ill under State welfare laws should be explored. At the Federal level, additional assistance should be provided, not only through increasing the present State grant- in-aid for community mental health programs, but through removal of restrictive eligi- bility requirements in the Public Assistance provisions of the existing Social Security Act, which now discriminate against the mentally ill. Research and Planning Funds Finally, the eflicacy of a program, whether for provision of service or for construction of needed facilities, and the extent to which it will meet the real needs of the State or community, will depend, in large part, upon the availability of adequate funds for research, planning, and administration. The lack of sufficient funds at both State and local levels for these activities constitutes a basic problem which must be re- solved. Adequate funds and staff must be made available both for initial survey and planning procedures, and for continuing study of the op— eration of the developing program and the effectiveness with which it is meeting changing needs. PERSONNEL AND STAFF Probably the most serious problem facing the field of mental health today is the scarcity of professional and skilled personnel needed for the care and treatment of the mentally ill. This shortage, in varying degrees, exists in all cate- gories of personnel and in all sections of the country. Most of our existing State mental hospitals do not have enough professionally- trained and psychiatrically-skilled staff to pro- vide the individual therapeutic attention needed for optimum care and recovery. A recent sur- vey indicated that, as a national average in 1958, there were only 3.4 professional patient care personnel per 100 patients in public non- Federal hospitals. This figure includes physi- cians, registered nurses, social workers, psy- chologists, psychometrists and therapists. While this ratio represents an increase over the comparable figure of 2.8 reported for 1956, its significance in terms of man-hours of service per patient has been reduced by adjustments in working conditions and a shorter work week. In none of the categories listed has an adequate level of staffing been reached. Shortage of Psychiatrists A serious shortage of qualified psychiatrists still exists throughout the Nation. While estimates 38 vary, it is generally agreed that the number of psychiatrists currently in active practice should be at least doubled, if existing need for services is to be met. The effects of the overall shortage of psy- chiatrists are further aggravated by the strong tendency of professional people to congregate in urban areas. Psychiatric services are sig- nificantly more available in the urban northeast region of the country than in the more rural regions as represented by the South Central States. Added evidence of the concentration of psychiatric services in areas of high popula- tion density is given by a report that in 1957, 54.1 percent of all psychiatrists resided in the 15 larger metropolitan areas of the country, which contained only 30.8 percent of the total population. Related Professional Groups Psychologists are in greater supply. As a re- sult of increased interest in the field since World War II, the number of psychologists in this country has quadrupled. However, only about a third of the total number are engaged in clinical services. The remainder are employed in teaching capacities, governmental research, private industry and other activities not directly related to mental health.“ In 1955 mental hospitals employed slightly less than 14,000 professional nurses. This means that only 5 percent of the professional nurses employed in hospitals of all types pro- vided care in mental institutions which con- tain about 50 percent of the Nation’s total hospital beds.10 Data published by the Amer- ican Nursing Association in 1957 further em- phasize the nursing shortage in mental hos— pitals. These data indicated that the nurse/ bed ratio in that year was one nurse to every 53 beds in psychiatric hospitals, whereas in general hospitals it was one to every three beds. Estimates by the US. Department of Labor for 1957 place the total number of social workers in the United States at approximately 80,000. Only a very small proportion of these devotes time to psychiatric cases. However, the number of individuals in this specialty ap- pears to have been increasing during the past few years, while other areas of social work have decreased. Again, studies of the distribution of this specialized group show a marked con- centration in urban areas, with the highest worker population ratio occurring in the heavily populated northeast region of the country.10 Adequacy of Stafing Estimates of the adequacy of the supply of the various categories of mental health personnel are available only in terms of standardized needs of public mental hospitals. Based on a recent review of the problem, the American Psychiatric Association concludes that, except for a few teaching centers, no tax—supported hospital in the United States can be considered adequately stafl'ed. However, the same source reports evidence of some improvement in this situation in recent years. In terms of the needs of public mental hospitals, measured on the basis of APA standards, the number of physi- cians employed in these hospitals increased from 45 percent adequacy in 1956 to 57 percent in 1958. During the same period, the percent ade- quacy of numbers of psychologists has increased from 65 to 76 percent; of registered nurses, from 20 to 23 percent; and of social workers from 36 to 40 percent.