a. Community Mental Health Aide d. Community Mental Health Technician For each step upward on the ladder there are increased responsibilities, additional in-service training, increased salary and decreased supervision of the subprofessional by professional staff. 3. TRAINING The most important goals of New Careers training for entry level positions are: a. To prepare the trainee in the shortest possible time to successfully and responsibly undertake the duties and roles of the entry-level position; b. To ensure that the trainee, in his on-the-job training is quickly given the responsibility of performing relevant and meaningful tasks, and c. To provide the trainee with a number of basic skills and attitudes that can be put into practice in the job as soon as possible. This provides him opportunity for identification with a role and for the reception of feedback on skills and performance. It allows the individual as well as others to see his competence, and is the base on which further skills can be built. This, training for role rather than simply learning a set of skills is an important and successful approach. In order to get maximum returns from the training program, several principles should be followed. First there should be training in generic issues as well as specific entry-job training, basic training in a particular human service area, and remedial training. These training elements should be provided within the context of a small group. Secondly, there should be basic generic training in a particular area of human services such as health or mental health. There should also be specialty skill training for the specific entry position. Lastly, a supervised on-the-job work training experience is essential for each trainee. 4. EDUCATIONAL LINKAGES The first step in career oriented training for disadvantaged and under-educated people must be directed toward enabling them to acquire high school equivalency diplomas. Some accrediting agencies, for example, the District of Columbia Board of Education and the New York State Board of Regents, have provided guidelines for high school and college accreditation of work experiences and on-the-job training. For advancement beyond the high school level, to the associate of arts or bachelor's degree, linkages must be established between the community educational institution and the human service agency, in which the school would provide accreditation for on-the-job training and field placement, as well as assistance to the agency in job and career development. 5. TRAINING OF TRAINERS For many of the professionals, this will be the first experience in training or supervising disadvantaged people. They will have many unspoken doubts about the ability of trainees to be of any help to other people and about their own ability to teach or supervise the trainees. Therefore, careful training and preparation of trainers and orientation of employing agency staff is a necessary component of the New Careers training model. Without this there is loss of motivation, confusion, conflict between trainees and professionals, and loss of effective ness. Dr. FISHMAN. We have been particularly gratified with the results, contrary to the usual expectations that these people would have only difficulties, and that the "vulnerable could not help the vulnerable." Mr. ROGERS. We would be happy to have material on that. Dr. FISHMAN. I will be happy to supply it. (The following information was received by the committee:) STATEMENT OF DR. JACOB FISHMAN, DIRECTOR, HOWARD UNIVERSITY COMMUNITY HEALTH CENTER, ON PARTICIPATION OF SUBPROFESSIONAL AIDES IN REHABILITATION TREATMENT PROGRAMS In several years of experimentation with such training programs at the Howard University Institute for Youth Studies and in other research centers in various parts of the country, it has been found that this approach is highly successful. Two brief examples of this kind of program follow: 1. A group of 125 youths, ages 17 to 21, who were school dropouts or unemployed, with multi-problem backgrounds, were trained and employed in the human services, including mental health, education, welfare and child care. During training, students were assisted in working toward high school equivalency and increasing their general knowledge and skills. Eighty-seven percent of the trainees finished the training program and were subsequently employed. A study done from one to two years after employment began showed that 52 percent were still in the same jobs in human services and each job change had been accompanied by an increase in salary. 2. A program was developed at Cardozo High School in Washington, D.C., for similar students which combined human service training with the regular curriculum leading toward both a diploma and a certificate of training. Part of the day was spent in classroom work, part of the day in supervised on-the-job training in local human service agencies. The trainees received stipends for the latter. Students were selected from the bottom of the class. On graduation, these students filled jobs in the agencies in which they were trained. A few went on to higher education such as community college or college. Half of these students spent their on-the-job training as classroom aides in elementary schools and half as health aides in local health facilities. There are several programs in Washington, D.C., which have demonstrated success in the use of ex-addicts and ex-alcoholics in treatment centers. The D.C. Public Health Department has a Drug Addiction Treatment and Rehabilitation Center in Northwest Washington. Over half the staff are ex-addicts who have been trained at the center to work with addicts. There are five Drug Addiction Counselors, at the GS-5 level and five Mental Health Aides at GS-4. These subprofessionals assist the other staff in such areas as determining which of the patients are sincerely motivated in the direction of breaking the habit, and which are trying to "work the system," as well as tasks such as screening, intake records, and therapeutic techniques. At the Rehabilitation