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is their interest in the use of transitional facilities. On a theoretical basis, a discussion of the continuum of care in any one of these fields, as well as in addiction, has integrated within it the concept of the halfway house as a means by which the afflicted is introduced into the complexities of modern society. The theoretical model has come of age, but there is a sizable lag between the concept and its application in the affairs of people in need.

The one overriding consideration which seems to unite the many and diverse programs under the label of halfway house is their lack of consistent financing. It seems that it is the lack of financial security which unites, as much as the program services which are provided. When talking to administrators of halfway house alcoholism programs, the common problem which all face is funding. Few consistent patterns have emerged so that each program looks almost unique in terms of its fiscal structure. What I believe is needed is the development of a philosophy of halfway houses and funding. Halfway house alcoholism programs may be able to exist on the basis of getting funds where they can, but it will not be until consistent funding is worked out will the halfway house be able to relate effectively to the total community structure.

The halfway house can best be thought of as a bridge. A means by which the individual moves from one point of his addiction to another point which represents successful treatment. In most instances we are relating to in-patient intensive care on one hand, to out-patient supportive care within the halfway house, and then, finally, to independent living within society. I am well aware that halfway houses have at times been seemingly forced into the situation of being a treatment facility, but it is my firm conviction that the primary in-patient role is not the proper area of the halfway house and every effort should be used to divest the program of that element of responsibility. The reason for this is that the halfway house is simply not equipped by either its facilities or staff to carry on the intensive in-patient care that is often needed in the treatment of alcoholism.

The halfway house makes its main contribution in providing a substitute family for the person in the course of his treatment and is not a substitute for the primary treatment of alcoholism. The transitional facility provides a peer group experience where the individual can learn how to live without the help of chemical crutches. It is a transference of dependency from chemical means to interpersonal relationships that are characteristic of the family setting. Many individual who find their ways into the cycles of addiction have never learned how to live so the process of socializing is very difficult for persons with addictive histories. This can be most effectively accomplished within the living situation in which there is a common identity and supportive staff.

The dynamics of the halfway house are in the community of mutual support which is generated by people who have similar affilictions, who join together not out of their strengths, but out of their weaknesses and contribute to each other's recovery by providing support, identification, and hope. The principle that the afflicted can help others who are afflicted recover has been dramatically demonstrated within the program of Alcoholics Anonymous, and this principle has been accepted and re-applied over and over again in the multitude of self-help organizations which are now in existence. The same principles apply to the halfway house where out of a common experience of misery, there can develop a shared experience of hope and the learning experience necessary to live a new life.

In that the community of mutual support is the basic therapeutic ingredient of the halfway house, therefore I believe that halfway houses will invariably, of necessity, be specialized facilities. The individuals entering the halfway house are often by definition incapable of accepting the broad spectrum of community maladies and are so preoccupied with their own state of misery that they are able only to identify with people of similar experience. I can foresee that there will be those who are interested in comprehensive planning who will want to seriously consider multi-purpose types of halfway houses, but I cannot see practical application. I defend as a practical consideration that the specialization of halfway house facility is necessary and there is need to provide specialized facilities and to adequately fund them.

The claim that halfway houses can be self-supporting outside of capital investment has often been made in a well-intentioned way to insure the private donors that there would be a limitation on the appeals made in behalf of halfway house facilities. Time has been the teacher and we have come to learn that good halfway houses must be supplemented on an annual basis. Halfway houses which have become financially self-supporting do so invariably at the cost of staff, and they degenerate too often into boarding house situations rather than adequate halfway houses where people learn how to live.

The present dilemma in which we find ourselves is that all of the elements of sound halfway house program development are present but are not coordinated or blended in a harmonious way. The private halfway house is having its effectiveness curtailed by the demands which are made on the staff and the board of directors in fund-raising activities. Its effective resources are being devoured in the struggle with survival, curtailing its essential functions of "bridge building" in the lives of the afflicted. Program budgets are being starved in the face of economic necessity.

In an attempt to go beyond the mere definition of the problem, let me attempt to create a model program which could blend the many constructive elements in a harmonious and creative way. It will of necessity be a joint venture between the voluntary agency and public responsibility in funding. The private voluntary halfway house has the tools to do the job if it can be given financial security and the means to provide sound programming. The basis of this joint venture is the familiar phrase that has become a byword to the people working in the field of alcoholism, but nevertheless profound in its ramifications, “Alcoholism is a public health problem and hence a public responsibility." The establishment of this public responsibility has been developed on a voluntary basis as well as through the coercive activity of the court as in the Driver and Easter cases, and hence it is a real factor today.

It is necessary to affirm again the valid contribution that the halfway house makes in the care and treatment of the alcoholic. It is a legitimate and necessary element in the continuum of care if alcoholics are in fact to be successfully rehabilitated. The detoxication units in Des Moines and St. Louis, as well as inpatient facilities across the country, have clearly seen the need of after care facilities if the money the public spends on detoxication and treatment is to be a sound investment. Detoxication and returning the alcoholic back on the street can be a new revolving door somewhat more humane but nevertheless just as revolving. The halfway house provides the vehicle which can make the detoxication center a worthwhile investment.