“ Even with these im- provements, the problem of staff adequacy continues to be serious. These universal shortages prevent the op- eration of current programs at full potential. In addition, these shortages are apt to impose basic limitations upon the development of more progressive approaches to the problem of mental care. Methods of augmenting existing personnel resources must be developed, both by exploring creative ways to use personnel and by developing procedures of direct assistance in education and training through a form of con- trolled subsidy. In addition, activities should be directed toward such immediate objectives as an active recruitment program, more attrac- tive salary scales, in—service training programs, and more efficient utilization of present person- nel. While the particular approach in each State must be guided by existing conditions, any proposed program for improvement of mental treatment and care must have, as a par- allel development, a practicable method of as- suring the availability of adequate and com- petent stafl". SOCIAL ATTITUDES Successful implementation of a program of mental health sevices depends, in large part, upon public recognition of the need for services and acceptance of the purpose and objectives of the program. A receptive community attitude gives greater assurance of effective utiliza- tion of a service or facility and of continuing community support. A negative attitude, on the other hand, because of apathy, indifference or actual opposition, may prevent the achieve- 39 ment of a desirable level of program operation. Community indifference stems largely from a lack of understanding of the nature of mental illness, the forms in which it is mani- fested, and the feasibility of treatment. This indifference is abetted by the feeling of social stigma which, while becoming less pronounced, is still connected with mental illness. Result- ing unwillingness by the individual to admit to being mentally ill and to seek treatment, at- tempts at concealment by family and friends, and, finally, the accepted pattern of removal of the individual from the social group to insti- tutional care, have all contributed to a lack of community realization of the extent of the problem and the need for community services. Community resistance to a proposed pro- gram or facility may be due to a reluctance to assume the added economic burden upon the 40 resources of the community, civic objection to the location of a care or treatment facility in the community, actual fear of contact With the mentally ill, and, on occasion, a feeling of ri- valry and competition on the part of existing services. The existence of these attitudes constitutes a serious deterrent to the development and ef- fective operation of a community-based pro- gram of mental health services, and to the planning of a coordinated system of facilities. Assessment of their intensity and significance as determinants of community action, and an evaluation of the potential for change through an intensive program of community education, represent factors of major importance in de- veloping a statewide program for construction of mental health facilities. Chapter IV Implementing the State Plan CONSIDERATION or procedures for implementing the statewide plan and program should be an intrinsic part of the planning process. To assure that a positive program of implementa- tion will be developed, the planning body must clearly define the roles and responsibilities of the various participating agencies and groups, and their planned courses of action. The specific action programs undertaken to implement the plan will vary from State to State depending upon existing conditions. There will, however, be many general areas to which planning groups in all States must direct their attention. Accordingly, the committee has developed a number of recommendations in these areas which may be used as general guide— lines in implementing the statewide plan and program. STIMULATING INTEREST Successful implementation of the statewide plan and program will depend to a large extent upon the degree to which interest in the pro- gram and acceptance of the program objectives can be generated throughout the State. As an initial step in this direction, efforts should be made to enlist the understanding and support of the professional groups involved. In addi- tion, support should be sought from news- papers and