cover more patients. In many hospitals even now a psychiatrist has in his charge four or five times the number of patients recommended by competent psychiatric authorities. The result will be that more responsibility for the care of patients will devolve upon nurses, practical nurses, and attendants or psychiatric aides. Mental hospital authorities all over the Nation have urged training for these hospital personnel. Now the military draft and the lure of better-paying jobs in defense industries have made more urgent than ever the need to hold in the hospital staff the best of the psychiatric aides through training and up-grading.

There is no more acute shortage anywhere in the country than the shortage of psychiatric personnel for the defense program. The country as a whole needs 20,000 psychiatrists and only about 5,000 are now available. The Armed Forces will need at a very minimum 1,500; civilian-defense units throughout the country will require several hundred more some of these part time. And mental health services, particularly in the strategic defense areas will require hundreds more. All this will place a terrific strain on the sparsely developed network of psychiatric personnel and services which we now have throughout the Nation.

We next call your attention to the item in the citizens' budget of $8,000,000 for construction grants, for research and training facilities connected with mental hospitals and medical schools.

For several years we have been urging that funds be provided for construction of additional facilities for research and training activities. Such construction was urgent enough in those days.

But now with this research and training activity becoming root and branch a part of the Nations' fight for survival, it has become absolutely imperative that defense priorities be granted such construction. We know that machinery is being set up to weigh the granting of such priorities. In the face of shortages of building materials it has become a matter of the utmost importance that Members of Congress see to it that research and training facilities for mental health research and training are provided.

A first step is the provision of appropriations for this purpose and the next step is a follow-through to see that the necessary priorities are granted by the proper authorities.

The next item in the budget is the grant to States for early treatment of mental illness and other control services. This item needs special attention. If the President's budget is not adjusted upward, mental-health services in the States of this Nation will have to be curtailed. Such a situation would be extremely unwise in the light of conditions brought about by the defense program. The situation we face today is aggravated by the movement of populations, turnover of industrial personnel, the uncertainty of many payrolls, inadequate school facilities generally throughout the country, swollen populations in defense-impacted areas. Many other stresses and strains connected with the defense program cannot be brought out fully here. Today is a time of turmoil, of anxiety, of turbulent uncertainty, and yet this is a time also when no stone must be left unturned to assure the steady flow of production, community living, and family solidarity.

Therefore, we recommend that these community bulwarks of the mental and emotional vigor of the Nation be increased, by raising the amount for community services to $4,000,000 for the year 1952.

The next item on the budget is one of $750,000 for special project grants for alcoholism for the specific purpose of attacking absenteeism in defense production. I should like here to present for the record a statement on the need for this item by authorities in the field of alcoholism.

(The statement referred to is as follows:)

STATEMENT OF DR. SELDEN D. BACON, DIRECTOR, SECTION OF STUDIES ON ALCOHOL, YALE UNIVERSITY

Alcoholism is a gradually developing illness manifesting psychologic, social, and sometimes physical maladjustments closely connected with chronic, excessive, uncontrolled, and impulsive drinking. In the United States it is to be found chiefly in men between 35 and 55 years of age. Thus it hits the working force of the Nation with greater direct impact than the diseases of infancy, childhood and old age. In times of military stress the economic impact is even more severe: First, because the stress period increases responsibility, mobility, and uncertainty for workers (also the amount of available cash), thus speeding the vicious cycle of the illness; second, because the military forces reduce to a mere trickle the number of those under 30 who enter the working force and, more important, who would be maturing in industry to fill positions of increased responsibility; third, because of the enormous rise in the demand for manpower which results in the retention of some who ordinarily would be fired and the hiring of others who ordinarily would not be considered for employment. The role of chronic excessive drinking is large in these last two categories.

It is estimated that there are more than 1,700,000 alcoholics in the areas of industry and utilities. If business is added to industry, there is small doubt but that a minimum of 2,000,000 alcoholics are presently employed. As the demand for manpower rises, that figure will increase materially.

