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IV. Federal funding structure

Since, as was pointed out before, mental health services in municipalities do not stand to benefit significantly from revenue sharing, National Health Insurance or Titles IV-A and XVI, New Federal money-allocated to impact on all designated catchment areas, not just on a few-could be provided for dense urban areas as follows:

A. A city should be funded, according to a needs analysis and plan, with an amount of money that can be awarded to its sections and communities for:

1. Meeting gaps in priorities revealed by an ongoing community planning process-special target groups, elderly, alcoholics, etc.

2. Giving communities staff capacity to coordinate existing services and monitor changing needs (community based information system) for both planning and continuity of care.

3. Applying or developing innovative treatment methods.

B. Grants for citywide programs

1. Services accessible to employees. An occupation mental health model, onthe-job mental health treatment and prevention programs. Cooperation with unions.

2. Public education about mental health and mental retardation problems and services.

3. Applied research projects to test effectiveness of combined services or services for special populations.

4. Evaluation.

5. Data gathering, case registry, other aspects of information systems.

C. Community and citywide plans

1. Needs analysis.

2. Goals and Priorities statements.

3. Gaps in service and plans to fill these.

D. Create a system for information dispersal

1. Federal should gather evaluation results, innovative programs, education concepts, etc.

2. Disperse good ideas to all the cities; spin off operations results. The link should be at the National Institute level, tying research, demonstration grant and operations evaluation information together.

V. Issues, Barriers, and New Directions in Mental Health in New York City

New York City has been moving ahead to begin to develop the planning infrastructure which will make the administration of the proposals indicated above possible. I believe it would be instructive to those considering new legislation to hear of our problems and accomplishments.

New York State and New York City are working together to bring more services to communities and to reduce the emphasis on the traditional long-term, custodial State hospital or school. Unified Services legislation, signed by the Governor only this week to be effective in 1974, will for the first time encourage State and City to work together to develop a plan for integrated services with funding shared in such a way that the patients' needs, not the source of funds, will determine the service he receives. It is worth noting that the term Unified Services as used in New York refers to a more limited concept than is the case in California, where the term originated. Here, the State hospital system, is not being phased out, and separate budgets will still exist for City and State services.

The past years have seen a change in the organization of the New York City Department of Mental Health and Mental Retardation Service toward decentralization in Regional Offices; the construction, opening, and operation of six community mental health centers; the development of Borough Federations of City, State, public and voluntary agencies, citizens and consumers as the base for local planning; the development and funding of many new programs and networks of programs; and the linkage of State institutions, voluntary agencies and their resources as a part of network of Unified Services toward which we work. Nevertheless "*** in view of the current knowledge about the magnitude of mental health problems in this city, the existing inadequacies and fragmentation of many ongoing services, the obsolescence and ill-distribution of many facilities and the availability of new approaches awaiting implementation in mental health as well as in other areas of human services *** to plan forward into the future is necessary."

Strengthened by staff and local planning groups in each borough, we seek to work collaboratively with others in meeting our goals for improved services in this City.

These goals are: First, to develop a system of care in which all servicespublic or voluntary, preventive, treatment or rehabilitative; city and state-are integrated to provide a coordinated and comprehensive system, to which each level of government contributes according to its abilities;

Second, to provide this care on a regional basis to a defined population so that services are accessible and available to those who need them and responsive to local community needs;

Third, to give priority to services for populations at high risk:

Fourth, within the limits of available resources, to provide services that are sufficient in quantity and high in quality;

Fifth, to monitor services and programs sufficiently well to ascertain their effectiveness, their costs, and their replicability, as well as to determine the need for new programs.

As the agency mandated by City Charter to supervise, review, plan and monitor community mental health, mental retardation and alcoholism services within this city, regardless of funding, the Department has a number of interrelated activities it must carry out to fulfill its responsibilities. They can be categorized as the planning and allocation of resources; implementation of plans; and monitoring, supervising and evaluating efficiency, equity, and effectiveness. Any consideration of future community mental health services should take these areas into account.

Consistent with the intent of Unified Services the City is already administering a joint city-state public-voluntary planning process which will result in the development and submission of a single comprehensive plan of service to the State Department. The established vehicle for such planning in New York City is the Borough Federation of providers and consumers. Subregional planning groups meet regularly, identify gaps and duplications, propose plans, state priorities for their locality and are advisory to the Department Regional Directors and their staffs. Boroughwide committees review issues of borough concern; state and local planning committees complement the local group activities.

The subregional groups include providers (both city and state, contract and non-contract agencies) and also related human services agencies (schools, courts health care, social service and other organizations), and citizens, both individuals and representatives of community and consumer groups.

