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Mr. Chairman, I now refer to section 305 on page 14 of the bill. This section adds language to the Community Mental Health Centers Construction Act of 1963, providing for a set-aside of 2 percent of the construction money allotted to each State. This 2 percent, when matched 50-50 by the State, is to be used by the State, for "proper and efficient" administration of the State plan for construction of mental health centers.

This is a long-overdue amendment, and it was at the specific request of our association to HEW officials that this amendment was included in the draft bill sent to Congressman Staggers, which is now H.R. 15758.

Matching Federal assistance to State central offices for administration of Federal grant programs is an integral part of many existing laws. Thus, there is broad precedent for adopting section 305 of the bill before you. Actually, this provision should have been in the original law, and this association was derelict in not forcing this issue several years ago.

A provision similar to the one we now have in the bill before you has been in the Public Health Service Act for years. Section 606 (c) (2) of the PHS act provides to the State Hill-Burton agency 2 percent of the federally allotted money for administration of the State plan.

Last year your committee initiated a bill, which became Public Law 90-170, which authorized each State to use for administration purposes up to 2 percent or $50,000, whichever is less, of the $30 million Federal allotment for construction of facilities for the mentally

retarded.

In the Elementary and Secondary Education Act there is administration money available to the States under several sections of the act:

Five percent is available to the States for administration of the school library resources program.

Five percent is available to the States for administration of the education of handicapped children program.

One percent is available to the States for administration of the Federal school aid programs for education of children of low-income families. The maximum amount of money available to a State agency under this provision is $150,000.

Seven and one-half percent is available for administration of the supplementary educational centers and services program. The maximum amount of money available to a State agency under this provision is $150,000.

Under the Vocational Rehabilitation Act as amended, section 2, authorizing grants to States for rehabilitation services, provides that a portion of the State allotment may be used by the State agency for administration of the program. There is no limitation on the amount of money the State agency may request for this purpose.

You will note, Mr. Chairman, that in several instances the maximum sums available to the States for administration of the various Federal programs is $150,000. In the bill before you the sum, on line 20 of page 14, is $50,000.

We consider this an inadequate share, and we recommend that the sum be $100,000 per State. The Federal Government through this fiscal year will have granted about $125 million toward development

of community mental health centers in the States. The States are administering this $125 million with no Federal help.

In Public Law 90-170, extending the mental retardation centers program, the Congress allowed $50,000 per State for a $30 million annual program. The community mental health center program involves annual grants twice the size of the Public Law 90-170 program, or $60 million. The administration proportion should be $100,000.

PROGRAM EVALUATION MONEY

We suggest a further amendment of section 305, Mr. Chairman. We recommend the addition of language on line 19 following the word "part." Strike the semicolon and all language through line 24 and add the following language:

and for evaluation of the programs, by the State agency, under Part A of Title II; except that not more than 2 per centum of the total of the allotments of such State for a year, or $100,000, whichever is less, shall be available for the purpose of administration for such year, and not more than 1 per centum of the total of the allotments of such State for a year, or $50,000, whichever is less, shall be available for the purpose of evaluation of programs for such year. Payments of amounts due under this paragraph may be made in advance or by way of reimbursement, and in such installments, as the Secretary may determine.

Our proposed amendment would provide a small amount of money to each State central office, to be matched by the State, for purposes of evaluating the community mental health center program as it functions in each State.

Again, there is strong precedent in recent Federal legislation for provision of funds to evaluate a program to determine its efficacy and judge whether or not the congressionally authorized and appropriated money is being spent wisely.

In the Elementary and Secondary Education Act there are at least six separate sections of the law in which "program evaluation" money is made available. The Office of Education has asked the Congress for $14 million to fund these programs, most of which will be carried out by State agencies.

In the extension of the partnership for health program, Public Law 89-749, which originated in this committee last year and passed the Congress as Public Law 90-174, you included "program evaluation" money for several parts of the law, namely: 314(d), 314(e), 314(c), 304 and 309.