Center for Alcoholics (RCA) at Occoquan, Va., another D.C. Health Department facility, 65 subprofessionals are employed as alcoholic counselors. A large proportion of the counselors are or have been alcoholics, themselves, and are currently members of Alcoholics Anonymous. They were trained at RCA and are rated at the GS-7 level. Their duties include security, training, control and counseling. Each counselor acts as "house father" for a group of eight patients which he follows throughout their stay at Occoquan. The counselor orients the patient to the program at RCA, teaches good work habits, conducts the Alcoholics Anonymous program, refers the patient to professional staff members for medical or other services when necessary and in general observes, evaluates and advises. The close relationship developed between the counselor and the patient enhances the therapeutic aspects of rehabilitation. The use of local community residents as subprofessionals in alcoholic and narcotic addict rehabilitation centers has been proven successful in various programs throughout the country. The subprofessional increases the effectiveness of services in these programs because his background and familiarity with the community from which he comes enables him to provide the important link between the client and professional, where it possibly would not otherwise exist. The important therapeutic effect on the subprofessional, his family and his community cannot be overlooked. Significant and lasting behavioral change has been found in these people, through training and employment for nonprofessional careers in mental health and other human services. The concept of helping oneself through helping others is an aspect of this effect. The local resident now undertakes to deliver the services of which heretofore he was only the dependent recipient. In addition, this is a most significant answer to the critical problem of training effective manpower which is now confronting alcoholism, addiction and other mental health programs. New Careers training can provide a meaningful em ployment and career opportunity for the above population. I would like to urge the committee to emphasize in this legislation the use of local residents and former addicts as subprofessionals in New Careers in these programs. Mr. ROGERS. Thank you very much. Our next witness is Dr. Gerald L. Klerman of Yale University and director of Connecticut Mental Health Center. STATEMENT OF DR. GERALD L. KLERMAN, ASSOCIATE PROFESSOR OF PSYCHIATRY, SCHOOL OF MEDICINE, YALE UNIVERSITY, AND DIRECTOR OF CONNECTICUT MENTAL HEALTH CENTER Mr. ROGERS. We appreciate your presence. We will make your statement a part of the record, following your summary. Dr. KLERMAN. We welcome the proposed legislation, and in particular I wish to support those provisions which link these new specialized facilities for alcoholic and drug-dependent and narcotic individuals to the newly developing mental health centers. I will not read the entire statement, but I would like to address myself to one question that came up earlier. The question has come up: "Why make these centers part of the community health centers?" "Why not create separate centers for alcoholism and drug addition?" My belief and experience indicates that the development of separate facilities unrelated to community health centers would be a serious error, and I would like to offer a number of reasons for this judgment. First, there is substantial evidence that alcoholic and narcotic addict patients have a high proportion of associated medical and psychiatric conditions. These require active involvement, consultation, and collaboration with neurologists, internists, and other health specialists. Our Connecticut Mental Health Center, like many other centers, is located adjacent to a general hospital, to which it is linked architecturally, and programmatically. Thus we have available X-ray, laboratory, surgical, and other treatment resources on an immediate basis without red tape. Second, I wish to emphasize the desirability of treating the individual in his own community. Treatment at distant resources, even such excellent ones as Lexington and Fort Worth, have unfortunately resulted in high rates of relapse when individuals are returned to their own communities. Programs of after-care are needed, and these require the continued involvement of the patient's family, neighborhoods, clergymen, and local institutions. This is true where the new drug techniques are being used. Mr. ROGERS. May I interrupt there? How is methadone used. You say you are using this? Dr. KLERMAN. We are about to initiate a project on long-term methadone therapy. Mr. ROGERS. Have you not yet gotten into this program? Dr. KLERMAN. Not yet. We have used methadone in the withdrawal phase. In order to initiate such projects, you must be in continual contact with the addict, there must be facilities for special laboratory tests, as well as for pharmacy and for other things. This can only be done in the local community and if the person in treatment has a sense of trust and rapport with the treatment team. I feel that a community resource has a distinct advantage. Ideally the same staff treating the patient during the acute detoxifiaction and rehabilitation phase should be involved with the patient in the followup phase. The third reason is that cooperative linkages already exist with established community agencies such as police, social welfare, and neighborhood groups through present programs developed in many community mental health centers. The effectiveness of ongoing alcoholism and narcotic addiction programs, I believe, can be increased by strengthening existing linkages rather than having to establish new ones. Fourth, our experience and the experience of others indicates that the families of addicts have associated emotional problems, and a more comprehensive approach is more readily facilitated. Fifth, recruitment of qualified and experienced personnel who are scarce. Currently, the areas of alcoholism and addiction do not have made public