I have been over on teaching missions to Austria, Hungary, Finland, and Poland while we were still allowed to go in there. I have been very much impressed by the fact that the American student or the American citizen trained in American medicine is trained in a remarkable type of education.

We do not take those people into the first year class and let them go whether they sink or float because we are not interested in them very much.

We are very much interested in training people and giving them the best possible training, and this is extremely expensive.

The medical schools have the same economic problems that industry has. The funds that they have available for teaching do not pay for the medical education which is given to the students. It costs approximately $2,800 a year to educate a doctor throughout each year of his medical training, and the tuition he pays to the school, whether it is $300 or $500, in some States supported by State funds, or in some private institution, the kind of which I belong to, where they pay $800 a year tuition nowhere nearly pays for the training they get.

This field has been helped first because of Federal funds being made available for the training of physicians which will reflect itself in better care of the citizens of the United States.

Dr. SANFORD. On the question of manpower shortage there is one important factor that I should like to mention, and that is this recent change in selective service procedures whereby postponements from induction into the service are no longer given to any students in scientific fields. It is a matter of great concern that the Government should spend money through the Public Health Service and other sources for the support of scientific and technical educational and then have another branch of the Government come along and cut it off before that education is completed rather than having a postponement of that student's induction.

The CHAIRMAN. That point is very well made.

Dr. BRACELAND. The Federal money which has been coming to medical schools has come to them with no strings attached to it, and it has been accepted very gladly by the deans and has been utilized to the very best of their ability.

I might say we are particularly fortunate in psychiatry that we can talk freely, without the question of cost of mental diseases in it because in 1773 nobody wanted patients with mental disease. Nobody else was interested in them, and they all wanted the States and the Federal Government to take care of them. So we have been able to talk rather freely because we are outside of the pale. If this were not done by the States and the Federal Government it would not be done. Now, without confusing the other groups who have helped with research, I am talking simply about the care of the mentally sick. The CHAIRMAN. Are there any further comments?

Dr. BLAIN. I would like to say that there is one method by which we can pull ourselves up by our boot straps, which is still important in the personnel situation that has to do with further investigation and administrative practices all down the line. What I am thinking is possibly our national authorities, and particularly the National Institute of Mental Health be encouraged one way or the other to have more money available to make such studies.

In one State in which I personally made a survey about the utilization of manpower it was generally agreed that they were not making the best use of the people that we did have.

We could improve our service I believe 10, 15, or 20 percent by better administrative practices.

There are some researches going on as to the actual time being spent by people working in certain wards.

Informally in mental research we need to see whether all those people are using their valuable time properly.

One major factor in this whole personnel matter throughout the country lies, I believe, in the general principle of the pyramid with the most highly trained people being at the top or the apex of the pyramid, that they can be taught to delegate a certain amount of their wisdom and authority to people who are slightly less trained, who will, in turn, delegate it to those slightly less trained below them, and then you get on down to the vast reserve of those available citizens in the communities and others who can be used.

I would suggest that a lot of effort should be made into looking into that field.

The CHAIRMAN. We feel greatly indebted to you gentlemen for your appearance here today. You have made a very real contribution to the work of this committee.

Last night, in speaking of the work of this committee, I stated that I wished people generally could appreciate the extent to which research is being carried on by distinguished doctors and laymen who are interested in promoting public health, who are not doing it because of any financial return that will come to them which would adequately compensate for the time and effort that is put forth, but who are doing it solely and entirely because of their very great desire to be of help to their fellow men.

That has been one of the most encouraging elements of these hearings that we have held, to see the vast number of individuals who are distinguished in their particular activity who are working in behalf of their fellow men.

We feel greatly indebted that so many of these people, including yourselves today, have come before this committee and given of your knowledge and of your experience to this committee, and it is my hope that the committee will be able to do something that is commensurate with the fine effort that has been put forth by those who have appeared before us as witnesses.

This summary and recommendations on training and research in State mental-health programs will be included in the record at this point.

(The matter referred to is as follows:)

TRAINING AND RESEARCH IN STATE MENTAL HEALTH PROGRAMS SUMMARY AND RECOMMENDATIONS

By the Council of State Governments, Chicago, Ill.

THE RESPONSIBILITY OF THE STATES IN THE FIELD OF MENTAL HEALTH

1. The field of mental health has broadened rapidly in recent years. Care and treatment of the severely psychotic and the mentally deficient in State institutions remain as important as they ever were, but action for mental health no longer is confined to the hospitals. Concern is growing for the mentally ill

who do not require hospitalization. Important efforts are being made toward early recognition and treatment of all mental illnesses-in mental health clinics, child guidance centers, schools, welfare agencies and other community institutions. New emphasis is being placed on development of measures aimed at prevention of mental illness, through biological, psychological and social research and through public education.

