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Mr. ROGERS. Our next witness is Dr. Isadore Tuerk, commissioner of mental hygiene, State of Maryland, accompanied by Mr. Harry Schnibbee.

STATEMENT OF DR. ISADORE TUERK, REPRESENTING THE NATIONAL ASSOCIATION OF STATE MENTAL HEALTH PROGRAM DIRECTORS; ACCOMPANIED BY HARRY C. SCHNIBBEE, EXECUTIVE DIRECTOR

Mr. ROGERS. We are delighted to have you here, gentlemen, and appreciate your presence.

Mr. TUERK. I am Isadore Tuerk, M.D., commissioner, Maryland Department of Mental Hygiene.

I am here today representing the National Association of State Mental Health Program Directors, and I am accompanied by Mr. Harry C. Schnibbee, executive director of the association.

The members of our association are responsible for the administration of the major portion of the residential and outpatient public mental health programs in the United States. We administer 1,161 treatment facilities, both residential and outpatient. We have under treatment annually 1,500,000 persons.

Last fiscal year the State mental health program directors administered programs funded at $2.4 billion, which is 212 times bigger than all other State public health programs combined.

In 31 States the director of the State mental health program is also responsible for administering the treatment program for alcoholics, and virtually all major, public narcotic addict treatment programs are under the administration of our members.

It is from our experience in administering these vast public programs, and especially the alcoholism programs, that I wish to speak today.

Mr. Chairman, in general we endorse and support both the objectives and the specific approach of H.R. 15758.

Alcoholism and drug addiction are serious public health and social problems. The impact of alcoholism in terms of human suffering, physical illness and complications, financial and economic loss, disruption of family life, highway accidents, and suicides, is incalculable.

Physicians and psychiatrists and other professional personnel have only recently begun to involve themselves with the important problem, despite the fact that for some time the American Hospital Association and the American Medical Association have urged that alcoholism be considered a disease and that physicians and general hospitals provide treatment for the alcoholic.

There has been encouraging progress in the treatment of the alcoholic, but still much needs to be learned in coping with this grave disorder. Alcoholism is a chronic illness which cannot be treated exclusively in a hospital setting, and any attempt to evaluate the effectiveness of the treatment program must depend upon the availability of a wide variety of treatment facilities, programs, and resources. Individual psychotherapy, group therapy, antabuse, Alcoholics Anonymous, tranquilizing drugs, general health management, churches, industrial counseling, family group therapy, utilization of family agencies, welfare departments, departments of education,

schools, parole and probation, courts, labor, et cetera, are all valuable and necessary elements in a comprehensive approach to the treatment of alcoholism.

A comprehensive community mental health center program should include among its elements facilities and programs for the treatment of the alcoholic. The comprehensive community mental health center is in a strategic position to integrate the many resources and programs necessary for a coordinated comprehensive approach to this problem. The elements of a spectrum of services in a broad approach to this problem would include detoxification centers, treatment of the acute phase of alcoholism in a general hospital, inpatient treatment for such complications of alcoholism as delirium tremens or acute hallucinosis, general hospital care for such complications as cirrhosis of the liver and peripheral neuritis.

Halfway houses, diagnostic clinics, outpatient long-term treatment resources, public health nursing, long-term rehabilitation centers for the chronic alcoholic who had little or no personal resources, shelters for those who have reached the point of chronic dependency with no capacity for rehabilitation, with our current knowledge of the treatment of this illness.

Many of these programs can be related to a community mental health center. Some should begin to develop apart from community mental health centers, particularly where such centers have not yet come into existence but could then become affiliated with, and integrated with, community mental health centers as they emerge.

The following motion was unanimously adopted by the members of the National Association of State Mental Health Program Directors in meeting at the Drake Hotel, Chicago, Ill., March 14, 1968:

The proposed Federal alcoholism legislation should provide mechanisms to strengthen services to alcoholics and drug addicts and encourage the development of these services as components of programs of comprehensive community mental health services rather than as separate autonomous units.

Federal support of such developments, both in terms of concept and in terms of financing, will go far in overcoming current resistances to developing programs, and will emphasize and stimulate the urgent desirability of including programs in behalf of the alcoholic in the community mental health services now taking shape throughout the country.

Another powerful factor at work is the judicial decisions which have already occurred and which are now in the process of being formulated by the Supreme Court making it illegal to punish the chronic alcoholic for public intoxication and requiring his treatment. as a sick person instead.

Drug addiction and drug abuse have become significant in recent years as challenges to psychiatric and medical knowledge and enterprise and have provoked professional leaders to develop liaison with other innovating personnel in the antipoverty programs and the war on crime.

Drug addiction and drug abuse play salient roles in the perpetuation of poverty and in the incidence of crime.

