A proposed comprehensive mental health plan for Georgia

(j

".
!'v

A PROPOSED COMPREHENSIVE MENTAL HEALTH PLAN FOR GEORGIA

MAY 1965

DIVISION OF MENTAL HEALTH GEORGIA DEPARTMENT OF PUBLIC
HEALTH

MEMBERS OF MENTAL HEALTH PLANNING STAFF

John H. Venable, M. D., Director Georgia Department of Public Health
Thomas F. Gibson, Director Mental Health Planning Project
O. Henry Harsch, Ph. D. Psychology Consultant
Wayne Adams Social Work Consultant
Jane Lewis Health Education Consultant

Addison M. Duval, M. D., Director Division of Mental Health
Ilhan Ermutlu, M. D. Psychiatry Consultant
H. Eugene Hodges Sociology Consultant
Rose L. Cashman Mental Health Nurse Consultant

,'..'!;

COMMITTEES

TECHNICAL AND SCIENTIFIC ADVISORY COMMITTEE

E. James McCranie, M. D., Chairman Joseph C. Massee, M. D. Dr. Cecil K. Harbin Dr. John T. Doby The Reverend Robert E. Lee W. D. Lundquist, M. D. Mr. A. R. Kenyon

Herbert D. Tyler, M. D. James N. Brawner, Jr., M. D. William S. Jackson Miss Julia Miller Mr. J. W. Fanning Honorable Luther Alverson

INTERDEPARTMENTAL MENTAL HEALTH COORDINATING COMMITTEE

Dr. A. P. Jarrell Dr. Mamie J. Jones Mr. Jerry S. Sims Jack N. Thomas Mr. Harold Parker Dr. John H. Venable, Chairman

Dr. H. T. Singletary Miss Florrie Still R. H. Burson John T. Mauldin, M. D. Thomas M. Parham, Jr.

INTRA-DEPARTMENTAL ADVISORY COMMITTEE
Miss Dorothy Barfield Dr. A. H. Robinson Mr. H. M. Chester Dr J. E. Chrietzberg Dr. R. F. Corpe Mrs. Diane Stephenson J. C. Terrell, Ph. D. Mr. J. M. Sitton

Dr. A. M. Duval Mr. J. D. Humphreys Dr. J. E McCroan Dr. L. M. Petrie Dr. S. C. Rutland Mr. Frank C. Smith Dr. O. F. Whitman Dr. John H. Venable, Chairman

TABLE OF CONTENTS

PART ONE MENTAL HEALTH IN GEORGIA - TODAY

Chapter I

Setting the Stage

1

Chapt~r II

Extent and Dimensions of the Problem

9

Chapter III Existing Resources

28

PART TWO MENTAL HEALTH IN GEORGIA - TOMORROW

Chapter I
Chapter II Chapter III Chapter IV Chapter V Chapter VI

Programs, Facilities and Services Needed for Prevention, Treatment and Rehabilitation 1

Manpower

43

Financing

70

Legislation

87

Research

96

Health Education in Mental Health

105

PART ONE MENTAL HEALTH IN GEORGIA . . . TODAY

Chapter I "SETTING THE STAGE"

UR~fl

Mental health is becoming a primary concern throughout the United States. Aside from periods of world conflict, no cause has so united the nation toward a single objective as it is now united in planning for comprehensive mental health programs. Since 1963, all 50 states have focused intensely on studying their mental health needs and resources.
An important outgrowth of this interest is the growing recognition of mental health, which is considerably more than the mere absence of mental illness. More and more behavioral and social scientists are turning their attention toward the
;.'
concept of mental health in its dynamic and positive quality. It requires continuity in personality development and maturation. It is marked by an increased ability to adapt and adjust. It is, basically, being comfortable with self and others.
For decades, psychiatry has been preoccupied with mental illness alone and, as a result, program development has been largely confined to treatment facilities. This has been the traditional approach in Georgia as well as in other states.
Brief History of Mental Health in Georgia Current planning for mental health in Georgia marks the first major change in approach since 1837 when the state legislature authorized construction of the "Georgia Lunatic Asylum" in Milledgeville. The state's first mental health program began six years later with the appointment of the institution's first superintendent. In the early years, a succession of compassionate and understanding superintendents achieved a good program for that era. However, by the beginning of the 20th Century, increasing numbers of patients in the deteriorating buildings, together with lack of adequate funds and staff combined to contribute to the overall decline of conditions at the hospital. As the state program grew, private practice of psychiatry was also developing. Georgia's first private mental institution, Allen Hospital, was established in the

- 2-
latter part of the 19th Century, and Brawner Hospital opened in 1910 and has been in continuous operation since that time. Private hospitals and their psychiatric staffs have contributed significantly to the mental health needs of the state.
By 1929, when the institution's name was changed to Milledgeville State Hospital, there had been a few efforts to improve facilities but available funds fell far short of the hospital's needs. By the early 1930's, one study ranked Milledgeville State Hospital the lowest of all 190 state mental hospitals in the United States.
The hospital's difficulties were multitudinous. Compelled to accept all patients sent to it, and restricted by a budget lagging behind its increasing population, the hospital could achieve little more than custodial care. New patients arrived faster than space could be made available and overcrowding was a normal situation.
The hospital faced a constant shortage of trained personnel with no nearby source of supply. The state's first department of psychiatry was established at the Emory University School of Medicine in 1934, but there was no program for psychiatric residents for nearly three decades. In 1939 the University Hospital in Augusta, associated with the Medical College of Georgia, opened six rooms for psychiatric patients, but 17 years passed before a full-time professor of psychiatry was added to the Medical College faculty.
In the period following World War II, public interest and concern across the nation brought action in the field of mental health. In 1946 Congress passed the National Mental Health Act which, among its other provisions, authorized the establishment of the National Institute of Mental Health. The same year, Atlanta citizens organized the Atlanta Mental Hygiene Society, one of the parent groups of the present Georgia Association for Mental Health. This association, composed primarily of laymen, concerns itself with the many needs in staffing and financing mental health programs, promoting legislation and educating the public about mental illness and

- 3-
for mental health. National impetus for widespread planning of state programs began in 1955, when
Congress passed the Mental Health Study Act. This Act directed the establishment of a Joint Commission on Mental Illness and Health to f:analyze and evaluate the needs and resources of the mentally ill in the United States and make recmnmendations for a national mental health program."
With discussion underway on a national scale, Georgia was moving in the same general direction. In 1957, the Joint Legislative Con~ittee on Mental Health was established by the General Assembly. Four major recommendations of the Committee have already been enacted into law. They include:
1. Transfer of Milledgeville State Hospital to the Department of Public Health. 2. Legislation to prOVide for voluntary and involuntary treatment of mentally
ill persons. 3. Establishment of a Division of Mental Health in the Department of Public
Health, with authority to administer and supervise a mental health program. 4. Amending of the state constitution to allow state funds to be used for
training mental health personnel. By 1960, Milledgeville State Hospital, Gracewood State School and Hospital for the Mentally Retarded, and the Alcoholic Rehabilitation Service were transferred to the Health Department, placing all the state's major mental health programs under the administration of the official state health agency. During the period when the spotlight of concern was turning toward Georgia's mental health program, many individuals, organizations, and state agencies contributed substantially to the effort, particularly in p~tient-care efforts at Mi1ledgeville.
Plans for Planning The last day of 1960 marked the publication of the report, Action for Mental Health, which was the final report of the Federal Joint Commission. Probably the

-4-
most thorough and intensive study of a national health problem ever undertaken, this report made specific recommendations in three major areas of difficulty in mental health planning--manpower, facilities and cost.
Among the chief recommendations were those stressing need for increased research activities; methods to provde greater inducements for professionals to enter the field of mental health; improved utilization of professional and non-professional personnel; need for a national manpower recruitment and training program; establishment of additional and diversified facilities; desirability of bringing facilities closer to the individual, and provision of additional funds on all levels to expand present programs and to create new ones.
One purpose for which funds were made available was for planning, and Georgia was prepared to move ahead in that area. The Health Department had established a Division of Mental Health and had begun staffing it with full-time professionals. A "plan for planning" was drawn up, submitted to the Federal government and, on July I, 1963, the official two-year planning period began. Financed by threefifths Federal and two-fifths state funds, a total of $234,282.00 was made available to the Georgia Department of Public Health, which was designated by the Governor as the official planning agency.
The Division of Mental Health, working with many groups and agencies, spent the major part of the two-year planning period gathering data, establishing relationships and providing the mechanism to pull together the various components of the state plan. Recruitment was difficult and, while it was possible to employ some staff members almost immediately, it took much of the first year to round out the full complement of pl~nning-team members.
As finally constituted, this staff consisted of a director, a psychiatric consultant, a psychologist, a social worker, a mental health nurse, a health educator and a sociologist. Important to Georgia's long-range program was the concept that

5-
~.
~ ~~ this team, after completing the planning project, would move into permanent Division
positions and would be involved in implementing the plan it had helped develop. From the beginning it was recognized that any plan for Georgia's future in
mental health would be seriously delayed or discarded unless the people of the state had a part in the endesvor. Therefore, several programs were utilized to insure the involvement of the average citizen. One of these was the formation of three major cowaittees which provided the backbone of the planning effort.
The first group, the Technical and Scientific Advisory Committee, was a i\ multidiscipline body composed of representatives from the following: nursing,
~ internal medicine, social science, social work, psychology, general medicine, law,
the ministry, psychiatry, planning technology, preventive medicine and public health, and the con~unity at large. This committee's primary task was to help judge emerging plans and to make recommendations for change and modification when necessary.
Another group, the Interdepartmental Mental Health Coordinating Committee, was formed. Its existence recognizes the truism that mental health is not, nor mould be, the sole province of anyone agency. Existing departments of state government have inescapable responsibilities in the broad area of mental health. This committee consists of representatives from the following state agencies: Education, Family and Children's Services, Health, Labor, Corrections, Pardon and Parole, and the Commission on Aging. Its major function is to promote interagency coordination of mental health programs to insure that all needs are met and that each agency is assuming its responsibilities.
In addition to these committees, there was an Intradepartmental Mental Health Advisory Committee within the Georgia Department of Public Health. Composed of representatives from the major public health programs, its major function was to assure the necessary integration of services and program activities within the Health Department, and to see that emerging mental health plans were within the

-6-
boundaries of well-established public health practice. Establishment of this committee recognized mental health as administratively and philosophically a part of the broader reaches of public health.
Each of the three committees proved so valuable in the planning, it was recommended that the present crnmnittees or similar ones be continued on a perrnanent basis.
With the co~nittee structure serving the needs of the planning mechanism, it was recognized that a workable communications system between the planning effort at the state and local levels was essential. To promote the flow of communications, a series of meetings were planned, co-sponsored by the Health Department and the Georgia Association For Mental Health. The first meeting, held in Atlanta, included state level representatives of numerous professional, civic, voluntary and lay organizations. This was immediately followed by a series of seven regional meetings throughout the state.* The major purpose of these meetings was to outline the "plans for planning," establish cOUIDlunications, and discuss methods of identifying existing mental health needs and develop con~unity mental health resources.
Direct relationships were established between the planning effort and dozens of professional organizations through the appointment of liaison members from the organization to the planning effort. These representatives served as the communications channel between the planning staff and their organization. Along with this, The Georgia Association for Mental Health and its local counterparts, agreed to serve as the mechanism through which information from the planning project could be fed to the literally hundreds of voluntary, lay and civic organizations.
With the major principal emphasis being placed on community responsibility, every effort was made during the course of the planning project to stimulate local planning efforts. Toward this end, each member of the planning team was assigned a specific region of the state to serve as the contact person between the citizens
* Waycross, Albany, Macon, Augusta, Rome, Athens, Atlanta.

- 7-
from th8t region and the Division of ~1ental Health. To further local planning, eighteen public health districts elilployed summer planning assistants. These planning assistants were local professional people (largely school system employees) hired for the summer of 1964 to gather local data bearing on mental health problems, and serve as stimulators in aiding their own communities to develop local mental health planning councils. Each of these assistants compiled a written report containing information intended to be helpful to local planning efforts.
During this time, data were also being collected on a state-wide basis concerning staffing patterns in public and private facilities, patient information such as: length of stay, type of treatment, age, race, sex, and county of residence, and information to estimate the need for additional mental health resources. Generally speaking, the attempt was to acquire information that would allow for meaningful interpretation of Georgia's overall needs in the area of mental illness. Questionnaires, surveys, personal interviews were among the major techniques used in collecting information. The Biostatistics Service of the Georgia Department of Public Health, was of inestimable value in the collecting, storing and analYZing of this information. In such areas as manpower, staffing patterns e.nd needed personnel resources, those members of the team representing psychiatry, nursing, psychology and social work were able to easily relate to their professional peers outside the agency and gain objective information and value judgments. Indeed, the members of the various mental health disciplines, individually and through their respective professional organizations, have made outstanding contributions to the planning effort. They have voluntarily served on conL~ittees and study groups and have given generously of their private time.
Various techniques of mass co~~unication were employed throughout the planning project. A bi-monthly newsletter with a mailing list of 1,600 was circulated throughout the state, along with news releases to all newspapers and radio and television

-8-
stations. A speakers bureau listing composed of 91 persons who expressed their willingness to serve as speakers in one or more areas of mental health was compiled and distributed, while the planning staff continued its policy of meeting with interested individuals and groups. Eight thousand copies of the publication - "Mental Health Planning - A Guide for Georgia Communities" were distributed to persons interested in establishing local planning groups.
This plan for Georgia's future in mental health programs is, then, the culmination of two years of intensive effort, not only by the planning staff employed to direct the effort, but by numerous citizens. It is tangible evidence of many thousands of man hours and is believed to be accurate in content and, it is hoped, purposeful in concept.
It is recommended that:
1. A COMMITTEE SIMILAR IN PURPOSE TO THE TECHNICAL AND SCIENTIFIC ~NTAL HEALTH ADVISORY COL~iITTEE BE ESTABLISHED ON A PERMANENT BASIS.
2. A COMMI'rTEE SIMILAR IN PURPOSE TO THE INT~~DEPARTMENTAL MENTAL HEALTH COORDINATING COMMITTEE BE ESTABLISHED ON A PERMANENT BASIS.
3. A COMMITTEE SIMILAR IN PURPOSE TO THE INTRADEPARTMENTAL MENTAL HEALTH ADVISORY COMMITTEE BE ESTABLISHED ON A PERMANENT BASIS.

... 9 -
CHAPTER II EXTENT AND DIMENSIONS OF THE PROBLEM
This chapter presents a brief analysis of the scope of mental illness in Georgia. Items discussed include: (1) the types of services which are being secured by the state's population, (2) existing gaps in services and, (3) predictions of the impact an increasing and aging population might have on the future mental health facilities and services. Data presented are based primarily on a series of surveys conducted during 1963 and 1964.
It should be clearly recognized that these data represent gross estimates of existing and predicted situations; however, they do serve as objective guides in providing a rational basis for decision-making.
A. Scope of Mental Illness in Georgia Today
To delineate the scope of mental illness in Georgia, it is necessary to make two kinds of estimates. One is the estimate based on the number of patients per 1,000 population receiving mental health services during a given time period. This is called the "utilization rate". The second is the estimate of number of persons who have never received mental health services, but who could be presumed to be in need of them. This is called the "unmet mental health need". Neither of these quantities should be considered completely intrinsic or invariant with respec to a given population. They are certainly influenced by the amount and types of mental health services available. If the availability of services were altered, different utilization and non-utilization patterns would undoubtedly emerge. The utilization rate does, at leaDt, represent a minimum of mental health services in demand.

- 10 -
1. Utilizat.~on Rates a. How nata Were Collected
An attempt was made to survey all facilities in the state providing services for the mentally ill, the alcoholic, the drug addict. Included in this survey were public and private hospitals, outpatient clinics, and nursing homes. In addition, private psychiatrists and psychologists were asked to furnish information on patients seen in their offices during a two ,reek period. Other programs surveyed included Vocational Rehabilitation, State Prison System, and classes for exceptional children.
Information was collected on the age, race, sex, county of residence, diagnosis type of service sought, length of stay and frequency of admission of persons receiving mental health services during a one-year period. Where possible, population data were secured; however, sampling was done where volume dictated its necessity. Rigid confidentiality concerning the patien~ names was maintained.
Cooperation received was considered excellent. Of 30 inpatient facilities requested to participate, only one refused. Of 167 nursing homes 155 agreed to interviews which involved certain statistical as well as attitudinal data. Fiftyfour private psychiatrists out of 70 contacted participated and 19 of the 19 private psychologists did so.
b. How many Georgians received services in outpatient and inpatient treatment facilities? Analysis of the data, exclusive of that from nursing homes and private psy-
chologists and psychiatrists, shows that over 40,000 persons, or approximately one of every 100 Georgians received mental health services in a treatment facility in 1963. Of these, over 4,200 were readmitted for treatment during the year. Table 1

- 11 -

indicates that 77 percent were treated in hospitals and other inpatient facilities. and that treatment itself was the largest category of service secured.

Table 1
Type of Service Received In Outpatient and Inpatient Facilities -- First A9m~ssions During 1963

Tvpe of Service
Total Treatment Diagnosis.
Evaluation Only Psychological Testing Other Unknown

Total

42,508 39,313

1,618

353 694 530

II
I, i,

Inpatient
32.692 32.681
2
9

Outpatient
9.816 6,632
1.616 353 685 530

What types of people make up the one in 100 who did secure this type of mental health service during 19637 In the following sections. there is a further analysis by age, sex, and race, and socio-economic factors.

c. Services and Diagnosis Vary by Age During 1963 it is estimated that 46,722 patients received mental health
services (See Table 2). The highest utilization rate for all services was in the 35-44 year age group, showing a rate of 20.54 per 1.000 population. This age group has the highest rate for outpatient facilities. but falls slightly behind the 45-54 year group in utilization of inpatient facilities. Both of these age groups have relatively high rates, with a fairly abrupt rise in utilization rates as these ages are approached and a steep de~line after they

- 12 -

are passed. The utilization rate for outpatient service falls off abruptly in the 55-64 year age group and continues to decline, whereas the inpatient utilization rate is fairly constant after declining in this age group. The 75 and over age group received less outpatient service than any of the othe r age groups.

Table 2

Estimated Number and Rate Per 1,GOO. Population of Individuals

~en During Year of Survey in Inpatient and Outpatient Facilities,

Bl A~e Groups' U9-63)1

i
I
I

Total Inpatients & Outpatients

I

Inpatients

Outpatients

Age Group -..

Number : Rate*

;
Number Rate*

Number

I
I

Rate*

..

Total

46,722

11.21

35,709

8.57

I 11,013 2.64

!

0-4 years

309

0.62

117

0.23

192 0.38

5-9

1,115

2.40

115

0.25

1,000

2.15

10-14

1,540

3.54

397

0.91

1,143

2.63

15-24

6,731

10.56

5,204

8.17

1,527

2.40

25-34

8,859

16.50

7,058 13.15

1,801

3.35

35-44

10,957

20.54

8,259 15.48

2,698

5.06

45-54

8,821

55-64

I 3,978

65-74

I 2,326

I 75 and over 1,166

Unknown

I

I I

920

I

19.62

6,984

13.11

3,387

11.30

2,144

11.51
-

1,151
893
.'

15.53 11.16 10.41 11.36
-

* Rates based on July 1, 1963 Estimated Popu1adon

1,837 591 182 15 27

4.08 1.95 0.88 0.15
-

13 -
In the younger age groups the rates primarily represent the utilization of outpatient sel~ices. In the 15-24 year age group the utilization rate for inpatient services rises abruptly to 8.17 per thousand population. The small utilization rate of inpatient services for age groups below 15 years of age is not unusual.
The pattern which emerged is high utilization rates in the middle age groups for both inpatE nt and outpatient services and low utilization rates
for tre very young. The elderly have a high utilization rate for inpatient
services but a low rate for outpatient services. Table 3 gives a breakdown of diagnosis by age groups. Patients with
psychotic disorders constitute the largest diagnostic group and account for 37 percent of all patients. Psychotic disorders are concentrated in the age range from 15 to 65 years. Fifty percent of all patients in the 25-34 year age group are in this diagnostic category. Then the percentage declines after this age to approximately five percent in the 75 and up age group.
Patients in the 0-4 year age group are predominately in the psychotic disorders diagnostic category, but in the 5-9 and 10-14 year age groups the largest numbers are in the transient situational personality disorders category. The chronic brain disorders rise sharply in the 55-64 year age group, and become the largest diagnostic category in the 65 and over age group.
The second largest diagnostic group, comprising 18 percent of the total patients, is psychon~urotic disorders. These patients are found mostly in the 35-54 years age range. About one-fourth of the patients in each of the age groups 35-44 and 45-54 are in this diagnostic category.

Table 3
Estimated Number of Patients 'Receiving Services 'in Inpatient and Ou'tpatient Facil:tties .During a Year by Diagnosis and Age Group (1963)

Diagnosis (A.P.A. Code*)

I Total

TOTAL

146,722

Acute Brain Disorders (01-09) I 1,173

Chronic Brain Disorders (lO-19~ 6,232

Psychotic Disorders (20-25*) 117,116
II
Psychophysiologic, Autonomic and Visceral Disorders (29*-391 406

Psychoneurotic Disorders (40) 8,523

Personality Disorders (50-53) , 6,842

Transient Situational Personality Disorders (54)
Personality Disorders, Unclassified (59*)
~~ntal Deficiencies (60-63*)
Diagnosis, Unspecified and Unknown (91)
Other

1,201 11Li1 315

I II

214 2,900

I!
I- 1

I I
-I

2'-'1

I II,

I

-I
I 143 I I,

-I
254 I
I

78 988

1,777 64
!11
338 " I 7
II

376 I I ,34 1 I

367 I 28 I

412 38

Ii

* Special Codes added to A.P.A. Diagnostic Codes.

217 433

1

171 56

!

2

102

23 I I

- 5 I 15 I

I

10

26

12

3 -I

282

102

25

4

63

I

I 88 I 47 I 42

33

9

- 15 -
There are many conclusions that can be drawn from this analysis, but the most important one for planning purposes is that both the amount and types of emotional disorders are seen to vary with the age of the patient. Consequently, services should be programmed to reflect these changing patterns.
d. Sex and Race Influence Utilization The utilization rates of mental health resources vary with the sex and
race of those receiving service. In both races males are found to utilize the resources much more than females (See Table 4). There were approximately four more white males per 1,000 population receiving mental health services in 1963 than white females, and approximately two more nonwhite males per 1,000 population than 'nonwhite females. Numerically, an estimated 5,821 more males received mental health services in 1963 than females, representing a 12 percent higher utilization rate. This higher rate for males is perhaps explained by the position of the male in our society as the "breadwinner." When he fails to per"': form this function there is considerable social pressure to have him treated and rehabilitated as early and as fast as possible, while the female suffering from the same degree of emotional disorder may in many instances be retained in the home for a longer period because of child-caring responsibilities.
So while the male seeks psychiatric services more readily than the female, there are strong indications that this can be explained by factors other than a higher rate of mental illness in the male.
Table 4 also shows the utilization rate of nonwhite Georgians to be belOlI1 that for white Georgians. In 1963 nonwhites comprised an estimated 29 percent of the total state population, but only 19 percent of the total estimated number of patients receiving mental health services. This represents a utilization rate of 7.45 per 1,000 nonwhite population, as opposed to 12.73 per thousand white population.

- 16 -

Table 4
Eatimated Nwnber" Percent, and Rate of J;>atients aeceiving Psychiatric Inpati~t, Outpatient, and Clinic Services During a Year By Race 9ud SeK (1963)

i
Race and Sex of Patient
TotAL White Male White Female Nonwhite Male Nonwhite Female

Number of Patients
4~,722*
21,525 16,259
4,744 4,189

Percent of Total Patients
100,',
46 %
35 %
10 %
9%

Rate Per 1,000 PODulation
11.21 14.68 10.83
8.34 6.64

* Total includes 5 patients, race and sex unknown.

There are many social and cultural factors to be considered in the explanation of the differences in utilization rates by race. Part of the lower nonwhite utilization rate reflects the characteristic low-use-rate of psychiatric services by the lower socio-economic class, since there is a much higher percent of nonwhite population in this class than white. This is in part related to the smaller capacity of the low income groups to secure or purchase psychiatric services, but also the lower socio-economic class seem to have a higher tolerance level for pathological behavior of its members. This results in the mentally ill being tolerated within the context of the family and social group in this class when a person with the same degree of mental illness in a higher socioeconomic class would be referred for mental health service.

- 17 -
e. What Are the Other Effects of Socio-economic Class? Due to the lack of time and field personnel, data were not collected re-
lating to the socio-economic class of those seeking mental health services; ho\rever, several points in addition to those indicated earlier should be mentioned.
One of the paradoxes in the mental health field is that even though in the last few decades there have been major breakthroughs in the diagnosis, treatment and rehabilitation of the mentally ill; costs for services have increased so rapidly that benefits have become financially unattainable for large segments of the population. One-third of the families in Georgia in 1959 had an estimated annual income of under $3,000, (See Table 5). Over half were under $5,000. Even though the annual family income has risen somewhat in the last five years, a large segment of the state's population cannot afford to pay the full cost for mental health services. This inability of the lower socio-economic class to buy mental health services certainly affects the utilization rate of this class. As coverage by prepaYment insurance improves and services for the psychiatrically indigent are added, an increase in the utilization rate may be expected. Also, a conscientious program of mental he&theducation could be expected to substantially increase the utilization rate, expecially of outpatient mental health services, by the lower socioeconomic class.

- 18 ..

. --.----...

1ab1e 5
Number and Percent of Families in Georgia By' Specified Annual Income in 1959 . (1960 U.S.Census Data)
.....-... _..._-- "--lFami!i:.sB~:,;~~clfiedIn~o;;'"

Estimated Annua~ Family Income

~

---II Number

; Perce~~---

.... '''''''''.'-'-'''- "-Tota1-r;;;;;ili;;;'::-=~-::: 949,4081100.0 .-

1. Under $3,o00.. ------------- .. --- .. ----1 338.120

------1 2. $3,000 - 4,999--------.. ----- ..

220,268

3. $5,000 - 6,999--------------------- 173,681

4. $7,000 - 9,999----------------- .. --- 129,967

5. $10,000 and over------------------- 87,372
----=---_..__. ._._1

35.6 23.2 18.3 13.7
9.2
-_._-,.

f. Does Length of Stay Affect Utilization Rates? Of the 22,881 discharged patients in Georgia during 1963, nearly one-
half were discharged in less than one month following admission. (See Table 6).

Table 6

Length of Stay of Patients Discharged During a Year (1963) From

Inpatient and Outpatient Treatment Facilities

" " - ' - - ___...,_

~_



. . . _ _ . _ . . . , _ , . _ _ ,~,~v_ . '_ . _ . _ , . , _ , '

. _ . _. . . ._ . " . _ _ .. _ . " ,

.._ .... _ _ ~._ .... _ _ ~.,

.

. _ . _ , _ _ _. _. _ . ~ . _ , _ . _ ~

_

-.---- --.- ... _.._.-.....----r-\'-T-o-t-a-l-..In-.p-a-t'i-e"n!_=.s-. -,;,----"-- .,,-1- ..- - - -... I

________.Length of Stay .._._ -----to' ._ and Outpat~ents

Total

II

22,881

I : In atients ,Outpatients _ I

16,360

6,521

Less than one month 1 month to 3 months 3 months to 6 months 6 months to 1 year

I

10,295

Ii

3,475 1,812

,1,559

8,462 I
2,215 I
552 427

1,833 1,260 1,260 1,132

1 year to 2 years 2 years to 5 years

3,071 1,468

III 2,383 1,152

688 316

5 years to 10 years 10 years to 15 years

656
214

,d!It

625 213

31 1

15 years to 20 years

134

~.~.I 134

__ 20 years and over

.

._---------"._--~-~-

197

197

~i

- 19 -
The average length of stay for all patients discharged during 1963 was 1 year and 69 days. One reason for this long average length of stay is evident when one looks at the number of patients who were discharged over five years after admission. Most of these were inpatients who were in the State thspital. Through the use of mOl"C rr.odc:-n treatment ~~:tho(1!; the State Hospital was able :0 discharge this unusuaHy lax-ge nUl::lJer of those previ.ously considered to be life-time residents.
Of the 16,360 irLpatients discharged in 1963, over 50 percent had stays of less than 0110 month and 65 percent had stays of less than three months. The majoLity of those with over one year of stay were discharged from the State Hospital. Of the 6,521 outpatients discharged in 1963, 84 percent (5,485) had stays of less than one year and 47 percent (3,093) had stays less than three months.
It would not be meaningful to compare average lengths of pat~t stay in state hospitals with the substantially shorter averages in private psychiatric hospitals. This is because if it appears that a patient's illness will be long and too costly for his family to finance in a private hospital, he may be sent directly to a state hospital or transferred there after a brief treatment elsewhere. Nor will many private psychiatric hospitals or general hospitals accept patients knowingly if their illness has progressed to the point where it requires long term hospitalization. Most of the psychiatric units in general hospit21s, for example, have policies limiting stay to not over 56 days. If, at the end of such a period the patient has not recovered, he will probably be moved to a state hospital or to a custodial type of private institution.

- 20 -

g. Utilization Rates of Patients Seen During Office Visits to Psychiatrists and Psychologists Because of the differences in types of patients and types of services
offered, patients seeking services through office visits to private psychiatrists and psychologists are presented separately from those receiving services in inpatient and outpatient facilities.
In 1964 it was estimated that 15,842 persons received services during office visits from 70 psychiatrists and 19 psychologists. Of these an estimated 7,317 were male, 8,286 were female, and only an estimated 353 were nonwhite. These data include 239 of unknown race and sex.
The age group with the highest utilization rate was the 35-44 year age group with 7.29 per 1,000 population (See Table 7). The next highest was the 25-34 year age group with 5.99 per 1,000. The 15-24 and 45-54 age groupings had rates of 4.75 and 4.70 respectively. The younger and older age groups had much smaller utilization rates than the middle age groups.

Table 7
Estimated Number of Patients and Rate Per ThQusand Population Receiving Services During Office Visits From Psychiatrists and Psychologists in Private Practice for a Year by Age (1964)

Age Group

Number

I Rate per Thousand Population

---------01------------1i ----------------

Total

15,842

3.75

0-4 Years 5-9 10-14 15-24
25~34
35-44 45-54 55-64 65-74 75 and over Unknown

2 546 679 3,068 3,261 3,947 2,143 793 380
4 1,019

0.00 1.16 1.54 4.75 5.99 7.29 4.70 2.58 1.82 0.04

- 21 -
Summary It is evident from the data that the demand for psychiatric service of all types is greater in the middle age white population. Several questions could be raised. Would the demand be equally as great in the younger and older age groups if more clearly defined services were available? Are public services reaching all segments of ti~ population in ways which produce a maximum, effective response? At what ages should priority be placed on preventive programs? This leads us to attempt to project in more detail the types of situations in which needs are not being met.
2. What are the Areas of Unmet Need? Unmet need is that need for mental health services by persons in the
coramunity which for one reason or another is not being met. The reason most frequently given for the failure to meet this need is the lack of mental health services of t~ type and amount which are required. There are other reasons such as the failure of people to seek service when they need it, and failure of professional persons to recognize and refer emotionally disturbed persons to treatment resources. But these reasons are dependent on the availability of services, and in a state which has far too few mental health resources, especially within the comn1unity, the lack of resources will have to be the primary explanation at this time for the urunet mental health need.
There are many estimates of the amount of mental health need. The estimate most commonly stated is that one in ten of the population is mentally ill or psychologically disturbed. This does not mean that one in ten could be sent to a hospital for psychiatric services; rather, that one in ten could be substantially benefited by some type of mental health service. When this estimate

- 22 -

is limited to those with severe disorders that are socially disruptive or individually incapacitating, the ratio is perhaps one in 100.
In order to arrive at an estimate of unmet mental health need in Georgia, a 27 percent sample of all physicians in private practice throughout the state, exclusive of psychiatrists, was interviewed. On the basis of the sample it is estimated that 385,519 persons were seen in a typical week by private physicians. T~ey were asked to estimate the number of these patients whom they considered to be suffering from mental health problems. From these responses it is estimated that 25 percent of those patients seen by a physician during a typical week of medical practice are suffering from some type of mental health problem. (See Table 8) The majority suffered from functional or emotional disorders, one percent were estimated to be alcoholics. 0.2 percent were drug addicts, and 1.4 percent were mentally retarded.*

Table 8

Estimate of Total Patients Seen by Private Physicians During a Typical Week, And Estimate of Number of Patients with Functional or Emotional Disorders,
Alcoholic Problems, Drug Addiction, and Mental Retardation

Diagnostic Categories

Number

Percent of Total Patients Seen By Physicians

----------------------+--------/------------

Total Patients Seen By Physicians

385,519

100.0 %

Total Patients With Mbntal Heal th Problems

96,367

25.0 %

Patients With Functional and Emotional Disorders

86,517

22.4 %

Alcoholics Drug Addicts

3,502 792

0.9 % 0.2 %

Mentally Retarded

J ._5.,_5'56. "__. . 1.4 %

_

* For a breakdown of these data by county,see Appendix.

- 23 -
Because of the lack of community resources the vast majority of these were not referred for mental health service. Consequently, they can be classified as the physician's opinion of unmet mental health need as interpreted from his private practice. This estimate of 25 percent by no means can be applied to the entire community as a percentage of unmet need but only to the percentage of the patients seen by private physicians.
Also, it should be pointed out that the estimated number of mentally retarded is extremely low as is the number of alcoholics. Estimates used nationally for the mentally retarded generally show three percent of the total population, whereas the percent in this study was 1.4. According to a formula developed by Dr. Jellinek at Yale University for estimating the ratio of alcoholics to population, Georgia ~uld have 100,000 alcoholics at this time. A high percentage of these are also addicted to drugs; some to narcotics.
Thus, one can see that an estimate of the amount of unmet mental health need in Georgia is little more than an intelligent guess. That there is a great amount of unmet need is indicated by the high divorce rate, delinquency rate, arrest rate due to public drunkeness, and suicide rate. In 1963 suicides were the 6th leading cause of death for the 15-24 year age group, 7th leading cause of death for the 25-44 year age group and 10th for the 45-64 year age group. The 1963 suicide rate for Georgia was 10.7 per 100,000 population.
If one would apply what is considered to be a conservative estimate of one in ten of the population being mentally ill, or psychologically disturbed, then the number in Georgia during 1963 would have been 407,500. To arrive at the unmet need the met need of 42,508 (the unduplicated count by facility of

- 24 -

persons receiving service) plus the number of persons receiving services from

private psychiatrists and psychologists, 15,842, should be substracted from the

total mental health need (407,500) and the remainder sh~uld give some indication

of the minimum amount of unmet mental health need in Georgia.

407,500
-42,503 -15,842
349.150

Estimate of the number of mentally ill or psychologically disturbed in the population. The unduplicated count by facility of persons receiving service. Estimate of the number of persons receiving services from private psychiatrists and psychologists. The minimum estimate of tre number of persons with unmet mental health need in Georgia in 1963.

This estimate of 349,150 persons not served could be considered minimum.

A maximum estimate would be 25 percent of the population or around 1,000,000.

Estimates of the amount of unmet mental health need fluctuate from results of

one study to another. We can only be concerned with gross estimates at this

stage of our knowledge. The basic fact is that Georgia has enough mental health

resources to meet but a small part of existing need. The price which is paid for

this lack can be read through such tragedy as suicide, divorce, delinquency, and

loss of tax dollars through temporary or permanent loss of economically and

socially productive citizens. An adequate mental health program will not be

an answer to all our problems, but a sound beginning to the answer of some of

them.

B. Mental Health Needs in Ten Years

The population of Georgia is increasing and a corresponding change is occurring in the proportion of the population in particular age categories.
Since both the type and number of persons requiring mental health services differ at different ages, it is important to have knowledge about future chapges in the size and age distribution of Georgia's population.

- 25 -
There is no reason to syppose that tl~re will be less mental illness in the next decade than there is today. Further improvements in diagnosis and treatment techniques may result in shorter periods of hospitalization and expanded additional rehabilitation programs may be expected to somewhat reduce the readmission rate to mental hospita~s. But programs for the prevention of mental illness and tre promotion of mental health will not be developed overnight, and unless significant breakthroughs occur as a result of research, substantial reduction in the number of Georgians needing diagnostic and treatment services will not occur in the near future.
On the other hand, with increasing public awareness of the nature of mental illness, the demand for mental health services can be expected to increase. Also a substantial increase in number of patients seeking service may be expected to increase with additional community mental health resources and the continued improvement of existing programs. For instance, the development of tre intensive treatment program at Milledgeville State Hospital resulted in almost doubling first admissions to the Hospital in a five-year period. There is no method available to obtain a reliable estimate of the amount of expected increase for mental health services. Any estimation based on present utilization rates will of course, be relative to the amount, type, availability and quality of existing mental health resources as well as to culturally derived understandings and expectations. Such an estimate would be little more than a pro~ jection of Georgia's present mental health situation into the future, only taking into consideration demographic changes. Even this may have some value, because it, in fact, will show the additional mental health services which will be needed in the next decade in order to simply maintain the present level of services.

- 26 -
Table 9 is a projection to 1975 of the number of psychiatric patients computed by applying the estimated present utilization rates to the 1975 projected population.
Table 9 compares the number of patients which utilized the inpatient and outpatient resources in 1963 to be projected numbers in 1975. The increase of 10,632 patients seeking inpatient services over the 1963 number, about 30 percent, may be considered to be a very conservative estimate. The increase of outpatient services is 2,820 patients, or 26 percent over 1963.
It will be no insignificant task to meet the increased demands for mental health services in the next decade, while at the same time improving the quality of care. These figures point to one fact -- Georgia will have to run to stand still.

--

.-

Age Group

TOTAL 0-4 years 5-9 : 10-14 15-24 25-34 35-44 45-54 5.5-64 65-71. 75 and over Unknown

~aDLa ~
Estimated and Projected Number of Patients Utilizing M~ntal Health Resources, by Type Service,
By Age Group, 1963 and 1915

._ Total

1963

1915-

62,564 80.125

311

413

1,661

2,032

2,219

2,691

9,799 14,609

12,120 16,905

14,904 16.767

10.964 12,998

4,771

7,136

2,706

4,409

1,170

1,959

- I 1,939

Inpatients 1963 1915

35,109 46,341

111

158

115

141

397

519

5,20t..

7,717

1,058 9,805

8,259

9,263

6,984 8,266

3,387

5,057

2,144 3,486

1,151
893

1,929
-

Outpatients 1963 1915

11,013 13,833

192

252

1,000 1,200

1,143 1,463

1,527 2.214

1,801 2,446

2,698 2,958

1,837 2,126

591

862

182

288

15

24

27

-

Office Visits to Private Psychiatrist and Psychologist
1963 1915

15,842 19,951

2

3

546

691

679

915

3,068 4,618

N

3,261 4,654

"-J

3,947 4,546

2,143 2,606

793 1,217

380

635

4

6

1,019

-

._-

- 28 Chapter III EXISTING RESOURCES TO MEET MENTAL HEALTH NEEDS IN GEORGIA
While it was necessary to survey the extent and dimensions of the problem of mental illness in Georgia, it was equally as important to survey what was being done to alleviate tt~ problem. To accomplish this task required the cooperation and support of numerous agencies, organizations and individuals, presently engaged in providing direct and indirect services for the primary, secondary and tertiary prevention of mental illness.
Because the scope of mental illness and mental health is so broad, it was impossible to enumerate every available resource in the state which provided some type of mental health service. Thus, we have limited this report to include those programs with clearly identifiable mental health responsibilities, engaged in serving greater numbers of people.
A. Official (Public-Tax Supported) Agencies
Although the following agencies will be described as they are programmed from the state level, it is important to remember that services are usually rendered to the individual in his own community through local counterparts of the state agency. Services ascribed various programs are generally uniform throughout the state, but variations in their application will naturally occur from one local administrative unit to another. Minimum standards for service are usually set at the state level. This provides the local unit a common framework within which it can function, making appropriate adaptations when necessary.

1. Department of Education

- 29 -

The following services. offered by the State Department of Education. are designed to assist students. who. from the mental health standpoint are susceptible to emotional disorders and largely fall within the area of primary prevention of mental illness.

a. Visiting Teacher Services
The services offered by school social workers) known in Georgia as "visiting
teachers") are directed toward those pupils whose emotional or social problems are
such that they interfere with the child's ability to adjust or attend school.
'l'hese services take the form of:
Direct work with children) individually or in groups. to prevent or correct certain personal, emotional or social maladjustments.
Consultation with parents and school personnel, as an integral part of working with the child) to increase their understanding, and enlist their cooperation and participation.
Referring and encouraging pupils and their families to utilize appropriate "helping. agencies" in the conmunity.
Those applying for positions as "visiting teachers" are required to hold a
bachelor's degree. To be eligible for certification, they must have completed
three initial courses in school social work, along with a planned period of
in-service training. All are encouraged to then obtain a masters degree in social
work, with an emphasis on school social work.

b. Guidance and Counseling Program While these services have been operating in selected locales for 25 years, it
is during the last decade only that guidance and counseling functions have been emphasized as a program entity. The major components of this program include:

- 30 -
Coordinating an educational testing service for students.
Providing vocational guidance services to aid students in selecting a vocation and helping them choose courses which will be beneficial toward this vocation.
Counseling services for students on educational, personal and family problems -- as related to the student's adjustment to the school setting.
Referral of certain problems to appropriate individuals or agency when necessary.
Student analysis service -- information about the individual student is collected, studied and evaluated by counselors and teachers to utilize in working with pupils.
Follow-up service -- information is compiled and studied on school graduates and "drop-outs" to evaluate effectiveness of a guidance program. Results of these ~tudies reveal areas in the school that need attention.
Orientation service -- to assist new pupils to adjust to new environment.
While the point of origin for receiving referrals differs, both the school
counselor and the visiting teacher are in strategic positions to assist with
emotional problems. Despite the fact that the school counselor receives cases
resulting from academic difficulties, he or she is in a position to focus his
or her attention on immediate interpersonal conflicts, seeking cooperation and
help from the family and other conununity resources.
School counselors are specifically trained on the graduate level in the area
of guidance and counseling. Provisions have been ~de for three levels of
certification: Provisional SC-4; Professional SC-5; and Professional SC-6.
(The Professional SC-5 requires a masters degree, while the SC-6 exceeds the
masters degree and includes a minimum of 45 hours of guidance and counseling
courses.)

- 31 -
In 1952, there were 122 school counselors in Georgia; in 1964, the number had increased to 584 a gain of nearly 400 percent in 12 years. The ratio is still one counselor to 864 students as versus the desired ratio of one to 250. Services are limited to high school students although exploratory measures are unden~ay to extend this coverage to the elementary grades.
c. Division of Vocational Rehabilitation Responsible for administering rehabilitation services to individuals 16 years
of age and over, this Division plays a key role in improving the health and welfare of the general population. To be eligible to receive services an individual must have " .a physical or mental disability which constitutes a substantial handicap to employment, but which is of such a nature that Vocational Rehabilitation Service may reasonably be expected to render him fit to engage in a renumerative occupation. '!* The following services, outstanding examples of tertiary prevention of mental illness, are as follows:
Diagnostic and treatment services (medical and psychological) Vocational counseling and guidance Treatment for physical rehabilitation Prosthetic devices Individual training and development of work skills Transportation and maintenance during training Purchase of tools, equipment Job placement and follow-up. Georgia has been unusually fortunate in that vocational rehabilitation services are now available to patients at Milledgeville State Hospital. The Yarbrough Comprehensive Rehabilitation Center, located on the grounds of the Hospital, is believed to be the most complete of its kind in the nation. Vocational rehabilitation services are planned in conjunction with the individual's medical treatment program, while he is in the hospital and after his release. Upon leaving the Hospital, his
* !!Rehabi1itation Restores Disability". Division of Vocational Rehabilitation.

- 32 -

program is transferred to one of the nearest 37 area offices staffed by 153 couuselors and other vocational rehabilitation specialists.
In 1962-63, 14,675 persons received one or more of the services offered. The total cost was $5,688,032, making the average cost per case $387.60. Seventy percent of these total expenditures were met by utilizing matching funds from the federal government. Because the state has not been able to provide all the necessary matching funds, this program is not yet fully implemented.

d. Services for Exceptional Children

The purpose of this program is to provide an educational experience to students

who otherwise are denied an opportunity for maximum growth in the traditional

classroom setting because of intellectual, emotional, physical or language

deviations. Under the guidance of the staff of the State Department of Education,

the following special classes have been offered:

Categories

Number of Classes Operated in 1963-64

Educable Mentally Retarded Speech Correction Hospital/Home Instruction Visually Impaired Crippled Emotionally Disturbed Impaired Hearing Trainable Mentally Retarded Coordinators
TOTAL

436Jz
96~ 34~
25 10 27 12
6 ~
653Jz

The services offered by this program generally provide primary prevention, in the sense that their first concern is the education of the child. But, because of the special groups of children served, these same se~Tices have significantly important secondary and tertiary prevention aspects. It is apparent that special classes are not only necessary for developing positive mental health but also serle as a basic resource for children with mental disabilities.

- 33 -
2. State Department of Family and Children Services
Historically, this Department has been perceived as the agency responsible for assisting those in need of subsistence and health care. However, through its two major divisions, it also offers treatment and rehabilitative services to the extent that budgeted funds permit.
a. Division of Social Administration Through their local county units, this Division administers financial assistanc
to indigent individuals and families. Popularily known as "categorical assistance programs", the following services are important primary and tertiary prevention activities:
aid to the blind aid to the permanently and totally disabled aid to families with dependent children old age assistance medical care for recipients of adult programs general relief In contrast to the other programs included in the Division, "Aid to Families with Dependent Children" is solely concerned with and operated for children. Payment rates, as in the other programs, are determined on a formula basis derived from a subsistence budget -- an entirely inappropriate approach. Society has too great a stake in the future development of these children not to make provisions for them on a more encompassing basis. The ultimate goal should be to provide whatever services are necessary to insure the child's total physical, emotional and social development. Future progress in reducing the populations of state facilities will depend, in part, on the availability of funds to pay the cost of care necessary for maintaining released patients in their own communities. For some, financial assistance may be required during a transitional or convalescent period, while for

- 34 -
others, such as chronic patients, it may have to be prolonged. "Aid to the
Permanently and Totally Disabled" and "Old Age Assistance Programs" will be
increasingly important resources in planning to meet the needs of the mentally ill
and the retarded.
b. Division of Children and Youth
Established by the State Legislature in 1963, this Division brought existing,
state-funded programs for children together under one administration and created
additional ones. Its major responsibilities is to provide services for children
without stable, responsible parental guidance -- including the dependent, the
neglected and the delinquent. Some major programs, such as institutional services,
are operated directly by the Division, others through the child welfare sections
of local departments of family and children services, with the state agency providing
staff supervision and consultation in local program development. Local costs are
partially reimbursed by the state.
Major program elements of this Division are as follows:
Institutional Section. This section is comprised of the three existing training schools where seriously maladjusted, usually delinquent, children are cared for. Rehabilitative experiences are being added to the original custodial service as rapidly as professionally trained staff can be employed. Funds have recently been secured for the construction of six regional detention centers which will offer short-term care and diagnostic evaluation for delinquents before and after juvenile court hearings.
Child Welfare Section. This section encompasses a group of essential child welfare services including: services to unmarried mothers, foster care, adoptions, and casework for children in their own homes. The dire need to make service available in these essentially crisis situations is of prime importance.
Court Services Section. The purpose of this unit is to provide a staff service to courts having responsibility for dependent, neglected or delinquent children. Pre-trial studies assure that essential information is made available to the presiding judge. Probation and aftercare services are also provided through the assigned worker.

