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What role can psychologists play in this health maintenance approach? Much of it hinges on the approach to the health problems described above. Psychologists are often confused with their medical colleagues, the psychiatrists, particularly since the services of a sizeable number of psychologists parallel those of psychiatrists as they deal with problems of mental disturbance. (Psychologists have been licensed or certified in 43 states to perform psychological services. Many of these services--including psychotherapy--are similar to those performed by psychiatrists.)

Psychiatrists are trained first as physicians and their approach to mental problems has a medical orientation. Psychologists, however, are typically trained in graduate schools of arts and sciences in programs leading to a Ph.D. degree. Psychologists by training tend to view symptoms such as discomfort, anxiety, unhappiness, as the result of an individual's failure to deal effectively with life's problems. The symptoms are frequently signs, not of a medical illness, but of ineffectiveness in coping. With this kind of perspective, psychologists are breaking away from traditional, somatically-oriented solutions to health problems and attempting to deal with problems of living by a variety of procedures flowing from the science of psychology. The attempt is to provide individuals with more effective behavior patterns or more constructive alternatives for the use of existing behavior.

Psychologists have for many years been concerned with individual differences in ability and aptitude. They have developed tests and other instruments for understanding and assessing such dimensions within individuals. From the information gained from such tests, they have helped individuals to utilize their relatively strong abilities and encouraged them to avoid areas in which their aptitudes do not augur adequate performance. Similarly, psychologists have used a variety of procedures to modify the skills of individuals so that they may be maximally effective in coping with problems with which they are confronted. It is not surprising in the light of this expertise that psychologists have been significantly involved in personnel selection and in the design and evaluation of training programs in the armed forces and industry.

We would also stress the uniquely significant role being played by psychologists in psychotherapy and other forms of behavior modification. It is encouraging that the new behavior therapies have been successful enough to represent a breakthrough in dealing with a large variety of behavioral problems from classroom management to phobias. These approaches typify the psychologist's goal of emphasizing the individual behavior patterns appropriate to given situations. The approaches flow from the fundamental knowledge about psychological processes that has been gained from the laboratory and brought to maturity in practice. Learning has been a major subject matter area in experimental psychology for at least fifty years, and psychologists have played a leading role in education throughout that time. (It should be pointed out that many of the helping procedures are relatively short term and can be performed with minimal training. Teachers and parents, for example, can be taught the procedures almost on a prescription basis. Thus these forms represent relatively inexpensive investments in the health of the nation. We would hope their use would contribute to curbing the cost of any national health program.)

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The psychologist with a social and community orientation can also make contributions to the overall health picture by efforts to make the social structure more supportive of the individual's abilities.

The role of the psychologist in the long range view of health planning thus is seen as one of researcher, teacher, and provider of services.

As a researcher the psychologist has, as we have noted, developed conceptually new ways to view what in the past were considered to be medical problems. Research activities of pscyhologists are contributing to the fundamental understanding of a number of health-related conditions and behaviors. The seminal work of psychologists Schachter with obesity, Shakow on schizophrenia, and Miller with autonomic conditioning, etc., are significant advances that will enable us to deal more effectively with factors contributing to poor health and disease.

Psychologists are to a large extent teachers. As many as 1,500 of them are employed in medical schools in teaching and research capacities, and many more are engaged in training the 2,000 doctorates, the 5,000 masters and the more than 30,000 bachelors degree recipients in psychology each year.

Third, psychologists are performing direct mental health type activities in a wide variety of institutional settings. Approximately 18,000 psychologists presently hold statutory or non-statutory credentials regulating psychological practice in the various states. While many of these are currently employed in non-profit institutional settings and a small minority may be trained in non-health related professional activities, the great majority represent a pool of professional personnel competent in the rendering of personal mental health services to those in need. A corollary fact is that 85% of psychologists have their major employment in public service settings (schools, universities, hospitals, public agencies and the like) while under 10% are full-time self employed. Many of those in institutional employment may do additional part time consultation or service for a fee.

We have pointed out that psychologists have approached the health area with some fresh perspectives and have provided alternative solutions and a healthy competition. We firmly believe that psychology has significant contributions to make to the broad area of health care. The scope of planning efforts for the health programs now being considered implies a major system that may affect the shape of health care for a long time to come. We urge that this system be kept open, that various health professions be allowed to participate on equal terms so that new techniques by all professional groups may be evaluated competitively for cost effectiveness. We believe that psychology is developing and will continue to develop high quality effective procedures to deal with health problems. We feel that the health of the country will profit if we, and other professionals who will make their contributions from non-traditional viewpoints, are not frozen out of the health system prematurely. Competition provides the arena for evaluation of effectiveness; it also serves to inhibit needless cost increases.

The message of the foregoing remarks is that the inclusion of mental health care in national health planning may be an inexpensive form of preventive medicine. Studies on the effect of short term psychotherapeutic

intervention on medical utilization have suggested that it tends to reduce the need for expensive medical services. Mental health treatment does not necessarily entail the stereotyped long term interaction of a troubled indi-· 'vidual with a high priced professional. New procedures are being developed that are short term and may be performed by professionals of various kinds at various levels of training and experience. We are encouraged that the thinking of many legislators takes a broad view of the problems of health. Consideration of the health maintenance organization concept is a commendable option to break impasses in the delivery system. We hope that the general health maintenance concept forms a foundation for all health legislation in the interest of both cost and effectiveness.

