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Rehabilitation in Canada : policies and provisions : a study of obstacles to the implementation of comprehensive… Choy, Ivy Fung-Tsing 1965

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REHABILITATION IN CANADA: POLICIES AND PROVISIONS A study of obstacles to the implementation of comprehensive r e h a b i l i t a t i o n services for Canadians by IVY FUNG-TSING CHOY ALLAN S. HARTLEY JANET KERR MICHAEL SIEBEN Thesis submitted i n P a r t i a l F u l f i l l m e n t of the requirements f o r the Degree of MASTER OF SOCIAL WORK i n the School of So c i a l Work Accepted as conforming to the standard required for the degree of Master of So c i a l Work School of S o c i a l Work. 1965 The University of B r i t i s h Columbia In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I f u r t h e r agree that per-m i s s i o n f o r extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . I t i s understood t h a t ; c o p y i n g or p u b l i -c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n p e r mission. Department of The U n i v e r s i t y of B r i t i s h Columbia, Vancouver 8, Canada In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that permission f o r extensive copying of th i s thesis f o r s c h olarly purposes may be granted by the Head of my Department or by his representatives. I t i s understood that copying or pu b l i c a t i o n of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. School of Social Work The U n i v e r s i t y of B r i t i s h Columbia, Vancouver 8, Canada. In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I f u r t h e r agree that per-m i s s i o n f o r extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . I t i s understood that, copying or p u b l i -c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n p e r mission. Department of The U n i v e r s i t y of B r i t i s h Columbia, Vancouver 8, Canada ABSTRACT It should be axiomatic that R e h a b i l i t a t i o n i s part of the s o c i a l p o l i cy of any modern state. When Canada signed the United Nations Charter, she pledged h e r s e l f to implement a comprehensive range of health services for her people. Health services according to United Nations d e f i n i t i o n s , have always included the f i v e major aspects of prevention, diagnosis, treatment, r e s t o r a t i o n and r e h a b i l i t a t i o n . The purpose of t h i s study, which i s the f i r s t of a planned s e r i e s , i s to examine what progress Canada has made toward the implementation of that promise, made to her people i n 1948. Its focus i s on i d e n t i f i c a t i o n of the b a r r i e r s l e g a l , p o l i t i c a l , economic sociaicahci administrative which -mitigate against the r e a l i z a t i o n of t h i s n a t i o n a l l y set objective. The study began with the hypothesis that because i n modern i n d u s t r i a l -ized s o c i e t i e s , programmes of r e h a b i l i t a t i o n services usually stem from a l e g i s l a t i v e base, the l o g i c a l place to begin i d e n t i f i c a t i o n and analysis of obstacles to implementation of a f u l l range of services, would be a review of the statutory provisions f o r s e r v i c e s . I f obstacles were i d e n t i f i e d at th i s l e v e l , t h e i r e f f e c t on the patterning and l e v e l s of services could then be examined and in d i c a t i o n s could be obtained as to how f a r a modification of the l e g i s l a t i v e s tructure of services might contribute to the development of a more comprehensive system. As a prelude to t h i s analysis i t was necessary f i r s t to delineate what i s e n t a i l e d i n the concept of a comprehensive system of services and to define the terms " d i s a b i l i t y " and "handicap". International sources were used extensively, and i t was found that i n s p i t e of widely d i f f e r i n g p o l i t i c a l , economic and s o c i a l i n s t i t u t i o n s , and arrangements, there was almost complete agreement on the basic p r i n c i p l e s of r e h a b i l i t a t i o n . Ten major p r i n c i p l e s were i d e n t i f i e d and recorded. Next an attempt was made to i d e n t i f y c r i t e r i a for r e h a b i l i t a t i o n goals as r e l a t e d to the i n d i v i d u a l disabled person. It was found that both the national and the i n t e r n a t i o n a l material consulted was geared to vocat i o n a l r e h a b i l i t a t i o n as a goal and that most statements did not take s u f f i c i e n t cognisance of the person who cannot reach t h i s goal, but who might achieve a d i f f e r e n t l e v e l of achievement and s a t i s f a c t i o n . An attempt was made to c l a s s i f y these goals i n a way which would be us e f u l both to c l i e n t s and agencies. Because each country has implemented the basic r e h a b i l i t a t i o n p r i n c i p l e s i n i t s own way, there i s no one system of services which can be used as a model for a comprehensive system. However, working from the base of the philopsophy and the ten p r i n c i p l e s , i t was found possible to c l a s s i f y the kind and range of services which would have to be included i n a comprehensive scheme. This was s p e l l e d out for use i n t h i s study and i n future projects i n the se r i e s as a "touchstone" or model p r o f i l e of services with a cautionary reminder that no.system of services i s or should be s t a t i c and that r e h a b i l i t a t i o n i t s e l f i s a constantly evolving concept. I t i s anticipated that i t w i l l serve at lea s t as a u s e f u l base against which to examine a wide range of problems r e l a t i n g to r e h a b i l i t a t i o n i n future parts of the s e r i e s . i i The many faceted nature of r e h a b i l i t a t i o n as a concept was next examined i n more d e t a i l because the t o t a l concept needs to permeate the whole range of s e r v i c e s . Emphasis was placed on the concept of r e h a b i l i t a t i o n not j u s t as a set of services but as a process, a "for ward movement towards a go a l " which the c l i e n t chooses and which the various r e h a b i l i t a t i o n personnel help him to reach. The study then focuses on an examination of the current Canadian p i c t u r e i n r e h a b i l i t a t i o n . This was preceded by a b r i e f summary of the early developments i n r e h a b i l i t a t i o n i n Canada, s t r e s s i n g the "piecemeal" and " c a t e g o r i a l " approach c h a r a c t e r i s t i c of the times, and the unique features i n the Canadian s i t u a t i o n . M a terial f o r th i s was obtained from the general l i t e r a t u r e , together with material obtained from the o f f i c e of the National Coordinator of R e h a b i l i t a t i o n f o r Canada and from correspondence with the P r o v i n c i a l Coordinators officeslof nine provinces, excluding Quebec. The r o l e of the f e d e r a l government was then analysed, with p a r t i c u l a r reference £0 i t s r e s p o n s i b i l i t i e s under the d i v i s i o n of c o n s t i t u t i o n a l powers made under the B r i t i s h North America Act of 1867. The s p e c i f i c groups f o r whose r e h a b i l i t a t i o n the fede r a l government has r e s p o n s i b i l i t y are then r e f e r r e d to. ; The p o l i c y of the f e d e r a l government i n i t s attempts to a s s i s t the provinces to carry t h e i r r e s p o n s i b i l i t y f o r r e h a b i l i t a t i o n services i s c r i t i c a l l y reviewed. There i s then a closer examination of the three s p e c i f i c act r e l a t i n g to the disabled i n Canada, f i r s t the Disabled Persons Allowance Act, secondly the Vocational R e h a b i l i t a t i o n of the Disabled Act, and t h i r d l y the relevant sections of the Technical and Vocational Training Act. There i s next a focussing on the e f f e c t s of t h i s l e g i s l a t i v e structure on the patterning of services i f i one p a r t i c u l a r province, B r i t i s h Columbia. Emphasis i s l a i d on the r e l a t i o n s h i p between the r o l e of the P r o v i n c i a l Coordinator, the place of the government agencies, and the important r o l e of voluntary agencies. Material f o r t h i s s e c t i o n was gathered from government s t a t i s t i c s , Royal Commission Reports, surveys and reports of l o c a l agencies, interviews with the P r o v i n c i a l Coordinator and the P r o v i n c i a l Consultant i n R e h a b i l i t a t i o n f o r the Province of B r i t i s h Columbia as w e l l as with the personnel of selected representative agencies o f f e r i n g a broad coverage of the spectrum of services i n B r i t i s h Columbia. As a contrast, the neighbouring province of Saskatchewan was selected as an i l l u s t r a t i o n of the d i f f e r i n g ways i n which i d e n t i c a l f e d e r a l statutes can be inte r p r e t e d and followed, and th e d i f f e r i n g ways i n which a p r o v i n c i a l programme of r e h a b i l i t a t i o n s e r v i c e can be structured and administered. In Saskatchextfan, the p r o v i n c i a l government of the Co-operative Commonwealth Federation party coming in t o o f f i c e i n the 1945, took an active r o l e i n the r e h a b i l i t a t i o n f i e l d from the time i t f i r s t took o f f i c e , u n t i l i t s defeat i n 1962, the now famous "medicare i s s u e . " i i i This government interpreted i t s own statutes and those of the f e d e r a l government very broadly, i n c l u d i n g from the beginning s o c i a l l y handicapped groups such as the Metis. In r e l a t i o n to the federal acts, i t included groups such as a l c o h o l i c s i n i t s concept of the "disabled" which i s not yet a common pr a c t i c e i n the r e s t of Canada. This govern-ment's approach was also characterized by an extensive use of the "needs" tes t rather than the means test as a base from which to o f f e r r e h a b i l i t a t i o n help to the e n t i r e family i f necessary. While the "needs" te s t i s used i n B r i t i s h Columbia also there are a number of r e s t r i c t i o n s i n i t s use, which do not operate i n Saskatchewan, such as a "maximum f l o o r " of f i n a n c i a l aid which might be below the l e v e l of help an i n d i v i d u a l or family needed i n order to become r e h a b i l i t a t e d . Among the findings of the study are the following (1) that the fate of a Canadian needing r e h a b i l i t a t i o n sew ices depends very much on which part of Canada he l i v e s i n . Even wit h i n h i s own province, h i s neighbour across the s t r e e t who happens to l i v e w i t h i n the boundaries of another municipality may fare f a r better than he does. (2) The kind and amount of help he receives would appear to be determined by three factors (a) the nature of the help a v a i l a b l e under the statutes, (b) the l i b e r a l i t y or r i g i d i t y of t h e i r i n t e r p r e t a t i o n by the a u t h o r i t i e s of t h i s p a r t i c u l a r l o c a l i t y (c) the a v a i l a b i l i t y of the kind of help he needs through the voluntary agencies(3) a l l the attempts by the Federal government to overcome the obstacles posed by the c o n s t i t u t i o n a l d i v i s i o n of powers have not r e s u l t e d i n "national minimum" f l o o r or service below which no Canadian s h a l l be allowed to f a l l , despite many r e i t e r a t i o n s by the f e d e r a l government that t h i s i s the intent, both of the l e g i s l a t i o n and of the e f f o r t s to a s s i s t the provinces which the f e d e r a l government has made to date.(4) In essence, the federal r o l e i s b a s i c a l l y l i m i t e d to a s s i s t i n g the provinces with whatever services or f a c i l i t i e s the provinces themselves are w i l l i n g to i n i t i a t e . ( 5 ) The conclusion i s inescapable that the e f f e c t of the present c o n s t i t u t i o n a l d i v i s i o n of powers on the development of comprehensive r e h a b i l i t a t i o n services i s an impeding one. (6) In e f f e c t , the provinces and the voluntary s o c i t i e s carry f u l l r e s p o n s i b i l i t y and the major po r t i o n of the load, without having ei t h e r the l e g i s l a t i v e authority or the f i n a n c i a l capacity. A s e r i e s of recommendations broad,and s p e c i f i c , a r e then made. They include (1) Changing the B r i t i s h North America Act as a necessary step to the f l e x i b i l i t y of patterning needed to make Canada's R e h a b i l i t a t i o n Services comprehensive.(2) That the Federal government should assume a vigorous r o l e as the standard s e t t i n g body i n the f i e l d of r e h a b i l i t a t i o n s e r v i c e s , and should implement the concept of a national minimum of s e r v i c e . This i s viewed as a necessity whether the f e d e r a l government continues i t s p o l i c y of extending f i n a n c i a l a i d to the provinces, or whether a d i f f e r e n t system of l e g i s l a t i v e and f i s c a l r e s p o n s i b i l i t y i s eventually worked out. A s e r i e s of"research questions" a r i s i n g out of t h i s study are l i s t e d with the intent that these w i l l form a nucletra of further research follow-up studies l a t e r i n the s e r i e s . ACKNOWLEDGEMENTS We wish to acknowledge our s p e c i a l thanks and appreciation to Mrs. Mary Tadych, our thesis advisor, who directed the project, f o r her d i r e c t i o n and encouragement. We also wish to thank Mr. C. E. Bradbury, P r o v i n c i a l Coordinator f o r the Province of B r i t i s h Columbia, Mr. Frank Hatcher, P r o v i n c i a l R e h a b i l i t a t i o n Consultant and ':-> Mrs. Rhona Lucas, Executive Secretary of the D i v i s i o n f o r the Guidance of the Handicapped, Community Chest and Council, who gave of t h e i r time i n interviews and i n steeri n g us to sources of mat e r i a l . We are also indebted to the personnel of a number of government and voluntary agencies who granted us interviews and allowed us to see t h e i r f a c i l i t i e s , and so courteously answered our many questions. We also wish to thank Mr. Ian Campbell, National Coordinator, and Mr. Keith Armstrong, of the Canadian R e h a b i l i t a t i o n Council f o r t h e i r assistance. We also owe thanks to the P r o v i n c i a l Coordinators of a l l the provinces ( except Quebec) f or t h e i r h e l p f u l l e t t e r s f u l f i l l i n g requests f o r information, and t h e i r generous o f f e r to help us i n any way they could. V TABLE OF CONTENTS Abstract Acknowledgements Tables and Charts Introduction Page i i v v i i v i i i Nature of the study. Rationale for the study A p r i o r i assumptions Chapter 1 Chapter 2 Chapter 3 SECTION I PROFILE OF THE PROBLEM Perspectives and Definitions International Perspective. Rehabilitation defined Classification of handicapped groups. Analysis of Rehabilitation as a Composite Concept Rehabilitation as a Philosophy. As a set of principles, As a process. As a series of stages. As a Series of Services. Criteria for successful rehabilitation. Classification of rehabilitation goals. Identification of necessary Services. Profiles of a "model" System of Services. Profile of the Early Developmental Pattern of  Rehabilitation Services i n Canada Early services of the voluntary agencies. Entrance of the Government into the Fi e l d . Piecemeal and Categorial Approach. Developments i n the Thirties. Developments i n the Post World War II Period. Developments i n the F i f t i e s and Sixties. SECTION II THE ROLE OF THE FEDERAL GOVERNMENT IN REHABILITATION Chapter 4 The Legislative Base for Rehabilitation Services  i n Canada The British North America Act. The Constitutional Division of Power. The Role of the Federal Government Analysed. Current Interpretations. VI Chapter 5 Federal Responsibility for the Rehabilitation of Specific Groups Programmes' for Mariners, Indians, Eskimos, Veterans and the Blind, Some Historical Anomalies. Chapter 6 Federal Financial Assistance to the Provinces i n Rehabilitation An overview. Health Grants Programmes Viewed as an Example. The Hospital and Diagnostic Services Act. SECTION III CRITIQUE OF SPECIFIC FEDERAL AIDS RELATING TO REHABILITATION Chapter 7 Critique of the Disabled Persons Allowances Act Chapter & Critique of the Vocational Rehabilitation of of the Disabled Act Chapter 9 Critique of the Technical and Vocational Training Act SECTION IV PROFILE OF THE PATTERNING OF REHABILITATION SERVICES IN A  PARTICULAR PROVINCE - BRITISH COLUMBIA Chapter 10 Rehabilitation Servic es i n British Columbia, with Special Reference of the Legislative Base. Effects of the Division of Responsibility of the Patterning of Services. SECTION V PROFILE OF A DIFFERENT PERSPECTIVE ON REHABILITATION THE SASKATCHEWAN APPROACH Chapter 11 Chapter D_2 Rehabilitation i n Saskatchewan Conclusions and Recommendations VI t TABLES AND CHARTS IN THE TEXT Table No. Schedule A 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. A c t i v i t i e s of Daily L i v i n g P r o v i n c i a l Percentage of Rejected Applicants Organization Chart - C i v i l i a n R e h a b i l i t a t i o n Program R e h a b i l i t a t i o n Cases and Cost of Support Compared to Incomes Payments to Provinces and P r o v i n c i a l Populations F i n a n c i a l Status Before and After R e h a b i l i t a t i o n Occupation Before and After R e h a b i l i t a t i o n D i s a b i l i t y Groups by Age, Sex, and Location Federal Payments and Program Breakdown Primary Cause of D i s a b i l i t y i n Accepted Cases of Disabled Allowance Cause of D i s a b i l i t y i n New Admission, G.F. Stong Centre Employment Status of Discharged Patients from G.F. Strong Chapter II p.20 Chapter VII p.9 Chapter VIII p.4 Chapter V i l l i p.9 Chapter VIII p.23 Chapter VIII p.24 Chapter VIII p.25 Chapter VIII p.26 Chapter IV p.8 Chapter X p.26 Chapter X. p.59 Chapter X. p.60 PART I OBSTACLES ORIGINATING IN THE LEGISLATIVE BASE OF SERVICES v i i i INTRODUCTION The role of rehabilitation i s becoming increasingly important in modern societies* Congenital d i s a b i l i t i e s , accidents, and the degener-ative diseases of the later part of the lifespan w i l l continue to tax our knowledge and resources i n the remaining decades of the twentieth century, Bike most modern states, Canada i s concerned with the implementation of a comprehensive system of rehabilitation services for her people. We pledged ourselves to this as a nation when, i n 1948, we signed the United Nations Charter, The recent Royal Commission on Health Services reminds us how far we have yet to go. One way i n which we might hasten our progress i s to examine our current pattern of services to see what changes might need to be made i f we are to reach the goal of comprehensive rehabilitation services available to a l l Canadians who need them. This i s especially necessary at the present time because the Royal Commission stated that i t was outside i t s terms of reference to consider anything other than the health aspects of rehabilitation. In modern times, rehabilitation i s a welfare matter also, and i t Was that great Canadian, Harry Cassidy, who gave a definition of welfare services which i s almost synonomous with some modern definitions of rehabilitation, viien he da?ined them as " Those organized act i v i t i e s which are primarily and directly concerned with the conservation, protection and improvement of human resources." Yet there are s t i l l surprisingly few studies of Canadian social programmes made by Canadians, This i s not because Canada has not had her experts i n the welfare f i e l d who have constantly striven to bring this need home to us. As far back as 1949, Leonard Marsh said " We need to record and analyse the origins, development and current progress of leg i s -lation, programmes, and :.. .institutions., .in a l l the various fields of welfare, ... A great deal has happened in the las;t twenty to f i f t y years. ... Are these developments and their lessons recorded?" In the years since 1949, some very interesting developments and experiments i n the f i e l d of i x r e h a b i l i t a t i o n services have taken place i n Canada. Can i t be said that we have adequately recorded them, interpreted them and learned the lessons they can teach us as to our future d i r e c t i o n s ? When we look at the wealth of mat e r i a l of t h i s kind which some other countries produce i t might perhaps be said with t r u t h that Canada i s tending to overlook the lessons of her own development. I t was with t h i s i n mind that i t seemed appropriate to the writer to inaugurate a s e r i e s of studies i n the area of comprehensive r e h a b i l i t a t i o n services} that a u s e f u l focus would be to concentrate on i d e n t i f y i n g the obstacles, l e g a l , p o l i t i c a l , economic, s o c i a l and aclministrative - which operate as b a r r i e r s to the implementation of a comprehensive range of se r v i c e s , because t h i s would be the necessary prelude to dev i s i n g ways of dealing with them. Accordingly, t h i s f i r s t part of the study was undertaken with the assistance of four students working f o r t h e i r Master's Degree i n S o c i a l Work at the School o f S o c i a l Work, Un i v e r s i t y of B r i t i s h Columbia, and forms the t h e s i s requirement f o r that degree. A l o g i c a l place to begin appeared to be the l e g i s l a t i v e base of services since the pro v i s i o n of r e h a b i l i t a t i o n services i n most modem countries u s u a l l y stems from t h i s l e v e l . I t was postulated that obstacles e x i s t i n g at t h i s l e v e l would have far reaching r e s u l t s on the e x i s t i n g pattern of services and would need to be reviewed most c a r e f u l l y i n any planning for change. Part 1 of the study has therefore been c a l l e d " A Study of Obstacles i n the Lej.slative Base f o r Services." I t should be the forerunner of a s e r i e s of projects which w i l l i n v e s t i g a t e other obstacles i n greater depth i n future years, ^ 1 This i n t r o d u c t i o n has been written by Mrs. Mary Tadych, Director of the Thesis project, to give the r a t i o n a l e and background of the present study, as the f i r s t of a planned s e r i e s . SECTION I PROFILE OP THE PROBLEM TABLE OP CONTENTS Page Chapter I: Perspectives and Definitions International perspectives on rehabilitation. The concept of rehabilitation defined 1 Chapter II: An Analysis of Rehabilitation as a Composite  Concept Rehabilitation as a philosophy. Rehabilita-tion as a set of principles. Rehabilitation viewed as a process. Rehabilitation viewed as a series of services. Rehabilitation