other information media to pub- licize the purposes and activities of the planning group and the nature of the proposed program. Effective dissemination of such in- formation would stimulate interest and create a favorable climate of opinion for more direct activities with appropriate State and local opinion-molding groups. State Organizations and Groups A special information program should be de- veloped by the State planning group and affiliated bodies for presentation to meetings of State organizations and groups such as hos- pital associations, medical societies, nursing home associations and other associations and interested groups. Discussion topics and guide materials for these meetings should cover the following areas: (a) The overall objectives 01' the statewide plan and program. (b) The advantages of the proposed coordinated sys- tem of facilities and services as contrasted with cur- rent conditions. (c) The relationship of the mental health facilities and services to other types of medical care facilities. ((1) The manner in which the program is geared to provide the various kinds and levels of treatment and care required under present conditions and knowledge and the reasons why it will provide better and more adequate treatment and care. (e) Suggestions as to the ways in which such or- ganizations and groups can assist in achieving the immediate and long-range objectives of the program. (1’) The need for educational programs and publicity through the various means of mass media and through working with professional and lay groups. Regional and Local Organizations Local interest in providing needed mental health facilities and services should be stimu- 41 lated through a program of education and assistance to local groups. Under this program, representatives of the State planning body and affiliated groups, including the State Hill- Burton agency, would work with regional and local organizations, professional and lay groups and community leaders to inform them of : (a) The overall objectives of the program and the advantages of the coordinated system set forth in the statewide plan. (b) Those provisions of the statewide plan applicable to the area or community concerned, including its relationship to other areas or regions and the services, if any, available outside the community. (c) The types of facilities and services programed for the area. ((1) The kind of financial aid available to the com- munity for capital construction, maintenance, and operation. In addition, representatives of the planning body could assist in creating sponsor interest by meeting with representatives of the local hospitals, nursing homes, or other groups which are or may be involved in providing some form of treatment, care, or service to the mentally ill. As interest is developed, aid could also be given in (a) determining the type of facility to be constructed and the scope of the proposed program, (b) assessing the staffing needs for the planned facility and of the stafl‘ing resources in the community, and (0) developing programs for securing additional staff, if necessary. FINANCIAL BASIS FOR IMPLEMENTING THE PLAN The extent to which the plan for mental health facilities can be implemented will depend in great measure on the availability of Federal, State, and local funds for construction pur- poses, and the degree to which appropriate stimuli can be applied to assure use of these funds only for projects programed in the approved State plan. Federal Aid Heretofore, only a small portion of the funds allocated to the States under the Hill-Burton program have been used to assist in constructing mental health facilities. In recognition of the current need for mental health services at the community level, the State Hill-Burton agency should examine its policy for allocation of available funds and take steps to assure that a greater proportion of these funds will be utilized in the field of mental health, with spe- cial emphasis on community mental health facilities. In addition, the Department of Health, Education, and Welfare should con- sider the advisability of requesting legislative authority for a categorical grant to States to 42 further assist in the implementation of the program. State Aid A system of State aid for constructing locally sponsored public and voluntary nonprofit facili- ties should be developed, preferably as a part of more comprehensive community mental health legislation. Such State assistance should be in accordance with the State plan and the priority system. Programing of facilities and services must include consideration of means for assuring their effective operation and utilization. To this end, proposed community mental health legislation should include provisions for State assistance to local communities in financing the cost of maintaining and operating local mental health facilities. Local Aid Funds provided for capital construction by local agencies and groups and the general public should be made available only to those project