Effective treatment programs and prevention programs in the areas of drug addiction and drug abuse should have an important impact.

upon the reduction of illness and human suffering, but also in the reduction of crime and the alleviation of poverty.

Treatment of drug addiction is still a very perplexing and difficult problem. It requires more than an inpatient program. The experience of hospital programs alone has been that fairly prompt relapse into drug addiction occurs upon the release of the patient back to the community.

An effective spectrum of services would require treatment of addicts in the community with such measures as methadone, counseling by cured drug addicts, vocational rehabilitation, vigilant monitoring of urine for evidences of relapses, appropriate involvement of courts and probation officials, ministers, general practitioners, public health nurses, family agencies, and Narcotics Anonymous.

Facilities should include hospital programs, clinics, self-help groups such as Syn-Anon and related residential treatment centers and halfway houses.

Many addicts who are incarcerated after having committed a crime should be prepared for return to the community by appropriate programs in the penal institutions. Many addicts have concurrent. problems with alcoholism, and both problems need to be treated by professionals knowledgeable in both fields.

It is imperative that research and evaluation be an important part of the approach to the treatment and prevention of alcoholism and drug addiction.

Education of industrial leaders and management is important in enabling both addicts and alcoholics to regain effective roles as citizens through appropriate employment.

As is the case with the alcoholics, the community mental health centers would be in a strategic position to coordinate and integrate a great variety of programs and resources in behalf of the addict. However, I would want to emphasize that many such programs for the addicts may need to start prior to the development of community mental health centers and then become integrated into the total program of the community mental health center as it evolves.

It is my hope and concern that facilities and programs for the alcoholics and drug addicts, which are a part of comprehensive community mental health centers, will not compete with the amount of money available to such centers, but will attract sufficient funds from the Federal sources to add to available financing for existing comprehensive community mental health centers and community mental health centers which will come into existence in the future.

As in the case for the alcoholic, so would it be in the case of the addict, that Federal support and stimulation of programs in behalf of drug addiction will encourage professional personnel, hospitals, community mental health centers, community mental health services, to bring to bear whatever talents are available in coping with a serious threat to the health and social well-being of this Nation.

I now wish to address myself, Mr. Chairman, to a particular section of the bill, page 6, section C, starting at line 6 and ending at line 14. This matter involves the efficient administration of the new program. The section on page 6 says that an application for a grant for construction of alcoholism facilities may be made only if it contains satis

factory assurance that the application has been "approved and recommended" by either:

(1) The single State agency designated by the State as being the agency primarily responsible for care and treatment of alcoholics in the State or

(2) The agency designated pursuant to section 204(a)(1) (of Public Law 88-164, which is the Community Mental Health Centers Construction Act of 1964).

It is the concern of the directors of mental health programs in the States that some confusion in the administration of the proposed alcoholism treatment program might result from the language on page 6 of the bill unless it is either modified or clarified.

The directors of State mental health programs have sole responsibility for administration of the alcoholism treatment programs in only 27 States. In four other States they have partial responsibility. And in an additional four States mental health is in an agency where another branch of the agency has responsibility for the treatment of alcoholics.

In 16 States the mental health agency of the State has no administrative connection at all with the State alcoholism program.

I might add that despite all the foregoing about "administrative responsibility," alcoholics are treated in virtually every State mental hospital in this country and in some cases represent as much as 40 percent of the admissions to these State hospitals.

If the language of the bill starting at line 6 is interpreted by a State as requiring it to designate the agency presently "responsible for care and treatment of alcoholics," then it is possible that in 16 States the State mental health agency will not be involved in approving and recommending the proposed facilities.

If the language starting on line 10 ("in case this agency is different ***") is applied, then the agency designated under 204(a) (1) of Public Law 88-164 must approve or recommend the facility.

The 204 (a) (1) agency is the "community mental health center construction authority."

In 20 States the 204 (a) (1) designated agency is not the State agency that is responsible for the mental health program. I have a list of these States here, which I will not read at this point.

However, in 11 (out of the above 20) States the "alcoholism treatment program" is in the mental health agency. And out of the remaining nine States only four of the 204 (a) (1) designees have any responsibility for an alcoholism program.

The defect in the substance of the "designated agency" paragraph on page 6 could be partially corrected by adding language to the effect that the "mental health authority" of the State will be consulted for construction and staffing of alcoholism facilities.

It is a matter of grave concern to me that there be a significant role provided the State mental health director. This is a matter of concern to the other State mental program directors, too. I hope it will be possible that the language of the bill can be modified to include this concept and that the legislative history of this proceeding call attention to my concern and the concern of other State program directors for preservation of their roles in developing effective, broadly based programs for alcoholics and drug addicts.

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