- 35 -
Licensure Section. This unit has the statutory responsibility for inspecting and licensing children's facilities, maternity homes, child placing agencies and day care centers. This is important in assuring that the child's experiences while in these facilities are favorable ones. Community Development Section. The object of this unit is to extend and improve the range of services provided by communities to children. It should be apparent from the foregoing enumeration of services that this Division occupies a crucial role in relation to children whose immediate well-being is in jeopardy. Although the scope of services presently included in this program appears to be comprehensive, actual statewide coverage is spGrse. At present, there are 60 counties with one or more full-time child welfare workers, about 75 with workers assigned part-time and the remaining with no coverage at all. Extension of these services depends upon the availability of additional professionally trained staff. While psychologists, educators, vocational rehabilitation specialists and others are necessary, program development will be geared e~~tensively to recruiting and training people in social work at the graduate level. Because of the wide range of services offered -- including institutional care this Division incorporates all three levels of prevention, and although it is not considered a "psychiatric resource," as such, the Division of Children and Youth undoubtedly provides services for many children with emotional problems.
3. Georgia Department of Labor
The major responsibilities of the Department of Labor, composed of two divisions, include job placement, helping employers secure employees, and administering an unemployment insurance program.

- 36 -
The Inspection Division inspects places of employment for compliance with state safety and sanitation regulations, enforces the "Georgia Child Labor Law", supervises operation of private employment agencies, and offers a voluntary conciliation service for labor disputes.
The second and largest division within the Department, the Employment Security Agency administers two major programs:
Job Insurance. This section supervises the state-wide system of job insurance to workers during periods of unemployment. Employment Service. As the title suggests, this operation serves as the meeting ground between the employee and the employer in need of additional workers. It operates through 37 local offices under centrally determined policies. In addition to these major responsibilities this agency administers job placp.ment programs for youth, veterans, handicapped and older workers -- including employment counseling when necessary. Since most of the Department's services are geared to promote economic wellbeing, they are, by and large, directed toward primary prevention of mental illness.
4. State Board of Corrections
The State Board of Corrections operates the state prison system, thus carrying the responsibility for planning and providing programs for prisoners from the time of their sentence until their release. Under the Board's jurisdiction are the following:
Georgia State Penitentiary (Reidsville), the central institution of the prison system. Georgia Indusstrial Institute (Alto), the state's facility for reforming younger criminal offenders. Prison branch systems, the inmates of which are assigned to work on state highways.

- 37 -
County maintained work camps. Under this arrangement, both county and state prisoners are incarcerated and provide a source of labor on local public projects. Historically, the role of prisons' systems hec been to protect society from further assaults from those sentenced to its care. Recent trends have been toward seeking methods for achieving change or reform during incarceration. A program including screening, testing, and work evaluations for inmates is currently underway at the Georgia Industrial Institute through the combi~ed efforts of the Board of Corrections and the Education Department's Division of Vocational Rehabilitation. A new classification and diagnostic center which will be used for prisoners coming into the prison system is presently under construction. Tnis center will provide comprehensive evaluations for each prisoner upon which individual rehabilitation programs can be formulated. Whether or not the objectives of these programs will be attained will primarily depend upon recruitment of professional staff representing such disciplines as: psychology, psychiatry, vocational rehabilitation and social work. In contrast to other programs, the main purpose of the corrections system has been to protect society. However, this original purpose is being broadened to incorporate measures to benefit the individual, as well as society and services appear to fall into all three levels of prevention.
5. State Board of Pardons and Paroles
This agency is administered by a three-member full time board, assisted by additional staff members. Among the Board's duties is that of deciding upon actions which affect all non-statutory determined changes in the prisoner's fulfillment of his court sentence, including pardons, and commutations, paroles and removal of disabilities.

- 38 -
Field services are carried out by the following personnel who have the attending responsibilities:
Investigators -- carry primary responsibility for making pre-parole investigations. Thirteen presently employed. Supervisors -- have assigned the supervision of parolees. Sixteen employed. General Parole Officers -- serve both as investigators and supervisors in a one-man office. Twelve employed. Institutionsl Par.ole Of~cers -- perform services for the inmates at Gaorgia State Prison and Georgia Industrial Institute. lwo eMployed. The quality of service which the field staff is able to render is affected by the size of present case loads and the qualifications of those employed. Efforts are being made to improve service by reducing case loads (often in excess of 100) and increasing minimum qualifications of those considered for future employment. The services of this agency, which are designed to protect the community and aid the individual, are essentially rehabilitative in scope and represent tertiary prevention.
6. State Commission on Aging
Created by action of the state legislature this unit of government became operative on July 1, 1962. By statute, the Commission is "the designated state agency to hand;_e all programs of the Federal government relating to the aging requiring acts ~:ithi~ the state which are not the specific responsibility of another state agency under provision of Federal or state law". Major responsibilities are as follows:
Coord5_natio:l of state agency planning. Many state agencies admir,-(.Dter n.ajor progrn'11G specifically plil-.:l.ned to meet needs of oJ.der citizens. Because prograr::: planning is often carried on concurrr;ntly by several state ae2~cies, overlapping occurs which resul.ts in a lack of cor.~?leme:l:ary and coo:,:dinated

- 39 -
services. As the area of government having legislated authority in the broad field of aging, this agency is in a position to serve in a coordinating capacity between other state agencies in their planning activities. Assistance to local communities. A second function of the Commission is stimulating and encouraging local communities to assess the needs of their aging citizens and to develop necessary services. Communities are encouraged to provide such activities as home care, homemaker services, "meals-on-wheels" , senior activity centers, information and referral services and housing and transportation. Public education and program promotion. The Commission is in an ideal position to serve as a central clearing house. Legislation. The Commission works through and with state legislative channels in proposing and endorsing legislation favorable to older citizens.
7. Georgia Department of Public Health
Created and established as a department of state government by the Georgia legislature, the Department of Public Health, is under the direction and control of an l8-member Board of Health. The Director of the Department is elected by the Board with the approval of the Governor. His responsibilities are to H carry ont the objectives of the Department, subject to policies and procedures determined by
the Board of Hea 1th . "*
The State Health Department is organized into four divisions: Administration and Finance, Epidemiology, Mental Health and Physical Health (See Organization Chart). Each division, in turn, is separated into branches, services and sections, responsible for various programs some of which overlap in delegated authority.
It should be noted that identifying mental health activities in local health departments is much more difficult in Georgia because we have a total of 159 counties each with an established bo.ard .of health (as IJL-escL-ibed by J.aw) and 156 local health
* Georgia Health Code, 1964.

IWATER QUALITY CONTROL BOARDI

-----------------------

II

DIVFIOSRION

.I

WATER QUALITY CONTROL

DIVISION OF
PHYSICAL HEALTH

OF THE
GEORGIA DEPARTMENT OF PUBLIC HEALTH

GENERAL ASSEMBLY OF GEORGIA
I I GOVERNOR I I
I I STATE BOARD OF HEALTH

DIRECTOR

**

GEORGIA DEPARTMENT OF PUBLIC HEAL TH

DEPUTY DIRECTOR

DIVISION OF
MENTAL HEALTH

DIVISION OF
EPIDEMIOLOGY

II ,I ADMINISTDRAIVT~IS~NIOaNFINANCE

BRANCH OF
EIIYIIIOIIiElHAL HEALTH
SERVICE
GENERAL ENGINEERING_ SANITATION
HOUSING HYGIENE AND ACCIDENT PREVENTION
INDUSTRIAL HYGIENE
WATER RESOURCES

BRANCH OF
PREYEIloTABLE DISEASES
SERVICE
CARDIOVASCULAR DISEASE CONTROL
OCCUPATIONAL HEALTH S.E.H.S. SECTION
T. B. CONTROL
CANCER CONTROL SECTION
V.D. CONTROL SECTION

BRANCH OF
DEfHH HEALTH
SERVICE
DENTAL PUBLIC HEALTH

BRANCH
OF SPECiAl SERYICES
SERVICE
CHRONIC ILLNESS AND GERIATRICS
MEDICAL FACILITIES
BATTEY STATE HOSPITAL

BRANCH OF
HEAL TM CONSERYATtON
SERVICE
CRIPPLED CHILDREN'S
MATERNAL AND CHILD HEALTH
NUTRITION
SCHOOL HEALTH

BRANCH OF
LOCH HEALTH
SERVICE
LOCAL HEALTH ADMINISTRATION
REGIONAL OFFiCES

HOSPITALS
GEuRGIA MENTAL HEALTH INSTITUTE
GEORGIA MENTAL RETARDATION CENTER
GRACEWOOD STATE SCHOoL eo HOSPITAL
MILLEDGEVILLE STATE HOSPITAL

SERVICE
ALCOHOLIC REHAB~ ILITATION
COMMUNITY MENTAL HEALTH
MENTAL HEALTH PLANNING
MENTAL RETARDATION PLANNING

BRANCH OF
EPIDEII'OL06IClNYESTleATION
SERVICE
BIOLOGIC STUDIES SECTION
a DISEASE DISABILITY
STUDIES SECTION
PUBLIC HEALTH VETERINARY SECTION

BRANCH OF
LABORATORtt:S
SERVICE
TECHNICAL PROGRAM
CENTRAL eo REGIONAL LABORATORIES
TECHNICAL STAFF

SERVICE
ACCOUNTING BIOSTATISTICS GENERAL STAFF HEALTH EDUCATION
AND TRAINING PERSONNEL
VITAL RECORDS
DATA PROCESSING SECTION
PATIENT ACCOUNTS SECTION

*

CHAIRMAN IS ALSO OIRECTOR, GA. DEPT. OF PUBUC HEALTH

* * CIVIL DEFENSE HEALTH SERVICES PROGRAM AND CHIEf

COORDINATOR, PUBUC HEALTH NURSING

STATUS 1/1/611

LOCAL HEALTH DISTRICTS LOCAL HEALTH DEPARTMENTS

- 40 -
departments. The State Health Department is authorized, with the consent of local boards of health and county authorities, to establish health districts comprised of one or more counties. At the present time, there are 38 such districts. However, each county board of health is largely autonomus in the sense that it is given the authority, by law, to have and discharge certain functions within its jurisdiction. Among these are: (1) to determine health needs and resources, (2) to develop, in cooperation with the State Health Department, programs, activities and facilities necessary to meet health needs, (3) to secure compliance with rules and regulations of the State Health Department, and (4) to enforce, or cause enforcement of, all laws pertaining to health (unless this is a responsibility of another agency). Thus, various activities may be programmed at the state level but it is largely the responsibility of the local health department to see that they are actually implemented.
Although the Division of Mental Health assumes the greatest responsibility for mental health programs in Georgia, other divisions have ongoing programs with mental health implications. In this report, we will attempt to examine some of these programs ar.d identify the mental health components and their contributions to Georgia's total mental health program.
a. Mental Health in Public Health Within the many public health programs administered by a state health department
services are rendered which contribute to the emotional well-being of the recipients. These services may not be formalized mental health activities but are part of the public health programs and carry with them mental hygiene aspects.
Examination of Georgia's public health programs that have activities which contribute to the promotion of mental health and the prevention of mental illness provide an insight into the possibilities of intensifying existing services or

- 41 -

adding new ones to present health programs. Of course, the integration of mental health services into public health programs must not occur only at the state level but must also be purposefully planned and directed at the local level for maximum effectiveness.
Three levels of prevention were used in assessing mental health components of public health programs. These levels are: primary prevention -- preventing what we know how to prevent; secondary prevention -- terminating or mitigating illness; tertiary prevention -- reducing the disabilities suffered as a result of illness.

. (1) Di,vision of Physical Health

.

~

(a) Health Conservation Branch

The major responsibilities of this branch include promoting, maintaining and

extending programs which protect the physical health of families. Emphasis is

placed on the obstetrical aspects of maternal health and the physical well-being cf

the child up through school age. Although the primary objective of this branch is

good physical health, there are also mental health implications as a part of the

total health concept. Included in the branch are Crippled Children's Service,

Maternal and Child Health Service, Nutrition Service and School Health Service.

Crippled Children's Service, through its local clinics, is aiding families of

crippled children in recognizing, understanding and coping with their problems.

Although some emotionally disturbed children are accepted for treatment, they arc

accepted on the basis of physically handicapping conditions. However, considerable

medical, nursing, social and psychological support is given both the children and

their families. The correction of crippling conditions in the child contributes

materially to his emotional well-being.

Maternal and Child Health Service recognizing that high maternal and infant

morbidity and mortality rates and high premature birth rates cnn affect the mentai.

- 42 -
health of the families concerned, helps to reduce these hazards through maternal clinics. Well distributed over the state, these clinics provide prenatal care, including preventive activities directed towards reducing complications of pregnancy such as toxemia and anemia factors which can lead to premature births and, in turn, mental retardation. Serologic tests for syphilis and Rh factor determinations are done in order to anticipate and prevent their resultant effects on the fetus and the newborn child. About 16,000 mothers receive care in these clinics annually.
Other activities of Maternal and Child Health Service with mental health implications include: programming well child conferences and preschool health supervision activities to help promote better physical health and healthier parent-child relationships, operation of an extensive family planning program and four special projects. Two of these projects provide special obstetrical care to "high risk" mothers and infants from lower socio-economic groups to reduce the incidence of birth defects and conditions related to mental retardation, as well as improving the health of the mothers. One project centered in Augusta and involving eleven counties serves a primarily rural population; the other, centered in Atlanta, serves a highly urban population. Despite the fact that every effort is made to encourage hospitalization for delivery, over 7,000 mothers are still delivered at home each year without a medical attendant.
The other two projects which help to promote better family mental health include diagnostic and evaluation centers for children known or suspected to be mentally retarded. Staffed by a pediatrician, a public health nurse, a social worker and a psychologist, these centers are designed to evaluate the problem and give counsel and guidance to the families concerned. The center located in Decatur serves two counties, the one in Columbus, serves twelve.
Nutrition Service has the overall objective of promoting a high level of nutritional well-being so that the individual may begin life well-nourished and

- 43 -
, maintain health and productivity throughout live to prevent handicapping conditions associated with poor nutrition, including mental illness. School Health Service has two projects with mental health implications. One, an ongoing program in cooperation with the Georgia Academy of Pediatrics, offers physical examinations and psychological evaluation to school children through local health and education departments. The purpose of these examinations and evaluations is to define physical, emotional and social factors which may help in reducing drop-out rates. A second special project, approved by the National Institute of Mental Health and to be initiated in the fall of 1965 is to determine the v~lue i~ using a questionnaire as a screening instrument for detecting emotionally disturbeJ children by the classroom teacher.
(b) Environmental Health Branch The Environmental Health Branch is concerned primarily with the control of the physical environment, however, many facets of the program affect the mental health of our citizens. Thus, many activities of this branch which are included in Housing Hygiene and Accident Prevention Service (including Metropolitan, Urban and Community Planning), Water Resources Service, General Engineering and Sanitation Service, Industrial Hygiene Service and Environmental Health Training may be classified as promoting mental health. A summary of these activities is as follows:
Assisting local health departments in becoming actively engaged in community planning directed toward the elimination of future environmental public health problems. Training public health officials in code enforcement of housing regulations. Actively participating in and promoting housing designs to eliminate accident hazards and reduce frustration from overcrowding and fatigue due to the pCJ..-foJ..ma{l(-e of household tasks under unfavorable conditions.

- 44 -
Offering consultation to local health departments and other state agencies in regard to special housing needs of the aging) chronically ill, the handicapped and homes for adopted children. Offering consultation and planning for the prevention of unnecessary exposure of any and all segments of the population to amounts of radiation which might prove biologically harmful.
(c) Branch of Dental Health Concerned with preventing and correcting oral disorders, this branch has a program which is aimed primarily toward professional and lay education, including dentists, school children, parents and the community. Activities which encourage the use of principles and techniques proposed by behavioral scientists to motivate high risk populations to use available services, such as topical fluoride application, utilize mental health concepts.
(d) Local Health Branch The purpose of Local Health Administration Service located within the Local Health Branch " is to make public health services available to all Georgia citizens through adequately staffed full-time local health departments." Activities are therefore primarily administrative in nature and centered around the philosophy that lasting benefits in public health must be achieved through local health departments. In areas of the state where local health departments are not fully staffed or where there are none, this branch functions through its three regional offices in a direct service capacity, carrying on minimal activities. Some of the responsibilities include:
Coordinating communications from various state programs to local health departments. Collecting data on reported activities of local health departments. Providing financial assistance to local health departments through grant-in-aid.

- 45 -
It serves as a vital link between mental health programs in local health departments and the Division of Mental Health in the state office, in the areas of program development, communications and recruitment of manpower.
Among the needs identified by the branch itself is a more realistic monthly activity report by local health units, including mental health activities.
(e) Special Services Branch Chronic Illness and Geriatrics Service and Medical Facilities Service are the two major services of this branch which is engaged in several program activities, including the responsibility for operating Battey State Hospital for tuberculosis ~ patients, which have implications for prevention of mental illness. The Diabetes Program with its emphasis on early case finding and the Arthritis Program with its emphasis on helping patients to adjust to handicapping conditions are in excellent positions to aid patients and families to cope with long-term illnesses. A Home Care Service program for the chronically ill and aged is underway in Whitfield County utilizing the services of a psychiatric social worker, public health nurses, licensed practical nurses and home aides. Special attention has been given to reducing anxiety accompanying chronic illness. A portion of the actual caseload actually includes patients diagnosed as mentally ill. Under the guidance of a qualified physical therapist, a social worker, and a
.,::';l
dietician, local arthritis clinics take patients referred by private physicans and instruct them and their families on proper home care. Jointly operated by the Georgia Chapter of the Arthritis and Rheumatism Foundation, these clinics also double as "group therapy" clinics for these patients.
Restructuring the physical environment of emotionally disturbed patients can help reduce the disabling effects of the particular disease. Confusion and

- 46 -
disorientation of aged patients can be somewhat reduced by a suitable physical environment. Feelings of worthlessness and depression are helped by "brightening" surroundings, providing storage facilities for personal belongings and privacy when needed. Respect for human dignity can be conveyed by attitudes of nursing personnel. Promoting changes from a "custodial care" to a more therapeutic environment in nursing homes is part of the responsibility of the Nursing Home Licensure Program. However, personnel shortages limit activities in these areas. Present emphasis is mostly limited to safety standards and nursing needs of patients through requiring certain minimum nursing care personnel coverage in the different nursing home classification.
Tne training program for nursing home personnel reflects the concern for improving quality of nursing care. Seventy-two percent of all patient care in licensed nursing homes is done by untrained personnel. An active training and consultation program for nursing home personnel is underway, utilizing a consultation team composed of nurses, physical therapists and nutritionists. This team has been also used for some beginning consultation in care of aged patients in our mvn state institutions.
Studies are currently underway to examine the sera of chronically ill patients undergoing drug therapy. Because some of these patients are on the very same drugs being used to control behavior problems, the results, especially as they relate to disturbances on liver functioning, should provide valuable information in the treatment of mental illness.
(f) Branch of Preventable Diseases Composed of six sections and/or services, namely Cancer Control Section, Cardiovascular Disease Control Service, Georgia State Employees Health Service, Occupational Health Se~,ice, Tuberculosis Control Service and Veneral Disease

- 47 -
Control Section, this branch has ongoing activities which contribute toward prevention of mental illness.
Problems which have mental health implications include: Resistance of people seeking care "for preventable disease." Resistance of medical professionals to provide care for preventable diseases, particularly in use of the screening devices proven to be worthwhile in detecting early symptoms of preventable diseases, such as the use of cervical cytology to detect early cancer in women. Delay in tuberculosis patients receiving treatment; 33 percent of the admissions to Battey State Hospital during 1963 had far-advanced tuberculosis. 2,000 tuberculosis patients at home, overdue for medical examination. Four percent of the patients in Battey State Hospital are identified as uncooperative problem patients.
Knowledge alone is not enough to motivate many people to seek early diagnosis and treatment. Thus, it becomes important for mental health personnel through consultation to work with those persons on the "firing line" to improve their skills in encouraging persons to utilize available health resources.
(2) Division of Epidemiology As of January 1, 1965, the Division of Epidemiology consisted of two main branches -- Epidemiologic Investigations and Laboratories. Various services ane programs carried out by the branches, as a whole, are mostly directed toward prevention in terms of mental illness. For example, the serology section conducts testing activities for syphilis on blood and fluid specimens, along with the Rh and blood group tests on prenatal patients. Rh antibody titrations are also done for those patients from local health department clinics who are Rh negative. These procedures, in turn, help to identify patients who are in high risk groups in terms of developing mental disorders.

- 48 -
At the present time, no emphasis has been placed on applying the epidemiologic approach to assessing mental illness, as there has been physical illness.
(3) Public Health Nursing Services Operating as a centralized, distinct Service until 1962, all public health nursing services on the state level are now coordinated by the Chief of Nursing Services who is directly responsible to the Director of the Health Department. Responsibilities of this position include development of the nursing component of each department program through conferences, workshops and the like. The Division of Mental Health (state office) includes two trained mental health nurses; one is working in Community Mental Health Services and the other as part of the Mental Health Planning Project team. The former provides leadership services for developing aftercare programs in local communities, consultation on specific problem areas and, on occasion, renders direct service to patients as a demonstration service for public health nursing education. The 602 public health nurses employed in 153 counties in Georgia, along with their other duties, offer supportive services to the mentally ill and their families (See section of Plan on Aftercare). Some local health departments, as in Spalding County, are beginning to utilize the public health nurse in working with the alcoholic. Others have established family discussion groups where nurses and family members of the mentally ill patient explore the implications of mental illness to family and community living. Inservice training opportunities are made available for all public health nurses and vary according to the individual's previous academic training. As of June 30, 1964, 364 nurses (or 58 percent) working in health departments in Georgia had no academic preparation in public health. To help compensate for this lack of academic training, three classes a year -- three months in length each -- are offered

- 49 -

diploma school graduates by the State Health Department. Included in these three

months are experiences which focus on nursing functions as they relate to the areas

of mental retardation, growth and development, genetics and maternal deprivation.

In addition to the above and including those nurses who have received academic

training in public health but are new to public health nursing in Georgia, there

is offered the following orientation:

Type of Experience

Length of Time

Follow-up of the mentally ill (Milledgeville State Hospital)

3 days

Community Hospital Psychiatric Program (Eugene Talmadge Memorial Hospital and Grady Hospital)

2~ to 3~ days

Introductions to attitudes and techniques useful in rehabilitating the chronic alcoholic (Georgian Clinic)

5 clays

Emotional aspects of the stroke patient

1 lecture

Emotional aspects of tuberculosis (Battey State Hospital)

1 lecture

Through joint planning, efforts are made to provide nurses in local health

departments with the opportunities to participate in programs aimed at increasing

their awareness of the emotional components of every activity with which they are

involved. The amount of time and frequency of these programs varies, as does the

individual nurse's ability to grasp and apply mental health aspects. However,

supervisors and district directors of nursing use every opportunity available to

support these concepts throughout the generalized nursing program.

As of June 30, 1964, a total of 632 nurses were employed by the state and

local health departments in Georgia, thus comprising the largest single professional

discipline represented in the field of public health. But it is not the sheer

weight of numbers that has and will continue to make the nurse one of the most

important resources we have for preventing mental illness, promoting mental health,

- so -
and sharing in supportive services to furloughed patients and their families. Records will never be able to show the actual amount of time and energy that goes into working in the area of mental health, for everytime she visits a family, consults with a teacher or helps her community solve its health problems, the nurse is in a position to serve as one of the most important "firing line" professionals we will ever have.
b. Division of Mental Health Before discussing the Division's position and responsibility in a mental health
program, it is important to review some of the events which have led up to the position it occupies today. Extending back into colonial dnys, providing care for the mentally ill was universally understood to be an obligation and concern of state governments only. This national pattern prevailed in Georgia, and it is only within the past generation that any avenues of care were open -- public jails e~ccepted to the mentally ill, other than the State Hospital at Milledgeville. However, within the relatively brief timespan of a quarter century, changes have occurred in the care of the mentally ill which can best be described as "revolutionary.1I Knowledge about the mentally ill and methods of treatment have progressed so rapidly that implementing them continues to lag far behind. Nevertheless, total advancements have been dramatic and an entirely new sector of care has been made available through private psychiatry. Now, a mentally ill person can receive help through visits to the psychiatrist's office or by entering 8;..private psychiatric hospital.
Within this maelstrom of progress operation of the historical programs of institutional care were transferred, in 1959, to the Georgia Department of Public Health. Subsequently, all programs of the Health Department involving direct treatment of the mentally ill, as well as the broad responsibility of planning for total mental health, have been united within the Division of Memtal Health. Hhile

- 51 -
no longer having to carry total responsibility for treatment of the mentally ill,
it is understood that the state remains the ultimate guarantor of care when, for a
variety of reasons, the person is not able to avail himself of more recently
developed resources. Within this historical framework, the Division of Mental
Health administers these services:
(1) Milledgeville State Hospital This facility represents the sole medium through which the state, for decades, has met the mental health needs of its citizens. While se~lices have been substantially altered and improved, this facility is still the only hospital operated by the state for the mentally ill. Mil1iPgeville State Hospital's major responsi-
bility of treating the mentally ill through hospitalization has been unfortunately diluted by its having to care for patients with other forms of disabling conditions.
These patient groups include many hundreds of mentally retarded, alcoholics without
psychosis, and -- on a more temporary basis -- certain persons convicted by the courts for whom a psychiatric opinion is required.
Due to the large number of programs that must be included in this section, it
is impossible to describe, in depth, the activities and services for each. Because
Milledgeville State Hospital is the major resource in Georgia for treating the
mentally ill, it is helpful if the reader is acquainted with the following references:
Treatment Programs for the Mentally III and Mentally Retarded in Georgia. In 1964, the Governor's Commission for Efficiency and Improvement in Government (Bowdoin Commission) conducted a study to examine and evaluate the organization, administration and services provided by Milledgeville State Hospital. Based on their findings, this report contains extensive recommendations relative to broad measures for improved state mental health services, as well as for changes in operation of the hospital. Treatment Services for the Mentally III and Mentally Retarded in Georgia. Preliminary to its own investigations, the Bowdoin Commission engaged the services of the National Institute of

- 52 -

Nedal Health, United States Public Health Service, to conduct a thorough study of the Hospital. Findings reported and recommendations for future changes in this study are similar to those contained in the Bowdoin Commission Report.
Annual Report for 1963-1964, Milledgeville State Hospital. The complete report contains extensive information on services provided, statistical data on patients and current levels of staffing now in effect for the Hospital.*
While it is obviously im~08sible to include lengthy descriptive information
on the entire operation of the hospital, it is necessary to delineate certain
major characteristics, such as:
(a) Hospital capacity and annual caseload. An appreciation of the
number of patients under daily care and the annual case load served by the hospital
can be obtained by examining the following data for fiscal 1964:

Average Daily Population . l2,046

~kwement into Hospital

Movement out of Hospital

New Admissions

5,221

Direct Discharge

1,580

Readmissions . Return from Furlough.

1,565 4,040

Placed on Furlough .

8,049

Deaths

. . . . 1.114

TOTAL

10,826

TOTAL

10,743

The simple realization that on any given day there are in excess of 12,000 Pl persons whose progress in recovery depends upon access to helping services is sobering indeed. The unique characteristic of this group is that they do require complex services if they are to be successfully treated and rehabilitated. Among these 12,000 are many with extensive physical illness which necessitates additional medical care. The majority of these patients require the special skills of a psychiatrist, supplemented by other members of the treatment team. For those

* See Summary in Appendix

- 53 -
patients whose mental illness has been accompanied by pronounced failure in family or community relationships, the hospital must be ready to provide corrective experiences in social aspects of daily living. Experience as a member of a social group, opportunity for religious expression and access to the stimulation provided by participating in arts and crafts activities all represent vitally needed therapeutic experiences. When these opportunities are not available, patients are likely to continue unchanged in their illness.
Despite its enormous case load, the hospital is able to help patients as reflected in the preceding data which show that during one year, 1,580 patients were discharged directly from the hospital and 8,049 were able to leave on convalescent status.
(b) Hospital budget. While it is recognized that there are other factors which influence the quality of service, the amount of funds available to support operations is a major consideration. In fiscal 1964, Milledgeville State Hospital had a total of $17,300,000 to finance all costs of operations; $16,000,000 of which was appropriated from the state budget. These funds result in a per diem rate of $4.00 per patient witpin which the cost of all services provided to patients must be paid. Contrasted with the average daily cost of care in general hospitals in Georgia of $31.57* per day, one can readily appreciate the overwhelming obstacles faced by the administration at Milledgeville State Hospital in being able to employ sufficient numbers of qualified staff to insure adequate patient care.
(c) Geographic area served. A third characteristic of this hospital that has a direct effect on its ability to function at an optimal level is its obligation to provide a statewide coverage for service. According to available informatioT there is no other institution in the nation having total responsibility for
* Medical Facilities Planning Section, Georgia Department of Public Health

- 54 -
hospitalization of the mentally ill in a state with the extent of Georgia's population. Since Georgia has a population in excess of 4,000,000 and represents the largest geographic area of any state east of the Mississippi River, these factors combine to seriously handicap the hospital in fulfilling its mission. These conditions make it impossible for the hospital staff to have anything other than a very general familiarity with the countless communities throughout Georgia from which patients originate. Distances -- often in excess of 150 miles -- families have to travel to see patients seriously restricts visitations, thus adding further handicaps to successful treatment programs.
Action is now underway to reduce the present tendency for isolation of staff members from the communities from which the patients originate. While the hospital has been operating on a unit system for several years, patients are now being transferred to units that will be made up of patients from their own geographical area in the state. In this way, the staff of each unit can confine their relationships with the community to the area served by that unit.
A final consequence of the hospital having to serve as the only such facility in the state is the effect on the extent to which personal support and supervision can continue to be made available to patients after their return home. After the patient has sufficiently benefited from hospital treatment, staff needs to anticipate help that may be required during the continuing period of convalescence. Release plans should ideally include referral to community agencies and, where appropriate, continued opportunities for scheduled appointments with professional staff. The great distance separating the hospital from the communities it serves seriously restricts fulfillment of this potential.
Aftercare services, including visiting patients in their own communities by social service or other staff, are virtually non-existent. However, since 1963. the hospital has operated an out-patient clinic in which all patients able to make

- 55 -
the return trip to the hospital are seen by staff. During its first full year of operation, over 2,000 patients were served. A major benefit accruing from the clinic is that patients are able to receive continuous drug supervision. While not a function of the hospital itself, it is appropriate to note that aftercare services are being provided to released patients by nursing staff of local health departments.
(d) Training and research activities. The hospital conducts a very expensive training program in all the mental health disciplines. Generally, standards for field service experiences are established according to the University responsible for the educational program. In addition to residencies in psychiatry, the hospital participates in the training of psychologists, social workers, nurses, chaplains, music therapists and others. Besides serving as a training center, Milledgeville is a center for numerous research programs.
In summary, Milledgeville State Hospital is obligated to, and does, accept any mentally ill ~itizen of Georgia committed by the state. In this respect, it provides complete coverage at the commitment level which tends to restrict voluntary admissions. Finally, the ponderous size of the hospital, its rapid admission rate, the geographic area it serves and budget limitations combine to form imposing barriers in giving optimum care.
(2) Alcoholic Rehabilitation Service In 1951, the state legislature created the Georgia Commission on Alcoholism and charged this agency with the responsibility for developing treatment, research and education programs in the field of alcoholism. Transferred to the Georgia Department of Public Health in 1960, this program now operates within the Division of Mental Health as the Alcoholic Rehabilitation Service. Individuals with a fully developed addiction to alcohol have long represented a group within the broad field of mental illness who are recalcitrant to traditional

- 56 -
treatment measures. Although the exact number is unknown, estimates from those working in the field indicate that there are around 100,000 persons in the state with a significant alcohol problem. Because of the frequency with which alcoholism adversely effects family, friends and the community, the total impact extends far beyond the person actually afflicted. Therefore, the importance of finding successful treatment measures and ultimately moving into action programs for primary prevention assume high priority.
Georgia represents one of the pioneer sta~s in recognizing the incidence and consequences of alcoholism as being of such proportions as to require intervention. At the present time, the Alcoholic Rehabilitation Service includes the following:
(a) Treatment services for alcoholism. Present treatment services include the Georgian Clinic, Rehabilitation Center in Atlanta and the Chatham Clinic in Savannah. The former resource includes a 40 bed in-patient facility which accepts persons requiring residential care; both offer out-patient services. These out-patient clinics represent important resources in aiding those individuals sufficiently motivated to receive help. Because treatment services offered by these programs vary from more common forms of psychiatric care, exceptional importance is placed on the clergYman who is included in addition to the usual psychiatric team. Extensive reliance is also placed on the use of group therapy as a major medium of treatment.
(b) Community education and program promotion. Alcoholic Rehabilitation Service relies heavily upon public and professional education in encouraging communities to set up local treatment services. Through education on successful techniques for treating the alcoholic, communities are stimulated to establish their own out-patient clinics. Such a service has been in operation for well over a year in Griffin, Georgia; now a second community, Rome is setting up a similar

- 57 -
service. Consultative service is made available by the staff of the Alcoholic Rehabilitation Service to communities inaugurating a clinic.
(c) In-service training. In-service training courses are offered to those persons in communities who. because of their work, are in strategic positions to help alcoholics. For example, staffs from social agencies and local health and welfare organizations are brought into the Georgian Clinic for a week of in-service training. Courses include orientation on current therapeutic approaches through contact with patients and staff, as well as didactic teaching. A chaplaincy training program is also offered to ministerial students at both graduate and under-graduate levels.
~fuile this service serves as a valuable treatment resource, its primary function is pioneering, through research and demonstration, proven methods of prevention. In contrast to Milledgeville State Hospital, Alcoholic Rehabilitation Service is not obligated to accept all persons referred by the courts; this makes it possible for them to concentrate on broader objectives of public education, research in treatment methods and program promotion.
(3) Community Mental Health Services Community Mental Health Services has been a part of the State Health Department for many years before the Division of Mental Health was created. Activities have been related to the basic cOncern and responsibility of traditional public health programs which emphasize primary prevention measures health promotion and early intervention. Community Mental Health Services coordinates or directly administers three distinct programs and offers consultative services to local communities interested in assessing and improving their mental health resources. Programs under the immediate jurisdiction of Community Mental Health Services are as follows:

- 58 -
(a) Comnlunity Mental Health Clinics in Local Health Departments. The State Health Department, through Community Mental Health Services, supports the operation of mental health clinics as a program element of local health departments. Assistance is in the form of partial reimbursement for the cost of mental health clinic staff and consultation service on program development.
Interest by communities in providing professional mental health services is reflected in the number of local health departments (twelve) nOW operating such programs. Professional staffing patterns include the district health officer as medical director, a part-time psychiatrist, and a full-time psychiatric social worker and/or psychologist. Local health departments in some communities are able to employ staff well in excess of the minimum team required.
Local mental health staffs provide direct clinical service to families with emotional problems amenable to short-term, out-patient treatment and indirect community services through consultation with other agencies. Diagnosis and treatment services have been somewhat limited due to the shortage of psychiatric time which, in turn, reduces the extent to which these programs are able to serve the more emotionally disturbed.
(b) Community Hospital Psychiatric Program. This service makes possible the voluntary hospitalization in psychiatric units of general hospitals those persons unable to afford private psychiatric care. Length of stay under this program is limited to eight weeks; consequently patients are selected whose prognosis is considered favorable for recovery within this relatively short period of time.
Objectives of this service are two fold. In addition to the obvious goal of making hospital care available to the mentally ill near their own homes, the service is of equal importance as a stimulus for the expansion of psychiatric resources in the state. It provides financial support to communities in opening psychiatric wards in general hospitals, thereby encouraging psychiatrists to open private

- 59 -
practice in the area. Through cooperative arrangements between units operated in Atlanta and Augusta with the medical schools, important support has been given to resident training programs for psychiatrists.
While this program can only meet a small portion of the total need for hospital care of the mentally ill, the number of persons served is significant. \Jith this service now operating in six communities,* a total of 476 patients received care during fiscal 1964 and over 3,000 since the program was established in 1957.
(c) Aftercare service by Public Health Nurses. Public Health Nurses in all local health departments offer supportive services to mentally ill patients and their families. These services are available to the patient and his family prior to his hospitalization, to the family during his hospitalization, and to the patient and family upon his return to the community following hospitalization. These aftercare services include the following:
Observations of the patient to determine degree of readiness to resume normal activities in the home and community. Assistance to the family in understanding any special problems or needs of the patient, including re-hospitalization if indicated. Supervision of patients undergoing group therapy. Assistance in arranging for medical supervision in the community or through the Outpatient Clinic at Milledgeville State Hospital. Referral to appropriate community agencies when indicated. Assistance with other health problems of the patient or family. The public health nurse's caseload is established through: Applications to the Community Hospital Psychiatric Program. Applications for voluntary admission to Milledgeville State Hospital.
* Albany, Atlanta, Augusta, Col~bus, Macon and Savannah

- 60 -

Referrals from county ordinaries of involuntary admissions to Milledgeville State Hospital.

Release notifications of voluntary and involuntary patients from Milledgeville State Hospital.

Referrals from private physicians and community agencies.

The figures below represent the number and estimated number of patients and

their families in public health nursing case loads for the years 1961 and 1964.

!ype of Case load

Caseload for 1961

Case load for first six months 1964

MSH Patients Families of MSH Patients

3,524 4,726

7,064 7,508

CHPP Patients Families of CHPP Patients

1,980 1.849

2,234 1.969

TOTAL CASELOAD

12,079

18,775

Although the increase in caseloads has been substantial for the first six months

of 1964 over 1961, the number of public health nurses employed during the same time

period has increased less than one percent. Because of current hospital admission

procedures, the public health nurse is more actively involved with the patient

following his hospitalization. The figures above relate primarily to those patients

and their families to whom the nurse is rendering aftercare services.

Among the problems that deter the public health nurse in the aftercare program

are the lack of communications between county ordinaries and local health departmentE

Local health departments have requested county ordinaries to notify them of all

involuntary admissions to Milledgeville State Hospital. This is essential if the

public health nurse is to assist the family during the patient's hospitalization

and help plan for care following hospitalization. In the majority of counties, the

communication system between the ordinary's office and the health department is

~ effective. Thus, the health department has no knowledge of many patients until

a release notification is received from Milledgeville State Hospital.

- 61 -
Another problem area involves release notifications and discharge summaries from Milledgeville State Hospital. Arrangements have been made to notify the local health department when a patient is released from Milledgeville State Hospital. A medical discharge summary containing information about the patient's treatment and recommendations for continued care should accompany this notification. In actual practice, there is a time lag of several weeks or months before this is received by the local health department. The public health nurse attempting to offer aftercare services is often severely handicapped because of this lack of information from the hospital.
Aftercare services to mental patients is only one part of the public health nursels total program. Increase in caseloads with no increase in nursing staffs limits the quantity and quality of service available.
(4) Georgia Mental Health Institute The Georgia Mental Health Institute, under construction in Atlanta, is scheduled to begin operation about July I, 1965. This facility will represent a giant step forward in moving into a new era of care for the mentally ill. Opening of the Institute will, among other advances, mark the first time that hospitalization in a state facility has been available outside of Milledgeville State Hospital. The program of the Institute will consist of the following major activities:
(a) Training in the Mental Health Disciplines. The original decision to establish the Institute was greatly influenced by the realization that future progress in improving care for the mentally ill would largely depend upon increasing the professional manpower pool to staff new facilities. Preparations are presently underway to initiate training programs for psychiatric residents, psychological interns, social workers in graduate training, psychiatric nurses and clinical pastoral trainees. Training goals will be materially strengthened through a

- 62 -
contractual agreement between the Department of Psychiatry, Emory University Medical School and the Georgia Department of Public Health. Under this agreement, faculty of the Department of Psychiatry will be joined with employees of the Institute in conducting the teaching program.
(b) Research. Research in a variety of areas associated with mental illness will be conducted as an integral part of the overall activities of the Institute. It is anticipated that an active research program will not only contribute to existing knowledge about mental illness but will also make it possible to conduct studies between causal factors specific to Georgia~ such as the relationship between geographical area and the kinds of mental illness.
~
(c) Treatment Services. The Institute will add materially to the resources for treating the mentally ill. Upon completion~ it will include a five story administration building housing research and teaching facilities and eight cottages, each of which will operate as a self-contained treatment unit, having its own staff. The physical characteristics of these cottages, complete with their own staffs, will provide maximum flexibility in patient treatment. All modes of care will be provided in each cottage, including in-patient, out-patient and partial hospitalization. This will eliminate transferring patients from one unit or staff to another and increase the capacity of each cottage substantially beyond their rated bed capacity of 25 patients. Of the eight cottages, five will care for adults, one for geriatric patients and one each for adolescents and pre-adolescents. Because of the unique mission of the Institute, selection of patients for admission will be influenced greatly by their relevance in providing necessary case material in support of training and research operations.

- 63 -
8. Medical College of Georgia
Another tax supported resource for meeting mental health needs in Georgia is the Medical College of Georgia. The Department of Psychiatry and Neurology) a unit of the Medical College, participates in the education of all medical students and in operating a residency program in the speciality of psychiatry. It is through this psychiatric training program that the Department makes its major contribution to better mental health through increasing the manpower supply.
The Department also operates psychiatric treatment services, consisting of both in-patient and out-patient facilities. In 1963, 260 patients were admitted for hospital care. During the same year, there were over 5,000 visits to the out-patient psychiatric clinic. The Department also provides consultation services to other medical clinics relative to psychosomatic conditions.
B. Non-Official Agencies
The term non-official (or private) is used to refer to those agencies with organized service programs which derive their operating costs from sources other than tax revenue. In the community, they serve to complement the official or tax supported agency by providing citizens with a wide-range of services they could not possibly provide for themselves.
The most comprehensive analysis of the activities of non-official agencies can best be illustrated by examining those presently operating in the Atlanta area, since this is the largest population center in Georgia and has developed the most inclusive array of services. We will also examine three other cities in smaller population classifications to give a more complete picture of the role of nonofficial agencies in serving Georgia communities.

- 64 -

1. Metropolitan Atlanta

The 1963 issue of the Directory of Community Services, published by the

Community Council of the Atlanta Area, lists the following:

Private Agencies United Appeal affiliated and supported .... 42 Other private sponsorship .... lll

Governmental Agencies .....,,f,

TOTAL

215

We have indicated the number of governmental agencies only to show the complete

account in this prototype community. The United Appeal affiliated agencies represent

those whose financial support is derived either partially or entirely from Atlanta's

central fund-raising body -- the United Appeal-Community Chest-Red Cross -- which

in 1963, raised a total of $3,825,000.* However fees or income from other sources

significantly increased the total funds available to agency members. In addition

to these agencies, there are III others that obtain no financial assistance from

this organization.

a. Analysis by type of program Probably the most practical method of measuring the activities of non-official
agencies is by type of program offered. Although each individual agency may provide several services, generally they can be classified in one of the following ca tegories:
(1) Residential care -- This program represents a vital resource for a variety of dependent persons whose needs, at some period during their lives, cannot be met by themselves or their families. Examples are: residential homes for dependent youth; foster family placements for children in private homes; living

* Directory of Community Services. United Community Funds and Councils of
America, Inc., 1963.

- 65 -
arrangements for unmarried mothers; overnight shelter for the transient or indigent person; and full-time living accommodations for the aged. The Y.M.C.A., Y.W.C.A. and the Salvation Army all offer living accommodations for a particular segment of the population, along with a wide range of supportive services.
(2) Education and fund raising -- Numerous non-official agencies have been established primarily to enlist sufficient citizen interest and ultimately financial support -- necessary to initiate services to meet a specific need such as cancer, polio or tuberculosis. Promotional campaigns and educational programs are designed to encourage active citizen support. Although some referral help is made available to the community, direct patient care is not.
(3) Individual and family counseling service -- Agencies such as Family Services, Travelers Aid and Child Service provide counseling or casework services which are available to individuals and families alike. Although their major function is to help the person become more effective in solving his own problems, these agencies do offer services to fulfill immediate needs, such as adoptions, housing arrangements and emergency financial relief. Most staff members have received professional social work training and continue to increase their skills through on-the-job training.
(4) Administrative Services -- Operating for the sole purpose of carrying out defined administrative responsibilities on behalf of all other member agencies, organizations, such as the United Appeal, conducts fund raising campaigns and carries the overall responsibility for budgetary approvals or changes. The Community Council, a central planning and program-coordinating body for private agencies conducts research programs for studying community needs. It also operates a limited number of direct service programs to test new methods and procedures for solving social problems.

- 66 -
(5) Recreational and organized group activities -- These agencies primarily provide services for the public-at-large, rather than a specific group, through organized social and recreational programs. Community centers, for example, have programs designed to serve a particular geographical area or a specific population group. Many of these programs are operated specifically for children.
(6) Health care agencies -- Several agencies, such as the Cerebral Palsy Center and the Easter Seal Rehabilitation Center, are designed to meet particular health needs. Staffed by professionally trained personnel, these centers are equipped to provide direct clinical services.
b. Analysis by Target Population Served To effectively illustrate the non-official agency's role in a total mental
health program, it is necessary to review their activities in terms of the target population to which their services are being rendered.
(1) General population ".- SOm& of the non-official agencies, including boys clubs, scouting organizations, Golden Age Clubs, comr.lunity centers, and the Armed Forces' special service programs, are designed to reinforce and promote, among other things, good mental health practices. Others, offer services which facilitates their intervening in situations where there are identifiable vulnerabilities which could readily lead to mental illness, such as:
Adult social-behavioral disorders: severe marital discord, alcoholism, anti-social behavior and the general inability to fulfill social role expectancies. These problems commonly represent the grist of private cou::lseling"case,\mrk agencies. Children's problems: juvenile delinquency, behavior disorders, child dependency and neglect. All impose a major service demand on the non-official agency. Economic and environmental problems: inadequate housing, financial indigency and unemployt~nt.

- 67 -
(2) Services to the mentally ill and borderline mentally ill -- Generally,
non-official agencies do not provide direct treatment services for the more severely
emotionally disturbed. However, in instances where the community is disrupted as
a result of the illness, they perform the following services:
Pre-admission services - Travelers Aid, Family Services and Child Service Association are in a particularly strategic position to be aware of an individual's need for treatment; for example, one third of the 1,700 clients served by Travelers Aid in 1963 were considered to have significant mental health problems. For some of these people, the agency served as a referral source for psychiatric hospitals, however, the agency itself carried a large part of the caseload.
Aftercare for patie~ts released from psychiatric hospitals As a total group, released patients may require any of the services associated with the programs listed earlier, but of special importance is the accessibility of counseling services to patients and their families for personal problems.
Casework - Trained and experienced agency personnel can offer casework services to socially disorga~ized persons and many times the consultation services of a psychiatrist are used to increase their effectiveness. Treatment in these instances representS social ccsework rather than psycho-therapy and the focus of treatment is social pathology not psyco-pathology.
c. Barriers to Service
Although agencies in the Atlanta area offer various kinds of services, adequate
coverage is limited in many instances because of one or more of the following
barriers:
Age and sex restrictions - agencies, for one reason or another, often have to limit their services to certain age and/or sex categories.
Racial restrictions - this particularly applies to residential and recreational facilities.
Waiting lists - this is especially true of agencies whose services are on ar. appointment basis.
Location - agencies are often not located within easy reach of those being served.