In support of the principles of Unified Services, we established the policy of working closely with other public agencies, together developing programs and/or networks of service. We recommend that both Federally and locally such joint programming and creative funding that breaks down barriers to service be facilitated, and that restrictions that would make this difficult be eliminated. The need to replace competition and jurisdictional rivalries with cooperation goes hand in hand with the need to face several other issues which, if not dealt with, may hamper progress. We are painfully aware that mental health is part of a non-system; fragmentation, lack of coordination, many gaps and some duplications, are the rule rather than the exception. Fiscal constraints, limited definitions of programs; rigid adherence to guidelines appropriate for one type of community and not another, and models of care that fail to take account of changing times and conditions-all these work against improvement of service systems.

Equally as important is the need to develop an approach to service which is based upon concepts appropriate to those who are the focus of service-the people, not the institution. It is these principles and premises which guide the Department in its work and which we believe are worthy of consideration.

A basic premise of community mental health is that responsibility should be assumed for the health needs of a defined population. Attention is given not only to current cases and current needs, but there is also concern with potential cases through efforts at primary prevention. This responsibility include provision of a full range of coordinated services in quantities sufficient to meet the mental hygiene needs of all persons in this designated population, regardless of whether or not they have been labelled patients by themselves or by others. In large cities the catchment or service area concept, as developed, has only fortuitously matched the boundaries of existing neighborhoods, even though the aims of the provision of services on a regional basis are not only to ensure that they are both available and accessible, but are also responsive to locally identified

needs and expressed demands. Ideally, programs draw upon the culture and life style of the community and relate to its people, not only as recipients of service or as low paid staff but also as co-planners and as primary therapeutic agents, both professional and paraprofessional.

Further, there is emphasis on new modes of service organization. This innovation is particularly marked in programs serving persons at high risk, including those of lower socio-economic and/or racial minority status who have not previously been served in large numbers by the private practice of psychiatry, in moderate fee psychotherapy clinics, or even in public mental hygiene clinics. Multiple forms of interventions are developed, ranging from the medical, psychiatric, and somato-chemical to social, educational and environmental approaches. A continuum of care; varied types and sites of service; organizational structures providing degrees of support-independence; and a variety of residential arrangements are encouraged. Immediate availability; problem-centered responses; family, milieu and group therapies; and short-term interventions are characteristic of this approach. This is a far cry from a rigid adherence to five essential services.

Yet, in keeping with an emphisis on decentralization, there is acknowledgement that localities and people vary; so their needs also must vary. It thus becomes necessary to describe the conditions and assess the status of the specific population under consideration and to use these data for rational planning. The epidemiological approach and the collection of information can reveal patterns of utilization and gaps (and occasionally, duplications) in service. Demographic data and the development of social indicators may suggest possible interrelationship of social-economic factors and mental disorder. They also raise questions regarding influences tending toward or deterrents hindering entrance into the health care systems. Such utilization and information will have to be sought increasingly if primary prevention is to be carried out more extensively. Mental health services are conceived to differ both qualitatively and quantitatively. Indeed, direct service (including psychotherapy and casework) should now be only one of a variety of therapeutic, social and psycho-educational activtities. Consultation and education have assumed a major place beside group and individual psychotherapy. Day treatment programs, diagnostic and training services for the retarded, remediation, therapeutic residencies and group homes, sheldered workshops for the mentally handicapped, rehabilitation programs and activities therapies must be, if not yet the rule, certainly no longer only the exception.

In this view, mental health is conceived as optimal pyschosocial functioning. Mental disorder and social dysfunction are considered as disturbances on intrapsychic, interpersonal and social levels, resulting in a variety of outcomes, including altered communication, loss of adaptive ability, and psycho-pathological symptoms. Community mental health services must take all these factors into account.

Ideally, community mental health programs should be capable of providing for the individual or family services which are available, accessible, related to his life-style, and effective. Members of a community should be involved from at least three points of view: as consumers of services, as participants in planning, advice, control and in decision making; and in roles as staff providing services. This requires a greater openness to evaluation and monitoring than we as psychiatrists have shown; far too many of hypotheses have gone untested. It would be unfortunate to discard all of traditional psychiatric services as too costly, time consuming and elitist. It would be almost equally as unfortunate to assume that community mental health or sociopsychiatric approaches, which have to date, stood the test of neither time or evaluation, are by their very nature, effective. Program planners and policy makers should both be concerned with evaluative criteria, in spite of the fact that hard data are difficult to come by. It also requires collaboration in which professional, paraprofessional and community viewpoints are valued. The need for evaluation is most marked in relation to prevention, particularly among children.

The idea that there should be concern with efforts to maintain the health of the well exerts little pressure on legislators who dole our relatively few funds for health care, ill men are a relatively powerless constituency. Well men (and health professionals) have not yet learned that health maintenance is a goal to be attained.

The result of prevention are difficult to measure, particularly in areas of psycho-social disorder. Yet, we must complement our long-standing commitment to treatment with energies and resources devoted to prevention and rehabilita

tion. Difficult as it may be to measure the effectiveness of preventive programs or of consultation to social agencies, the clergy, the police or schools, nevertheless, our services may be multiplied as we reach the helpers and caregivers. It is in the social system of the school that much of the child's world is centered; it is to the natural support systems of his community that the individual turns, before he enters the system which we define as the field of mental hygiene. It is this same community-but not of the addict, the alcoholic that the chronically mentally ill, often does little more than exist, for lack of rehabilitative services. And it is the same community that has tracked the child in trouble out of the mental health and educational system and into the courts, the detention centers, the training schools and prisons.