viewed as a set of f a c i l i t i e s . The organiza-tion of rehabilitation 10 Chapter III: Profile of the Development Pattern of  Rehabilitation in Canada Early developments in rehabilitation in Canada. World War II and early post-war period. Developments during the 1950's. Developments in the 1960's 61 i CHAPTER I PERSPECTIVES AND DEFINITIONS International Perspective on Rehabilitation Crippling disease and injury respect no international boundaries. The afflictions of mankind and the social or economic consequences of those afflictions are as common to Asians as to Americans. Pain, doubt, fear, anxiety, discourage-ment, and the f i n a l surrender to disability are universal emo-tions and experiences. Just as rehabilitation seems to c a l l forth the best in individual and community understanding and effort, so the challenge of man's attempt to conquer his own handicaps appear to strike a chord of deep response in the area of international concern and cooperation. The character of rehabilitation services which have been developed in various countries through-out the world is necessarily different by reason of the social, economic, cultural and p o l i t i c a l variations and requirements. This, however, does not negate the importance and necessity of the sharing of ideas and knowledge, of encouragement, guidance, cooperation and financial assistance among the countries of the world. It is significant that some of the most f r u i t f u l co-operation among countries has taken place in the fi e l d of rehabilitation of the handicapped. A world federation of - 2 -voluntary agencies has been in existence since 1922 when the International Society for the Welfare of Cripples was founded to study causes of crippling diseases, collect and disseminate information and to stimulate action for the benefit of the physically disabled by local national and international organizations. The Society has also sponsored a productive series of international conferences. At the Eighth World Congress in New York in I960, in keeping with the times, the Society adopted the new name of "The International Society for Reha-b i l i t a t i o n of Disabled". At the governmental level, when the World Health Organization came into being in 1948, i t inherited the func-tions of the antecedent organizations of the League of Nations and has since made i t s own unique contributions to the f i e l d of rehabilitation. Its stated purpose is to aid attainment by a l l peoples of the world of the highest possible level of health. Its activities i n the areas of publicity and informa-tion, research and promotion of standards, preventive health measures, technical advice, and supplies and the training of personnel through fellowships and seminars, backed by the tremendous weight of i t s authority and prestige have proven of immense value in stimulating the coordination of world effort on behalf of the disabled. Two of i t s most notable contributions bear special mention. The f i r s t i s the International Labour Office Re-commendation concerning vocational rehabilitation of the disabled, which was unanimously adopted by the International Labour Office Conference in June, 1955 as follows: - 3 -Vocational rehabilitation services should be made available to a l l disabled persons what-ever the origin and nature of their disability and whatever their age, provided they can be prepared for and have reasonable prospects of securing and retaining, suitable employment. This was adopted by the 78 member states as a formal I.L.O. Instrument. The significance of this is best expressed in the words of the Director General of the International Labour Office. But the adoption of an international instrument is not the end of the affair; i t is only a beginning. Under the Constitution of the I.L.O. each member state, must, with-in eighteen months after the close of the Conference, consider whether to give effect to a Recommendation by legislation or other means; a statement on this action must then be submitted for information to the Interna-tional Labour Office. Subsequently, members have to report at appropriate intervals the position of the law and practice in their countries on the subject matter of the Recommendation and any action they may have taken on i t . With this information, the Conference can see what positive action has resulted from it s previous decisions. Even more important, then reports can prepare the ground for the organization to provide any further adviee or assistance which a country might need and ask fo r i We have already received reports from a number of countries.... Some of the reports state that the standards set are already sub-stantially covered in their own legislation. Others indicate that further action is being considered. To bring legislation up to the level indicated in the Recommendation. We anticipate that the I.L.O. w i l l be able to expand i t s technical assistance services to help governments which wish to create or improve services for the disabled.1 David A. Morse, Planning for Victory over Disablement, "Way Back to Working Life",Address given by D.A. Morse, Dir.-Gen. of the A second important contribution was that of the Expert Committee on Medical Rehabilitation which published i t s report in 1958. While this has not been proclaimed an 'international- -instrument1 as vocational rehabilitation recommendation was, nevertheless, the experts agreed "that medical rehabilitation forms the fourth phase in the whole scheme of health and medical measures applicable to an individual or to a commun-it y - namely the promotion of health, the prevention of disease the treatment of disease and medical rehabilitation.""^ So there are already some identified areas of agree-ment on principles and standards at the international level. Nevertheless, the pattern of rehabilitation services to be developed and implemented in each individual country must be adapted and geared to the actual need, the pattern and level of development of the related services,as well as to the social and economic setting of the people, as recognized and decided by themselves. One of the f i r s t problems facing a country is i t s own definition of the term "rehabilitation". The Concept of Rehabilitation Defined The term 'Rehabilitation' has been variously defined. The American National Council on Rehabilitation defined i t as International Labour Office, Geneva at the Seventh World Con-gress of the International Society for the Welfare of Cripples, London, 1957. Proceedings of the Seventh World Congress published by the Central Council of the Caape of Cripples, London, 1957, pp. 263-4. ''"Expert Committee on Medical Rehabilitation World Health Organization Technical Report Series, No. 158, p. 5. - 5 -the "... restoration of the handicapped to the fullest physical, mental, social, vocational and economic usefulness of which they are capable." 1 Perhaps, this definition is too ideal as i t is doubtful as to how many individuals presently l i v i n g can be said to be 'fully' developed according to their poten-t i a l i t i e s . The Canadian Department of IIHealth and Welfare has stressed that the aim of rehabilitation is not only to restore human capacities, but to cultivate and conserve residual 2 a b i l i t i e s . In both of these definitions, the focus is on restoring the 'residual' disabilities of the handicapped per-son. The definitions offered by Allen, provides us with a broader focus of the concept* Looking at i t in terms of i t s objectives, Allen stated that i t is "... making a person aware of his potential and then providing him with the means of attaining that potential." In a more specific sense, he used i t to mean the "... combination of disciplines, techniques and specialized f a c i l i t i e s which are intended to provide physical restoration, psychological adjustment, personal and vocational counseling, job training and placement."4 Allen's f i r s t "^National Council on Rehabilitation, Cleveland 1944, p. 6. Department of Health and Welfare, Research and Statistics Division. Rehabilitation Services in Canada. Part I . Health Care Series, Memorandum No. 8, Ottawa I960, p. 3. •5 Allen, S. Rehabilitation: A Community Challenge. John Wiley & Sons, Inc., New iork, I9t>o, pp. J L - 2 . 4 I b i d . - 6 -definition i s important as i t introduces the concept of indi-vidual motivation. In the f i n a l analysis, the success of the rehabilitation process i t i s very much up to the client - the basic principle of self-determination. It is here also where the concept of 'Habilitation' comes in, to be applied to the process of not only restoring, but achieving independence, self-care and work-potential in the f i r s t instance. This applies especially to the group of children,who have been disabled from early l i f e on, owing to congenital or other reasons. Distinctions between the terms "disability" and "handicap" were f i r s t enunciated by Kenneth Hamilton and have since become part of the literature of rehabilitation.''" A handicap i s the cumulative result of the obstacles which disability interposes between the individual and his maximum functional level. It i s an individual thing, composed of the barriers which the handicapped person must surmount in order to attain the fullest physical, mental, social, vocational and economic usefulness of which he is capable. Thus, a 'disabled' person i s "an individual with a condition of physical, mental or emotional impairment which can be quantitat-ively and qualitatively evaluated in medical or other objective terminology." A 'handicapped' person, on the other hand, is "an individual with a condition of physical, mental or emotional impairment in which the emphasis is on the cumulative results Hamilton Kenneth. Counselling the Handicapped in the  Rehabilitation. Ronald Press, New York, 1950, p. 17. - 7 -which the disability has interposed between the individual and his maximum functional level." A 'disabled* person may or may not be 'handicapped' while a 'handicapped' person always has a disability. The latter, of course, determines the handicap by causing a measure-able loss in the individual's capacity and by creating barriers which the 'handicapped' person must surmount in order to attain the maximum usefulness of which he is capable and to achieve independence. The concept of the handicapped individual has been broadened in recent years. Generally speaking, "rehabilita-tion" to date has tended to be oriented primarily towards the physically handicapped, and the majority of i t s resources are geared to the medical and vocational rehabilitation of such patients. Consequently, rehabilitation f a c i l i t i e s for the following groups have, in one way or another, been greatly overlooked and neglected. 1. The Mentally Handicapped; Included in this group are the mentally i l l as well as the mentally retarded indi-viduals. The former category includes the variety of patients ranging from the mildly 'neurotic' to the severely 'psychotic' where expert psychiatric and other services are needed for their treatment and rehabilitation. In the latter category, there are the 'mildly' retarded who are able to function relatively 'independently' in society, the moderately retarded who wilh training and supervision can contribute something to their own support, and the 'severely' retarded who need custodial institutionalized care. 2. The Emotionally Handicapped: There i s some doubt as to where this g£oup should he classified. They have been li s t e d under the "mentally" handicapped, but this has led to con-fusion. They need psychiatric and other related services for their rehabilitation, though they may not be "mentally i l l " in the lay sense of the term. 3. The Socially Handicapped: This i s a miscellaneous group, which appears under a number of classifications. It may include certain disadvantaged cultural groups, such as the Indian and the Eskimo -sometimes separately l i s t e d as the "culturally handicapped" and also recent immigrants , minority cultural and religious groups, such as the Doukhobours and the Hutteries.lt certainly included migrant labouring groups. It might also include in some classifications the "marginal!' group on social assistance, the socalled multi-problem family and the vagrant. Some classifcations include the alcoholic aid the drug addict. 4. Children with Special Needs" Included in this group are the so called "exceptional" children who are in need of special education. It has been estimated that 3$ of the nation's children are mentally retarded and need special program and f a c i l i t i e s for the ful l e s t development of their capacities. On the other side of the continuum are the ten to - 9 -15?° who are 'gifted*, whose intellectual protentialities can only he achieved and developed when properly guided by the environment, by challenge and stimulation. In the Brief by Canadian Mental Health Association to the Royal Commission on Health Services, 1962, i t was stated that 5$ - 10$ of school children show symptoms of emotional and mental disorder sufficiently serious to require the help of specially trained personnel. Similarly, children with multiple handicaps such as deafness together with blindness also need an increase in the specialized range of services. 5. Old People: Included in this category are the 'aged* who are bed-bound and home-bound, where the rehabilita-tion 'goal' l i e s at the level of self-care and the activities of daily liv i n g , without ever reaching the 'goal' of gainful employment. CHAPTER II AN ANALYSIS OF REHABILITATION AS A COMPOSITE CONCEPT Any attempt to assess the extent to which Canada may be said to have a comprehensive system of rehabilitation services must be related to an analysis of the concept of rehabilitation i t s e l f as a composite involving many elements. Rehabilitation attempts often f a i l because one of the v i t a l components in the rehabilitation process was overlooked. It is proposed to make a review of rehabilitation i n it s varied aspects to serve as a kind of "touchstone" which later phases of the study can refer to as the parts of the study relating to specific services and programmes are under-taken in the future. Rehabilitation as a Philosophy The philosophy of rehabilitation can be said to be the rationale behind any rehabilitation program recognized and developed in any country, While i t is not intended to dwell on this, nevertheless, i t is important enough to be noted because many of our failures in rehabilitation can be traced to a failure to imbue services rendered to the handicapped person with the "living breath" of the philosophy. - 11 -In western countries, i t is said that the Judaeo-Chris-tian heritage has played an important role in the in-creased interest in rehabilitation in recent years. However, the philosophic base from which rehabilitation begins is fundamentally related to two moral principles to which most of mankind in modern societies would subscribe: 1. Value of the Human Being. The dignity and worth of the individual is to be cherished and respected regardless of how severe his disability may be. This includes his rights to be assisted in the unfolding of his personality and the development of his potentialities for his own sake and for the good of society as a whole. 2. Membership in Society. The mutual dependence and trust which form the base of a society's organization imply that the person with a disability, like anyone else, should partake of the activities that society has to offer in so far as he is able. Consequently, society is obliged to establish schools, hospitals and work opportunities that will meet the needs of a l l i t s members. When special needs are evident, special arrangements to accomodate them are implied. In short, i t can be said that the philosophy is echoed in the Universal Declaration of Human Rights adopted and pro-claimed by the United Nations' General Assembly on December 10, 1948: Everyone has the right to a standard of liv i n g adequate for the health and well-being of him-self and of his family, including food, clothing, housing, medical care and necessary social services, and the right to security in the - 12 -event of unemployment, sickness, disability, widowhood, old age or other lack of l i v e l i -hood in circumstances beyond his control. (Article 25 (1)) . Similarily, a corresponding view i s expressed by the World Health Organization with regard to children as follows: Every child has the right to develop his potentials to the maximum. This implies that a l l children, irrespective of whether or not they suffer from mental or physical handicap, should have every access to the best medical diagnosis and treatment, a l l i e d therapeutic services, nursing and social services, educa-tion, vocational preparation, and employment. They should be able to satisfy f u l l y the needs of their own potentialities and become, as far as possible, independentand useful members of society.1 Principle 5 of the United Nations Declaration on the Rights of the Child, adopted by the Commission on Human Rights of the United Nations in 1959 states: "The child who is physically, mentally or socially handicapped shall be given the special treatment,1 education and care required by his particular condition." Rehabilitation as a Set of Principles One way to view rehabilitation is to see i t as a set of principles flowing from the value system of i t s philosophic base. Again, many of our failures in the f i e l d of rehabilita-tion can be traded to the violation of one or more of these principles in some way or to some degree. Hence the principles W.H.O. Technical Report Series No. 75, Geneva, World Health Organization. - 13 -play a prominent role in any assessment of comprehensive ser-vices. 1. The Principle of Individualization: People with the same or similar disability have different needs and thus re-quired a flexible and variable overall treatment plan geared:..-, to the particular individual person. If rehabilitation is to be truly successful, every step in the process must be care-f u l l y planned to take into account the patient's attitudes, his tolerance, and his eventual goal. General laws of behavior and disease entities are important in understanding the specific character of the individual and his needs, but there is no such thing as a standard method for handling similar cases. As a consequence, the concept of Variability in Treat-ment should be used. 2. The Principle of Comprehensive Treatment: The many ramifications of adjustment to disability require attention to the individual's physical, emotional and social problems i n -cluding economic matters and the nature of his interpersonal relations at home and in the wider community. The importance of 'treating the person as a whole' becomes more important when such areas are realized to be interdependent; improvement in one area often depends on improvement in others. Thus, as a consequence, a whole range of services; health, medical, educa-tional, social, psychological, vocational are required. This does not preclude the use of 'normal' or 'general' services available in the community whenever and wherever possible. - 14 -"5* The Principle of Adequacy: This principle evaluates services both quantitatively and qualitatively. There should be sufficient coverage in every area of need in the range of services and the adequacy of the standards in dealing with the problems. 4. The Principle of Availability: Rehabilitation services should be available to any person in need of them regardless of which locality he is from. Provisions must be made to ensure that such person knows where he i s to start his enquiries about services. He should be able to begin in his own particular place of residence, rural or urban, even though he may have to go outside his community for some of the time in order to get the services he requires. 5. The Principle of the Multi-disciplinary Approach: This principle recognized that no one discipline can meet a l l the rehabilitation needs of the handicapped person through i t s own resources. Hence the many para-medical personnel to be found in the rehabilitation f i e l d today. Basic to the "team approach" is a common understanding and broad evaluation of the needs of the handicapped person, plus joint planning and regular review with clear delineation who shall carry which roles and for how long. In referring to the staffs of rehabilitation centres, Allen pointed out that there is some chance for the staff to err in the direction of one extreme or another; toward jealous assumption of prerogatives by one particular discipline or toward the un-discerning insistence upon a l l members of the rehabilitation team exerting their efforts upon each and every patient, regardless of whether he may have any real need for some of the services.1 Team cooperation seems to be taken for granted whereas i t is actually d i f f i c u l t to achieve. Where team "differences" exist, the patient can sense i t . These would be eliminated through constant staff education, group discussion of both patient and methods, definitive leadership on the part of the administer or coordinator. There should be recognition that the treat-ment team may operate out in the community outside of the setting of the rehabilitation centre and the hospital. 6. The Principle of Patient-centred Approach; This may be seen as a corollary of the Multi-Disciplinary Approach, where the patient is conceived as a member of and central to the rehabilitation team. Though this does not necessarily always follow in practice, i t implies a flexible approach which adapts service to the disabled person as contrasted with f i t t i n g a l l patients into a single regimen. Above a l l , i t focuses attention upon the point of view and attitudes of the personnel, their positive attitude and warmth provide a bridge which permits the patient to move toward his rehabilita-tion 'goal'. 7. The Principle of Integration and Coordination: Coordination of services requires a process of understanding and agreement between individuals and agencies which permits Allen, S., Rehabilitation: A Community Challenge, op.cit., p. 64 . - 16 -them to function effectively together to secure a more promising result for the disabled person. Integration, on the other hand, implies not merely the understanding and harmony as between services but the uniting of those services for a common purpose and to a ciommon end. Although coordination is both necessary and important among community rehabilitation agencies, the key-stone in the development of successful rehabilitation of the handicapped i s integration of aims and services; an applica-tion of a l l services necessary to insure the patient's restora-tion to his fullest capacity. "Whereas the principle of comprehensive services points to horizontal integration of a variety of disciplines at a given time, the principle of long range planning stresses integration of present and proposed services.""'