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Mr. ROGERS. Thank you, Mr. Carpenter and Mr. Moore, for being here.
I think it would be helpful to the committee if you could give us the number of alcoholics, the number which you have made studies of in major cities, or by State, and those areas where the problem of the homeless alcoholic is greatest, and any facts like that.
Also, I would like to have some memorandum from your organization as to how they feel these emergency rooms or facilities would operate, how the domiciliary care would work as proposed in the bill.
If you have any experience that we could go on, I think it would be helpful, because I think the committee is going to want to know more facts about this, rather than to get into the beginning of a large building program.
Can't this be integrated within the community health center, in this program we have already done, as an adjunct there? Must it be separate and apart, or how much is it supposed to be tied together?
If you could let us have your thinking on this for the record, we would appreciate it.
Mr. CARPENTER. I will be happy to supply that information.
(The following supplemental statement was subsequently submitted by Mr. Carpenter:)
SUPPLEMENTAL STATEMENT OF THE NATIONAL COUNCIL ON ALCOHOLISM, INC.
Statistics on the incidence of alcoholism are necessarily rough estimates, based on inferences derived largely from the prevalence of cirrhosis of the liver in communities. Obviously, it is not possible to use routine questionnaires and sampling techniques in determining the number of alcoholics in a given state. It has been noted that denial of the condition of alcoholism is a symptom of the disease. Because of the effects of social stigma, those who have alcoholism are not likely to state that they do.
Efron and Keller have published a state-by-state breakdown for 1960 of the number of male and female alcoholics, the rates of alcoholism and the rank order of the states by rate. It should be noted that these figures are unquestionably a conservative estimate. For example, the California Department of Public Health in March 1965 estimated 850,000 alcoholics in the State of California, while Efron and Keller estimate a total of 623,400. Similarly, Colorado's State Department of Health in October 1967 declared that there were 275,000 alcoholics in the state; Efron and Keller estimated there were 42,500. Other states have also estimated that they have many more alcoholics than the Efron and Keller study would indicate. Hence it may be said that the statistical analysis presented here probably represents the least number of alcoholics, rather than the opposite.
The viewpoint of the National Council on Alcoholism is that regardless of whether estimates of the number of alcoholics in the United States are 5 million or 8 million, the basic fact is that alcoholism is a health and social problem of immense magnitude. When it is considered that every active alcoholic affects at least four other persons, the significance of the problem is apparent. One of the principal objectives of the National Council on Alcoholism is to make community leaders and the general public aware of the very large number of Americans whose lives are blighted by alcoholism. The statistical data follows as Appendix A.
DETOXIFICATION CENTERS AND HALF-WAY HOUSES
A detoxification center is generally understood to be a short-term treatment facility for the acute symptoms of withdrawal from alcoholism, i.e., delirium tremens, alcoholic convulsions, etc. The usual duration of emergency treatment is approximately 5 days, although some have reported adequate detoxification in 72 hours.
Essentially, detoxification centers provide withdrawal from alcoholism under medical supervision and with minimum risk of death to the patient during the withdrawal period. They are designed to replace the hit or miss searching by concerned friends and relatives for a health facility which will accept alcoholics or the potentially dangerous "drunk tank” in jails, which may or may not provide any medical supervision, and invariably has minimal facilities for treatment of the physical symptoms of alcoholic withdrawal. Although a few detoxification centers in the United States and abroad have reported some effort at beginning rehabilitation of patients, their prime function is not long-term treatment of alcoholism. They are a way of returning the patient to a physical condition which allows him to be free from the dangers of withdrawal from acute alcoholism,
Half-way houses, on the other hand, are temporary residential facilities which provide a “substitute family for the person in the course of his treatment. . ."
transitional facility provides a peer group experience for the individual to learn how to live without the help of chemical crutches." See Appendix B for description of a model half-way house.
After a detoxification period, some patients with alcoholism find they are unable to benefit from treatment unless their environment is conducive to it. Since they may have failed to develop a sense of community orientation, or through their alcoholism may have lost this sense, they need the reassurance of an orderly existence among congenial persons who have the same problems.
A half-way house can serve as a bridge between the disorienttaion of latestage alcoholism, and the ability to lead a normal life characteristic of the majority of Americans. A half-way house is not usually thought of as a custodial institution. Its residents are encouraged to find work as soon as they are able to do so, and they henceforth pay for their room and board. The goal of the half-way house is to enable its residents to take their place in the community as self-respecting and self-supporting individuals, free of their disease.
Half-way houses are heartily endorsed by the National Council on Alcoholism as a means of providing help to homeless alcoholics. It should be pointed out, however, that the homeless alcoholic represents no more than 10% of the total number of alcoholics in the United States. Hence the provision of half-way houses, while eminently desirable, does not in any sense deal with the entire population affected by alcoholism.
Detoxification centers also are endorsed without qualification by the National Council on Alcoholism. These facilities would provide emergency treatment for alcoholics in the acute stages of withdrawal from alcoholism regardless of economic status. They will do much to close the gap which exists between emergency facilities available to alcoholics and the number of alcoholics requiring such facilities. We would find it highly desirable for the legislation to specifically mention the construction, maintenance, staffing and operation of detoxification facilities under the provision of HR 15758 Title III, Part A.
