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Mr. ROGERS. Thank you very much. We appreciate your testimony and your being here today.

Are there any questions?

Thank you very much.

Dr. FARABEE. May I add one thing. There was a rational explanation for "the 499 persons"-mentioned in the testimony preceding mineand that was not the correct number. "Convalescent leave" means they are in nursing homes-they are there or at home. It was fully knowledgeable by the home where they were, and it was merely an administrative change in the recordkeeping mechanism, by which they were discharged, with the centers later picking up the care. There was no problem in our minds ever about the situation.

Mr. ROGERS. Thank you so much. We appreciate your giving us this testimony.

[The following letter and attachments were received for the record:]


Frankfurt, Ky., May 18, 1973.

Chairman, Subcommittee on Public Health and Environment,
House Office Building, Washington, D.C.

DEAR CONGRESSMAN ROGERS: I was deeply appreciative of the opportunity to testify at the oversight hearing on the Community Mental Center Act (HR 5608) on May 9.

The great knowledgeability and humane concern of the subcommittee members were most heartening to all of us who have been in the field developing community mental health programs. I left Washington much encouraged about the outcome of HR 5608 and the future of federal support for community mental health. As you will remember, the pressure of time left no opportunity for the committee members to direct questions to me. Therefore, I wonder if it would be possible for an additional statement to be placed into ther printed record of the hearings answering some of the questions undoubtedly raised by the testimony preceding mine. In that way there would be a full record available in the event of any future debates concerning the Kentucky mental health program. I have taken the liberty of enclosing this and would be most grateful if it were possible to enter this statement as an addendum to the testimony.

At any time in the future that you may wish clarification or additional information from me, please be assured I would be delighted to reply either personally or by mail.




ADDENDUM TO TESTIMONY OF DALE H. FARABEE, M.D.-MAY 9, 1973 Since the inception of the Kentucky comprehensive community mental health program the Department of Mental Health, mindful of its regulatory responsibilities, has built a quality control component into our system. From the beginning it has been a stated and often reiterated objective of Kentucky's program that the centers provide the highest possible quality of care. In no way was this, however, to be confused with a traditionalistic approach that might prevent the development of creative programs and innovative methods of delivering services, particularly necessary because of Kentucky's geography.

From time to time it has become apparent that those who question the quality do not have first-hand knowledge of the actual performance of the centers in relation to the patients, but are questioning new and innovative ways of presenting these programs.

At any time that innovative programs are developed, those who are more comfortable with traditional approaches, no matter how limited, appear to be threatened and uncertain of the more creative, more wide-ranging approaches. To further enhance its evaluative capability the Department of Mental Health has within the past year established in the Office of the Commissioner a Licensure, Standards Research and Development Section. In addition to the staff necessary to regulate statewide alcohol and drug abuse programs in accordance with legislation enacted by the 1972 General Assembly, this section includes an evaluation component to provide measurements and scientific study methods for review and study of all facets of the mental health center programs, and of the department's own facilities. This section is at present directed by a staff member who holds two Ph.D. degrees-one in mathematics and one in clinical psychology. In tandem with the nationally recognized computer system of the department described earlier in our testimony, and the regularly scheduled clinical on-site evaluations by department staffs and outside consultants, this evaluation section places the Department of Mental Health in a superior position to judge quality of treatment and performance of the centers.

In addition, centers around the state have developed client satisfaction questionnaires and their own evaluation components which will also provide considerable information on the efficacy of the program in the future.

Since the "Survey of Mental Health Needs in Kentucky" has been placed into the record by the testimony of Mr. Ashar Tullis, I feel it is necessary for me to enter the following comments.

As Mr. Tullis stated, the membership of the Kentucky Psychiatric Association, one of the co-sponsors of the original survey, discredited the final document by refusing to endorse it. In addition, a doctoral candidate at the University of Kentucky, intrigued by noticeable gaps in the final survey document, developed a rather intensive study of the manner in which the document presented as the final survey report was prepared, as part of her course work under the supervision of a professor on the graduate staff of the university.

The professor wrote in her introduction to the student's analysis of the survey: "This study clearly shows that the findings of the Urban Studies Center1 were not reported accurately in the Survey (the final published report). Thus, the membership of the Association, as well as the citizens of Kentucky, had misinformation on which to base their decisions about the mental health programs they would or would not support."

