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They failed year after year, and they just could not keep up with the great majority, and in adult life they were able to do only simple jobs. That also includes a severe group which amounts to about 150,000 who are in institutions at any one time.

Now, below that, you have a considerable group of more or less incapacitated individuals who are living in their communities. Some of them are very severe cases of psychoneurosis, and that severity might run down into cases who are able to carry on their regular work, and maybe their chief handicap is social or domestic, but they have still a serious handicap although not serious enough to incapacitate them. There are others whose difficulties are more along the lines of inability to follow the usual lines and dictates of society. They represent å distinct—not too distinct-I should say, clinical grouping, but we find them more frequently as violators of the law and we find many of them in our penal institutions. We find quite a number of them in our institutions for alcoholics or for drug addiction.

Then, there is that strata-and that is a very sizable group-and we cannot count them because the borderlines are always too uncertain and numbers tend to accumulate-I mean the size of the numbers accumulates at the borderline. Then we have below that in severity what we might call primarily behavioral disorders. We would not say that they are essentially neurotic, although some of them are not differentiated from neurotic patients, but they are people who get into difficulty. Perhaps the best way by which we could identify them would be to say the "unapt group that we found in the armed services.

Below that and still in this same general group of people we have a large number-an uncounted number--who come to the attention not of physicians—some of them may be referred to a psychologist or other physician—but they come to the attention of other functionaries in the community. Some are very disturbed over philosophical matters or are in a religious quandary, and naturally they go to their clergymen. Some of them have problems entirely within the area and functions of the clergy. If the clergyman is well informed, he recognizes problems which he would want to handle only in cooperation with one experienced in the area of mental illness. Some of these people, as I indicated before, the teacher finds in school. There are those who fail year after year.

Then there are those who are chronically economically incapable of handling their own lives, and there are agencies which run into a large number of those.

There are those who come into the courts, and I have referred to them already.

There are other functionaries in the community that run into this large borderline group, and they can sort out some of them for psychiatric study, but the majority of them they have to handle in the course of their own techniques and their own daily activities.

That constitutes the full range and it is a rather immense range. You have then the alcoholic, the delinquent, the addict, and the extension of delinquency into the criminal problems. Then we come to that large group that is found in our general hospitals. About 40 percent of the patients in our general hospitals have a sizable element in their disabilities and health that is dependent primarily on the same sorts of life experience that handicapped the mentally ill, and the handling of their problems is inadequate. Many of the hospitals would reject these as patients if they came with that label, and so they have to be admitted, and often honestly so because the nature of their disability is not recognized as nonorganic disease.

I mentioned four functionaries in the community, and perhaps the one who advises with people more frequently than anyone is the employer. There is the real test of the man's effectiveness. Of course, the courts find them in divorce actions also, but the employers find then, and some of them deal with those cases with remarkable humanity. Recently I was talking with the head of one medical service in one industry, and I was astonished at the extent to which they bend their practices to get alcoholics back. They feel it is a disgrace to discharge these people, and if they are confronted with no alternative, they sometimes promote a man from down below and put him alongside of the weak one that they are dealing with in order that they may retain him in his position.

These are or this is a sort of general perspective on problems that cover the spectrum, and I think the word "spectrum" is an excellent word when applied to this matter and which was referred to by Dr. Wortis, and you know when it comes to definition that that presents a real problem. I know what red is, but if somebody said "Where docs red end and orange begin,” I would be up against it, but I know what red is.

The CHAIRMAN. That was a very complete statement as to the different types of cases. I wonder if there is another class that think they are all right and that everybody else is queer.