ALCOHOLISM AND COMMUNITY MENTAL HEALTH CENTERS
The U.S. Department of Health, Education and Welfare, National Institute of Mental Health, has published an excellent pamphlet entitled "The Community Mental Health Center and Alcoholism Programs.” It is felt that this pamphlet is so concise and well presented that an appropriate quotation will be adequate to cover this question of the Committee. There follows a section of the pamphlet which sketches the various ways that alcoholism programs may be meshed into the community mental health centers :
"Complete 'integration of alcoholism services with other activities of the mental health center. Under such an arrangement all services of the center are open to problem drinkers with no special arrangements made for their care, This presupposes that staff are adequately trained and well motivated to work effectively with these patients.
"Special alcoholism services or 'units' within the mental health center. Under this arrangement services for persons with drinking problems are physically located within the center's facilities and the alcoholism staff is administratively responsible to the director of the center.
"Special alcoholism services or 'units' as an administrative part of the mental health center program but not physical y located in the center's facilities. Under this plan, overall program direction is the responsibility of the center's director.
"Special alcoholism programs not administratively part of the center but closely coordinated with it. In communities where adequately staffed alcoholism services already exist, formal administrative integration with the center may be neither possible nor desirable. However, such alcoholism services should work collaboratively with the mental health program to assure continuity of care and appropriate referral and consultation.
"Specialized treatment personnel in the community mental health center, but no separate alcoohlism 'units.' Staff with particular interest and training can be designated as 'alcoholism specialists,' available to work with problem drinkers, as well as other patients. They can also serve as the center's alcoholism consultants.
"Special personnel to function primarily in nonclinical roles, but no alcoholism 'units. This type of personnel engages in little or no treatment but works primarily to ensure that problem drinkers receive appropriate attention in all the activities of the community mental health center. In this capacity they function not only as consultants and as liaison persons with other community agencies, but also as a kind of 'conscience for both the mental health center and the total community in relation to alcohol problems. They act principally as 'catalysts' and 'change agents' rather than as therapists."
This presentation appears to cover all possible methods of including alcoholism in the community mental health center complex.
The position of the National Council on Alcoholism regarding the community mental health centers has been enunciated in an address delivered by Thomas P. Carpenter, President of the National Council on Alcoholism, in New Orleans, Louisiana February 9. The following quotation from this statement indicates the thinking of NCA in this regard : ... assuming that community mental health centers all over the country become operative with a full range of services as outlined above—both the required and the suggested services—and assuming that alcoholism is included in the services (as I fervently hope) there still remains a critical gap with respect to alcoholism. This gap is the function that the Alcoholism Information Center was invented to perform.
"Dr. Fritz Kant in his treatise on "The Treatment of the Alcoholic" stated it this way:
‘Discussions of treatment always assume that the patient is under the care of the therapist. To get him there is often the greatest difficulty.'
"He goes on to note that public education has made some impact and :
‘More awareness and better recognition of the impending danger of alcoholism has on the whole improved the situation by bringing the patients for treatment earlier than would have been the case 10 years ago.'
"This, however, is only part of the problem. It is not just the 'increased awareness and better recognition of the impending danger of alcoholism' that removes the blocks to effective treatment and prevention. Availability for treatment implies more than the mere getting together of the patient and the therapist, as I am sure Dr. Kant would agree. The major block to effective treatment of the alcoholic and to the establishment of effective programs for such treatment, would seem to lie more in misconceptions of the nature of the problem and therefore what kind of measures are indicated..
"I think it its apparent that the community mental health center as conceived is in this respect lacking for effective service to alcoholics. I have little doubt but that the prospectuses of many, if not most, community mental health centers will include 'services for alcoholics.' Likewise, I predict, that they will be programmed on the assumption that the patient is already there under the care of the therapist, is there by his own choice and has faith in the therapy offered.
"Obviously, the thing that throws most people off in their thinking and planning about alcoholics is that these are entirely warranted assumptions in the case of most illnesses. Most sick people in our society ‘know that their problem is illness and they know what kind of help is effective and where and how to find it. Moreover, they approach the helping source person or institution—with faith and willingness to cooperate.
"People are not born with this knowledge or these attitudes; they are taughtvery carefully taught-by the society in which they live. In fact, in his respect, we might say that the alcoholic is a very good citizen-he believes implicitly about himself, the same things that his society believes. Unfortunately these beliefs prevent him from availing himself of whatever effective help there is and he is even accepting of the barbarous methods of his society for handling his behavior.
“Remedying this situation is the function that is missing in the mental health center outline and it is the function to which the Alcoholism Information Center addresses itself. Thus the Alcoholism Information Center fits into the general plan as a necessary adjunct at least until such time as the community changes and undertakes this therapeutic function as it does in other illnesses—which I presume will be some time from now."