- 68 -
Administration and financing - dependent upon voluntary contributions, for their support which fluctuate from year to year, agencies are often restricted as to the amount of service they can offer, personnel they can employ and so forth. The effect of restrictive policies of official agencies often result in the nonofficial agency's having to Iifill the gap" in many crisis situations. For example, restrictive legal residency requirements often force non-official agencies into sharing a disproportinate amount of time and expense on the non-resident requiring financial assistance or hospitalization. They are also frequently required to intervene in behalf of low and middle income families ineligible for various services offered by the official agency.
2. Smaller Cities
a. Communities with a population of 100,000 to 500,000 Of the four cities in Georgia falling within this classification, we selected
Columbus. Serving a population of 122,000,* this city has 28 non-official agencies which are financially supported by United Givers who raised a total of $630,000 in 1963. Eleven of these agencies offer recreational type programs, seven public education and promotion and five some form of residential care. Three agencies provide individual and family counseling services, two of which are local chapters of the American Red Cross. One agency offers health care service and another, the United Givers-Community Chest, provides overall administrative service.
The majority of those receiving services fall into the category of the "normal population;" however Family Service-Travelers Aid being staffed ';-lith professional social workers is equipped to provide services to people with personal problems. Though it is difficult to estir~te the service to the mentally ill or borderline
ft 1963

- 69 -
person, it is assumed that agencies with counseling or casework services provide referral aid when psychiatric treatment is required.
b. Communities with a population of 35,000 to 100,000 Of the eight cities in this group, Albany was selected. In 1963, this
community of 59,000 raised $150,000 in its United Fund drive for support of 12 associated agencies. In addition to these 12, there are two non-official agencies which do not receive support from the United Fund. Four agencies have recreational or group activity programs; four provide some form of residential care, and two are primarily interested in program prorootion. A Red Cross Chapter offers very limited counseling service and the United Fund Agency provides central administration. Again, the major segment served is the "normal population," and services are primarily designed to meet the needs of the community-at-large. No agency in Columbus offers counseling/case'iwrk aid for the socially disabled it:dividual or family.
c. Communities with under 35,000 population \Jaycross with a population of 21,000 was selected for this category. In
1963, this community raised $62,500* for seven agencies, financed only in part through the United Fund. TIle programs represented are similar to those listed for Albany and again, there is no private agency set up to provide individual counseling help. We may note, however, that the Salvation AlinY provides aid to the destitute transient; offers an organized arts and crafts program; and provides emergency or supplementary relief in situations of critical need.
* Suevey for Mental Health Planning for Public Health District #14,
Mrs. Dorothy Smith, 1~S4.

- 70 -
c. Private aad Non-Profit ~~dical Facilities*
The overcrowded conditions of Georgia's only state operated mental hospital and the increasing demand for psych~atric services would seemingly have stimulated the development of mental health resources by private and philanthropic organizations and local governments. Except for the trend toward developing psychiatric programs in general hospitals, this has not been the case. At the present time, there are seven licensed private psychiatric hospitals in the state -- three of which are concerned with treating alcoholics. (It is interesting to note that during the past eight years only one new private psychiatric hospital has been established in the state, despite the fact that the admissions to Milledgeville State Hospital have more than doubled.)
vlliile there are twelve conununity mental health clinics operating in local health departments, only three are non-tax supported. The children's clinic at Emory University is the only mental health clinic specifically serving children which is not a cOffinlunity sponsored program.
There are many reasons why growth of private and non-profit psychiatric resources has been slow, including lack of professional personnel and the increased responsibilities and requirements being placed upon the facilities themselves for service. The costs aId complexities involved in treating mental illness are two additional factors that have perpetuated the current trend toward developing state and community non-profit psychiatric resources. Increased personnel from psychiatric training programs and prepayment coverage for mental illness should help to alleviate this trend in the near future.
* The terms "private" and "non-profit" for the purpose of this report are used to
distinguish between private facilities operating on a profit basis and private
facilities B! operating on a profit basis, including community-county owned
facilities.

- 71 -
Existing private and non-profit medical resources will be discussed in this section as they relate to psychiatric services in the state and will be grouped under the headings of: General Hospitals, Private Psychiatric Hospitals and Mental Health Clinics.
1. General Hospitals
General Hospitals in the United States are fast becoming the focal point in the community's battle against mental illness. Georgia has been slower in moving in this direction than other states, and as a result has only eight non-profit general hospitals with organized psychiatric programs. (Eugene Talmadge Memorial Hospital in Augusta is state owned and operated. As this sestion deals only with private and non-profit facilities, Eugene Talmadge Memorial will not be discussed here.) Of the eight general hospitals with psychiatric programs, five* participate in the state's Community Hospital Psychiatric Program; two are church owned and operated and the other is operated by the community.
During fiscal 1964, three general hospitals began or completed additions to their psychiatric units. Grady Memorial Hospital in Atlanta added nine beds, bringing their total to 27 and Memorial Hospital in Savannah completed construction for 50. The Medical Center in Columbus started construction on 27 additional beds which will bring their total to 39. In addition to the projects under constructio~, formal applications are peLding to expand existing facilities at Macon Hospital, Phoebe-Putney Memorial Hospital in Albany and Floyd Hospital in Rome. Informal applications are pending for new psychiatric units at Hall County Hospital in Gainesville, Athens General, DeKalb County Hospital and Kennestone Hospital in Marietta.
* Macon General, Medical Center in Columbus, Phoebe-Putney in Albany, Grady in Atlanta and Memorial in Savannah.

- 72 -

The added impetus of financial support for construction through the "Community

Mental Health Centers Act of 1963" will undoubtedly stimulate future development of

psychiatric programs in general hospitals. Aside from financial factors, lack of

psychiatric personnel, again, has been a major factor in deterring hospitals from

moving into the mental health area. But with the increased opportunities for

training psychiatric personnel in the state and the influx of personnel from outside

the state, this retarding factor should eventually be minimized. There is a point

at which the problem of developing a psychiatric program in the general hospital

and the problem of attracting psychiatric personnel to a particular community

become one. The reason for this lies in the fact that psychiatric personnel are

attracted to communities which have some inpatient services or are ready to develop

them. Thus communities with general hospitals ready to develop psychiatric programs

will be in a key position to recruit personnel.

The following is a list of non-profit general hospitals which have an organized

psychiatric program:

Hospital

Location

Number of Beds

Grady Memorial Hospital

Atlanta

27

Emory University Hospital

Atlanta

20

University Hospital

Augusta

54

Macon General Hospital

Macon

20

Memorial Hospital

Savannah

50

St. Joseph's Hospital

Savannah

13

The Medical Center

Columbus

12

Phoebe-Putney Memorial Hospital

Albany

22

Total Beds

218

In addition to the above general hospitals with organized psychiatric programs, two

general hospitals -- Floyd in Rome and Athens General -- each have a psychiatrist

on their hospital staff and do admit psychiatric patients for treatment.

General hospitals which do not offer treatment services to psychiatric patients

may offer other types of mental health services. For example, hospitals with 50 bed

- 73 -
or over generally have an isolation room which may be used to retain psychiatric patients until they can be hospitalized elsewhere. Frequently, in communities where general hospitals do not offer this service, the psychiatric patient is incarcerated in the local jail until he can be transferred elsewhere for hospitalization.
a. Out-patient Services Only three general hospitals in the state offer outpatient services: Emory
University Hospital, the Medical Center in Columbus and Phoebe-Putney* in Albany. Emory's low cost, out-patient department saw 952 patients in 1963. Patients are primarily selected on the basis of whether or not they fit the educational needs of . < "~ the University's training program and not according to their need for treatment. Fees are based on a sliding scale system according to the income of the family and above a certain level, patients are always referred to private psychiatrists.
The Medical Center saw 321 patients in 1963 on an out-patient basis. Selection in this instance is based upon the patient's prognosis to respond to out-patient treatment with local psychiatrists in private practice providing the service. A limited number of indigent patients are provided service under this program.
b. Other Mental Health Services General hospitals offer a variety of mental health services. For example,
Grady Memorial Hospital offers mental health clinic services, in addition to inpatient services, to persons from Fulton and DeKalb Counties. It also houses an alcohol study and rehabilitation project which is administered by Emory University's Department of Psychiatry. In 1963, this program alone saw 470 patients and families
A word should be mentioned concerning general hospitals that ~ ~ provide psychiatric treatment services. At present, there are 209 general hospitals serving
* Since out-patient services at Phoebe-Putney were not offered at the time the data were collected, they will be eliminated from this discussion.

- 74 -
every major community in the state (see map in Appendix). These hospitals are in an ideal position to perform a valuable community mental health service for two reasons: (1) they are already integrated into and accepted by the community; and (2) all general hospitals are faced with having to deal with psychiatric cases, whether they have a psychiatric program or not. When surveyed, administrators of general hospitals mentioned that they were frequently faced with the problem of how to deal with patients who have serious emotional disorders. Such patients may enter the hospital with oerious psychosomatic disorders which are not recognized until after their admission. Regardless of how carefully patients are screened, the administrator is faced with the problem of how to treat the mentally ill in a hospital which has neither facilities nor services for the psychiatric patient.
2. Private Psychiatric Hospitals
There are seven non-governmental (or private) hospitals in the state which are primarily concerned with treating the emotionally disturbed. Four of these facilities are located within the five county-metropo1itian Atlanta area, the remaining in Waynesboro, Augusta and Milledgeville. The location* of these private hospitals generally near existing psychiatric training programs and public psychiatric hospitals is indicative of the importance of the availability of psychiatric personnel to the development of resources.
Of the _even, three generally limit their services to treating alcoholics while the other four are concerned with a broad range of emotional disorders. For the most part, these hospitals render services which may be classified as acute care, even though some of their patients may receive only custodial care.
* It should be noted that this present geographical distribution leaves large sections of the state without easy access to private psychiatric hospitals.

- 75 -

The following is a list of the private psychiatric hospitals by name, primary

type, location and bed size:

Name of Hospital

Prima ry Type

Location

Number of Beds

Northside Manor

Psychiatric

Atlanta

16

Peachtree Hospital

Psychiatric

Atlanta

64

Brawner's Hospital

Psychiatric

Smyrna

50

White Cross

Alcoholic

Jonesboro

43

Tidewater

Alcoholic

Augusta

40

Allen's Hospital

Psychiatric

Milledgeville

46

Thompson Hospital

Alcoholic

Waynesboro

28

Total Bed Capacity

287

Ranging in size from 16 to 64 beds, these private psychiatric hospitals provide a total of 287 beds. Those concerned primarily with treating the alcoholic maintain an occupancy rate of around 40 percent, the others range from 70 percent and above. Because of the short, average length-of-stay period, the yearly patient population is high; in 1963 six of these private licensed psychiatric hospitals* had a combined yearly patient population of 4,377.
Five of these private psychiatric hospitals are owned by corporations (Brawner's Hospital, Thompson's Hospital, Tidewater Hospital, Peachtree Hospital, and Allen's Hospital); one (~ij)ite Cross) is owned by a partnership; and one (Northside Manor) is individually owned.
No systematic effort was made to obtain descriptions of the buildings and grounds or to evaluate the operational aspects of the various institutions. However the Georgia Department of Public Health is responsibile for licensing all hospitals in the state (including private psychiatric facilities) and certain minimum standards for the construction and operation of psychiatric hospitals are set forth in the "Hospital Regulations Act, Rules and Regulations for Hospitals in Georgia."*+

*** Thompson Hospital did not open until January 1, 1964. October, 1948.

- 76 -
They are as follows:
Standards Required
Any individual, or group of individuals, responsible for maintaining and operating a hospital in Georgia, shall maintain within the facility such standards as are hereinafter set forth or subsequently adopted by the Georgia State Board of Health.
Governing Body
There shall be at the head of each hospital organization a governing body with final authority and responsibility for administration of the institution. This supreme authority may be a board of trustees or directors, a partnership or an individual. When this authority is vested in a governing board, there shall be a well qualified executive officer (designated as administrator, superintendent, director or by some other title) designated to carry out its policies.
Medical Staff
In each hospital the professional service to patients shall be performed by a licensed professional staff appointed by the governing body of the institution.
If the medical staff is composed of five or more members, such staff shall be organized. Such organization shall include officers (such as president, secretary and others) and committees elected or appointed according to an adopted constitution and by-laws.
Personnel Requirements
There shall be sufficient service personnel to insure the comfort and protection of the patient.
The hospital shall have on the staff professional personnel especially qualified in the diagnosis and treatment of nervous and mental patients.
Facilities
Facilities shall be provided for the protection of the patients and staff against physical injury by patients becoming violent. Specific regulations are given under Sections V and VI (of said Act) concerning nursing, surgery, obstetrics, pediatrics and adjunct services when these special services are offered in the institution.

- 77 -

In addition to the seven private licensed psychiatric hospitals, there are

four non-medical, non-profit programs which deal with the alcoholic and are sometime~

classified as "hospitals." In 1963, these four facilities admitted a total of

720 patients. These are:

Location

The Anchorage The Harbor Victory Home Hope Haven

Albany LaGrange Tullulah Fa 11s Braselton

a. Out-patient Services in Private Psychiatric Hospitals Only two private psychiatric hospitals in Georgia have out-patient programs,
Northside Manor in Atlanta which admitted 544 patients on an out-patient basis in 1963 and Brawner's Hospital in Smyrna which admitted 452* patients.

3. Mental Health

There are 16 mental health clinics operating on a non-profit basis in Georgia; 13 of these are community-county owned; one is church owned and the remaining two are supported by foundations. Twelve of the 13 community-county owned clinics are administered by local health departments and operated with local and state financial support.
The following is a list of the mental health clinics in the state indicating location and number of patients served during 1963:

Name of Clinic
Bradley Center, Inc.
Bibb County Health Department Mental Health Clinic

Location Columbus Macon

Patients Served 470 102

* This is 1964 data and was not collected as part of the regular Project survey
material.

- 78 -

~tal Health Clinics in Georgia (Continued)

Name of Clinic

Location

Patients Served

Chatham County Health Department

Savannah

170

Mental Health Clinic

Clarke County Health Department Mental Health Clinic

Athens

(recently opened)

Cobb County Health Department

Marietta

94

Child Guidance Clinic

DeKalb County Health Department

Decatur

246

Guidance Center

Dougherty County Health Department

Albany

269

Mental Health Clinic

Emory University Children's Clinic

Atlanta

54

Floyd County Health Department

Rome

150

Child Guidance Clinic

Fulton County Health Department

Atlanta

487

Child Guidance Clinic

Glynn County Health Department

Brunswick

200

Child Guidance Clinic

Grady Out-patient Clinic

Atlanta

264

Hall Connty Health Department Mental Health Clinic

Gainesville

(recently opened)

Muscogea County Health Department

Columbus

105

Mental Health Clinic

Americus - Sumter County

Americus

132

Guidance Center

Thomas County Health Department Mental Health Clinic

Thomasville

(recently opened)

Total Patients Served

2,743

The twelve out-patient clinics, administered by local health departments with the district health officer serving as medical director, are primarily involvec in rendering direct clinical-diagnostic and treatment services and consultation to

- 79 -
community agencies. Staffs are composed of a social worker and/or psychologist with a local psychiatrist serving on a consultation basis. Two of the clinics, Gainesville and Thomasville, have been recently organized and, as yet, do not have a psychiatric consultant. Services in most of these clinics are limited to residents of the particular county or health district in which the clinic is located.
Although Grady's mental health clinic, located in the hospital itself, limits its diagnostic screening and evaluation services to indigent patients from Fulton and DeKalb Counties, some minimum fees may be charged. Patients are seen by psychiatric residents in one of the four "diagnostic screening groups!' which range in size from five to ten persons. This ~rogram, operated as part of Emory University's psychiatric residency training program, has a staff which is made up of four, first-year residents, three, second-year residents and one board certified psychiatrist -- all serving on a part-time basis.
The Bradley Center in Columbus is a non-profit, foundation sponsored, mental health clinic staffed by two psychiatrists, a clinical psychologist, a social worker and a clinical chaplain. Direct clinical services are available for children and adults within a 100 mile radius of the city and training, education and consultation services are offered to physicians and ministers within a 200 mile radius.
Services of the Americus-Sumter County Guidance Center are limited to diagnostic testing and short-term counseling for problems centering around social adjustment and restricted to residents of Sumter County and Americus.
Emory University's Children's Clinic limits its low cost clinic services and private patient care services to residents of Georgia and cost varies according to the type of service rendered. Private patient care is limited to children whose parents' total income exceeds $7,500 a year while fees for low cost clinic services are based on the ability to pay. The staff is composed of three psychiatrists, one clinical psychologist, two part-time social workers, one psychiatric technician, a child development specialist, and a special education teacher.

PART TWO MENTAL HEALTH IN GEORGIA . . . TOMORROW

Chapter I PROGRAMS, FACILITIES AND SERVICES
In attempting to define and enumerate the kinds of programs, facilities and services necessary to meet mental health needs in Georgia, we have tried to be as general as possible, yet as specific as necessary. Realizing that any recommendatiol made would have to be based on sound theoretical concepts, as well as practical considerations, we utilized the best thinking available from the fields of medicine, education and the behavioral and social sciences applicable to Georgia.
Totality and comprehensiveness have dominated our basic approach in terms of looking at the community with all of its resources -- both private and public. In some instances we have clearly identified specific functions, roles and responsibilities for individuals and agencies, while in others we have not. Thus, the reader must bear in mind that the plan addresses itself to the whole community and that within each community are private and public resources which must cooperate, collaborate and coordinate their energies if the citizens of Georgia ever hope to meet their mental health needs.
The recommendations presented in this chapter will be outlined under the three major headings of prevention, treatment and rehabilitation. In developing these programs, it is important to remember that enough flexibility should be built into each so that future changes in either methods or philosophy can be adequately incorporated.
A. Programs to Prevent Mental Illness and Promote Mental Health
Mental Health, and its associated capacity for healthy adjustment to life's problems in ways which are consonant with the values and traditions of the prevailinr culture, is thought to be based upon providing a person, throughout his life, with adequate physical, psychological and social opportunities. If these are available at the appropriate times and in the right dosage, a person is likely to develop the

- 2-
psychological robustness of personality that will enable him to make optimal use of his inborn capacities and to be an effective and cooperative member of society, as well as being able to maintain his mental balance in the face of life's unexpected hazards.*
It is safe to assume that mental illness will never be controlled unless adequate programs of prevention and promotion are fully implemented. Despite the fact that early treatment plays an important role in preventing more severe emotional problems, programs must be developed to alter stressful elements within the environment and to increase the individual's capacity to effectively master such stresses.
Products of private and public concern and support, programs to prevent mental illness and promote mental health must, in principle, provide statewide coverage, be available to everyone, be well-coordinated and be well utilized.
1. General Health Programs with a Direct Bearing on Hental Health
Emotional and physical health are so fused in the modern concept of total health that it is completely invalid to separate the mind from the body or mental health from physical health. (This is especially true in certain mental disorders where definite organic factors are the main causative agents.) Because of this, general health programs in themselves are effective tools in preventing mental illness.
a. Pre-natal care A well-developed, well-integrated central nervous system is an essential pre-
requisite for emotional well-being, which means that measures should be taken to insure healthy growth and development of the fetus from the moment of conception. Hence, prenatal care of the mother, physically and psychologically, is of paramount importance. Early diagnosis of pregnancy, control of communicable and metobolic
k Caplan, Gerald. The Encyclopedia of Mental Health, 5:156-66, 1963.

- 3-
diseases, supervision of medications and proper nutrition can help prevent the development of excess stress on the fetus. Thus, it is important to remember that every medical procedure must be carefully considered prior to its application as to the effect it may have on the unborn infant. It is recommended that:
PRIVATE AND PUBLIC RESOURCES BE FULLY UTILIZED TO BRING COMPLETE PRE-NATAL CARE TO EVERY MOTHER IN GEORGIA AND THAT LOCAL HEALTH DEPARTMENT SERVICES BE REINFORCED AND INCREASED TO PROVIDE SUFFICIENT COVERAGE FOR THE MEDICALLY INDIGENT.
b. Obstetrical Services Adequate obstetrical services are essential in preventing and managing
possible complications of childbirth. During labor, the infant is subjected to numerous stresses which may result in irreversible injury, possibly leading to mental disorders. It is recommended that:
ADEQUATE HOSPITAL FACILITIES AND MEDICAL CARE BE MADE AVAILABLE FOR MEDICALLY INDIGENT MOTHERS. Coordination among agencies, including departments of family and children services and health will play an important role in establishing effective services.
c. Child Health Supervision Continuous health supervision begins at birth and should be maintained through-
out the school life of the child. Well child conferences, offered through local health departments, and periodic physical examinations by private practioners have proved to be two of preventive medicine's most valuable tools. However, more emphasis must be placed on the emotional aspects of growth and development, including counseling and educating parents, and psychologically evaluating the child, along with detecting and correcting certain physical handicaps which may affect the mental health of the child and his family. Parents should be encouraged to utilize resources at hand and SPECIAL DIAGNOSTIC AND TREATMENT RESOURCES PRIVATE

-4-
AND PUBLIC -- SHOULD BE MADE AVAILABLE FOR EVERYONE IN GEORGIA. It is desirable tha t ALL SCHOOL CHILDREN RECEIVE A COMPLETE MEDICAL EXAMINATION PRIOR TO ENTERING ELEMENTARY AND HIGH SCHOOL AND THAT SPECIAL EMPHASIS BE PLACED ON DETECTING AND CORRECTING VISUAL, HEARING AND SPEECH DEFECTS.
d. Disease Control Frequently, the central nervous system becomes involved in various infectious
diseases. Many of these diseases can cause irreversible damage to sensitive brain tissues, especially if contracted during childhood. Immunizations, epidemiological investigations, early detection and control methods are essential elements in any disease control program. It is important that
EVERY COMMUNITY IN THE STATE HAVE AN ADEQUATE COMMUNICABLE DISEASE CONTROL PROGRAM ENLISTING THE COOPERATION AND SUPPORT OF PRIVATE AND PUBLIC RESOURCES.
e. Accident Prevention - Poison Control Accidents resulting in major injuries to the central nervous system constitute
a serious health hazard, physically and emotionally. However, many so called "minor" injuries can alter an individual's emotional balance to the extent that he may become seriously handicapped. It is essential that
BUSINESS, INDUSTRY AND PRIVATE AND PUBLIC AGENCIES TAKE IMMEDIATE ACTION TO DEVELOP AND IMPLEMENT STRONG ACCIDENT PREVENTION PROGRAMS. Science has proved that various chemicals can cause certain kinds of mental disorders. The abundance and availability of household chemicals, pesticides, insecticides and medications in the home make it imperative that POISON CONTROL AND POISON INFORMATION CENTERS CONTINUE TO BE EXPANDED THROUGHOUT THE STATE SO THAT SERVICES ARE AVAILABLE TO ALL.

- 5-
f. Nutrition Poor nutrition has been associated with certain mental disorders, which makes
it imperative for children and adults to receive balanced diets. Plans are now underway in the state to evaluate the diets of children in child caring institutions. It would be extremely desirable if:
THE STATE REALTII DEPARTMENT, IN CONJUNCTION WITH TIlE AGENCIES RESPONSIBLE, WOULD EVALUATE THE DIETS OF PERSONS BEING CARED FOR OR ATTEh~ING INSTITUTIONS SERVING LARGE QUANTITIES OF FOOD, SUCH AS SCHOOLS, HOSPITALS AND CORRECTIONAL INSTITUTIONS.
g. Family Planning During the last few years several authorities have focused their attentions on
the possible role the "population explosion" may have in mental health. Their expressed views indicate that, at times, the size of the family is an important factor in the mental health of its members. Uncontrolled fertility may produce additional economical, social and emotional stress especially on low income families. This, in turn, can result in marital discord, emotional deprivation and unhealthy patterns of life which may create serious mental health problems. Therefore family planning should be considered an important aspect of preventing mental illness.
Because family planning is also a medical problem, as well as a social and religious issue, THE PUBLIC SHOULD BE SUFFICIENTLY INFORMED TO OVERCOHE THE }~NY MISCONCEPTIONS AND PREJUDICES 'WHICH PRESENTuY EXIST. Cooperation between various agencies, the medical profession and others is necessary for achieving a successful program. PUBLIC AND PRIVATE RESOURCES ARE NEEDED TO COUNSEL APPLICANTS AND PROVIDE THEM THE NECESSARY HEASURES IN FAHILY PLANNING. All concerned should be totally familiar with the principles and numerous implications involved.

- 6-
2. Psychological Environment and Mental Health
The environment, from the mental health point of view, is the sum of the interaction between "people" and "what they do" in a given space. If the influence of this interaction promotes psychological growth and development, the environment is considered satisfactory and healthy.
Although early experiences help form the basis for later behavior patterns, the experiences one encounters during his lifetime continue to influence his behavior. To deal with environmental stresses satisfactorily, the individual must remain fairly flexible in his ability to adjust. At the same time, controlling and removing excessive environmental stresses, as indicated .in the following discussion, are valuable in preventing mental illness.
a. Family Life Marriage and the first child, for example, raise many questions in the minds
of young people, expectant parents and parents. From the time a couple decides to marry, they find themse lves faced with many uncertainties. "Living together" in itself is a challenge and the changes each partner undergoes may be crucial to his or her mental health. The impact a new child has on his parents is equally as important as the parents' influence on the child.
Every transitional period -- starting school, reaching adolescence, choosing a career, getting married, having a child or retiring -- brings with it, its share of anxieties.
PROGRAMS DESIGNED TO ORIENT PEOPLE AS TO WHAT TO EXPECT DURING TRANSITIONAL PERIODS IN THEIR LIVES, IF ESTABLISHED IN THE COMMUNI TY, WOULD PLAY AN IMPORTANT ROLE IN PREVENTING EMOTIONAL PROBLEMS AND PROMOTING MENTAL HEALTH. Individuals and agencies responsible for these programs should be familiar with )asic mental health concepts, as well as the principles involved in normal growth

- 7-
and development and family life education.
b. Maternal Deprivation A newborn baby needs the love, warmth, security and close companionship of his
mother or a "motheringll person. l>lithout this, he is unable to develop his capacity for achieving satisfactory human relationships, necessary for emotional health. Depriving the infant of these very basic needs can lead to serious problems
immediate and future. Maternal deprivation is a complex problem which needs to be dealt with carefully.
Too often, we tend to think only of the child who has been physically separated from his parents as being maternally deprived. This is not always true; some mothers are incapable of providing these essential ingredients, especially in situations where there is overt parental negligence and abuse and protection of the child becomes a critical issue. For whatever reason the child has to be separated from his mother, placement in a foster home or adoption should take place as early as possible. Quality, degree, timing and duration of this separation period should be carefully evaluated.
IT IS IMPORTANT THAT ALL AGENCIES INVOLVED IN ADOPTION OR FOSTER HOME PLACEMENT PROGRAMS COORDINATE THEIR EFFORTS FOR MAXIMUM EFFECTIVENESS.
c. Economic Factors Good mental health is partially related to the individual's ability to satisfy
his basic needs for food, clothing and shelter. Today, poverty and unemployment have forced many Georgians to maintain a level of substandard living, which can produce a great deal of stress and a higher incidence of mental illness.
PROGRAMS TO PREVENT UNEMPLOYMENT, INCREASE OPPORTUNITIES FOR JOB TRAINING AND ENCOURAGEMENT OF SLUM CLEARANCE NEED TO BE CONTINUED AND EXPANDED.

-8-
Economic progress in Georgia during the last few years has resulted in increased industrialization and additional job opportunities in population centers. Consequently migration from rural to urban communities will give rise to new problems in metropolitan areas.
IT IS IMPORTANT THAT CITIES DEVELOP CAREFULLY PLANNED PROGRAMS TO COPE WITH THESE PROBLEMS.
3. The School and Mental Health
Learning is best achieved when the child's emotional, social and physical growth coincide with his formal education. The school as a stimulator of intellectual, emotional and social growth has the unique opportunity of being able to influence the child's total development. Unless he is approached with this concept of "totality", the child's education is limited. For this reason MENTAL HEALTH PRINCIPLES MUST BE INTEGRATED INTO EVERY ASPECT OF THE SCHOOL PROGRAM.
a. The Teacher The teacher plays a key role in the total development of his or her students.
He or she should have a keen understanding of individual psychology, as well as group behavior. He should be able to recognize the individual needs of his students and approach them on that basis. All this calls for a well-rounded teacher training program and A BElTER ORIENTATION IN 11ENTAL HEALTH PRINCIPLES AND NORMAL GROWTH AND DEVELOPMENT AT THE COLLEGE LEVEL.
The mental health of the teacher is equally as important. Schools are responsible for furthering his or her professional and personal needs by PROVIDING BETTER WORKING CONDITIONS, SALARIES Al~ OTHER FRINGE BENEFITS.

- 9-
b. Activities and Special Classes School activities and programs should be balanced and adjusted to meet the
individual needs of students. Periods of scheduled classroom work should be interrupted with periods of recreational activities in order to broaden the students overall interests and create a healthy social and emotional climate within which to work.
Special classes for those children unable to follow the regular curriculum have been established in many Georgia schools to provide the necessary "environment" conducive to learning. Despite the fact that the State Department of Education is adding new classes every year, we are still falling short of meeting the needs of the emotionally handicapped child. Unfortunately, limited training opportunities have resulted in an acute teacher shortage to conduct these classes. It is important that:
UNIVERSITIES AND COLLEGES ADD THE NECESSARY PROG~~S TO THEIR CURRICULUMS TO PREPARE TEACHERS TO TEACH THE EMOTIONALLY ~IDI CAPPED CHILD INSERVICE TRAINING OPPORTUNITIES BE PROMOTED ON TP,E LOCAL LEVEL TO AID THOSE PRESENTLY IN THE FIELD ADDITIONAL HOME INSTRUCTION PROGRAMS BE EXPANDED STATEWIDE PROGRAMS BE DEVELOPED TO REHABILITATE HANDICAPPED CHILDREN AND SPECIAL EDUCATIONAL OPPORTUNITIES BE MADE AVAILABLE FOR THE ACADEMICALLY ADVANCED.
c. Services Among the main functions of the school is to observe, evaluate and guide the
child throughout his school life. Because the teacher is with the child the greater part of the day, he or she is in a position to constantly evaluate his behavior and can play an important role in preventing emotional problems.
Resources for conducting psychological evaluations are very limited. It is hoped that more and more SCHOOL SYSTEMS WILL PROVIDE PSYCHOLOGICAL EVALUATION AND CONSULTATION SERVICES TO AID TEACHERS AND STUDENTS BY HIRING THEIR OWN CONSULTANTS. Schools should also be encouraged to take advantage of the services provided by

- 10 -
local mental health resources including health department clinics, voluntary and social agencies, psychologists, psychiatrists and social workers.
Guidance and counseling services need to be reinforced and expanded. Educational and vocational guidance should begin in the elementary grades so that students can be helped to develop to their fullest potential within their own capabilities. Thi.s again calls for well-trained personnel, which means that additional training opportunities must be made available through our own colleges and universities.
INSERVICE TRAINING PROGRAMS AND SUMMER WORKSHOPS CO-SPONSORED BY THE DEPARTMENTS OF HEALTH AND EDUCATION IN CONJUNCTION WITH COLLEGES AND UNIVERSITIES MUST NOT ONLY BE CONTINUED BUT EXPANDED. The Visiting Teacher Program has added a very important dimension to Georgia's educational system. Through their efforts to establish contact between the home and the school, visiting teachers have made possible a more comprehensive evaluation of the individual student. TI1is entire program, which includes prevention, early detection and intervention needs to be expanded but financial limitations and personnel shortages have been serious handicaps. To help overcome these deterrents, FUNDS MUST BE MADE AVAILABLE TO HELP INCREASE STATE AND LOCAL STAFFS. Additional scholarships are needed to aid in recruitment of new personnel, along with summer workshops and seminars to increase the skill of those already in the program. IT IS URGENTLY RECOMMENDED THAT THIS ENTIRE PROGRAM BE EXPANDED TO INCLUDE ADDITIONAL VISITING TEACHERS IN THE ELEMENTARY SCHOOLS. All of these programs require close cooperation and coordination between school officials, private and public resources, and parents. State and local support, including citizen interest and participation, will insure better services in the school systems.
d. Instruction Knowledge and understanding are helpful tools against anxiety and emotional
unbalance and the school is responsible for seeing that the student gains an

- 11 -

objective view of emotional, social and physical health through the courses it provides and the material it presents. Classes containing information on general mental health principles, family life education, human growth and development and interpersonal relationships should begin in the elementary grades and continue throughout high school and college. Information should be arranged according to the child's level of understanding and incorporated on an informal and formal basis both. Because of their specialized skills, teachers may want to call in mental health professionals to aid them in planning and implementing actual course content.

e. Vocational Training and Education

;.

It has been demonstrated that high school level vocational training centers

have preventive and rehabilitative potentials in aiding those students with less

aptitude for academic studies.

IT IS RECOMMENDED THAT ADDITIONAL CENTERS BE ESTABLISHED THROUGHOUT THE STATE.

f. Colleges and Universities
ALTHOUGH MANY COLLEGES AND UNIVERSITIES HAVE STUDENT HEALTH PROGRAMS AND COUNSELING SERVICES, HOW ADEQUATELY THESE SERVICES ARE ACTUALLY ~IEETING THE TOTAL NEEDS OF THE STUDENTS HUST BE EVALUATED.
National statistics indicate that ten percent of the students enrolled, experience
some kind of emotional tunnoil during their college years. General preventive
measures, if systematically applied, may substantially decrease this percentage.
This may require employing counselors or full-time mental health personnel plus more
effective utilization of consultants in psychiatry, psychology and social work.

4. Religion and Mental Health
Religious activities provide a solid foundation for a healthy community. Down through the years, the church has been actively engaged in promoting mental health

- 12 -
by helping people to sustain themselves in their struggle to achieve meaning and satisfaction in their lives.
The clergyman in Georgia continues to play an increasingly active role in mental health. His position in the community affords him many unique opportunities, such as counseling a delinquent child or a couple whose marriage is in danger. He advises couples contemplating marriage, adolescents who may want to drop out of school or the parents of a retarded child.
Usually he is the first person called upon in a time of crisis. How he handles the situation at that time may have a crucial effect on the individual's or family's emotional state.
For these reasons, ministers, priests, and rabbis must be trained to assume the responsibilities.
SEMINARIES SHOULD INCLUDE COURSES ON HUMAN BEHAVIOR AND GROUP DYNAMICS IN THEIR CURRICULUMS. SnJDENTS ALSO NEED TO RECEIVE DIRECT EXPERIENCES IN MENTAL HEALTH FACILITIES, INCLUDING COMMUNITY PROGRAMS. POST GRADUATE COURSES AND IN-SERVICE TRAINING OPPORTUNITIES SHOULD ALSO BE MADE AVAILABLE TO THOSE WHO HAVE COMPLETED THEIR EDUCATION.
5. Business and Industry in Mental Health
Mental health in business and industry has been a relatively neglected area. Only a few large companies have active, identifiable mental health programs.
In spite of automation, the human element is still the most important element. Problems such as, absenteeism, accident proneness and alcoholism, are directly related to efficiency and productivity. It has been proven, time and again, that a person's ability to function parallels his emotional well-being.
Improving relations between management and labor is an important aspect of mental health too often ignored. To maintain and better these relationships, it is recommended that:

- 13 -
ALL CANDIDATES FOR SUPERVISORY AND MANAGERIAL POSITIONS SHOULD BE EVALUATED FOR POTENTIAL LEADERSHIP QUALITIES. COUNSELING SERVICES SHOULD BE MADE AVAILABLE TO EQUIP EMPLOYEES TO BETTER HANDLE WORK SITUATIONS. PSYCHOLOGICAL AND SOCIOLOGICAL STUDIES SHOULD BE UNDERTAKEN TO IMPROVE PERSONNEL RELATIONSHIPS AND TO INVESTIGATE SPECIAL PROBLEM AREAS SUCH AS ALCOHOLISM AND ABSENTEEISM. EDUCATIONAL PROGRAMS SHOULD BE MADE AVAILABLE FOR ADMINISTRATORS ON SUPERVISORY AND MANAGERIAL DEVELOPMENt FOR ALL EMPLOYEES -- TO HELP AVOID RESISTANCE PRECEEDI~ CHANGES IN PROCEDURES PRESCRIBED BY MANAGEMENT -- AND FOR PERSONNEL OF THE EMPLOYEE r S HEALTH SERVICE ON BASIC MENTAL HEALTH PRINCIPLES.
Implementing many of these recommendations requires the skills of mental health professions and social scientists. If possible, business and industry should employ their own professional mental health personnel or utilize the services of outside consultants. Industrial organizations and associations need to assume an active leadership role in Georgia to see that this is accomplished.
6. Community Programs and Activities
Various community activities and programs can have a direct bearing on prevention of mental illness and promotion of mental health. Organizing such activities and securing the support and participation of people, reinforce the basic strength and qualities in the community which are necessary for better mental health.
The level of mental health in any community largely depends upon the kind of environment it provides for its members. Correcting undesirable elements and maintaining progress require unified and concerted effort on the part of the community. Sound and effective leadership is essential for such community action.
Formal or informal programs on self-understanding, family relationships) emotional growth and development, and other mental health principles have significant preventive values. These programs can be carried out in various forms -- group

- 14 -
discussions, lectures, seminars -- and sponsored by civic and voluntary organizations in the community.
Local mental health associations should assume greater responsibility in arranging continuous educational programs in their communities, to promote better understanding of mental health principles. Private and public mental health personnel and state and social agencies should cooperate with such efforts by providing speakers and consultants.
Recreational and cultural activities enrich the lives of every individual, and are integral parts of his (or her) total health picture. Therefore, provision of adequate facilities and programs of this nature for all age groups within the community will have positive effects on physical, emotional and social health.
Support in time of crisis such as death, natural disasters and the like, is seen as an effective method of prevention of mental illness. If individuals and families are given immediate support and assistance at this time, psychologically detrimental effects can be neutralized before symptoms are developed. Every community has individuals, professionals and agencies who are capable to interven in a crises situation. Advanced preparation and planning can increase the effective ness of this technique. Case finding is an important aspect in the application of this concept. Identifying the affected individuals and using the proper resource requires close communication and coordination among resource people and agencies. The establishment of a permanent "interagency council" in the community has a real value in providing coordinated planning and efficient services to the community.
Community planning and organization is valuable in regard to programs and activities for senior citizens. According to the 1960 census, the number of Georgians over 65 years of age reached almost 300,000 or 7.4 percent of the state population. The most recent estimates place the figure at about 312,000. In

- 15 -
G::o.gia, the State Commission on Aging has actively stimulated communities to develop programs to maintain and improve the general health, welfare and living conditions of the aged. Among the recollll1ended programs are: (1) "Senior Citizen Activity Centers" to provide information and referral services; educational and recreational programs; part-time employment services through sheltered workshops; and leadership opportunities for older citizens, and (2) Golden Age Clubs which primarily concentrate on meeting social and recreational needs.
Since the emotional well-being of the aged is largely dependent on the degree of independence achieved, COMMUNITY PLANNING AND ACTION ARE NECESSARY TO INITIATE AND SUPPLEMENT STATE GOVERNMENT PROGRAMS. Their goals should include such things as: (1) providing better incomes through employment; (2) economical health care and medications in the home or institutional setting; (3) better housing; (4) opportunities to develop satisfying leisure time activities and (5) educational programs to promote family and community understanding of the elderly person as an individual.
7. Community Agencies and Mental Health
The role of the helping agencies in preventing mental illness in the community cannot be over emphasized. Providing a broad range of services, activities of these agencies have a direct bearing on the entire community's mental health. However, the demands being placed on these agencies, today, by the community are so great, that no single agency can hope to meet all the requests it receives for service. "Isolated functioning ll is a thing of the past. Duplication of effort has to be avoided or otherwise valuable time can be lost on such routine tasks as filling out forms. The answer is the same as it is in any kind of a well rounded program COORDlNATION.

- 16 -
What does COORDINATION among agencies mean'l It means: finding out what other agencies are doing and how they're doing it lt means open communications It means consistency in approach to mutual clients lt means planning together. How is COORDINATION achieved'l Although there are many methods, one of the most successful has been the formation of an inter-agency council in the community with regularly scheduled meetings. Therefore it is strongly recommended that:
COltiUNITIES IN GEORGIA FORM PERMANENT INTER-AGENCY COUNCILS TO PROMOTE BETTER COORDINATION AMONG THE HELPING AGENCIES.
B. Recommended Programs for Treatment
Present information and projections on future psychiatric case load in Georgia clearly indicate the wide gaps which exist between available resources and needed services. Even if new facilities and resources continue to develop at the present pace, this gap will not only remain but grow wider as the demand increases.
Nothing short of a "crash program" will supply Georgia with the needed services and modern weapons needed to fight mental illness. At best, it will take at least ten years to bring the level of care of the mentally ill to an optimum level.
The following programs and recommendations are based upon a thorough evaluatioL of Georgia's present resources and future trends in such areas as economics, manpower, population trends and any other factors which may have a bearing on implementing mental health programs. Particular emphasis has been placed on being realistic -- not rigid.
1. Community Mental Health Resources and Programs
The availability of services to the individual in his own community is the core of mental health programming. Early detection and treatment of emotional disorders

- 17 -
are among the most important measures available to prevent more serious mental illnesses. For this reason, corrective measures taken against seemingly "minor problems" assume greater importance.
Due to the lack of manpower, it is obvious that all of these minor problems cannot be handled by trained mental health personnel. In fact, a large proportion of the problems which occur in everyday working or living situations could be h handled by people from other disciplines. The philosophy behind comprehensive community mental health programs incorporates this very concept " utilizing all available resources in the community to better the mental health of its members. 1I
Nearly every community has a variety of resources which can be used when minor crises occur. In reality, nearly everyone finds himself in the role of helping others solve their problems just by talking or working with them. Physicians, teachers, ministers, pharmacists, lawyers, law enforcement officials, judges and nurses, as well as various social agencies, to name a few, are called upon everyday for their assistance and constitute the community's first line of defense against mental illness. Thus each community has to identify these resources and use them before psychiatric help is called. (This is particularly true for rural Georgia where the availability of mental health facilities will be limited for some time to come.)
To equip these people or "firing line professionals ll with the knowledge and skills necessary in detecting and managing emotional problems, a well-coordinated educational program is essential. It is recommended that:
VARIOUS PROFESSIONAL ORGANIZATIONS. TRAINING CENTERS AND STATE AGENCIES COLLABORATE IN PROMOTING GRADUATE. POSTGRADUATE AND INSERVICE TRAINING COURSES IN MENTAL HEALTH PRINCIPLES AND PROBLEM MANAGEMENT FOR "FIRING LINE PROFESSIONALS." COLLEGES AND UNIVERSITIES STRESS THE SOCIAL AND BEHAVIORAL SCIENCES IN THEIR CURRICULUMS.

- 18 -
THE ON GOING "INTERAGENCY CASE CONFERENCES" INITIATED BY THE DEPAR'lMENT OF PUBLIC HEALTII BE INTENSIFIED. With the participation of professional consultants, these conferences contribute significantly toward the development of needed skills in evaluating and handling emotional problems by the agency personnel.
CERTAIN PROGRAMS ESTABLISHED BY TIlE DEPARTMENT OF EDUCATION BE REINFORCED AND EXPANDED, INCLUDING THE VISITING TEACHER PROGRAM. THE PROGRAM FOR EXCEPTIONAL CHILDREN AND GUIDANCE COUNSELING IN SCHOOLS. These programs have significant therapeutic value along with the contributions they make toward primary prevention.
AN UP-TO-DATE DIRECroRY OF ALL MENTAL HEALTH RESOURCES AND FACILITIES IN TIlE STATE BE COMPILED AND DISTRIBUTED TO ALL THE PRIVATE AND PUBLIC AGENCIES. PHYSICIANS AND THE LIKE. The Department of Public Health should assume the responsibility for developing such a directory.
ESTABLISHMENT OF VOLUNTARY HELPING ORGANIZATIONS. SUCH AS ALCOHOLIC ANONYMOUS. SHOULD BE ENCOURAGED AND SUPPORTED IN THE COMMUNITY.
When emotional problems develop into more serious social conflicts, more
specialized helping resources are needed. Marriage counsellors, family service
agencies, traveler's aid societies and similar agencies are skilled in handling
such problems. However, in Georgia, these resources are primarily limited to
certain urban areas. Therefore, it is recommended that
AGENCIES SUCH AS FAMILY AND CHILDREN SERVICE, TRAVELERS AID AND THE LIKE WHOSE PRIMARY PURPOSE IS ro AID INDIVIDUALS AND FAMILIES IN TIME OF SOCIAL CONFLICT BE ORGANIZED IN AS MANY COMMUNITIES AS POSSIBLE -- AS SOON AS POSSIBLE.
Planning bodies, especially in larger communities, should direct part of their
attention toward seeing this recommendation is implemented.
a. Comprehensive Community Mental Health Programs
The most urgent need this state has today, from the standpoint of mental health
programming, is to develop comprehensive community mental health programs. Offering
a wide range of mental health services, these programs are designed to utilize all
of the resources previously mentioned.

- 19 -
According to the "Community Mental Health Centers Act", a comprehensive community mental health program includes: (1) inpatient services; (2) outpatient services; (3) partial hospitalization services -- such as day care, night care, and weekend care; (4) emergency services (24-hours per day must be available within at least one of the first three services listed above); (5) consultation and education services -- available to community agencies and professional personnel; (6) diagnostic services; (7) rehabilitative services, including vocational and
educational programs; (8) precare and aftercare services in the community, including foster home placement, home visiting and halfway houses; (9) training; and (10) research and evaluation.
Six of these are considered "essential services" for communities in Georgia inpatient, outpatient, partial hospitalization, 24-hour emergency services, aftercare, consultation and education services. They constitute the minimum number of services that would make up a comprehensive community mental health program. The development of community mental health programs will depend upon local interest, initiative and funds to share in the cost of construction and operation. Planning these programs will necessitate following certain basic principles to insure adequate services.
(1) Services should be available reasonably close to where the patients live.
(2) According to the regulations of Community Mental Health Centers Act of 1963 (PL. 88-164), a comprehensive community mental health program should serve a population range between 75,000 - 200,000. In Georgia this rule will necessitate establishing multi-county service areas.
(3) Utilization and expansion of existing resources should be the focal point of local planning.
(4) Services should be provided for all age groups. (5) All diagnostic categories should be treated, including alcoholism
and drug addiction.

- 20 -
(6) Continuity of services and coordination among the various components are the essential and unique characteristics of a comprehensive community mental health program. Mechanisms must be established to insure instant information exchange between the different services.
(7) Because a comprehensive community mental health program is directed toward meeting the changing needs of the patient at different stages of his illness, the patient should be moved from one service to another easily, without affecting the continuity of treatment.
(8) Community programs should be constituted so that they are flexible enough to employ new treatment techniques and facilities.
(9) It is expected that community mental health facilities will be utilized by private practitioners; therefore, cooperation between public and private resources is the only way to develop effective community health services.
(10) Since it is not mandatory to develop all components of a compre-
~,.
hensive community mental health program under one roof or single authority, it is essential to build in and maintain sufficient coordination and communications between separate services, beginning with the planning phase.
(11) Many communities in Georgia will not be able to establish comprehensive community mental health programs with all the essential services all at once; therefore, "the step-by-step approach" is the only feasible method. However, projections for future services should be considered in the initial planning.
(12) In the rural areas bringing the suggested minimum number of population (75,000) for a service area will result in a rather large geographical coverage. This is not compatible with the concept of community programs. For this reason in the smaller communities of Georgia where it is not feasible to join with the service area of a comprehensive community mental health program limited scope community programs such as an outpatient clinic, should be developed.
(13) In the early stages of program development, key staff members (psychiatrists, psychologists, social workers and nurses) may have to be employed on a part-time basis. However, every effort should be made to secure full-time professionals to insure continuity and efficiency as quickly as possible.
(14) Other agencies and institutions should be encouraged to develop their own mental health resources as they relate to their specific program. Schools, courts, the Department of Corrections and Family and Children Services are already moving in this direction. In such instances, communications and coordination between agencies are of utmost importance.

