(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