Senator CRANSTON. Our final witness is Harry A. Schweikert, Jr., representing the National Paraplegia Foundation. Mr. Schweikert, we are delighted to have you with us.

STATEMENT OF HARRY A. SCHWEIKERT, JR., NATIONAL PARAPLEGIA FOUNDATION AND PARALYZED VETERANS OF AMERICA

Mr. SCHWEIKERT. I am pleased to speak on behalf of the National Paraplegia Foundation and the Paralyzed Veterans of America, and all of the paralyzed citizens of this country that these organizations represent. We sincerely appreciate this opportunity to present testimony in support of the improvement and expansion of programs for the disabled of our Nation, with special reference to the spinal cord injured.

Mr. Chairman, I earlier submitted a statement for the record, so I am only going to submit some of the highlights of our presentation. Senator CRANSTON. Thank you. Your entire statement will go in the record at the conclusion of your testimony.

Mr. SCHWEIKERT. Both organizations I represent support all facets of the bill. There may be some question in the mind of the chairman as to why the Paralyzed Veterans of America supports this bill. I would like to point out to you that while present legislation does provide basic medical care, the rehabilitation aspects of the program are not available to veterans who have suffered spinal-cord injury which is not service-connected. There are a lot of veterans who would be benefited by this bill.

We are most enthusiastic about the provisions of H.R. 8395 relating particularly to the spinal-cord injured and other severely disabled.

We recognize that the greatest resources of the United States are directed at the afflictions of man which cause the highest mortality rates. And this is as it should be. Yet there are too many of our citizens who are not too far from that terminal state.

These are the spinal cord afflicted who have been accumulating for years in back rooms and institutions, waiting for someone to champion their cause. The techniques of modern rehabilitation have not been available to them. They have been shunted aside by a society which didn't have the faith, the desire, or the courage to accept their challenge and rehabilitation personnel who blamed it on a lack of time, a lack of space, and a lack of money.

For reasons stated, we most strongly support title III of the bill, which would apply comprehensive rehabilitation services to the very seriously disabled, the goal of which would be to improve substantially the ability of these disabled to live independently and function normally in their families and communities. We are most relieved to see relaxed the restrictive sections regarding full employment as an expected end product. The reassimilation of the disabled individual into a family and community life is the true first step in any whole rehabilitation program.

We are extremely happy to see the intent of title IV to establish national centers for the spinal cord injured. It was, admittedly, a distinct disappointment not to find a particular number of centers which would be created, or any appropriation to cover their costs. If I may be so bold, Mr. Chairman, I must submit that at least 50 such centers

would be required to bring the essential basic services to those who so desperately need them.

That is one horrendous backlog to catch upon, if it is ever possible. And there is frustration in our ranks that perhaps some of our Legislative Representatives are not aware of what we speak. For instance, there is no spinal cord injury center in the Metropolitan District of Columbia area at which one could observe or inquire. The closest thing to it is Glenn Dale Hospital in Maryland, to which the severely disabled of the District are referred and accumulated, mostly without any promising future. To my knowledge, no spinal cord injury center is planned for the District of Columbia metropolitan area now or in the near future.

The basic and primary area of concern for the spinal cord injured is the need for emergency medical care from the onset of their very serious disability. It is unclear as to whether the proposed national spinal cord injury centers would be authorized to furnish this type of care. It would be tragic if these centers were to provide benefits only to those who survive their early injuries. The case for this early care has been well documented by the medical profession. It is well-known that rehabilitation must start at the earliest moment possible if we are to salvage constructive human beings from this greatest of all living wreckage. Such care can only be provided in an experienced center which applies its programs to the whole person. It is this type of center for which the two organizations I represent urgently plead.

Good health and a vocation can be all for naught if that healthy, trained individual can't find a home that is accessible and usable, and within his personal economic means. And both home and ability mean nothing if there is no transportation which he can use to seek and maintain employment. Yet these are two of the severest drawbacks that the wheelchair-bound individual faces in trying to maintain himself or his family, and in trying to become a taxpaying member of society.

It is hoped that quick implementation of section 413 of the bill, creating a National Commission of Transportation and Housing for the Handicapped, would alleviate the shortages in these areas. We are particularly pleased to see that the Commission will also include representatives from the consumer groups.

The proposal of section 410 to establish a National Information and Resource Center for the Handicapped would benefit far more than

the disabled themselves.

The establishment of a center would go far toward efficiency and economy in Government operation but, more important, it will bring more quickly to the disabled the most newly devised techniques and equipment. Toward this end, it is our hope that, among the duties assigned to the National Information and Resource Center, will be the science of biomedical engineering.

It should be the duty of this Center to maintain an up-to-the-minute index of newly developed engineering concepts to technology benefitting the disabled. There is an impressive array of mechanical and electronic systems, spinoffs of the defense and aerospace industries, which could dramatically hasten the physical restoration of the disabled and handicapped. But a tenacious resource is necessary to overcome the great time lag between development and application.