The voluntary private halfway house makes its contribution to the whole field of alcohol treatment in its ability to mobilize the needed multi-disciplinary community of interest necessary to develop a sound recovery program. It is able to involve people within the whole process which can give content and substance to program.

The partnership which emerges is the volunteer program supplemented by public funds. The private volunteer halfway house has its financial crises in the area between income received from the residence and the cost of the program needs. This is the area mentioned before in terms of the need of supplementation. This is the area where historically the private halfway houses have struggled to scratch up dollars and pennies to keep the programs alive. But if the halfway house is really going to be integrated within the total health program, it is going to have to be underwritten by public policy and public money

I support this bill for I believe that it develops public policy which will integrate the halfway house into the total community of treatment. I urge the committee to amend the bill to cover existing halfway house programs which meet the appropriate standards and which are integrated into the total community plan. If existing programs are no included, a premium will be placed on the development of new programs rather than using the experience of existing services. Any financial plan for halfway houses must take into account that supplementation must come from some source, either public or private, if the programs are to carry out their intended purpose.

The halfway house makes each dollar spent on treatment of the addicted significantly more productive.

Mr. Rogers. Thank you very much, Doctor, for your testimony.
Dr. Carter?
Mr. CARTER. Yo question.

Mr. Rogers. Let me ask you this: Who would run the halfway houses?

zation process.

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Mr. BOCHE. Halfway houses have been staffed for the most part by recovered addicts who have been especially trained. Now, this is not

Mr. ROGERS. I mean, would it be a staff that runs the community mental health center, or would it be private groups? Or who would establish it, in other words?

Mr. BOCHE. I think a strong point can be made for the private nonprofit, community-oriented group working on a voluntary basis in cooperation with the community mental health clinic.

I think the big value of this is that you provide in this kind of organization, an army of volunteers which can help in the resociali

Mr. ROGERS. Could you let us have a rundown of examples of halfway houses, the costs of maintaining them, the services provided, maybe some examples of success, or problems?

Mr. BOCHE. Yes. I could deliver for you outlines of some of the more successful and ideal programs.

(The information requested by Mr. Rogers and submitted by Mr. Boche may be found in the committee files.)

Mr. Rogers. If it is going to be voluntary—that is, you don't envision that the people running the halfway house would all be voluntary?

Mr. BOCHE. Oh, no. I am saying that in terms of its organization and board of directors, that we are dealing with a voluntary agency which hires a staff and then is able to enroll and bring in an army of volunteers.

Mr. ROGERS. Yes. This would provide shelter, I presume.

Mr. BOCHE. Yes; we find the halfway house is providing a substitute home, with all the productive possibilities that a substitute home can provide.

Mr. ROGERS. This is what would be covered, I assume, in the legislation by residential

Mr. BOCHE. Yes, sir; or after-care facilities on a live-in basis; yes. Mr. ROGERS. Do you estimate how much would be needed ?

Mr. Boche. This is very difficult. Out of the experience of St. Louis, for instance, they could probably use, without any difficulty, six or eight facilities of 30 beds each.

The big advantage that the halfway house has is that it is able to operate at significantly less cost, and that approximately-in facilities for men-about half of the cost of running the house comes from their own contribution. With women, this runs approximately a third.

Mr. ROGERS. While they are in the halfway house, is it essential that they take treatment?

Nr. Boche. We believe that before a person comes to a halfway house that they should be involved in significant inpatient treatment, and that such after-care as indicated by the professional community be carried on when the resident is living in the halfway house, so that when he leaves the halfway house he basically takes with him all of his therapeutic relationships.

Hence, we do not believe that these kinds of supportive therapeutic relationships should be contained within the house, but rather within the community, so that this continuum of care can be continued beyond this living-in situation.

Mr. ROGERS. Is there any compulsion, or is this all voluntary?

Mr. Boche. Well, there is, of course, a question always raised, Is alcoholism ever voluntarily treated! Working in a community program, I have known of many instances where a man went voluntarily to get help because if he didn't his wife was going to divorce him.

So there are many forms of coercion.
Mr. ROGERS I mean in a legal sense.

Mr. BOCHE. In a legal sense, no. The halfway houses in operation do not use legal means to keep a man in residence. At the present time we have had no experience in that area.

Mr. Rogers. Thank you very much. We appreciate your help to the committee.

The record may stay open for 5 days for anyone to make a statement, if they desire.

There are no other witnesses. This concludes the hearings.
The committee is adjourned.
(The following material was submitted for the record :)
STATEMENT OF Judith G. WHITAKER, EXECUTIVE DIRECTOR, AMERICAN NURSES'

ASSOCIATION, INC. The American Nurses' Association wishes to record its support of the provisions of H.R. 15758 which will extend and improve the provisions of the Regional Medical Program, extend the special grants for health of migratory workers, and provide for specialized facilities for alcoholics and narcotic addicts.