* 8. The Principle of Recognition of the Time Dimension: Rehabilitation i s a continuous process that applies to the individual as long as she needs help, and to society so long as conditions exist that interfere with the welfare of any group of i t s citizens. Rehabilitation should begin at the time of recognition of any type of disability that interferes with 'satisfactory' social functioning and performance, health, education, work or other areas. Without early diagnosis and Dean W. Roberts, The Planning of Rehabilitation Centers, "Evolution of the Rehabilitation Center Concept", Proceedings of the Institute on Rehabilitation Centers Planning, Chicago, February 25, March 1, 1957, published by U.S. Dept. of Health, Education and Welfare, U.S. Government Printing Office, Washington, D.C. 1957, p. 13. - 17 -treatment, with each passing month, the result w i l l be a greater fixation of the disability thus reducing the opportun-i t y for restoring the physical, mental, social and economic function of the patient. 9. The Principle of Maximum Integration of the Handi- capped into the Community: The 'handicapped' individual should not be separated from the 'normal' community except when and only for as long as necessary. Blind children, for example, should be placed or kept in the ordinary kindergarten or school as much as possible. 10. The Principle of Community Responsibility and  Participation: Experts and services alone cannot solve the problem of the attitude of the public to the disabled. The local blueprint for rehabilitation, the f a c i l i t i e s , the personnel, the services, the recreational opportunities, the job possibilities, the public attitude, w i l l a l l be created in and by the community. Only acceptance of the 'handi-capped* on equal terms w i l l offer real opportunity for the success of rehabilitation efforts. The role of the volunteer services may range from voicing the need for rehabilitation to entire participation in direct services to the handi-capped . Rehabilitation Viewed as a Process A dictionary definition of process is "forward move-ment, progressive or continuous proceeding ... and advance ... passage". It is often forgotten "that the essence of rehabilita-- 18 -. tion i s that i t is a process with a l l that this implies. It is truly a passage for the "patient" or "client" and i t should be a passage toward a goal. The 'Goal' in the Rehabilitation Process Restoration and achievement of maximum function of ab i l i t i e s that are l e f t is the ultimate 'goal' of rehabilita-tion for people of a l l ages and di s a b i l i t i e s . Thus, i t must be realized that the rehabilitation process is a relative matter depending on the unique condition of the individual. Regardless of how 'limited* the level of 'goal' i s , effort should be made to help the person's achievement. We can speak of 'levels of possible goals' that might be classified as follows: 1. Competitive employment in the labour market. 2. Employment under special (sheltered ) conditionst remunerative or for social satisfaction. 3. Working at home for remunerative, occupational or diversional purposes. 4. Training in homemaking s k i l l s for the disabled homemaker. 5. Training in communication s k i l l s : such as in speech or writing from the blind child to the bed-ridden and adult stroke patient. 6. Training in activities of daily l i v i n g : these may range from self-care activities such as eating, dressing, toileting, to wheel-chair s k i l l s , locomotive s k i l l s and use of - 19 -public transportation and f a c i l i t i e s i n public buildings. 1 7. Achievement of activities leading to personal  satisfaction: this would include activities as painting with the use of teeth or feet; recreational or any other diversional or "self-expression" activities which a bed-ridden person may wish to try out. Whaterver level of goal the handicapped person may set himself, because rehabilitation is a process, i t can usually be achieved only through a series of steps. Case-Finding This is the sine qua non of rehabilitation. It is not listed as the f i r s t step in the process because i t i s the in -dispensable " f i r s t activity" without which the rehabilitation process cannot begin. Sometimes, this service^is equated with medical diagnosis. St r i c t l y speaking, i t is a broader concept. It is also a most controversial area in rehabilitation in the sense that in most countries a compulsory registry is not con-sidered a good way. Another case-finding device i s through a designated agency which serves as a central place in the com-munity where the handicapped can go and to be advised as to where to proceed. Regardless of how this service i s to be performed, i t should include medical, educational, vocational and social aspects. While case-finding usually begins with a medical diagnosis, this is only one aspect. The phrase "Activities of Daily Living was coined by Dr. Howard Rusk and has since come into general use in the Rehabilitation f i e l d . He covers this topic extensively in his book Rehabilita- tion Medicine, the C.V. Mosby Co. St. Louis, 1958, p. 146. - 20 -Schedule A - Activities of Daily Living CLASSIFICATION OF PATIENTS ACCORDING TO INDEPENDENCE FUNCTIONAL ACTIVITIES GROUP PATIENT NEEDS HELP PATIENT IS INDEPENDENT LIGTING ASSISTANCE I A l l A.D.L. Patient not ready for any functional activity II A.D.L. Bed and wheel chair activities: Self-care activities III A.D.L. Bed activities Wheel chair activities Self-care activities bating activities Dressing activities Toilet activities Travel: Private care (from wheel chair) IV A.D.L. Travel: Placing wheel chair into car. Ambulation in parallel bars: To standing position Standing and walking A.D.L. Bed and wheel chair activities Self-care activities Travel: Private care (from wheel chair) Ambulation: 30 feet inside Climbing: "5-inch steps with r a i l A.D.L. Bed and wheel chair activities Self-care activities Travel: Private car (from wheel chair) Placing wheel chair into car VI Ambulation: Climbing: 3 to 8 inch steps with r a i l 2 to 6-inch curbs A.D.L. Bed and wheel chair activities Self-care activities Travel: Private car (from wheel chair' Placing wheel chair into car Ambulation: 40 feet inside A.D.L. Bed and wheel chair activities Self-care activities Travel: Private care (from wheel chair), (standing Elevation: wheel chair, bed, toilet Ambulation: 40 to 80 feet i n -side Climbing: 10 to 12 8-inch steps with r a i 6 to 8-inch curb A.D.L.: Wheel chair and ambulatory Ambulation: 80 to 120 feet continuously Cross street while light changes including curbs Climbing: 12 to 15 8-inch steps with r a i l Travel: Private car; public transportation (bus). - 21 -Steps in the Rehabilitation Process 1. The Assessment or Evaluation of Client Assessment is the f i r s t step in the process and like so much in the f i e l d of rehabilitation is a composite concept in i t s e l f . It involves (a) Medical Evaluation: To establish the nature and ex-tent of the disability; appraise the general (total) health status of the individual in order to determine his capacities and limitations; ascertain i f physical restoration services might remove, correct, or minimize the disability condition(s); and contribute a sound medical basis for selection of a rehabilitation objective. Medical evaluation is a continuing or recurring activity throughout the rehabilitation process, not just a mere i n i t i a l step. (b) Social Evaluation: This involves securing social history material which, taken as a whole, brings the client into focus as an individual distinct from others and points up his potential for benefiting from the rehabilitation process. Social history is necessary for a diagnosis of the total problem and is the background against which planning and treatment are undertaken. This would include the understanding of the family; his cultural and economic background of the client, and his particular l i f e experiences. (c) Psychological Evaluation: This results from a synthesis of psychometric data and information obtained during interviewing, counselling, and other aspects of the rehabilita-tion process,. Psychological evaluation is not an isolated - 22 -service but is closely related to counseling and a l l other rehabilitation services. Psychological tests, especially such personality or projective tests, may be valuable at any point of the process, as they throw light on the person's reaction to himself as well as to the environment. They may also be useful in vocational planning as well as to see i f psychiatric help is needed before a patient can benefit from rehabilitation. (d) Vocational Evaluation: This is viewed as gathering, interpreting, analysing and synthesizing a l l the vocational significant data regarding the individual and relating them to occupational requirements and opportunities. These include: relating work and vocational training history and family opportunities, personal adjustment, mobility and family circumstances. It is especially important to relate the results of vocational evaluation in to the needs and wishes of the individual, as well as to training opportunities and types of jobs available<near the client's home. Relocation of the family to enable the handicapped bread winner to get a suitable job may have to be considered but is not usually resorted to except in extreme circumstances in a number of countries. In other countries, i t is expected accepted planned for, with considerable help to the family both in planning and follow-up. 2. Rehabilitation Diagnosis: The rehabilitation diagnosis is the second step in the process. It brings together significant data to enable an - 23 -evaluation to be made regarding: (a) the identification of problems, (b) the appraisal of rehabilitation objective or goal, (c) the identification of rehabilitation services needed. Determination of e l i g i b i l i t y for services may be necessary in certain cases, and may create obstacles to the carrying out of the next phase of the process. 3» The Rehabilitation Plan and i t s Implementation: In planning and making the necessary arrangements for the program of services the basic principle should be observed that the client needs to participate in the planning and assist himself as far as possible. The counselling relationship which should be available to the handicapped person at each stage of the process should be devoted to and assisting the client to involve himself in the treatment plans and to make the best use of the program of services offered. Planning, like diagnosis, is an on-going, changing and developing thing as the client and his circumstances change, and thus should be continuously re-evaluated as to i t s appropriateness. 4. Follow-up of Evaluation: 1 After the patient has learned and mastered whatever techniques are required for dealing with his disability, the Sometimes, the term 'evaluation' is used in relation to follow-up and should not be confused with the use of the term 'evaluation' in the assessment phase. When i t i s used in relation to follow-up i t refers to the evaluation of the total helping process. - 24 -counselor should continue to help him to cope with problems in the new situation by means of follow-up v i s i t s . Evaluation should also be made as to the adequacy and suitability of the patient's functioning in relation to his capacities and the objectives in the rehabilitation process both at home in his daily-living, and afterwards, in his new work placement i f the rehabilitation goals reached so far. Evaluation should also be made as to the adequacy and suitability of the person's functioning in relation to his capacities and the objectives in the rehabilitation process. In certain cases, i t may be necessary to encourage patient to reach a higher level of achievement than the original in the rehabilitation goal; in others i t may be necessary to help him accept the reality of a "lower" or less demanding goal than the one originally set. Sometimes some of'the steps in the rehabilitation process are formulated as "principles of the rehabilitation process" or "principles of the placement process" which makes rehabilitation literature so confusing at times. One formulation of these principles is to be found in the monograph "The Place-ment Process in Vocational Rehabilitation Counselling" published by the U.S. Department of Health, Education and Welfare, which is as follows: (l) Action must be based upon adequate diagnostic information and accurate and re a l i s t i c interpretation of the information that is secured. - 25 -(2) ^ach rehabilitation client must be served on the basis of a sound plan. (3) Guidance and counseling of clients and close supervision of a l l services are essential at each step of the process. (4) Bach service must be thoroughly rendered and followed-up. (5) The cooperation and involvement of the client and a l l others concerned with his rehabilitation is necessary and must be secured before adequate rehabilitation can be accom-plished. (6) Adequate records must be kept."** It has been impossible to review the steps in the rehabilitation process without refering to the role of the counsellor. There are differing views as to whether there should be one single counsellor through the entire process to ensure continuity or whether i t is more feasible to expect that the person on the treatment team taking major respons-i b i l i t y for counselling the client may vary at any given moment and should do so as the client progress through the various phases of the process. Who should be designated to the •counsellor role' and what training should best equip a person for i t are questions which have not yet been satisfactorily U.S.. Dept. of Health, Education and Welfare, Office of Voca-tional Reh. The Placement Process in Vocational Rehabilitation  Counselling. Thomason, Bruce and Barrett, Albert M., (ed.) tf.S. Government Printing Office Washington, U.S.A. Rehab. Service Series #545, p . 42. - 26 -answered in rehabilitation. Social workers have sometimes la i d claim to priority in the counsellor role. Some have even been known to claim a monopoly in i t . Although the social worker certainly f i l l s this role for some of the time during the rehabilitation process, i t is by no means clear at present how this function should be allocated in the different stages in the rehabilitation process. The counsellor role is viewed as that of a person, who through a professional relationship, helps assess the client's psychological readiness for change, helps him deal with any 'inner obstacle' of his own attitudes and feelings which may hinder his reaching of his rehabilita-tion goals, interacts with him in such a way as to maximize his assets, yet at the same time, fosters r e a l i s t i c self acceptance of the disability by the client. If the task of the counsellor seems a formidable one, i t s d i f f i c u l t i e s are minor compared to the tasks which the rehabilitation process usually involved for the client. An-other way of viewing rehabilitation, and an essential one in the understanding of the total process is to view i t as a series of stages, each involving the mastery of certain tasks, which the client must undergo in most instances i f he is success-f u l l y to achieve his rehabilitation goal.. Although the term 'adjustment' is in bad odour in some quarters, i t is perhaps the best one to indicate what is involved for the client. In some way, hopefully, a constructive one, he must come to terms with his disability. The Adjustment Process in Rehabilitation The client undergoing rehabilitation goes through a number of stages in adapting to his disability. These have been variously identified in rehabilitation literature. One approach is to view the stages as adaptive processes of the ego.1 Prom this viewpoint, there are three phases of "re-covery" in the rehabilitation process. 1. Emergency Reactions to Stress of Onset of Disability: Under the impact of sudden and severe stress, such as occurs with severe injury or illness, emergency defence mechanisms such as repression and denial are called into play in order to protect the patient from the f u l l impact of the stressful situation. Thus, the patient may 'forget' the experience or claim that he hardly f e l t the pain following the amputa-tion of his leg by a railroad locomotive. This defense mechanism can also operate where i t s onset is gradual or has been present since birth. These reactions are universal and normal and are not necessarily an indication that the person is neurotica There is also often a period of depression following the i n i t i a l shock. 2. Transitional Phase: As a person is able to appreci-ate more clearly the extent of his disability or the seriousness "^ See the paper by Jay Bisgyer "The Adaptive Processes of the Ego" in Proceedings of the Workshop: Practice of Social Work  in Rehabilitation given at the University of Chicago, I960. - 28 -of his illness, additional reactions tend to occur. At the reality level, the person is confronted with certain factors, such as the effect of the disability on his a b i l i t y to f u l f i l l his roles as spouse, worker, parent, or in the case of a child, the role of student. He is also confronted with some limita-tions of function and possibly some effects on his general health. While a person does not usually f u l l y accept a l l the implications of his disability, at f i r s t , nevertheless in this phase he should begin to allow these reality considerations to predominate. When this happens, such responses are considered "normal" for this phase. Certain responses also occur at the unconscious level. These psychological factors are related to the personality structure together with symbolic implications of the experi-ence. The injury may have a variety of meanings, such as realization of long-awaited punishment; confirmation of hidden feelings of loathsomeness and shame; and increase in dependency that is unconsciously deeply wished for. A certain amount of discharge of emotional tension is inevitable in the course of successful treatment and a certain amount of indulgence of the patient is required. 3 . Phase of Later Convalescence, the Readjustment to  Outside Living: During this phase, the complications of the problems of 'secondary gain' through illness may occur. In the case of a child his handicap may bring him special atten-tion, such as the presidency of his class, and protective attitudes on the part of certain teachers and class-mates, or give him a special place within his family group. Adults too may be overproteeted by their families. Instead, the patient is now required to make an adaptation to a new reality. He must return to a competitive world recognizing that he is less well equipped than formerly to cope with the competition. To-gether with the deleterious effect of well meaning but over-protective relatives and friends, the patient may wish to cling on to his dependency. These needs may go back to child-hood experience and psychiatric treatment may be needed before they can be worked through. 4. Some Indications of Malfunctioning of the Adaptive Process; (a) a prolonged shock stage of emergency defenses, (b) prolonged depression or the absence of i t , and (c) the sacrifice of rehabilitation in favor of secondary gain. In such instances, extra help and services are necessary, especially those of psychiatric nature, before the patient can move along and foreward in the rehabilitation process. Disability and the Body Image One of the fascinating paradoxes of the human condition is that the human body, which unites us as a biological species, gives rise in each of us, on a psychological level, to a body-image that is one of the subtly unique features of the individual personality. This body-image which basically has to do with how a person's body seems to him is not only of the body as a whole, but also of different parts of the body. One person takes pride in his muscular development and others are preoccupied with the - 30. -condition of the stomach or heart. To a certain extent, the body image is culturally determined. But the intimate associa-tion of body image with a person's sense of his own worth and his place among other people goes even deeper than this. Thus, the rehabilitation worker should realize that he is treating not only disabled limbs, organs and bodies, but that he is treating the patient's body image of the broken limb, at-rophied muscles, blinded eyes or paralyzed body or malfunction-ing heart or lungs. Just as surely as the psychiatrist does, the rehabilitation worker is treating the patient's personality,-insofar as the patient's sense of personal worth, his conception of his relations to other people, his hopes and fears, his f e e l -ings of disgust, guilt, shame, wounded pride, are involved in the particular organ or limb or body system that has been disabled. The adult patient who has suffered sudden disablement has two kinds of adjustment to make: f i r s t he must adjust him-self to the r e a l i s t i c limitations and adaptations imposed by the disability and then he i s suddenly called upon to modify his body-image, his conception of himself, his relations to people, his work, in accordance with the nature and extent of disablement. In the process of revising his body image, the patient may experience a reawakening of long-forgotten conflicts and associa-tions with emotionally painful events and feelings of the past, the result being that he f a l l s back on immature patterns of be-haviour characteristic of his childhood. This psychological ad-justment may be a temporary phase or i t may have implications for the patient far more crippling to his total functioning as a person, than the physical disability i t s e l f . - 31 -Human Motivation and the Rehabilitation Process Human motivation is a complex phenomenon. The literature on the subject, while vast, indicates how l i t t l e wefreally know about i t . It is not a simple thing to motivate a patient to work toward his own recovery as the situation depends very much on conscious and unconscious needs; needs for love and attention, dependency strivings and struggles against them; feelings of ho s t i l i t y and guilt. These patterns are found in the development of every individual and d i f f i c u l t i e s arise when they have been imperfectly resolved in the course of matura-tion. The onset of a disability may reactivate earlier partially repressed attitudes to dependency and to authority which may interfere with the patient's cooperation in the treatment plan. The rehabilitation team should be alert to these forces which impair motivation. The disabled individual may equate service from others with love and attention previously denied him in the past; punishment of those who neglected him; or retribution for his own host i l i t y and guilt. Just as the victim of sudden dis-ablement must work through the inevitable depression he feels, so he must work through his dependency needs as he becomes aware of the nature and extent of his disability. Even those patients who show good motivation for rehabilitation and progress rapidly may tend to have occasional brief lapses. In some instances a certain degree of dependency w i l l be inescap-able; the patient cannot be entirely self-sufficient and he - 32 -must be encouraged to accept this. The question as to how much dependency such patients must accept and how much responsibil-i t y and ini t i a t i v e they should be encouraged to assume in their future adjustment i s , of course, entirely dependent upon the severity of the disability and the patient's resources for developing new s k i l l s and interests. Thus, these factors w i l l determine how much and to what extent the patient w i l l u t i l i z e the rehabilitation re-sources and his participation and cooperation w i l l determine i t s success or failure. While efforts should always be made to help patients overcome these inner obstacles, sometimes the reasons for the lack of success of the rehabilitation process do not seem to be due to "inner obstacles" of this nature. Every rehabilitation service has i t s quota of "baffling" cases, where rehabilitation goals seem to have been set within the client's competency to achieve both physically and psychologically and to everyone's surprise, She client f a i l s to achieve them. Converselyy, we are equally surprised by those clients who achieve rehabilitation goals that no one would have estimated would have been physically possible for them. Rehabilitation Viewed as a Complex of Services Yet another way of viewing rehabilitation is to see i t as a series of services. A rehabilitation service is the application of a combination of talents and methods, usually professional or technical in character, which produce a result; - 33 -the alleviation of the consequences of disability. In dis-cussing these services, they w i l l be generally divided into five main categories: medical, psychological, social, vocational and educational. It must be noted that there is no clear-cut dividing line between them and services do often overlap in their functions. 