Dr. STEVENSON. There is a minority of us there. I thank you.
The CHAIRMAN. Are there any questions, gentlemen?
Had you finished, Dr. Stevenson?
Dr. STEVENSON. Yes, sir.
(The prepared statement of Dr. Stevenson follows:)

STATEMENT BY GEORGE S. STEVEN SON, M. D., THE NATIONAL ASSOCIATION FOR MENTAL

HEALTH, NEW YORK, N. Y. I am representing the National Association for Mental Health. That is a national citizens organization concerned with improvements in the care and treatment of the mentally ill and deficient, in the prevention of mental disorder, and the advancement of mental health. It was founded in 1909 by Clifford W. Beers, a former patient who suffered seriously from neglect as a patient in mental hospitals. The National Association for Mental Health has affiliated State associations in 29 States and over 200 local mental health associations. It is a member of the World Federation for Mental Health, which has similar objectives and operates on an international level. Each of these organizations focuses its effort upon activities carried on primarily within the scope which it represents.

The offering of testimony before this Federal body is a typical function of the national organization. In addition, it advises in the establishment of services, it promotes improvement in professional training, and promotes and supports research.

I personally am a psychiatrist, but my work has for years been organizational rather than clinical.

I hardly know where to begin in trying to bring before this committee an adequate perspective on mental illness. The allotment of time is so short and the problem so tremendous that I am bound to understate the case. You may have heard it said that mental illness is our No. 1 health problem and I shall try to explain why it occupies this unenviable position. The fact that you allow only 3 bours in which to gather a perspective on it leads me to question whether you are convinced that it is really a first-line issue. If you have doubts as to its position, I must hasten to say that you are not alone in this viewpoint. You are not exceptional. You are in large company and that is the main problem of those who are attempting to do something about mental illness.

I can hardly believe that members of our State legislatures could believe that this is our No. 1 problem and at the same allow the overcrowding of our mental hospitals to continue to be as serious as it is, and to allow only $3 a day on the average for the provision of every aspect of care and treatment. In many instances I know that the doubts about the importance of this field stem more from the will to disbelieve than from ignorance, for disbelief is bound to make those feel better who otherwise would recognize that they are parties to a serious neglect. Reducing the significance of mental illness makes those feel better who, because of their own unrational thinking-a fault into which all of us fall, think that their mental health is vulnerable. It makes those feel better who would economize at any cost. It makes those feel better who would put administrative expediency or administrative simplicity instead of patient care in first place in running an institution. For the more we try to do to serve patients, the more we must join hands with other State and local governmental and nongovernmental services and the more complicated administration becomes. For example, the great benefits offered by the Barden-La Follette Act of 1943 for vocational rehabilitation have been made known to our hospitals. It provides a service to recovered patients which in many cases the vocational history of the patient clearly calls for. Still in many places no advantage is taken of the opportunities offered under this act. It is this subordination of the mentally ill to expediency that blocks many other efforts that we are making in their behalf.

The research carried on today is extremely important, but is in no way a source of pride when one considers the immensity of the field and how much research should be going on. And the same may be said of professional training.

But it is obvious that this committee has not closed its mind as completely as many others have done and I sincerely congratulate you on that. You have asked for frank comment and from your openmindedness endless gain can come.

Never has the association which I represent had resources to work with which are at all commensurate with the problem. After 44 years it is now just beginning to lay the foundation for adequate financing, but progress is slow and we are working against great odds. Our inclination, in fact our policy, is to conduct our campaign wherever possible through the medium of organized fund raising in communities, for we recognize that the opportunities to influence mental health reside with many community agencies and we cannot afford to set ourselves up in competition with or isolated from those other agencies. So far we have had only a pilot campaign and this year have raised in all about $1 million, all but about $100,000 of which is supporting the budgets of State and local mental health associations, for without strong State and local mental health associations we can expect neither adequate financial support nor adequate citizen action in building up the national, State, and local services and protections that are needed.

Many of the activities which this association has carried on in the past have been transferred to other jurisdictions because they are more appropriately located there. For example, the collection and reporting of statistics is now a function of the Federal Government. Both the Federal Government and the American Psychiatric Association are now carrying on investigations of mental hospitals which formerly was a part of our work. The approval of training centers for psychiatrists again is no longer a function of this organization, being now appropriately carried on by a professional association. But it was our task to initiate these things.