We believe that the Regional Medical Programs, P.L. 89-239 is one of the very significant programs enacted by the Congress in the last few years. It is demonstrating that it has great potential for making more readily available to the people of this country the results of the latest advances in the treatment of heart disease, cancer and stroke and related diseases. Physicians, nurses and other health personnel have the opportunity through the programs to becoine familiar with these advances and to update their skills in caring for patients. The programs have further stimulated cooperation between members of the health professions as they prepare to give the highest quality of service to people.

The legislation was devised as a means of reducing the gap between care possible in a medical center and that available to persons remote from the centers. To achieve this end we have encouraged active participation of the registered nurse as a member of the health team in both the planning and the implementation of the law.

Title II of H.R. 15758 proposes the extension of the special grants for health of migratory workers. We urge that this extension of the special grants for health proposed in the bill.

Migrant workers have always faced difficulties in obtaining adequate preventive and therapeutic health services. Studies show the disease rate for farm workers to be three times that of industrial workers. Forty percent of these diseases result in permanent disability for regular work as compared with twenty-seven percent among industrial workers. Women in farm worker families reecive no prenatal care or late care in 33% of cases as compared with 6% in skilled worker families. Special means have to be taken to correct these serious deficiencies in the provision of health and preventive care services. Assistance from the federal government is essential. Many states alone are unable to provide such services because of insufficient resources. Also, eligibility to receive medical and health care services is often governed by the residence requirements of a state. Since migrant farm workers move from state to state, establishing residency is frequently not possible.

The Association also supports Title III of H.R. 15758 which proposes construction grants and staffing, operation and maintenance grants for centers for the treatment and rehabilitation of alcoholic and narcotic addicts.

We urge the Committee to act favorably on H.R. 15758.

STATEMENT OF MYRON KOWALS, ASSISTANT DIRECTOR, SEATTLE MENTAL

HEALTH INSTITUTE

Alcoholism in particular has long been a critical problem in the Seattle area. Facilities such as the Pioneer Fellowship House, the Women's Studio Club, the Lewis Martin Home, and the Alcoholism Treatment Clinic, have been struggling to devote services to alcoholics in an effort to promote their rehabilitation. However, the financing of these projects is a constant struggle. We recognize alcoholism as a mental health problem which is properly the province of the community mental health center and therefore these facilities dealing with the problem of alcoholism should be funded under community mental health centers legislation. Due to the immense problem of lining up state and local support in order to permanently fund these facilities, it is felt that a declining federal support over a period of ten years would give the facilities the best chance for permanent success.

Because the Seattle Mental Health Institute feels so strongly about the problem of alcoholism a great effort was made to establish working agreements with the alcoholic facilities as part of the grant application for community mental health centers staffing funds. Even though SMHI felt that alcoholism was a mental health problem and therefore should be included in the service centers, it is still important that the legislation puts clearly into writing the eligibility of the alcoholic rehabilitation facilities.

However, to allow a period of ten years of federal support alcoholic facilities and at the same time to limit community mental health centers in general to a period of support of 51 months seems to me to be putting the cart before the horse. Every effort should be made to amend the bill to lengthen the period of support for community mental health centers in general to a period longer than 51 months. It is my personal belief that community mental health centers can be supported by state and local sources without any permanent federal support, but achieving this will definitely be a challenging task. State legislation is going to play an important part in establishing the permanent sources of non-federal support. County funds can also be expected to play an important part in local support. However, promoting state legislation to provide the support funds would take considerable work in more than one session of the legislature. Under the present federal law the level of support by the fourth year of funding of a community mental health center is at a critical low level. If two sessions of the legislature were sufficient to provide legislation for the funds needed by the time the laws became effective the centers would have already experienced considerable financial difficulty.

If community mental health centers are unsuccessful within the 51 month period in lining up sources of support to supplant federal funds it is inevitable that these centers will gravitate towards the serving of the paying patients. This will result in a drastic cut-back of service to citizens who are unable to pay or capable of paying only a portion of the cost. Naturally this would defeat the purpose of the federal community mental health legislation.

I strongly urge the committee to consider amending the bill in such a fashion as to provide longer period of support than 51 months. To wait for community mental health centers to begin failing before doing so would be indeed shortsighted. I believe there is enough evidence to this date to show that the entire burden of the community mental health centers cannot be shouldered by state and local sources in such a short period of time.

STATEMENT OF THE NATIONAL CONSUMERS LEAGUE The National Consumers League has for over half a century concerned itself with the problems of the migratory agricultural workers, the most neglected segment of our working population, and in their behalf wishes to go on record in support of extension of the Migrant Health Act of 1962, as amended in 1965, provided for in the Health Services Act of 1968, H.R. 15758.

It is estimated that there are about one million Americansmigrant farm workers and their families—who suffer from inadequate health care. Until the Migrant Health Act was passed in 1962, health care for migrants was practically nonexistent. Since that time, some real progress has been achieved, but the "health gap" among this group is still shockingly large. Only about one-third of the migrants have received health services under the program, and almost 40% of the counties where seasonal migrants work still have no grant-assisted project

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