1. Medical Services: Faced with a growing number of disabled persons and a larger percentage of aging population, medicine i s called upon tbsaccept a larger responsibility for the social and economic welfare of the patient, and thus the attention on rehabilitation. Modern rehabilitation medieien involves not only the services of the general practitioner and the various specialists including the psychiatrist but adequate services in diagnosis, examination, laboratory studies, X-ray, therapy, drug prescription, team evaluation of disability, and reconstructive surgery and many other special services. The practice of rehabilitation for any doctor rests on the convic-tion that his responsibility continues beyond the stage of acute illness or the convalescence from surgery; that i t must continue u n t i l the patient has been trained to li v e and work to the maximum effectiveness permitted bji his disability. It is also generally recognized that the definitive medical guidance, the sound prescription for treatment and therapy procedures, can come only from the doctor. S^yaiujpsing: The principal contributions of the nurse in rehabilitation care are in the areas of rehabilitation nursing - 34 -service management, c l i n i c a l teaching and basic bedside nursing. In the controlled environment of a hospital rehabilitation service, the nurse must recognize and u t i l i z e the hygiene, nutrition, exercise, elimination, relaxation, recreation, and occupational preparation which contribute markedly toward maximum possibility of successful rehabilitation. 3» Physical Therapy; This service supervises and carries out a program designed to accomplish the maximum of physical restoration. It consists of active and passive exercise, often against resistance, to develop strength, muscle re-education, increased range of motion. Various exercise devices such as pulleys, weighs, wheels, steps, and walking r a i l s are used to bring about the desired results. Heat from lamps, paraffin baths and the li k e , water and heat in whirlpool baths or tanks electrical stimulation or sound waves, massage of injured parts are a l l designed to increase circulation, relieve pain, relax muscles, and make the patient feel better. Instruction in daily activities or home exercise routines, as well as certain testing and measuring for diagnostic or prognostic purposes, is also part of the physical therapist's job. In some European countries this profession includes the "medical gymnast" as well. 4. Speech and Hearing Therapies: Services to supervise and carry out a program which is designed to correct or to compensate for defects in speech or hearing. This type of therapy is directed at speech or hearing disorders which may - 35 -be either organic or functional in nature and which may be either congenital or the sequelae of disease or injury. S k i l l i s required in the testing and evaluation of hearing loss through the use of modem acoustical equipment. Speech read-ing, correction, and conservation of speech contribute to the conquest of disorders which halt or interrupt the patient's communication with the world around him. t 5. Corrective Therapies: This service supervises and carries out a program which consists of medically prescribed physical activity, primarily exercise and self-care. A series of conditioning exercises, ambulation, and socialization activities are given to the bed, wheel-chair, aor ambulant patient. Highly individualized routines may be devised for each patient or the work may be done in groups. Gymnasium-type f a c i l i t i e s and equipment, swimming pools, and adapted gear for bed exercise form the working tools for the correct-ive therapist. 6. Prosthetics and Orthotics: These services supervise and carry out a program which include the selection, f i t t i n g , and training in the use of prescribed gadgets, braces, crutches, a r t i f i c i a l limb, wheel-chair and other devices. These devices offer support to help maintain body alignment against weakened segments; to encourage early motion and function in order to prevent atrophy from disuse; to increase function of permanently weakened muscles; to replace function totally and permanently lost either from muscle weakness or from loss of body parts. - 36 -Thus, they are not only helpful as a more dynamic approach to present treatment and resultant recovery ih patients with many diseases and injuries, hut also may be considered as a necessity in promoting self-sufficiency for the patient with residual permanent severe disability. 7. Psychological Services: Much of the work of psychologists in the area of rehabilitation has stressed the observation that psychological disturbance of those with dis-a b i l i t i e s is related to psycho-social factors to which the patient is reacting"rather than to specific and unique effects of the disease process. Physical defect, for example, has a unique, personal and often deep, unconscious significance for the disabled person. It also has social significance as i t is the grounds upon which class and caste distinctions are made. The role of the psychologist, then, l i e s in the area of objective assessment of the intellectual and emotional a b i l -i t y and disability; a measurement of the potential of the dis-abled patient.. In the more serious cases, involving deep-seated neuroses or psychoses, where referral for psychiatric or neurological consultation is indicated, the psychologist may act as liaison in Interpreting psychiatric findings for the rest of the rehabilitation staff and helping them to carry through treatment recommendations. This service requires the use of various diagnostic tests as, tests of intelligence, achievement, aptitude® and personality and various methods, individual or group, to be administered and interpreted according to psychological principles and techniques. Like the psychologist, the psychiatrist i s concerned with assessment and treatment, "but his area i s more focused on |fhe emotional aspect of the patient, the psychological hazards of his disability, and the acceptance of the handi-cap. The problem of motivation is an extremely complicated one, which, in its technical aspects, involves the psychiatric approach to rehabilitation. It is in this area that the psychiatrist with his particular insight into the deep-lying irrational and unconscious forces that determine the direc-tion and intensity of motivations, can make a specific con-tribution to the rehabilitation team. In recommending ways of handling patients that transcend the narrowly common-sense approa.ch.es, the psychiatrist acts as consultant, his role i s thus also advisory and educational. 8. Social Services. Social Work: Implicit in social work philosophy i s the deep belief in the integrity of the individual, in his capacity and right to determine the way of l i f e that is best for him. Coupled with this belief in self-determination is the conviction that man, to attain f u l l self-realization, must know the choices of action possible for him, and should be able to look to society to assist him in obtain-ing those basic health and welfare services he is unable to obtain through his own efforts. In social work terms, man is viewed as a whole human being who brings to his present situa-tion a significant past and aspirations for the future. - 38 -Translated into rehabilitation efforts, this means that social workers'in rehabilitation view the person with a physical and mental handicap in terms of the psycho-social forces that have helped to shape him, in terms of the potential that he possesses, with his resources of past and present, for a meaningful l i f e . This view of the handicapped person places emphasis not only knowing the individual patient but upon f u l l knowledge of the resources of family, friends, and over-all community as they have affected and w i l l continue to affect the outcome of rehabilitation efforts. One can say, then, that social work is concerned with helping individual families and groups to repair damage in social functioning which has occured as a result of the faulty interplay between social resources and individual need and as a result of insufficient development or availability of individual resources for the execution of designated social roles. These individual re-sources may be of a social, economic, cultural, physiological, intellectual or psychological nature. The belief in change and growth is seen as related to the uniqueness of the person and his situation and the opportunities available for i t to take place and to be nurtured. Briefly, then, the social caseworker's responsibility in the rehabilitation plan i s to help to identify the direction and potential strength of the patient's motivation for recovery, training, work, i f not for l i f e i t s e l f . But, identification is not enough. The caseworker then has the responsibility to help the patient find this himself, help to fan i t , enhance i t , - 39 -but mostly, to help the patient put i t to work in his own interest. One social worker has said that major value of social casework should be the conviction that his basic, most useful function is to help motivate the unmotivated. Psychiatrist and psychologist have pointed out that acceptance or resistance to rehabilitation depends on the 'premorbid' personality, that is the sum total of the individual and his l i f e experience (including his present situation). It includes his intellectual functioning; the state of his physical health, and his conscious and unconscious needs. In fact, i t can very well be that the unconscious factors are more import-ant determinants than conscious factors during this process, as shown in similar cases responding in opposite ways to their d i s a b i l i t i e s . One common kind of reaction to permanent disability is the desire of the individual to return to his previous non-disabled state; to be regarded as non-disabled and to be treated like anyone else. The means by which the patient can prevent himself from f u l l y comprehending his reality situation are termed by psychiatrists as the mental defense mechanisms of 'denial' and 'flight'. Denial has been defined as "the rejection by a person of some easily recognizable and consensually validated aspect of external reality so that the person thinks, speaks, or acts as i f the aspect of reality did not, in fact, exist." Plight serves the same function as denial except that the individual avoids coming into physical contact with the external realities that may cause him emotional pain. It must - 40 -be realized that these methods of defense are deeply rooted in the human personality, going way back into childhood. Also, this reaction to chronic disability should not be confused with either the regressive tendencies that may be associated with illness or the use of illness to f u l f i l l neurotic needs. In dealing with clients in this group, the caseworker can u t i l i z e the concepts of ego psychology, applied to the casework process to help the client achieve a more rea l i s t i c orientation and to u t i l i z e various resources available to him. Perception, memory and the anxiety accompany these defences. In situations of this kind, the worker may be able to help the client to examine why he has been resisting acknowledgment of his disability and evaluate the negative effects this has on his social functioning. The goal here is to help the client to give up fighting for a state of health or social function-ing which cannot be achieved and to redirect his energies into activities more constructive. While i t would be damaging to some clients to be faced with this kind of self knowledge, there are many clients who can be helped by these means and this i s often an important part of the social worker's contribution. In the case of disabled young children, the mother-child relationship may constitute an obstacle to their effective rehabilitation. Proper understanding of the dynamic nature of this relationship as well as the involvement of the 'body-image' both of the child and mother, is neeessary for diagnosis, evaluation and referral. - 41 -Other Aspects of the Social Worker's Role in Rehabilitation 1. Communication and Interpretation of Social Findings  to the Team: As a member of the team, the worker gathers knowledge about the client, his family and his community which he commu-nicates to the others. From his direct contact, he contributes information regarding the client's feelings and attitude toward his illness, his past responses to c r i s i s , his capacities and strength in using service. The assessment of family relation-ships and equilibrium is another important area. The reacr-tions of the family members toward the client are v i t a l factors which affect his recovery. The worker also has the respons-i b i l i t y to determine the various reality needs related to illness and to help client to meet them. Lastly, the worker should also bring unmet needs to the attention of the commun-it y and help in creating new resources in meeting the, 2. Preparing client to Use Services Other than Casework: Often, i t i s necessary that casework service be offered to prepare an i l l person to use other services. This may simply be a concrete service as temporary domestic help and arrangements for medical care, or more complex involvement in familial attitudes and resistance to treatment by means of the various casework treatment techniques. 3 . Concurrent Treatment: The worker's role in concurrent treatment depends to a great extent upon the setting and function of the agancy. His s e r v i c e s may be on an environmental and supportive l e v e l and a c l a r i f i c a t i o n and i n s i g h t g i v i n g according to the needs of the c l i e n t . 1 4. Services to c l i e n t ' s f a m i l y , r e l a t i v e s and c o l l a t e r a l s such as employer and l a n d l o r d . 5. L o c a t i o n and use of a v a r i e t y of community resources f o r the b e n e f i t of the c l i e n t and h i s f a m i l y . 6. Group work s k i l l s and s e r v i c e s i n c l u d i n g group therapy. 9. Educational S e r v i c e s : The f i e l d of " S p e c i a l Educa-t i o n " i s defined as the educational program which i s planned by p u b l i c or p r i v a t e agencies f o r the education of the various groups of e x c e p t i o n a l c h i l d r e n . A c h i l d i s defined as educa-t i o n a l l y e x c e p t i o n a l i f h i s d e v i a t i o n i s of such a kind and degree that i t i n t e r f e r e s w i t h h i s development under ordinary classroom procedures and n e c e s s i t a t e s s p e c i a l education e i t h e r i n conjunction w i t h the r e g u l a r c l a s s or i n a s p e c i a l c l a s s or school f o r h i s maximum development. S p e c i f i c a l l y , s p e c i a l education i s concerned w i t h the f o l l o w i n g types of exceptional c h i l d r e n : The vis \ 3 a!3.y handicapped: This group can be d i v i d e d i n t o two c a t e g o r i e s : ( l ) The b l i n d who are educated through channels other than v i s i o n ; and (2) The p a r t i a l l y sighted who are able These c l a s s i f i c a t i o n are taken from "The Role of the Case-worker i n R e h a b i l i t a t i o n " by C e l i a Benney i n S o c i a l Casework, March 1955, pp. 118-121. - 43 -to use vision in acquiring educational s k i l l s . The acoustically handicapped: In educating the acoust-i c a l l y handicapped, educators are interested in two groups. The f i r s t consists of the deaf in whom the sense of hearing is non-functional for the ordinary purposes of l i f e . This group includes the congenitally deaf and the adventitiously deaf. The second group comprises the hard-of-hearing, although defect-ive, is functional with or without hearing aid. The crippled and neurologically impaired: Included in this is a large group of physically handicapped children who suffer from neurological and non-sensory impairments to whom the word 'crippled' is sometimes applied as a general term. These consist of three major groupings: (1) brain-injured or neurologically impaired children such as the epileptic, those suffering from organic behavior disorders, and others who have a retarded development in the processes of speech, language, reading, writing and arithmetic that is due to cerebral dysfunction. (2) orthopedically handicapped children, where the impairment which interferes with normal functions of bones, joints, or muscles, whether they are born with such handi-caps or have acquired them later through poliomyelitis, tuberculosis or accidents. (3) children with special health problems as muscular dystrophy, hemophilia and those with low v i t a l i t y . Speech-handicapped children: There are two major kinds of speech defects: (l) functional speech defects, which are due to inadequate learning, perseveration, imitative habits, emo-- 44 -tional factors, and inadequate auditory discrimination; and (2) organic speech defects, which are due to structural mal-formations or neurological dysfunction. Gifted Children! Attempts to improve the education of gifted children in schools may be divided into three categories: (1) Acceleration: this is defined as progress through an educational program at rates faster or ages younger than the conventional, according to the evaluation of each child and his needs. (2) Special classes:for the most part, these classes are provided for the top one to three per cent of intellectually able children. The class needs to be smaller than the average, and the course of study requires enrichment in both depth and breadth. (3) Enrichment: the gifted youngster needs a broad background of interrelated knowledge that is meaningful to him. Rich resources must be available in the classroom in the form of books, audio-visual aids, art materials, and elementary science equipment. Group dis-cussion, group projects, independent study, research, and c r i t i c a l and creative thinking are encouraged, so that he may realize himself most completely and make his maximum contribu-tion to his fellow men. Mentally retarded children: Three general categories can be seen under the educational program: (1) the dependent mentally retarded who need continuing help in caring for per-sonal needs and are unable to be trained to any degree in self-care and economic usefulness or in socialization. (2) the trainable mentally retarded. The education provided for this group must aim at helping him to adjust to his immediate environment so that he may become as far as possible a con-tented member of his family and community. This means provid-ing the trainable child with r e a l - l i f e experiences which w i l l develop acceptable attitudes, adequate personal habits, health habits, safety habits, working habits, and the a b i l i t y to ex-press himself in language. (3) the educable mentally retarded. This group have a minimum educability in the academic subjects of school - usually not beyond the Grade 5 or 6 level. With adequate training, their social adjustment w i l l enable them to get along independently in the community. They have minimum occupational adequacy to a degree that w i l l enable them, as adults, to support themselves partially or totally at an adult level, usually in unskilled or semi-skilled occupations, but may require some social supervision. Emotionally disturbed children; Prom the educator's point of view, a child is considered emotioaaikly disturbed when his behavior is so inappropriate that regular class attendance has a disrupting effect on the rest of the class, places undue pressure on the teacher, and furthers the dis-turbance of the pupil himself. Methods of dealing with the emotionally disturbed child may be divided into the following categories: (l) he may be l e f t in a regular class with special help provided through special counsellors, therapists, remedial teachers, and other school personnel. (2) he may be placed in a special class in a regular school or in a special day centre. (3) he may be placed in a residential school or treatment c entre. - 46 -Delinquent and pre-delinquent children; Delinquency may be defined as behavior by non-adults which violates specific legal norms as the norms of a particular societal institution with sufficient frequency or seriousness so as to provide a firm basis for legal action against the behavior of the indi-vidual or group. In the treatment of these children, teachers should be trained in mental health courses in the understanding of such children. Also, special educational services of the following categories should be provided to assist the teacher in dealing with a pre-delinquent or delinquent child. These include the services of school psychologists, school nurses, v i s i t i n g teachers or school social workers, mental health consultants, school counsellors, remedial teachers and school adjustment services or child guidance c l i n i c s . Socially handicapped children; These would include the children of the socially disadvantaged groups previously men-tioned - the marginal "group', the minority groups, the migrant and th4 immigrants and others. In Canada, this would include Eskimoes, Indians, Doukhobours, and others. They are some-times referred to as the "culturally disadvantaged" or the "culturally deprived". Special educational provisions for handicapped adults; Some classification of special educational services include any "special educational" f a c i l i t i e s which have to be set up for adults outside the regular training and educational pro-grammes, especially when these are aimed at enabling the adult to qualify for one of the regular or special vocational train-- 47 -ing programmes, f o r example, a requirement of Grade 10 to q u a l i f y . Others include t h i s i n the l a t t e r c l a s s i f i c a t i o n . 