acceptance. Integration of mental health centers with this program, particularly those linked with medical schools and hospitals will help recruitment. I have discussed this problem with Mr. Ernest Sheppard, of our department, and with Dr. W. Bloomberg, Commissioner of Mental Health. We all agreed that one of the major obstacles to the development of quality programs in these fields has been the resistance within the health professions to assume an adequate responsibility for these important public problems. This is evidenced by inadequate instruction upon these topics in medical schools and in training programs for psychiatrists, social workers, nurses, et cetera. Moreover, only a small fraction of mental health professionals are devoting themselves to the sub-specialties. There is an air of pessimism and an air of pervasiveness that these are hopeless. Our society continues to attach stigma to these conditions. While this legislation would go a long way to improving this condition, I would like to recommend amending the regulation for mental health centers so as to make the inclusion of facilities of addicts and alcoholics part of them. The current regulations do not include these important public health areas as necessary components for community mental health centers. In my opinion, consideration should be given not only to permissive legislation, but to a future mandatory requirement, so that a community center with specialized facilities on panels for alcoholic and drug addiction must be included along with the existing five essential components of in-patient, out-patient, emergency, partial treatment and education, I realize that this proposal may seem radical to some of my colleagues, but it is my prediction that within a decade we will come to expect that just as emergency treatment in today's hospitals is part of the mental health center, so will the treatment of alcoholism. I also wish to offer my special enthusiasm and support for section 252, which authorizes grants for training and evaluation of programs. 93-453-68-19 We must acknowledge that our current treatments have only limited efficacy. However, new and exciting treatments are being developed, and there is promise that they will be joined by other techniques. The recent introduction of drugs such as methadone and cyclazocine is attracting bright young scientists and professionals into the field. However, research is needed to undertake field trials to assess the long-term efficacy of these programs. Investigation should include followup studies to ascertain the longterm consequencies of alcoholism and drug addiction. It is my conviction that the enactment of this legislation will further strengthen these programs. (Dr. Klerman's prepared statement follows:) STATEMENT OF GERALD L. KLERMAN, M.D., ASSOCIATE PROFESSOR OF PSYCHIATRY, YALE UNIVERSITY SCHOOL OF MEDICINE AND DIRECTOR, CONNECTICUT MENTAL HEALTH CENTER My name is Gerald L. Klerman, M.D. I am an Associate Professor of Psychiatry at Yale University School of Medicine and Director of the Connecticut Mental Health Center. The purpose of my testimony today is to support the proposed legislation to amend the Community Mental Health Centers Act to make provision for specialized facilities for alcoholics and narcotic addicts. My support for this bill is derived from my general experience in psychiatry and mental health, and my recent experience as Director of the Connecticut Mental Health Center in New Haven. It has long been my conviction that the problems of alcoholism and narcotic addiction are best treated as integral parts of a comprehensive mental health program rather than in isolation. As part of this comprehensive program, I recommend that adequate training be provided for mental health workers, general physicians, personnel in the police and law enforcement agencies, and other groups to enhance their understanding of the nature and effects of alcoholism and drug addiction. I also strongly support the need for further research, especially in the development of new treatments. THE CONNECTICUT MENTAL HEALTH CENTER AND THE NEW HAVEN COMMUNITY These convictions have been reinforced by very recent experiences in the year and a half since the opening of the Connecticut Mental Health Center in July, 1966. The Connecticut Mental Health Center is a facility of the Connecticut State Department of Mental Health, and is operated jointly by that agency and Yale University School of Medicine. Located in the center of New Haven, immediately adjacent to the Yale-New Haven Medical Center, it represents the first such facility in Connecticut. We are proud that while the center was initiated and constructed prior to the enactment of the federal program for community mental health centers, our building and program embody the essential elements called for by the federal legislation and regulations, including in patient and out patient treatment, day hospital, emergency treatment, and community consultation and education. Early in our operation we applied for and were awarded a National Institute of Mental Health comprehensive community mental health center staffing grant to support our activities in a catchment area composed of the Hill neighborhood of New Haven and the city of West Haven, a population of 80,000 persons. In addition to providing comprehensive mental health services for this catchment area, we are involved in less intensive ways with the remainder of greater New Haven. Furthermore, as part of our university involvement we have major teaching and research programs in concert with our patient care and community activities. Let me say a few words about the Hill neighborhood, on whose periphery the Center is located. The Hill is a typical inner city neighborhood, with characteristic social unrest and high rates of mental illness, accompanied by pervasive unemployment, substandard housing, poor schools, and racial discrimination. This neighborhood is in the midst of marked social transition; relatively large numbers of Blacks and Puerto Ricans have moved in, following upon the exodus of |