- 21 -
In light of these principles, an attempt has been made to develop a model comprehensive community mental health program. that could be adapted to suit most any community in the state. It is obvious that no single model can be used to fit every coanunity. However, considering the "facts of life" -- as they are today, and what they ''might be" tomorrow -- it may be possible to visualize a general model to illustrate the theoretical aspects of the entire concept of comprehensive community mental health programs.
In developing a model program which would be applicable and practical for Georgia, an analysis was made to determine possible variables. A review of available information from other states revealed that basic differences between various programs, as well as community mental health centers themselves, occurred primarily in two areas -- operation and administration.
How a mental health program or center operates depends upon three factors: (1) the community's needs, (2) the experience and training of the professional staff, and (3) the existing services within the program. But from the standpoint of staffing and basic services, operational variations are not considered determinin: factors in defining a model. In other words, a comprehensive community mental health program embracing each of the six essential services referred to earlier, should employ similar personnel and provide similar services, although their functiol may differ.
On the other hand, the administrative structures and actual composition of various programs reveal definite variations. One program may be a part of a general hospital, the other of a state institution. Some are independent "centers" governed by an agency or agencies, others by an advisory board. As far as program developmen' is concerned, the deciding factors seem to depend upon the basic administrative
See enclosed sketch

.,'

COMPREHENSIVE

COMMUNITY MENTAL HEALTH PROGRAM

....................................

~
~
so ~-<
(')

-I
z0 - ~--I

fe'r"1,

l>
,...

;:tj

lJnSl

- 22 -

structure, the source of funds and the geographic location of the various components

or services involved.

The present structure of Georgiats communities and trends in past program

development bring two major health resources into focus: the community general

hospital and the local health department. These two facilities plus existing private

medical resources constitute "the hub" of a comprehensive cotmlunity mental health

program. Inpatient, outpatient, partial hospitalization, emergency, aftercare,

education and consultation services, which comprise the six essential elements of a

comprehensive program, are divided between the general hospital and the health

departmentts mental health clinic.* Additional services, such as: rehabilitation

services, halfway houses, sheltered workshops, foster homes, and the like can be

added to the essential ones as needed. Continuity can be achieved through over-

lapping in staffing patterns; for example, a psychiatrist may work part-time in a

clinic and part-time in the hospital; and maintained by well-designed referral

systems.

Considering the population concentration, future trends in growth and economic

development, existing resources and other pertinent factors, the following counties

seem to have the best potential for developing comprehensive cotmlunity mental health

programs (See Map).

Bibb Chatham Clarke

Clayton Cobb DeKalb

Dougherty Floyd Fulton

Glynn
Hall Laurens

Lowndes Muscogee Richmond

Thomas Walker Ware Whitfield

It must be emphasized that most of the proposed comprehensive programs ought to

have multi-county service areas to reach the required population level of 75,000 -

200,000. In populace counties, more than one program may be necessary.

* Outpatient and consultation services can be provided by a mental health clinic financed by a private foundation or other source. Emphasis was placed on local health departments because they already form the nuclei of twelve mental health programs.

POSSIBLE LOCATIONS OF COMPREHENSIVE COMMUNITY MENTAL HEALTH PROGRAMS

;i l

, ., rJ. / l CATOO"

J

~'-'-""N

N

'

N

"
\)

> . . . . . . . I,

'I"""

I "URR.V

r' \. ~-,) WHITf'IELD?

w.eKER

)

."..

\

.,

j

-'j ,..,. \ ) , ~~ ..-r,:I,.j ~ J.'-'JJ l ~~'---r-'-' .~

I

o'e"ER

.

,J

r' LlTOWN

J

RABUN

UN'ON.}.lL-"";1' -....,

.r l ) "-.. ....

I I I WHITE H'BEROH

STATE OF
GEORGIA

l fI \
HATTOCCA ,/ \

GORDON

I \ . ' , ~._.A.JL.o.-'1"" ~ LU"PK'N l

..,

II.TEPHrN.

~

P'CKEN'''1

".

5

'

l
/

-

n

.

.

_

.

<\

/

r

-

.....

,

.

-

,

-

"i

..../
_J. i r-----\ /

'--''''~'---'~'-r-'L

J Y D.W'ON

)

, .--.r-- ,

{

!


H'LL

.
( eANKS
'..

I ; FRANKLIN
1 ' .

fLOYD

,~

BARTOW

, i;:..---' CHEROKEE

I FORSYTH )

/ /i ,- ~'"./y._........-<'r--V'_.~

i r- , ,....... <.' ----J--....,-1!.--r _. __I~..-... ~ '-'.!

/ I."

'

:j

.....(. \.. I J'CK'ON"

'-\

MADISON , ELBERT

I '-_?-::

"

POLK

,-j

~

i (! " ., . ./ "--_., r " ' " ----.--~ PAULDING

COBB

'J(.;.....'~, - J '

\.
GWINNETT"

B'RROW'\ ........".".-./.".,.-.....

1:--" cLJII .

...

. . ..........)1"..-.'""'(.

! ' (' ~.,. ' '7 HARALSON 1,.L '-. .

..I...:--\

.
/f

II'
,

OEKA'L"B" ~\

//
/'

.-

'\

" ' - , ) "1 OCONEE

OGLETHORPE

r/

7',

\

/

WILI<ES

\

LINCOLN

, !1 / r....... _.,.J>... .".r....., " .....,(' '_ __J I i _ Y "-~.,,~ t ~.-' CARROLL

DOUGLAS ,
,J

,

/r-'

L. ....

I

w.eTON

/ '.

F'ULTON "

i,y

/

:I C.L-A.YT/O,N'j~ ' ' ' ,. .\..o /,' :~"~Q'V/ N)EWTO, N ',,, -. ,/- MO. RGA

, \
N

,,

\

..........
GREENE

'> \ .J

-./'-~\

~

)

_.~.r,

I ' \ TALlAF'ERRO

1

/ . c<.":, "" r / "''-'-' \ .f----f-- ~-.l /~ --_. __ -(.....

\ rAYETTE

"r.......

I HrNRT

),

A1......

_.~")

/.-J<' .~.~/ _.;

\ . . '.MCDUFFI'E( COLUMBIA

\

\ //.

HEARD

,
i L.,_ \ / '. COWETA

'I ,

',.

... .:.... __ ' - . - .

r-I \.Y,

I

'", ,/

PUTNA"-l

\

)~l W.RREN

>---( .... \

\.1

....../

\ JASPER ,

)

\

~ ..-,. ........ ............

i- i '\.< \ . . . .' i- .J---._.~.~.-,.J--~SPALDING

/
}.

BUTTS \
__._.{

I

~
i

.....A, HANCCCI<

~ .--'

7

CL.SCOCK/

, ' - ' 1 ' - ' : - I, ! r \'- ! 'I

I ? P,KE

'

I

L....R '

' ' ?\.-.--- . _ , - y v,. , - " ' - - . _ . ...,

\.

I,

~.~,..,;'

(' -,

,

, j

\" RICH"-lOND

"

'-'-'

/ ,

TROUP

MERIWETHER'

J

J

\

\ BALDWIN 'yo

\. JF'f'ERSON \

BURKE

I,1

1. .s'" r
L



-



-



-

(

-

-

-

,~_J1' '

'

O

N

ROE

,
/.~.\.\

JONES'"
.\>--. ......J" ~\

WASHINGTON

' \ ...."

t.

I

/' . -.......y , / '

c., ----._.L.__ ;-~ )./

UPSON'

/

c ............ ...;

r'-'-'l,

"';, '.

"
"\

!
..... ' "

._~.I.<..~._((

;'

HARRIS

!
~~ ,

TALBOT

\.'\
J' .. (' \ '-:>'V-, r \. ./J.--......... \ /' ... S ,r

I

\

BIBB

/'

\

-'\ CRAWF'ORD -......

(

TWIGGS

WILKINSON

) . _ . - . \ . ......... --.
T ........... --~ JOHNSON

"'
,r'
/

' JENI<,NS

\

/

\~

_I_.' _

!CREVEN

'_.,--._.J

/

.r-0\ .J;-. "U'COC(E

TAYLOR ....~.~:;:;:~/lrPr/.c~).,j

\

\ ...........,

\'y .----.---- \,

l". '........5.~...

E.... NUrL

.... ~~.

(/'...(,'1

"',
........--.._"""/

__. . I ...... ....,..j

~

,
L.r,~ r.__.\/

r" . \ ......... , . .,l"J HOUSTON

~/ BLECKLEY

/'\.

I

r/ -. . ., LAURENS

, '-.
! TREUTLEN'

)

\., '\ BULLOCH

,CANDLER I

\

I . ,
CHATTAHOOCHEE, MAAION

' '- J 1

r
MACON'

/ " "~

"/

, \

~

_.-~.1r~\ A( -

;

\.\

! r '-. J "./ '- /'-"C; '-' ._~.-l..
r!-i. '--I \ <) }\ S i \". I, \. " _.-' \V J: "

~.L-~-i'

~j ." c-H-e~E.-v.l'.1

'

'

-..
......-r

'

,-----
/

DOOLY

,



! PULAS.' \'"

rJ -~-'~-v

DODGE

,r-------J,. i' ". / \ ! ~(.SrTE-W,AR~T-~Li~I,W_IE.B_ST.E'R~I,'

SU"'HR

I QUITMAN

,

-.I......

j I TERRELL \,

1\ - . - . - . - . , Jr

"1

\

/

W'LCDX ' . ' /

CR'SP
,r! '~

I '
1

-

--

;



--

-

--

"-''.1~~.

>

/'

" __/

\.,'./

'\~,8~~!,I

,.-.-.,_1..-

\

,..........

TOOMas)

\ EVANS

\~-

' ./

/~
TrL'

A

WHHCER

!<

'... , "
'R

,.../....\ /r " :.'- /'j..., ..~. , II.'''l--~ ..s---',...I.I,..~,T1A. TTN

~-----T,,>-.'-,

.LL



'

/""

I"
f

I\,

.I..B.R~T--'N, I..

\,
\,
'--.
'
l,

.1

r-

r:a-"""l. /

'"

LIBERTY 1...... .......

----1 -......... r

:,

~

1 r '\ RANDOLPH

\

~

J--\ ,
I ! ['-',_ ?

I ' I ,

i '-.-.-.-f..." .L.-r__- l

:-"

LEE

,)

-:

...../~

T----~
\ ,TURNER
'-.~

'.

-..~ ........

r--...J'; BEN HILL

I I JEFF' DAVtS ~

APPLING

J

I

f

'

-

-

7I

'
L

~._.,-

,

.

'"

I

'"

_t)
I

.~
"'1 '

~., LONe.

"

. ...........

~

'

'",

! .",._.

1

\..

! . ? ' CL'V j

'{

(

WORTH '1l' ~---{....... J 'RW'N'

A. _.-! CALHOUN

DOUGHERTY,

\'

COFFEE

...,

'"

~

BACON

.,

J
0I

W'TNr

'\ ' ' C ,-~.j. "-lC INTOSH

,-- ~

\

~

~

\. _.__ ;'

.L~;-' ......,~,

')

r '--~~'L<----r--l

~ TIFT

I ' r ' ('" I
r ErAR_LY-~...J,,"'-l

B'.ER

r''''.. ""J.
f'

.

,L , --.-.~.'r-I~._.\

I

I'

.
'.

,

~

MITCHELL

I

-.

i /'( L ._.\ I

M'LLER

I

coeQu'TT

)!

"r \\'.--'~'-"
,

I '1.... ,r

__.__ -! l ,"

PIERCE

I t\ _~

'J BERRIEN

ATK'N'ON ,l ' J

t,.,.....'(,'-' W.RE .r-..::..../ BR.NTL(Y

/\

....... I

',_

'I

OLTNN

!

j

i ' r i ; r- T \ , ! Y . --'--T~..l-L-,T----T-,-_1._.~.~-_.,( ~.C\O O..)L.._.L,; !I L.NIER

!I

I,

I

\',

"

i \ i ' ....'NOLr I DEC.TUR

L__ \ I

-1 "__ _/".,'....-./

\'

IJ

J

'--. :'---'--

"

CUNCH

'1 I

! i (
! !. I I j
,

,CR'DV! THO....

I

I

r

r~') BROO.' I........ LOWNDrs

j ,J.._
v-I.

'

<'

i

....-......- .

L liL .

CHARL TON
., '

,

,

I,

\....

~' E C H o e '

! ! "'.

i'

;I

- 23 -
Because the community's own initiative is the prime factor in developing these p~ograms, no attempt has been made here to establish priorities. Actually, the need is such that all of these programs should be developed as soon as possible. At this time the community's interest and willingness to participate financially, the availability of manpower and funds and comprehensiveness in planning are some of the factors that will influence decisions and priorities. Designation of service areas for each program have been omitted for two reasons: (1) this is basically a local decision and (2) it's. possible that changes may occur in the state's political and administrative subdivisions within the next decade.
b. Limited Community Mental Health Programs In discussing a "model" for comprehensive community mental health programs,
it was noted how difficult it would be to apply this concept uniformly throughout the state. Although most of the urban areas will be able to develop comprehensive community mental health programs, a great many smaller communities will not. Many smaller counties are limited in their ability to develop these programs because of: (1) lack of population and (2) lack of resources -- financial, personnel and so forth. The most realistic and practical thing to do in these cases is to develop what could be referred to as "limited community mental health programs" which could provide one or more of the following services:
outpatient consultation and education diagnostic pre and aftercare services through, such facilities as a community mental health clinic with full and/or parttime personnel. By cooperating and working closely with larger communities that have fully developed programs, these limited programs would serve to complement and supplement neighboring comprehensive community mental health programs.

- 24 -
In order to develop community mental health programs in Georgia as rapidly
and efficiently as possible it is recommended that:
COMPREHENSIVE COMMUNI'lY MENTAL HEALTH PROGRAMS SHOULD BE DEVELOPED IN THE FOLLOWING 19 COUNTIES: BIBB, CHATHAM, CLAlU<E, CLAYTON, COBB, DEKALB, DOUGHERTY, FLOYD, FULTON, GLYNN, HALL, LAURENS, LOWNDES, MUSCOGEE, RICHMOND, THOMAS, WARE, WALKER AND WHITFIELD AS A FIRST STEP TOWARD ACHIEVING A STATEWIDE COMMUNITY MENTAL HEALTH PROGRAM. Financial arrangements should be made between neighboring counties to enlarge present and future service areas, since most counties do not have resources to develop independent programs.
SMALLER COMMUNITIES, NOT INCLUDED IN SERVICE AREAS OF COMPREHENSIVE COMMUNI'lY MENTAL HEALTH PROGRAMS, SHOULD DEVELOP THEIR OWN LIMITED CO!IruNITY PROGRAMS.
COMMUNITIES PARTICIPATING IN MULTI-COUNTY PROGRAMS ESTABLISH A MECHANISM FOR INSURING COORDINATION AMONG THE SERVICES OFFERED. This could take the form of an advisory group composed of representatives from local governments, professions and the lay public. This advisory group, in addition to its coordinating role, would act to give overall vision to the ongoing program -- strengthening its various components.
LOCAL HEALTH DEPAR1MENTS ROLES AND GOALS OF EXISTING MENTAL HEALTH PROGR..~ BE RE-EVALUATED AND DEFINED, SINCE '11lESE PROGRAMS CONTAIN MANY OF THE COMPONENTS OF A COMPREHENSIVE COMMUNITY MENTAL HEALTH PROGRAM. With a few exceptions, the majority of these clinics serve only as child guidance clinics. EXPANSION INTO ALL PURPOSE CLINICS IS ADVISED.
EVERY EFFORT SHOULD BE MADE AT STATE AND LOCAL LEVELS TO SECURE FULL OR PART-TIME PROFESSIONAL PERSONNEL FOR LOCAL MENTAL HEALTH PROGRAMS.
PSYCHIATRIC/MEDICAL ORIENTATION BE STRENGTHENED TO ALL PROGRAM OPERATIONS THROUGH RECRUITMENT OF ADDITIONAL PERSONNEL, AS WELL AS UTILIZATION OF EXISTING PERSONNEL.
c. Psychiatric Units in General Hospitals
Today, a fairly well-developed general hospital system in Georgia is providing
essential medical services. If the modern tcend in medical practice, which is
bringing psychiatry into "the mainstream of medicine", continues treating the
emotionally disturbed should be considered one of the main functions of general
hospitals. Psychiatric units in general hospitals can provide: (1) inpatient

- 25 -
services* as a part of the total community program; (2) care for acute cases not requiring prolonged hospitalization; (3) facilities for emergencies; and (4) diagnostic evaluations. Providing beds in general hospitals for patients waiting to be committed to state institutions, instead of putting them in jail, is urgently needed 1n many counties.
Some progress has been made in these areas during the last decade. The Health Department's Community Hospital Psychiatric Program has interested several general hospitals in developing psychiatric units. Up to now, a psychiatrist has always had to be present in the community before psychiatric services could be established. But as time passes, more and more general practitioners and other medical specialists will be treating patients with psychiatric disorders. For this reason the psychiatric unit should be a necessary part of the total medical services of a general hospital.
Another service that would have an impact on the general hospital's mental health program is treating alcoholics. Detoxification of alcoholics and drug addicts is a medical problem which requires intensive care in a highly developed medical setting. In most instances, the medical aspect of the problem during the toxic stage is more important than the psychiatric one and general hospitals, general practitioners and other physicians should assume greater responsibility in this area.
Any community general hospital using Hill-Burton funds shquld be required to make provisions for psychiatric beds. 1his is especially true in large metropolitan areas, such as the Atlanta area, where the need for psychiatric units in general hospitals is extremely acute.
* Providing one of the .ix ~e96ential elements" referred to earlier.

- 26 -
d. State and Local Responsibilities in Community Mental Health Programs State and local governments are responsible for promoting and providing
services for those unable to afford private care and for developing programs not offered by private enterprise.
The Georgia Legislature has delegated the responsibility for leadership in planning, promoting and developing health programs in the community to the Departmen: of Public Health and local boards of health. Active leadership on the part of the state's mental health authority, which in Georgia is the Health Department discharging its responsibilities through the Division of Mental Health, is essential for the success of a coordinated, statewide community mental health program. This leadership should be in the form of guiding and planning "with" the community, encouraging active participation on the part of the community at all times. The state can initiate programs and services when the community is unable to develop them themselves; however, this mechanism is not employed unless the community's resources and potentials are inadequate.
Until recently, tradition in Georgia has promoted the idea of state responsibility for treating the mentally ill. Now it is clear that a balanced sharing of responsibilities by the state and the community, including the private sector, is the only way to insure that programs and services will meet the community's own individual needs. Thus, community programs should be administered locally and policies regarding patient eligibility and program operations determined at the community level. However, construction and operational costs for community mental health facilities and programs will be shared by local and state monies, along with federal funds (if available).

- 27 -
.; e. Private Resources in the Community The community's overall mental health needs can only be met when both private
and public resources are available. When possible, each citizen should bear the cost of his own personal illnesses and those of his family, utilizing private medical resources. Reliance on private care must be emphasized and encouraged. Government supported, public programs simply fill the gaps in service created by one or both of these reasons: (1) private enterprise has not provided the necessary services or (2) the services are not within easy reach of those needing them. Private practitioners and private psychiatric hospitals are two valuable resources which have helped to carry a large burden of the community's mental health needs.
(1) Private Practice In recent years, there has been a significant increase in the number of psychiatrists in private practice in Georgia. At present, eleven counties -- Bibb, Chatham, Clarke, Cobb, DeKalb, Dougherty, Fulton, Floyd, Glynn, Muscogee and Richmond -- have psychiatrists in private practice. As new training programs develoI and others expand and the state continues to progress economically, more and more psychiatrists will be attracted to the state. In the meantime, concentrated recruitment efforts by communities, local medical societies and the Georgia Psychiatric Association could help attract additional psychiatrists to those communities which need them. Today psychiatric coverage in community mental health programs is grossly inadequate. As a result of manpower shortage, adequate services can only be achieved if private psychiatrists are willing to assume an active role in community mental health programs. Therefore, psychiatric coverage in present and future programs will have to be increased by utilizing more psychiatrists on a part-time or consultation basis.

- 28 -
A coordinated effort between private resources and public agencies to provide consultation services to non-psychiatric physicians could have far reaching effects on the care of the emotionally disturbed. In a recent survey, Georgia physicians in private practice indicated that at least 2S percent of their case load was composed of patients with emotional disorders (other national studies bring this figure up to 60 percent). Psychiatric consultation, provided on a continuous basis through a planned statewide program, could aid local physicians in handling psychiatric problems. Local and state funds should be utilized to provide these consultation services to rural counties where the development of mental health programs will be especially difficult.
Other mental health professionals, namely psychologists and social workers, are also providing valuable services. Clinical psychologists in private practice are offering psychological evaluations, individual and group psychotherapy and consultation services with industry and various official and non-official agencies.
(2) Private Psychiatric Hospitals Private psychiatric hospitals play an important role in meeting the needs of the mentally ill. With the help of insurance coverage for the treatment of mental illness, private hospitals in many states are now within economic reach of many low and middle income individuals. National statistics indicate that private hospitals are carrying an increasingly larger proportion of the total caseload of mental patients. When the availability of this type of insurance coverage increases in Georgia, additional private facilities will no doubt be established. Since furthering private enterprise is one of the basic aims of our society, governments and all concerned should make every effort to encourage the development of private mental health resources.

- 29 -
With tlleir qualified personnel private psychiatric hospitals can provide services for the community similar to those of private practitioners. If emergency beds for the indigent could be made available in these hospitals they could help fulfill an urgent community mental health need. Local governments or other agencies should explore the possibility of financing these programs in conjunction with the hospitals themselves.
Utilizing private hospitals as field training centers for training mental healtt professionals may also be a possibility. In order to help meet some of these needs in the community private hospitals should establish liaison and develop a close working relationship with other agencies and mental health resources in the community.

2. Regional State Ho~eital Programs

Since the 1840's the mentally disabled in Georgia have found shelter at

Milledgeville State Hospital. As the state's only public oental hospital,

Hilledgeville gradually grew to become one of the largest institutions of its kind

in the world. Today it houses around 12 000 patients end 3,(.';X' f:':",I,',ky,:?es. Over-

crowding understaffing and lack of adequate funds are serious b"m,~lr;a?s toward its

becoming a modern psychiatric hospital.

.

It is recommended that strategically located smaller re8iom:l stBte hospitals

be built around the state as soon as possible. Each of theoc h03p~tals (See Map)>>

along with Milledgeville State Hospital should provide services for mentally ill

adults and children alcoholics and drug addicts geriatric patients and the

mentally retarded from a specified geographical area. Because of their composition

these facilities would serve as "multi-purpose hospitals" operated in unit systems

under a single administrator and would be economical professionally sound and

efficient.

POSSIBLE REGIONAL STATE HOSPITALS

'// !,

li j \ CATOO"

.., J

)

, J \) r' " , . . . J

~._.---F- . N N I N "

LlTOWN

,UUN

1> "..> L"r;HITF'lELD

Y frIlURR4

........, '1 UNION J1..-",'"'\

~_': W.LKE' ~j

(GIL....

\.

) /.1"-.....,1

) ~.".

A ! 1
-~_-r--

.~..-IjO-....l

,l.....,.;;j.-../

if l / WHITE ; H.....H... /

STATE OF
GEORGIA

(!,I \
;HATTOOGA ,/ \

GORDON

~I ._.A.JI...A...rl('-J ',-~ LU..PKIN

~ 1-.

~ N " 1 Plc..

........5"/'

X ... "
i I'

~--,.,.....r----,..-Tl..

)

.'

-~--J.

DAWSON

)

/ .TEPHrN.

<.'

~

''y.;-.J....y-._.-''

(BANKS

I
I f'RANKllN

.J. i ; r---.-., HALL,

\

)

FLOYD

~

BARTOW

I

CHEROKEE

I FORSYTH )

,/;""-~, ./y'--.....""..')--l..r'_.....

i

!

(-1;:'---'

,/

'<.

z..

._' -r--_. --:... ' ""-', "l __ ......J i....r--;. .

1,--'"

I ....... ..... {'(J, 'CK'ON

j\

MADISON

ELBERT

. T ! "'-- t' ... POLK / ! , . j

~


~--'11..r.....

:iI
.-r-J

~ 'A.'OW'. ,....-'

"r"/'

COBB

I . ) ro .-J1,

GWINNETT:....\

l:" , / ,--_CLAP. [ <'

~ .,. -"'>.""'~'-''''""C
__.

i '. '-'~'-'i PAULD,"G I

(

i HARALSON



'1

I,.L. -~I'. __ -:--'\'

/r'-.(

/"---''-<:

-''')'

/

[

" / ,



,DE KALB '\. / '

.."'\
"7 \ -\1 r OCONEE

OGLETHORPE


WILKES

'-"'7
\

t...... >. " J '

'y'

I

)"...... WALTON / .

LINCOLN

...-""'-
CARROLL

1. I. OO.U...G...L.J r4S' ,
L_-,?,'

/

fU

LTO\l :CNL'A: ~Y-IT' OLl N'j "~".\,.J.'/0~~.).~.')!/7.?.".,..

......

~

,

/

"/
MORGA

~--'

\ \

N

,

.

.

.

.

.

~--,_(.., "J
\

,\

.1

;,/'...

.

.

.

_

,

,-

<,

""~' '\-"i./. '-"~-

r

,

GREE.NE "TALl4FERRO / '

1

-

-,) ~----r-_-

I

, . , i /'. r r ' //.,.J., \ ' , ._.~ __

..... /

i ( FAYEn.

,~

'r

NEWTON

I

i,
HrN.Y _.~\

}., / , ..:,. '- ..... ,

! J \' , " ,COWETA

\ '.

I
...-"---L .......,

..,

I

\ ")
.----\
'Vo\/
PUTNAM

\j
~

,_/, \

...

,MCDUFFIE?

I,

\

/

i )~I WA"EN

\\// RICHMOND

\.1 ..... \ _", HEARD

~

~_/

J4SPER "

,..--)

\

~ >~, , _............. ............

7-......." " \

J r-

SP4LDING (

BUTTS \

.->-.j----....... -...... _......J'

'

I

/ ' / j ' - - - . ,

j-.--,.--T---j-.;-----.y

I ' 'r'

H4NCOCK

_,-.r--~.rL.._

'-\' , GLASCOCK,./ 1,'

')
/

.

I

.

I

\---.--

,

.....,,...'-. j

,

,-~--./

! ~ r'.I .,/'\ 1)...,. r -' '\ ! TROUP

I, MERIWETHER'

PiKE

I I J LA"A' '

\\,

I.

r~.-.-.- [ - - ; I \ 'MONROE,

I.

JONES

\ y,- B4LDWIN

\. JEF'FERSON \

,,,'~'( \

"\......

WASH'NGTON"

\

...-J "'\

l"

BURKE

,,/

_

_

~.

~.......,

/

'
/

i -- ',." -_-.--L._.

h

UPSON'~._---\ ,/

---. -:; \, , ......,.--:

\.""\

/.(I .~,.//..~._(('-

/f

HARRIS

~

J' \..'\_

I

')-'V'.

.._ (' \

BIBB

/'

,\ WILKINSON L.- .... \.-.....-"-"' ", \

I

,r

'JENKINS

\

/

SCREVEN

l

TALBOT

[

\.

CRAWFORD "::..

,

TWICCS ,

/_............. JOHNSON ,/

\

('

..........? ',- ._,~

1
"

'1./ '.---.--: J I. \ / ! h4USCOCiEE
r/ -. .) /. __.j

.-~l,.~....-...~\

I

-'\

,/ ":"-...,,,",,

\

'

,
t,

;
T
,

'\~./ / '

I' i

,.,.....~-1_ 4YLOR
.

i ' , ' / PEACH . ~.~ J-J.-..!

,/

..vI HO

UST

'. ~
ON ~

'/'
,/ \ .,--'. / ,\
BUCKLEY / \

/

-.., LAURENS

\
\~'!,f....,
' -.~,

~''>--''

EM'NUEL

,.

/' /"" "/'1

""
'''-.,'-...-......(\" /'

I

\

BULLOCH

L_, r'" /" _' i I ! ( i 7 \,\ r~ <: \ -_...{." CHATTAHOOCHEE, MARION
.r-,,,--,' '.-'---':-.-.-- '. -\ ! J -_......-._L

,-1
r:"', I ' SCHLEY

T'> '-'1\ TL....... \,/ is' ) \ ,!1..', i /-, i! \. \, '\ \ i---.

I

MACON r.~ L-~.-{/

,/'"

C

''-"
'-'/
'

! PULA'KI \',

DOOLY

It~-_",/('

~

TREUTLEN'

'-

>,,~/_' /\.;;..,

/ CANDLER

\

~ ....,

DODGE

'/'/

\.

WHtELE' (

~

TOO....

EVAN' \..

EFFINCHAM

,,~ ~.--
\,

.,/ \/

\ r \.! ! \----.---.-1 \ ./ \...... ~ ~ ~----7>''''''', ~_ STEWART

I WEBSTER'

SUM".

:

I

'I

/' ''-"

,

\,

'TATTNALL /

' \ OT'N

\..

.,.c-------J t

.

~

OUITMAN

rI---"

'-

--'

"L,._._ I

.',

-~-"""-r-[. '\ RANDOLPH

I "RRELL \

,

'

i
\

~,....

LEE

\
CRISP
i
...:~._......~
', ) ~I

I WI LCOX \

/

I

''"\.,/'

TELFAIR

\ )....,/L"-.,....k-'T"I''--...f--..., "

r' '-'j
)'

\.._.-,
\.

\~;)

.. ._J ...... / '-. .~ r-' -~, .~ f5..s... " ;

-.--
- .....r.;

'<,. --:l,

J~,./- '

, I '""""",~"""'1----'

.If"
I

JEFF

DAVI

BEN HILL

S

I c-::

,

......--...,

r""'\.

4PPLING

f'!

I,~.

"LIBERTY"'"'.

"'1

LONG

~ ........... ~

"! . .

.

I

{

I CLA!~Y._.~ _._f"lf.~.-\-,_._.L_._

_

-"~
l

~_~_.-<',{ CALHOUN

(
,

r'
DOUGHERTY,

! i ,TU'NE'

j

'
WORTH

-'1. l'~'~ -'.,(' \...

.'\

'I , - - r - - -' "rI

'
I L - - - -7

J-1
- . . . . .'....

I
I'

"WIN

..1J

COFFEE

~
I

',;

BACON

"A CI

"\

"- " ....

WAYN,

" \ . . 1 l , . , / '
r MC INTOSH

I .. : \ (---,----...--\"""-----;--1\

r~'

TIFT

EARLY

!!. . / BAKER r'/ ,'l -----....,_..r. "!"'----r

I / \. :- f ."'---.



f ... , \-\--~-_.'\--.-

t--_-~ r ,I

L

.-
'1..._

.

;-
,"

..... l~

! , PIERCE

'.

....

')

-

1 I' ". ') l... r_._N...J-l

II

.

I /'. ,

MILLER

J'
(..

MITCHELL

I'

.

I- , BERRIEN

,COLQUITT';.'1

~' TAT-K-IN-SO-N--,l..\J

, . r J (( \ .i. .r;--! '\ ,i !'_. ---'---T---lL T----l-1

I ' J ,

,

,

COOK

-..~ -,...-.- _ _ .J

....L

J l.-,LANIER

\

WARE

.._.J

(

f i " J

'r~-...-...--~-.,/

BRANTLEY

f'

j .,........-./

IJ

y'

.

I ! !\ '> II'

\.

L__. 'I

'--\, :,. - - - , - -

I ,

DECATUR

i

~

CLINCH,

,

! j ! i 7 (
I I'

, GRADY

THOMAS
I

j
'

,-1.. .~,) ; - BROOKS '''''"-. LOWNDES v

~ --I

L. '

CHARL TON

.--

I'

I,

'I

(I

i

............~.

1iL ' - - - - - ,

,

,

.,

\....,

~

ECHOL'

"!' .!?

iI

- 30 -
In a sense t regional hospitals are considered complementary parts of community mental health programs. The old concept of isolated mental hospitals will have to be replaced by the dynamic philosophy of closely tying the state hospital to the communities it serves. However, a regional state hospital will not provide all the services furnished by a comprehensive community mental health program. For this reason t it should not be assumed that the existence of a regional hospital in a particular area will eliminate the necessity for community programs.
The need and demand for state hospital beds for psychiatric patients will vary according to the population of the particular area t the availability of other private and public services and facilities, the economic level of the region and the effectiveness of primary prevention measures. Hence, a simple projection of present statistics will not represent a true picture. Projected figures, on the other hand, may indicate certain trends and help direct the thinking of planners.
In 1963 t an estimated 32,681 psychiatric inpatients were treated in hospitals in Georgia. This represents a rate of 780 patients per 100tooO population. The rate of Georgians hospitalized in state and federal mental hospitals was 622 per 100,000. With a projected population increase to 5,454,000 in 1975, it will be necessary to provide enough hospital beds to take care of approximately 33,924 patients. It is estimated that approximately one-third of this group will require short-term care (less than 30 days); one-third medium-care (60 to 120 days); and one-third long-term care (more than 120 days). If the major portion of short-term cases is taken care of in community mental health programs and private facilities, 8,000 to 10,000 beds would be required in regional state hospitals.
Milledgeville State Hospital now has about 12,000 beds. If overcrowding is relieved and obsolete buildings eliminated t approximately 7,000 acceptable beds will remain. Of these 7,000t 2,000 will be needed for special programs t such as mental retardation and other special groups. To keep Milledgeville State Hospital

- 31 -
relatively manageable in size, all additional psychiatric beds should be located in
regional hospitals.
It is recommended that:
IMMEDIATE STEPS BE TAKEN FOR BUILDING n> REGIONAL STATE HOSPITALS WITHIN THE NEXT FIVE YEARS -- ONE IN THE VICINITY OF AUGUSTA AND ANOTHER NEAR ATLANTA. Both areas have dense populations, training centers, and state property available for construction -- sufficient justifications for this recommendation. The buildings would be constructed on the campuses of Gracewood State School and Hospital (Augusta) and the planned Georgia Retardation Center (DeKalb County). The size of these hospitals should be 300 beds in Augusta and 500 beds in Atlanta, with provisions for future expansion to 500 and 1,000 beds respectively.
MILLEDGEVILLE STATE HOSPITAL WOULD IMMEDIATELY BECOME A REGIONAL HOSPITAL, AS SOON AS THE FACILITIES IN AUGUSTA AND ATLANTA BECAME OPERATIVE.
DURING THE NEXT FIVE TO FIFTEEN YEARS, ADDITIONAL REGIONAL HOSPITALS SHOULD BE PLANNED AND CONSTRUCTED IN MAJOR POPULATION CENTERS IN THE SOUTHERN AND NORTHERN AREAS OF THE STATE. POSSIBLE LOCATIONS ARE ALBANY, ATHENS, COLUMBUS, ROME AND SAVANNAH. The size of these additional hospitals should be about 300 beds each, with provisions for future expansion. Bed capacity should never exceed 1,000 in any unit.
EACH OF THE REGIONAL HOSPITALS SHOULD PROVIDE SEPARATE, SPECIAL PROGRAMS FOR MENTALLY ILL ADULTS AND CHILDREN, ALCOHOLISM AND DRUG ADDICTION, GERIATRICS AND MENTAL RETARDATION.
a. Present and Future Role of Milledgeville State Hospital
For the next few years at least, Milledgeville State Hospital will still be
the only state facility for the mentally ill. Although the Georgia Mental Health
Institute, scheduled for completion in 1965, will provide another 200-250 beds, its
main emphasis will be directed toward training and research. Because patients will
be selected on this basis, the Institute will have a limited impact on reducing
Milledgeville's case load. Consequently, improvements must continue to be made as
quickly as possible at Milledgeville and the per diem appropriation increased.

- 32 -
The reports* of the "Governor's Coamission for Efficiency and Improvement in
Government" and of The National Institute of Mental Health provided some specific
recommendations, based on extensive evaluation, for improving various aspects of
Milledgeville State Hospital's overall program. The following recommendations are
some of the highlights from the reports:
(1) A comprehensive system of services for the mentally ill should be developed on a state-wide, geographically dispersed basis, with Milledgeville State Hospital functioning as only one psychiatric hospital within the state-wide system.
(2) No additional capital should be invested to expand the capacity of Milledgeville State Hospital.
(3) To begin moving into a state-wide system of care, the present psychiatric program and organization of the unit system at Milledgeville State Hospital should be reorganized into autonomous "geographic units", each serving a particular region of the state.
(4) Special treatment programs should be developed for patients whose needs can best be met through central specialized services. This would include a geriatric service, a children's unit, an alcoholism treatment center and a mental retardation service.
(5) Admission of non-psychiatric geriatric patients to Milledgeville State Hospital should be discontinued. Efforts should be concentrated on helping as many geriatric patients to leave the hospital as possible.
(6) Recruitment efforts to attract more professional and administrative staff should be intensified.
(7) Activity and industrial therapy programs should be improved or initiated and better patient participation in these activities should be encouraged.
(8) Various training programs in the hospital and its units should be specifically directed toward state-wide community interaction.
(9) Priority should be given to expanding and upgrading the medicalsurgical unit.
(10) The operational support services of the hospital should be strengthened by reorganizing the engineering and dietary departments and establishing a separate housekeeping department.
* Treatment Programs For The Mentally III and Mentally Retarded in Georgia, Report No.6, 1964; Treatment Services for the Mentally III and Mentally Retarded in Georgia, A Survey Report, 1964, U. S. Department of Health, Education and Welfare

- 33 -
It should be emphasized that the above items are only a few of the recommendations from these reports and that plans are currently underway to implement the entire range of recommendations. However, time, money and personnel will be needed to elevate services and operations to a satisfactory level. How rapidly Milledgeville State Hospital can progress will be determined, in part, by the amount of support the people of Georgia are willing to give.
3. Special Programs
Certain kinds of emotional disorders are better managed in specialized program units. From the standpoint of future mental health programs, services for alcoholicf and drug addicts, children, geriatric patients and mentally disordered offenders are of particular importance.
a. Programs for the Treatment of Alcoholism and Drug Addiction Plans are now underway to replace the present Georgian Clinic in Atlanta* with
a new and larger facility. This new facility would provide expanded opportunities for treatment, research and training in the problems of alcoholism and drug abuse.
EMPHASIS SHOULD BE PLACED ON INCREASING CONSULTATION SERVICES TO LOCAL COMMUNITIES WICH l)ULD ENABLE MANY TO DEVELOP THEIR OWN PROGRAMS FOR ALCOHOLISM AND ADDICTION. These local services in turn, would be one component of comprehensive community mental health programs. CONSULTATION SERVICES SHOULD ALSO BE MADE AVAILABLE TO CORRECTIONAL INSTITUTIONS, COURTS. INDUSTRY. TUBERCULOSIS AND GENERAL HOSPITALS. MANY OF THESE FACILITIES SHOULD BE ENCOURAGED 10 DEVELOP TREATMENT SERVICES IN CONJUNCTION WITH THEIR OWN PROGRAMS. LARGER CITIES IN GEORGIA SHOULD DEVELOP DAYCARE CENTERS FOR ALCOHOLICS. similar to the Chatham Clinic in Savannah (also part of Alcoholic Rehabilitation Service). THESE CENTERS COULD BE
* Under the direction of the State's Alcoholic Rehabilitation Service, Division
of Mental Health, Georgia Department of Public Health.

- 34 -
LOCATED IN GENERAL HOSPITALS, LOCAL MENTAL HEALTH CLINICS, OR IN SEPARATE FACILITIES, SERVICING A MINIMUM OF 25 PATIENTS PER DAY. SINCE DETOXIFICATION IS AN ACUTE MEDICAL PROBLEM, IT SHOULD BE HANDLED BY MEDICAL SERVICE SECTIONS OF GENERAL HOSPITALS, RESERVING THE PSYCHIATRIC SERVICE SECTIONS FOR THE SMALL PERCENTAGE OF THESE PATIENTS WHO ARE ACUTELY PSYCHOTIC. As mentioned previously, centralized programs for alcoholism and addiction should be established at Milledgeville State Hospital and in all future regional hospitals. The size of these units will depend upon the existent need in each region and will be reserved for the patients who need relatively long-term psychiatric care.
b. Residential Treatment Facilities for Children and Adolescents There has been a steady increase in recent years in the demand for services
for emotionally disturbed children and adolescents. For example, in New York State the resident patient rate per 100,000 population for children less than 15 years old) rose from 13.5 in 1955, to 32.5 at the end of fiscal 1963. By 1975 this rate is expected to climb to 45 per 100,000 population, representing a 63.6 percent increase between 1963 and 1975.
In Georgia 38.8 percent of the total population is under 18 years of age. This alone is sufficient to assume that the unmet needs in the area of emotionally disturbed children are significantly broad. Milledgeville State Hospital figures may not represent the true picture but they are indicative of a trend which is quite similar to that of New York State.
Children treated in inpatient services usually have rather severe emotional problems. For this reason, the average length of stay is relatively longer for children than adults and inpatient treatment programs are designed accordingly. On the other hand, short-term hospitalization for diagnosis and evaluation purposes is not uncommon, as it may be helpful to observe the child in a different environment.

- 35 -
Certain cases, too, may beneiit from relatively short-term hospitalization. It is important to keep these aspects in mind when programs are being developed, as rapid turnover of short-term cases may be too disrupting in a program designed for longterm hospitalization.
Residential centers and childrens' units should provide separate programs for adolescents and younger children, since the former do not mix easily with the latter. Such programs and facilities are urgently needed.
Treatment facilities for children must maintain close communications with community agencies and resources. Parent involvement, aftercare services and school programs are important elements of the total treatment program. The staff of these facilities must be aware of circumstances in the community and the home to be able to make long-range plans for the individual patient.
There is an urgent need for residential treatment facilities for children and adolescents in Georgia. Milledgeville State Hospital is opening a 60 bed childrens unit, which will function as an evaluation and diagnostic center. The only special program activity for 400 children at the hospital 1s about 10 special education classes. Plans are being made to convert one of the wards into a children's unit as soon as possible.
The Georgia Mental Health Institute in Atlanta will provide units for children and adolescents, primarily for short-term cases. Long-term tr~3t~nt will be provided through an outpatient clinic which will continue to follow patients after they are discharged from inpatient programs.
It is recommended that: PRESENT AND FUTURE STATE HOSPITAL PROGRAMS ESTAELISH SP~CIALIZED
CHILDREN'S AND ADOLESCENT'S UNITS WITH PROPER Th-.i:AT...g:<iT A.:m
ACTIVITY PROGRAMS. THESE UNITS SHOULD PROVIDE BOTH Si.iJRT AND LONG-TERM CARE.

- 36 -
ADEQUATE PROFESSIONAL STAFF BE PROVIDED FOR THESE PROGRAMS. COMPETITIVE SALARIES HAVE TO BE ESTABLISHED TO ATTRACT CHILD PSYCHIATRISTS A!~ OTlIER WELL-TRAINED PERSONNEL. PRIVATE AND NONPROFIT RESIDENTIAL TREATMENT AND EDUCATIONAL CENTERS FOR EHOTIONALLY DISTURBED CHILDREN AND ADOLESCENTS SHOULD BE ESTABLISHED IN MAJOR CITIES AROUND THE STATE. GENEP~ HOSPITAL PSYCHIATRIC UNITS SHOULD BE MADE AVAILABLE TO YOUNGER PATIENTS FOR EMERGENCY PURPOSES A1~ DIAGNOSTIC STUDIES.
THE POSSIBILITY OF UTILIZING PEDIATRIC UNITS IN GE~mRAL HOSPITALS FOR DIAGNOSTIC STUDY OF EMOTIONALLY DISTURBED CHILDREN BE EXPLORED vJHERE PSYCHIATRIC AND CLINICAL PSYCHOLOGICAL CONSULTANTS ARE AVAILABLE.
c. Special Programs for Geriatric Patients
To manage the problems presented by geriatric patients, who require continuous
nursing and medical care, state hospitals have to establish special geriatric units.
While ambulatory geriatric patients in good physical condition may be treated in
regular psychiatric units, a separate "geriatric infirmary" for patients needing
closer nursing supervision and care is the most practical solution. Dividing
geriatric patients into these two categories would facilitate concentrating on the
special problems ~ach group presents.
Establishment of a geriatric infirmary at Milledgeville State Hospital is in
the planning stags. When the new unit system with geographical distribution and
centralized special services is established, the approach mentioned above will be
put into practice. No future regional state hospital should be built without a
special geriatric infirmary.
State mental hospitals should not be responsible for the care of non-psychiatric
elderly individuals. Coordinated efforts between the Departments of Health and
Family and Children Services will be essential for placing geriatric cases, no
longer requiring psychiatric treatment, in nursing homes or other community

- 37 -
facilities. Screening procedures prio~ to commitment t adequate planning before and during hospitalization and full implementation of various old age assistance p~ograms will play important roles in bettering services for the elderly.
It is expected that the recent increase in nursing home construction will continue. Nursing homes located in communities are needed resources for the elderly. State and local governments should continue to encourage nursing home construction t by sharing in the cost of the care of econemically deprived citizens in these facilities.
d. Facilities for Mentally Disordered Offenders Care of mentally disordered offenders has been the responsibility of Milledge-
ville State Hospital in conjunction with the State Board of Corrections. However t a new maximum security facility is needed to provide services for both male and female offenders. The State Board of Corrections is already going ahead with the establishment of a diagnostic and classification center; adding treatment facilities for mentally disordered offenders t under the saas authoritYt would seem reasonable and practical. Decentralization of mental health facilities is already an accepted concept in Georgia. The development and operation of facilities to care for special problems can best be achieved by the agency whose main responsibility lies in that particular area. In many states prison systems and correctional departments operate thei.r own treatment and rehabilitation programs.
C. Recommended Programs for Rehabilitation
One .0 the ~~st crucial issues facing the mental health field today is maintaining and furthering improvements which have been accomplished through treatment. Modern psychiatry with its present tools and skills is able to suppress the overt

- 38 -
symptoms of emotional disorders in a relatively short period of time, which has resulted in a rapid discharge rate of patients from mental hospitals. However, a person who has overcome the disabling effects of mental illness passes through a critical period following the treatment phase. Unless he receives further support and help, the newly built pillars of emotional health may not tolerate the sudden weight and stresses of everyday living. Skyrocketing readmission rates during the last ten years have clearly demonstrated the need for supportive programs in the form of aftercare services, vocational guidance and rehabilitation, emploYment opportunities and social acclimation.
1. Aftercare Programs
Aftercare services for patients released from mental hospitals should be an essential part of community based programs. The importance of this service takes on even greater dimensions when we know that very few of the 6,000* patients on furlough from Milledgeville State Hospital receive any kind of medically supervised aftercare service.
During fiscal 1964 alone, 4,040 furloughed patients returned to the hospital, and 1,565 previously discharged patients were readmitted to the hospital, bringing the total number to 5,605. It is assumed that a significant number of these could have been maintained in their communities if statewide aftercare services had been available.
Aftercare services provided by public health nurses have been somewhat limited due to the lack of proper referral resources and the absence of drugs in the community for the indigent. These patients have to travel long distances to obtain their medication from Milledgeville's out-patient clinic.
* During any given time

- 39 -
Certain communities have shown interest and initiative in developing aftercare
programs. For example, Hall County now operates a part-time aftercare clinic in
the local health department through the efforts of local physicians who voluntarily
donate their time to supervise drug therapy and conduct supportive psychotherapy.
Such programs, however, can only have a limited impact on the vast problem which
presently exists.
An effective, statewide aftercare program would be the soundest investment
Georgia could make in the area of mental health. For example, such a program
could be implemented through geographically distributed "aftercare clinics,"
staffed by physician-social worker-nurse teams. These clinics would provide one
of the essential services of comprehensive community mental health programs.
Availability of psychiatric consultation would add another dimension to such
aftercare programs. These consultation services could be obtained from the state
hospital, local mental health programs or psychiatrists in private practice.
It is recommended that:
EXISTING COMMUNITY MENTAL HEALTH RESOURCES ACTIVELY PARTICIPATE IN AFTERCARE PROGRM1S.
PRACTICING PHYSICIANS BE ENCOURAGED TO ASSUME RESPONSIBILITY IN LOCAL AFTERCARE SERVICES. Discharge plans should include contact with the family physician and sharing the plan of treatment with him.
LOCAL DISTRIBUTION OF DRUGS TO INDIGENT PATIENTS BE PROVIDED. Through a financial arrangement state and local authorities may share the cost of medication.
AFTERCARE SERVICES BY PUBLIC HEALTH NURSES BE REINFORCED THROUGH INTENSIFIED INSERVICE TRAINING, INCREASED MANPOWER AND AVAILABILITY OF MEDICAL AND PSYCHIATRIC SUPERVISION AND CONSULTATION.
PHYSICIAN-SOCIAL WORKER-NURSE TEAMS BE ORGANIZED IN COMMUNITIES WITH SPECIFIC RESPONSIBILITIES FOR SUPERVISING FOLLOW-UP TREATMENT AND PROVIDING CONSULTATION SERVICES TO PUBLIC HEALTH NURSES OR OTHER AGENCIES DEALING WITH NEWLY DISCHARGED PATIENTS. This team must maintain a close working relationship with the psychiatric hospital and coordinate the activities of those

- 40 -
agencies in the community whose programs are aimed toward rehabilitating individuals recovering from eluotional disorders. MILLEDGEVILLE STATE HOSPITAL ORGANIZE VISITING TF~S TO PROVIDE AFTERCARE SERVICES IN THE NEIGHBORING COUNTIES FOR DEMONSTRATION PURPOSES. THE ABOVE RESOURCES BE UTILIZED FOR SCREENING PATIENTS BEFORE THEIR RE-ADHISSION TO TUE STATE HOSPITAL. Counseling with the family and adjusting the medication dosage are sometimes enough to overcome a critical situation, which otherwise may result in re-admission for the patient.
2. Halfway Ho'!.ses and Foster Home Care
Many patients who are ready to leave mental hospitals benefit from living in a supportive environment until they find a job, earn the first pay check or overcome the initial anxiety of being "outside" and lion their own. 1I Halfway houses and foster home programs are invaluable means of support for the patient during this transition period from institution to the community. Coordinated activities in these and other aftercare programs will insure the success of the long and hard treatment pr6cess.
The Division of Vocational Rehabilitation has been active in program development and present plans call for establishing six to eight "rehabilitation
residences" around the state. Two such residences - .. one f6r men and ene for
women -- are operating in the Atlanta area. Basically this program is a pilot project and it is hoped that- the communities will assume greater responsibility in developing such facilities
The foster home program in Georgia has maoe very limited beginnings . Lack ~f cmnmunity'interest and a shortage Af supervisory personnel have been largely responsible for the slow development of this useful resource for indiviouals who need a different, more neutral environment. -than their home. Devel~nt of foster home programs for the emotionally disturbed will add a needed component t8 comprehensive community mental health programs.