10. V o c a t i o n a l Services 1. Occupational Therapy: This s e r v i c e supervises and c a r r i e s out a program aimed at r e s t o r i n g f u n c t i o n and enabling the p a t i e n t t o work or to pursue c r e a t i v e i n t e r e s t s . Manual and i n d u s t r i a l s k i l l s are developed as a means of promoting b e t t e r motion, stren g t h and c o o r d i n a t i o n , but a l s o as a means of he l p i n g the pati e n t to go back to work. Creative a r t s and c r a f t s , r e c r e a t i o n a l a c t i v i t i e s , s e l f - h e l p devices and programs, and t e s t i n g f o r a b i l i t y to hold a job, are a l l part of t h i s s p e c i f i c therapy. In a d d i t i o n to the p h y s i c a l r e s t o r a t i o n technique, the t h e r a p i s t i s i n t e r e s t e d i n the mental and p s y c h o l o g i c a l a d j u s t -ment of the p a t i e n t . Wood-working shops, bench l a t h e s and other machines,, hand and power t o o l s , hand looms, and other c r a f t devices help the p a t i e n t t o r e g a i n h i s working a b i l i t y and tolerance or t o prepare f o r a d d i t i o n a l v o c a t i o n a l t r a i n i n g . The occupational t h e r a p i s t may al s o be c a l l e d upon to, develop and teach the handicapped i n d i v i d u a l how to l i v e s e l f r -s u f f i c i e n t l y i n h i s home environment. In some programs, the occupational therapy i s almost f u n c t i o n a l and p r a c t i c a l , i n others i t may be more d i v e r s i o n a r y , as i n the case of the c h r o n i c a l l y i l l , the mentally d i s t u r b e d , or the e l d e r l y . - 48 -2. Work Evaluation: Vocational evaluation means to gather, to interpret, to analyze and to synthesize a l l the vocational significant data regarding the individual and to relate them to occupa-tional requirements and opportunities. The patient is usually assessed in a vocational evaluation laboratory where experi-ences which simulate conditions in employment are offered but do not include definitive vocational training. This service is of value to the patient in determining the relationship of his capacities and disabilities to a given occupation and are designed to build up his confidence in his a b i l i t y to over-come the vocational handicap inherent in his disability. 3 . Work-Schemes: These range from work for the home-bound; sheltered workshop as well as schemes organized by the handicapped per-sons themselves. 4. Vocational Placement and Follow-up: The client must be helped to obtain insight and motiva-tion adequate to help him move into this f i n a l phase of the rehabilitation process. An appraisal of client progress through the rehabilitation process to the placement stage must be made to determine whether the client is ready for placement. The placement of the client may be performed by the training agency, by the former employer who rehires the client, the employment office, or by the client himself in securing his own job. Before the case can be 'closed as - 49 -r e h a b i l i t a t e d ' the counselor should work concurrently and con-t i n u o u s l y w i t h whatever source, u n t i l employment can be deter-mined as s u i t a b l e i n that the c l i e n t i s h a p p i l y and o p t i m a l l y employed according to h i s c a p a b i l i t i e s and p o t e n t i a l s and tShat the employer, too, i s s a t i s f i e d . For both the i n i t i a l and subsequent follow-up contacts, a schedule should be prepared and met. I t i s important that the worker stay close t o the s i t u a t i o n , so he w i l l know how the c l i e n t i s a d j u s t i n g , how the employer i s r e a c t i n g , what problems are developing, whether he should remove the c l i e n t from the job, and other d e t a i l s e s s e n t i a l to h i s g i v i n g proper s e r v i c e to both. 11. Other Necessary Services to Help Integrate Handi-capped People Into Community: I f the p r i n c i p l e of r e t u r n i n g the p a t i e n t t o h i s own environment and community as soon as p o s s i b l e i s followed as a sound therapeutic measure, then the next decade should show considerable increase i n the f o l l o w i n g type of s e r v i c e which do not lead to easy c l a s s i f i c a t i o n . Homemaker or housekeeper s e r v i c e : This s e r v i c e provides the performance of personal and household tasks by an e x p e r i -enced and mature person, not o r d i n a r i l y a p r o f e s s i o n a l person but not merely a domestic e i t h e r . A l s o , help and d i r e c t i o n are given to the d i s a b l e d woman i n s i m p l i f i e d methods of food pre p a r a t i o n and laundry a c t i v i t i e s ; the p h y s i c a l care and s e l f -help c l o t h i n g f o r preschool c h i l d r e n , and f a m i l y co-operation - 50 -and developing independence i n young c h i l d r e n i n the t o t a l home management problem. I t i s a l s o necessary t o enable old or i n f i r m people, whether d i s a b l e d or not, to remain i n t h e i r own homes. I t should a l s o be used to r e l i e v e the parents of handicapped c h i l d r e n f o r shopping, h o l i d a y s and r e c r e a t i o n purposes. Trans p o r t a t i o n s e r v i c e s : This form of s e r v i c e i s o f t e n overlooked, yet i t s absence can n u l l i f y the e f f o r t s of a l l the other s e r v i c e s put together. A s u b s t a n t i a l number of handi-capped people w i l l never be able to use the p u b l i c t r a n s p o r t a -t i o n system. Some homebound and bedbound people could and should be able to leave t h e i r homes i f t h i s s e r v i c e were available® Even i f i t i s not p o s s i b l e to take some handi-capped people outside t h e i r homes more than a few times a year, t h i s s e r v i c e should be a v a i l a b l e to them. Adaptations i n housing - p u b l i c b u i l d i n g s : The handi-capped person cannot become a f u l l y fledged member of the community unless c e r t a i n adaptation i n housing and p u b l i c b u i l d i n g s become es t a b l i s h e d p o l i c y : - ramp, i n s t a l l a t i o n of r a i l alongside t o i l e t f a c i l i t i e s ; doors wide enough f o r the passage of wheel-chairs and l i g h t - s w i t c h e s low enough to be of reach. S p e c i a l housing h o s t e l f a c i l i t i e s : I t i s not the u s u a l type of boarding home but where some as s i s t a n c e i s o f f e r e d to the p h y s i c a l l y , mentally and emotionally handicapped. I t i s the "next" stage or a l t e r n a t e to the day or night h o s p i t a l . Included under these are " h o s t e l s " and "half-way" houses as w e l l as f o s t e r homes f o r people w i t h various d i s a b i l i t i e s . - 51 -Recreation s e r v i c e s : This i s necessary t o i n t e g r a t e the handicapped person as f a r as p o s s i b l e w i t h s p e c i a l p r o v i s i o n s as camping f a c i l i t i e s . A l s o included are a c t i v i t i e s as B l i n d Bowling League, Paraplegic Basket b a l l Team. Home care s e r v i c e s : The range of s e r v i c e s encompassed i n t h i s concept make i t d i f f i c u l t to c l a s s i f y as e i t h e r a medical, p s y c h o l o g i c a l , educational or s o c i a l s e r v i c e . I t may range a l l the way from very complex h o s p i t a l - home care schemes i n which s e v e r a l members of the h o s p i t a l team, doctor, nurse, p h y s i o t h e r a p i s t , speech t h e r a p i s t , occupational t h e r a p i s t , s o c i a l worker v i s i t the home to c a r r y out a h i g h l y concentrated treatment pl a n to r e g u l a r v i s i t s by one member of the treatment only such as the physio-therapist. Educational (and treatment) s e r v i c e s to handicapped  ( c h i l d r e n ) i n t h e i r own homes: For many reasons, any comprehens-i v e scheme of r e h a b i l i t a t i o n s e r v i c e s w i l l i n v o l v e a number of se r v i c e s i n t h i s category. Though expensive and time consuming, they cannot be overlooked. I t i s known as " V i s i t i n g Teacher" or "Home Teacher"' f o r c h i l d r e n . T r a v e l l i n g d i a g n o s t i c and treatment s e r v i c e s : In any country as l a r g e and as sp a r s e l y populated as Canada, s e r v i c e s of t h i s kind must i n e v i t a b l y play a considerable p a r t . They c a l l f o r many c r e a t i v e adaptations by the treatment team and of t e n i n v o l v e some f l e x i b i l i t y i n c e r t a i n r o l e s , e s p e c i a l l y t h a t of c o u n s e l l o r s . 12. Income maintenance programme: This type of s e r v i c e which i s a sine qua non of a l l the others, as f a r as the d i s -abled person and h i s f a m i l y i s concerned, i s o f t e n l i s t e d under welfare s e r v i c e s as 'maintenance grants' or as s o c i a l allowances. I t should apply not j u s t t o the g r a n t i n g of l i v i n g stipends during v o c a t i o n a l t r a i n i n g , but to a whole range of income maintenance s e r v i c e s , temporary or permanent, covering not only the d i s a b l e d person but a l s o h i s f a m i l y . The ensurance of cash income during sickness and d i s a b i l i t y i s not only a necessary s e r v i c e i n modern i n d u s t r i a l s o c i e t y , but often acts as preventive measure against increased d i s -a b i l i t y and dependency. 13. Services to f a c i l i t a t e c o o r d i n a t i o n and i n t e g r a t i o n : This type of s e r v i c e i s p r i m a r i l y important i n r e h a b i l i t a t i o n . I t i s one t h i n g to enunciate the p r i n c i p l e s , but, q u i t e an-other to t r a n s l a t e them i n t o p r a c t i c e . Members of the team have made use of the 'case-conference' f o r t h i s f u n c t i o n . At the community l e v e l , l o c a l and r e g i o n a l r e h a b i l i t a t i o n committees are u s e f u l devices. These need to be strengthened by coordina-t i o n c o u n c i l s at the p r o v i n c i a l and n a t i o n a l l e v e l s . This kind of s e r v i c e i s s t i l l one of the most d i f f i c u l t and c h a l l e n g -i n g , but must be undertaken i n any comprehensive scheme of s e r v i c e s . 14. P u b l i c information and educational s e r v i c e s : The value of s e r v i c e s aimed p r i m a r i l y at educating the p u b l i c i n the understanding of the handicapped and i n c r e a s i n g acceptance of them as i n d i v i d u a l s and c i t i z e n s , i s one of the most c o n t r o v e r s i a l areas i n the r e h a b i l i t a t i o n f i e l d . I t i s i n -cluded here because much informed opinion tends to the view t h a t such s e r v i c e s have a v a l i d r o l e and w i l l play an i n -c r e a s i n g l y important one as more people l i v e t o the l a t t e r part of the l i f e - s p a n . 15. Personnel t r a i n i n g schemes: As a l l of these s e r -v i c e s r e q u i r e a s u f f i c i e n t supply of s u i t a b l y t r a i n e d personnel to operate them, i t i s axiomatic that no comprehensive scheme of r e h a b i l i t a t i o n s e r v i c e s can operate s a t i s f a c t o r i l y without a s e r v i c e of educational programs, f o r the m u l t i p l i c i t y of personnel required i n the welfare f i e l d today. As i t i s b a s i c a l l y an educational problem i t w i l l not be d e a l t w i t h i n t h i s study, but i t i s mentioned because subsequent a n a l y s i s of s p e c i f i c r e h a b i l i t a t i o n programmes l a t e r i n the study may f i n d that i n s u f f i c i e n c y of s u i t a b l e personnel i s a r e c u r r i n g problem i n e v a l u a t i n g the e f f i c i e n c y of r e h a b i l i t a t i o n s e r -v i c e s . 16. Research and s t a t i s t i c s : No scheme of r e h a b i l i t a -t i o n can be considered complete unless i t includes s e r v i c e s i n these areas. A major d i f f i c u l t y i s the inadequacy of s t a t i s t i c s and l a c k of u n i f o r m i t y of measurements among those s t a t i s t i c s a v a i l a b l e . Continuing r e h a b i l i t a t i o n i s needed not only i n medical, but a l s o i n r e l a t e d areas i n r e h a b i l i t a t i o n that might equ a l l y be included under the heading of 'education' and welfare aspects. These l a t t e r have often not received s u f f i c i e n t a t t e n t i o n , and yet they are b a s i c to any e v a l u a t i o n of the - 54 -adequacy and efficiency of rehabilitation services. Rehabilitation Viewed as a Set of F a c i l i t i e s Another view of rehabilitation sees i t as a set of f a c i l i t i e s , that is buildings or institutions in which certain definite services are given to patients. This would include hospitals, rehabilitation wings or wards or departments in hospitals, rehabilitation centres, sheltered workshops, voca-tional training schools and any special institutions or schools for particularsdisabilities. This is not seen as overlapping the view of rehabilita-tion as a set of services, but rather a recognition that certain services in rehabilitation cannot be given even though personnel and space may be adequate unless certain f a c i l i t i e s and equipment are also present. Some of these f a c i l i t i e s of course involve very expensive equipment. This raises the important factor of "capital costs" often a deterring factor in establishment of such f a c i l i t i e s . While i t is impossible to describe a l l of these f a c i l i t i e s f u l l y , two w i l l be singled out as distinctive of modern trends in rehabilitation. These are the rehabilitation centre and the sheltered workshop. The Rehabilitation Centre The development of this type of f a c i l i t y has taken place mostly since World War II. A rehabilitation centre is defined as "a f a c i l i t y which is operated for the primary purpose of assisting in the rehabilita-t i o n of handicapped and d i s a b l e d persons through an integrated program of medical, p s y c h o l o g i c a l , s o c i a l and v o c a t i o n a l e v a l u a t i o n and s e r v i c e s under competent p r o f e s s i o n a l super-v i s i o n . " 1 Thus, i t f u n c t i o n s as one of the best t e s t i n g grounds f o r such cooperative endeavor, and the 'team approach' i s the accepted method of c o l l a b o r a t i o n between the d i s c i p l i n e s . I t serves as a means of communication and provides a u n i f i e d b a s i s f o r viewing p a t i e n t s . Each member of the team plays h i s part i n implementing t h i s approach by c o n t r i b u t i n g h i s respect-i v e s k i l l s , by understanding the s p e c i a l i z e d knowledge of h i s team-mates, and by a d j u s t i n g h i s treatment emphasis to the i n t e g r a t e d treatment process. Other gu i d i n g p r i n c i p l e s i n r e h a b i l i t a t i o n centre operation, such as ' i n d i v i d u a l i z a t i o n ' ; 'the whole man'; 'comprehensive and i n t e g r a t i v e s e r v i c e s ' ; 'patlent-centre approach'; which have been discussed under the s e c t i o n on p r i n c i p l e s , are a l s o important. Others have pointed out the v i t a l n e c e s s i t y of d i r e c t and d e t a i l e d medical s u p e r v i s i o n . This implies s p e c i f i c a l l y , the a c t u a l examination of each p a t i e n t , review of diagnosis, c o n s i d e r a t i o n of past medical h i s t o r y , and the completion of needed l a b o r a t o r y t e s t s and X-rays. This study i s necessary i n order to determine whether the p a t i e n t i s ready to under-take a r e h a b i l i t a t i o n program i n a centre and whether such a program can reasonably be expected to m a t e r i a l l y a s s i s t i n h i s p h y s i c a l or mental recovery, i n h i s adjustment to the remain-i n g handicap, and i n h i s r e s t o r a t i o n to s o c i a l and work "Allan, S., R e h a b i l i t a t i o n , o p . c i t . , p. 46. a c t i v i t y . I t has been s a i d that very few centres are t r u l y comprehensive, and that they tend t o be e i t h e r "medically" ori e n t e d or " v o c a t i o n a l l y " o r i e n t e d . A l s o some take only out-p a t i e n t s , which often means they cannot s t a r t r e h a b i l i t a t i o n procedures e a r l y enough. A l s o , they have tended t o concent-r a t e mostly on p a t i e n t s w i t h orthopaedic d i s a b i l i t i e s . Few of these take p a t i e n t s w i t h p h y s i c a l d i s a b i l i t i e s other than orthopedic, though there has been a trend to i n c l u d e n e u r o l o g i c a l l y d i s a b l e d and stroke p a t i e n t s . Even fewer take mental p a t i e n t s , f o r whom there i s great need f o r r e h a b i l i t a t i o n f a c i l i t i e s . Nevertheless, centres on the whole do good work and made a great advance i n the h i s t o r y of r e h a b i l i t a t i o n . The Sheltered Workshop Workshops can be c l a s s i f i e d i n a number of ways: by the type of work performed; by the c l i e n t e l e served, or by t h e i r aims and objects. Regardless of these d i f f e r e n c e s , the she l t e r e d workshop b a s i c a l l y provides a work experience without the s t r e s s and te n s i o n of competitive employment, t h e i r func-t i o n s b e i n g : 1 1. To provide a l a b o r a t o r y f o r v o c a t i o n a l diagnosis and e v a l u a t i o n . Thompson, N e l l i e , Z., The Role of the Workshop i n R e h a b i l i t a ' t i p n . (Ed.) A Report of the N a t i o n a l I n s t i t u t e on the Role of the Workshop i n R e h a b i l i t a t i o n , Bedford, Penn. Wash., D.C. A p r i l , 1958, p. 43. - 57 -2. To provide a practical and r e a l i s t i c setting for vocational training and adjustment. 3 . To provide a setting for a sustained focus on the total needs of the individual, especially for motivation, vocational exploration, and try-out. 4. To provide a controlled environment with a graduated amount of shelter between physical restoration and vocational rehabilitation. 5. To provide therapeutic work experiences. 6. To provide follow-up services. 7. To provide gainful employment. 