sponsors who will provide facilities which are geared to meet needs as set forth in the State plan. In addition to the stimulus of State and Federal assistance, action toward this goal should include (1) the achievement of public acceptance of the program through widespread publication of program objectives and (2) di- rect persuasion of the local agencies and groups which control and distribute construction funds. Third Party Payment Plans Third party payment systems, whether through State or local public assistance programs, medi- cal coverage under Social Security, or prepay- ment insurance plans, should be encouraged to lessen or remove present restrictions on assist- ance to mentally ill patients. LEGISLATIVE AND ADMINISTRATIVE PROGRAM Restrictive provisions in existing legislation affecting the field of mental health and the need for modified or new legislation will come to light as the plan and program are developed. The planning group, therefore, should establish working arrangements with appropriate ad- ministrative and legislative bodies so that the following activities may be undertaken: (a) An analysis of all pertinent mental health legis- lation to determine the need for changes in restrictive provisions and the kind of modifications or new legis- lation needed to eliminate this problem. (b) The development of action programs directed toward such legislative and administrative objectives as: (1) Enactment of community mental health legisla- tion which would provide, on a permissive basis, for State financial assistance to locallybperated mental health facilities operating under an ap- proved community-Wide mental health program. The impetus provided through adequate State appropriation of funds for such facilities would be a major factor in developing an adequate com- munity-oriented program of mental health services. (2) Modification of existing legislation, at local, State and Federal levels, to provide greater recognition of and a more definitive approach to the problems of treatment, care, and rehabilitation of the aged and the mentally retarded. (3) Modernization of restrictive admission and dis- charge procedures in order to stimulate voluntary admissions to treatment and to encourage the free use of available mental facilities. (4) Adoption of a statewide merit system of per- sonnel administration for all publicly-owned mental health facilities. (5) Removal of existing restrictions on transfer of patient records to permit more effective imple- mentation of the concept of continuity of care. 43 Appendix Tables Tables 1-8 The data for these tables were developed from a Master Register of Hospitals, compiled by the Division of Hospital and Medical Facilities of the Public Health Service, from the following primary and supplementary sources: Primary Sources .' Hill-Burton State Plans for Fiscal Year 1959 Veterans Administration Field Summary Report, January 1958 Listing of Public Health Service Hospitals, compiled by the Division of Indian Health and the Division of Hospitals Supplementary Sources .' American Hospital Association, Guide Issue, August 1958 Osteopathic Directory, 1958 Catholic Hospital Association Directory, 1958 Listing of Mental Hospitals, compiled by the National Institute of Mental Health, March 1958 Table 9 Information for this table was obtained from the 1959 State Plans for Hos- pital Construction, as recorded by the Division of Hospital and Medical Facilities, in the publication, “Hospital and Medical Facilities in the United States, as of January 1, 1960.” 45 TABLE 1. Territories, 1959 Psychiatric Hospitals and Institutions for Mentally Deficient, by Type of Ownership, United States and Number Number Number Average Number Ownership and type of service of hospi- of beds of admis- daily of person- tals sions census nel Non-Federal PUBLICLY OWNED: State or Territorial: Psychiatric ___________________________________ 235 459, 949 204, 281 507, 414 151, 487 Mental deficiency _____________________________ 87 85, 925 29, 000 76, 204 20, 737 County: Psychiatric ___________________________________ 49 17, 337 8, 453 20, 625 3, 330 Mental deficiency _____________________________ 1 835 199 789 267 City: Psychiatric ___________________________________ 1 72 368 61 N.A. Mental deficiency _____________________________ 1 36 1, 304 34 25 NONPROFIT: Psychiatric ___________________________________ 76 9, 322 38, 179 7, 172 8, 452 Mental deficiency _____________________________ 6 1, 102 1, 214 944 295 PROPRIETARY: Psychiatric ___________________________________ 259 16, 621 63, 232 9, 129 6, 401 Mental deficiency _____________________________ 169 5, 389 N.A. 4, 917 N.A. TOTAL NON-FEDERAL: Psychiatric ___________________________________ 620 503, 301 314, 513 544, 401 169, 670 Mental deficiency _____________________________ 93, 287 31, 717 82, 888 21, 324 Federal VETERANS: Psychiatric ___________________________________ 41 59, 350 38, 263 52, 978 37, 811 OTHER FEDERAL: Psychiatric ___________________________________ 1 5, 582 1, 615 6, 994 2, 591 TOTAL FEDERAL: Psychiatric ___________________________________ N. A.