In view of those facts, the States have a widening responsibility for the promotion of mental health both inside and beyond the State hospitals.

Each State, therefore, should appraise the breadth and adequacy of its entire present mental health program in the light of future needs and, within the limits of its resources, assume necessary additional responsibilities for the early recognition, treatment, and prevention of mental illness.

2. Care and treatment by existing methods alone, however, are not sufficient to cope with mental illness. Better treatments and more positive means of prevention are needed, and also a larger number of persons competently trained to put them into effect. Training and research are primary hopes for eventual reduction of admissions to mental hospitals. In addition, immediate benefits accrue to institutions engaged in training and research activities because competent staff can more readily be obtained and retained under these conditions. Mental health training and research programs, accordingly, should be encouraged and supported by the States, and specific appropriations should be made for them.

ORGANIZATION AND ADMINISTRATION

3. The administration of training and research programs in most States is unsystematic and uncoordinated. Although it is impractical to unify the administration of all State agencies concerned with mental health (hospitals, correctional institutions, public schools, university laboratories, public and mental health authorities, etc.) under one department of State government, increased integration and coordination of their programs is feasible and desirable.

It is recommended that a position of director of training and research be established within the mental health agency in each State to assume responsibility for the coordination of mental health training and research within the State's jurisdiction. It is recommended further that, where possible, regular meetings of the heads of all State agencies concerned with mental health be held for the purpose of integrating their efforts. A technical advisory committee, composed of scientists and educators in the field of mental health, should be established in each State to advise and assist the mental health agency and other State departments concerned in the coordination of training and research activities.

The advisory committee should include qualified representatives of the State hospital system, institutions of higher education in the State and such other private and public agencies as are involved in training and research efforts. The committee should be of the highest technical competence, and thus command the respect of scientists and the public generally. To insure continuity its members should be appointed for specific terms on a staggered basis.

In regular consultation with the advisory committee, the director of mental health training and research should recommend the allocation of appropriate funds for training and research, facilitate arrangements between State hospitals and teaching institutions for internship and affiliate training, cooperate in interstate agreements for professional training, assist individual hospitals and other institutions in establishing training and research activities, secure information on research projects in his own and other States, and participate in an interstate clearinghouse for mental health training and research.

4. Present lack of communication and coordination among State hospitals, universities, professional schools and community agencies makes procurement of staff for hospitals more difficult than it need be, isolates hospitals from the main streams of research activity, prevents maximum improvement in the quality of training and results in duplication of effort and equipment.

The States should encourage their mental hospitals and clinics to affiliate with teaching centers in order to encourage greater participation of State hospitals in field training and internship in the biological and social sciences. Through joint university-hospital staff appointments and other means members of university faculties should be encouraged to originate and participate in research in State mental hospitals. The State mental health advisory committee can be active in promoting close communication between hospitals and teaching centers. 5. One of the important obstacles to adequate evaluation of procedures and therapies is the lack of uniformity in statistical methods in mental hospitals

and clinics throughout the country. Differences in terminology and reporting systems prevent the results of treatment in one hospital from being compared accurately with results in another. Thus the findings of many research studies are not being used as effectively as possible to achieve better understanding of mental disease. The United States Public Health Service is striving to correct this in a pilot group of 15 States.

All States should cooperate with the Public Health Service in the adoption of uniform terminology and statistical reporting procedures in the field of mental health.

TRAINING

6. The adequacy of staff in State hospitals for the mentally ill has improved in the last decade. Substantial increases have been made in the number of attendants, occupational therapists, social workers, and psychologists. Despite the overall increase in staff, however, serious shortages of trained personnel today interfere with effective treatment of patients. The average number of patients per staff member in most mental hospitals fails to meet necessary standards of staff-patient ratios. Especially critical are the heavy case loads of psychiatrists and graduate nurses. Few State hospitals, therefore, are able to make full and effective use of present treatment methods, which could speed improvement of patients and increase the number returned to productive life. The States should appraise the personnel situations in their State mental hospitals and support, where necessary, training of increased numbers of personnel. They should take steps to encourage an increase in the number of students at the graduate and undergraduate levels in the professions immediately concerned with psychiatric treatment and also in the basic biological and social sciences which affect progress in mental health. State institutions which are not accredited for residency or as affiliate training centers for psychiatrists, clinical psychologists, social workers, nurses, and other professional groups should endeavor to raise the level of teaching and supervision in their institutions to secure accreditation.