8. To provide purposeful activities not necessarily remunerative. Sheltered workshops can exist by themselves or be attached to larger units as the hospital or the rehabilita-tion centre. This is also true with the work-evaluation unit. The term 'vocational evaluation unit' is sometimes used, and is synonymous with the terms 'prevocational evaluation unit 1 and 'vocational diagnostic unit'. The f i r s t two terms are used to emphasize the unit's function of establishing voca-tional goals, and to differentiate i t from a therapy shop. As such, i t i s used extensively by state vocational rehabilita-tion agencies to c l a r i f y and establish objectives for their clients. The National Institute on Workshop Standards defined sheltered workshop as a work-oriented rehabilitation f a c i l i t y which provides a controlled working environment and individ-- 58 -u a l i z e d v o c a t i o n a l programs and goals. I t u t i l i z e s the work experience and other r e l a t e d s e r v i c e s to a s s i s t the handi-capped person to progress toward a normal l i v i n g and a pro-d u c t i v e v o c a t i o n a l s t a t u s . There are g e n e r a l l y two broad c a t e g o r i e s : ( l ) The t r a d i t i o n a l type of workshop which provides s h e l t e r e d employ-ment and other s e r v i c e s i n the area of s o c i a l and personal adjustment. The term i n d u s t r i a l workshop f o r sh e l t e r e d employment has been used t o describe t h i s category of shops. (2) The r e h a b i l i t a t i o n workshop which concentrates on the pre-p a r a t i o n of handicapped i n d i v i d u a l s f o r competitive employ-ment. In a d d i t i o n to remunerative or on-the-job t r a i n i n g or employment, the workshop provides, through i t s own f a c i l i t i e s or other community resources, medical examinations and super-v i s i o n , s o c i a l and personal adjustment. R e t r a i n i n g f a c i l i t i e s , i n the sense used as contrasted w i t h the p r e v o c a t i o n a l t r a i n -i n g u n i t s or workshop operations, are those programs f o r a c t u a l l y teaching a trade or s k i l l which can be used as a means of g e t t i n g a job i n i n d u s t r y or running a s m a l l business. This s e r v i c e may be part of the ordinary school t r a i n i n g f a c i l i t i e s . The Organization of R e h a b i l i t a t i o n Services From the i n d i v i d u a l p a t i e n t ' s point of view, someone must take the r e s p o n s i b i l i t y i n i n i t i a t i n g the r e h a b i l i t a t i o n process and i n c o o r d i n a t i n g the va r i o u s s e r v i c e s according to - 59 -it s ongoing changing nature for the patient's benefits. At present, in both United States and Canada, there is not a single group agency or individual to whom this responsibility is allocated. At transitional points, with no clear allocation, the patient often gets lost. Whom can he return to in his planning for the next stage? Who w i l l look after him in his waiting period? Who w i l l re-assume the responsibility to continue the plan i f the patient is finished with the rehabilitation centre? If the patient is not placed in employment, what alternatives are open to him? How is he to appeal? Is this the responsibility of the Social worker? the doctor, or the vocational placement worker? Patients often have to be helped to locate and use the services and someone must assume the responsibility in re-planning, and reassessing continuously during the process especially in the case of children. Many, though not a l l services should be made available to clients in their own communities in line with rehabilitation plans they have chosen for themselves. Co-ordination and integration are the two major problems in the organization of rehabiliation services. It has been pointed out that co-ordination implies a horizontal functioning effectively together of the various services, whereas integration implies the uniting of those services for a common purpose and to a common end, which is longitudinal or long-range in nature in each individual case. Although co-- 60 -ordination i s necessary and important, the major need in success-f u l rehabilitation is the integration of i t s aims and services. This idea of integration applies not only to the need for agencies working together to develop a complete rehabilita-tion program for the disabled individual, nor only to the various individuals involved functioning cooperatively for the benefit of the handicapped person, but also to recognition by a l l disciplines that the patient requires a total program, an application at the proper time of the services necessary to insure his restoration to fullest capacity. Of equal importance to community integration of services is integration with public opinion and action. Basic to this effort is communications. Within a community this cari&be achieved through councils of rehabilitation, agencies and organizations, u t i l i z i n g common f a c i l i t i e s or buildings, group meetings, and joint planning efforts. As between individual workers, i t can be achieved through staff meetings and discussions, exchange v i s i t s to agencies, educational interpretation, publications, and work-ing agreements or a f f i l i a t i o n s and the "case conference", method. Communication to the general public by newspapers, radio, television, distributed material, open house invitations, and exhibits is decidedly effective. Lay participation through volunteer workers in agencies and fund-raising assignments are other methods of establishing rapport with the 'man in the street'. CHAPTER I I I PROFILE OF THE DEVELOPMENTAL PATTERN OF REHABILITATION IN CANADA E a r l y Developments i n R e h a b i l i t a t i o n i n Canada In Canada, as elsewhere the e a r l i e s t e f f o r t s to help the handicapped were made by p r i v a t e r e l i g i o u s and c h a r i t a b l e o r g a n i z a t i o n s , which set up i n s t i t u t i o n s t o care f o r the b l i n d , the deaf and f o r c r i p p l e d c h i l d r e n . When government entered the f i e l d i t d i d so, as e l s e -where i n the "piecemeal" f a s h i o n of s i n g l i n g out c e r t a i n "categories" of di s a b l e d persons f o r whom i t would provide s e r v i c e s . In Canada, these were l i m i t e d f o r many years t o war veterans, workmen and the b l i n d , deaf, the tuberculons and some o r t h o p a e d i c a l l y d i s a b l e d persons, e s p e c i a l l y c h i l -dren. Some of the s i g n i f i c a n t developments i n these e a r l y years included the formation of the Canadian N a t i o n a l I n s t i t u t e f o r the B l i n d i n 1918. The o r g a n i z a t i o n of the Ontario S o c i e t y f o r C r i p pled C h i l d r e n by l o c a l Rotary clubs took place i n 1922. The Canadian J u n i o r Red Cross set up i t s handicapped and c r i p p l e d c h i l d r e n ' s fund i n the same year. As i n d u s t r i -a l i z a t i o n increased, so d i d the number of impaired workmen. With Ontario t a k i n g the lead i n 1914, most of the provinces - 62 -had passed a Workmen's Compensation Act by 1920. In 1921, a s e l e c t committee of the Ontario l e g i s l a t u r e studied the f e a s i b i l i t y of a p r o v i n c i a l r e h a b i l i t a t i o n plan and recommended an expanded program f o r d i s a b l e d workers. The Workmen's Compensation Act was amended i n 1924 to incorporate broad p r o v i s i o n s f o r r e h a b i l i t a t i o n i n the compensation system, and v o c a t i o n a l t r a i n i n g and placement s e r v i c e s were supplied i n s e l e c t e d cases where needed. Developments During the Depression Years Progress was slow i n subsequent years during the 1930's. The Ontario Workmen's Compensation Board set up departments of physiotherapy and occupational therapy during the 1930's, and. a separate r e h a b i l i t a t i o n department employing r e h a b i l i t a t i o n o f f i c e r s i n 1938. Quebec Rotary Clubs founded a s o c i e t y f o r - -C r i p p l e d C h i l d r e n i n 1930, and joi n e d w i t h the Ontario S o c i e t y to form the Canadian C o u n c i l f o r C r i p p l e d C h i l d r e n i n 1937. But, g e n e r a l l y , d i s a b l e d persons were ovelooked during the depression years b.when l a r g e numbers of able-bodied persons were unemployed and the p u b l i c purse was pinched. 1 World War I I and E a r l y Post-War Period I t was during the e a r l y years of World War I I that the ordinary c i t i z e n was included f o r the f i r s t time i n a govern-ment sponsored programme i n the r e h a b i l i t a t i o n f i e l d . True, t h i s was l i m i t e d t o one aspect only - that of v o c a t i o n a l r e -h a b i l i t a t i o n . Nevertheless, i t was a milestone i n Canadian - 63 -developments i n r e h a b i l i t a t i o n when, i n 1942, tinder the V o c a t i o n a l T r a i n i n g Co-ordination A c t , a f e d e r a l - p r o v i n c i a l t r a i n i n g program was i n i t i a t e d which was to be a v a i l a b l e to a l l t r a i n a b l e persons, c i v i l i a n or veteran. In 1943» the N a t i o n a l Employment Service e s t a b l i s h e d a S p e c i a l Placement Section t o provide c o u n s e l l i n g and placement s e r v i c e s to persons w i t h occupational handicaps seeking g a i n f u l employ-ment i n c l u d i n g the p h y s i c a l l y d i s a b l e d . These s e r v i c e s helped thousands of persons r e q u i r i n g v o c a t i o n a l re-establishment a s s i s t a n c e but were, of course, i n s u f f i c i e n t f o r those r e -q u i r i n g medical and s o c i a l r e h a b i l i t a t i o n as a p r e l i m i n a r y measure. The key development during t h i s p e r i o d , however, was the comprehensive program worked out f o r the d i s a b l e d veterans. Using a great v a r i e t y of new techniques and f a c i l i t i e s adapted to the i n d i v i d u a l needs of each war c a s u a l t y , the department demonstrated th a t most handicapped veterans could be r e -e s t a b l i s h e d under an i n t e g r a t e d program of medical, psycho-l o g i c a l , educational and v o c a t i o n a l r e h a b i l i t a t i o n s e r v i c e s provided by a h i g h l y q u a l i f i e d , m u l t i - d i s c i p l i n a r y team. Many of the most s u c c e s s f u l methods of r e h a b i l i t a t i o n of the s e v e r e l y handicapped, i n c l u d i n g s e l e c t i v e placement, were developed through t h i s program. Many other agencies and s e r v i c e s during the e a r l y post-war years were eager to apply the methods learned from veterans' r e h a b i l i t a t i o n to other groups of d i s a b l e d . - 64 -New national voluntary societies were formed to combat chronic conditions such as arthritis and rheumatism, cancer, deafness, diabetes, heart disease^; multiple sclerosis, muscular dystrophy and poliomyelitis. The efforts of these groups were focused on medical research, public education, and various patient services, chiefly for medical rehabilitation. Other long established agencies, too, such as the Victorian Order of Nurses, became increasingly concerned with rehabilitation of the chronically i l l . Rehabilitation services for workers disabled by industrial accidents or diseases expanded rapidly also. An outpatient rehabilitation centre was established in Vancouver by the British Columbia Workmen's Compensation Board in 1942. The Quebec Compensation Commission set up a Rehabilitation Department in 1944 and 1947, and a Rehabilitation Clinieiifor Outpatients in Montreal. Ontario opened its widely-known inpatient Rehabilitation Centre at Malton in 1947, and Alberta started an outpatient centre for injured workmen in 1952. Most ofthe provincial boards were empowered to make additional specific expenditures on rehabilitation, mainly for vocational services, to return as many industrial casualties to work as possible. Widespread sympathy for the handicapped child was reflected in the extension of crippled children's societies to other provinces. In the larger c i t i e s , general and c h i l -dren's hospitals set up special f a c i l i t i e s to improve the treatment of children with orthopedic d i s a b i l i t i e s . At the - 65 -same time, many of the p r o v i n c i a l and l o c a l educational a u t h o r i t i e s exercised g r e a t e r concern about the education of handicapped c h i l d r e n , and s p e c i a l c l a s s e s f o r d i f f e r e n t d i s -a b i l i t i e s were organized w i t h i n the r e g u l a r p u b l i c schools systems. Parents' groups a l s o sprang up i n many parts of the country to organize separate treatment and educational day centres f o r c e r e b r a l p a l s i e d and mentally retarded c h i l d r e n . Some of the most s i g n i f i c a n t movements were sparked at the community l e v e l . S o c i a l agencies became aware of the need f o r coordinated s e r v i c e s f o r a l l types of d i s a b i l i t y . One of the f i r s t instances of co-operative community a c t i o n was the formation of the Vancouver Council f o r Guidance of Handi-capped i n 1943; the only o r g a n i z a t i o n of the kind which has had a continuous existence since that date. S i m i l a r planning a c t i v i t i e s were i n i t i a t e d l a t e r i n such c i t i e s as Montreal, Toronto, Hamilton, Windsor and Edmonton among others. P h y s i c a l r e h a b i l i t a t i o n centres, f o r c i v i l i a n s began to be e s t a b l i s h e d . A number of centres were organized, under volu n t a r y auspices where a program of assessment, medical s e r v i c e s , p h y s i c a l and occupational therapy, v o c a t i o n a l guidance, and other r e h a b i l i t a -t i o n s e r v i c e s were made a v a i l a b l e to p h y s i c a l l y d i s a b l e d per-sons. Outstanding examples were the G.P. Strong R e h a b i l i t a -t i o n Centre i n Vancouver and the R e h a b i l i t a t i o n I n s t i t u t e of Montreal both opened i n 1949. Teaching h o s p i t a l s , the medical schools and p r o f e s s i o n a l a s s o c i a t i o n s , too, became i n c r e a s i n g l y aware of the development and t r a i n i n g of medical r e h a b i l i t a t i o n s e r v i c e s . There was - 66 -a l s o a trend towards the growth of l o c a l s e l f - h e l p organiza-t i o n s formed by the d i s a b l e d themselves as f o r example the Canadian Parap l e g i c A s s o c i a t i o n . These were mainly concerned w i t h s o c i a l and v o c a t i o n a l a c t i v i t i e s e s p e c i a l l y w i t h s h e l t e r e d workshops. P r o v i n c i a l governments began to support c e r t a i n v o l u n t a r y a c t i v i t i e s f i n a n c i a l l y , and some provinces i n i t i a t e d r e h a b i l i t a t i o n s e r v i c e s d i r e c t l y f o r c e r t a i n d i s a b i l i t y groups such as p o l i o m y e l i t i c s , the c e r e b r a l p a l s i e d and the mentally i l l . Saskatchewan was the f i r s t province to introduce a province-wide general v o c a t i o n a l r e h a b i l i t a t i o n program f o r i a d u l t c i v i l i a n s i n 1946. In 1948, the Federal Government introduced the N a t i o n a l Health Grants Program which stimulated the development of numerous p r o j e c t s and the expansion of voluntary and p r o v i n c i a l s e r v i c e s that q u a l i f i e d f o r an a s s i s t a n c e through various h e a l t h grants administered by the Department of N a t i o n a l Health and Welfare. Several grants, such as those f o r tuber-c u l o s i s , mental h e a l t h and c r i p p l e d c h i l d r e n , made s p e c i f i c p r o v i s i o n f o r r e h a b i l i t a t i o n measures on a shareable b a s i s . W i t h i n a short time, f e d e r a l and p r o v i n c i a l h e a l t h grants became an i n f l u e n t i a l f a c t o r i n the development and expansion of r e h a b i l i t a t i o n s e r v i c e s and f a c i l i t i e s . In Vancouver, the grants enabled a Seizure C l i n i c to be est a b l i s h e d at Vancouver General H o s p i t a l which was l a t e r taken over by the h o s p i t a l i t -s e l f . Grants a l s o made p o s s i b l e a demonstration p r o j e c t by the Vancouver Family Welfare Bureau of the value of Homemaker Services where the mother was i n c a p a c i t a t e d f o r an extended - 67 -pe r i o d . This agency already had a supervised Homemaker Service, but was very much aware of the need f o r such a s e r v i c e o f t e n extended beyond a few months which tended to the maximum le n g t h of time the agency might be able to provide the s e r -v i c e . Developments During the 1950's A h i g h l i g h t of t h i s decade was the Canadian Sickness Survey c a r r i e d out i n 1950-1951 i n some 10,000 households throughout Canada. In the words of the H a l l Report I t showed the a p p a l l i n g s o c i a l , economic cost to Canada of i l l h e a l t h , proving that the f a m i l y and n a t i o n pay h e a v i l y i n terms of l o s t production f o r f a i l u r e t o make a v a i l a b l e to a l l Canadian c i t i z e n s the standard of h e a l t h s e r v i c e we know how t o provide. Nor i s i t only i n l o s s of production that we pay. Many of our s o - c a l l e d 'welfare expenditures' are the end r e s u l t of i l l n e s s , d i s a b i l i t y and premature death. Not a l l of these expenditures are a v a i l a b l e of course but c l e a r l y many of them a r e . l The survey i n d i c a t e d that 7.4 % of the population s u f f e r from some degree of permanent d i s a b i l i t y , and about 3 i" were seve r e l y or t o t a l l y d i s a b l e d . These f i g u r e s d i d not inclu d e mental i l l n e s s or d e f i c i e n c y as categories nor d i d they include r e s i d e n t s of i n s t i t u t i o n s , m i l i t a r y e s t a b l i s h -ments and Indian r e s e r v a t i o n s . There would need to be con-Royal Commission on Health S e r v i c e s , 1964, V o l . 1, Queen's P r i n t e r , Ottawa, 1964, pp. 5-6. - 68 -s i d e r a b l e upward r e v i s i o n to make them at a l l comprehensive. One r e s u l t of the survey was the reinforcement of the view of workers i n the r e h a b i l i t a t i o n f i e l d that s e r v i c e s were incomplete and uncoordinated. For a long time, attempts by pressure groups and other i n d i v i d u a l s i n the f i e l d of r e h a b i l i t a t i o n t o urge the f e d e r a l government to assume a more v i t a l r o l e i n the f i e l d d i d not seem to meet w i t h much success. However, i n 1951, the f e d e r a l government announced that i t would convene a n a t i o n a l conference on the r e h a b i l i t a t i o n of the p h y s i c a l l y handicapped t o consider s o l u t i o n s to the problem. This proved to be one of the most f r u i t f u l development i n Canadian r e h a b i l i t a t i o n . Over 200 delegates and observers from the three l e v e l s of governments as w e l l as from major v o l u n t a r y s o c i e t i e s concerned w i t h the d i s a b l e d met i n Toronto. Re-commendations made at t h i s conference "became i n f l u e n t i a l f a c t o r s i n more-co-ordinated development and expansion of comprehensive s e r v i c e s to c i v i l i a n d i s a b l e d and brought about formal, j o i n t , f e d e r a l - p r o v i n c i a l p a r t i c i p a t i o n i n r e h a b i l i t a -t i o n i n Canada." 1 Three important developments took place i n the f o l l o w i n g year. In 1952, the f e d e r a l government appointed a Roeher, A., "Progress and Needs of R e h a b i l i t a t i o n i n Canada" R e h a b i l i t a t i o n and World Peace. Proceedings of the 8th World Congress of the I n t e r n a t i o n a l S o c i e t y f o r the Welfare of C r i p p l e s , New York, I960, p. 62. - 69 -N a t i o n a l Advisory Committee on the R e h a b i l i t a t i o n of Disabled Persons w i t h nation-wide representatives from f e d e r a l depart-ments, p r o v i n c i a l governments, organized labour, employers, u n i v e r s i t i e s , the medical p r o f e s s i o n and v o l u n t a r y h e a l t h and welfare agencies, to serve as a forum f o r the exchange of ideas and information. I t a l s o e s t a b l i s h e d a C i v i l i a n R e h a b i l i t a t i o n Branch i n the N a t i o n a l Department of Labour and i t a l s o appointed, as head of t h i s new department, a n a t i o n a l co-o r d i n a t o r of R e h a b i l i t a t i o n to co-ordinate r e h a b i l i t a t i o n a c t i v i t i e s at the f e d e r a l l e v e l and to a s s i s t the provinces t o co-ordinate and develop t h e i r r e h a b i l i t a t i o n programs. In 1953 matching grants were a l s o made a v a i l a b l e t o provinces s i g n i n g a r e h a b i l i t a t i o n c o - o r d i n a t i o n agreement. In commenting on these developments a Canadian observer has remarked "This a s s i s t a n c e was predicated on the p r i n c i p l e that to meet the primary needs i n developing an o v e r - a l l r e h a b i l i t a -t i o n s e r v i c e would r e q u i r e considerable p r e l i m i n a r y planning, experience, t e c h n i c a l equipment and a l a r g e number of t r a i n e d personnel. The f e d e r a l support was, t h e r e f o r e , i n the nature of t e c h n i c a l , advisory and f i n a n c i a l help.""1" In the same year, the f e d e r a l government a l s o increased the a v a i l a b l e funds f o r medical r e h a b i l i t a t i o n by adding a Medical R e h a b i l i t a t i o n Grant to the N a t i o n a l Health Program t o support s e r v i c e s f o r d i s a b l e d persons not a s s i s t e d under Roeher, A., "Progress and Needs of R e h a b i l i t a t i o n i n Canada", op. c i t . , p. 63. - 70 -other Health Grants. This grant made a v a i l a b l e on m i l l i o n d o l l a r s annually f o r approved p r o j e c t s f o r the purchase of r e h a b i l i t a t i o n personnel on a non-matching b a s i s , and f o r the extension of r e h a b i l i t a t i o n s e r v i c e s on a matching b a s i s . Every province now has i n operation a means of co-o r d i n a t i n g r e h a b i l i t a t i o n a c t i v i t i e s . Between 1953 and 1955 nine provinces have appointed a Co-ordinator of R e h a b i l i t a t i o n , whose r o l e i s t o co-ordinate p u b l i c and p r i v a t e e f f o r t s i n the province on behalf of d i s a b l e d i n d i v i d u a l s . Another forward step was the extension i n 1953 of the f e d e r a l - p r o v i n c i a l v o c a t i o n a l t r a i n i n g scheme (Schedule fR'), administered by the Department of Labour, to incl u d e v o c a t i o n a l t r a i n i n g of d i s a b l e d persons. The S p e c i a l Placement Section of the N a t i o n a l Employment Service was a l s o expanded i n the same year. In 1955, another j o i n t f e d e r a l - p r o v i n c i a l program was inaugurated through the Disabled Persons Allowances. People who were permanently and t o t a l l y d i s a b l e d were granted a l l o w -ances on a means t e s t b a s i s . The Act a l s o made p r o v i s i o n f o r the r e h a b i l i t a t i o n assessment of a p p l i c a n t s who might b e n e f i t from such s e r v i c e s , "thus a c t i n g as a device f o r c a s e - f i n d i n g and r e f e r r a l to r e h a b i l i t a t i o n services.""*" At the 1960-61 s e s s i o n of Parliament, these e f f o r t s t o develop a comprehensive and co-ordinated program of r e -h a b i l i t a t i o n f o r d i s a b l e d persons were given f u r t h e r s t a t u t o r y Roeher, A., "Progress and Needs of R e h a b i l i t a t i o n i n Canada" o p . c i t . , p. 63. - 71 -r e c o g n i t i o n w i t h the passing of the V o c a t i o n a l R e h a b i l i t a t i o n of Disabled Persons Act. This Act s p e c i f i e s the r e s p o n s i b i l -i t i e s of the Federal Government i n t h i s area ;fof r e h a b i l i t a -t i o n and provides f o r agreements wi t h the provinces thus en-a b l i n g them to proceed even f u r t h e r i n t h e i r c o - o r d i n a t i o n e f f o r t s to meet the needs of disa b l e d persons. The Federal Government, through i t s agreements, w i l l share w i t h the provinces the cost incured i n p r o v i d i n g comprehensive voca-t i o n a l r e h a b i l i t a t i o n s e r v i c e s to d i s a b l e d persons who need them. The Act a l s o provides f o r c o - o r d i n a t i o n of Federal a c t i v i t i e s i n the f i e l d of r e h a b i l i t a t i o n , research i n voca-t i o n a l r e h a b i l i t a t i o n at the f e d e r a l l e v e l and i n co-operation w i t h the provinces and the p u b l i c a t i o n of information. These a c t i v i t i e s are undertaken through the o f f i c e of the N a t i o n a l Co-ordinator i n the C i v i l i a n R e h a b i l i t a t i o n Branch of the Department of labour. The N a t i o n a l Co-ordinator and h i s s t a f f cooperate c l o s e l y w i t h the provinces and with the P r o v i n c i a l Oo-ordinators and stand ready to advise and a s s i s t i n the development of programs requested by the provinces. Development and improve-ment of r e h a b i l i t a t i o n s t a f f and s e r v i c e s i s encouraged i n many ways: through c o n s u l t a t i o n , conferences, workshops and by continuous exchange of information and experiences w i t h i n the provinces and between the various provinces and the Federal Government. - 72 -Developments i n the 1960's In the decade of the s i x t i e s , r e h a b i l i t a t i o n pro-gramming appears to date t o have continued along the same l i n e s as i n the f i f t i e s . However, at the beginning of the decade, a Canadian observer made t h i s comment about the general s t a t e of our r e h a b i l i t a t i o n s e r v i c e s : As a general conclusion, i t can be s t a t e d that the b a s i c foundation f o r sound r e h a b i l i t a -t i o n programming has been e s t a b l i s h e d but comprehensive s e r v i c e s are s t i l l e i t h e r un-a v a i l a b l e or inadequate f o r the greater number of Canadians whose d i s a b i l i t i e s could be prevented or r e h a b i l i t a t e d . This optimum stage of development w i l l not be r e a l i z e d u n t i l r e h a b i l i t a t i o n p r i n c i p l e s , processes and p r a c t i c e s are i n t r i n s i c aspects of r e g u l a r h e a l t h , education and s o c i a l s e r v i c e s of the community. The momentum of current a c t i v i -t i e s suggests that these goals w i l l be reached w i t h i n the next generation.1 The w r i t e r s of t h i s study would be i n s u b s t a n t i a l agreement w i t h t h i s observation, w i t h the exception of the l a s t sentence. An a l t e r n a t i v e viewpoint, which i s explored " i n t h i s study i s that these goals cannot be reached i n the next generation or indeed at a l l without two important p r e l i m i n a r i e s - f i r s t a c a r e f u l review and a n a l y s i s of our present r e h a b i l i t a t i o n p o l i c i e s and programs as a p r e r e q u i s i t e to necessary redesigning and secondly, a w i l l i n g n e s s to con-s i d e r some r a t h e r r a d i c a l r e v i s i o n s of p o l i c y . Roeher, A., "Progress and Needs of R e h a b i l i t a t i o n i n Canada", op. c i t . , pp. 72-73. BIBLIOGRAPHY (Chapters I, II, III) Books Al l a n , Seott, Rehabilitation: A Community Challenge. 