——Not available. TABLE 2. Number of Psychiatric Hospitals and Beds, by Size of Hospitals, United States and Territories, 1.95.9 NON-FEDERAL FEDERAL Publicly owned Nonprofit Proprietary Total non— Total Size of Federal hospitals Number Number Number Number Number Number Number Number Number Number hospi- beds hospi- beds hospi- beds hospi- beds hospi- beds tals tals tals tals tals Under 25 beds--- 2 38 8 154 61 1,041 71 1, 233 ---------------- 25—49 ----------- 3 98 17 618 77 2, 764 97 3, 480 ---------------- 50—99 ----------- 15 1, 113 23 1, 575 73 5, 162 111 7, 850 ---------------- 100—199 --------- 30 4, 634 12 1, 780 34 4, 292 76 10, 706 ---------------- 200—299 --------- 17 4, 314 10 2, 344 4 871 31 7, 529 ---------------- 300—399 --------- 13 4, 778 4 1, 356 3 1, 100 20 7, 234 ---------------- 500—999 --------- 25 19, 217 2 1, 495 2 1, 391 29 22, 103 14 11, 506 1,000—1,999 ______ 85 125, 985 ________________________________ 85 125, 985 18 26, 986 2,000—2,999 ------ 56 136, 928 ________________________________ 56 136, 928 8 17, 257 3,000-0ver ------- 38 180, 253 ________________________________ 38 180, 253 2 9, 183 Unknown ________ 1 N.A. ---------------- 5 N.A, 6 N.A. ---------------- Totals _____ 285 477, 358 76 9, 322 259 16, 621 620 503, 301 42 64, 932 TABLE 3. Number of Institutions and Beds for Mentally Deficient, by Size of Institution, United States and Territories, 195.9 NON—FEDERAL Size of institutions Publicly owned Nonprofit Proprietry Total Number Number Number Number Number Number Number Number institutions beds institutions beds institutions beds institutions beds Under 25 beds- - - - 4 71 ____________________ 41 572 45 643 25-49 ------------ 8 294 ____________________ 22 692 30 986 50—99 ------------ 9 617 2 110 22 1, 508 33 2, 235 100—199 ---------- 12 1, 773 1 100 6 812 19 2, 685 200—299 __________ 5 1, 241 ____________________ 1 250 6 1, 491 300—499 ---------- 4 1, 510 1 392 1 405 6 2, 307 500—999 __________ 14 9, 535 1 500 2 1, 150 17 11, 185 LOCO—1,999 ------- 12 17, 245 ________________________________________ 12 17, 245 2,000—2,999 ------- 8 19, 275 ________________________________________ 8 19, 275 3,000—over ________ 8 35, 235 ________________________________________ 8 35, 235 Unknown _________ 5 N.A. 1 N.A. 74 N.A. 79 N.A. Total___- _ -_ 89 86, 796 6 1, 102 169 5, 389 264 93, 287 47 TABLE 4. Number of Psychiatric Hospitals and Beds, by Size of Community, United States and Territories, 1959 NON-FEDERAL FEDERAL Publicly Owned Nonprofit Proprietary Total non- Total Size of Federal community Number Number Number Number Number Number Number Number Number Number hospi— beds hospi— beds hospi- beds hospi- beds hospi— beds tals tals tals tals tals 250,000 and over- 31 41, 507 26 2, 899 63 3, 800 120 48, 206 3 10, 149 100,000—249,999_- 19 28, 787 7 719 18 1, 478 44 30, 984 1 546 50, 000-99, 999--- 21 43, 792 9 866 25 1, 437 55 46, 095 6 9, 120 25,000-49,999--__ 36 57, 609 9 1, 222 12 749 57 59, 580 9 13, 409 10, 000—24, 999--_ 38 59, 110 7 344 29 1, 777 74 61, 231 6 7, 574 2, 500——9, 999 ..... 67 95, 930 5 915 4] 2, 537 113 99, 382 6 9, 573 Under 2,500 ----- 73 150, 623 13 2, 357 71 4, 843 157 157, 823 11 14, 561 Total _____ 285 477, 358 76 9, 322 259 16, 621 620 503, 301 42 64, 932 TABLE 5. Number of Institutions and Beds for Mentally Deficient, by Size of Community, tories, 1959 United States and Terri- NON-FEDERAL Size of community Publicly owned Nonprofit Proprietary Total Number Number Number Number Number Number Number Number institutions beds institutiom beds institutions beds institutions beds 250,000 and over_- 3 7, 630 2 60 15 480 20 8, 170 100,000—249,999-_ - 3 315 ____________________ 12 230 15 545 50,000—99,999 ----- 1 360 -------------------- 4 124 5 484 25,000—49,999 ----- 10 12, 416 ____________________ 9 277 19 12, 693 10,000—24,999 _____ 15 18, 118 1 100 21 1, 126 37 19, 344 2,500—9,999 _______ 27 18, 577 1 500 36 995 64 20, 072 Under 2,500 ------ 30 29, 380 2 442 72 2, 157 104 31, 979 Total ------ 89 86, 796 6 1, 102 169 5, 389 264 93, 287 48 TABLE 6. Mental Beds in General Hospitals, by Ownership, United States and Territories, 1.959 Mental beds Hospitals Total Number of Ownership with number general mental of beds beds Percentage beds Number of total capacity N art-Federal PUBLICLY—OWNED: State or Territorial ______________________ 22 14, 986 10, 958 2, 857 19. 1 (State prisons) _________________________ (4) (1, 484) (44) (1, 440) (97. 0) County ________________________________ 35 23, 079 14, 222 4, 275 18. 5 City __________________________________ 24 21, 515 16, 036 2, 932 13. 6 City-county ____________________________ 13 6, 464 4, 708 519 8. 0 Total ____________________________ 94 66, 044 45, 924 10, 583 16. 0 NONPROFIT: Church-operated ________________________ 99 33, 242 29, 052 2, 981 9. 0 Other nonprofit _________________________ 78 36, 906 32, 244 3, 152 8. 5 Total ___________________________ 177 70, 148 61, 296 6, 133 8. 