This observation speaks for itself. The recommendation concerning the Commission which appeared in the final Survey was the work of a small hand-picked committee and had little relationship to the Survey itself.

It has been noted that Kentucky has completed its network of comprehensive centers, giving coverage to the entire state. Development of such a broad spectrum of services, recruitment of major professional personnel and establishment of a system of record keeping and accountability has been done in a few years with almost a remarkable lack of major crisis. There have been a few, however, that obscure the daily successes of citizen boards and staffs they employ. There is much yet to be done, but we are confident that we have a flexible system that will grow and flourish.

Kentucky's problems with one of the 22 centers-that of the Barren River Comprehensive Care Center which covers the Glasgow/Bowling Green area in western Kentucky-have been much publicized, and I am sure is known to this committee.

I believe the committee has received the report of the special investigator, Mr. William Druhan, who was assigned to Kentucky by the House Committee on Interstate and Foreign Commerce, to study first-hand the audit reports, accounting records and present status of the Barren River Comprehensive Care Center. As Mr. Druhan can corroborate, the Department opened all books and records, as did the center staff, to his inspection. I, of course, have not seen Mr. Druhan's report but I believe that I can say truthfully that the Barren River program is now fiscally sound and that program development is taking place at a healthy growth rate. Staff morale is now at a much higher level, internal auditing procedures and controls have been firmly established, and all aspects of the Kentucky community program-services covering mental illness, developmental disabilities, alcohol and drug abuse-are now being offered or developed.

One other failure in the system has recently been recorded in the press-and in testimony before this Committee-that of the Crisis Center in Louisville. I am enclosing copies of several articles in The Courier-Journal which instigated the initial critical article which indicate the steps taken by the staff to correct the failure in its system.

The fact that the Crisis Center had served more than 30,000 persons last year and that in the month of March, 3670 callers were cared for was not mentioned in the testimony before this committee, although mention of this did appear in the critical newspaper report. The staff and director of the Louisville center concerned have made extensive evaluations of the problems involved to the extent that The Courier-Journal has written a laudatory editorial concerning the non-defensive attitude of the center leadership and the steps they are taking to prevent a recurrence.

I would like to directly address the statement by Mr. Tullis in his testimony before the subcommittee that there has been a de-emphasis of the state hospital program.

All of the four state psychiatric hospitals have been accredited and re-accredited by the Joint Commission on Hospital Accreditation for the first time in Kentucky's history, since the development of the community mental health center

1 (NOTE. the original researchers with whom the Mental Health Association and Psychiatric Association contracted and who actually conducted the survey itself.)

program, which began in Kentucky shortly after I assumed the position of Commissioner in 1965. This hardly appears to be a diminution of quality.

There has been, in fact, an integration of the state hospital program into the total circle of services which includes community mental health centers, the private hospitals referred to in our previous testimony, halfway houses, alternative care homes provided by the private sector and a host of others to provide a full spectrum of comprehensive services for the mentally disabled of Kentucky. While the hospital population has diminished, the staff has remained at the same level, thus providing a realistic ratio of staff/patient coverage. The hospitals no longer are the prime decision makers and the only recourse for those who are mentally ill. If that is de-emphasis, then that is in accordance with the goals of the community mental health program.

As members of the subcommittee implied in their questioning of the witness, it is quite difficult to believe that a state now in the process of reorganzation for greater coordination of human resource services and a department which has not only provided the leadership for the first complete network of mental health centers in the program and which has brought its own facilities from low levels to highly respected and accredited levels of treatment, cannot regulate or judge the efficacy of a system of services for the citizens that we have sworn to assist. I deeply appreciate the opportunity you have given me to appear before this most knowledgeable and concerned committee.

[Courier Journal, May 16, 1973]


When a reporter tested the effectiveness of the agency that offers to help you "build a life you can live with" by posing as a potential suicide, Louisville's River Region system broke down. But the aftermath was a kind of vindication.

After the reporter called the mental health agency's Crisis Center, it will be recalled, 31⁄2 days elapsed before he got face-to-face help from an interested counselor. For a truly suicidal personality, the experience could have been fatal. When River Region authorities were told what had happened, several defenses must have occurred to them: Perhaps the reporter's pose wasn't convincing. The whole thing was sneaky. Or, one breakdown doesn't indict a whole system. Instead, the River Region executive director, Del Combs, met the questions head-on. Then he ordered a thorough study, and Medical Director Alfred Chatman suggested changes in procedure.