(APPENDIX A) ESTIMATES OF ALCOHOLICS WITH AND WITHOUT COMPLICATIONS, UNITED STATES, BY STATES, 1960, AND RATES
PER 100,000 ADULT POPULATION (AGED 20 YEARS AND OVER) 1
32, 700 22, 500 29, 700 623, 400 42, 500 76, 300 10, 700 108, 900 55, 300
7,200 315, 300 106, 800 45, 700 32,000 57, 100 70, 100 24, 200 73, 800 184, 800 200, 100 66. 500 26, 700 143, 100
14.300 25, 600 11,700 13. 200 184,900
15,800 583, 100 51.600 12,500 247,600 29, 600 27, 400 302, 100 31, 600 34,000 10, 100 59, 800 153, 200
9, 500 9, 400 44.600 49,000 33. 200 117, 800
48 29 32
9 18 23 39 47
6 20 35 40 26 19 14 17
4 11 25 41
7 21 30
1 22 10 28
5 45 24 13 44 37 12
3 36 38 31 34 46 15 42 33 27
1 Selected statistical tables on the consumption of alcohol, 1850–1962, and on alcoholism from 1930-1960. Prepared by Vera Efron and Mark Keller. Published by Rutgers Center of Alcohol Studies, New Brunswick, N.J.
Note: These estimates are derived by the original Jellinek formula; the rates (on which the numbers are based) are those of the year 1945, with R=5, applied to 1960 populations. The formula may be less reliable in units with smaller populations. These estimates should be considered as very rough approximations. Numbers are rounded to nearest hundred.
"MODEL" HALF-WAY HOUSE
The surveyed half-way houses give the impression that there is a good deal of variety in the operations of these houses. Nonetheless, even with these differences in approach, all of the half-way houses have had some success. We would like to select the best features from this survey to fabricate a composite picture of what, to the writers, would be a model half-way house.
The location of the facility deserves careful consideration. It should be in a central urban area where there is low cost public transportation, and near centers of occupation, particularly unskilled and semiskilled employment. It should also be in a city near the homes, or former homes and families of the men. It should be located in a respectable residential neighborhood whose social status is neither too high nor too low, and not close to Skid Row habitats or concentrations of bars. It is also desirable to choose a central urban location so that qualified staff, including part-time, consultive, volunteer, and either unpaid personnel, may be obtained and can travel with relative ease to the treatment center. This would also enable the half-way house to use existing educational, research, and training facilities that are available in such areas.
As for physical charactertistics, the half-way house should be a “family" type residence with furnishings that are adequate though simple, and furniture that has firm rather than stylish construction. There should be space for offices, meetings, recreation, a lounge for quiet reading and relaxation, dining facilities, and sleeping accommodations. Regarding sleeping accommodations, the Belmont Rehabilitation Center in Worcester, Massachusetts, has worked out an interesting and successful system. The men live closely at first in dormitory style. As selfimprovement progresses, the men are advanced to accommodations for three. And finally, when a man is considerably improved he is “graduated” to a single room. Each step in this ladder-like progression provides more comfort, greater convenience, and added prestige through a concrete recognition of his progress. But whether or not some system is used for assigning different accommodations within the plant, it would seem that the model half-way house should have different types of arrangements and, above all, emphasis should be on creating a home and club-like atmosphere.
The bed capacity should be limited to 30. Admission and eligibility requirements should be decided by the administrator and staff with consideration in particular of age, sex, and sobriety. The residents must agree to abide by some general rules and regulations such as curfew, schedules, house chores, program attendance and the like, which should be designed to maximize chances for recovery. Fees should be waived initially, but when employment is obtained the resident should pay a reasonable fee of $15 weekly.
On entering the program of the model half-way house each individual should undergo a three-day orientation phase, beginning with an initial interview and ending with a commencement of the regimen of daily activities. In this orientation period the man would receive a physical examination and would be introduced to procedures and rules, the program and methods, the philosophy and its bearers. At this time he would learn what he can expect from the staff, fellow residents, and the half-way house in general, and what is expected of him. At the same time the staff would formulate suitable plans for his future participation in the program.
The program itself should provide for participation in some kind of counseling or psychotherapy, either individually or in a group. An AA group should be formed for residents only, using their own and outside speakers, and they occasionally should attend outside meetings. The men would also participate in frequent group meetings concerned with daily problems and policies related to government and management of the center. Using principles of self-government, the men themselves would exercise responsible authority in enforcing the rules and policies which govern the behavior of residents. Each man should be helped to find employment as soon as possible after completing orientation, and should receive both casework and vocational counseling in this regard as required. Arrangements should be made for clergy of various denominations to be available for religious counseling and spiritual help at the request of the men.
The staff for carrying out the program should include a top-level professional with training in the social or behavioral sciences who would be the director. He should have some experience in administration, supervision, institutions work, treatment, and research. An assistant director with similar qualifications, although of less experience, would aid the director. There also should be a resident supervisor, perhaps a recovered alcoholic who has clearly demonstrated a capacity to assume responsibility. The latter individual is a key figure, for he must see that the affairs of the institution are run smoothly, and be available to meet the needs of the men in times of stress. The director, assistant director, and