7 PROPRIETARY: Total ____________________________ 2 182 152 30 16. 5 Total Non-Federal ______________________ 273 136, 374 107, 372 16, 746 12. 3 Federal PHS __________________________________ 3 1, 392 856 121 8. 7 Veterans _______________________________ 100 53, 273 37, 575 10, 773 20. 2 Other Federal (prisons) __________________ 1 117 104 13 11. 1 Total Federal ____________________ 104 54, 782 38, 535 10, 907 19. 9 Total General Hospitals With Mental Beds __________________ 377 191, 156 145, 907 27, 653 14. 5 49 TABLE 7. Mental Beds in General Hospitals, by Size of Hospitals, United States and Territories, 1.95.9 Number of Mental beds hospitals Total num- Number of Size of hospital with mental ber of beds general beds beds Number Percent of total capacity All general hospitals with mental beds 25—49 beds _____________________________ 2 79 49 30 38. 0 50—99 _________________________________ 3 252 213 39 15. 5 100—199 _______________________________ 46 7, 381 6, 032 985 13. 3 200-299 _______________________________ 71 16, 687 14, 289 2, 098 12. 6 300-499 _______________________________ 125 49, 499 39, 727 5, 496 11. 1 500—999 _______________________________ 92 64, 638 50, 775 7, 547 11. 7 LOGO—1,999 ____________________________ 26 31, 553 22, 993 5, 035 16. 0 2,000—2,999 ____________________________ 4 10. 019 6, 605 1, 687 16. 8 3,000—0ver _____________________________ 3 9, 447 5, 076 3, 283 34. 8 Total ____________________________ *372 189, 555 145, 759 26, 200 13. 8 Non-Federal PUBLICLY—OWNED: 50—99 beds _____________________________ 1 73 67 6 8. 2 100—199 _______________________________ 4 608 342 77 12. 7 200—299 _______________________________ 14 3, 291 2, 697 411 12. 5 300-499 _______________________________ 25 9, 807 7, 351 696 7. 1 500—999 _______________________________ 30 21, 843 16, 480 1, 986 9. 1 1,000—1,999 ____________________________ 11 14, 094 10, 302 1, 894 13. 4 2,000—2,999 ____________________________ 2 5, 397 3, 565 790 14. 6 3,000—over _____________________________ 3 9, 447 5, 076 3, 283 34. 8 Total ____________________________ *90 64, 560 45, 880 9, 143 14. 2 NONPROFIT: 25—49 beds _____________________________ 1 32 25 7 21. 9 50—99 _________________________________ 2 179 146 33 18. 4 100—199 _______________________________ 32 5, 015 4, 156 684 13. 6 200—299 _______________________________ 38 9, 069 7, 903 1, 083 11. 9 300—499 _______________________________ 62 23, 650 20, 735 1, 750 7. 4 500—999 _______________________________ 38 26, 568 23, 572 2, 022 7. 6 LOGO—1,999 ____________________________ 3 3, 135 2, 889 224 7. 1 2,000—2,999 ____________________________ 1 2, 500 1, 870 330 13. 2 Total ____________________________ 177 70, 148 61, 296 6, 133 8. 7 PROPRIETARY: 25—49 beds _____________________________ 1 47 24 23 48. 9 100—199 _______________________________ 1 135 128 7 5. 2 Total ____________________________ 2 182 152 30 16. 5 Total Non-Federal ________________ *269 134, 890 107, 328 15, 306 11. 3 See footnote at end of table. 50 TABLE 7. Mental Beds in General Hospitals, by Size of Hospitals, United States and Territories, 1959—Con. Number of Mental beds hOSpitals Total num- Number of Size of hospital with mental ber of beds general beds beds Number Percent of total capacity Federal PUBLIC HEALTH SERVICE: 300—499 beds ___________________________ 2 876 419 42 4. 8 500—999 _______________________________ 1 516 437 79 15. 3 Total ____________________________ 3 1, 392 856 121 8. 7 VETERANS: 100—199 beds ___________________________ 9 1, 623 1, 406 217 13. 4 200—299 ______________________________ 19 4, 327 3, 689 604 14. 0 300-499 _______________________________ 36 15, 166 11, 222 3, 008 19. 8 500—999 _______________________________ 23 15, 711 10, 286 3, 460 22. 0 l,000—1,999 ____________________________ 12 14, 324 9, 286 3, 917 20. 4 2,000—2,999 ____________________________ 1 2, 122 1, 170 567 26. 7 Total ____________________________ 100 53, 273 37, 575 10, 773 20. 2 Total Federal ____________________ *103 54, 665 38, 431 10, 894 19. 9 *Excludes prison hospitals (4 State and 1 Federal). TABLE 8. Mental Beds in General Hospitals, by Size of Community, United States and Territories, 1959 Mental beds Hospitals Size of community with Total beds General mental beds beds Percent of Number total capacity All General Hospitals with Mental Beds 250,000 and over _______________________ 137 95, 237 75, 553 11, 807 100—250 thousand _______________________ 77 33, 102 26, 670 3, 436 50—100 thousand ________________________ 62 23, 296 18, 584 2, 848 25-50 thousand _________________________ 40 14, 722 11, 051 2, 061 10—25 thousand _________________________ 25 6, 807 4, 761 982 2,500—10,000 ___________________________ 12 3, 623 2, 423 632 Under 2,500 ____________________________ 19 12, 768 6, 717 4, 434 Total ______________________________ *372 189, 555 145, 759 26, 200 See footnote at end of table. TABLE 8. Mental Beds in General Hospitals, by Size of Community, United States and Territories, 1959—C0n. Mental beds Hospitals Size of community with Total beds General mental beds beds Percent of Number total capacity N art-Federal PUBLICLY-OWNED: 250,000 and over- - .. - ___________________ 37 37, 030 27, 896 4, 258 11. 