This implies the need for services which recognize the social context, and without forsaking that which is distinctly psycho-therapeutic for sociological intervention, encompass the immediate and pressing concerns of the individual in his familial and social environment. It means the provision of service where the people are, through a variety of approaches, and the use of new patterns of staffing. It is not only the SRO's or the detention centers or the schools, but the street corner society, the well-baby clinic, the Vietnam veterans in the unemployment office, the retarded adult hidden away in his family. If I dwell at length on the need to reach the socially disadvantaged or those-like the retarded-considered expendable, it is only because the inadequacy of services and the maldistribution of programs are so marked for those whose lives are scarred by poverty, war, racism, and a devalued social position.

It is with all our citizens that we must be citizens, that we must be concerned as we work together to extend and improve mental health and mental retardation services. The opportunity that we take today to consider our tasks for the future may, hopefully move us beyond the limitations of the past.

Mr. SYMINGTON. Commissioner, I want to thank you for an excellent, succinct statement and assure you that your full report will be made a part of the record.

I have one or two questions at this time. We may have others to submit in writing.

There has been some criticism in the Congress of the suggestion that the community mental health centers be required to assist in the field of alcoholism, drug abuse, and so on and to mix the people up in some fashion where the service renders each patient less than he ought to get from the service in some way, it hurts. How would you respond to that, Dr. Christmas?

Dr. CHRISTMAS. I would disagree quite heartily with that. I think that approach would tend toward an elitist situation which means the mental health approach is at the highest level but the addict is at the bottom of the scale.

If we talk about mental health and retardation, we have to consider the range of disabilities of which alcoholism and drug abuse are unfortunately a part. If we look at the people coming into public institutions in New York, 30 to 40 percent of the people enter with secondary or primary diagnoses of alcoholism.

We are avoiding dealing with a specific problem to which our mental health energies ought to be directed. Certainly we need both specialists within centers and we need specialized programs staffed by persons with particular skills in dealing with particular kinds of problems and limited to certain populations. Yet, equally as important we need also specialized programs within those multipurpose centers; they too should be available. Further, we need to stop discriminating against and excluding from our programs alcoholic or addicted per


Mr. SYMINGTON. Thank you. Mr. Hastings?

Mr. HASTINGS. Thank you very much, Dr. Christmas. Your statement was, in my judgment, one of the best I have heard on the sub

ject. I suppose one of the reasons I say that is that I had my staff people suggest some questions and you answered all their questions in your


There are a couple of areas I would like to briefly touch on. Are provisions actually being made for the termination of Federal assistance in the program today? Are provisions being made for States and localities to be able to carry on totally after the Federal assistance terminates on schedule?

Dr. CHRISTMAS. In New York City, we have been for the last year trying to update what was a master plan of 1967, to see what services should be developed within the city. I joined the Department about a year ago, at that time we were taking a long hard look at where services should be going so I can say that, although we knew perhaps that cutbacks would be coming at some time and they are going to be a great disadvantage, yet New York, and perhaps other large cities, have been able to look at their total program needs and to plan for them.

It does not mean we are going to have the revenue to do it but it does mean we have begun to look. Even the termination in itself was for some people within the sphere of something that was going to come. Yet, 7 or 8 years seem far enough when one begins to plan.

Mr. HASTINGS. That is a concern we quite often express because too often when any seed money goes into a program, the effort is always made for the Federal Government to continue on a permanent, ongoing basis. That was not intended and many consumers, I suspect, feel that the Federal share will always be there.

It was never intended to be permanent, as we both know. We do have a concern that the communities themselves start to prepare themselves to take over the full scope of the program after termination.

Do you have any relationship with comprehensive health planning in the city of New York?

Dr. CHRISTMAS. Yes, we do. In New York City, our planning groups are interrelated to CHPA and in local communities, we have local, city and State and voluntary agencies working together in our subregional planning groups. On the executive board of each borough there is a representative from CHPA.

A number of our staff, including myself, serve on the Comprehensive Health Planning Agency committees. When CHPA started in New York mental health was not one of its standing committees. We are now considering that perhaps we should integrate the awareness of mental disabilities and competence in this area into all communities.

Mr. HASTINGS. There is some feeling among the gentlemen on the committee that, as we write the long-range programs that we are discussing, we include mental health, comprehensive planning on a regional basis, Hill-Burton, and perhaps some others, in a consolidated approach to provide better health care to the country.

How far we should go along this line I am not sure at this moment, but the general thrust of the legislative intent right now is to do that. So I am delighted to hear you have that relation with CHP.

I have many, many questions and I will say to you as I did to Dr. Miller that I hope we have an opportunity to discuss this most important and serious matter at a later date.

Dr. CHRISTMAS. We will be ready.

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