These 2,000,000 men are not common drunks, staggering around shops or offices, not people with long jail records, not skid-row characters. They are primarily men between 40 and 50 who have worked 5 to 15 years for their current employers. They do show greater absenteeism and a higher accident rate. They are losing occupational efficiency and becoming poorer and poorer risks for the assumption of technical, financial or executive responsibility. Under conditions of tension, higher wages, changing and extended responsibilities, the gradually developing alcoholism tends to speed up. It should be added that during severe manpower shortage, as in the period 1940-45, industry does begin to employ people who come much closer to the skid-row type. Careful estimates of the measurable loss to industry rising from alcoholism exceed $1,000,000,000 annually.

Something can be done about this impressive manpower loss. A large proportion of these men, varying from 25 to 75 percent, can be kept on their jobs, with absenteeism and accidents reduced to a minimum with cessation of drinking, with marked improvement in family and ohter social relationships of the individual concerned, and with striking improvement of occupational morale and efficiency. This has been shown through work in alcoholism clinics, as in Hartford, New Haven, Pittsburgh, Washington, D. C. This has been shown within industrial plants, as in Allis-Chalmers, Eastman Kodak. The pilot or demonstration phases of this work are not to be considered complete, but it is clear that the manpower deficit can be sharply reduced if the men, money, and facilities are made available and if there is a responsible, organized, and sincerely motivated effort to accomplish this purpose. This does not require large sums of money, long and involved training programs, complicated administrative changes within industry, extensive additions to industrial staff, or other such changes.

Two major lines of action are indicated. The first concerns industry and business. It calls for recognition of the problem and understanding of projected remedy and prevention by top management. In each industry it calls for the selection of an appropriate individual from the staff to organize and carry through such a program and special training of that individual in relation to industrial alcoholism and methods of meeting the problem. The work of education of the plant employees, of determining policies of diagnosis, of retirement, of discipline, of severance, and of rehabilitation would follow. One function of the appointed man is the discovery and full utilization of resources of all

sorts which already exist in the community and which can be used and further developed in his program.

The other major line of action concerns, first, reinforcement and extension of those existing nonindustrial facilities, and, second, the analysis and verification of both the understanding of alcoholism and the techniques of rehabilitation and control.

There is reason to believe that industry will itself promote the development of intraindustrial competence and activity and will also aid in the development of research. The Yale Center of Alcohol Studies has prepared an extensive program to make this large saving of manpower broadly available. For 15 years this group has conducted integrated research on the many scientific levels involved in alcohol problems, has pioneered in educational and rehabilitation efforts, and has conducted demonstration clinics and industrial information campaigns on alcoholism.

It is suggested that the United States Public Health Service through a new division or through a largely autonomous section of an existing division be given the responsibility and the necessary funds to realize the second line of action. In considering this suggestion, it should be kept in mind that existing health divisions and their personnel, whether in Federal, State, or local units, as well as privately operated organizations in the field of health, are not trained, experienced, or motivated to work in the field of alcoholism. It is no secret that professional schools have avoided this area; that except for a few organizations in the last 5 to 10 years the methods used were uniformly failures, and that attitudes on all therapeutic levels were antagonistic toward the alcoholic. Unless a full-time, responsible, and fairly autonomous position is given the group asked to meet this problem, it would be better to avoid action since, as experience has already shown, mixed responsibility and part-time action tend to be casual, misdirected, and highly frustrating to all. This does not imply perpetual independence; it does mean that, until the problem and effective programs are understood and accepted, independent responsibility is essential.

At least five States and five metropolitan areas in other States already have existing facilities which could make effective use of additional funds in the near future. Naturally, the problem of gaining adequate personnel will be difficult to solve.

On the same level it should be kept clearly in mind that advice on and direction of research, both practical and theoretical, must be in the discretion of people with competence and motivation in relation to problems of alcohol and alcoholism. These problems are not only imbedded in a tradition of misconception, ignorance, and high emotion, they are also subject to undisciplined, illbalanced, and often emotionally unsettled ideas, sentiments, and activities. Public interest in the problems of alcoholism has so increased in the last 10 years that there has been a field day for prophets and pills.

Granted that the United States Public Health Service can organize a competent, relatively autonomous, and well-motivated unit-and there is every reason to believe that it can-this unit could fulfill the following much-needed functions: (1) Forward the work of existing alcoholism services, most of which are inadequately supported. (2) Set minimum standards. (3) Integrate alcoholism study and service with industrial and other health needs. (4) Direct the activities and energy of newly developing services along the most efficient lines. (5) Greatly assist in making more widely available existing training facilities. (6) Stimulate research, practical and theoretical, in this area. Such research, aside from the activity at Yale University, has been spasmodic, extremely limited in scope, and, at Yale as elsewhere, sharply restricted as to funds-more restricted than any other health-problem field with even a quarter of the number of cases or a tenth of the social impact.