- 41 -
3. Vocational Rehabilitation
Vocational rehabilitation services are playing an important role in the treatment and rehabilitation of the mentally ill. Many patients, after their prolonged ordeal with emotional problems, need to reorganize their activities and their general pattern of life. The sooner this reorganization takes place the better it is for the patient, as striving toward new goals and fresh hopes have significant therapeutic value.
The foundations of a good working relationship have been established between the Division of Mental Health and the Division of Vocational Rehabilitation. Within this progressive framework, the future role of vocational rehabilitation in Georgia will be one of expansion, increased involvement and better coverage.
It is recommended that: THE VOCATIONAL REHABILITATION PROGRAM AT MILLEDGEVILLE STATE
HOSPITAL BE ENLARGED IN SCOPE AND VOLUME. Shortages in personnel
and lack of funds must be met before the Hospital's Yarbrough Rehabilitation Center can be fully utilized. AN INDUSTRIAL THERAPY PROGRAM BE DEVELOPED IN CONJUNCTION WITH OTHER VOCATIONAL REHABILITATION ACTIVITIES. This would aid in helping the mentally ill to prepare for a more productive future life. THE "VOCATIONAL REHABILITATION SPECIALIST" JOIN THE MENTAL HEALTH TEAM IN COMMUNITY PROGRAMS, HELPING TO COORDINATE REHABILITATIVE SERVICES TO THE PATIENT. VOCATIONAL REHABILITATION SERVICES BE EXTENDED TO INCLUDE CHILDREN UNDER 16 YEARS OF AGE.
4. Employment Services and Job Opportunities
The stigma attached to mental illness has been a serious handicap to the individual who has been ill. In applying for jobs, inquiry into past or present mental illnesses still singles him out and often means the difference between

- 42 -
his being hired or not.
EMPLOYERS MUST BE EDUCATED ABOUT MENTAL HEALTH AND JOB OPPORTUNITIES FOR THE RECOVERED MENTALLY ILL SHOULD BE CREATED AND EMPLOYMENT OF SUCH PERSONS ENCOURAGED.
Close communications between treatment facilities and state employment agencies would increase the effectiveness of rehabilitation programs.
TRAINED PERSONNEL SHOULD BE HIRED BY EMPLOYMENT AGENCIES TO &\NDLE AND GUIDE EMOTIONALLY HANDICAPPED IlIDIVIDUALS.
For individuals who cannot function under ordinary working conditions, "sheltered workshops" provide opportunities for them to be useful and help further their rehabilitation. An individually tailored work program designed to gradually increase his job responsibilities is an effective method of preparing the individual for regular employment. Such a program in the state would have a significant impact upon rehabilitation of the handicapped.
5. Social Rehabilitation
One of the most common difficulties an emotionally disturbed individual faces is in the area of social interaction. Opportunities to relate to others in a relaxed atmosphere helps the person to regain his confidence in social situations. Social groups, such as "friendship houses" and "social clubs" have been organized to provide those who are in need of this therapeutic, rehabilitative atmosphere. This mutual understanding and acceptance helps to eliminate the usual feelings of uncertainty and sensitivity. ~fuen members of such groups are together, there is no need for them to pretend to be different. "Being themselves" without feeling anxious promotes "self acceptance," an important ingredient of emotional "wellness."
In some communities in Georgia such groups are quite active, and THE
DEVELOPMENT OF ADDITIONAL SOCIAL CLUBS SHOULD BE ENCOURAGED AND SUPPORTED.

- 43 Chapter II
MANPOWER
A comprehensive mental health program requires the services of many professions, each of which makes its own contribution to the total effort. However, delineating the responsibilities of the various disciplines and professions in terms of specific roles and functions is a highly complex task.
One of the major difficulties in pinpointing the responsibilities of each professional group stems from the broad range of emotional disorders, resulting from causes not yet fully understood. There is no definite boundary between health and pathology in the area of emotions. Social and environmental factors can influence the kinds of behavior thBt will be tolerated or rejected within a given culture or society. As a result, one may expect to find different behavioristic expectations from one ethnic group or special class to another.
If mental health were placed on one end of a continuum and mental illness on the other, one would find that in between lay various degrees or levels, not sharply divided. It is along this continuum that professions can find their specific roles and responsibilities, many of which should not be interpreted only in terms of activities directed toward pathology. Professions not primarily mental health disci,lines can discharge their responsibilities more efficiently and effectively by ,ursuing the goals of their own profession, concentrating on the health aspects of :hose with whom they work. In other words, they function at the health end of the )ntinuum by helping to maintain health and promote emotional growth.
Teachers, for example, are responsible for helping create a healthy atmosphere ~n in the classroom conducive to academic and social growth. Their knowledge of ~ntal health principles, grounded in the basic concepts of normal growth and develtpment, should be utilized with these purposes in mind. This frame of reference also ~ides them in handling the emotionally disturbed child by giving him every opportunity o utilize his positive personality assets. This way the teacher is able to help

- 44 -
the child without "treating" him, and often the opportunity to grow and to develop is what the child needs, not treatment.
The "firing line" professionals can make the majority of their contributions on those levels closer to the health end of the continuum. Intervention during crises situations, dealing with problems of everyday living and counseling are typical examples of problem solving activities as differentiated from treatment. In problem solving, attempts are made to find solutions to those problems which are usually related to realistic, acute, environmental situations without clearly defined, permanent psychological impairment. The quality of help an individual receives under these circumstances may determine whether or not the present problem will develop into a more serious one.
Physicians, nurses, social workers, counseling and guidance psychologists, visiting teachers, school counselors, parole officers and others can assume responsibility for promoting mental health and, in some cases, expand their services to work with people whose difficulties could be classed as "illness." However, more serious emotional problems require the specialized treatment skills of mental health professionals.
Professionals in the field of mental health -- psychiatrists, clinical psychologists, psychiatric social workers, psychiatric nurses and a recent addition to the group, clinical chaplains -- form the core of what is generally referred to as the nental health team. They have developed a concern for an increased knowledge of cental health and have broadened mental health programs in the United States. These )rofessions have changed in role and responsibility as knowledge in the field of nental health has expanded, and there will be further changes as comprehensive ~ommunity mental health programs develop. By virture of the variations in their ,rientation, each of the mental health profeosionals has particular roles and ~esponsibilities within the broad spectrum of emotional and mental disorders. While

- 45 -
there is sometimes a paralleling of function, each professional group has developed a general area of emphasis. Working as a team, they eerve to compliment one another and insure a more comprehensive approach to treatment.
Following is a brief description of each of the professions, its range of responsibility, training procedures and needs.
A. Mental Health Professions 1. Psychiatry
Psychiatry is a branch of medicine and it is the one which is concerned with the study, treatment and prevention of mQntal illness. Its functions include:
Prevention, diagnosis and treatment of mental disorders. Participation in the training of mental health professionals in related disciplines which deal with emotional illness. Research and experimentation to learn more about the causes, nature and treatment of mental illness. Preparation for a career in psychiatry requires broad training and experience in both the physical and emotional aspects of health. After graduation from a medical school and completion of an internship, a physician serves a three-year psychiatric residency in an approved institution. To be eligible for certification by the American Board of Psychiatry, the highest degree of professional certification in the profession, a psychiatrist must spend another two years in the full-time practice of psychiatry before taking the Board Examination. If he chooses to specialize in work with children, the psychiatrist must complete two more years of residency in an approved training center for child psychiatry, and to become eligible for Board c~rti.fication in child psychiatry, he must first be Board-certified in general psychiatry. There are additional training programs available to develop the psychiatrist's skills, including the various psychoanalytic schools providing special programs in this treatment technique. Once his lengthy training program is completed, the psychiatrist has a choice of areas in which to work. Partially dependent upon his own background and special

- 46 -
interests, he may choose any of the following: Private office and hospital practice. State and other public institutions. Community health programs. Administration. Teaching. Research.
As a physician, the psychiatrist is the only member of the mental health team with training in both the physical and emotional aspects of health. His medical orientation and knowledge of physical treatment techniques, such as drug therapy and electroshock, together with his skills in psychoth~Tapy, are essential to the ~am so that it can function within the entire range of emotional disorders .
.. psychiatry in georgia ... As of July, 1964, there were 143 practicing psychiatrists in Georgia, 47 of whom were Board certified. Of the total number, 84 were in private practice, 30 held salaried positions in governmental institutions and training centers, and 37 were involved in psychiatric training. There was some overlap among the categories. From a geographic standpoint, only 11 of Georgia's 159 counties have resident psychiatrists, and the majority of the private practitioners are in the Atlanta netropolitan area. Today there is one psychiatrist for every 29,543 persons in 3eorgia, as compared with a national average of one psychiatrist for every 11,356 )ersons. In order to meet the national level, Georgia would need a total of 372 )sychiatrists -- 229 more than are now in practice. Considering that the national lverage is short of meeting the need, the gap in psychiatric services available in ;eorgia is clearly visible. Availability of training centers is considered one of the most important factors .n developing psychiatric manpower. The present training programs, which have leveloped during the past 15 years, have already increased the number of psychiatrists racticing in Georgia. At present there are five institutions in the state offering approved residency

- 47 -
training programs in psychiatry. They are:
Medical College of Georgia, Augusta Emory University School of Medicine, Atlanta Lenwood Division, Veterans Amninistration Hospital, Augusta Milledgeville State Hospital, Milledgeville Georgia Mental Health Institute, Atlanta (after July, 1965)
Even with the increasing opportunities for psychiatric training in Georgia,
much remains to be done to supply and utilize the manpower in this profession. The
following measures are recommended:
PSYCHIATRIC RESIDENCY TRAINING PROGRAMS IN THE STATE SHOULD BE INCREASED AND EXPANDED.
PSYCHIATRY SHOULD BE EMPHASIZED AT THE UNDERGRADUATE LEVEL OF MEDICAL EDUCATION AND TEACHING METHODS SHOULD BE IMPROVED.
SALARIES AND FRINGE BENEFITS FOR PROFESSORS OF PSYCHIATRY SHOULD BE INCREASED TO HELP RECRUIT HIGHLY QUALIFIED PERSONNEL.
ADEQUATE SALARIES, IMPROVED LIVING CONDITIONS AND ENLARGED FRINGE BENEFITS SHOULD BE MADE AVAILABLE TO PSYCHIATRISTS EMPLOYED IN STATE HOSPITALS AND OTHER PUBLIC PROGRAMS.
EXTERNSHIPS SHOULD BE ESTABLISHED IN PRIVATE AND PUBLIC MENTAL HEALTH FACILITIES TO HELP IMPROVE THE PSYCHIATRIC ORIENTATION OF UNDERGRADUATE MEDICAL STUDENTS, AS WELL AS TO SERVE AS A RESIDENCY RECRUITMENT RESOURCE.
POSTGRADUATE TRAINING PROGP~MS IN PSYCHIATRY AND PSYOiOANALYSIS SHOULD BE DEVELOPED. (A BRANCH OF COLUMBIA PSYCHOANALYTIC INSTITUTE HAS BEEN ESTABLISHED IN ATLANTA.)
DURING THEIR RESIDENCY, PSYCHIATRISTS SHOULD BE INVOLVED IN COMMUNITY AND OTHER MENTAL HEALTH PROGRAMS. BY PARTICIPATING IN PROGRAM DEVELOPMENT DURING TRAININ~PSYCHIATRISTS MIGHT BE ENCOURAGED TO PURSUE CAREERS IN THESE AREAS.
PSYCHIATRISTS IN PRIVATE PRACTICE SHOULD TAKE AN ACTIVE PART IN COMMUNITY HEALTH PROGRANS, BOTH AT THE PLANNING AND OPERATIONAL LEVELS.
ACTIVE RECRUITMENT PROGRAMS SHOULD BE UNDERTAKEN BY COMMUNITIES AND PROFESSIONAL ORGANIZATIONS, USING ALL AVAILABLE MEDIA.
2. Clinical Psychology
Psychology is both a science and a profession. As a science, it formulates
theories, develops a systematized body of knowledge and engages in research concern-
ing human development, learning, functioning and personality. As a profession, it

- 48 -
applies such theories and research findings in the practical affairs of child rearing,
education, interpersonal relationships, personality assessment and treatment of
emotional disorders.
Clinical psychology has developed six main areas of function. These are:
Psycholgical evaluation and diagnosis, including the administration and interpretation of standardized psychological tests for measuring intellectual level, formulating personality dynamics, ascertaining psychological functioning and arriving at a diagnostic impression.
Treatment, in which modification of behavior is accomplished by means of psychotherapy. Psychologists practice different types of psychotherapy such as individual, group or family therapy.
Training and education, which includes not only academic and inservice training within the discipline of psychology, but other social science and mental health professions as well. In education, psychologists have disseminated psychological concepts and mental health knowledge and, more recently, the new technique of programmed learning has been developed by psychologists.
Research in which the psychologists functions as a social scientist there is strong emphasis placed on research in the training and functioning of psychologists.
Consultation is provided to other mental health personn~l, related professiona~s, community agencles, schools and industry.
A&~inistration of mental health programs and facilities is among the functions of psychologists.
Clinical psychologists are found in many settings; private practice, mental
health facilities, universities, schools, industry and others.
To enter the practice of clinical psychology, an individual begins with a
bachelor's degree in the liberal arts, usually with a major in psychology. The next
step is a master's degree followed by further university work culminating in a Ph. D.
in clinical psychology. Included in this training is one year's internship at a mental
health facility affording the trainee experience as a member of a mental health team.
The American Psychological Association, through its Education and Training Board, is
responsible for the formal accreditation of training and internship programs in
clinical psychology.

- 49 -
The profession of psychology has taken a number of steps toward upgrading standards and safeguarding the public interest in psychological services. Licensure of psychologists is one such step. Georgia was one of the first states to enact a law requiring a license to enter the private practice of psychology. The Georgia Board of Examiners in Psychology, consisting of psychologists appointed by the Governor, grants licenses to persons holding a doctor's degree in psychology who have passed oral and written examinations prepared by the Board. Forty-one states now have such examining boards. In the other nine states, standards are set and maintained by the American Psychological Association.
As an advanced level of professional standards, the American Board of Examiners in Professional Psychology was established by the American Psychological Association. It identifies those psychologists who are judged by the Board, after examination, to have qualified themselves as advanced specialists in either clinical, counseling or industrial psychology. A psychologist must have five years of postdoctoral experience before he is eligible to take his Board examinations.
There are several levels of psychology-trained personnel with less than full training, who function under the supervision and direction of fully trained clinical psychologists. A pGychology technician, a person with a bachelor's degree with a major in psychology, performs certain routine and time-consuming tasks that are part of the psychologist's job but which can be delegated to personnel with less training. On the staff of many facilities are persons trained at the master's level or above who are classed as psychology assistants. Their responsibilities are commensurate with their level of training. a. Psychology Manpower
There are 25,000 psychologists who are members of the American Psychological ~ssociation and, in addi,tion, there are probably 5,000 psychologists who are not nembers. This estimate of 30,000 includes psychologists in all specialties, from

- 50 -
clinical psychologists to experimental psychologists. It is estimated that there are about 12,000 clinical psychologists in the United States, including those in universities, training programs, public agencies and private practice. Georgia has approximately 200 psychologists in all specialties, of which about 100 are clinical psychologists. This places Georgia at a point well below the national average.
In terms of activity, about 50 of Georgia's psychologists are in full or part time private practice of clinical psychology. Most of these are in university or agency settings. The majority of the state's psychologists are concentrated in the Atlanta metropolitan area and a few of the larger cities. They are very scarce or non-existent in most areas of the state. b. Educational Pacilities
When the lack of educational facilities is considered, it is not surprising that Georgia has comparatively few psychologists. The state has been especially late in initiating programs in clinical psychology. The only existing program was established in 1960 at the University of Georgia, where 34 graduate students are now enrolled in the doctoral program in clinical psychology. It is estimated that 100 clinical psychologists will be trained at the University within the next 10 years.
Emory University is beginning training in clinical psychology at the doctoral level in the fall of 1965. They will train from 75 to 100 clinical psychologists in the next 10 years.
Georgia State College has received approval to begin a master's level program in clinical psychology in the fall of 1965. It will graduate approximately 150 Masters in the next 10 years. The department hopes to move toward the Ph. D. level aE soon as feasible and a possible date for this is a beginning program by 1970.
Atlanta University offers training in counselling psychology at the masters and doctoral levels. They project by 1975, they will train 425 counselling psychologists at the masters level and 30 at the doctoral level. Georgia Institute of Technology offers a master's degree in psychology with experimental and industrial

- 51 -
emphasis. They have plans for offering a Ph. D. degree in these fields in the near future.
The most critical problem for mental health in Georgia is obtaining and keeping staff. We must develop new training facilities, since there is a tendency for people to accept employment in the region where they are trained.
However, with the present shortage of clinical psychologists and with the rapidly increasing national population, it is not probable that enough psychologists will be trained within the foreseeable future. Therefore, Georgia must effectively complete with other areas of the nation.for the short supply of trained psychologists With the demand great and the supply short, psychologists and otherprofessionals are highly mobile. It is estimated that 50 percent of the nation's psychologists move every two years.
We must pay salaries sufficient to keep personnel and to attrach others. These salaries must not only be equal to the average of those in other states but must be sufficient to draw professionals to rural areas of the state. To attract psychologis to less populated areas requires supplementation of Merit System salaries by local funds. In addition to good beginning salary levels, the Merit System scales must provide sufficient increases to keep senior-level professionals, otherwise continual turnover will hamper program development. This is particularly important in communit mental health programs where considerable time will be invested in developing working relationships in the community. c. It is recommended that:
LICENSURE SHOULD BE REQUIRED OF PSYCHOLOGISTS WORKING IN PUBLIC AGENCIES WHICH ARE NOW EXEMPT FROM THE LICENSING LAW. AT LEAST ONE PSYCHOLOGIST IN EACH FACILITY SHOULD BE TRAINED AT THE PH. D. LEVEL, WITH A DEGREE FROM AN APPROVED SCHOOL AND HOLDING A GEORGIA LICENSE. PRIVATE PRACTITIONERS SHOULD BE ENCOURAGED TO MAINTAIN RELATIONSHIPS WITH PATIENTS HOSPITALIZED OR TREATED IN PUBLIC FACILITIES.

- 52 -

PRIVATE PRACTICE OF CLINICAL PSYCHOLOGY, TO BEST BE UTILIZED AS A PUBLIC MENTAL HEALTH RESOURCE, SHOULD BE INCLUDED IN PREPAID HEALTH INSURANCE TO PROVIDE MENTAL HEALTH CARE.

EVERY ENCOURAGE~mNT SHOULD BE GIVEN TO UNIVERSITITES STARTING PROGRAMS IN CLINICAL AND COUNSELING PSYCHOLOGY. SUPPORT SHOULD BE GIVEN TO GEORGIA STATE COLLEGE IN INITIATING A DOCTORAL PROGRAM AND ATLANTA UNIVERSITY SHOULD BE ENCOURAGED TO DEVELOP A DOCTORAL PROGRAM IN CLINICAL PSYCHOLOGY IN ADDITION TO THE ONE THEY ARE NOW OFFERING IN COUNSELING PSYCHOLOGY.

STATE MERIT SYSTEM SALARIES FOR PSYCHOLOGISTS SHOULD BE INCREASED TO ENABLE GEORGIA TO COMPETE FOR PSYCHOLOGICAL TALENT .AND LOCAL SUPPORT SHOULD BE ADDED TO ATTRACT PROFESSIONALS TO REMOTE AREAS.

3. Socia 1 Work

Social work, concerned with man's interaction with society, supports measures

which will strengthen the individual's capacity for self-realization and, at the

same time, encourages changes to strengthen society itself. As a profession, it

traditionally relates itself to the community and the environmental aspects of man's

functioning.

The functions of the professional social worker, whether engaged in casework,

;roup work, community organization or administration and research are basically the

arne. They are:

To operate programs effecting environmental change such as financial assistance, employment and housing to dependent persons.

To assist individuals and families with problems which have resulted in social failure.

To become involved in social action programs.

To serve in a consultant capacity to communities on mental health needs of the population.

Professional status in social work is based on preparation at the master's

~gree level. However, the greatest number of persons employed in social service

)sitions hold the bachelor's degree and render "preprofessional" services.

Social work is not subject to licensure or registration, although exploratory

tempts have been made in various states to establish such a legal indication of

(

- 53 -
competence. There is a recognition of professional standards by the National Association of Social Workers and its associate organization, the Academy of Certified Social Workers. To be eligible for membership in the Academy, a candidate must have graduated from a school of social work and have completed two years of supervised experience in a single agency.
Social workers are concerned with mental illness at the prevention, treatment and rehabilitation levels. In prevention, the skills of social group work in recreational, residential and community centers maintain mental health and promote personal growth. Social casework, on the other hand, provides help to troubled persons who come to social agencies. While the social worker makea his greatest contribution to primary prevention within the network of private social agencies, the profession is also significantly represented in public facilities.
In treating mental illness, the social worker is a member of the mental health team and his skills, such as making social evaluations, are essential for complete diagnosis. Other specific areas in which the competencies of the social worker can be utilized in mental hospitals or psychiatric clinics include:
Collection of preadmission data. Collection of social-history data. Casework and/or group work with patients and their families. Participation in pre-release planning for hospitalized patients. Participation in convalescent care. Social work, oriented toward providing resources, is well-prepared to participate in the rehabilitative phase of mental illness. The psychiatric social workers knowledge of available resources permits him to match the patient's rehabilitative needs with the proper service or services. He is similarly well-equipped to provide supportive services to patients during convalescence, and to their families. a. Providing Personnel in Social Work A 1963 study by Dr. Eileen Blackey on graduate education in Georgia has some significant statistic on social work.* At the time of the report there were 240
*"Report on Study to Determine Whether a Graduate School Should Be Established in the University System of Georgia" (Unpublished report, conducted by Dr. Eileen Blacke) 1963.)

- 54 -
social workers in Georgia -. a ratio of 6.1 per 1,000 population as compared with the national rate of 12.4. Membership in the National Association of Social Workers, another index for determining the number of professional social workers, reported a Georgia membership of 363 in 1964, a total which includes people who are retired and not employed. Dr. Blackey's study further shows that a minimum of 600 to 700 professional social workers will be needed in Georgia during the next five years to meet expanding programs. It is estimated that public health alone will add approximately 107 new positions within the next five years to meet expanding program needs.
Graduate schools of social work in Georgia will supply some of the manpower. At present there are two such schools in the state-one at Atlanta University and one at the University of Georgia. The former, a long-established and nationally recognized training facility, graduates approximately 35 persons a year, with an anticipated increase to 50 by 1966 and to 70 by 1969. The University of Georgia, which has a new social work school, enrolled its first class of 23 in the fall of 1964. Anticipating 30 students a year by 1967, the University of Georgia is presently limited to the specialties of casework and group work with plans for expanding into community organization.
Although Georgia can benefit to some extent from the 2,500 social workers being graduated yearly from nearly 60 graduate schools scattered throughout the country, the best recruiting possibilities are in neighboring states. The University of Tennessee and Florida State University continue to be major centers for graduate training in social work.
Field placement outside the university setting is an important phase of the graduate educational program. Unless agencies develop their social work programs to meet necessary standards, universities will be limited in their expansion of programs. Plans are underway to place students at Gracewood State School and Hospital, the Georgia Mental Health Institute, the Georgia Retardation Center (when

- 55 -
completed), and local mental health programs, as well as private agencies.
To help fill the manpower shortage it is important to interest young people in
pursuing careers in social work, but it is equally important to nttract experienced
personnel from other states. Salary scales in Georgia are not yet competitive
enough to make this possible. State Merit System salaries for master's degree
graduates range from $482 a month for a recruit to $765 for the highest position.
While this range approaches the national average of budgeted positions, the acute
shortage of trained social workers enables professionals to start at the higher
salaried positions rather than the beginning rates. The noncompetitiveness of
Georgia's salaries is emphasized when compared with those of the Federal government
~hich range from $600 8 month up to $1,180 as a starting salary for top level
3dministrative positions.
). It is recommended that:
HIGH PRIORITY MUST BE GIVEN TO EXPANDING THE PRESENT TRAINING CAPACITY OF GRADUATE SCHOOLS OF SOCIAL WORK IN THE STATE. SUPPORT FOR THIS OBJECTIVE MUST COME FROM THE GEORGIA CHAPTERS OF THE NATIONAL ASSOCIATION OF SOCIAL WORK, FROM THE GRADUATE SCHOOLS OF GEORGIA AND FROM PRIVATE AGENCIES EMPLOYING SOCIAL WORKERS.
GREATER ATTENTION ~roST BE GIVEN BY PROFESSIONAL SOCIAL WORKERS TO THE DEVELOPMENT AND UTILIZATION OF UNDERGRADUATE-LEVEL SOCIAL WORK ASSISTANTS. SUPERVISION AND INSERVICE TRAINING PROGRAMS SHOULD BE USED TO INCREASE THE RANGE OF SKILLS OF THE NON-PROFESSIONALS.
PROFESSIONAL SOCIAL WORKERS NEED TO INCREASE THEIR USE OF CONSULTATION AS A MEANS OF EXTENDING THE SERVICES OF ortHER RELATED PROFESSIONALS. JUVENILE COURT WORKERS, PUBLIC HEALTH NURSES~ LAW ENFORCEMENT OFFICERS, TEACHERS AND OTHERS MAY BE ABLE TO FILL URGENT NEEDS WHEN THEY USE SOCIAL WORKERS AS CONSULTANTS.
THERE MUST BE PROVISION FOR PERIODIC REVIEW OF PERSONNEL POLICIES IN BOTH PUBLIC AND PRIVATE SOCIAL AGENCIES SO THAT GEORGIA DOES NOT LOSE ITS SOCIAL WORKERS TO OTHER STATES. FRINGE BENEFITS, OPPORTUNITIES FOR PROMOTING STIMULATING PROGRAMS AS WELL AS SALARIES MUST BE COMPETITIVE WITH THE NATIONAL SITUATION.
Nursing
Psychiatric nursing is a specialty in nursing, which prepares its professionals
) be patient-centered, therepeutically oriented members of the mental health team.