4 100— 250 thousand _______________________ 18 8, 229 6, 599 686 8. 3 50—100 thousand ________________________ 12 5, 590 4, 512 562 10. 1 25—50 thousand _________________________ 11 6, 023 4, 329 667 11. 1 10—25 thousand _________________________ 4 1, 266 516 132 10. 4 2,500.10,000 ___________________________ 3 1, 430 799 140 9. 8 Under 2,500 ____________________________ 5 4, 992 1, 229 2, 698 54. 0 Total ____________________________ *90 64, 560 45, 880 9, 143 14. 2 NONPROFIT: 250,000 and over _______________________ 69 35, 648 31, 100 3, 477 9. 8 100—250 thousand _______________________ 39 16, 235 14, 171 1, 149 7. 1 50—100 thousand ________________________ 34 10, 662 9, 429 755 7. 1 25—50 thousand _________________________ 18 4, 197 3, 676 338 8. 1 10—25 thousand _________________________ 12 2, 390 2, 086 274 11. 5 2,500—10,000 ___________________________ 2 378 306 30 7. 9 Under 2,500 ____________________________ 3 638 528 110 17. 2 Total ____________________________ 177 70, 148 61, 296 6, 133 8. 7 PROPRIETARY: 100—250 thousand _______________________ 1 135 128 7 5. 2 2,500—10,000 ........................... 1 47 24 23 48. 9 Total ............................ 2 182 152 30 16. 5 Total Non-Federal ________________ *269 134, 890 107, 328 15, 306 11. 3 Federal PUBLIC HEALTH SERVICE: 250,000 and over ....................... 1 470 296 24 5. 1 100—250 thousand _______________________ 1 406 123 18 4. 4 Under 2,500 ___________________________ 1 516 437 79 15. 3 Total ____________________________ 3 1, 392 856 121 8. 7 VETERANS: 250,000 and over _______________________ 30 22, 089 16, 261 4, 048 18. 3 100—250 thousand _______________________ 18 8, 097 5, 649 1, 576 19. 5 50—100 thousand ________________________ 16 7, 044 4, 643 1, 531 21. 7 25—50 thousand _________________________ 11 4, 502 3, 046 1, 056 23. 5 10—25 thousand _________________________ 9 3, 151 2, 159 576 18. 3 2,500—10,000 ___________________________ 6 1, 768 1, 294 439 24. 8 Under 2,500 ____________________________ 10 6, 622 4. 523 1, 547 23. 4 Total ____________________________ 100 53, 273 37, 575 10, 773 20. 2 Total Federal ____________________ *103 54, 665 38, 431 10, 894 19. 9 *Excludes prison hospitals (4 State and 1 Federal). 52 TABLE 9. Existing Acceptable Mental Hospital Beds in Each State and Possession, and Beds per 1,000 Population 1969* Population 1' Acceptable State Number beds 100)” Year Total population ____________ 174, 291, 000 449, 532 2. 58 4.00—4.99 Beds Per 1,000 Population - Rhode Island _______________________________________ 1957 830, 000 3, 622 4. 36 New York __________________________________________ 1958 16, 184, 000 65, 381 4. 04 Connecticut _________________________________________ 1958 2, 304, 000 9, 247 4. 01 3.00—3.99 Beds Per 1,000 Population New Hampshire _____________________________________ 1957 565, 000 2, 180 3. 86 Massachusetts _______________________________________ 1958 4, 813, 000 18, 053 3. 75 Nebraska ___________________________________________ 1957 1, 439, 000 5, 256 3. 65 New Jersey _________________________________________ 1958 5, 697, 000 19, 345 3. 40 Oklahoma __________________________________________ 1958 2, 250, 000 7, 580 3. 37 Maryland ___________________________________________ 1958 2, 899, 000 9, 379 3. 24 California ___________________________________________ 1958 14, 025, 000 45, 119 3. 22 Maine ______________________________________________ 1958 935, 000 2, 955 3. 16 Georgia ____________________________________________ 1958 3, 749, 000 11, 702 3. 12 Wisconsin __________________________________________ 1958 3, 932, 000 12, 131 3. 09 2.00—2.99 Beds Per 1,000 Population Minnesota __________________________________________ 1958 3, 370, 000 9, 907 2. 94 Montana ___________________________________________ 1958 682, 000 1, 906 2. 79 North Dakota _________________________________________ 1958 649, 000 1, 766 2. 72 Oregon _____________________________________________ 1958 1, 768, 000 4, 703 2. 66 South Dakota _______________________________________ 1958 692, 000 1, 790 2. 59 Florida _____________________________________________ 1958 4, 348, 000 11, 111 2. 56 Ohio _______________________________________________ 1958 9, 323, 000 23, 565 2. 53 Missouri ____________________________________________ 1958 4, 241, 000 10, 617 2. 50 Wyoming ___________________________________________ 1957 309, 000 772 2. 50 Vermont ____________________________________________ 1957 374, 000 916 2. 45 North Carolina ______________________________________ 1958 4, 471, 000 10, 911 2. 44 Louisiana ___________________________________________ 1958 3, 077, 000 7, 418 2. 41 Pennsylvania ________________________________________ 1958 11, 081, 000 26, 551 2. 40 Kentucky ___________________________________________ 1958 3, 034, 000 7, 159 2. 36 Delaware ___________________________________________ 1957 430, 000 1, 000 2. 