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Department of Labour, C i v i l i a n R e h a b i l i t a t i o n , Canada, R e h a b i l i t a t i o n i n Canada. Summer, 1962, Queen's P r i n t e r and C o n t r o l l e r of S t a t i o n e r y , Ottawa, 1962. Department of N a t i o n a l Health and Welfare, Research and S t a t i s t i c s D i v i s i o n . R e h a b i l i t a t i o n Services i n Canada. Part I : General Review, Ottawa, I960. Department of N a t i o n a l Health and Welfare, Research and S t a t i s t i c s D i v i s i o n . R e h a b i l i t a t i o n Services i n Canada. Part I I : P r o v i n c i a l and L o c a l Programs, Ottawa, 1959. United States American P u b l i c Health A s s o c i a t i o n Inc., Services f o r Handi- capped C h i l d r e n : A Guide to General P r i n c i p l e s and P r a c t i c e s f o r P u b l i c Health Personnel, New York, 1955. American A s s o c i a t i o n of Medical S o c i a l Workers: S o c i a l Work P r a c t i c e i n Medical Care and R e h a b i l i t a t i o n S e t t i n g s : Monograph I : The Evolv i n g Concept of R e h a b i l i t a t i o n . Washington, D.C., 1955. American A s s o c i a t i o n of Medical S o c i a l Workers: S o c i a l Work P r a c t i c e i n Medical Care and R e h a b i l i t a t i o n S e t t i n g s : Monograph I I : Teamwork: Philosophy and P r i n c i p l e s . Wash., D.C., 1955. American A s s o c i a t i o n of Medical S o c i a l Workers: I n s t i t u t e Proceedings: Teamwork i n the Medical S e t t i n g . Oct., 1953, Montreal, Canada. Royal Commission on Health S e r v i c e s . 1964, V o l . 1, Queen's P r i n t e r , Ottawa, 1964. U.S. Department of Health, Education and Welfare: V o c a t i o n a l R e h a b i l i t a t i o n A d m i n i s t r a t i o n . McGowan, John F. (ed.), An I n t r o d u c t i o n to the V o c a t i o n a l R e h a b i l i t a t i o n  Process. U.S. Government P r i n t i n g O f f i c e , Wash., D.C., U.S.A., I960. - 75 -U.S. Department of Health, Education and Welfare: O f f i c e of V o c a t i o n a l R e h a b i l i t a t i o n . The Placement Process i n  V o c a t i o n a l R e h a b i l i t a t i o n Counseling. Thomason, Bruce and B a r r e t t , A l b e r t M., (ed.) U.S. Government P r i n t i n g O f f i c e , Wash., U.S.A. I960 R e h a b i l i t a t i o n Service Ser i e s #545. U.S. Department of Health, Education and Welfare: O f f i c e of V o c a t i o n a l R e h a b i l i t a t i o n . Proceedings on the I n s t i t u t e  on R e h a b i l i t a t i o n Centre Planning. Chicago, 111. Feb.-March, 1957. U.S. Government P r i n t i n g O f f i c e , Wash., U.S.A., R e h a b i l i t a t i o n Service Series #420. U.S. Department of Health, Education and Welfare: O f f i c e of V o c a t i o n a l R e h a b i l i t a t i o n . P a r r e t t , James F. (ed.), P s y c h o l o g i c a l Aspects of P h y s i c a l D i s a b i l i t y . U.S. Government P r i n t i n g O f f i c e , Wash., U.S.A., R e h a b i l i t a -t i o n Service S e r i e s #210. United Nations I n t e r n a t i o n a l Labour O f f i c e , V o c a t i o n a l R e h a b i l i t a t i o n of the D isabled. Report IV (1) I n t e r n a t i o n a l Labour Conference, Geneva, 1954. I n t e r n a t i o n a l Labour O f f i c e , V o c a t i o n a l R e h a b i l i t a t i o n of the  D i s a b l e d . Report IV (2) I n t e r n a t i o n a l Labour Con-ference, Geneva, 1955. World Health Organization, Expert Committee on Medical  R e h a b i l i t a t i o n . Geneva, 1958. Technical Report Se r i e s #158. B r i t a i n M i n i s t e r of Labour and N a t i o n a l S ervice to Parliament, Report of the Committee of Inquiry on The R e h a b i l i t a t i o n  T r a i n i n g and Resettlement of Disabled Persons. Her Majesty's S t a t i o n a r y O f f i c e , London, 1956. Others Gorthy, W i l l i s : D a r l i n g , Robert; Tsu P a i , L u c i l l e and Obrien, Jay, V o c a t i o n a l E v a l u a t i o n by Work Sample Technic and  i t s Dependence upon Medical C o n t r i b u t i o n s . New York, 1959. - 76 -I n s t i t u t e f o r the Cr i p p l e d and Disabled . R e h a b i l i t a t i o n of  Mental P a t i e n t s i n a Comprehensive R e h a b i l i t a t i o n  Centre. New York, I960. I n s t i t u t e f o r the Cri p p l e d and Disabled. R e h a b i l i t a t i o n Trends: Midcentury to 1956, New York, 19567 Raimy, V i c t o r (ed.), Coordinated T r a i n i n g i n R e h a b i l i t a t i o n . Report of the Western I n s t i t u t e on Coordination of Tr a i n i n g i n R e h a b i l i t a t i o n , March, 1959, Boulder, Colorado, 1959. Tulane,University, School of S o c i a l Work, Newer Concepts of Mental Retardation i n Medical Care Programs f o r C h i l d r e n . New Orleans, LA. 1957. Journals Benney, C e l i a , "The Role of the Caseworker i n R e h a b i l i t a t i o n " S o c i a l Casework. V o l . 36, #3 March 1955, pp. 118-121. S t i t e s , Mary, " P s y c h o l o g i c a l Diagnosis i n V o c a t i o n a l Rehabilita-t i o n S e r v i c e s " S o c i a l Casework, V o l . 39, #1 Jan., 58, pp. 12-21. S t i t t , Pauline George, "The Co-operation of the Disabled i n t h e i r R e h a b i l i t a t i o n " S o c i a l Casework, V o l . 33, #4 A p r i l 52, pp. 153-160. Wallace, Helen, "The Role of the S o c i a l Worker i n the R e h a b i l i t a -t i o n of the Handicapped" S o c i a l Casework, V o l . 38, #1 January 57, pp. 9-15. Papers Braeeland, F r a n c i s J r . , The Role of P s y c h i a t r i s t i n R e h a b i l i t a -t i o n , Reprint from the Journal of American Medical A s s o c i a t i o n , Sept., 1957. B r i c k e r , June, Planning f o r R e h a b i l i t a t i o n S e r v i c e s , Reprint from the Journal of Home Economics, Nov., 1958. Gilmour, S.M., The Employers' R e s p o n s i b i l i t y i n the R e h a b i l i t a -t i o n of the Disabled, Reprint from Conquering P h y s i c a l Handicaps: Proceedings of the P a n - P a c i f i c R e h a b i l i t a -t i o n Conference, 1958, Sydney, A u s t r a l i a . - 77 -Martin, Paul, The Honourable, Minister of Health and Welfare, Health Grants, excerpt from Hansard p. 4680 under •Supply' May, 1953. Sims, Valeria A., The Development of Vocational Rehabilitation  in Canada. Obtained from the office of the National Co-ordinator of Civilian Rehabilitation, Ottawa, 1961. SECTION::, II THE ROLE OF THE FEDERAL GOVERNMENT IN REHABILITATION CHAPTER IV-1 THE LEGISLATIVE BASE FOR REHABILITATION SERVICES IN CANADA Canada's Commitment to Implement Comprehensive R e h a b i l i t a t i o n Services It i s perhaps appropriate to begin a consideration of the l e g i s l a t i v e base f o r r e h a b i l i t a t i o n i n Canada from the viewpoint that Canada signed the c o n s t i t u t i o n of the World Health Organization, and has accordingly subscribed to the following p r i n c i p l e enunciated i n the preamble to i t s charter:-"The enjoyment of the highest attainable standards of health i s one of the fundamental r i g h t s of every human being without d i s t i n c t i o n of race, r e l i g i o n , p o l i t i c a l b e l i e f , economic or s o c i a l condition. The health of a l l peoples i s fundamental to the attainment of peace and s e c u r i t y and i s dependent upon the f u l l e s t cooperation of i n d i v i d u a l s and States." (1) It should be remembered that the United Nations d e f i n i t i o n of health has always been a comprehensive one, encompassing the preventive, diagnostic, curative and r e h a b i l i a t i v e phases. Canada, then i s on record at the i n t e r n a t i o n a l l e v e l as pledging h e r s e l f to implement the p r i n c i p l e s she has subscribed to i n the United Nations Charter. In a modern society, implementation i s impossible with-out government a c t i o n at the l e g i s l a t i v e l e v e l . In Canada, as was seen i n Chapter I I I , r e h a b i l i t a t i o n services grew up at many d i f f e r e n t times under d i f f e r e n t auspices to meet d i f f e r e n t needs 1 World Health Organization, Constitution, Geneva,. The Organization, 1960, p. 1 IV-2 f o r d i f f e r e n t groups. This i s not necessarily an insurmountable obstacle to the development of a comprehensive scheme of services, as a number of countries have shown. However, i t cannot be done unless r e h a b i l i t a t i o n i s made an objective of national p o l i c y . The question then arises as to what Canada's p o l i c y i n r e h a b i l i t a t i o n may be said to be and how f a r i t may be considered adequate to the challenges and needs of Canadian society today. Because of circumstances pec u l i a r to Canada, any review of govern-ment p o l i c y i n the r e h a b i l i t a t i o n f i e l d must be preceded by a consideration of the c o n s t i t u t i o n a l d i v i s i o n of powers. The C o n s t i t u t i o n a l D i v i s i o n of Power i n Canada The B r i t i s h North America Act of 1867, often r e f e r r e d to as "Canada's co n s t i t u t i o n " , provides for a d i v i s i o n of j u r i s d i c t i o n between the f e d e r a l and p r o v i n c i a l governments. Under that d i v i s i o n , the provinces are generally held responsible f o r the areas which today have become known as "Health," and "Welfare" as w e l l as f o r Education, a l l of which are involved, to some extent, i n r e h a b i l i t a t i o n . As time went by, i t became impossible for the provinces to meet t h e i r f i n a n c i a l r e s p o n s i b i l i t i e s i n these areas without assistance from the f e d e r a l government. Successive Canadian governments have extended a i d to the provinces i n a v a r i e t y of ways. In the f i e l d of r e h a b i l i t a t i o n the government has increasingly defined i t s r o l e . Role of the Federal Government i n R e h a b i l i t a t i o n It i s possible to trace the r o l e of the f e d e r a l government i n rehab-i l i t a t i o n from the early years following Confederation. A b r i e f summary, however, must s u f f i c e f o r purposes of t h i s study. In essence, the f e d e r a l government has v i s u a l i z e d i t s r o l e i n r e h a b i l i t a t i o n as a f o u r f o l d task:-IV-3 (1) To provide s p e c i a l concessions to the disabled i n the general l e g i s l a t i o n . (2) To take d i r e c t r e s p o n s i b i l i t y for the r e h a b i l i t a t i o n of c e r t a i n s p e c i f i c groups of c i t i z e n s . (3) To extend f i n a n c i a l aid to the provinces through a v a r i e t y of cost sharing devices and d i r e c t grants i n a i d . (4) To act i n a coordinating r o l e , o f f e r i n g assistance, advice and consultation services and acting as a c l e a r i n g house for inform-a t i on. In general, i t might be s a i d the f e d e r a l government has acted as "enabler" i n system of what i t has c a l l e d "Cooperative federalism." I t i s important to examine how t h i s system a c t u a l l y works i n p r a c t i c e . Each of the four functions w i l l now be reviewed. Concessions to the Disabled i n the General L e g i s l a t i o n From very early i n Canadian h i s t o r y , the f e d e r a l government has provided i n d i r e c t f i n a n c i a l a i d to the disabled through c e r t a i n con-cessions to them i n the general l e g i s l a t i o n . In the taxation structure of Canada, for instance, a considerable number of sections of statutes and regulations e x i s t which o f f e r to the disabled c e r t a i n tax r e l i e f s . Customs and excise tax on a r t i c l e s used by the disabled are waived as i s sales tax on goods produced i n workshops for the b l i n d , on a r t i c l e s used by h o s p i t a l s for the benefit of the disabled, and on materials printed by organizations e x i s t i n g to help the disabled. There are also c e r t a i n tax concessions i n r e l a t i o n to estate duties. The Canadian R e h a b i l i t a t i o n Council for the disabled has recently commissioned a study on Canadian l e g i s l a t i o n as i t a f f e c t s the d i s a b l e d . ^ (1) Personal communication from the National Executive Director, Mr. Keith Armstrong, i n a l e t t e r to Mrs. Mary Tadych, Director of t h i s study, 24th November, 1964. The Council Study w i l l be under the d i r e c t i o n of Professor A.M. Linden of Osgoode Hall,Toronto. IV-4 Such a study has been long overdue, because, as the Council stated i n i t s B r i e f to the Royal Commission on Taxation:-" L i t t l e thought seems to have been given to the natio n a l Taxation p o l i c y i n r e l a t i o n to the d i s -abled. The l e g i s l a t i o n i s a patchwork. I t has grown up b i t by^bit over the years. There i s no meaningful o v e r a l l policy...There are only fr a g -ments of a p o l i c y . This p o l i c y seems to be that 'The government w i l l help some of the disabled i n some ways some of the time'. ...Careful consider-at i o n must be given to t h i s problem. A national p o l i c y must be created. Then l e g i s l a t i v e draughts-man must do a systematic r e v i s i o n of the pertinent l e g i s l a t i o n i n i t s image. Provision must be made for continual and easy r e v i s i o n " , The Council advocated that t h i s r e v i s i o n be i n the i n t e r e s t s of (2) " s i m p l i c i t y , consistency and f a i r n e s s . " It i s assumed for purposes of t h i s study that there i s merit i n a p o l i c y of general concessions of t h i s kind, and that they can be made, i n the words of the Council's b r i e f " i n such a way as to promote s e l f s u f f i c i e n c y , rather than to make the i n d i v i d u a l dependent upon (3) government largesse." However, as the Council's study w i l l be an extensive one, there seemed l i t t l e point i n devoting a f u l l chapter i n t h i s present study to a consider-at i o n of the e f f e c t s of present f e d e r a l p o l i c y i n t h i s area on the i n d i v i d -u a l disabled c i t i z e n . It i s an area which requires d e t a i l e d study and 1 Canadian R e h a b i l i t a t i o n Council for the Disabled B r i e f to the Royal Commission on Taxation, pp.12-13 2 Ibid, p.8 3 Ibid, p.8 IV-5 c l a r i f i c a t i o n p r i o r to any v a l i d consideration of changes i n national p o l i c i e s , For t h i s reason, the reader i s r e f e r r e d to the various sections of the Council's study as they become a v a i l a b l e . ^ 1 The Council plans to have health l e g i s l a t i o n and educational l e g i s l a t i o n ( as they a f f e c t the disabled), reviewed as w e l l . CHAPTER V FEDERAL RESPONSIBILITY FOR THE REHABILITATION OF SPECIFIC CITIZEN GROUPS According to the B r i t i s h North America Act, and subsequent amendments, the federal government agreed to take d i r e c t r e s p o n s i b i l i t y f o r c e r t a i n groups of c i t i z e n s , and t h i s extended to t h e i r r e h a b i l i t a t i o n needs. I r o n i c a l l y , the assumption of fe d e r a l r e s p o n s i b i l i t y for these groups was to demonstrate the best and the worst i n r e h a b i l i t a t i o n p r i n c i p l e s , p o l i c i e s and p r a c t i c e s . The groups for which the federal government has d i r e c t r e s p o n s i b i l i t y are Mariners, Indians, Eskimos, Veterans, and Blind People. Mariners As we are increasingly approaching the "One World" of Wendell Wilkie's dream, i t follows that a l l the countries of the world have a s p e c i a l r e s p o n s i b i l i t y to mariners, In s p i t e of a i r transport, they are s t i l l the key people i n enabling us to enjoy the goods of the world. They are exposed to many health hazards, e s p e c i a l l y accidents, and often s u f f e r from r e s i d u a l d i s a b i l i t i e s f a r more severe than necessary because they are not transported to necessary care i n time or they have to because of economic necessity, return to ship duty while they could s t i l l benefit from remedial measures. While the Canadian government has a reasonably good record i n the care of t h i s group, much remains to be done which cannot be accomplished by the government of one country a c t i n g alone. Much of the d i s a b i l i t y consequent economic dependency found i n this group i s because once they have suffered an i l l n e s s or accident, t h e i r way of l i f e makes i t extremely d i f f i c u l t to V-2 bring the f u l l benefits of modern r e h a b i l i t a t i o n practices to bear on t h e i r p a r t i c u l a r problems. This group i s often overlooked i n r e h a b i l i t a t i o n studies. Indians and Eskimos The intent of the fe d e r a l Acts which gave the r e s p o n s i b i l i t y f o r these groups to the central government was to ensure them "protection". The p l i g h t of the f i r s t native born Canadians under t h i s " p r o t e c t i v e " p o l i c y i s one of the worst blots i n Canadian h i s t o r y . That they are prime can-didates for our r e h a b i l i t a t i o n programmes for " s o c i a l l y disadvantaged groups" i s a t e l l i n g comment on the p o l i c i e s that enabled them to become "disadvantaged" c i t i z e n s on the country of t h e i r o r i g i n . I t i s heartening to note evidences of a reawakening of the Canadian conscience i n r e l a t i o n to these two groups, which has already led to improved r e h a b i l i t a t i o n p o l i c i e s . Health and Welfare services f o r these groups are found i n a number of d i f f e r e n t government departments, and t h i s tends towards fragmentation of r e h a b i l i t a t i o n s e r v i c e s . It i s to be hoped that future policy towards these groups w i l l f i n d expression i n the implementation of the "Royal Commission On Health Services" recommendation to the e f f e c t that:-"Administration of Health Services for these groups should be entrusted to the provinces and health services provided i n the same manner and of the same quality as those enjoyed by other "Canadians." (D 1 The Royal Commission on Health Services, V o l . 