If industry and business on the one hand and the United States Public Health Service on the other activate such a program, it will not only produce a major change in the long run in the entire field of health, to say nothing of problems related to alcohol, it will also produce noticeable results in manpower potential within 3 years. There are many and obvious problems involved in such an effort. However, there is organized experience available which can be put to immediate use. That use has been tested, and it works.

To meet the problem of manpower shortage and manpower inefficiency stemming from problem drinking and alcoholism, rapid extension of out-patient clinic services is indicated. Such clinics are not replicas of existing clinics which could, with additional financing, take on the rehabilitation of alcoholics. These clinics

require specialized clinical training of professional personnel, a fair degree of administrative autonomy, and, of great importance, orientation in the larger field of problems of alcohol. Experience has shown that a large proportion of incipient alcoholics and chronic problem drinkers (who form the major problem for industry and business) can arrest their alcoholic development and can markedly improve both their personal and occupational way of life if appropriate clinical facilities become available. About 2,000,000 men presently listed as regular workers are in this category. Under conditions of great manpower demand, this number will rise to about 2,500,000.

Granted the clinical resource as a pivotal service, it becomes possible to extend rehabilitation and prevention operations in four directions: (1) to industries which with this resource can develop industrial counseling and educational services; (2) to hospitals and rest homes which can play an important role in perhaps a quarter of the usual run of cases if a specialized service for diagnosis and follow-up therapy is available; (3) to a certain proportion, perhaps only a tenth, perhaps as much as a third, of the jail population, which includes a good many men who are potential workers if some guidance and support are available; however, it is unlikely that by itself the usual jail can do much in this field; (4) to the general education of the public, especially to such segments of the public as welfare workers, the police, the therapeutic professions; such education is essential to the change of attitude and understanding requisite for realistic prevention of alcoholism, and this education will occur most effectively where treatment, especially successful treatment, is regularly available.

Three conditions need to be met for the achievement of effective clinical service in this field. First, money is needed to obtain the requisite personnel. Second, specialized training is needed. Third, a favorable setting, favorable in understanding and in cooperaiton, within the area to be serviced will be a major factor in determining the degree of success.

The third condition, which would have been most difficult to meet as recently as 1915, can be satisfied in several areas which are significant from the viewpoint of industrial manpower needs. Not only has introductory educational work proceeded in many of these centers, but specialized clinical facilities, usually on a small scale, have had a year or more of experience in such widely separated places as Portland, Oreg.; Detroit, Mich.; Fort Worth, Tex.; Pittsburgh, Pa.; Richmond, Va.; Buffalo, N. Y.; Boston, Mass.; five cities in Connecticut, and several other places in Wisconsin, California, New Hampshire, and Ohio. Practice is not standardized in these various facilities, although most of them are modeled to a greater or lesser extent on the Yale Plan Clinics. Other things being equal, it is probable that extension or elaboration of therapeutic and preventive service would be more effective and a more prudent investment if made in such environments than in areas as yet untouched by the recent spread of newer understanding and techniques.

The need for specialized training of the therapist and for orientation of those responsible for such work cannot be overemphasized. Medicine, psychiatry, social work, and therapeutic counseling all have a part to play in the rehabilitation of the alcoholic, but it must be clearly recognized that all have tried to work with the alcoholic during the past 50 years and all, apart from a handful of exceptional individuals, failed. Not only did they fail, they also developed a tradition in the therapeutic professions which was openly antagonistic to the alcoholic and which blocked experience, research, or training. Only in the past 2 or 3 years has this attitude started to change. Ordinary therapeutic practice will fail with alcoholics until the training and experience of therapists is successfully applied in that direction. That the abilities of such therapists can be of great value in alcoholism diagnosis, rehabilitation, and prevention is unquestioned. Such training can be accomplished for these professionals with a brief indoctrination period, less than 4 weeks, if thereafter they are to proceed to a clinical facility where they can work with those already experienced in the field. Although only one training center is presently available for this work, it is clear that two or three others could be developed within few months.