Your committee made the following comments about "program evaluation" in your Report No. 538 (August 3, 1967), and we heartily

concur:

As a basic tool of program implementation and development, evaluation is insurance that the health research, service, facilities, demonstrations, and related activities proposed in this bi-1 will fully accomplish their purposes.

Evaluation studies and analyses should be conducted to identify and extend the application of those program methods and approaches which show high success and to spot program weaknesses in time to permit steps to be taken to improve program performance.

Although the funds available for evaluation will be a small fraction of those available for the programs which are authorized, no more than 1 percent, the committee feels that making these funds available for evaluation will contribute substantially to the success of the programs proposed in the bill.

What we now ask is that everything you said about the need for program evaluation be applied to the community mental health centers.

program, and we respectfully request that your committee adopt the amended bill language we have provided today in this testimony.

Mr. Chairman, I thank you for your courtesy in hearing the testimony of our association today, and, as always, we stand ready to assist the committee and its individual members in any way that we can.

Mr. ROGERS. Thank you very much. Your testimony is most helpful, and we have, I guess, all of your proposed amendments now. Thank you very much.

Our next witness is Dr. Jacob Fishman, professor of psychiatry, Howard University College of Medicine, and director, Howard University Community Mental Health Center.

STATEMENT OF DR. JACOB FISHMAN, PROFESSOR OF PSYCHIATRY, HOWARD UNIVERSITY COLLEGE OF MEDICINE, AND DIRECTOR, HOWARD UNIVERSITY COMMUNITY MENTAL HEALTH CENTER Mr. ROGERS. We are delighted to have your comments.

Dr. FISHMAN. Thank you. I appreciate the opportunity to testify as an individual here on behalf of the bill, and in particular on behalf of the alcholism and narcotics addiction programs contained therein.

I would certainly like to lend my support for the alcoholism addiction components of these programs, particularly stress the importance of these programs in the poverty areas of our urban centers, since, as we all well know, alcoholism and addiction are a major problem in the mental health of the poor, particularly as they are related to the social, educational, employment, and psychological factors connected with poverty and the general problems of the urban ghetto.

However, I am here particularly to speak to one aspect of alcoholism and addiction programs as they relate to community health centers, and that is to urge the committee to stress consideration of the employment and use of local residents as nonprofessionals in new careers providing alcoholism and addiction services in these health centers.

In our experience in community mental health work, we have found that there are enormous advantages to the systematic recruitment, training, and employment of such persons in the delivery of services. They increase the effectiveness of services in these communities because of their unique backgrounds in connection with the community and experience. They provide an important link between the professional and the client population, with whom frequently the professional has had little real life experience.

They provide an important vehicle for helping people to help themselves in the community, and they also provide an important potential vehicle in these local health centers for meaningful employment and career development for the poor.

Now, this is true in general for community mental health programs. It is particularly true in addiction and alcoholism where we find that the use of ex-addicts and ex-alcoholics is a potential manpower resource of very significant effect.

Because of their previous personal experiences, contact with others in the community, and the knowledge of their own living situation, when they are given structured training, employment opportunities and career potential as nonprofessionals in these programs, they give

very important, extremely significant assistance to the professional in providing treatment and rehabilitative services for alcoholics and addicts.

In fact, there are some who feel that in many ways you can't run an effective program for alcoholics and addicts without the use of such subprofessionals providing a kind of treatment resource.

I would urge you to emphasize this approach for the staffing and organizational patterns for these centers. And, in fact, if it were possible to develop an amendment to the existing legislation for community mental health centers to provide for the development of systematic programs for the use of such subprofessionals in new careers, I would urge that, too.

It is especially important in developing manpower resources for these centers to recognize that today there is an extreme shortage of trained manpower for all community mental health programs, particularly for alcoholism and addiction.

This manpower shortage focuses on some of the basic problems in the philosophy of approach to treatment. We have found in our experience in Washington, and in many other communities of the country, that in reassessing the issue of manpower utilization in these centers (which I must add is an extremely urgent problem for all centers and all programs) a great deal can be gained by considering the use of local residents, employing them and providing them with subprofessional careers in these programs.