Please keep in mind that in the case of no other illness do our States treat so many patients, nor does the Federal Government. In fact, well over half of the patients hospitalized under Federal auspices are frankly mentally ill cases, to say nothing of the psychoneurotic patients who are often classified under other medical and surgical categories. Most of the States fall far short of enough provision even of poor quality. I would remind you that New York provides 1 bed in its State mental hospitals for every 175 of its population, compared to an average of the whole country, which provides 1 to only about 330 of its population, barely half as much. I do not want to convey the false impression that New York has more mental illness than other States. By all indications there is no important difference in the incidence of mental disorders. Many of the other States just don't care for them. Instead of more than the 800.000 patients that it would be expected would be found in our State mental hospitals, on the basis of studies of incidence, we find about 300,000 less. This is a measure of the failure of the States to make provision for patients who are so severely ill that legal commitment is possible. And this figure does not include the million and a half mentally deficient who are the dullards, the alcoholies, the neurotics, and the other deviants.

This field offers many promising leads for research, leads that have not been followed up. Our researches have shown that in schizophrenia, which is the most common of the serious mental disorders in our mental hospitals, the adrenal glands are not behaving properly. This is a lead of such tremendous human significance that instead of a few laboratories in which biochemical research is being pursued, it would pay us to put 100 researchers in one place, sweeping through this problem and ferreting out every promising path of progress. An industry spending as ich would certainly do it if it were confronted with a baffling obstruction to the success of its endeavor.

The mental illnesses of the aged, hardening of the arteries of the brain and the inactivation of brain cells, constitute the greatest group among the admissions to our mental hospitals. We suspect on good grounds that in many cases the deterioration has not gone so far as to be hopeless. The fault may be more a nutritional interference with the function of brain cells than the destruction of brain cells.

Where else in medicine would we find such promising leads passed by or given so little recognition? What other disease of major magnitude offers so much promise of recovery? Even with the limited resources of $3 a day, the results achieved are surprising, for in 1949, when 104,000 patients were admitted to our State hospitals, nearly 15,000 were discharged as recovered and over 32,000 as improved. What other illnesses result in such a tremendous loss of working years? Malzberg has shown that there is an average loss of 8.3 years by those who become mentally ill enough to be admitted to our State hospitals, and this average includes the senile and arteriosclerotic who break down so close to the actuarial limit of productivity that the loss is negligible.

It includes, on the other hand, the schizophrenic whose average loss is 20 years. Think how much saving has already been achieved by the empirical and superficial use of shock therapies and how much more the gain would be if research should lead us to more rational therapies and to ways of protecting the recoveries that we have brought about at great cost. Malzberg has shown again that on the average the loss in productivity per case is $9,932. This is a most conservative figure, for it is a loss calculated only after hospitalization, and many of these patients have suffered additional severe loss of working years because they have been sick a long time before reaching the hospital. Of course, there are other mental illnesses that bring the total up to as many as 9 million people, but many of those are not as seriously and economically incapacitated. What else completely incapacitates an estimated 2 million people for so long, 1 million psychotic and 250,000 low-grade mental defectives, uncounted severe alcoholics, and severe neurotics?

Mental illness is, as a rule, not a killing disease, and that partly accounts for the fact that it is not taken as seriously as some others. But there are more than 17,000 who commit suicide annually, and to that extent it is a killing disease.

What other disease calls as heavily upon the taxpayer as does mental illness? In the case of what other disease would the public tolerate a change of professional staff with a change of political administration? Fortunately, this is not the rule, but it happens far too often. What other illness is neglected until the patient becomes sick enough to be hospitalized ? What other illness is a disgrace? What other disability than mental deficiency, involving 2 million cases, is represented by so few Federal research grants? What other disease than mental illness appears so often as a complication of other illnesses? Peptic ulcer, highblood pressure, and asthma are outstanding examples. Do you appreciate how often a doctor or a nurse is trained to the point of licensure with almost no preparation in this field ?

So I could go on and on in supporting the fact that this is our No. 1 health problem. But if these facts are not impressive and conclusive, adding more will not serve any purpose. An organization such as I represent attempts to stand as the citizen's conscience in meeting it because it is composed of citizens who know, who understand, and who care.