- 56 -
~~~' The functions of the professional nurse, whether in hospital or community services, are: To assist individuals and families with health care. To use a broad approach in assessing the clinical process. To intervene therepeutically and to promote the potential for growth. To teach and supervise other nursing personnel. To collaborate with other disciplines in total patient care. Nurses are trained at several levels, primarily divided into two areas of competency - technical and professional. A technical nurse can be trained in a twOyear nursing program in community colleges, while a professional nurse has a fouryear educational program in a liberal arts college. Between these two is the hospital-school program of three years. Psychiatric nursing is a part of the curriculum of all three basic programs, however specialization for psychiatric mental health nursing is available only at the graduate level. There is a difference in the academic preparation of the professional psychiatric nurse and the nurse who may be working in a psychiatric service. In addition to nurses who have had academic or hospital-school training, there is the licensed practical nurse who has had one year of hospital or vocational school training and is prepared to function at a limited level of respolLsibility. Registered nurses are licensed by the Board of Examiners of Nurses for Georgia; and to qualify for licensure, a nurse must be a graduate of a state-approved school of nursing. The National League for Nursing, through its accrediting service, has sought to improve the quality of education both in the hospital and collegiate schools of nursing. In Georgia only 10 of the 19 state-approved schools of nursing meet the criteria of the National Association. Licensure is provided for nurses at less than professional levels in Georgia, which allows a permissive--but not mandatory-examining board for licensing practical nurses. a. Nursing and Mental Health The public health nurse has opportunities for promoting mental health in her

- 57 -
~ teaching and counseling role in the various service programs. Both the public health nurse and other nursing personne.l can help prevent emotional problems by intervention in patient crises and stress periods. Knowledgeable use of this opportunity enables the nurse to utilize the patient's needs for assistance at critical stages. In the area of prevention, the public health nurse is in an opportune position since she has access to the home. This is important in the case of people who either do not know from where or whom to seek help or are too self-conscious to ask for it. On referral from other institutions in the community, such as the school, the public health nurse can be an invaluable adjunct in taking mental health assistance to those who are in need of it. Treatment of mental and emotional disorders are the province of psychiatric nurses. They provide counseling, supportive services to the patient and participate in using the environment for therapeutic experiences for the patient. Nurses in the Alcholic Rehabilitation Services at the Georgian Clinic function as team members in the Clinic's therapeutic community. In the regional hospitals, recognition should be given to the nurses' role in treatment services both in the individual relationship and the patient group service. Personnel shortages have often forced nurses to assume administrative responsibilities which dilute the responsibilities of the profession and remove the best-qualified nurses from the patient-care function. Treatment programs suffer when this occurs. Nurses have an important function in rehabilitation. In the Milledgeville 3tate Hospital outpatient clinic, a public health nurse administers the clinic, with 1irection from the psychiatrist. The clinic provides service to 4,500 patients furloughed from the institution. Major emphasis is focused on liaison with local )ublic health nurses who offer supportive services to the hospital patients who are :eturned to their own communities.

- 58 -
b. Nursing Manpower Nursing shortages, particularly at the professional level, exist allover the
nation, and Georgia is no exception. In 1964, the state had a total of 7,437 active registered nurses. The recommended ratio is 500 active nurses per 100,000 population. Present ratio in Georgia is 194 per 100,000. Georgia will need a total of 10,908 nurses by 1975, based on population projections. The state will also need to increase its supply of licensed practical nurses.
In planning for mental health programs, it is important to remember that nursing personnel to staff these facilities will have to come from the already short supply of nurses. A critical analysis should be made of the role of nursing at all levels, with emphasis on the work that can be done by licensed practical nurses and auxiliary workers, such as nursing aides and ward clerks.
Emory University, the only Georgia institution offering graduate work in nursing, will offer a master's degree in psychiatric nursing beginning in the fall of 1965. This program will graduate five psychiatric nurses a year -- and at the present time there are only 13 qualified psychiatric nurses in the state. Every effort should be made to recruit these professionals for leadership positions in Georgia's mental health program.
There are three institutions in the state preparing nurses with four-year baccalaureate degrees, and two of these are nationally accredited. There are 14 diploma schools, conducted under the auspices of hospitals and there are two of the two-year community college programs. During the past five years, 2,519 students have been graduated from the diploma and four-year college programs. Considering the number of young women who leave nursing after a few years of active practice, the annual output of 595 diploma nurses, 31 associate degree nurses and 78 collegiatedegree nurses will not be sufficient to staff expanded mental health services.

- 59 -
c. It is recommended that:
A PERMANENT PSYCHIATRIC NURSING ADVISORY COMMITTEE SHOULD BE ESTABLISHED TO ASSIST THE DIVISION OF MENTAL HEALTH IN PLANNING FOR NURSING NEEDS IN MENTAL HEALTH SERVICES.
NURSES SHOULD BE CONSULTED IN EARLY PLANNING STAGES OF THE CONSTRUCTION OF REGIONAL HOSPITAL FACILITIES IN ORDER THAT PATIENT SAFETY AND UTILIZATION OF NURSING PERSONNEL CAN BE MAXIMIZED.
THE STATE BOARD OF EXAMINERS OF NURSES SHOULD CONSULT WITH PSYCHIATRIC NURSES IN DETERMINING CRITERIA FOR EVALUATION OF THE MENTAL HEALTH CONTENT OF EDUCATIONAL PROGRAMS FOR NURSES.
EACH SCHOOL OF NURSING SHOULD HAVE AT LEAST ONE QUALIFIED INSTRUCTOR IN THE CLINICAL AREA OF PSYCHIATRIC NURSING.
SCHOOLS OF NURSING SHOULD FORM A SUB-COMMITTEE FOR ON-GOING EVALUATION OF THE PSYCHIATRIC CONTENT OF THEIR CURRICULA.
GRADUATE PROGRAMS IN PSYCHIATRIC NURSING SHOULD BE ENCOURAGED.
NURSING SERVICE FOR THE PATIENT SHOULD BE COORDINATED BY ASSURING CONTINUI'IY WHEN A PATIENT IS MOVED FROM ONE SERVICE TO ANOTHER. NURSES WITH COORDINATING RESPONSIBILITY SHOULD BE STRATEGICALLY PLACED IN THE VARIOUS PARTS OF THE SERVICES.
CONSULTATION FROM PSYCHIATRIC NURSES SHOULD BE AVAILABLE FOR ALL NURSES WORKING IN MENTAL HEALTH SERVICES.
THE INCREASED WORKLOAD OF PUBLIC HEALTH NURSES IN AFTERCARE SERVICE IN THE COMMUNITY REQUIRES THE EMPLOYMENT OF ADDITIONAL PUBLIC HEALTH NURSES.
INTENSIVE INSERVICE TRAINING PROGRAMS SHOULD BE PROVIDED FOR PUBLIC HEALTH NURSING SUPERVISORS TO INCREASE THEIR MENTAL HEALTH SKILLS.
PILOT PROJECTS SHOULD BE ENCOURAGED TO DETERMINE THE PATIENT'S NEEDS AND THE EFF~CTIVENESS OF NURSING'S CONTRIBUTION IN MEETING THOSE NEEDS IN ALL SERVICES PROMOTING MENTAL HEALTH.
WORKING HOURS AND SALARIES SHOULD BE MADE EQUITABLE TO ATTRACT QUALIFIED NURSING PERSONNEL AT ALL LEVELS.
VIGOROUS RECRUITMENT MUST BE INSTITUTED FOR QUALIFIED PERSONNEL TO FILL GAPS IN NURSING SERVICES IN EXISTING PSYCHIATRIC SERVICES.
THE EMPLOYMENT OF PART-TIME NURSES SHOULD BE ENCOURAGED.
5. Clinical Chaplaincy
Clinical chaplaincy is a specialty within ministry. Clergymen are given special
training to prepare them for work with the mentally ill, especially in institutioaal

- 60 -
settings. This is a relatively new movement which began in 1925 when a clergyman was first hired as a full-time chaplain in a mental hospital. There are now 450 members of the National Association of Mental Hospital Chaplains.
The functions of clinical chaplains in mental health facilities are: To conduct pastoral interviews with each newly admitted patient. To lend supportive pastoral interest to the patient. To participate as a member of the treatment team. To serve as liaison be~een the patient and his local clergyman and/or the treatment team and the local minister. To participate in the follow-ups of discharged patients through direct counseling and development of community pastoral resources.
Any clergyman who has been graduated from a four-year college and has completed three years of theological training culm~nating in a Bachelor of Divinity degree can qualify for clinical training after he has served three years in active ministry. Clinical training consists of one year's internship in pastoral care in an institutior such as a general hospital, a mental health center, a mental hospital or a clinic for alcoholism.
Once a clergyman has qualified as a clinical chaplain, he may take additional training and become a clinical chaplain supervisor. In this program he spends from six months to two years as a resident in clinical pastoral care, pastoral counseling and clinical pastoral supervision. After completing the residency requirement and passing an oral and written examination, the applicant has an indeterminant probationary period before receiving accreditation as a clinical chaplain supervisor is given by a national group, qualifying the clergyman to supervise and train clinical chaplains.
Working in community mental health programs, clinical chaplains have a decided :ontribution in the prevention of mental illness. There are many persons in the :ommunity who, for various reasons, need to be sustained on whatever marginal level ,f community life is possible for them. This is particularly true of persons with :hronic illnesses, many of whom will always need dependable support. The clergyman ~n his normal role, assumes some of these responsibilities as part of his everyday

- 61 -
work. Clinical chaplains, with their additional training, may be key persons in the mental health team serving as sustainers for the chronically ill and as consultants to the rest of the staff in developing new concepts of sustaining care. In conjunction with other ministers in the community, they can develop methods for offering sustained services to the mentally ill, thus enabling them to maintain a marginal adjustment in the community.
In the area of treatment, a professionally mature, well-trained clinical chaplain functions as a part of an interprofessional team. He is the member who is expected to raise questions on the ultimate meaning and value of a particular course of action in its effect on the patient and his family, both morally and ethically.
This distinctive function of the clinical chaplain is particularly pertinent, considering the presQnt level of development in the behavioral sciences and the whole mental health movement. Questions concerning the relationship between psychotherapy and value systems, the basic nature of mental illness -- whether it is rooted in a medical problem or a problem of human existence -- and positive approaches to mental health are foremost in the minds of mental health authorities today. The theologically and clinically trained pastor with his unique perspective on these problems can contribute to mental health programs. a. Areas of Service
The church counseling center, largely sponsored by Protestant demoninations in urban areas, is a new mental health resource developed during the past decade. The Georgia Association for Pastoral Care, under its pastoral counseling and referral service, op~ned three such centers in the Atlanta area in 1964 -- the first of their kind in the state. During the first six months of operation, a total of 120 people were seen in these three centers. Only those who had been referred by local ministers or churches in the community are accepted. These counseling centers also

- 62 -
participate in clinical training programs.
In mental hospitals, the clinical chaplain fulfills three distrinct roles
simultaneously. He is a pastor in the traditional sense, a mental health clinician
and a r~ve of the patient's community pastor and church. In the hospital,
the clinical chaplain performs five different functions. They are:
(1) .Providing pastoral care to patients, such as conducting worship services, burials and religious education. In these duties the clinical chaplain transcends denominational lines.
(2) Interpreting religious ideation and behavior of patients particularly when patients communicate their illness by religious thought patterns or activities. He is trained to clarify the type of psychological disturbance a patient is experiencing from observing the type of religious disturbance the patient is showing. He also interprets colloquial religious expressions which, when not understood may appear devious and even bizarre.
(3) Actively participating in the hospital's treatment program as a member of the treatment team.
(4) Participating in the training program for other mental health professionals and for clergYmen both in the hospital and in the community. Community education is an important function of the clinical chaplain for, by working with local pastors, he is able to reach thousands of people.
(5) Conducting research in religious as well as mental health problems.
b. Personnel in Georgia
There are nine institutions in Georgia where clergymen may receive part or
full-time clinical pastoral training: Emory University Hospital, Fulton County
Child Guidance Clinic, Georgia Baptist Hospital, The Georgian Clinic, Georgia Train-
ing School for Girls and Milledgeville State Hospital. During 1964, a total of 472
ministers, theological students, chaplain interns and pastors participated in these
programs.
Twenty clinical chaplains completed the~r training in Georgia in 1964 and it
is projected that the present training institutions will prepare 300 clinical
chaplains within the next 10 years. Most of the clergymen receiving clinical

- 63 -
training will return to their duties as parish ministers and will be classed as "tlliinically trained clergymen" in contrast to "clinically trained chaplains" who work in mental health programs.
The desirable scope of clinical training for clergymen in Georgia has not yet been determined and there is doubt as to whether it would be feasible to give some clinical training to all clergymen. It does appear that, for the present, all regional hospitals and comprehensive community health centers in Georgia should engage in clinical pastoral training.
The state Merit System provides a starting salary of approximately $8,500 a year for clinically trained chaplains. This salary level is about average for the
nation. c. It is recommended that:
CHURCH COUNSELING CENTERS SHOULD BE SUPPORTED BY THE CHURCH AND THE COMMUNITY AS AN IMPORTANT MENTAL HEALTH RESOURCE. THE GEORGIA ASSOCIATION FOR PASTORAL CARE SHOULD BE ENCOURAGED TO DEVELOP MORE COUNSELING CENTERS THROUGHOUT THE STATE. CO~J1'il.jNITY MENTAL HEALTH PROGRAMS SHOULD EXPLORE THE POSSIBILITY OF USING CLINICALLY TRAINED CHAPLAINS OR CONSULTANTS ON A PART-TIME BASIS WHERE PROGRAMS DO NOT WARRENT THE USE OF FULL-TIME CHAPLAINS.
SINCE EACH COMMUNITY HAS A READY SUPPLY OF POTENTIAL CLINICAL CLERGYMEN IN THE LOCAL PASTORS, IN THOSE CASES WHERE OTHER MENTAL HEAL'llI PROFESSIONALS ARE IN SHORT SUPPLY CLINICALLY TRAINED CLERGYMEN CAN BE USED TO RELIEVE THE COUNSELING LOAD.
6. Adjunctive Therapies Adjunctive therapies have a recognized place in any program ~f care for the
mentally ill in residential facilities. Although their place and value has been demonstrated in mental hospitals, their use and development in comprehensive community health programs remains an open question. Some adjunctive therapists f~el they have addefinite contributi"-n to make in this area, such as recreation therapists, who indicate that a combination of hospital recreation therapy and community recreation programs would be highly desirable for community mental health

- 64 -
programs. Different background and training programs characterize the several adjunctive
therapies. A brief description of each of the major fields follows: a. Music Therapy
Music therapy is the scientific application of the art of music to accomplish mental health therapeutic aims. The use of music by a skilled therapist can influence behavior and change. Through these changes, it is hoped that a patient will experience a greater understanding of himself and the world about him, reBulting in a more effective adjustment to society and better mental health.
A registered music therapist holds a degree in music therapy with six months
,
of clinical intern training, and is registered with the National Association for Music Therapy. A senior registered music therapist po sse sses the basic qualifications plus two years of experience in the field and/or a master's degree in music therapy.
There are about 15 universit~es in the nation offering degrees in music therapy, slightly more than half of which have graduate programs in the field. The Woman's College of Georgia is planning an undergraduate degree in music therapy, and it will be the first Georgia institution to have this program. It is recommended that:
MORE SCHOOLS IN GEORGIA OFFER THIS DEGREE. Milledgeville State Hospital is one of 15 hospitals in the United States to have a clinical internship program in music therapy, which consists of a six-month clinical training period.
Of the approximately 500 registered music therapists in the United States, 12 are in Georgia. Milledgeville State Hospital has eight registered music therapists on the staff, as well as six aides and one intern. It is believed that the hospital's music therapy department is the largest in'tbe country, even though its staff is not nearly sufficient to maintain an adequate program in such a large hospital. A staff of twice the present size is needed for the hospital, according

- 65 -
to present estimates. b. Occupational Therapy
Occupational therapy consists of individual or group participation in restorativ, activities. The therapy may be needed because the patient has been disabled by an accident or disease; is physically or mentally ill; is handicapped by a birth defect or by the infirmities of age.
Treatment may include the use of creative and manual arts; recreational, educational and social activities; prevocational testing and training, or training in everyday activities such as personal care and homemaking. The objective of occupational therapy is to make the patient as independent and well-adjusted as ~' possible through improving or restoring emotional, physical or vocational capacities and promoting and sustaining social and psychological functions.
To prepare for this work, an occupational therapist earns a bachelor of science in occupational therapy, with nine months of clinical intern training. Qualified therapists are registered by the American Occupational Therapy Association, and there are nearly 7,000 registered occupational therapists in the country. Approximately 30 colleges and universities offer training in occupational therapy and they are accredited by the Council on Medical Education and Hospitals of the American Medical Association. However, there are no schools of occupational therapy in Georgi Emory University has considered incorporating occupational therapy into its curriculv It is recommended that:
BOTH EMORY UNIVERSITY A~"D THE UN:r.VERSIT"i OF GEORGIA BE ENCOURAGED TO START PROGRAMS IN OCCUPATIONAL THERAI''1. In Georgia there are now about 60 occupational therapists, only half of whom are employed on either a full or part-time basis. Milledgeville State hospital has an occupational therapy director, one registered occupational therapist and 52 occupatic therapy aides.

- 66 -
c. Recreation Therapy Recreation seeks to satisfy man's need to find experiences that afford release
from tension and strain, providing him with refreshment and fulfillment. Recreation therapy is a specialty within the broader field of recreation which provides the patient with activities that are group-oriented and help satisfy the need to belong, to achieve and to be recognized.
Recreation therapists hold a bachelor's degree with a major in recreation and are registered by the Council for the Advancement of Hospital Recreation. Two schools in Georgia offer degrees in recreation: Georgia Southern College has a bachelor of science in recreation including a three-month internship, and the University of Georgia gives a bachelor of science in education with a major in recreation.
Some schools, such as Florida State University and the University of North Carolina, give degrees in recreation therapy but there is no institution in Georgia offering the specialized degree. It is recommended that:
THE n\'O OEORGIA SCHOOLS NOW GIVING DEGREES IN RECREATION MOVE TOWARD
EXPANDING THEIR PROGRAMS IN INCLUDE RECREATION THERAPY. Emory University and the Medical College of Georgia could consider development of a recreation therapy program in conjunction with their departments of psychiatry, and there should be at least one graduate program in recreational therapy in the state. Training programs in Georgia would probably increase the number of recreation therapists in the state -- at present there are six, three of whom are at Milledgeville State Hospital. Community recreation programs are closely related to recreation therapy, and today Georgia has full-time recreation directors and staffs in 70 communities. The Georgia Recreation Commission, an adVisory agency, offers consultation to community recreation programs and could develop some guidelines for the use of existing community recreation programs as mental health resources.

- 67 -
B. Related Prof~ssions Most people who want professional help with personal problems do not seek out
mental health professionals but appeal to the related professions of ministry and medicine, according to a recent survey. According to the report, 42 percent of the people went to their clergyman and 29 percent to their physician. Less than 30 percent sought aid from the entire range of mental health resources -- private practice psychiatrists, psychologists and marriage counselors, mental health clinics, hospitals and agencies.*
On the basis of this eVidence, it is obvious that related professions have been and will continue to be in "firing line" positions. One reason these professions remain in the front line of mental health defense is that the minister, the physician, the classroom teacher, the agency social worker, the visiting teacher and the school counselor have an ongoing relationship with persons under their care. The continuous giving of care in these professions is essential in the process of development, maintenance and support of people in their functioning in the family and community. When functioning falters and when problems develop, it is only natural for the majority of persons to go first to the professionals they know well. Mental health professions have an important role to fulfill in understanding more fully the mental health resources in the related professions, developing more consultative services to them, offering them workshops in mental health practices and making it easier for them to refer the more difficult cases without feeling they are giving up care of the person who sought their aid.
Since medicine and ministry are the professions preferred by people in need of help, they are of major interest in their potential role in increased mental health services. 1. Parish Ministers
In Georgia, as in many parts of the nation, there are two broad categories of clergymen: those who have had formal theological education and those who, without *Gurin, G.} Veroff, J., and Feld, Shelia: American's View Their Mental Health
Basic BOOKS, 1960.

- 68 -
meeting Bny specific educational requirements, have become accepted leaders by their congregations. Denominational religious leaders should be encouraged to work toward raising educational standards of the ordained ministry, but in the meanttme, the ministers and religious leaders who have not been graduated from theological schools must be enlisted in community mental health servics. They should have the opportunity to attend workshops and seminars to develop their unde=standing of the problems of mental heslth.
The clergyman with the custo~ary liberal arts and theological ed~cation, who has earned a coll F.g= dcgr..~e and had three or more years of theo,"ogical education, is able to more fully show a co-worker relationship with the professionally trained mental health worker in dealing with mental health problems of parishioners.
There is probably no better ~ducational rostrum than the pulpit. A clergyman with considerable edu-::ational ba~kground may disseminate many of the mental health concepts urged by pr.0f~Gsionally trained mcntal health workers. By virtue ~f Lis position in the con~nunity, the parish minister can often take the initiative in contacting those who seem to be emotionally disturbed. He has access to the homesof persons in his congregation and, to a lesser degr.ee, other persons in the community who may be experiencing such things as maritial difficulties.
The minister's maximum resource value to the comprehensive community mental health program would be facilitated by a clinical chaplain on the mental health team. The clini~al charlnin could serve as a liaison person between pari.sh pastors and the community mental health centers. 2. !hW:.C:~
Four yzars of ma~ical school plus o~p. year of internship produces a physician who is fully trained and can be licensed to practice medicine. Those who do so at this livel of training are usually referred to as general practitioners. Others may continue training in specialties such as inter!~l medicine, pediatrics, surgery,

- 69 -
psychiatry or anyone of the approximately 15 broad medical specialties. Physicians see many patients whose primary symptoms are based on emotional
disturbance. Such patients are not always referred to mental health specialists there may not be a specialist in the vicinity, the patient may refuse referral or the physician may prefer to treat the patient himself. Physicians should be encouraged in the practice of maintaining and treating most of their patients who have psychological problems, and refer to mental health specialists only those cases they cannot handle.
Most physicians interviewed said they would welcome consultation from mental health professionals. Physicians particularly stressed the need for practical, workable suggestions and solutions from the consultants.
Mental health consultation to the physician need not be concerned only with the severe emotionally disturbed patient. Often in the average patient, it is more difficult to treat the emotional components of a physical disease than it is to treat the disease itself. Mental health consultation could help the physician become more aware of these factors and how to deal with them effectively.

- 70 -
Chapter III FINANCING MENTAL HEALTH PROGRAMS
In recent years. one major principle regarding financing has been made clear that significantly greater sums of money must be made available on all levels (Federal. state and local) if mental health programs are ever to approach a level of adequacy. Attempting to find solutions to monetary problems as encompassing as those encountered in mental health programming. is difficult. and it is immediately obvious that no one source. at anyone level can provide all the funds that will be needed.
Competition for funds is keen at all levels and mental health, like education. welfare, and highways, must enter into this competition. Significant increases in tax funds allocated to mental health at the local level must be concurrent with increases in state funds and federal participation. There are still many in Georgia who firmly believe that responsibility for treating mental illness and promotion of mental health is. by and large. a state and/or federal responsibility. It is fiscally ~nhealthy to perpetuate the image that anyone level of government can assume total financial responsibility. If the philosophy of future program development is that )f bringing services closer to the people. then it follows that communities will have t !ssume a portion of this financial responsibility, with appropriately matched state md federal aid.
The proportionate shares of state - Federal funds as compared with local funds Ls analagous to a set of scales. When the proper amount of local funds is matched ,1th the proper amount of "outside" funds. the scales are in balance. Should a lisproportionate share of state and Federal funds be added to one side of the scales. :hat side will fall deeper into "outside" controls. resulting in less program flexi)ility and greater dependence on some other source for initiative and progress. If. lowever. more money is added to the scales on the local side. the scales will revert :0 a balanced state.

- 71 At present, there are many barriers to achieving adequate community financial support from tax sources. Very few single counties in Georgia can support adequate programs on their own. However, more fortunate counties should hopefully assume greater responsibility in helping to provide services to adjacent counties without adequate resources, which however, can contribute to the health of the richer county in terms of human and material resources. Where there are demographic, geographic and socio-economic ties between less favored counties, some form of cost-sharing between them is ultimately the only solution to achieving a comprehensive mental health program. Tied in closely with this 1s the widely recognized need for revising existing tax structures in Georgia's 159 counties. Despite the fact that trends in recent years have been encouraging these re-evaluations must be stepped up. Though still inadequate, Georgia is spending larger amounts for mental health services, not nearly all of which are reflected in the state's annual appropriations for this specific purpose. Substantial funds, for example, are made available through the Department of Family and Children Services for families whose circumstances are directly traceable to mental or emotional problems. Classes for emotionally disturbed and mentally retarded children, will continue to absorb a larger percentage of the state's education budget. The criminal courts are beleaguered with cases that represe other direct costs traceable to mental illness, as are agencies, such as the State Board of Fardons and Faroles and the State Board of Corrections. Loss of personal income and time due to mental illness, are two factors which directly affect families, business, and industry alike. The sum total of all costs such as the above would, no doubt, reveal staggering sums that are, in one way or another, traceable to mental illness. Looking at Georgia's standing among the other states and the District of Columbia with respect to fifteen selected indices will lend emphasis and urgency to the need for more adequate financing:

Number

Index

Fifteen Indices*

u.S.
Aver.

GA. Aver.

1962 GA.
Raolts

1

Daily resider.t patients in public mental 283.7

296.4

15

hospitals per 100,000 general population.

2

Public mental hospital physicians per 100 .90

.53

41

resident patients.

3

Professional patient-care personnel

per 100 resident patient in public

mental hospitals.

4.5

1.9

49

4

Full-time employees per 100 patients in 36.6

21.2

51

public mental hospitals.

5

Average daily maintenance expenditure per $5.43

$3.00

49.5

resident patient, public mental hospitals.

6

American Psychiatric Assoc. physicians per 6.7

2.7

42.5

100,000 population (1963)

7

Scheduled professional man hours in out- 174

41

45

patient psychiatric clinics per wk. per

100,000 population.

8

Per cpaita personal income.

$2366.00 $1759.00 43

9

Per capita general expenditure of state $ 321. 35 $ 256.71

43

and local governments.

10

Per capita total general state expendi- $ 168.96 $ 156.20

37

tures.

11

State mental hospital operating expendi- 2.91%

2.09% 29.5

tures 8S a percent of total general state

expenditures.

12

Annual per captia maintenance expenditures $5.56 $3.19

41

of public mental hospitals.

13

Per capita expenditures for community

$.50

$.43

13

mental health programs.

14

Per capita expenditures for public

1.89% 1.41%

28.5

mental hospital maintenance and community

mental health programs, as a percent of per

capita general expenditures of state & local governments.

15

Per capita expenditure for public hospital 25.94% 13.17%

46

maintenance and community mental health as

a percent of total per capita expenditures

for health and hospitals.

rJoint Information Service of Am. Psy. Assn. & the National Assn. for Mental Health 'ifteen Indices: An Aid in ReViewing State & Local Mental Health & Hospital Programs,
!.964 p.d1 ti."n.

- 73 -

<:,.,
~~:~

It may readily be seen that Georgia is extremely low in financial support in

~; nearly every instance. While there has been improvement in these standings since

1962 (the latest comparative figures available), other states have been improving

also, and there is little reason to expect that Georgia's comparative standing has

improved proportionately. Index #3, which shows the number of professional patient-care personnel per

100 resident patients, ranks Georgia as 49th - reflecting the great need for additiona

trained personnel at Milledgeville State Hospital. Index #4, showing the number of full-time employees (in all categories) per 100 resident patients in mental hospitals,

ranks Georgia as 51st. Numbers 8 and 9, respectively, show how low Georgia ranks in per capita personal

income and per capita general expenditure of stste and local governments.

TABLE iFl COMPARISON OF MENTAL HEALTH, TOTAL HEALTH, AND
TOTAL STATE ALLOTTMENTS, 1961-65

YEAR
1961 1962 1963 1964 1965

MENTAL HEALTH ALLOTTMENTS (Thousands of Dollars)
18,376 19,802 20,345 23,390 27.090

TOTAL HEALTH ALLOTTMENTS (Thousands of Dollars) 32,448 34,427 33,666 37,256 41,320

TOTAL STATE ALLOTTMENTS

(Thousands of Dollars)

396,946

-

419,989

448,987

475,202

522.029

TABLE in PERCENTAGE EXPENDITURES, 1961-65

YEAR 1961 1962 1963 1964 1965

MENTAL HEALTH TO TOTAL HEALTH 56.6% 57.5 60.4 62.8 65.6

MENTAL HEALTH TO TOTAL STATE 4.6% 4.7 4.5 4.9 5.2

- 74 -

LOCAL HEALTH DEPARTMENT IvIENTAL HEALTH BUDGETS PROPOSED FOR JULY 1, 1964 - JUNE 30, 1965

Total Amount COUNTY TOTALS

Fulton Co.*

57,600.

Bibb Co. Jones Co. Twiggs Co.

29,504. 739. 739.

Chatham Co.

47,584.

Glynn Co.

23,848.

DeKalb Co.

40,411.

Cobb Co.

26,304.

Clarke Co.

9,115.

Muscogee Co.

24,240.

Dougherty Co.

26,956.

Floyd Co.

23,637.

Hall Co.

16,200.

Lowndes Co. Echols Co.

8,156. 164.

TOTALS

335,197.

Add 15% for raises and new programs State Totals

Present State Participation

State

State

Local

%

Amount

Amount

. 25

14,400 .

43,200.

. 30

8,.851 .

20,653.

. 65

480 .

259.

. 65

480 .

259.

. 30

14,275 .

33,309.

. 50

10,736 .

11,924.

. 30

12,123 .

28,288.

. 30

7,891 .

18,413.

. 50

4,557

4,557.

. 30

7,272 .

16,968.

.40

10,782 .

16,174.

. 40

9,455 .

14,182.

. 50

8,100.

8,100 .

50

4,078

4,078.

. 75

123 .

41.

113,603.

220,405.

(Est.)

17,337. 130,940.

Table #1 shows how Grorgia has increased its expenditures for mental health. This period covers the years in which the state has seen a tremendous upsurge of public interest and concern in mental health and illness, and unless it is viewed in this light, may tend to be misleading. While there have been significant increase
*Fulton County is actually on a lump sum basis ($14,400.00) and the 25% figure is only an estimation to help complete the summary.

- 75 -
in mental health, total health and total state allottments, a glance at the 15 indices will show that Georgia is among those states which has the greatest distance to go in order to reach levels of program adequacy. These increases should be continued into future years, of course, in order for the state to at least reach national averages.
Table #2 shows that over the same five year period there have been significant increases in mental health expenditures shown as a percentage of total health expenditures and as a percentage of total state expetLditures. In fact, from 1961 to 1965, while state expenditures have increased 31.5%, expenditures for mental health have increased 47.4%. Viewed from another perspecitive, there has been a .15.9% increase from 1961 to 1965 in mental health to total health expenditures. During the same period there was a 13% increase in mental health to total state expenditures.
Table #3 shows t for fiscal year 1964-65, the total amounts proposed and budgeted to be spent for local mental health in those departments having mental health clinics
or child guidance programs. The Table also shows the percentage and dollar amounts spent by the state.
A. Basic Assumption Involved in Financing The problems of financing mental health programs should be approached with several basic assumptions in mind. Some of these assumptions are so obvious they need no documentation; others can be easily documented, while others - no less apparent - cannot. Such assumptions include: 1. Fersons should utilize private mental health resources where feasible.
Agreements for purchasing services by public agencies is a sound concept and should be encouraged. However, no person needing services should be denied them because of his inability to pay. 2. No plan or policy for financing mental health services should be so constituted as to penalize communities ready to move ahead because of others that are slower. 3. There will be continuing population increases in the years ahead with concemitant greater need fort and use of all types of mental health facilities and services, including private ones. 4. It may be assumed that all related costs for mental health and mental illness services will increase in the foreseeable future.

- 76 -
5. All levels of government and business have a responsibility to provide supporting leadership in all aspects of mental health programs.
B. Existing Patterns for Financing Community Mental Health Programs in Georgia.
These programs are all described in this report and the following comments relate only to their financial support.
Guidance Clinics - Operated through District Health Departments these clinics are currently supported by the same formula which applies to other public health programs. This formula varies from 70 percent local and 30 percent state to 25 percent local and 75 percent state funds.
Community Hospital Psychiatric Program - This program operates through those community general hospitals with psychiatric beds and the state essentially pays 100 percent of the cost for the psychiatrically indigent. For those patients who can pay, fees are charged accordingly. Although initially started to encourage communities to assume total support, most local areas have been extremely slow in assuming financial responsibility. Little justification for continuance has been found. Support of all local programs should be on same financial basis.
Aftercare by Public Health Nurses - Operated through local and district health departments, utilizing public health nurses, this program is also supported on the same formula basis discussed earlier.
C. Existing Pattern For Financing State Programs State institutions are essentially state supported; exceptions are found among those patients who can pay all or a part of their per diem costs. In general, federal funds cannot be expended in institutions. There are some exceptions, such as project grants for specific purposes, as research. Through such grants it is sometimes possible to obtain personnel and equipment that would not otherwise be available. (Milledgeville State Hospital, Gracewood State School and Hospital, and Alcholic Rehabilitation Service have all been recipients.) While all of the institutions have

- 77 -
benefitted from private voluntary contributions (in money, goods, or services), such income is obviously not dependable and should not be relied upon. Rather, it is the means through which the institutions can sometimes achieve the desirable program "extrasll which are not possible through their regular budgets.
D. ~ntial Resources for Financing Mental Health Programs 1. Tax Dollars
The following paragraphs attempt to bring together all currently known information regarding possible sources of tax funds for mental health purposes. Though some of the descriptions have greater immediacy than others, all of them have at least some relevance to community mental health programming. a. Mental Health Community Centers Construction Act of 1963 (Public Law 88-164)
Federal funds may be obtained under this Act for construction of community facilities which meet certain criteria. Chief among such requirements is the regulation that such facilities must contain provisions for the following basic services: (1) Inpatient (2) outpatient (3) Fartial hospitalization (4) Emergency services (5) Consultation and education.
Funds are administered through the states' established Hill-Burton Authority, ~hich in Georgia is 1/3 state, 1/3 local and 1/3 federal. b. Economic Opportunity Act
Under this Act local areas may apply for special grants to support "Community Action Programs" intended to elevate the community's economic level and provide additional or improved employment opportunities. Although no monies will be allocated for construction, general operating costs can be supported on a 90-10 basis, 90 percent federal and 10 percent local or state. It is believed that funds will later be available for supporting program operational costs. c. The Appalachia Regional Development Act (1965)
Thirty-five of the state's northern counties are eligible to receive financial

- 78 -
aid, including construction funds for mental health facilities on a 80% federal 20% local basis. Up to 100 percent of all operating costs may be covered for the first two years - 50 percent for the next three. d. National Institut~f ~~ntal Health Project Grants
Grants are available to communities interested in demonstrating new mental health services. Again, no construction monies are available; but general operating costs can be supported up to 100 percent in the initial stages, with a general phasing out in three to five years.
- - e. H. R. Bill 2985
If passed, this bill will authorize the use of federal funds to assist in staffing comprehensive community mental health programs and become part of Public Law 88:164. Under the terms of the Act, federal monies will be available to support up to 75 percent of approved operating costs, for the first 15 months, 60 percent for the first year following, 45 percent for the second year, and 30 percent for the third year. Grants may be made to public or non-profit private agencies. 2. Private
Communities should investigate other avenues of support for financing mental programs such as private philanthropic organizations, voluntary agencies, and private foundations. Often times, individual citizens, as well as private industries and businesses, are willing to help underwrite some of the costs involved, if they are presented with a thoughtfully conceived, well-documented proposal.
',1

- 79 -
E. Policies of Fiscal Support in Selected Other States
In reviewing fiscal support policies of other states, it was interesting to note the complete lack of a common pattern. Financial support for community mental health programs ranged from 100 percent state in some cases to nearly 100 percent local in others.
In Missouri counties are required to reimburse state institutions at the rate of $6.00 per month for each patient from that county. Since hospitals are all state controlled, with relatively little emphasis on community programs, Missouri's program is essentially 100 percent state supported.
Under California's "Short-Doyle Act", each city, county or local health district is reimbursed for 50 percent of the amount spent for local mental health services, up to the amount they actually spent in the fiscal year prior to receiving state aid. For expenditures beyond the amount spent in such prior year, the state will provide 75 percent of the funds so spent. The approved expenditures under this Act which are eligible for reimbursement include personnel salaries, approved facilities and services contracted for, and operation, maintenance and service costs.
In South Carolina grants are made by the state to approved local programs not to exceed 50 percent of the total expenditures for: (1) salaries, (2) contract facilities and services, (3) operation, maintenance and service costs, plus certain other approved expenditures. This is further limited in that the state's contribution shall not exceed, in any fiscal year, more than 25 cents per capita of the area served by the program. All new programs under the Act will be supported by the state on a 50-50 basis.

- 80 -
For Georgia to be able to finance an adequate mental health program, it is
recommended that:
ADDITIONAL APPROPRIATIONS TO MILLEDGEVILLE STATE HOSPITAL, GRACEWOOD STATE SCHOOL AND HOSPITAL, ALCOHOLIC REHABILITATION SERVICE, BE MADE WITH THE GOAL OF EXCEEDING THE NATIONAL AVERAGE PER DIEM COSTS IN THE IMMEDIATE YEARS AHEAD.
INSTITUTIONAL AND COMMUNITY MENTAL HEALTH PROGRAM FEES BE COORDINATED, WHEN POSSIBLE, TO PREVENT OVER-USE OF LESS EXPENSIVE STATE SUPPORTED HOSPITALS.
A CLOSE STUDY BE MADE OF ANY 'BAlmIERS CURRENTLY PREVENTING THE FLOW OF FUNDS BETWEEN STATE DEPARTMENTS WHICH DETER THE KIND OF COOPERATIVE RELATIONSHIP ESSENTIAL TO ESTABLISHING PROGRAMS INVOLVING RESPONSIBILITY OF MORE THAN ONE AGENCY OR DEPARTMENT.
A SLIDING FEE SCHEDULE BE ADOPTED FOR ALL TAX-SUPPORTED HOSPITALS AND CLINIC PROGRAMS SERVING THE MENTALLY ILL, AND THAT THE SCHEDULE BE DETERMINED LOCALLY, WHERE APPLICABLE, BASED UPON THE PHILOSOPHY THAT THE INDIVIDUAL SHOULD PAY WHAT HE OR SHE CAN AFFORD UP TO THE TOTAL COST. NONE, HOWEVER, SHOULD BE DENIED SERVICES BECAUSE OF THEIR INABILITY TO PAY. HIGHER FEES ON THE SCALE SHOULD BE COMPARABLE TO PRIVATE FEES TO DISCOURAGE UTILIZATION OF PUBLIC FACILITIES BY FINANCIALLY ABLE INDIVIDUALS. IN CERTAIN CHRONIC MENTAL CONDITIONS PROVISIONS SHOULD BE MADE FOR REDUCING OR SUSPENDING FEES TO PREVENT A CONTINUOUS DRAIN ON FAMILY FINANCIAL RESOURCES.
"PSYCHIATRIC INDIGENCY" IS A VALID CONCEPT, AND SHOULD BE DIFFERENTIATED FROM "MEDICAL INDIGENCY" AND "WELFARE INDIGENCY".
ELIGIBILITY FOR SERVICE SHOULD BE DETERMINEO ACCORDING TO (1) FINANCIAL ABILITY, (2) AVAILABILITY OF PRIVATE RESOURCES, (3) NATURE OF PROBLEM AND (4) COMPETENT REFERRAL SOURCE.
PROVISION BE MADE, AND FUNDS BUDGETED, FOR COMPENSATING NON-PSYCHIATRIC PHYSICIANS WHO DEVOTE TIME TO PROGRAMS IN WHICH THE PSYCHIATRICALLY INDIGENT ARE TREATED.
STATE GRANT-IN-AID FUNDS AVAILABLE FOR MATCHING LOCAL PROGRAM FUNDS BE DISTRIBUTED IN ACCORDANCE WITH THE FOLLOWING PRINCIPLES:
1) Total state monies for Grants-in-Aid to counties should be increased.
2) From Grant-in-Aid Funds:
a) Allocate an unmatched grant to each district for 100% support of those positions designated as full-time district personnel.

- 81 b) Allocate sufficient monies to place a supporting Grant-in-Aid
"floor" under smaller counties for a basic program - matched approximately one dollar local to two dollars state. c) Divide remainder of Grant-in-Aid funds approximately equally as follows: (1) 50% according to population - 1 to 1 matching (2) 50% on basis of, and in proportion to, population weighted inversely by the real property index.
F. Insurance Coverage of Mental Illness When it is necessary for an individual to seek psychiatric care or be hospitalized for mental illness, the drain on the family's financial resources becomes acute. For this reason, increasing numbers of people seek (by one means or another) to obtain insurance coverage. In Georgia, it is estimated that 50 percent of the companies offering health and accident coverage include some coverage for mental illness. Many insurance plans, however, specifically exclude psychiatric care, or define a psychiatric hospital in such a manner as to exclude it from the "hospital" classification. Plans including hospital coverage for mental illness tend to limit the length of time the individual can remain in the hospital. Though adequate for many physical illnesses, it is often inadequate for recovery from mental illness. Total insurance coverage for hospital care for mental illness presents different problems from total coverage for physical illness because of the radical difference in length of stay. The average length of stay for physical illness in all short and long-term nonfederal, general hospitals in the United States is around nine days. Thus, a prepayment or insurance contract which allows 120 days per admission will give complete coverage in about 99.9 percent of all hospital cases and will probably cover 95 to 98 percent of all days of care.* During 1963, an insurance contract in Georgia which provided 120 days of care per admission for psychiatric inpatient service would have provided complete coverage for over 60 percent of all psychiatric cases, including those in general hospitals,
* Medical Care in Transition, Pub. Health Service Publication No. 1128; U. S.
Government Printing Office, Vol. 2, Jan. 1964, p. 155.

- 82 -
private and non-profit hospitals, as well as the State Hospital (See Table #1, "Length of Stay of Discharged Patients Receiving Psychiatric Inpatient Services ':)
But because of the prolonged length of stay for some of the remaining 40 percent, 120 days would have covered less than 10 percent of all days of psychiatric care. As of January 1, 1965, there were 8,767 patients who had been residents for two years and over at Milledgeville State Hospital (See Table 412, "Length of Stay of Resident Pad ents at M. S. H. by Age Group").
As a result of the changes in the diagnosis and treatment of mental illness, the average length of stay in psychiatric hospitals is being shortened. At present, however, the dominant feature of mental hospital care is the long length of stay; for example the average length of stay of all discharged patients in Georgia in 1963 was one year and 153 days. On the basis of present practices and costs, a 20 percent increase in cost of hospital insurance would be required to provide coverage of all hospital care for mental illness.
Because of these factors, it is doubtful that private insurance or prepayment plans will ever be able to provide effective coverage of all hospital care for mental illness. Nevertheless, it is quite feasible for Blue Cross and other private hospital insurance to provide limited coverage. (Limited coverage means coverage for the same number of days for mental as for physical illness.) Such insurance coverage would provide reasonably full coverage and be highly beneficial for patients, hospitals and the medical profession. The cost of limited coverage is partially assumed, at present, by some commercial insurance companies and Blue Cross plans. It has been found that adding this limited coverage to Blue Cross plans only increases the benefit expenditures between two and five percent.
It is difficult to summarize the present extent of coverage for mental illness by insurance plans, since most plans offer a variety of subscriber contracts with different benefits -- different benefit durations -- and in many cases .- different

- 83 -
provisions in regard to coverage. Data on the number of subscribers in Georgia who
are covered under each of the different contracts are not available; therefore, all
insurance companies offering reimbursement for mental illness are weighed the same
in the folloWing discussion, when, in reality, some companies have many more sub-
scribers than others.
In a survey of insurance companies in Georgia, offering health and accident
coverage, questionnaires were mailed to 269 companies.* Of the 206 companies that
responded, 123 reported writing some form of coverage for mental illness. Out of
these 123, 63 underwrote both group and individual coverage, 25 group coverage only,
and 35 individual coverage only. Only 28 companies reimbursed all expenses incurred
during hospitalization for mental illness for the period of time the company was
liable. Eighty percent of those companies offering coverage for mental illness
reimbursed for psychiatric treatment in private hospitals, While only 50 percent
for treatment in tax-supported institutions. Less than one half of the reporting
companies offered reimbursement for out-patient psychiatric treatment.
Based on the above information it is recommended that:
ALL PRE-PAYMENT HEALTH INSURANCE CARRIERS OPERATING IN GEORGIA BE REQUESTED TO PROVIDE COVERAGE FOR MENTAL ILLNESS ON A BASIS EQUAL TO THAT PROVIDED FOR ANY OTHER ILLNESS.
COVERAGE FOR MENTAL ILLNESS, UNDER PREPAYMENT AND OTHER FORMS OF HEALTH INSURANCE, BE BROADENED TO COVER OUTPATIENT AND PARTIAL HOSPITALIZATION, AS WELL AS TOTAL HOSPITALIZATION SERVICES.
INSURANCE PLANS COVER TREATMENT OF MENTAL ILLNESS IN QUALIFIED PRIVATE AND TAX-SUPPORTED MENTAL HEALTH RESOURCES.
COVERAGE FOR MENTAL ILLNESS BE MADE AVAILABLE IN ALL INDIVIDUAL AND GROUP COVERAGE.
HEALTH INSURANCE BENEFITS NOT BE LIMITED TO THE SERVICES OF A PSYCHIATRIST OR OTHER PHYS IClAN BECAUSE OF THE CONTINUING DEVELOPMENT OF THE CONCEPT OF THE MENTAL HEALTH TEAM AND THE PRESENT SHORTAGE OF PSYCHIATRISTS, BENEFITS SHOULD BE EXTENDED TO COVER THE SERVICES OF THE CLINICAL PSYCHOLOGIST, THE PSYCHIATRIC SOCIAL WORKER, AND THE PSYCHIATRIC NURSE.
*This survey was undertaken by the rolicy Forms Division, Georgia Insurance Department in February-March 1962. Even though the survey is 3 years old at the time of the present writing there has been no appreciable variation in coverage of mental illness by insurance companies during this period.

- 84 -
ADDITIONAL FINANCIAL RECOMMENDATIONS
REGAP~ING LEGISLATION
THAT APPROPRIATE LEGISLATION BE PASSED TO PERMIT LEVYING OF TAX MILLAGE EAID1ARKED SPECIFICALLY FOR HEALTH PURPOSES, AS IS PRESENTLY DONE FOR EDUCATION PROGRAMS.
THAT NECESSARY REVISION IN THE STATUTES BE ACCOMPLISHED TO PERMIT OF MORE EQUITABLE AND EXTENS IVE COLLECTING OF PATIENT FEE PAYMENTS IN INSTITUTIONS AND IN LOCAL HEALTH DEPARTMENT PROGRAMS. THE SETTING UP OF AN ADEQUATE ADMINISTRATIVE STRUCTURE TO INSURE VIGOROUS COLLECTION EFFORTS.
THAT THE STATE LEGISLATURE CAREFULLY STUDY THE PROBLEMS INVOLVED IN FINANCING MULTI-COUNTY MENTAL HEALTH PROGRAMS AND THAT THE NECESSARY STATUTORY PROVIS IONS BE MADE T-O ENABLE LOCAL TAX REVENUES TO BE EASILY TRAN::>FERRED ACROSS COUNTY LINES.
THAT THE GEORGIA LEGISLATURE STUDY THE QUESTION OF REQUIRING ALL PREPAYMENT HEALTH INSURANCE CARRIERS OPERATING IN GEORGIA TO PROVIDE COVERAGE FOR MENTAL ILLNESS ON A BASIS EQUAL TO THAT PROVIDED FOR ANY OTHER ILLNESS.

- 85 -

TABLE iil
LENGTH OF STAY OF DISCHARGED PATIENTS RECEIVING PSYCHIATRIC INPATIENT SERVICES DURING A YEAR BY RACE AND SEX

Length of Stay

Total

Inpatients, Total Less than one month 1 month to 3 months 3 months to 6 months 6 months to 1 year 1 year to 2 years 2 years to 5 years 5 years to 10 years 10 years to 15 years 15 years to 20 years 20 years and over

16,360 8,462 2,215 552 427 2,383 1,152 625 213 134 197

White Male
8,702 4,455 1,478
358 279 . 1,058 530 351
90 36 67

White Female
5,722 3,825
553 83 75 750 243 69 34 28 62

Nonwhite Nonwhite

Male

Female

1,290

646

116

66

154

30

90

21

SO

23

311

264

271

108

162

43

54

35

60

10

22

46

Unknown

Average length of stay for inpatients - 1 year, 153 days.

TABLE #2
LENGrH OF STAY OF RESIDENT PATIENTS M.S.H. BY AGE GROUP AS OF JANUARY 1, 1965

AGE GROUP

TarAL

All Ages

11416

0-4 Ages

'c"o

5-9 Years 10-14 Years

37
71

15-19 Years

298

20-24 Years

401

25-34 Years

1,134

35-44 Years

1,732

45-54 Years

2,343

55-64 Years

2,366

65-74 Years

1,654

75-84 Years

937

85 Years and over 236

Unknown Age

207

LESS THAN 1 MONTH
271
--
8 19 37 53 49 49
11
15 9
21

1-2 MONTHS
378
7 4 35 29 57
69 61
39 37 29 3 8

3-5
- - MONTHS.
411

6-11
MONTHS
656

3

14

15

20

30

50

30

33

46

76

54

90

56

104

67

91

50

80

40

67

7

24

13

7

1 ~
933
6 10 51 58 106 101 152 139 144 114
38
14

2-4 YEARS
1,562
5 9 62 123 197 227 217 240
206
160 31 85

5-9 YEARS
1,707
2 5 19 70 295 293 323 303 219 133 42 3

10-19 YEARS
2,729
8 43 39 312 636 691 557 271 130 26 16

20 YEARS AND OVER
.2,169
8
209 690 881 636 249
56 40

NarE: These data were taken from resident population as of February 1, 1965 and tabulated as of January 1, 1965.

- 87 -
Chapter IV
LEGISLATION
Webster's defines law as " ... a binding custom or practice of a community"
and laws pertaining to mental illness are clear indicators of public attitudes in
this area. This issue is further elaborated upon in the report* of the American
Bar Foundation on the rights of the mentally ill which states that:
The development of the law as it affects the rights of the mentally disabled has been dependent upon three factors: (1) the extent of medical knowledge of the cause, care and proper treatment of the mentally disabled, (2) the degree to which the politically organized community has acknowledged its responsibility for the care and treatment of its afflicted citizens, and (3) the legal profession's awareness of the social realities of mental disability, as well as the ac~teness of its concern for those unfortunates who have neither relatives nor close friends to safeguard their rights.
The same report further goes on to say that:
The factors conducive to a thorough examination and re-evaluation of the laws as they relate to the rights of the mentally disabled exist today to a greater extent than ever before. Medical science now knows a great deal about mental disability and can, therefore, furnish fresh insights into the medico-legal problems involved. Furthermore, communities have attained a far greater sense of responsibility for the fate of the mentally disabled, and the leg6l profession is now more Vitally concerned with their status.
In view of these new developments, this is an opportune time to re-evaluate the law to determine to what extent it is in tune with these new levels of perception and attainment.
The evolution of laws pertaining to the mentally ill in Georgia is a fitting
~xample of the above statements. During the last eight years, mental health laws
In this state have undergone three major revisions, the last one being in 1964.
~ny of the unnecessary restrictions of civil rights in previous laws have been
lliminated and additional provisions regarding voluntary and involuntary admissions
Ire definite improvements. However, changing concepts and new discoveries in the
lehavioral sciences, as well as sociological developments, necessitate continuous
~"The Mentally Disabled and the L6w". A report of the American Bar Foundation ,n the rights of the mentally ill; The University of Chicago Press, 1961.

- 88 -
re-examination of the laws for needed revisions to keep them concurrent with expanding bodies of knowledge.
To a large extent, society's assimilation of scientific progreas has been slow; this is especislly true in the field of mental health where the misconceptions and prejudices of the past still linger. Therefore, incorporation of new ideas and principles, resulting from scientific progress, into the law has been generally fragmentary and insufficient.