It gives the subprofessional and the people in the community a way of participating in the development and delivery of services in their own community, which has generally been denied by the typical staffing pattern in which the middle-class professional who lives in the suburbs spends the hours 9 to 5 in the ghetto and knows little else about the lives of the people there.

The use of such people adds a new dimension to these programs, and we feel it is essential to their implementation.

I would further urge that it is extremely important in the development of this model to consider the need for upward mobility possibilities so that these people do not wind up, as has been generally the pattern in health services, in dead-end jobs, doing low-level tasks, without the possibility for educational or financial advancement, or for new responsibility.

Such career ladders, when linked with more experience and training, provide additional opportunity for the poor, particularly the Negro poor in our communities, to move into responsible positions in health services which are generally denied to them because of existing educational, training, and employment barriers.

The current opportunities as nursing assistants in a variety of health service programs provide only dead-end situations for these people. Consequently, the turnover is rapid, there is a great deal of frustration, and their potential as a treatment resource and real help to the professional is generally lost.

We find enormous benefit for the center and the community as a whole.

I would urge the committee and the people who will be making operational such centers and programs to develop systematic and structures programs for subprofessionals and professionals in new careers

in alcoholism, addiction, and in all the other components of the community mental health center so that health services can be significantly improved and these people provided an opportunity for advancement. Thank you.

Mr. ROGERS. Thank you very much.

Let me just ask you: Have you done this in your center?

Dr. FISHMAN. Yes, we have; in all fields, including alcoholism and addiction.

Mr. ROGERS. How many people have you used in this capacity? Dr. FISHMAN. We have at this point trained and utilized 70 to 80 such people.

Mr. ROGERS. Have they been given the opportunity to advance?

Dr. FISHMAN. Yes. We have developed three levels of subprofessional advancement, beginning with the aide, on to the mental health assistant, mental health associate, and mental health technician.

Mr. ROGERS. Do you give them education along with the in-house training?

Dr. FISHMAN. We have programs to supplement the training, and are now negotiating with the Washington Technical Institute for a joint program that could lead to an associate of arts degree. Mr. ROGERS. It might be well if you gave us your setup.

Dr. FISHMAN. I would be glad to.

(The following information was received by the committee:)

STATEMENT OF DR. JACOB FISHMAN, DIRECTOR, HOWARD UNIVERSITY COMMUNITY MENTAL HEALTH CENTER, ON CAREER DEVELOPMENT AND RELATED TRAINING AND EDUCATION FOR PERSONNEL IN THE MENTAL HEALTH PROGRAM

In the past several years of experience with job and career development and related training and education we have found the following to be critical elements in the success of any such programs:

1. JOB DEVELOPMENT

The creation of permanent subprofessional positions in community mental health facilities or other agencies which can lead to career advancement is the ultimate test of the acceptance of a new level of personnel. Without such positions, training of mental health aides can have no real effect as a vehicle for social change or delivery of services.

The initial step, therefore, should be an analysis of structure and manpower needs of the facility, the climate of acceptance or resistance to innovative approaches, and the possible ways in which the subprofessional can help fill some of the gaps in the delivery of services in the community.

Usually the mental health aide job description includes primarily community outreach functions and group leadership. It is the mental health aide who provides treatment assistance to the professional team and acts as liaison between the alcoholic or the addict and the professional staff.

2. CAREER LADDERS

The availability of opportunities and career steps that will enable a person to move toward a desired career is necessary for continued motivation. This requires a linkage of the products of job development into a series of entry level, second, third and fourth level jobs with the potential for upward mobility built in. Local educational resources can provide the necessary training programs and certification for movement from one job to the next. This is a crucial component of the model and requires the combined efforts of the employing agency, civil service and the educational institution. An example of the career ladder as used for the mental health aide in the Community Mental Health Center is:

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