The current trend toward increasing the number of courses in basic psychological and psychiatric subjects in the curricula of other professions should be encouraged. Premedical and medical students in particular should receive a more comprehensive background in the fundamental psychological and social sciences, since those who do not specialize in psychiatry will receive little further formal training in them. Social workers, nurses, the clergy, teachers, lawyers, and law-enforcement officials also should be encouraged to include such courses in their training.

7. Inservice training in mental hospitals and other facilities is important for improving the competence of existing staff, for making the institutions attractive to new personnel, for maintaining staff morale and enthusiasm, and for integrating mental hospitals into the main stream of teaching and research in the country.

More extensive and effective inservice training programs for all grades of personnel should be provided in State hospitals. In the larger hospitals such programs may be the responsibility of a training or a research and training officer.

Narrow specialization within the field of mental health does not make for the best care and treatment of mental patients. Inservice training for all hospital personnel should include lectures and seminars designed to acquaint each professional group with the special knowledge and skills of the other professions represented. In many cases basic courses in hospital orientation, patient management, general psychology, psychiatry, the special therapies, and the functions of each occupational group can be organized advantageously into a common curriculum for most of the hospital staff. Inservice training also should provide for interchange of experience in the actual work of the different groups, so that each staff member may both understand and assist in duties other than those of his specialty.

8. The high cost of professional education and the relatively low salary scales in State employment now deter many competent people from entering State employment in the mental health field. Retention of existing staff and recruitment of teaching faculty and research scientists are made difficult because of large salary differentials that frequently exist between State and other medical and educational institutions. Stipends for graduate training are common incentives in many professions. They rarely are provided by States to encourage able students to enter the various mental health professions. It has been shown

that in particular instances a high percentage of students given stipends or field training by particular agencies return to employment in such agencies.

Individual States should consider the advisability of providing stipends for graduate training in psychiatry, psychiatric social work, psychiatric nursing. clinical psychology, physical and occupational therapy, public mental health and the basic biological and social sciences.

Salary scales should be adjusted to reduce to the extent possible differences between public and private scales so that public mental hospitals may compete effectively for the limited personnel available to fill treatment, teaching and research positions.

9. Nonmonetary factors, however, are of great importance in recruiting staff, especially research scientists, for the mental health programs. The adequacy with which hospitals and clinics can be staffed is directly related to the quality of research and teaching in them. Contributing factors include the amount of moral support and recognition given to teaching and research activities by the staff, the extent to which staff are selected and retained on the basis of merit, the availability of academic, library, and laboratory facilities, and other conditions that influence morale.

Hospitals, clinics and other agencies conducting research should make every effort to provide these factors, tangible and intangible, through administrative support of teaching and research programs.

10. The effectiveness of the hospital as a treatment, teaching and research center depends in part on the success with which it utilizes the resources of the community and becomes a community resource itself. An important step in this direction is to involve local physicians and other specialists in the hospital program as part-time staff members. This permits the community physician or specialist to maintain contacts with patients he has referred for hospitalization. It augments the hospital staff, increases the contact between institutional psychiatry and the remainder of medicine, broadens and strengthens teaching in the hospital and improves its community relations. Increased cooperation between community agencies frequently may be brought about by joint staff appointments among public and private hospitals and clinics, child guidance centers, community welfare agencies and correctional institutions.

Hospitals and other mental health facilities, therefore, should use part-time services of professional persons within the community to as great an extent as other requirements permit.

PREVENTION OF MENTAL DISORDER

11. An ultimate goal of research in mental illness is to prevent it. At present positive methods for prevention are limited to relatively few mental disorders. The urgent need for extending the area of prevention calls for increased research to determine the relative value of various new preventive measures. Future studies, for example, should evaluate scientifically the effectiveness of early treatment measures, such as those of clinics and child guidance centers. the results of improved prenatal care to reduce congenital brain damage, new chemicals which may prevent the onset of some diseases, the usefulness of school classes in "human relations" and the results of improvement in community and family environments. Since it is generally agreed that the foundations of mental disease are most commonly developed in childhood, studies of biological, psychological, and social development of children should be stressed.

RESEARCH

12. The kinds of training and research programs to be undertaken by the States should be determined by individual State resources and needs. The following considerations, however, should be examined closely in formulating a State training and research program:

(a) States which already possess major teaching centers, especially universities or medical schools, should coordinate their training and research activities to make maximum use of these institutions and their laboratories. They are natural centers for research scientists, technical personnel, professional meetings, etc.

(b) State-sponsored research efforts should be concentrated in or near existing facilities: academic institutions, hospitals, clinics or other laboratories. The acute shortage of trained research scientists usually makes it unwise to set up new research centers isolated from existing facilities.