Concern over protection of individual rights, deprivation of liberty and incompetency have influenced legislators and the legal profession to insist upon exercising strict and rigid procedures regarding the hospitalization of the mentally ill. Certainly one could hardly argue against this at the time when "institutionalization" meant life-time confinement. Now, the majority of patients are able to leave the hospital within 30 to 60 days after admission.
The classic image of the mentally ill has also changed considerably. The "raving, violent and uncontrollable maniac" of yesterday is rarely seen today. The phrase "dangerous to himself and others" has somewhat lost its pertinence, and the concept of "protection" is valid only in a small proportion of cases. While early treatment is be! ng promoted, the "fear of legal conunitment" may deter some patients from submitting themselves to hospitalization in an institution for the mentally ill.
These and other considerations have led more progressive societies to employ more medically oriented admission procedures, leaving legal protection as a device to be used in cases of abuse of an individual's rights.
Many states in the United States and several other countries now have such liberal laws governing admission policies and procedures. In designing a progressive nental health program for Georgia we cannot, and should not, overlook the tested and ~roven experiences of others. Programs have to be directed toward new and better ~ays of doing things.

- 89 -
The recommendations in this section are intended to serve as principles upon which needed improvements in existing mental health laws, including hospitalization, should be based.
A. Needed Legislation Regarding the Admission Procedures The Georgia Health Code does not provide a procedure whereby the admission of a patient on an emergency basis to a hospital could be possible without the regular admission proceedings. Present law permits the court of ordinary to take the patient in custody "during the proceedings", if en affidavit is submitted by a physician stating that the " .. patient is violent or for other reasons is liable to do physical harm to himself or others". However, at times when a patient needs emergency treatment and/or hospitalization, the prescribed procedure may be impractical or, from the medical standpoint, undesirable. Such an emergency may cause a great deal of inconvenience to the family, as well as the patient by subjecting him to measures such as arrest and confinement in jail especially at night during holidays or over the weekend. Therefore:
IT IS RECOMMENDED THAT A PROVISION BE INSERTED INTO THE LAW FOR ENERGENCY INVOLUNTARY ADMISSION OF A MENTALLY ILL PATIENT TO A HOSPITAL FOR A LIMITED PERIOD OF Tllm NOT TO EXCEED 72 HOURS, WITHOUT LEGAL PROCEEDINGS OR WARRANT, PROVIDING THAT A PHYSICIAN RECOMMENDS AND THE ADMITTING PHYSICIAN OF THE INSTITUTION CONCURS. A similar but more far reaching consideration, is the addition of a provision to the statute which would recognize involuntary hospitalization on medical certification by two physicians. The practice of temporary or observational hospitalization, as such, has received wide-spread recognition and been used extensively for many years in other states and countries. New York State has recently passed a law providing medical certification for voluntary hospitalization. Twelve other states have similar provisions in their statutes. England's "Mental Health Act of 1959" almost entirely removed legal commitment procedures from compulsory admissions. Court action is needed only for guardianship, declaration of incompetence and protection and management of the

- 90 -
property of the patient. As the majority of patients are able to leave the hospital within a relatively
short period, temporary commitment upon the certification of two physicians for a period of 45 days would eliminate the need for legal commitment proceedings in these cases. Legal proceedings should be utilized if the patient has to stay in the hospital longer than the prescribed term or if it is requested by the parties involved. If the patient sufficiently improves within 45 days, he is discharged from the hospital in the same manner a voluntary patient is handled.
IT IS RECOMMENDED THAT THE PROVISION BE MADE IN THE STATUTE TO PERMIT INVOLUNTARY ADMISSION OF A MENTALLY ILL PATIENT TO THE INSTITUTION FOR A MAXIMUM PERIOD OF 45 DAYS UPON THE CERTIFICATION OF TWO PHYSICIANS. At present, the Health Code limits the involuntary admission of alcoholics to the institution established for this purpose only. Chapter 88-407 indicates thet: fl this section shall not authorize the transfer of any patient to the Milledgeville State Hospital or any other institution for the treatment of mental illness operated by the Department of Health." On the other hand, the National Institute of Mental Health team and the Task Force on Mental Hospitals have recomreend( special alcoholism and drug addiction programs in Milledgeville and future regional state hospitals. The establishment of these services within these institutions will necessitate admission of such cases to the state mental hospitals. Recognition of the fact that some alcoholics and drug addicts are in need of long-term care in 8t8te institutions and permitting the admission of such patients to the above institutions may eliminate their commitment as "mentally ill." IT IS RECOMMENDED TIlAT THE LAW BE CHANGED TO PERMIT INVOLUNTARY ADMISS ION OF ALCOHOLICS AND DRUG ADDICTS TO TIlE STATE MENTAL HOSPITAL AS WELL AS TO THE INSTITUTIONS SET UP FOR THE TREATMENT OF SUCH DISORDERS. The present Code does not prOVide any procedure for the transfer of citizeno hospitalized in out-of-state institutions directly to the state hospitals in Georgia. The patient has to be delivered to his or her own county and usual commitment

- 91 -
proceedings have to be held before the patient can be admitted to the institution. In many instances, this routine procedure causes hardship on the patient and the family, as well as the agencies involved. There is an urgent need to develop a proper procedure to enable direct transfer of such patients to the institutions in Georgia.
In connection with the above, the adoption of the "Interstate Compact on Mental Health" will be a progressive step toward better care of the mentally ill, prOViding a well-coordinated system of services among the states. This Interstate Compact had its beginning at the 1955 meeting of the Governors' Conference in Chicago where one of the points discussed was how to deal with the very difficult problems of deportation of the non-resident mentally ill patient. Following this Conference, legislative, psychiatric, legal and administrative representatives from the States of Connecticut, New Jersey, New York and Pennsylvania met in New York City on April 22, 1955 to discuss the possibility of reciprocal arrangements under which each state would agree to accept its residents on transfer from an institution of another state. It was noted that a number of patients who committed criminal acts in one state recently had been released from institutions in other states or from federal institutions.
A detailed agenda of legal difficulties was discussed, but it was soon apparent that no common denominator of residence or settlement existed which could result in satisfactory agreements. Midway in the discussion, it was suggested that the whole emphasis was somewhat aside from a modern approach to mental illness namely, the welfare and clinical needs of the patient himself. The conferees then sought an alternative approach which would permit interstate cooperation aimed at the patient's needs and which would require minimum dependence- upon legalistic definitions of residence and settlement.
After thorough discussion, it appeared that an interstate compact could be developed which would avoid many difficulties of the repatriation process and would

- 92 -
emphasize the welfare of the patient. The original committee was enlarged to
include representatives from additional states and interested agencies of the federal
government. Several drafts of a proposed compact were prepared and revised and two
formal meetings of the full committee were held. The result was an agreed upon
text of a compact.
The proposed "Interstate Compact on Mental Health" was approved September 30,
1955 by the Northeast State Governments Conference on Mental Health in a strong
resolution urging early consideration and ratification by legislatures in the
northeast and other areas of the country. This action was subsequently reviewed
and reaffirmed by the Biennial Regional Conference of the Northeastern States,
meeting at New York City on December 15-16, 1955. The Compact also was discussed
thoro~hly at the Western Regional Meeting of the Council of State Governments at
Colorado Springs, Colorado, November 7-8, 1955. The conference adopted a resolution
approving the compact and suggesting ratification by the legislatures of the eleven
western states.
The purposes of the Compact, which has been adopted by 28 states, are:
1. To assure that any party state will give care and treatment to any person found in that state who is in need of institutionalization by reason of mental illness or mental deficiency;
2. To permit the transfer of such a patient to an institution in another state when clinical determinations indicate that such a transfer would be in the best interests of the patient;
3. To provide interstate cooperative machinery for after-care or supervision of patients on convalescent status or conditional release;
4. To authorize additional supplementary agreements between party states "for the provision of any service or facility or for the maintenance of any institution or a joint or cooperative basis" when any two or more states wish to do so.
IT IS RECOMMENDED THAT LEGISLATIVE ACTION BE TAKEN FOR THE ADOPTION OF THE INTERSTATE COMPACT ON MENTAL HEALTH AND THE NEEDED PROVISIONS BE INSERTED INTO THE HEALTH CODE FOR THE APPLICATION AND THE PRACTICE OF THE COMPACT.
Since the new Health Code (1964) became effective, there have been several

- 93 -
inquiries and criticisms about the various aspects concerning the admission proceduret as prescribed by this law. Although the new code is certainly an improvement over the previous ones, these reactions confirm the validity of continuous re-evaluation of existing mental health laws. When there is a rapid change in concepts and attitudes about mental health and illness, it is only natural to reflect these modalities in the law. For this reason, the rapid progress Georgia is experiencing in the mental health field will continually exert pressure for better and improved legislation, based on sound medical and legal practices.
IT IS RECOMMENDED THAT THE RE- EVALUATION AND EXAMINATION OF THE EXISTING LAWS CONTINUE AND THE CHANGES BE MADE AS THEY SEEM NECESSARY.
B. Cost of Care Program and Needed Legislation The Georgia Department of Public Health is charged with collecting from patients at state institutions, or the persons who are legally liable for their support, funds to offset state expenditures for the care of patients at the two institutions when such patients or relatives are financially able to afford payment:. Unfortunately, the statute defining financial ability to pay uses the criterion of gross income as defined by Georgia income tax laws. Thus many sources, such as veterans disability and pension payments, social security benefits, insurance payments, inheritances and gifts, cannot be tapped to reimburse the state for the care of these patients.
Analysis of the "Cost of Care" Program in Georgia
Below is a table which shows the per diem cost of care for each of the two state mental institutions and per diem collections made by the Georgia Department of Public Health to offset per diem cost of care:

-94 -

Institution Milledgeville State Hospital
Gracewood State School and Hospital

-,._--Per Diem Cost of Care

(1961) (1962) (1963) (1964)*

$ 2.87 3.35 3.45 3.83

(1961) (1962) (1963) (1964)*

4.73 4.64 5.36 6.23

Per Diem Collections
$ .06 .07 .08 .09
.14 .16 .18 .22

Total Amount Collected
$ 280,235.81 327,844.34 341,670.83 291,565.85
69,092.13 79,983.79 86,874.36 79,415.04

Obviously the amounts collected in Georgia fall far short of the per diem
cost of care.
IT IS RECOMMENDED THAT TrlE PROPOSED REVISION OF THE PRESENT COST OF CARE ACT SHOULD INCORPORATE THE FOLLOWING:**
1. Chapter 35-11 of the Georgia Code Annotated providing for charges for treatment and care at state mental institutions should be completely revised.
2. The Georgia Cost of Care program should provide that all types of state and federal benefits from pensions, disability or death should be subject in some manner, and to some degree to the Georgia Department of Public Health for the cost of care of patients entitled to such benefits.
3. The Georgia Cost of Care program should provide that a patient's benefits from private life insurance, disability insurance, sickness and accident insurance, and pension and profit sharing plans should be subject in some manner and to some degree to the Georgia Department of Public Health for the cost of care of such patient.
4. A revised statute should provide that hospital insurance payments be accessible to the Georgia Department of Public Health.
5. A revised statute should set out in detail the persons who are legally responsible under the statute for the cost of care of such patients.
*Figures represent calculations through month of September, 1964.
*\'From the report of The Go~rn.oL s Commi !'IS10n for Efficiency and Improvement in Government: TL'eat"lUent': Fl:ograIDs for the l-fcnt"ally III and Mentally Retarded in Georgia, 1964.

- 95 -
6. A revised statute should prcvide for some type of effective enforcement procedure to assist the Georgia Department of Public Health in collecting payments due under the statute.
7. A revised statute should provide that where the patient is a beneficiary of a trust, estate or fund that the income and under certain conditions the principal of such trust, estate or fund, be liable for the patient's cost of care in that institution.
In general. community mental health programs use sliding fee scales which
obligate the patient to pay, within his ability, for the services he receives.
However, local public health programs, which provide the nucleus of present and
future mental health services in Georgia, are prohibited by law to charge fees. As
these programs are essential parts of comprehensive community mental health programs
and have to operate within the same basic philosophy of other program components --
such as inpatient, daycare and the like -- it will be necessary to incorporate the
necessary provisions in the law to permit them to collect fees for services. It
can be argued that this is in conflict with traditional public health principles.
However, local health department clinics will be heavily involved with direct treat-
ment services, more so than other programs of the same agency. In addition to the
administrative policies of community mental health programs, the therapeutic role
of paying for the service should be among the factors in favor of such an exception.
IT IS RECOMMENDED THAT CHANGES BE MADE IN THE LAW TO PERMIT HEALTH DEPARTMENT MENTAL HEALTH PROGRAMS TO CHARGE FEES FOR SERVICE ACCORDING TO THE FINANCIAL ABILITY OF THE INDIVIDUALS.

- 96 -
Chapter V RESEARCH M"D EVALUATION
Research is a search for knowledge and knowledge is the discovery of new facts or newly discovered relationships between already known facts. Research utilizes every known method of studious inquiry in its careful search for unknown answers. Mental health research is directed toward discovering new techniques for preventing and treating mental health problems and promoting good health practices.
A. Kinds of Research
There are basically four kinds of mental health research. The following categories, although somewhat arbitrary, are: (1) operations research, (2) applied research, (3) basic research and (4) demonstration project research.
1. Operations Research
Operations research, commonly referred to as program evaluation, is concerned with monitoring mental health operations and is essential in realizing eventual goals of mental health programs, whether they be viewed broadly or in detail. Modern science has developed valid methods of determining if programs are doing what they were designed to do. Accumulating and analyzing collected data from good reporting systems can aid program directors and their staffs in evaluating the effectiveness of their programs. It takes maturity, perhaps, for a program staff to be able to look at itself objectively or to have the effectiveness of their programs measured. In the past, we have felt that programs could be justified on the basis of what they "seemed" to be doing, based on personal opinion and feedback from recipients who testified that they had been helped. We now know that this alone is a haphazard and dangerous way to evaluate programs. The maturity necessary

- 99 -
remaining were educators, sociologists, speech therapists and others. Of the research funds expended, 30 percent went to private academic institutions, 21 percent to public academic institutions, 17 percent to the State Health Department and eight percent to Federal facilities. When asked to name the hindrances to research, 23 of the 60 Georgia researchers ranked lack of time as first, 17 lack of money and 11 lack of professional and technical personnel.
The Southern Regional Education Board, in commenting on the results from all 16 states, pointed out that only 0.4 percent of all the mental health manpower was devoted to research. Their Eurvey showed fields most in demand for research are o . medicine, psychology and other behavioral scien~es. There is a tendency for a great many disciplines to be rapresented in mental health research, extending from the biological to the social sciences. The qU93tionnaires showed that there was a desire for more short-term cour.ses, seminars and inservice training opportunities in the field of research desj.gn, methodolC'gy and statistics. These requests came particularly froo administrators in community agencies. The survey showed that clinical agencies were more apt to have formal arrangements for obtaining advice and assistance in forming research policies; whereas, in general, academic administrators leaned more toward inrvr.mality. Research administrators in both clinical and academic settings tended to def:i.ne their jobs as that of "clearing the way," leaving the inve::l1:igatol"s frea to do research. There was a clear trend that research in clinical s~t~L1gS "d;;:S more susceptible to other pressures, such as patient welfare, the in:3titut~_on's welfare and public opinion than it was in academic institutions.

- 100 -
c. !!tilt..Q2.__(o.!__fuU.J.dl~.&..~~ch and .yal'gation
lnt~~0l!go:i~n&.And Future Programs
Having reviewed some of Georgia's past efforts in mental health research, we will attempt to project some needs and plans for the future.
One of the most important needs is to allocate state appropriations, specifical] earmarl,ed for research. The state could decide how much it wants to spend by looking to other major sponsors and supporters of research such as: the pharmaceutical industry, which allocates six to eight percent of its gross sales for research; the Army, Navy and Air Force - ten percent of the annual budget; foundations as a group - eleven percent of total expenditures; universities - 16 percent of income; and the American industry as a whole, which allocates an average of four percent of its net sales to research. It does not appear unreasonable or unjustifiable to recommend that:
FIVE TO TEN PERCENT OF THE STATE'S BUDGET FOR MENTAL HEALTH SERVICES BE SPECIFICALLY ALLOCATED FOR RESEARCH.
Increased effort should be made toward developing positions in which persons have time and responsibility to research. It is recommended that:
CIVIL SERVICE POSITIONS BE DEVELOPED FOR RESEARCHERS. THERE SHOm,D BE POSITIONS BOTH FOR RESEAR'::H TECHlUCIANS AND RESEARCH SCIENTISTS AT THE JU~IOR AND SENIOR LEVELS.
In addition to full-time staff with full responsibility for research, there needs to be support and encouragement of other staff members to engage in part-time research.
State money should be made available to support part-time or inexperienced researchers or small projects unlikely to be eligible to receive support from the federal government or large foundations. It is recommended that:
FUNDS BE SET UP FOR SMALL GRANTS TO ENCOURAGE BUDDING RESEARCHERS AND PROJECTS.

- 101 -
Increased awareness of research needs and good research practices should be developed. It is recommended that:
FUNDS BE AI,LOCATED FOR RESEARCH SURVEYS, WORKSHOPS AND FIELD TRIPS. The nature of the research effort makes it a difficult endeavor to administrate. This probably can best be done by a research office having a full-time research coordinator assisted by an interdisciplinary advisory committee. The advisory committee should have a rotating chairmanship and be composed of research scientists, within and without the health department, representing the best research know-how within the state. This office would administer research funds and grants, coordinate research being done throughout the Division, relate research being done by other agencies and universities in the state and offer or arrange for consultation to researchers. It is recommended that: THE DIVISION OF MENTAL HEALTH SET UP A RESEARCH OFFICE WITH A RESEARCH COORDINATOR ASSISTED BY AN INTERDISCIPLINARY ADVISORY COliMITTEE. There is a need for an inter-departmental state research center. This would be an administrative structure primarily for the purpose of stimulating research. The center should take responsibility for publication of a mental health research journal. Additional functions of the center would include conducting professional workshops and seminars on research and informing the public on what research efforts their tax dollars are buying. Also included could be a cooperative information service between all departments, agencies, and universities in the state engaged in mental health research. Informational service centers already exist on the national and international levels such as the Joint Information Service of the American Psychiatric Association and the National Association for Mental Health. There should be affiliations between the state informational service center and those at the national and international levels.

- 102 -
The research center could be directed by a governing committee composed of members from all departments and agencies which choose to become members of this cooperative effort. Part of the cost of the operation could be supported by subscriptions for services by member organizations. The center could be developed in stages, starting with one service, such as joint information, and adding others as needed. It is recommended that:
THE DIVISION OF MENTAL HEALTH TAKE INITIATIVE IN STIMULATING THE DEVELOPMENT OF A COOPERATIVE INTER-DEPAR1MENTAL MENTAL HEALTH RESEARCH CENTER. The kind and extent of the reporting system used by the Division of Mental Health is an important factor in facilitating research efforts, especially in the area of operations and applied research. Reporting systems could continue to be developed department-wide, possibly based in the Division of Epidemiology. The Division of Mental Health could then develop from the basic system the unique reporting needed for its program evaluation and applied research. An office set up to serve as a central clearing house for all department reporting would be useful in avoiding duplication of data collection efforts. All four types of research operations, applied, demonstration project and basic -- should be encouraged and supported in compre~nsive mental health programs, regional state hospitals and the Mental Health Institute. Some facilities will by necessity emphasize certain types of research. For example, the Mantal Health Institute may primarily emphasize basic and applied research, with less emphasis on project demonstration and operations research. The reverse is likely to be true in comprehensive community mental health centers. It is recommended that: ALL MENTAL HEALTH FACILITIES HAVE ACCESS TO AT LEAST ONE RESEARCH SCIENTIST WITH FULL RESPONSIBILITY 1'0 RESEARCH. IN THE CASE OF SMALL FACILITIES t POSSIBLY THIS PERSON COULD BE SHARED BETWEEN SEVERAL FACILITIES OR EMPLOYED ON A PART-TIME BASIS.

- 103 -
The research carried on in all settings of the Division of Mental Health should be closely coordinated with research being done in university settings, for it is there that most of the basic research is carried on. Just as there needs to be a two-way flow of communication between research and practice, the same should exist between settings doing primarily basic research and those doing primarily applied research. Closer communications could feed new discoveries and findings from basic research into practical research that could and should be applied to prevention and treatment. In turn, applied research, by feeding problems involving application into the area of basic research could stimulate and possibly direct new areas of investigation.
Today, basic research enjoys high prestige and status. The nature of and need for this kind of research is very well understood and represented nationally. However, we are lacking in understanding and support of applied research, operations research and the demonstration projects. We need to increase our investment in these areas of research to obtain answers to such questions as: How can we better operate our programs? How can we better practice some of the techniques and ideas already demonstrated by basic research? What are some of the new and bold approaches we should be taking toward solving mental health problems? How can we improve our ability to disseminate new knowledge so that it will change the practices of personnel in our mental health facilities? Even the problem of how we can find more program staff involved in research should be submitted to applied or operations research for some answers!
A researcher's frame of reference influences what he observes. For example, a person trained in a specific behavioral science, such as psychoanalytic theory, will make observations along certain lines and ignore others. Thus, it is important for the individual to be sensitive to new points of view or even non-traditional

- 104 -
approaches. Such shifts in observations could help direct attention and effort toward new approaches, which, in turn, could bring new discoveries leading to the development of new techniques.
Research efforts should be multi-disciplined in administration and investigation for no one knows from what field some of the answers to mental health problems will come. Thus, all disciplines concerned with human development and functioning should be encouraged and supported in their research efforts.

- lOS -
Chapter VI HEALTH EDUCATION IN MENTAL HEALTH
A great deal of time, energy and money have gone into defining mental health problems and it is probably safe to assume that we have a good idea of what has been done and what needs to be done to achieve sound mental health programs. But the question that has not been considered to any great extent is how can we, as citizens in our communities, promote mental health and prevent mental illness? How do we see that community resources are developed and utilized? How can we help alleviate the manpower shortage or encourage the enactment of needed legislation~
In an attempt to clear up some of these questions, it is felt that it would be beneficial to discuss some basic information that could be helpful to individuals or groups interested in developing health education activities within their own communities or organizations. Despite the fact that no two communities are alike in terms of the extent to which they can develop educational programs, every community -- no matter how swall -- has someone who can do something.
{{here Does Mental Health Education Take Place?
Mental health education begins in the home where values children place on healthful living and the degree to which they carry out desirable practices are determined. It continues in the school, which builds upon the foundations that are laid in the home, and is extended into the community through the application of sound health principles for all community residents.
Mental health education, as a part of health education, has two distinct goals.
One, which can be called education l2! mental health, seeks H to help indiv-
iduals manage their own lives better and achieve better mental, emotional and

- 106 -
social adjustment. 1i 1 Education for mental health takes place first in the home, second in the school and third in the community.
The other, education about mental health, or illness," . seeks to inform people in general about the facts bearing on mental health in their communities
2
so that they may work to improve relevant conditions." Education about mental health or illness takes place first in the community, second in the school and third in the home.
Although the former may sound easier to accomplish, it is actually more difficult because, first, it is more closely related to therapy and, second, it is less amenable to critical evaluation. Education about mental illness, on the other hand, is an easier concept for communities to deal with, in that change or improvement can be measured in terms of social action. This, in turn, results in something tangible, such as expanded facilities, additional counseling services, and the like.
Mental Health Education in the Schools
"Every school has numerous opportunities to promote the health of pupils and members of the community. Most boys and girls are enrolled in schools and are under the supervision of school staffs for a substantial part of the day for approximately half the days of the year. The conditions under which children live in school, the help they are given in solving their health problems, the ideals of individual and community health which they form, and the information and understanding that they acquire of themselves as human beings influence the development of attitudes Bnd behavior conducive to healthy, happy and successful living. In
1 Mental lle~lt:h EducaHnn! A Cririqllla. _Pa~ )fenr.ql. Healt-h. Inc :Philadelphia, Pa., 1960. p. 112.
2 Ibid.

- 107 -
all of its efforts the school must consider the total personality of each pupil and the mutual interdependence of physical, social and emotional health."l
However, the school cannot accomplish all this by itself. Since it is the parents who have the primary responsibility for the health of their children, the health education efforts of schools, health departments and other agencies should be aimed toward helping parents recognize and assume their responsibilities. But it is only through close cooperation that efforts will be successful in developing balanced programs of health and health care.
Community Coordination
One of the ways such coordination can be achieved is through the organization of a school health councilor committee. As an organization representing communitywide interests, school health councils can be effective in promoting coordination, evaluating progress and planning future developments. Depending upon the problems to be dealt with, membership in the council may vary. For example, if activities are confined to a single school, the committee might be composed of teachers, parents, a physician and a public health nurse; should the problem be centered around mental health -- a psychologist, psychiatrist or social worker might be included on the committee; often pupils may be asked to serve.
School health councils can also be organized on a city or district-wide basis; however, their purposes are somewhat different from those of individual school councils. The city or district council provides an opportunity for representatives of various groups or organizations, such as P.T.A.'s, health departments, departments of family and children services, school administrators, medical professions
1 Suggested School Health Policies. J. Com. Health Problems in Ed. Nat'l Assoc. of Ed. Am. Med. Assoc. 1956: p.l.

- 108 -
and social and voluntary agencies to meet conjoined. The composition of this committee, too, may vary from time to time, depending on the particular area of interest.
There are additional ways those in the community, who are interested in doing something about health education in the school, can work together. For example, individual conferences between teachers or teachers and nurses, staff meetings between the school staff and the health department, and periodic or special case conferences involving teachers, school counsellors, visiting teachers and health personnel provide excellent opportunities for planning and carrying out health education programs. Seminars, work conferences and workshops are becoming increasingly important tools for joint study, planning and action. These seminars or workshops may be sponsored by official agencies, such as the health and education departments, or various voluntary and social agencies. As an example, the Georgia Association for Mental Health has been sponsoring workshops at Milledgeville State Hospital for school counsellors.
School Programs
There are many methods of incorporating health education into the school's curriculum and every opportunity should be utilized for strengthening desirable health behavior and understanding. One of the greatest contributions the school can make toward the child's total education is to help him understand himself and others.
Because the child's emotional health reflects his experiences at home, in school and in the community, the school cannot be responsible for counteracting the effects of all unfavorable experiences. However, it does have the opportunity for working with children in light of these problems through each of the three

- 109 -
main parts of a school health program: (1) school health services, (2) healthful school living, and (3) health instruction. Too often we think only of the latter instead of the total program when we think of health education for and about mental health.
School health services which include: health appraisal, guidance and followup, emergency care, communicable disease control and care of the handicapped offer opportunities for the child to increase his knowledge and understanding of mental health concepts. For example, schools which offer special classes for handicapped children provide the other children with opportunities to understand that because a child has problems does not mean he is a person without feelings and that he too can grow up and be a part of the community. The positive manner in which the school itself handles these problems will also help determine the kinds of attitudes that future generations will have toward the mentally ill and the emotionally disturbed.
The kind of enviromnent the school provides, the manner in which the school is organized and the quality of interpersonal relations between teachers and pupils (which are all part of healthful school living) are important to mental health. They are also important to mental health education, for the school has an opportunity to mold attitudes and from such attitudes are formed the adult's opinions about mental health.
The third part of the school health program, health instruction, often has been limited to teaching health in a special, prescribed time period, in a certain grade. Systematic health instruction can be woven into the total curriculum through: (1) direct health instruction by means of planned health units, scheduled health classes and special health courses; (2) health units which are incorporated in other parts of the curriculum, such as in home economics, physical education,

- 110 -
social studies and so forth; and (3) planned integration of health concepts and health education activities throughout the curriculum.
Teaching Areas
Health education in elementary school is primarily the responsibility of the classroom teacher. Teaching at this level is directed toward helping children develop and maintain desirable habits and attitudes toward healthful living. Because the child's interests and needs vary so from day to day, the exact amount of time needed for health education cannot be stipulated other than to say that the time allotted should be at least equal to the time devoted to other major areas of the curriculum.
The emphasis at the junior high school level should be placed on each student's personal health problems, helping him to secure an increased understanding of health behavior in the home, school and the community. At the senior high level, course content should primarily center around problems of adult living such as: emotional health; personal adjustment; family living; child development; utilization of professional health services; organization and function of local, state and federal health agencies; industrial health; and responsibilities for community health.
Many times the parent's knowledge about health care of children is limited and because education of parents is a part of the broad program of community health education, it is important for schools to cooperate with other community agencies in conducting a program of health education for adults. Initiative for such a program may come from the schools, health departments or other community agencies. However, the final program should grow out of C'oopel:af:.:i.\'e planning and sharing of resources of P"'H:'''h'nnel "faci Ii,ti.es Dnd equipment.

- 111 -
Health Education in the Community
Every community has someone who can do something to help promote mental health. Finding these persons and defining their roles becomes the challenge.
Most communities already have organizations which have been active in varying degrees. For example, local mental health associations, local health departments and departments of family and children services, women's clubs, leagues of women voters, parent-teacher organizations, health councils. health and welfare agencies and garden clubs, to name but a very few. are dotted allover the stat~ and the majority of these groups have mental health chairmen or mental health committees. Unfortunately there is little coordination between such organizations.
There are many individuals -- physicians, mental health professionals, teachers, home demonstration agents, agricultural extension workers and others -- who also have an interest in furthering education in mental health. Here again the need is for a coordinated effort, with purposeful planning so that such activities will complement each other, and eliminate wasted effort.
Starting Point
One of the ways this has been accomplished has been through the organization of inter-agency case conferences where representatives of those agencies rendering services to individuals or families in a particular community come together to discuss mutual problems and ways of coping with them. These have proved to be excellent tools for uniting the efforts of these agencies, but this should be regarded as only One part of a total program. Consequently, communities need to coordinate their efforts in educational activities so that they fit together into a meaningful pattern.

- 112 -
The question that arises is -- where do you begin? As stated in the pub Iication: Local Meptal Health Planning .- A Guide For Georgia Communities, n These are numerous resources in every community which can be used to remedy many of the problems of mental illness. One of the methods of co-ordinating these resources is through a local planning group."
One of the things that this group might do is to look at its community in terms of mental health needs and resources. There are several ways this can be accomplished but one of the most common is the use of a community self-survey. However, before a community undertakes such a project, it should ask itself if facts are already available? In other owrds, has someone already done this same thing and who would know about it if they had?
Surveys can be conducted by outside specialists or by citizens themselves. However, most surveys done by the former are often high on facts but low on action because the people themselves are not actually involved. And since education is involvement, citizen's surveys, if they are well-planned are good educational tools.
The steps a small or medium size community should consider in conducting a citizen's survey include:
(1) The scope and size of the survey -- What particular areas should be covered and included.
(2) Sponsorship -- \~at group(s) or organization(s) rank high in prestige in the community and yet have the ability to organize and launch such an undertaking.
(3) Cost -- What expenses will be involved for supplies, publication of report, secretarial work, etc.
(4) Organizing survey committee -- Who should be included - representtatives of various group and organizations? Formation of subcommittees according to major outline of the survey (economics, government, health, welfare, education, etc.)

- 113 -
(5) Survey chairman -- ~10 can insure that each sub-committee is assembling meaningful information, assign persons to specific tasks, lend support, and assemble the results and draft material.
(6) Preparation of survey forms -- Forms should be designed according to information desired.
(7) Conducting field work -- All workers should be given adequate instructions as to what is expected of them; material should be recorded; the importance of requesting definite answers to specific questions, and to avoid liyes" and "no" answers when misleading.
(8) Writing survey report -- Should be simple and direct, using graphs and charts to illustrate points.
(9) Publicity and follow-up -- Let community know what is being done from the beginning; sustain interest through use of mass media, speeches, letters, etc. At the conclusion, hold a dinner meeting, for example, invite the press and mail copies of report to those who could not attend.
Educational Resources
Another important consideration for an overall community health education
program is to investigate the potential resources for health education that exist
both within and outside of the community. These might include people, places or
things, such as speakers, colleges, state and local agencies, the press, radio and
television and educational materials.
Physicians, for example, along with serving as excellent resources for case
finding are important in educating families about mental health and mental illness,
as well as for mental health. The local pharmacist is another person in the
community to whom people turn for health information. Others, include the public
health nurse, the clergy, policemen, and even local bartenders and taxi cab drivers.
These people are not only knowledgeable as to what is going on in the community but
are excellent for disseminating health inormation~ especially to people who are
trying to find out .where they can go for help.

- 114 -
Aside from the mass media, there are numerous other communications channels available to the community. Individual contacts, in the form of visits, letters and telephone calls, along with group contacts -- conference and discussion meetings, lectures, buzz sessions, panel discussions and seminars are all important resources for influencing people to change existing behavior patterns. (This is especially true for people in lower socio-economic groups who do not rely on radio or television as their primary source of information.)
It is interesting to note that people read. listen to and pay attention to communications that interest them, are important to them and are in accord with their current beliefs, customs. habits, attitudes and traditions. For instance, usually those who are already knowledgeable about health matters are the ones who read health columns. Thus. many of our attempts to communicate to people through pamphlets, newspapers, radio and television reach only those who are already motivated to some degree.
The mass media, however, are the most efficient means we have to disseminate health information to the largest numbers of people in the shortest time. They also provide the additional and often the decisive stimulation that is needed to channel existing motivations into action.
It follows, then, that the same channels or means of communication cannot be used indiscriminately across the board. Some programs may require the support of only certain kinds of people in the community, others may need full popular support. The decision as to what channel or channels of communication to use will be based on a careful analysis of ~ we whet to do ~, and in what kind of a community. To be able to do this takes time, knowledge. an understanding of people and planning.

- 115 -
Planning Educational Aspects of Health Programs
Health education \vi11 be expected to play an even more important role in future mental health programs than it has in the past. This will include state level programs, regional, multi-purpose hospitals and community mental health programs. Because eacll program will be serving different publics and will have different objectives, each will have to be planned accordingly. For example, many of the health education activities in a regional hospital will be directed toward the hospital staff, the families of the patients and the patients themselves, along with the total community.
In planning an educational program there are five basic elements that should be considered: (1) knowledge, (2) individuals, (3) the environment, (4) methods and materials, and (5) evaluation.
(1) Knowledge -- Each field has its own body of knowledge which it has acquired through scientific research as well as practical experience, and the mental health field is no exception. Since no one individual could possibly be expected to have all this information at his fingertips, he has to turn to those who can help him. But the important point to remember is that he has to know ~ and where to turn for help, because knowledge must first of all be sound -- gross assumptions, hunches and guesses are no substitutes for facts! Second, it has to be communicated or presented in a manner -- whether it is written or spoken that is understandable and third, it should be appropriate for those for whom it is intended. For example, the average layman would not be able to grasp the same details concerning the use of drug therapy in treating mental illness that a pharmacist would. TIlerefore, it is important to be selective in the kind and degree of information used, with the idea in mind that often times information must be given in progressive doses.

- 116 -

~,

(2) The lndivtdual -. The next important element in planning ia deciding

who it is that we want to help and what do we know about htm. How does he feel

about the world in which he lives? What are his customs and ideas? What influence

has his community had on him? How has he learned to cope with life? Unless we

know some of these things about the human personality, we can never hope to be able

to work with people.

Man has his biological needs, such as eating, sleeping and survival, to contend

with as well as his "ego-social" needs -- feelings of personal worth, recognition

and status. The important point to consider in planning educational programs is

how does the individual actually evaluate his biological and ego-social needs in

terms of importance for his own personal life and in relation to others in his

community? For example, does John Doe believe that adding psychiatric beds to the

general hospital instead of putting a traffic light at the end of his street will

increase his chances for survival?

A person's basic intellectual capacity and his educational level are as import~n as his previous knowledge and attitudes. Nunnally 1 found that the "average man" is,.,

not so much misinformed about mental health as he is uninformed, and what information

he does have exists largely in an abstract system. He is relatively unsure of his

opinions about mental health and consequently, eagerly looks to the experts for the

answers.

Nunnally also reaffirmed the concept that a stigma does exist concerning the

mentally ill, but that the stigma is very general, cutting across social groups. His research suggests that 2 one fl of the cornerstones of public attitudes is the

feeling that the mentally ill are unpredictable and . . consequently, most people

1... Nunnally, Jum C., Jr.: Popular Conceptionspf Mental Health. Holt, Rinehart and Winston. Inc., New York, 1961. p. 223
2 Ibid.

- 117 -
>,.~
~": . r~
are uncomfortable in the presence of someone who is, or purported to be, mentally ilL II
The access an individual has to sources of information raises two questions. First, what resources are available to him -- libraries, social agencies, newspapers, radio and the like, and the second, where does he go for his information? For example, how many people will be informed through the medium of educational television if they do not have (1) a television set, (2) a television set equipped to receive an educational television channel, (3) a channel that could be picked up even if they had the equipment, and (4) the inclination to look at television for other than recreational purposes?
The attitudes people have toward health workers are vital in determining whether or not they will accept what they have to offer. It has been demonstrated that the public health nurse can open doors that no one else can, especially among certain socio-economic groups. Nunnallyl also found that the general public holds moderately high, favorable attitudes toward psychiatrists, psychologists and other mental health professionals as individuals. What is "wrong" with public attitudes he goes on to say is " a moderate distrust and devaluing of mental-treatment methods and institutions. Consequently, the emphasis in information programs should be on improving attitudes toward the tools and methods used by mental health specialists ."
(3) Environment -- Everyone is a member of a particular community, no matter how large or how small, and within that community are certain factors that influence hm~ he feels and what he does and what he can do. Many people in the state are literally unable to seek mental health care because of the total lack of facilities,
1 Nunnally. Op.Cit. p. 223

- 118 -
and others, because of a lack of transportation or long distances to travel have no easy access to those that are available. Educating people to take advantage of services they neither have nor can utilize does nothing more than to create anxiety. (This differs from educating people to see that services are made available.)
A person's actions are deeply rooted in what is referred to as "primary education groups" -- family, friends and social groups. This means that ideas, ways of coping with problems, handling situations, and so forth, especially in more isolated tightly knit communities are perpetuated and passed down from one generation to another. A community should analyze its own attitudes and their source; then determine the most effective means of improving the environment.
Action results in being able to influence the opinion leaders or so called power structure of the community, whether the community consists of a block in a large city or an entire town. Sometimes these peoplemay be obvious or indigenous leaders and who they are will vary from one community to another.
(4) Methods and Materials -- In planning as well as implementing educational programs, it is highly important to select appropriate methods and materials suited to the program's short and long range goals. Sometimes the individual approach (informal, person-to-person or interview methods) can be used, and other times the mass media are important -- radio, television, and the newspapers. Sometimes group procedures -- single meetings, classroom instruction or a community study, planning and action groups are more appropriate.
(5) Evaluation -- One of the most important parts of an educational program, but often the least considered, is building in methods of determining how far a program has accomplished what it set out to do. Because evaluation is a continuous process, it should proceed concurrently with the program itself. This means it is

- 119 -
necessary to know the health status of the group exposed to the educational program itself. As the program or project develops, periodic stock should be taken to answer such questions as, "what has been accomplished so far?" "Where are we now?" "lfuat more needs to be done?" Evaluation should be made at the end of the project or program to determine results which will also aid in future program planning.
There are several instruments or devices that can be used to measure progress such as observation and listening, interviews and conferences, check lists and questionnaires, records and reports, surveys and so forth. Judiciously selected, these can be effective tools to help insure the successful implementation of any project or program.
Recommendations
Therefore, it is recommended that:
COMMUNITIES SHOULD ANALYZE THEIR RESOURCES, BOTH INDIVIDUAL AND ORGANIZATIONAL, AND DEVELOP MENTAL HEALTH EDUCATIONAL PROGRAMS USING THOSE COMMUNITY RESOURCES. SCHOOL PROGRAMS IN MENTAL HEALTH SHOULD BE ENCOURAGED. EMPLOYMENT OF PROFESSIONAL HEALTH EDUCATION PERSONNEL SHOULD BE ENCOURAGED IN LOCAL HEALTH DEPAR1MENTS AND OTHER APPROPRIATE CO~~ITY AGENCIES FOR THE FURTHERING OF ALL EDUCATIONAL ASPECTS OF ALL COMMUNITY MENTAL HEALTH PROGRAMS.

APPENDIX I

Facilities surveyed for Data Collection in Mental Health Planning Project

1. Inpatient Hospital Facilities (those starred also provide outpatient services)

Allen's Hospital - Milledgeville

Anchorage - Albany

Brawner's Hospital - Smyrna

Candler Hospital - Savannah

Charity Hospital - Savannah

Chatham Memorial Hospital - Savannah
* Emory Universi~y Hospital - Atlanta

Georgia Infirmary - Savannah

Georgian Clinic Grady Hospital

-

-

AAtltalanntata**

Harbor - LaGrange

Hope Haven - Braselton

Macon Hospital - Macon

Medical Center - Columbus * MNoilrltehdsigdeevi1l1laenoSr ta- teAtHlaonstpait*al

-

Milledgeville

*

Oglethorpe Hospital - Savannah

* Peachtree Hospital - Atlanta
Phoebe Putney Hospital - Albany

* St. Joseph's Hospital - Savannah
Talmadge Hospital - Augusta

Tidewater Hospital - Augusta
w. University Hospital - Augusta

Veteran's Administration Domiciliary Dublin

Veteran's Administration Hospital - Augusta

Veteran's Administration Domiciliary - Thomasville

Victory Home Tallulan Falls

2. Outpatient Facilities (in addition to those starred above)

Guidance clinics in local health departments: Bibb County, Chatham County, Cobb County, DeKalb County, Dougherty County, Floyd County, Fulton County, Glynn County, Muscogee County.
Bradley Center - Columbus Chatham Clinic for Alcoholism Savannah Emory Children's Clinic - Atlanta y~ Clinic ~ricus University of Georgia Clinic- Athens Veteran's Administration Regional Office Outpatient Clinic

3. Nursing Homes

Georgia Nursing Homes, Inc. Paradise Nursing Home Plains Convalescent Home, Inc. Goodwill Home

Johnson's Convalescent Home Happy Haven Home Martha Ivey Nursing Home Atlanta Convalescent Home

-ii-

Laura Be 11 Nu:;: sing Home Fidelis Nursing Hor~, Inc. Blakely Convalescent Home Twin oaks Nursing Home Georgia Grace Brown's Nursing Home Kennedy Memorial Nursing Home Pulaski Nursing Home Christ Sanctified Holy Church Nursing Home Ideal Nursing Home The Oaks Nursing Home Chapman Convalescent Home Bethany Home For Ladies Precious Nursing Home Fair Haven Nursing Home Boadwright Boarding Home Collins Nursing Home Central Nursing Home Ralschaven Nursing Home Hillcrest Convalescent Home Dalton Nursing Home Norman-Versen Convalescent Wing Sunrise Nursing Home
'rhe Rest Awhile Home
Whispering Pines Nursing Home The Presbyterian Home Lawson's Boarding Home Cherokee Acres Restorium Coker Medical Nursing Care Home Negro Old Folks Home Franklin Nursing Home Worthy's Nursing Home Alvaton Convalescent Home College View Rest Home
The Bell-Minor Home 'relstar Minor Convalescent Home
The Be 11 Home Cumming Convalescent Home
Cile Cook Home Middle Georgia Nursing Home Ebenezer Convalescent Home
Pine View Rest Home Northwest Georgia Medical Care Unit Elsberry Nursing Home Waters Nursing Home Faith, Hope and Charity Rest Home Westberry Nursing Home Nellie Killingsworth Nursing Home Memorial Nursing Home Yearwoods Nursing Home Crane Retirement Home Twin Oaks III

Valley View Rest Home Cedartown Convalescent Home #1 Cedartown Nursing Home #2 Langham's Rest Home
O'Nelll's aurstna Home
Peek's CQDv~le8cent Home Re8~ HaftD RuE'sloS Home Summerville Park Rest Home Ware's Convalescent Home Dixie's Rest Home White's Nursing Home Holliman's Nursing Home Virginia's Convalescent Home Amelia Sullivan Old Folks Home Anne-Marie Convalescent Home Smith Convalescent Home Myers Rest Home Bayvale Rest Home, Inc. Marioni Convalescent Home Winter's Rest Home Marnona Rest Home Raul's Convalescent Home Anthony Home
Bibb S~led Nursing Care Home 2
Goodwill Nursing Home Heath Nursing Home Memorial Nursing Home Lynn Haven Nursing Home Inez Thitford Nursing Home Pine Mountain Rest Home Restmere Convalescent Home, Inc. Wildwood Nursing Home Muscogee County Nursing Home
Meadowbrook Nursing Home Little Nursing Home Emory Convalescent Home Briarwood Nursing Center, Inc. Bella Vista Convalescent Home Stone Mountain Manor Nursing Ho~
Mary Elizabeth Nursing Home #2 Mary Elizabeth Nursing Home #1 Blair Nursing Home Norman Nursing Home Mary B. Moody Nursing Home DeKalb Convalescent center Savannah Beach Convalescent Home Cohen's Old Men's Retreat Victory Drive Convalescent Home Chatham Nursing Home Countryside Convalescent Homes Stafford's Convalescent Home Mills Memorial Home Amilia Sinclair Hall

-iii-

Hall Home for the Aged Sky Ranch Nursing Home Styron Nursing Home Highview Nursing Home Lusk Nursing Home Camilla Street Nursing Home A.A.A. Martin Nursing Home College Park Convalescent Home Home For Old Women Biddys Nursing Home Craig Nursing Home Our Lady of Perpetual Help Home Patterson Nursing Home The Jewish Home A. G. Rhodes Home, Inc. Ann Epting Nursing Home Mattie Elizabeth Memorial Nursing Home St. Charles Nursing Home St. Mary's Nursing Home Morris Nursing Home Rawlings Nursing Home

Grandview Manor Rest Home Dix Rest Home Maters Nursing Home Oakdale Nursing Home Rest Haven Nursing Home Shady Oaks Nursing Home Walton Co. Hosp. Convalescent
Unit Monroe Nursing Home Vecha's Rest Home Smith's Convalescent Home Lipscomb Nursing Home Mocking Bird Hill Rest Home Green Acres, Inc. Zebulon Nursing Home Hilltop Nursing Home Bethany Home for Men The Pines Nursing and Convales-
cent Home, Inc. Keysville Convalescent Home Gibson Rest Home

4. Other Services and Facilities

State Board of Corrections - Reidsville and Alto
Special classes for the emotionally disturbed in Atlanta, Milledgeville &
Savannah
Vocational Rehabilitation clients

APPENDIX II DATA COLLECTION FOR ALL FACILITIES
ESTIMATED NUMBER OF PERSONS RECEIVING SERVICES DURING A YEAR BY DIAGNOSIS AND AGE GROUP, GEORGIA 1963

Age Group

Diagnosis A. P.A. Code*)

-

20.24125'-34 135-44 45-54 5564 65-74175 Up ~nknown

TOTAL

I
I 46,722 II

i 3,339 8,859 110,957 8, 821 13, 97812.32&11,1&& I 920

! ACUTE BRAIN DISORDERS (01-09) j 1.173

sol 15 126!. 360' 403 I 1591

6 I 23

ACUTE BRAIN SYNDROME:

Associated with Infection (01

Associated with

Intoxication (02)

Associated with Trauma (03)

Associated with Circula-

tory Disturbance (04)

Associated with Convulsive

Disorder (05)

I Associated with Metabolic

Disturbance (06) Associated with Intra-

I

cranial Neoplasm (07) With Disease of Unkno~l or

I
I
II

Uncertain Cause (08)

I

Of Unknown Cause (09)

!

I

i

18

I
I

-

- 974 ! 2 16

19

1
IIii

-

211 -

II

- 2/~ i'il

Ii
- 2 ii:i

all ;1
110 II

--

I.

. -
1
11
-iI I
I
-II
-;i
11
I

1

I
1I

II
5

3

I
151

I
i
-i
I
-I I i
-I
1! I I I
-i
21
I

9
8
I
:I I
1
-II
I
-I
~
I

12.1I
- I1

.108 1 -

I II

315 3
1

-

-

-

-I

Ii
2

7

-

- I 11

340 I 133

-

1

-I 5 I

4
I

1

12

2I

- .1

-i - -I ! !2

10! 255

44

12211

I

I 1

I

321
11
8i
JI'
11
-I
~

21 21

-

1

-I 1

J

4

DATA COLLECTION FOR ALL FACILITIES ESTIMATED NUMBER OF PERSONS RECEIVING SERVICES LURING A YEAR BY DIAGNOSIS AND AGE GROUP (CONT'D)

Diagnosis (A.P.A. Code*)

~\

I Ag~GrOUD

"'\

Total 0-415-9 110-141 15-19 120-24125-34 135-44 1 4$'-541 55-64 I 65-74175 Up IUnknown

I CHRONIC BRAIN DISORDERS (10-19): 6,232

I

I CHRONIC BRAIN SYNDROME
ASSOCIATED WITH:

I
I

Diseases and Conditions Due

To Prenatal Influence (10)

67

Central Nervous System

I 51! 67 i 138
I

I

I
6\

10

I

10

Syphilis (11)

433

1I

-I

4

Intracranial Infection Other Than Syphilis (12)
Intoxication (13) Trauma (14) Circulatory Disturbance (15) Convulsive Disorder (16) Disturbance of Metabolism,
Growth or Nutrition (17)

i 102
~ I ~ 246 i'
444 9 j 15
I 2,332 12

I 990 Ii

1 6

21-

1,180 ~'j 5 i 2,

I
111
3~ I
66

New Growth (18)

7 Ii - i - I 1

Diseases of Unknown or Uncertain Cause; Chronic Brain Syndrome of Unknown

II:i

I
I

I

I

or Unspecified Cause (19)

431 I I

71 14 I
II

13 1

I PSYCHOTIC DISORDERS (20-25*)
Involutional Psychotic
I Reaction (20)

17,116 11113! 20

Ii

I

1,014 if 4\

112 !

- i 6 I Affective Reactions (21)

, 2,696 II 21 I

Schizophrenic Reactions (22)
2~ 110~ I Paranoid Reactions (23)
Psychotic Reaction Without

113,026 118
;I

:q,
hI,

88,
- II
i

Clearly Defined Structural I

'i I

I

-I I Change Other Than Above (24~

I Psychotic Reaction,

"

Unclassified (25*)

7 IIII ' 255 I"i -!i

_ ,I

1

234 239 492 619

718! 1,049 11,36711,041 217

i

I

14

7

9 I 71

4i

4

12 1 82 148

10~

52

18

2

5

9

5

24

24

I 4; 49

8 78

39 87

1

1 15 38

134 138 227 193

:I 3 I

8

18

2

14 99 58 l8l i
135

I3

3

1

62

19

I 39

20 1

680 880

40 I 11

9'
41 39~1

2
6
8
123 19

;

2~1

103
2

359: 617 39
-' -I1

25 I 241 41
863 !1,729 I 4,446

,- I 73 1741 5776

761 \1,528 3,786

-i

2

15

63
4,521
148 617 3,630 48

94 68 571

I

3,115 1,303 I

1

I

4011
I

517 267

43i

578 399 167:

1,950 609 173:

14 19 15

I
10 1 15

60 433

9 19

33 51

16 360

2

3

4

3

29 24 58 78

56

9

jI

-!

-!

DATA COLLECTION FOR ALL FACILITIES ESTIMATED NUMBER OF PERSONS RECEIVING SERVICES DURING A YEAR BY DIAGNOSIS AND AGE GROUP (CONTID)

Diagnos is (A.P.A. Code*)

' I -:--:--:--::---:--:'""::'--:-::-r-~--::-::--r--=-=-~A~ce~.$~G=-=r=-=o:.:P:~:u-~:-:-.--;-::~--:--;--=-=--:-~-=-=---=-=..-=-::-----r'---::---Total 10-4 5-9 1 10- 14 15-19 20-24 25-34135-44 45-54 55-64 65-74 75 UP! Unknolil

PSYCHOPHYS IOLOGIC, AUTONOMIC AND VISCERAL DISORDERS (29*-39)

'I
406 - 9

PSYCHOPHYSIOLOGIC:
Reaction, Unclassified (29*) I
Skin Reaction (30) l1usculoske1eta1 Reaction (31) Respiratory Reaction (32)

Cardiovascular Reaction (33) 'I

Hemic and Lymphatic

Reaction (34)

'I

Gastrointestinal Reaction (35) Genito Urinary ~eaction (36)

Endocrine Reactl.on (37)

Nervous System Reaction (38) I

Reaction of Organs of

'I

Special Sense (39)

17 I
I 10
I 20
14 i
96 \
1I
71 II
7I
21: 1661
I
2',

--- ,I

-
1-,

-
-

Ii --II

I

I - j -

-! 3 I

-I 3I

-' -,

I - ,I 2'
-I -

PSYCHONEUROTIC DISORDERS (40)

I I I I ,
8.523 22 87 1

fERSON~l~ :D.~S (~,"'~J)

Persona1Lty Pattern

Disturbance (50)

I

Personality Trait

'

Disturbance (51)

Sociopathic Personality

Disturbance (52)

Spe~i:al S)lmptom Reaction (53)1

I 6,842.!
453
I1
I 1,000
5,333,
56

8 II 62

-

13 II'

- 221

II
79

1 18

TRANS IENT SITUATIONAL PERSONALITY DISORDERS (54)

II ' I '

I
1,201 II

14

i
315 1

7

15

-I 1

1

-

1

2

2

1

1.

3

- II -

2I 3

-

2

-

-

-

2,

-I

I
1I

I

I

I1JI 311

164 1 491

42 39

59 115

32 332 I 31, 5
II
352 i 322 i

I

I1 :I

22

64 1171 112

31

28

-1

1

-I
1

I : I

!

I2-I

5 3

1

7

8

1

-

-1

-

1 2

2 6

2\ -

--II

--

-

3

3

I5 I 27

43

-I -. -

151

8

18

3 12
1 17

2 3
3

2

--II

--

i

1

--,I

1

-

-

1

1

-

- -! -

I- '
1

- I' 22 I

-
37

I

-

1i

-

2 65

14

23

--I'

--

1

-

-

-

-

-

1 5551 1.61 2,595 2,164 664 269

I
1~ 56

I 347111,18811,949 .1,833

586

110

49 119 85

72

21

13

III 267 214 '~163

37

7

186 802 1,650 1~598 528

90

1

-

-

-

-

-

~ 102

~I -

I...

5

l 97

-;

-

I

;

I
50 J 34 61

23

5

15 I

-!i 10

-vii-
DATA COLLECTION FOR ALL FACILITIES ESTIMATED NUMBER OF PERSONS RECEIVING SERVICES DURING A YEAR BY DIAGNOSIS AND AGE GROUP (CONT'D)

Diagnosis A.P.A. Code*
PERSONALITY DISORDERS, UNCLASSIFIED (59*)
MENTAL DEFICIENCIES (60-63)
MENTAL DEFICIENCY: Familial or Hereditary (60) Idiopathic (61) Unspecified (63*)

-

-

214

-I

43

35

52

43

26 12

3

i . 2.900 28 1143

254

I 546 I 442

567

444

282 102

25

I

i
2,073 18 61 139 I 291 362 445 365

761 8 56

89 I 252

80 119

79

I 24372

88 14

14
8

66 2 26

26 I 3

3

3.

3

4 63 Z 46 2 17

VASCULAR HEADACHES (80*) AVITAMINOSIS (81*) NO PSYCHIATRIC DIAGNOSIS (90)
DIAGNOSIS, UNSPECIFIED AND UNKNOWN (91)

45 II 1 I -

1

3

7 10 I 7

6

1

36

I

27

1

4 14

4

4

I I 266 6 34

28

9 24 43 51



t I I I I I _l_~~ 3~~J _~~_~ I 777 U 64 ':76

.. ..

..

173
..__ 166.. '.

46

10

15

88

47

42 33 9

... . _ __ ~.~._

~_ ~L-. ~_._,

~,_ .~_~ ... _ .._L-.

.

..1.. __._"0 -__

* Special Codes added to A.P.A. Diagnostic Codes.

Biostatistics Service Georgia Department of Public Health OCtober 5, 1964

-viii-
APPENDIX III DATA COLLECTION FOR ALL FACILITIES ESTI1'1ATED NUi'1BER OF PERSONS RECEIVING PSYCHIATRIC SERVICES DURING A YEAR BY COUNTY OF RESIDENCE, BY RACE AND SEX, GEORGIA, 1963

county
Tota1* Appling Atkinson Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleck1ey Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chattahoochee Chattooga Cherokee* clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia Cook CO'Weta Crawford Crisp Dade Dawson Decatur DeKa1b Dodge

Total
46,722 119 46 98 31 347
72
166 324 196
97 1,516
107 51 129 69 220 172 93
71
44 63 361 76 31 2,363 10 163 257 685 38 283 40 1,292 198 353 130 89 292 48 188 43 27 181 2,581 210

White Male
21,525 63 23 56 9 133 54 81
138 79 .
53 656
60 21
47 44 85 46 39 29 16 27 196 39
8 968
3
86 107 294
8
128 14
689 86 174 48 38 104 15 56 21 12 55 1,272 106

White Female
16,259 39 16 33 7
101 18
73
135 79 22
493 18 24 36 19
77
37 27 10 14 29 122 36 16 832 4 65 139 288 10 137 20 527 72 121 52 28 97 16 54 21 15 66 1,165 70

Nonwhite Male
4,744 7 4 6 7
75
8 28 24 13 207 14 4 27
3 28 37 12 23 9
2 23
4 300
1 9
3
51 7
11
2 45 18 28 21 17 47 12 50
1
20 69 15

Nonwhite Female
4,189 10 3 3 8 38
4 23 14
9
160 15 2 19 3 30 52 15 9 5 5 20 1 3
263 2 3 4 52
13 7 4
31 22 30
9
6 44
5 28
40 75 19

-ix-

DATA COLLECTION FOR ALL FACILITIES ESTI}~TED NUMBER OF PERSONS RECEIVING PSYCHIATRIC SERVICES DURING A YEAR
BY COUNTY OF RESIDENCE, BY RACE AND SEX, GEORGIA, 1963

County
Dooly Dougilerty Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene G'>linnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes

Total
85 842 160
94 10
72 221 247
78 130
72 769 101 160 7,514 95
36 528 139 176 123 322 416 613 97 151 94 115
39 153 365 69 245
72 85 200 119 100 63 124 38 306 41 101 43 30 333

White Male
22 330 78 28
4 37 98 109 38 80 41 397 54 86 3,524 52
13
222
71
66 46 152 219 319 35 74 47 58 18 67 167 29 123 15 46 74 47 49 15 61 15 133 13 38 18 5 137

White Nonwhite Female Male

29

12

345

76

72

5

34

15

4

2

17

11

71

29

76

25

24

7

50

22

6

294

33

47

60

10

2.576

726

43

17

3

218

41

63

70

21

37

18

158

5

90

106

232

35

16

27

55

18

23

10

39

11

17

53

6

148

28

24

9

100

12

23

14

26

7

78

24

32

21

26

11

14

22

27

27

11

8

100

27

9

11

28

13

11

7

16

4

106

43

Nonwhite Female
22 91
5 17
7 23 37 9
3 45
4 688
3 47
5 19 22
7 1 27 19 4 14 7 4 27 22 7 10 20 6 24 19 14 12
9
4 46
8 22
7 5 47

x
DATA COLLECTION FOR ALL FACILITIES ESTIMATED NUMBER OF PERSONS RECEIVING PSYCHIATRIC SERVICES DURING A YEAR
BY COUN"Y OF RESIDENCE, BY RACE AND SEX, GEORGIA, 1963

County
Lumpkin Macon Madison Marion McDuffie McIntosh Me ri-wether Miller Mitchell Monroe Montgomery Morgan Murray Muscogee* Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen

Total
64 112 112
117 175
55 172 35 176 118 85 103 64 1,550 240 83 64 168 110 82 80 104 292 105 107
1 82 101 2,023 96 19 216 34 463 188
71 320
89 43 171 56 119 86 449 228 233 30 66

White Male
30 24 46 70 66 19 52
11
60 36 45 35 33 575 107 22 22 88 24 48 30 38 135 33 26
6 62 45 859 37 2 67 13 208 106
11 131
41 10 81 14 45 25 191 70 108 19 23

White Female
33 31 40 14 68 14 55 12 63 32 25 27 30 651 88 49 20 64 32 31 32 23 119 20 33
20 13 795 32 4 90 16 162 52 13 121 20 11 68 15 38 27 136
HO
94 10 23

Nonwhite Male
1 21 15 25 25 13 23 11 22 29
5 16
156 22
5 13 14 22
1 16 28 23 26 27
1
20 200
12 7
20 2
53 22 19 34 16 10 12 13 13 20 61 24 13
15

Nonwhite Female
30 11 8 16 9 42
1 31
21 10 25 1 167 23 7
9
2 32 2 2 15 15 26 21
23 169
15 6 39 3 40 8 28 34 12 12 16 14 23 14 61 24 18 1 5

-xl-
DATA COLLECTION FOR ALL FACILITIES ESTI~~TED NUMBER OF PERSONS RECEIVING PSYCHIATRIC SERVICES DURING A YEAR
BY COUNTY OF RESIDENCE, BY RACE AND SEX, GEORGIA, 1963

County

Total

White Male

White Female

Nonwhite Male

Nonwhite Female

Troup

467

177

182

45

63

Turner

64

27

25

5

7

Twiggs

60

20

9

21

1

Union

54

35

19

Upson

255

89

97

46

23

Walker

283

163

110

6

4

Walton

257

107

.90

35

25

Ware

379

189

107

50

33

Warren

73

19

10

16

28

Washington

197

50

55

42

50

Wayne

234

133

70

24

7

Webster

20

7

8

5

Wheeler

54

14

28

6

6

White

64

47

17

Whitfield

326

178

131

8

9

Wilcox

71

30

17

13

II

Wilkes

127

36

26

34

31

Wilkinson

112

52

30

18

12

Worth

123

36

34

24

29

Unknown County

1,013

346

336

134

197

Out-of-State

2,964 2,272

472

219

1

*Total includes 5 with unknown race and sex, 4 in Cherokee County and 1 in Muscogee County.

Biostatistics Service October 9, 1964

-ui-
APPENDIX IV DATA COLLECTION FOR ALL FACILITIES TYPE OF SERVICE R3QUES~D-BY RACE AND 'SiX, GEORGIA, 1963 (Data tabulated for first admissions during year-of survey)

Type of Service Total
Treatment

I:

Il- Inpatient

Outpatien~

f I I!

I Non- 'Non-

il

I Non- ; Non-

I i
I

To~allII

Ii
Total,:

t-lhite Male

White ! white Iwhite

11 White !White white/ white

Fereale ! Male IFemale Total Ii Male (Female I Male IFemale

I I I 1 I ~2,508iI

32

,

692

II
11

13,808

j

U.SSS

I
I

3,607

3,722

9,816!i11 5, 392 I13 ,457

556 I 406

I I ' I i, 39,31311 32,681!1'I 13,801 11,551 3,607 3,722 6,632 IIIi 3,845Ii2,l69 I 391 I 226

_
Unknown 5 1

I!

II'

Diagnosis, Evaluation onlyl

1,618~il

Psychological I'

tl

Testing

3531

li
IIi
~2!1 -1

-I -I ! !' I II 21

",'
- j" 1,616 753! 674

I
105

4

-II

-ji

-! - I

II

I

353 !i 215! 118, 13!I

7,

Other
Unknown
______

6 9 4 11 !!

I 53011

I

I1II

911
-~,I'I
f ~

7 I!
_Ii
!

2I

-:

-

I 685 i,i 328,: 267

61 'I

29 I'

-

-I - Ii I I

i " .

I

530 251 229

11 j

39 I

II

' I, I _L_"! "!

i

Biostatistics Service October 9, 1964

-xiii-
APPENDIX V PRIVATE PSYCHIATRIST AND PSYCHOLOGIST PATIENT DATA
NUMBER OF PATIENTS SEEN IN TWO-WEEK SAMPLE BY COUNTY. AREA AND DISTRICT. GEORGIA 1964

State Total

2,441

Area IV (Contld.)

White Male

1,013

District 6

929

White Female

1,344

Fulton

929

Nonwhite Male

22

District 7

369

Nonwhite Female

26

DeKalb

350

Unknown

36

Forsyth

1

Gwinnett

11

Area I

8

Newton

3

District 1

8

Rockdale

4

Catoosa

District 8

40

Dade

Carroll

6

Fannin

Coweta

6

Gilmer

Haralson

4

Murray

1

Hea.rd

Walker

Meriwether

5

Whitfield

7

Troup

19

District 9

65

Area II

22

Butts

1

District 2

18

Clayton

38

Dawson

Fayette

2

Hall

17

Henry

1

Lumpkin

Lamar

2

Towns

Pike

1

Union

Spalding

17

White

1

Upson

3

District 3

4

Banks

Area V

41

Franklin

1

District 10

41

Habersham

2

Barrow

5

Hart

Clarke

17

Rabun

Elbert

Stephens

1

Greene

1

Jackson

3

Area III

81

Madison

3

District 4

81

Morgan

Bartow

9

Ocones

Chattooga

3

Oglethorpe

Floyd

55

Walton

12

Gordon

4

Polk

10

Area VI

81

District 11

81

Area IV

1.~18

Chattahooche

1

District 5

115

Harris

5

Cherokee

3

Marion

Cobb

109

Iv1uscogee

71

Douglas

2

Quitman

Paulding

1

Schley

Pickens

Stewart

1

Sumter

2

Talbot

Webster

1

-xiv-
PRIVATE PSYCHIATRIST AND PSYCHOLOGIST PATIENT DATA NUl1BER OF PATIENTS SEEN IN TWO-WEEK SAMPLE BY COUNTY, AREA AND DISTRICT, GEORGIA 1964

Area VII District 12 Bibb Crawford Monroe Twiggs District 13 Doo1y Houston Macon Peach Pulaski Taylor District 14 Bleckley Dodge Johnson Laurens Montgomery Telfair Treutlen Wheeler District 15 Baldwin Hancock Jasper Jones Putnam Washington Wilkinson
Area VIII District 16 Columbia Glascock Jefferson Lincoln McDuffie Taliaferro Warren Wilkes District 17 Burke Emanuel Jenkins Richmond Screven

195

Area IX

25

114

District 18

13

113

Baker

Calhoun

Clay

1

1

Dougherty

5

37

Early

2

2 ..... ~ Lee

25

Miller

2

l'1itchell

2

7

Randolph

2

Terrell

1

1

District 19

12

13

Ben Hill

3

3

Crisp

2

1

Irwin

1

Tift

3

7

Turner

Wilcox

2

Worth

1

2

Area X

22

31

District 20

10

16

Colquitt

1

Decatur

1

Grady

1

4

Seminole

Thomas

7

6

District 21

12

5

Berrien

1

Brooks

1

108

Cook

24

Echols

5

Lanier

1

1

Lowndes

9

1

5

Area XI

34

7

District 22

14

Appling

2

1

Atkinson

2

4

Bacon

84

Clinch

2

Coffee

4

5

Jeff Davis

2

Pierce

1

72

Ware

5

3

District 23

20

Brantley

2

Camden

Charlton

Glynn

17

Long

McIntosh

Wayne

1

-xv-

PRIVATE PSYCHIATRIST AND PSYCHOLOGIST PATIENT DATA NUMBER OF PATIENTS SEEN IN TWO-WEEK SAMPLE BY COUNTY, AREA AND DISTRICT, GEORGIA 1964

Area XII District 24 Bulloch Candler Effingham Evans Tattnall Toombs District 25 Bryan Chathaul Liberty
Unknown County of Residence

66

Out-of-State Total

164

7

Alabama

78

5

Connecticut

1

1

District of Columbia 1

Florida

9

Louisiana

2

1

Mississippi

2

New York

2

S9

North Carolina

9

Ohio

1

57

South Carolina

50

2

Tennessee

6

Texas

1

Virginia

2

76

APPEf1DIX VI DATA COLLECTION FOR PRr~ATE PSYCHIATRIST AND PSYCHOLOGIST ESTIMATED NUMBER OF PERSONS RECEIVING PSYCHIATRIC SERVICES DURING A TWO-WEEK PERIOD BY DIAGNOSIS AND AGE GROUP
GEORGIA, 1964

DiagnOSiS--'- -

-'----1-- - -.--= Age Group

_

j,A.P.A. Code*)
Total
Acute Brain Disorders (01-09)
Acute Brain Syndrome: Associated with Intoxication (02) Associated with Trauma (03) Associated with Convulsive D:i.Border (05) Associated wit~ Metabolic Diat:1rbBnce (06) Of Unknown Cause (09)
Chronic Brain Disorders (10-19)
Chronic Brain Syndrome Associated with:
Intoxication (13) Trauma (14) Circulatory Disturbance (15) Convulsive Disorder (16) Disturbance of Metabolism
Growth or Nutrition (17) Diseases of Unknown or

i I Total. 0-415-9 10-1I~Ji05-=-~0':'24f~-34135-44 I 45-54 i 55-64' 65-74175 UP tUnkno",

I I 2,44i 111
,I 18 III
!

2 I 62 II
1 - !;
1

I 98 157 Ii 231 566 i 652 . 315

1 Ii

1 II i

- iI
I

1

I

I3 I 10 I

1

I 112

431I

3 I 200

I- I

1 'I

-i
I
I

1IIii

-

II

-

I
I

1 IIIi - - I!

I ! I

-1

-

-II

1I
1

- II

-I
I

--! II ! 1-!I I

-
-I

--IiII

-I
-I -,

i,ll' - -I 4 Ii

2

i
Ii,

10 !

-
-

II

-
-

i - I. - I,

'I

I,'

- i I'

I

-

-i

I -;

i I - I I i -:I

3I i I
-

1I i 2 I' 6 I'

- I -I

I 1

-I
I

-I
- II
11 -I

19 II - 5 !

"I

I
I

I!

1 Ii - - 'I
41' - 3
41 - - ,
2 Ii - - !

2 ,!

- I'

1 ,i

I!

I
I

I
I

- 1 -I

--- II

I--I
-

1--1'I
-I

2:
Ii
i
---II
2I

1
I
:I

I
1 21

I

-I
-!

1I
i

3 11 1 1 I
-I
;1 I 1'

1:1 -. -I - I -I -I -I

1

Uncertain Cause; Chronic Brain Syndrome of Unknown or Unspecified Cause (19)

I

71

I 2 I I

2

I
-I
I

-I

1I

- II

1

-I 1 I

-XVLl.-

DATA COLLECTION FOR PRIVATE PSYCHIATRIST AND PSYCHOLOGIST ESTIMATED ~mER OF PERSONS RECEIVING PSYCHIATRIC SERVICES DURING A TWO-WEEK PERIOD BY DIAGNOSIS AND AGE GROUP (CONT'D)

Diagnosis (A. P. ~. Code*l
Psychotic Disorders (20-25*) Involutional Psychotic Reaction(20) Affective Reactions (21) Schizophrenic Reactions (22) Paranoid Reactions (23) Psychotic Reaction, Unclassified (25*)
Psychophysiologic, Autonomic and Visceral Disorders (29*-39)
Psychophysiologic: Reaction, Unclassified (29*) Skin Reaction (30) Musculosl~letal Reaction (31) Cardiovascular Reaction (33) Gastrointestinal Reaction (35) Genito-Urinary Reaction (J6) Nervous System Reaction (38)
Psychoneurotic Disorders (40)
Personality Disorders (SO-53) Personality Pattern Disturbance (5':) Personality Trait Disturbance (51) Socio~athic Personality Disturbance (52) Special Sympton Reaction (53)

.'::-;=':;:~:.:::::==::='~~

. , , , . _ ... ::"==---=-="'=::~'.---.

:==-:":.~--=:'.':'"

1_. _

.

._, A$~.GI'()1:!P_,_.

._.__ ., ._.__

. ..__..

I Total 110-4 15- 9 10-14 ! 15-19: 20-24 125.,34 !35-44 145-54: 55-641 65,:,Zij 75 Up , Unkno'

I i
I 623 I

I

!

r

I

7

13

291 65 \ 127 i 157 1 106 I 50 I 18 i - 5 1

'iI

i

3911 - I

I
-I

-I

- ,,

7

15

II
111

I.
5i

-

1

194 1\
375 i! 9 "ii

I
II 7
-I

1
12

31

4

26! 60

I
-!

1

28 98

61
85 3

48

28 ; 12 \

i

;

39 : 11 :

1

2

-

-
-
-

9 36
3

I !!
6 Ii
II;I
29 IIII

i

-I

1

1 2:

,i

1

i

I
-i

3

8

9

5

!
I!,

-

2

2

!I

2 1

Ii
IIIi

I
-j

411
3 Ii

I

15 II

2 !i

2

I!
Ii

11 1\ 1

::: II

11

96 II

2

- , i 329 1;11

101 3

IIII
II

-i7
I

!

-I -

-I- !

1

1 2

2

i

-i -i

-I
-

!

-j

1

, :1

i
~I

i
-I
- I!

-i

1

2

6

1

1 3 1 1

I!

- ,j

3 I - I -I - i 1

=1

-I !
- ,I,!

=i

111 I 25

73 259 278 125

I I i
20

24 !

61

135

157.

53

39 I

I
20 !

1

I

!

16 - I

2 1 70
I- I 52

I

3

8

I 16 25

23

5

13

8

I 35 I 83 ,

107

37

3

8

10

26

27

11

1

1
-I

1

I

I

!

9

-I
I

-I

5

3

-I

36

41 - I

11

-I

I - I

-I I

-xviii-
DATA COLLECTION FOR PRIVATE PSYCHIATRIST AND PSYCHOLOGIST ESTIMATED NUMBER OF PERSONS RECEIVING SERVICES DURING A TWO-WEEK PERIOD BY DIAGNOSIS AND AGE GROUP (CONT'D)

--===
Diagnosis (A.P.A. Code*)
Transient Situational Personality Disorders (54)

TO~~l!

1

48

i', 1,

_..

._.___

.._.;:. . .: ; ;. . ':,.:-"::;:;:..:':':.:;..';: ; _ .. __ :.,;;::::.::;==.:~:=:::-:;::: :::_~ ~_~_:::.;~;=.:=_.:..;..=:..~::::-.::_;;.:..-~

-_-=..:=~ ~-:;:~C~';:;:-_..;-~.o:.::::-:::;:::;-"""';::::::;:=~_''':

r 0-4 !5-9 IIO-14115-1?~ _20~~~~?135-~-64165-74i 7~Unkn;

I

- 17

40

52

I8 I

6

i II

9

41

-I

-,

-II 1~

Mental Deficiencies (60-62)
Mental Deficiency: Familial or Hereditary (60) Idiopathic (61) Unspecified (62)

12

II
i'

-

5

1

I
I

I

IiI
37/11:
2

I -

-

I - I 4,
-1

-
1-

2
1
1-

I- I'

1

2 I - I' -

-I

I

I

I

-
--

-!
1-

-2
-

II

t

--
-

--II

-
-I

-

I

- II

-I1

-

I

1

Nn psychiatric Diagnosis (90) Diagnosis, Unspecified and

1I 2l!i - -, 1 i!

1

2.

Unknown (91)

____,_____ _ 128./!1L ._-__ ___6.._1_ . __..8_ I .. 23/ .. __18.

2

3I 7

3

lI .... I 23

26 J,---__13.---. -- ~..

I

2

__-. . _~Il_-

I

J ..

~

*Specia1 Codes added to A.P.A. Diagnostic Codes.
Biostatistics Service Georgia Department of Public Health February 8, 1965

-xix-
APPENDIX VII ESTIMATED NUMBER OF PERSONS RECEIVING SERVICES FROM PRIVATE PSYCHIATRISTS AND PSYCHOLOGISTS DURING A YEAR, BY RACE AND SEX, GEORGIA 1964

Race and Sex
Total
White Male White Female Nonwhite Male Nonwhite Female Unknown

Number
15,842
7,160 8,090
157 196 239

k~PENDIX VIII PRIVATE PHYSICIANS STUDY
ESTIMATE OF TOTAL PATIENTS SEEN DURING A TYPICAL WEEK, AND ESTIMATE OF NUMBER OF PATIENTS WITH FUNCTIONAL OR EMOTIONAL DISORDERS, ALCOHOLIC PROBLEMS,
DRUG ADDICTION, AND MENIAL RETARDATION, GEORGIA 1964

County

Total Patients
Seen

Total Patients
With Mental Health Problems

Functional
&
Emotional Disorders

Alcoholics

Drug Addicts

Mentally Retarded

Total - Number 385,519 - Per Cent 100 .070

96,367 86,517 25.0% 22.4%

3,502 1.0%

792 0.2%

5,556 1.4%

APpling Atkinson Bacon Baker Baldwin , Banks Barrow Bartow Ben Hill Berrien Bibb Bleck1ey Brantley Brooks 3ryan 3ulloch Burke Butts :::alhoun
~amden
:andler :::arroll ::atoosa ::harlton ::hatham ::hat tahoochee ::hattooga ::herokee ::larke ::lay ::layton ::1 inch ::obb ::offee ::olquitt ::olumbia ::ook ::oweta ::rawford

552 50
970
2,857 150
1,960 1,501 1,176
500 16,528
200 200 1,104
90 3,861 1,656
800 700 1,243 597 3,568 1,136 250 18,251
2,080 1,824 9,394
800 2,757
917 11,751
1,724 3,348
364 1,500 2,380
110

224 343
1,943 63 360 620 318 320
2,268 52 104
216 17
2,073 513 128 238 556 259 405 457 253
5,188
330 878 3,979 280 1,029 201 3,308 552 672 186 717 571
0

20 302
1,429 60
212 565 294 300 1,894
40 100 173
14 2,034
497 108 231 497 243 312 441 238 4,981
280 818 3,787 280 917 193 2,994 545 578 182 632 526
6

2

2

23

18

143

371

3

88

60

39

16

12

12

5

5

10

14

360

2

10

2

2

15

4

24

2

1

21

18

8

8

12

4

4

7

13

46

8

8

38

6

49

11

5

5

10

156

51

27

23

44

8

8

138

54

69

5

38

4

4

93

62

159

7

17

17

60

4

13

13

59

36

9

-xxi-

PRIVATE PHYSICIANS STUDY ESTIMATE OF TOTAL PATIENTS SEEN DURING A TYPICAL WEEK, AND ESTIMATE OF NUMBER
OF PATIENTS WITH FUNCTIONAL OR EMOTIONAL DISORDERS, ALCOHOLIC PROBLEMS, DRUG ADDICTION, AND MENTAL RETARDATION, GEORGIA 1964 (Cont'd)

County

Total Patients
Seen

Total Patients
With Mental Health Problems

Functional
&
Emotional Disorders

Alcoholics

Drug Addicts

Mentally Retarded

Crisp

Dade

Dawson

Decatur

DeKalb

Dodge

Doo1y

Dougherty

Douglas

Early

Echols

Effingham

Elbert

Emanuel

Evans

Fannin

Fayette

Floyd

Forsyth

Fr.anklin

Fulton Gilmer

.

Glascock

Glynn

Go!:don

Grady

Greene

Gwinnett

Habersham

Hall .

Hancock

Haralson

Harris

Hart

Heard

Henry

Houston

Irwin

Jac}tson

Jasper

Jeff Davis

Jefferson

Jenkins

1,842 355
2,167 20,220
1,448 600
5,916 1,575
794
600 2,250 1,258
300 666 597 6,385 1,348 1,184 82,120 627 100
5~869
1,460 1,063 1,188 2,498 1,592 6,000
848 720 1,000 700 280 4,285 963 1,297 380 1,250 1,303 550

296 132
348 5,071
536 207 1,302
12 390
266 1,107
163 117 237
50 1,518
634 645 9,050 343
14 1,865
279 619 420 968 509 1,192
196 194 439 294 112 1,003 342 658
118
148 510 146

287 124
294 4,706
501 200 1,125
8 390
220 1,025
149 105 220 43 1,458 597 619 7,756 282
10 1,683
257 555 344 894 462 1,124
185 180 431 280
84 729 333 651 101 125 477 135

9

4

4

24

15

15

294

28

43

19

5

5

6

1

56

32

89

4

18

28

36

30

16

14

3

6

3

9

3

5

1

6

22

38

25

12

13

13

357

136

801

32

7

22

3

1

68

32

82

9

4

9

35

6

23

12

2

62

51

9

14

18

29

25

43

3

3

5

7

7

4

4

7

7

8

20

142

132

9

7

~

5

12

23

15

6

12

4

7

-xxii-

1" .. ;.:.
~
~;';;l-,

PRIVATE PHYSICIANS STUDY ESTIMATE OF TOTAL PATIENTS SEEN DURING A TYPICAL WEEK, AND ESTIMATE OF NUMBER
OF PATIENTS WITH FUNCTIONAL OR EMOTIONAL DISORDERS, ALCOHOLIC PROBLENS,

DRUG ADDICTION, AND ~1ENTAL RETARDATION, GEORGIA 1964 (Cont I d.)

County
Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether Miller Mitchell Monroe Hontgomery Morgan Murray Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole

Total Patients
Seen
120 320 351 201 2,970
18 522 300
4,221 448 650 280 682
1,250 130
1,069 545
1,212 486 299 610 424
13,188 1,513 240 520
1,334 1,875
780 120 2,548 825 250
580 652 21,027 940 245 742 1,125

Total Patients
With Mental Health Problems

Functional
&
Emotional Disorders

24

20

320

298

27

17

35

32

967

863

106

75

66

60

477 48 57 143 103 513 57 79 259 122 133 156 275 149
2,460
677 136
52

443 44 45 140
75 500
52 55 238
n2.
125 135 261 140
2~380
632 120
Jl

539

486

969

913

181

161

8

6

967

898

198

176

88

85

137 238 6,676 188
11
275 370

95 223
5~172
134 7
248 313

- - Alcoholics
4 :16
4 2 27

Drug Mentally Add~ Retarded

3

3

6

1

77

26

5

3

3

12

17

5

4

6

6

3

14

14

13

1

3

1

13

11

11

4

6

3

5

9

4

8

6

8

4

5

80

24

16

5

12

2

2

5

16

31

5

17

28

28

14

6

2

30

39

4

18

3

28

14

7

8

148

56

1,3QO

33

21

2

2

21

6

28

5

24

-~n~~,", ~.. ~L-

-.'

.,~

PRIVATE PHYSICIANS STUDY

ESTIMATE OF TOTAL PATIENTS SEEN DURING A TYPICAL WEEK, AND ESTIMATE OF NUMBER

OF PATIENTS WITH FUNCTIONAL OR EMOTIONAL DISORDERS, ALCOHOLIC PROBLE~~,

DRUG ADDICTION, AND MENTAL RETARDATION, GEORGIA 1964 (Cont'd.)

County
Spalding Stephens Stewart Sumter Talbot Ta1iaferro . Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treut1en Troup Turner Twiggs Union Upson Walker Walton Ware Warren {vashington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth

Total Patients
Seen
5,778 2,976
634 2,896
70
1,375 373
1,379 825
2,404 2,385 2,580
400 411 4,714 740
300 1,621 4,187 1,534 6,280
90 1,181 1,710
160 550 5,332
75 1,046
480 973

Total Patients
With Mental Health Problems

Functional
&
Emotional Disorders

1,318 1,226
86 547
6

1,243 1,163
80 467
4

417 105 381 541 562 440 1,404 116 116 972 266

398 97 371 506 498 408 1,274 100 111 876 260

174

150

566

519

790

771

693

616

1,056

973

9

9

130

102

572

512

57 302 2,152
20 396 182 602

35 270 1,902
19 377 120 588

Alcoholics
7
20 5
25 1
6 5 3 13 20 11 70 12 2 47 3
6 4 5 19 7
1/~
36
10 9 94 1 4 38 10

Drug Mentally Addicts Retarded

68

5

38

1

55

1

13

3

7

9

13

18

26

8

13

6

54

4

3

4

45

3

9

9

30

13

14

19

39

76

4

10

24

2

10

23

53

103

4

11

5

19

4

KEY to RECOMMENDATIONS
FROM "A PROPOSED MENTAL HEALtH PLAN FOR GKORGIA"
PART ONE - Mental Health in Georgia - Today
Chapter I - "Setting the Stage"
1. A committee s~ilar in purpose to the Technical and Scientific Mental Health Advisory Committee be established on a permanent basis.
2. A committee similar in purpose to the Interdepartmental Mental Health Coordinating Committee be established on a permanent basis.
3. A coamittee similar in purpose to the Intradepartlnett al MexEal Heal th Advisory Committee be established on a permanent basis.
*****************
PARr TWO - Mental Health in Georgia - Tomorrow
Chapter I - "Programs J Facilities and Servicesll
A. To Promote Mental Health and Prevent Mental Illness
(In general health programs)
1. Private and public resources be fully utilized to bring complete pre-natal care to every mother in Geot:gia and that local health department services be reinforced and increased to provide sufficient coverage for the medically indigent.
2. Adequate hospital facilities and medical care be made available for medically indigent mothers.
3. Special diagnostic and treatment resources -- private and public -- should be made available for everyone in Georgia. It is desirable that all school children receive a complete medical examination prior to entering elementary and high school and that special emphasis be placed on detecting and correcting visual, hearing and speech defects.
4. Every community in the state have an adequate communicable disease control program enlisting the cooperation and support of private and public resources.
5. Business, industry and private and public agencies take immediate action to develop and implement strong accident prevention programs.

- 2-

6. Poison control and poison infolination centers continue to be expanded throughout the state so that services are available to all.

7. The State Health Department, in conjunction with the agencies responsible, should evaluate the diets of persons being cared for or attending institutions serving large quantities of food. such as schools, hospitals and correctional institutions.

8. Because family planning is also a medical problem, as well as a social and religious issue, the public should be sufficiently informed to overcome the many misconceptions and prejudices which presently exist. Cooperation between various agencies, the medical profession and others is necessary for achieving a successful program. Public and private resources are needed to counsel applicants and provide them the necessary measures in family planning.

(In the psychological environment)

9. Programs designed to orient people as to what to expect during transitional periods in their lives, if established in the community, would play an important role in preventing emotional problems and promoting mental health.

10. It is important that all agencies involved in adoption or foster home placement programs coordinate their efforts for maximum effectiveness.

11. Programs to prevent unemployment, increase opportunities for job training and encouragement of slum clearance need to be continued and expanded.

12. It is important that cities develop carefully planned programs to cope with problems created as the result of shifting populations from rural to urban ones.

(The school)

13. Teachers should receive a better orientation in mental health principles and normal growth and development at the college level.

14. Schools are responsible for furthering professional and personal needs of teachers by providing better working conditions, salaries and other fringe benefits.

15. It is important that universities and colleges add the necessary programs

to their curriculums to prepare teachers to teach the emotionally handicapped

child .. inservice training opportunities be promoted on the local level

to aid those presently in the field .... additional home instruction programs

be expanded

statewide programs be developed to rehabilitate handicapped

children and special educational opportunities be made available for the

academically advanced.

1o,- . It is hoped that more and more school systems will provide psychological evaluation and consultation services to aide teachers and students by hiring their own consultants.

- 3-
11~ Inservice training programs and summer workshops co-sponsored by the departments of health and education in conjunction with colleges and universities must not only be continued but expanded.
18. Funds must be made available to help increase state and local visiting teacher staffs a~d it is urgently recommended that this entire program be expanded to include additional visiting teachers in the elementary schools.
19. It is recommended that additional vocational training centers be established throughout the state.
20. Although many colleges and universities have student health programs and counsEling services, how adequately these services are actually meeting the total needs of the students must be evaluated.
(In reU.gf.on)
21. Seminaries should include courses on human behavior and group dynamics in their curriculums. Students also need to receive direct experiences in meetal health dcilities, includi.ng community programs. Post graduate courses and in-service training opportunities should also be made available to those who have completed their education.
(In business and industry)
22. All candidates for supervisory and managerial positions should be evaluated for potential leadership qualities.
23. Counseling services should be made available to equip employees to better handle work situations.
24. Psyc~ological and sociological studies should be undertaken to improve perscnnel relationBhips and to investigate special problem areas such as alcoholism and absenteeism.
25. Educational programs should be made available for administrators on supervisory and managerial development for all employees -- to help avoid resistauce l)::,eceeding changes in procedures prescribed by management -and for personnel of the employee's health service on basic mental health principles.
(In the communityl
26. Since the emotional well-being of the aged is largely dependent on the degree of i.ndependance achieved, community planning and action are nece;"car.y to ini.tiate 371d sUl?t>lement stat~ government programs. Their goa~ls sl'"ould include s'..:.ch thh,gs as: (1) providi.ng better incomes through emp.l.oym\.~nt; (2) econon,ical h::'21th car.e and n:edications in the home or instit~tjonal set~iug; (3) better housing; (4) o;portunities to develop satis:,'Tix'6 l~ism:e time activities c;ud (5) educational programs to promote f~mily and community understanding of the elderly person as an individual.

-4-
(In community agencies)
27. It 18 tecommended that communities in Georgia form permanent interagency councils to promote better coordination among the helping agencies.
B. To treat mental illness
(Community mental health programs and resources)
28. Various professional organizations, training centers and state agencies collaborate in promoting graduate, postgraduate and inservice training courses in mental health principles and problem management for "firing line professionals."
29. Colleges and universities stress the social and behavioral sciences in their curriculums.
30. The on going "interagency case conferences" initiated by the department of public health be intensified. With the participation of professional consultants, these conferences contribute significantly toward the development of needed skills in evaluating and handling emotional problems by the agency personnel.
31. Certain programs established by the department of education be reinforced and expanded, including the visiting teacher program, the program for exceptional children and guidance counseling in schools.
32. An up-to-date directory of all mental health resources and facilities in the state be compiled and distributed to all the private and public agencies, physicians and the like.
33. Establishment of voluntary helping organizations, such as alcoholics anonymous, should be encouraged and supported in the community.
34. Agencies such as family and children services, travelers aid and the like whose primary purpose is to aid individuals and families in time of social conflict be organized in as many communities as possible -- as soon as possible.
35. Comprehensive community mental health programs should be developed in the following 19 counties~ Bibb, Chatham, Clarke, Clayton, Cobb, Dekalb, aougherty, Floyd, Fulton, Glynn, Hall, Laurens, Lowndes, Musco-
gee, Richmond, Thomas, Ware, Walker and Whitfield as a first step toward
achieviC8 a statewide community mental health program.
36. Smaller communities, not included in service areas of comprehensive community mental health programs, should develop their own limited community programs.
37. Communities participating in multi-county programs establish a mechanism for insuring coordination among the services offered.
38. Local health department's roles and goals of existing mental health programs be re-evaluated and defined, since these programs contain many of the components of a comprehensive community mental health program. With a few exceptions, the majority of these clinics serve only as child guidance clinics. Expansion into all purpose clinics is advised.

-5-
39. Every effort should be made at state and local levels to secure full or part-time professional personnel for local mental health programs.
40. Psychiatric/medical orientation be strengthened to all program operations through recruitment of additional personnel, as well as utilization of existing personnel.
(Regional state hospitals)
41. Immediate steps be taken for building two regional state hospitals within the next five years -- one in the vicinity of Augusta and another near Atlanta.
42. Milledgeville State Hospital would immediately become a regional hospital, as soon as the facilities in Augusta and Atlanta became operative.
43. During the next five to fifteen years, additional regional hospitals should be planned and constructed in major population centers in the southern and northern areas of the state. Possible locations are Albany, Athens, Columbus, Rome and Savannah. The size of these additional hospitals should be about 300 beds each, with provisions for future expansion. Bed capacity should never exceed 1,000 in any unit.
44. Each of the regional hospitals should provide separate, special programs for mentally ill adults and children, alcoholism and drug addiction, geraitrics and mental retardation.
(S pecial programs)
45. Emphasis should be placed on increasing consultation services to local communities which would enable many to develop their own programs for alcoholism and addiction.
46. Consultation services should also be made available to correctional institutions, courta,.industry, tuberculosis and general hospitals. Many of these facilities should be encouraged to develop treatment services in conjunction with their own programs.
47. Larger cities in Georgia should develop daycare centers for alcoholics, similar to the Chatham Clinic in Savannah. These centers could be located in general hospitals, local mental health clinics, or in separate facilities, servicing a minimum of 25 patients per day.
48. Since detoxification is an acute medical problem, .it should babandled by medical service sections of general hospitals, reserving the psychiatric service sections for the small percentage of these patients who are acutely psychotic.
49. Present and future state hospital programs establish specialized children's and adolescent's units with proper treatment and activity programs. These units should provide both short and long-term care.
50. Adequate professional staff be provided for these programs. Competitive salaries have to be established to attract child psychiatrists and other well-trained personnel.

-6-
51. Private and nonprofi.t residential treatment and educational centers for emotionally disturbed children and adolescents should be established in major cities around the state.
52. General hospital psychiatric units should be made available to younger patients for emergency purposes and diagnostic studies.
53. The possibility of utilizing pediatric units in general hospitals for diagnostic study of emotionally disturbed children be explored where psychiatric and clinical psychological consultants are available.
54. State mental hospitals should not be responsible for the care of nonpsychiatric elderly individuals. Coordinated efforts between the Departments of Health and Family and Children Services will be essential for placing geriatric cases, no longer requiring psychiatric treatment, in nursing homes or other community facilities.*
55. The development and operation. of facilities to care for special problems, including mentally disordered offenders, can best be achieved by the agency whose main responsibility lies in that particular area.*
C. Rehabilitation
(Aftercare)
56. Existing community mental health resources actively participate in aftercare programs.
57. Practicing physicians be encouraged to assume responsibility in local aftercare services.
58. Local distribution of drugs be provided to indigent patients.
59. Aftercare services by public health nurses be reinforced through intensified inservice training, increased manpower and availability of medical and psychiatric supervision and consultation.
60. Physician-social worker-nurse teams be organized in communities with specific responsibilities for supervising follow-up treatment and providing consultation services to public health nurses or other agencies dealing with newly discharged patients.
61. Milledgeville State Hospital organize visiting teams to provide aftercare services in the neighboring counties for demonstration purposes.
62. The above resources be utilized for screening patients before their re-admission to the state hospital.
* Appears in body of text (uncapped) on pages 36 and 37, respectively.

- 7-
(Vocational Rehabilitation)
63. The vocational rehabilitation program at Milledgeville State Hospital be enlarged in scope and volume.
64. An industrial therapy program be developed in conjunction with other vocational rehabilitation activities.
65. The "vocational rehabilitation specialist" Jo~n the mental health team in community programs, helping to coordinate rehabilitative services to the patient.
66. Vocational rehabilitation services be extended to include children under 16 years of age.
(Employment and job opportunities)
67. Employers must be educated about mental health and job opportunities for the recovered mentally ill should be created and employment of such persons encouraged.
68. Trained personnel should be hired by employment agencies to handle and guide emotionally handicapped individuals.
(Social rehabilitation)
69. The development of additional social clubs should be encouraged and supported.
Chapter 11 - "Manpower"
(Psychiatry)
70. Psychiatric residency training programs in the state should be increased and expanded.
71. Psychiatry should be emphasized at the undergraduate level of medical education and teaching methods should be improved.
72. Salaries and fringe beIfits for professors of psychiatry should be increased to help recruit highly qualified personnel.
73. Adequate salaries, improved living conditions and enlarged fringe benefits should be made available to psychiatrists employed in state hospitals and other public programs.
74. Externships should be established in private and public mental health facilities to help improve the psychiatric orientation of undergraduate medical students, as well as to serve as a residency recruitment resource.

-8-
75. Postgraduate training programs in psychiatry and psychoanalysis should be developed. (A branch of Columbia Psychoanalytic Institute has been established in Atlanta.)
76. During their residency, psychiatrists should be involved in community and other mental health programs. By participating in program development during training psychiatrists might be encouraged to pursue careers in these areas.
77. Psychiatrists in private practice should take an active part in community health programs, both at the planning and operational levels.
78. Active recruitment programs should be undertaken by communities and professional organizations, using all available media.
(Clinical Psychology)
79. Licensure should be required of psychologists working in public agencies which are now exempt from the licensing law.
80. At least one psychologist in each facility should be trained at the Ph.D. level, with a degree from an approved school and holding a Georgia license.
81. Private practitioners should be encouraged to maintain relationships with patients hospitalized or treated in public facilities.
82. Private practice of clinical psychology, to best be utilized as a public mental health resource, should be included in prepaid health insurance to provide mental health care.
83. Every encouragement should be given to universities starting programs in clinical and counseling psychology. Support should be given to Georgia State College in initiating a Doctoral program and Atlanta University should be encouraged to develop a Doctoral program in clinical psychology in addition to the one they are now offering in counseling psychology.
84. State Merit System salaries for psychologists should be increased to enable Georgia to compete for psychological talent and local support should be added to attract professionals to remote areas.
(Social Work)
85. High priority must be given to expanding the present training capacity of graduate schools of social work in the state. Support for this objective must come from the Georgia chapters of the National Association of Social Work, from the graduate schools of Georgia and from private agencies employing social workers.
86. Greater attention must be given by professional social workers to the development and utilization of undergraduate-level social work assistants. Supervision and inservice training programs should be used to increase the range of skills of the non-professionals.

-9-
87. Professional social workers need to increase their use of consultation as a means of extending the services of other related professionals. Juvenile court workers, public health nurses, law enforcement officers, teachers and others may be able to fill urgent needs when they use social workers as consultants.
88. There must be provision for periodic review of personnel policies in both public and private social agencies so that Georgia does not lose its social workers to other states. Fringe benefits, opportunities for promoting stimulating programs as well as salaries must be competitive with the national situation.
(Nursing)
89. A permanent psychiatric nursing advisory committee should be established to assist the Division of Mental Health in planning for nursing needs in mental health services.
90. Nurses should be consulted in early planning stages of the construction of regional hospital facilities in order that patient safety and utilization of nursing personnel can be maximized.
91. The State Board of Examiners of Nurses should consult with psychiatric nurses in determining criteria for evaluation of the mental health content of educational programs for nurses.
92. Each school of nursing should have at least one qualified instructor in the clinical area of psychiatric nursing.
93. Schools of Nursing should form a sub-committee for on-going evaluation of the psychiatric content of their curricula.
94. Graduate programs in psychiatric nursing should be encouraged.
95. Nursing service for the patient should be coordinated by assuring continuity when a patient is moved from one service to another. Nurses with coordinating responsibility should be strategically placed in the various parts of the services.
96. Consultation from psychiatric nurses should be available for all nurses working in mental health services.
97. The increased workload of public health nurses in aftercare service in the community requires the employment of additional public health nurses.
98. Intensive inservice training programs should be provided for public health nursing supervisors to increase their mental health skills.
99. Pilot projects should be encouraged to determine the patient's needs and the effectiveness of nursing's contribution in meeting those needs in all services promoting mental health.

- 10 -
100. Working hours and salaries should be made equitable to attract qualified nursing personnel at all levels.
101. Vigorous recruitment must be instituted for qualified personnel to fill gaps in nursing services in existing psychiatric services.
(Clinical Chaplains)
102. Church counseling centers should be supported by the church and the community as an important mental health resource. The Georgia Association for Pastoral Care should be encouraged to develop more counseling centers throughout the state.
103. Community mental health programs should explore the possibility of using clinically trained chaplains or consultants on a part-time basis where programs do not warrent the use of full-time chaplains.
104. Since each community has a ready supply of potential clinical clergymen in the local pastors, in those cases where other mental health professionals are in short supply clinically trained clergymen can be used to relieve the counseling load.
(Adjunctive Therapies)
105. It is recommended that more schools in Georgia offer an undergraduate degree in music therapy.
106. It is recommended that both Emory University and the University of Georgia be encouraged to start programs in occupational therapy.
107. It is recommended that the two Georgia schools now g1v1ng degrees in recreation move toward expanding their programs to include recreation therapy.
Chapter III - "Financing Mental Health Programs"
108. Additional appropriations to Milledgeville State Hospital, Gracewood State School and Hospital, Alcoholic Rehabilitation Service, be made with the goal of exceeding the national average per diem costs in the immediate years ahead.
109. Institutional and community mental health program fees be coordinated, when possible, to prevent over-use of less expensive state supported hospitals.
110. A close study be made of any barriers currently preventing the flow of funds between state departments which deter the kind of cooperative relationship essential to establishing programs involving responsibility of more than one agency or department.

- 11 -
Ill. A sliding fee schedule be adopted for all tax-supported hospitals and clinic programs serving the mentally ill, and that the schedule be determined locally, where applicable, based upon the philosophy that the individual should pay what he or she can afford up to the total cost. None, however, should be denied services because of their inability to pay. Higher fees on the scale should be comparable to private fees to discourage utilization of public facilities by financially able individuals. In certain chronic mental conditions provisions should be made for reducing or suspending fees to prevent a continuous drain on family financial resources.
112. "Psychiatric indigency" is a valid concept, and should be differentiated from IImedical indigency" and "welfare indigency".
113. Eligibility for service should be determined according to (1) financial ability, (2) availability of private resources, (3) nature of problem and (4) competent referral source.
114. Provision be made, and funds budgeted, for compensating non-psychiatric physicians who devote time to programs in which the psychiatrically indigent are treated.
115. State Grant-in-Aid funds available for matching local program funds be distributed in accordance with the following principles:
1) Total state monies for Grants~in-Aid to counties should be increased.
2) From Grant-in-Aid Funds:
a) Allocate an unmatched grant to each district for 100% support of those positions designated as full-time district personnel.
b) Allocate sufficient monies to place a supporting Grant-in-Aid Iifloor" under smaller counties for a basic program - matched approximately one dollar local to two dollars state.
c) Divide remainder of Grant-in-Aid funds approximately equally as follows: (1) 50% according to population - 1 to 1 matching (2) 50% on basis of, and in proportion to, population weighted inversely by the real property index.
116. All pre-payment health insurance carriers operating in Georgia be requested to provide coverage for mental illness on a basis equal to that provided for any other illness.
117. Coverage for mental illness, under prepayment and other forms of health insurance, be broadened to cover outpatient and partial hospitalization. as well as total hospitalization services.
118. Insurance plans cover treatment of mental illness in qualified private and tax-supported mental health resources.

- 12 -

119. Coverage for Mental Illness be made available in all individual and group coverage.

120.

Health insurance benefits not be limited to the services of a psychiatrist or other physician. Because of the continuing development of the concept of the mental health team and the present shortage of psychiatrists, benefits should be extended to cover the services of the clinical psychologist, the psychiatric social worker, and the psychiatric nurse.

121. That appropriate legislation be passed to permit levying of tax millage earmarked specifically for health purposes, as is presently done for education programs.

122.. That necessary revision in the statutes be accomplished to permit of more equitable and extensive collecting of patient fee payments in institutions and in local health department programs. The setting up of an adequate administrative structure to insure vigorous collection efforts.

123.

That the state legislature carefully study the problems involved in financing multi-county mental health programs and that the necessary statutory provisions be made to enable local tax revenues to be easily transferred across county lines.

124.

That the Georgia legislature study the question of requ1r1ng all prepayment health insurance carriers operating in Georgia to provide coverage for mental illness on a basis equal to that provided for any other illness.

Chapter IV - 'Legislationll

125.

It is recommended that a prov1s10n be inserted into the law for emergency involuntary admission of a mentally ill patient to a hospital for a limi ted period of time not to e}~ceed 72 hours, without 1ega 1 proceedings or warrant, providing that a physician recommends and the admitting physician of the institution concurs.

126. It is recommended that the provision be made in the statute to permit involuntary admission of a mentally ill patient to the institution for a maximum period of 45 days upon the certification of two physicians.

127. It is recommended that the law be changed to permit involuntary admission of alcoholics and drug addicts to the state mental hospital as well as to the institutions set up for the treatment of such disorders.

128. It is recommended that legislative action be taken for the adoption of the Interstate C:>mpact on Mental Health and the needed provisions be inserted into the Health Code for the application and the practice of the Compact.

129. It is recommended that the re-eva1uation and examination of the existing laws continue and the changes be made as they seem necessary.

- 13 -
130. It is recommended that the proposed revision ~f the present Cost of Care Act should incorporate the following:
1. Chapter 35-11 of the Georgia Code Annotated providing for charges for treatment and care at state mental institutions should be completely revised.
2. The Georgia Cost of Care program should provide that all types of state and federal benefits from pensions, disability or death should be subject in some manner, and to some degree to the Georgia Department of Public Health for the cost of care of patients entitled to such benefits.
3. The Georgia Cost of Care program should provide that a patient's benefits from private life insurance, disability insurance, sickness and aC2ident insurance, and pension and profit sharing plans should be subject in some manner and to some degree to the Georgia Department of Public Bea lth for the cost of care of such pa tients.
4. A revised statute should provide that hospital insurance payments be accessible to the Georgia Departme:lt of Public Health.
5. A revised statute should set out in detail the persons who are legally responsible under the statute for the cost of care of such patients.
6. A revised statute should provide for SOme type of effective enforcement procedure to assist the Georgia Department of Public Health in collecting payments due under the statute.
7. A revised statute should provide that where the patient is a beneficiary of a trust, estate or fund that the income and under certain conditions the principal of such trust, estate or fund, be liable for the patient's cost of care in that institution.
131. It is recommended that changes be made in the law to permit health department mental health programs to charge fees for service according to the financial ability of the individuals.
ella ,JLl! r V - 'j(LoCUI.'l:,l auJ ,.valua . icJ,l 132. Five to ten percent of the state's budget for mental health services be specifically allocated for research.
133. Civil service positions be developed for researchera. There should be positions both for research technicians and research scientists at the junior and senior levels.
134. Funds be set up for small grants to encourage budding rese~chers and projects.
135. Funds be allocated for research surveys, workshops and field trips.
136. The Division of Mental Health set up a research office with a research coordinator assisted by an interdisciplinary advisory committee.

- 14 -
137. The Division of Mental Health take initiative in stimulating the development of a cooperative inter-departmental mental health research center.
138. All mental health facilities have access to at least one research scientist with full responsibility to research. In the case of small faciiities. Possibly this person could be shared between several facilities or employed on a part-time basis .
. Chapter VI - Health Education in Mental Health 139. Communities should analyze their resources, both individual and organizational, and developmental health educational programs using those community resources.
140. School progralQS in mental health should be encouraged.
141. Employment of professional health education personnel should be encouraged in local health departments and other appropriate community agencies for the furthering of all educational aspects of all community mental health programs.

Subject Outline of Division of IViental Health Planning Project Report "A PROPOSED COMPREHENSIVE MENTAL HEALTH PLAN FOR GEORGIA. "
(Georgia Departl"nent of Public Health)

PART ONE Ivlental Health in Georgia - TCDAY
=:;;= sa ,-"-.
Chapter I Setting the Stage
Historical background - state and national
Planning project organization and work techniques; role of advisory committees

Chapter II Extent and Dimensions of the Problem How many Georgians are affected .. who they are Current services Current unmet needs Future needs - 10 year projection

Chapter III Existing Resources

A.

Official tax-supported agencies:

1. Department of Education 2. Department of Family and Children Services 3. Department of Labor

-2-
4. State Board of Corrections 5. State Board of Pardons and Paroles 6. State Commission on Aging 7. Department of Fublic Health including:
a. Milledgeville b. Alcoholic Rehabilitation Service c. Community N.l.ental Health Service d. Georgia lv~ental Health Institute

B.

Non-official agencies

1. Analysis by type of program: residential care; education and fund raising; administrative services; recreational and organized group activities; health care agencies.

2. Analysis by target population served: general population
and Atlanta, Columbus and v! aycross.

C.

Private and non-profit medical facilities

PART TWO IVlental Health in Georgia - TOI'v~CRROVJ

Chapter I Programs, Facilities and Services

Approach to problem - theoretical and practical

Prevention - mental and general health needs

Recommended treatment progralus including:
comprehensive conuuunity mental health programs with 19 suggested geographic locations; essential services
limited community programs
regional state multi-purpose hospitals with suggested locations
Recomluended rehabilitation programs including: aftercare, halfway houses, vocational rehabilitation

-3-
Present and future role of IVi.illedgeville Special programs for alcoholics, children and adolescents,
geriatric patients and mentally disordered offenders Vocational and social rehabilitation programs, aftercare -
rehabilitation houses and foster home care
Chapter II lv.;.anpowe.!.
Defining roles of m.ental health professionals and assessing person.n.el.needs: psychiatrists ps ychologis ts social workers nurses clinical chaplains supportive therapists: music, occupational, recreational related professionals: physicians, c1ergy:men
Chapter III Financing IV'::ental Health Pro~rams
Need for federal, state, local participation
Cost sharing between counties
Georgia's expenditures in relation to U. S . average, and rank nationally
Allotlnents and local budgets

-4General financing assurnptions Existing financial patterns Potential financial resources Fiscal policies in other states Insurance for mental illness
Chapter IV Legislation Legal background, changing concepts Hospital admission procedures Proposed "Interstate Compact on l\'~ental Health" Cost- of- care progl'am
Chapter V Research and Evaluation Kinds of research: applied, basic, operations, demonstration project Research in Georgia Iv~ethods for including research in current and future programs
Chapter VI Health Education in Iv.:.ental Health l:'Jeed for public education

-5Individual and group action potentials:
home schools community progranls edu(:ationa1 aspects of health programs Methods and evaluation Appendices
(Athens, Ga. IViay 27/28, 1965)