But apart from treating and caring for mental illness, we are interested in its prevention, and things brings us almost immediately into a demand for research. There is so much that we do not know about prevention. We know enough that is firm with respect to prevention to give us courage, but beyond that our foundations are uncertain and we need research to solidify them. We are certain, for example, that if one does not suffer a syphilitic infection or if he is treated promptly, he will not suffer from general paresis. We can understand the meaning of prevention when we realize that this disorder which

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35 years ago constituted 10 percent of the admissions to our mental hospitals is now with better preventive work providing only between 2 and 3 percent. There are a few other disorders in which prevention can likewise be confidently carried out. But in all they constitute only about 8 percent of all of the cases and do not include the mental illnesses of old age that are so abundant, nor schizophrenia.

It is true that we have important theories and leads and that we make every effort to promote preventive work even on a theoretical basis and even though the results are uncertain, for we are justified in leaving no preventive stone unturned. Only by applying what we know or even suspect do we learn and make progress. On the same basis we try to protect the recovered patient from relapse by seeing that he is not subjected to the conditions which broke him down originally. Proper occupation for about 15 percent of these patients seems to be important to their holding their gains, and yet as I have indicated before, this is not yet taken seriously enough because of administrative expediency.

Federal support of training and research has been emphasized by Secretary Hobby as being very appropriate Federal functions and great gains have been made through the partial realization of that principle. I say partial because much more could be done were the provision of research funds to the National Institute of Mental Health more extensive and more certain. A year-to-year support has its limitations for it forces a research worker to plan his work so that it can be completed within a 12-month period, when adequate pursuit of the research activity might call for a 5- or 6-year stretch. A short term project is uneconomical and frustrating to those who have long-range plans.

My organization is one of the pioneers in a coordinated and designed research program. For 18 years it has been spending money on research in dementia praecox, money supplied by the Northern Jurisdiction Scottish Rite 33o—at present $70,000 a year. There are about 17 research projects, but they are not independently conceived. They are 17 parts of a total interrelated plan and our effort is to weave a network of research about this disorder and gradually close in on it. I believe we are succeeding, but the speed with which the closing in takes place with that small amount of research money makes us impatient.

In addition to its work with schizophrenia, the National Association for Mental Health has on occasion devoted research funds to the study of psychosomatic problems, that is, a study of physical illness complicated by emotional disorders.

The job to be done in this field is so tremendous that an organization such as ours is forced to decide on priorities so that its resources may be applied most effectively and economically. In judging the priorities of any prospective activity or any area of the field, it asks itself certain questions. How seriously does the phase of mental illness under consideration or the proposal for action affect the people (patients) involved? Figuratively are we considering a pimple or a carbuncle? And next we ask how many people does this affect? Is it a common disorder like schizophrenia or is it a rare one? How seriously and extensively does it affect society? For example, does it disrupt a family? Is it related to crime? Does it handicap an industry? Does it upset a school or a college? Does it constitute a heavy tax burden? As a fourth question we ask: Where do we stand scientifically? How much do we know? What is the next step that we need to take and be sure that our feet are on solid ground?

And finally we ask: Has the public come along to a point where it is willing to back us up in doing what we should do? Often we find that the first four of these questions would lead us to vigorous action, but that the fifth question warns us that preliminary work must be done in order to bring about public backing. Sometimes, therefore, our sole effort is focused on public education when otherwise we are ready to move faster. Public education is essential in achieving our objectives. Public backing is the only safeguard for the legislator or Congressman who would move faster. We, however, recognize that education is an instrument leading to change and not an objective in itself, so that the audience, the objective and the message all must be clear before valid public ellucation can be undertaken.

This organization has since its beginning provided both impetus and professional counsel in the establishment of diagnostic services, therapy, care, and rehabilitation. It has conducted demonstrations. Its most recent experiments have led the way to vocational rehabilitation for patients recovering in mental hospitals and for patients attending outpatient clinics. It is now clarifying the statutory and nonstatutory facts that affect State administration of mental

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