33 Washington _________________________________________ 1958 2, 706, 000 6, 318 2. 33 Colorado ___________________________________________ 1956 1, 560, 000 3, 527 2. 26 Illinois _____________________________________________ 1958 9, 839, 000 22, 237 2. 26 Nevada ____________________________________________ 1958 258, 000 580 2. 25 District of Columbia _________________________________ 1958 804, 000 1, 742 2. 17 West Virginia _______________________________________ 1958 1, 968, 000 4, 128 2. 10 See footnotes at end of table. 53 TABLE 9. Existing Acceptable Mental H ospisal Beds in Each State and Possession, and Beds per 1,000 Population 1969*—Continued Population T Acceptable State Number beds Bger Year Total population 1.00—1.99 Beds Per 1,000 Population Tennessee __________________________________________ 1958 3, 451, 000 6, 634 1. 92 Michigan ___________________________________________ 1958 7, 850, 000 15, 026 1. 91 Hawaii _____________________________________________ 1958 578, 000 1, 075 1. 86 Mississippi _________________________________________ 1958 2, 169, 000 4, 044 l. 86 Utah _______________________________________________ 1956 809, 000 1, 483 1. 83 Virginia ____________________________________________ 1958 3, 782, 000 6, 558 l. 73 Kansas _____________________________________________ 1958 2, 079, 000 3, 518 1. 69 Texas ______________________________________________ 1958 9, 206, 000 14, 293 1. 55 Arkansas ___________________________________________ 1958 1, 749, 000 2, 700 1. 54 Iowa _______________________________________________ 1958 2, 820, 000 4, 251 1. 51 Idaho ______________________________________________ 1958 658, 000 966 1. 47 Indiana ____________________________________________ 1958 4, 574, 000 6, 426 1. 40 Arizona ____________________________________________ 1958 1, 118, 000 1, 538 1. 38 Puerto Rico ________________________________________ 1958 2, 306, 000 3, 151 1. 37 New Mexico ________________________________________ 1958 816, 000 1, 062 1. 30 Alabama ___________________________________________ 1958 3, 185, 000 4, 077 1. 28 Virgin Islands _______________________________________ 1957 24, 000 26 1. 08 Less Than 1 Bed Per 1,000 Population South Carolina ______________________________________ 1958 2, 346, 000 2, 112 . 90 Alaska _____________________________________________ 1957 165, 000 18 . 11 * Information from statistical tables prepared by the Division of Hospital and Medical Facilities, Public Health Service. Figures exclude all beds in Federally- operated facilities. Beds are classified as unacceptable on the basis of fire and health hazards, obsolete con- struction, etc. 54 TBureau of the Census population estimates for July 1 of the year indicated, as reported in the State plans for hospital construction. IIncludes beds in hospitals for the diagnosis and treatment of nervous and mental illness but excludes beds in institutions for the feeble-minded and epileptics. References (1) US. Department of Health, Education, and Welfare, Public Health Service, National Institute of Mental Health. Mental Health Statistics, Series MHB—H—4, January 1960. Washington, US. Government Printing Office. (2) Fein, Raschi, Economies of Mental Illness, Basic Books, Inc., New York, N.Y., 1958. (3) US. Department of Health, Education, and Welfare, Public Health Service. Patients in Mental Institutions, 1.957. Public Health Service Publication No. 715, Washington, US. Government Printing Office, 1960. (4) Bahn, Anita K. and Norman, Vivian B., First National Report on Patients of Mental Health Clinics, Public Health Reports, 74 :943— 956, November 1959. (5) Group for the Advancement of Psychi- atry, Basic Considerations in Mental Retarda- tion; A Preliminary Report. Report No. 43, New York, 1959. (6) White House Conference on Children and Youth, Children in a Changing World. Washington, 1960. (7) Masland, Richard L., et al. Mental Sub- normalitg, Basic Books, Inc., New York, 1958. (8) “Torld Health Organization, Expert Com- mittee on Mental Health. Alcoholism Sub- committee. Second report. Technical Re- port. Series No.48,1952. (9) Subcommittee on Appropriations, House of Representatives, Report on Juvenile De- linquency. Washington, US. Government Printing Office, 1960. (10) Albee, George W., Mental Health Man- power Trends, Basic Books, Inc., New York, N.Y., 1959. (11) US. Department of Health, Education, and Welfare, Public Health Service, Division of Hospital and Medical Facilities, The Mas- ter Register of Hospitals, 1959. (12) Frankl, George, M.D., Community Psy- chiatry and I ts Organizational Problems. Mental Hygiene, Vol. 35, No. 4, October 1951. (13) Alt, Edith S., Insured Psychiatric Care. Public Health Reports, Vol. 74, No. 8, August 1959. (14) Joint Information Service of the Ameri- can Psychiatric Association and the National Association for Mental Health, Fifteen In- dices, Washington, D.C., 1960. U.S. GOVERNMENT PRINTING OFFICE: ”Cl 55 Pl’BlJC HEALTH SERVICE I’l'Bl.l(I.-\'l'l()\' NO. 808 ERKELEY LIBRAH NW! NW IH * M II CDEHE?W?S? .l-‘“ _ u t O 0