At a public meeting, the River Region's board of citizen directors was told the facts. At present, Mr. Combs conceded, the same thing could happen again. Yet, by not taking a hostile and defensive stand, River Region showed real concern for service in the areas for which the agency is responsible: mental health, retardation, alcoholism and drug abuse.

The incident is one that other public officials and agencies could meditate on.

[Courier-Journal May 10, 1973]


(By Chris Waddle, Courier-Journal Staff Writer)

A continuing staff investigation into the handling of crisis situations by the River Region Mental Health-Mental Retardation Board already shows eight recommendations toward improving the board's 24-hour Crisis and Information Center and neighborhood mental health centers.

Among the recommendations announced last night are: face-to-face interviews with clients in the event of any life-threatening episode, improved communication between River Region's different offices, and preparedness by the agency's staff to provide crisis intervention services whenever they are needed.

The internal investigation was launched by the board's executive director, Del Combs, the day after an April 22 story in The Courier-Journal & Times revealed it took a reporter-posing as a potential suicide-31⁄2 days to make personal contact with someone in the agency responsible for dealing with such cases.

The Courier-Journal reporter twice failed to get face-to-face evaluations, was sent to a neighborhood center that turned out to be closed, and on a later visit to the center waited some time before a receptionist told him no counselor could see him.

Combs said in an interview yesterday the series of events was a "comedy of errors." But he said the agency is trying to deal with the problem in an honest way to see that such a thing does not happen again.

"If we are honest," he added, "we would have to say it could happen again." The official said he had ordered questionnaires sent to every component of River Region to see if staff members thought their offices could commit goofs similar to those the reporter encountered.

Not all the answers are back yet, but some mental health workers thought it's possible the series of events could recur in almost all of the 13 neighborhood mental health centers in the agency.

Communication among River Region's components is one of the main problems, according to a report prepared by Dr. Alfred L. Chatman, medical director for the agency.

The report said interviews with the principal River Region employes involved in the newspaper investigation revealed the workers doubted the degree of suicidal risk in the patient portrayed by the reporter.

But the official's report cited seven different errors on the part of the agency in the case of the reporter's portrayal, which was made with no warning to River Region.

Chatman listed the mistakes as the referring of a client to a closed clinic with no alternative procedure for him to follow, the fact that his name was not referred to the neighborhood center, the lack of a personal interview to assess the intensity of the suicide threat and problems in the neighborhood center's waiting


More recommendations for improving on the problem areas are expected to be presented to River Region's next board meeting. But the eight that have been made so far-with immediate distribution of them to River Region's different components are listed in Chatman's report. In brief, they are:

No office in the far-flung mental health agency should be completely closed during regular working hours. Or if closing is absolutely necessary, alternative courses of action for clients should be presented.

An in-service training program of analyzing the handling of crisis calls should be expanded in the Crisis Center and introduced in all units of River Region. Emphasis should be on dealing with life-threatening emergencies and other severe impact situations.

Staff should be rotated among the different service centers of River Region so they can understand the importance of communicating with each other about patients. Reception areas in the centers should be improved so that a client can't come into one without getting immediate attention.

Assumption should not be made about the emergency nature of a client's problem. Inquiry should be made to determine if immediate attention is needed before cases are given routine appointments.

In the case of life-threatening episodes, "error must be made in the direction of doing too much rather than run the risk of doing too little." If possible, such cases should result in face-to-face interviews by a professionally trained person. If any question exists about risk, a physician who has the ultimate medical responsibility should be brought in.

Receptionists should be free from duties that keep them from making immediate contact with persons who come into their centers.

Every center should be able to borrow personnel from other centers if necessary to deal with a crisis situation.

Every service unit of the mental health agency should have the immediate capability of dealing with clients regardless of previously scheduled appointments, meetings or lunch breaks.

"We should assume within all of our service areas that we are operating an emergency service and have no way of predicting when or what emergency will strike next," Chatman's report says.

"This is a fact in our work, and we must be able to react immediately and decisively to any problem as it presents itself to us."

Combs, the executive director of River Region, told board members yesterday that the agency is not being defensive about the newspaper's findings.

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