The general orientation to problems of alcohol is equally important for the success of this project. This is true not only for determination of goals and selection of techniques, it is also true for immediate administrative and therapeutic action. Viewpoints of different segments of the public; relation of alcoholism to other, often similar, problems related to alcohol; understanding of the differences between drinking, drunkenness, and alcoholism; perception of the social, ethical, legal, religious, and nationality group aspects of all maladjustments in this area, in addition to specific therapeutic knowledge is essen

tial. Without such understanding, money, time, and good will may be unnecessarily wasted, potential resources and friends will become unnecessarily antagonized, and trained specialists will find themselves unable to activate their proven abilities. The experience of public and private groups in attempting to cope with these problems should not be wasted. It should be remembered that the therapeutic professions are not naive in this field because they or their arts are incompetent. It is rather because the larger society has lacked knowledge, has been fearful, and has plunged into bitter controversy or remained in isolated aloofness; this has resulted in a lack of realistic morality and motivation. Until this vacuum is attended to, a technician, no matter what his competence, can accomplish little. In many areas there are people with adequate background for this work. In all areas more are needed.

Money is needed primarily for personnel, secondarily for the training of such personnel. There will be only minor need for administrative expenditures if presently existing structures are utilized.

A minimal out-patient clinic, operating 40 hours a week, will cost approximately $18,000 a year with variations according to regions of the country. It will consist of a half-time psychiatrist or psychiatrically oriented physician, a full-time psychiatric social worker or mental hygienist, a secretary-receptionist, and occasional use of laboratory or diagnostic specialists. Depending upon therapeutic policies it should see from 150 to 250 new patients a year. Such a minimal clinic could serve as a basis for the project here considered. However, to activate the industrial program proposed a second part-time physician and a second person equivalent to the social worker would be required; a typist would be added, and at least one more office needed. This would add approximately $15,000 to the annual cost. This could mean that the clinic would see from 250 to 400 new clients a year, but a more effective use of this personnel is suggested in line with the earlier suggested functions. With the development of industrial counselling for those with alcohol problems, the clinic could make possible, could give specialized background for, and could augment such programs in several industries, could help with the development or elaboration of hospital and rest-home facilities, and, with the addition of perhaps two further persons, could institute diagnostic and rehabilitation procedures in the jailalcoholic population. The addition of such personnel to an existing clinic is not, therefore, the mere addition to case loads of present facilities. It is the key to the redirection or new utilization of existing resources. This cannot be done by the minimal clinic since the larger part of their time is inevitably given to direct, immediate service.

Where there is an existing clinical facility with appropriate standards, it will be possible to extend services toward the solution of the problem-drinking or alcoholism-affected part of the manpower problem, a part consisting of more than 2,000,000 men, within a few months. In terms of money this will mean a basic cost of about $15,000 for a minimal clinic facility. If special projects with jails or hospitals are involved, additional amounts will be required. It is suggested that these more special projects be undertaken in a limited number of instances. In some situations an existing clinic might well initiate two subclinics with specific industries or industrial locations in mind. To suggest examples, the New Hampshire Commission on Alcoholism or the Western Pennsylvania Committee on Alcoholism might follow such a procedure. On the other hand, the Fort Worth or Detroit clinics might prefer to utilize a mobile clinic unit operating from the existing center. The Yale plan clinic in New Haven or the Connecticut Commission Clinic in Bridgeport might be well situated to direct augmented resources toward recapturing employable men from the jail population; Los Angeles already has a minimal plan of this nature, a plan which if realized could readily be made into a resource to meet specific manpower needs by the addition of two or three adequately trained men, granted that the purpose and organization of the proposed facility were integrated toward this function, a proviso that would almost certainly be met.

If 10 existing clinics were to be given such additional aid, the amount needed would be about $150,000. If two jail projects were added, this would cost about $40,000. If two projects developed rest-home or hospital facilities, this would cost about the same. Perhaps five of the existing State commissions could initiate new clinics in centers as yet without facilities, centers of importance for reasons of manpower shortage, centers which could be partly staffed by existing experienced personnel from the State commissions' present clinics. Six such clinics might cost $175,000. These suggestions total just over $400,000. 79807-51-pt. 4-17