1, p.21 V-3 Veterans Following the two world wars, the Canadian government introduced an excellent system of r e h a b i l i t a t i o n services for veterans. I t would be true to say that t h i s Canadian developed programme could s t i l l stand as an i n t e r n a t i o n a l model on which to pattern any comprehensive system of r e h a b i l i t a t i o n . Unfortunately, i t was l i m i t e d to a s p e c i f i c group i n the population. The intent of the f e d e r a l l e g i s l a t i o n i n t h i s area was to promote the best possible r e h a b i l i t a t i o n of disabled veterans, and t h i s i t did so w e l l that, i n e f f e c t , the r e h a b i l i t a t i o n services provided to veterans exceeded both i n q u a l i t y and quantity those provided to other c i t i z e n s . It has since been argued that gratitude to war veterans should not include r a i s i n g them to the status of a higher class c i t i z e n with r i g h t s to a higher class of r e h a b i l i t a t i o n services than i s a v a i l a b l e to the general population. I t has even been suggested that c e r t a i n aspects of the Veteran's R e h a b i l i t a t i o n services located i n the Veteran's A f f a i r s Depart-ment need no longer e x i s t . The Royal Commission on Government Organization ( the Glassco Commission) of 1962 recommended that veteran's h o s p i t a l s should be integrated i n the t o t a l Canadian h o s p i t a l programme, with better o v e r a l l use of the f a c i l i t i e s to the b e n e f i t of the average Canadian c i t i z e n as w e l l as the veteran. The B l i n d The f e d e r a l government has also undertaken c e r t a i n r e s p o n s i b i l i t i e s to-wards the B l i n d . Under the Blind Persons Act, the government authorizes the payment lof allowances to Blind people. This programme i s a good example of the " c a t e g o r i c a l " or "piecemeal" approach to r e h a b i l i t a t i o n which has been c h a r a c t e r i s t i c of Canadian r e h a b i l i t a t i o n p o l i c y f o r so long. There seems to be no s p e c i a l reason why the b l i n d , rather than any other group should be singled out for action of t h i s kind at the f e d e r a l l e v e l , when no other group of the disabled has had s p e c i a l l e g i s l a t i o n passed for them. The only answer seems to be that this was a group with which the p u b l i c conscience could r e a d i l y i d e n t i f y and sympathize. A maximum monthly allowance of $75.00 i s a v a i l a b l e to ihose b l i n d people who meet the requirements of a means tes t and who are c e r t i f i e d as b l i n d w i t h i n the meaning of the act. The Allowance i s administered through a p r o v i n c i a l board, s i m i l a r to the Old Age Assistance Board, or a c t u a l l y the same Board. Viewed as an income maintenance programme, t h i s allowance i s often i n s u f f i c i e n t to meet the f i n a n c i a l needs of the r e c i p i e n t . In some provinces, medical and h o s p i t a l benefits are included, i t i s true, as w e l l as p r o v i s i o n f o r supplementary monetary aid, but there i s no uniformity. Other needs of the Blind may be met through the Canadian National I n s t i t u t e f o r the B l i n d , a p r i v a t e agency, which assumes r e s p o n s i b i l i t y f o r meeting such needs as t r a i n i n g i n s p e c i a l s k i l l s , job placement and r e c r e a t i o n . Yet i n a number of respects, the b l i n d get more concessions from both f e d e r a l and p r o v i n c i a l governments than do other disabled groups. While there i s no d i f f e r e n c e i n the amount of t h e i r pension as compared to other groups, (such as Old Age Assistance and Disabled Persons Allowance), the means test i s more l i b e r a l f o r the b l i n d than f o r people s u f f e r i n g from other d i s a b i l i t i e s . A s i n g l e b l i n d pensioner can earn up to $1,500 per year, while a person with another d i s a b i l i t y i s l i m i t e d to $1,260, and a married b l i n d person can earn up to $2,580, as compared with $2,220 f o r other V-5 groups. Also, f o r a b l i n d person, an extra allowance i s made i f there i s a dependent c h i l d , but t h i s i s not given i n the case of a person with another type of d i s a b i l i t y . While these concessions may be l i t t l e enough, i t i s also true that persons with other d i s a b i l i t i e s may have extra expenses and may need the a i d of another person as a b l i n d person may need a guide. The only f a i r way i s to extend to the disabled person whatever kind of a i d he needs to provide for himself or to meet those needs which he cannot possibly provide for himself. F l a t rate allowances by themselves cannot do t h i s . At the f e d e r a l l e v e l , the government reimburses the provinces for 757. of t h e i r Blind Persons Allowance Expenditure, while i t reimburses them only 50% of t h e i r expenditures on other d i s a b i l i t y pensions. This i s yet another example of h i s t o r i c a l anomalies present i n the current patterning of s e r v i c e s . CHAPTER VI-1 FEDERAL POLICIES IN FINANCIAL AID TO THE PROVINCES A f u l l review of a l l the measures by which the f e d e r a l government has extended a i d to the provinces i n the r e h a b i l i t a t i o n f i e l d would be outside the scope of this study. Two of the p r i n c i p a l types of a i d w i l l be selected as c h a r a c t e r i s t i c of the Canadian pattern, an analysis of t h e i r e f f e c t on the present patterning of services w i l l be made. These are the Federal Health Grant Programme and the assistance a v a i l -able to the provinces under the Hospital and Diagnostic Services Act. National Health Grants Programme The p r i n c i p l e of grants i n aid to provinces to a s s i s t them i n carrying out t h e i r r e s p o n s i b i l i t i e s i n the health and r e h a b i l i t a t i o n f i e l d has proved to be one of the most productive ways i n which the fe d e r a l government can trans f e r f i n a n c i a l resources to the provinces. Since 1948, the National Health Grants Programme a v a i l a b l e through the Department of National Health and Welfare has assisted approved projects submitted by the provinces. In the f i r s t f i v e years of the programme, ten grants were i n existence, and i n 1953, Mr. Paul Martin, then M i n i s t e r of National Health and Welfare announced three new grants. Speaking i n Parliament on May 1, 1953 he s a i d : -The house knows the government's basic health objective, of course, to bring the best of health care w i t h i n reach of every Canadian. A few days from now we w i l l reach the f i f t h anniversary of the national health program, the symbol and centre of recent health progress i n t h i s country. When the l a t e prime minister, the Right Hon. William Lyon Mackenzie King, introduced t h i s program i n 1948, he placed i t i n proper per-spective i n r e l a t i o n to the government's larger and basic aim of securing for the people of Canada a national minimum of s o c i a l s e c u r i t y and human welfare. In so doing he pointed out that the new federal grants represented " f i r s t stages i n the develop-ment of a comprehensive health insurance plan f o r a l l Canada". VI-2 Nothing could better mark the success of t h i s program over i t s f i r s t f i v e years than the government's decis i o n , which I have the honour of announcing today, to move forward on three e n t i r e l y new health fron t s . The house w i l l be asked to approve the addition of three important fe d e r a l This i s one of the few references to a Canadian "national minimum" of serv i c e s , below which no Canadian i s to be allowed to f a l l , whether t h i s has been achieved, or whether i t ever can be achieved under the present d i s t r i b u t i o n of powers i s open to debate. Further reference to t h i s w i l l be made l a t e r i n the study, as i t i s one of the most c r u c i a l and controver-s i a l aspects of Canadian s o c i a l p o l i c y today. (2) Since that time, the grants have been further extended. They include grants for Public Health, Tuberculosis Control, Mental Health, C h i l d and Maternal Health. There i s a s p e c i f i c Medical R e h a b i l i t a t i o n Grant, which allows funds for medical r e h a b i l i t a t i o n f a c i l i t i e s equipment and ser v i c e s , i n c l u d i n g t r a i n i n g of personnel and also for research. Much of the aid i s on a non-matching basis, except for expansion of services, where i t must be matched. After s i x years a l l the provinces p a r t i c i p a t e d , i n varying degrees. But a l l of the money a v a i l a b l e has not been used. I t has been estimated that about 70% of the grants are used. The question arises as to why t h i s should be so. Is i t that the conditions for r e c e i v i n g the grant are too r e s t r i c t i n g ? One reason that has been suggested i s that the r i c h e r provinces have 1 Excerpt from "Hansard". p\ 4680 under "Supply" May 1st, 1953. . 2 For a summary of the pattern of these grants to date, the reader i s r e f e r r e d to the Royal Commission on Health Services Queen's P r i n t e r , Ottawa, 1964, Vol.1, p.405 health VI-3 already developed many of the f a c i l i t i e s and services for which they could q u a l i f y under the grants. Therefore they do not a v a i l themselves of the f u l l amount, as the poorer provinces tend to do, where many of these services do not e x i s t to the same extent. Another view i s that some provinces are s t i l l too poor to meet t h e i r share of the cost even with a general matching grant. Edward Dunlop, i n a paper given i n Toronto i n 1958, i n which he drew upon material he had prepared for the National Advisory Committee on the R e h a b i l i t a t i o n of Disabled Persons, made trenchant analysis of the fede r a l grants programme. He stated that:-E r o v i n c i a l governments are pursuing l i m i t e d objectives, using a v a i l a b l e f e d e r a l funds f o r i s o l a t e d a c t i v i t i e s — the p r o v i s i o n of some item of equipment f o r a h o s p i t a l here, providing a bursary to a physiotherapy student there, or meeting the salary of a technician somewhere e l s e . Such may be valuable i n themselves, but do l i t t l e to create an e f f e c t i v e r e h a b i l i t a t i o n program a v a i l a b l e to the d i s -abled generally.... Each expenditure under the Medical Rehab-i l i t a t i o n Grants Order depends upon the approval of a s p e c i f i c project by the Minister of National Health and Welfare. So long as the Minister's t o t a l authorizations do not exceed the d o l l a r amounts provided f o r a province f o r the year, h i s power to approve or r e j e c t i s almost unlimited. Today he can approve a project to send the disabled i n a rocket to the moon; tomorrow he can decline the purchase of t h e i r space s u i t s . I t i s sometimes suggested that t h i s system has the merit of f l e x i b i l i t y . I t i s f r e q u e n t l y d i f f i c u l t how-ever, to d i s t i n g u i s h between what may be regarded as reasonable f l e x i b i l i t y on the one hand and inconsistency, lack of p o l i c y or caprice on the other....The current measures are va r i o u s l y administered by four or f i v e separate d i v i s i o n s of at least two government departments. The i n e v i t a b l e consequences of th i s dispersion of m i n i s t e r i a l and departmental authority are a diminished sense of r e s p o n s i b i l i t y , remoteness of leadership, d i f f i c u l t y of administration and confusion i n r e l a t i o n s with p r o v i n c i a l governments....'1'' 1 The Paper was e n t i t l e d " R e h a b i l i t a t i o n for the Disabled i n Canada: A Plan for National Action". Its p u b l i c a t i o n was made possible by the Canadian A r t h r i t i s and Rheumatism Society. Extract i s from pp.20-21 Vl-4 Dunlop then went on to say that the purposes for which the f e d e r a l government w i l l a s s i s t the provinces are not c l e a r l y defined, except i n r e l a t i o n to v o c a t i o n a l t r a i n i n g . As a r e s u l t , the provinces and the voluntary agencies are deprived of information e s s e n t i a l i n planning r e h a b i l i t a t i o n s e r v i c e s . ^ Hospital and Diagnostic Services Act, 1957 This i s a j o i n t f e d e r a l - p r o v i n c i a l programme through which a l l provinces have entered into agreements with the f e d e r a l government as a r e s u l t of which h o s p i t a l insurance i s extended to about 99% of the Canadian population. However, t h i s i s l i m i t e d to care at standard ward l e v e l i n "active treatment h o s p i t a l s or i n h o s p i t a l s for the c h r o n i c a l l y i l l . I t does not include mental h o s p i t a l s , tuberculosis s a n i t o r i a or nursing homes. These r e s t r i c t i o n s impose servious l i m i t -ations on the act as a general r e h a b i l i t a t i v e measure. In addition, i t i s optional whether the province includes r e h a b i l i t a t i o n centres, and f a c i l i t i e s i n the schemes and t h i s s t i l l further l i m i t s the use of t h i s act as a general r e h a b i l i t a t i v e measure. The f e d e r a l share of costs i n t h i s programme i s 50%,. but i t does not include sharing i n c a p i t a l costs, i n t e r e s t on loans, or depreciation except on equipment. I t might be argued that aid i n c a p i t a l development i s a v a i l a b l e through the Hospital Construction Grants l e g i s l a t i o n , but there are l i m i t a t i o n s i n t h i s l e g i s l a t i o n also, which w i l l not be dealt with here. The non sharing of c a p i t a l costs, except i n l i m i t e d ways, i s one of the most r e s t r i c t i n g features of much Canadian l e g i s l a t i o n that has 1 I b i d , p.p.20-21 VI-5 to do with the creation of r e h a b i l i t a t i o n . In the poorer provinces, i t may be an insurmountable obstacle to the creation of the necessary f a c i l i t i e s . It might be noted that B r i t i s h and American l e g i s l a t i o n on the whole makes much better p r o v i s i o n for the sharing of meeting of c a p i t a l costs. Canadian observers have speculated as to the evidence that t h i s p a r t i c u l a r act has aided the development of r e h a b i l i t a t i o n services to any greater degree. While use i s made of p u b l i c h o s p i t a l s for medical assessment, treatment and p h y s i c a l r e s t o r a t i o n of disabled persons, Roeher main-tains that the generous government subsidies f a i l to induce h o s p i t a l s to develop f u l l y t h e i r p h y s i c a l medicine u n i t s . He f e e l s t h i s i s p a r t i a l l y due to the f a c t that public, pr of es si on al and administrative (1) persons do not r e a l i z e what can be done f o r the handicapped. On the other hand, the H a l l Commission points out that "We have found i t d i f f i c u l t to d i s t i n g u i s h c l e a r l y between treatment and r e h a b i l i t a t i o n . . . . F o r instance any h o s p i t a l units designed as convalescent, g e r i a t r i c or chronic or orthopaedic w i l l have a strong element of r e h a b i l i t a t i o n service, whereas on the other hand beds earmarked " r e h a b i l i t a t i o n " may w e l l be used f o r acute The three s p e c i f i c acts which the f e d e r a l government passed that r e l a t e s p e c i f i c a l l y to the needs of disabled w i l l be reviewed next. These are the Disabled Persons Allowances Act, the Vocational Rehab-i l i t a t i o n of Disabled Persons Act and part of the Technical and 1 Roeher, op.cit.p.70 2 Royal Commission on Health Services, o p . c i t . Vol.1, p.636 or chronic treatment IT1, VI-6 Vocational Training Assistance Act. These w i l l be analysed from the viewpoint of t h e i r effectiveness i n r e l a t i o n to the needs they were set up to meet and t h e i r place i n the o v e r a l l patterning of se r v i c e s . SECTION I I I CRITIQUE OF THE SPECIFIC FEDERAL ACTS RELATING TO REHABILITATION PART I I I CRITIQUE OF SPECIFIC FEDERAL ACTS RELATING TO REHABILITATION i TABLE OF CONTENTS Page Chapter VII Critique of the Disabled Persons Act, 1955 2 Purpose of the Act. A rehabilitation measure. Age requirement. Residence clause. "Total and permanent di s a b i l i t y " . Other categorical allowances. Transferability of allowance. Maximum allowable incomes. Social assistance. No right of appeal. Chapter VIII Critique of the Vocational Rehabilitation of Disabled Persons Act, 1961 A. Vocational Rehabilitation Act: 1 Agreements. Objectives of Act. Employment as a limited goal. Justification for rehabilitation costs. Cost sharing arrangements. Coordination. Purchase of services. Role of voluntary agencies. Advisory Council. B. The Individual Schedules: 16 i ) Schedule 1, Assessment and Counselling. i i ) Schedule 2, Services and Processes of Restoration, i i i ) Schedule 3, The Training, iv) Schedule 4, Employment Placement, v) Schedule 5, Training of Staff. C. Other Considerations of the Act: 19 Expenses of staff. Client contribution. Non-shareable costs. Variations of provincial spending. Financial status before and after rehabilitation. Movement i n occupation because of rehab-i l i t a t i o n . The type of people rehabilitated. Chapter IX Critique of the Technical and Vocational Training Act, I960. A. The Training Act: 2 Technical and vocational training. Purpose of Act. Coordination. National Advisory Council, Cost sharing. B. The Programs; 5 i ) Program 1, Vocational High School Training (V.H.S.) i i ) Program 2, Technician Training (T) i i i ) Program 3, Trade and Other Occupational Training (T.O.) iv) Program U, Training i n Cooperation with Industry (T.I.) v) Program 5 , Training of Unemployed (M.) vi) Program 6 , Training of the Disabled (R) v i i ) Program 7 , Technical and Vocational Teacher Training (T.T.) v i i i ) Program 8, Training Programs for Federal Departments and Agencies (G) ix) Program 9, Student Aid (S.A.) x) General Provisions under the Agreement i i G. General Conclusions; Inclusiveness of program. Three s p e c i f i c c r i t i c i s m s . Appeals* Rural a c c e s s i b i l i t y . Need to incorporate c l i e n t needs i n t o r e h a b i l i t a t i o n goals* 2 CHAPTER VII CRITIQUE OF THE DISABLED PERSONS ACT, 1955 The Disabled Persons Act Is ». . .designed to provide allowances for t o t a l l y and permanently disabled persons unable to make use of the r e h a b i l i t a t i o n services already established." Section 3, subsection (I) of the Act enables f e d e r a l -p r o v i n c i a l agreements whereby the federal government w i l l share f i f t y percent of the cost of allowances paid by the province to the disabled, providing the maximum allowance paid to any i n d i v i d u a l does not exceed seventy-five d o l l a r s per month. The Act makes no provision for r e h a b i l i t a t i o n , nor does i t provide for any other needs a disabled person might have. Even i f I t i s considered s o l e l y as an income-maintenance service, the question arises as to i t s adequacy. It i s not even s u f f i c i e n t to meet the basic physical needs of the ordinary person, l e t alone the disabled person who often, even at the physical l e v e l , has needs i n addition to those of the ordinary person. In effect t h i s means the allowance often has to be supplemented through " s o c i a l assistance" aids at the p r o v i n c i a l or municipal l e v e l . 1 Stanley F. Bodlak, D i s a b i l i t y Allowances: The New  Dominion-Provincial Provisions and Their S o c i a l Welfare  Implications. Master of S o c i a l Work Thesis, University of B r i t i s h Columbia, Vancouver, B.C., 1957» P. 34-. 3 To be more comprehensive the allowance paid should be based on actual need rather than on the exi s t i n g "means t e s t " . The means test demands that the recipient show proof of i n d i v i d u a l f i n a n c i a l needy but then contrariwise, the actual money, paid to the disabled person does not ac t u a l l y meet the "needs" he has been compelled to show he has not the means to meet. I f the allowance i s to be a fixed pension then there should be no need to prove indigency nor the necessity to make annual reinspections of the recipient's f i n a n c i a l condition. Perhaps more fea s i b l e would be an adoption of the more advantageous "needs tested" plan whereby actual income i s compared to actual need and provisions are made f o r the remaining deficiency* The section of the Act having administrative implications, and one that i s controversial, i s section 3, subsection (2)s Payments to a province pursuant to t h i s section s h a l l be made only i n respect of a recipient who (a) at the date of the proposed commencement of allowance payments to him ( i ) has attained the age of eighteen years, and ( i i ) has resided i n Canada f o r ten years immediately preceding that date, or i f he has not so resided, has been present i n Canada prior to those ten years f o r an aggregate period equal to twice the aggregate period of absences from Canada during those ten years; (b) i s t o t a l l y and permanently disabled as prescribed by the regulations; (c) i s not i n receipt of an allowance under the Blind Persons Act or assistance under the Old Age Assistance Act or an allowance under the War Veterans Allowance Act, 4 or a pension under the Old Age Security Act; (d) i s not i n receipt of money or assistance from any province or municipality by way of mothers allowance; (e) i s not a patient i n a tuberculosis sanatorium or mental i n s t i t u t i o n ; ( f ) i s not a patient or resident i n a h o s p i t a l , nursing home, infirmary, home f o r the aged, an i n s t i t u t i o n f or the care of incurables, or a private, charitable or public i n s t i t u t i o n , except as prescribed i n the regulations, and (g) i s (1) an unmarried person, and his income, Inclusive of allowance, i s not more than eleven hundred and f o r t y dollars a year, ( i i ) married and l i v i n g with h i s spouse, and the t o t a l income, i n c l u s i v e of allowance, of the recip i e n t and his spouse i s not more than nineteen hundred and eighty d o l l a r s a year, or ( i i i ) married and l i v i n g with his spouse who i s b l i n d w i t h i n the meaning of the Blind Persons Act, and the t o t a l income, in c l u s i v e of allowance, of the reci p i e n t and h i s spouse i s not more than twenty-three hundred and f o r t y d o l l a r s a year. While the b i l l was introduced i n Parliament before passing i n 1955, considerable p r o v i n c i a l disagreement resulted over the age requirement. Some provinces advocated a lower age condition for e l i g i b i l i t y , hoping i t would narrow the gap i n services extended to children and those available to adults. Presently the regulations allow for p r o v i n c i a l d i s c r e t i o n i n setting an age l i m i t higher than eighteen, but not lower. The Act i s primarily an economic measure and the minimum age 5 s t i p u l a t i o n is made so that a id i s paid only to adul t s ; those below the q u a l i f y i n g age are considered as dependents and should seek resources through t h e i r parents or guardians. This seems l o g i c a l , but are not the t o t a l l y and permanently disabled u s u a l l y dependent a l s o , regardless of t h e i r age? In reviewing the scope of t h i s programme one would have to say to be f a i r that i t i s not intended to cover those below eighteen years of age and those with less severe d i s a b i l i t i e s , who would not thereby qua l i fy as t o t a l l y and permanently d i s a b l e d , yet who would not be e l i g i b l e for vocat iona l services on the grounds that there would not be "reasonable prospeet" of t h e i j b ' r ? being able to f i n d and hold a job . I f one values t h i s view, then i t i s a l so necessary to point out that these two general groups are at present nowhere s p e c i f i c a l l y covered i n l e g i s l a t i o n per ta in ing to the d i s a b l e d . A close look at the amount and kind of a id that i s ava i l ab l e to these groups through the services presently ava i lab le to the general populat ion , i t i s at once evident that there are some very serious gaps. Those who do not q u a l i f y because of age, can often be re ferred to the many pr iva te agencies that cater to ch i ldren ' s d i s a b i l i t i e s . The gap here however, i s that such organizat ions are s e l ec t ive and may not be inc lus ive of a l l d i s a b i l i t i e s . The o lder group, i f they are incapable o f 6 earning their subsistance may apply for Social Assistance (known as Social Aid in some provinces), a programme administered on a needs test basis, which w i l l be discussed later. The ten year Canadian residence clause permits movement within a province and inter-provincial movements which are bound by reimbursement clauses. Movement outside the country necessitates suspension. The intra-national movement conditions enable determination of who has the financial responsibility. The residence clause receives more appropriate criticism when viewed along two different lines. F i r s t , the person who absents himself from Canada does not immediately acquire new citizenship and therefore would not lik e l y qualify under the receiving country's programs. As long as a person retains Canadian citizenship he should remain eligible for her benefits. Secondly, past experiences indicate that residence laws do not make an appreciable difference on the movement of recipients of public assistance. An exception to this might be the greater stimulation of transient social assistance recipients toward a more lenient and generous l o c a l i t y . The contention that residence laws are necessary to prevent the disabled from flocking po provinces with less restrictions has never been proven. Seen from the residence viewpoint of Canadians outside Canada, this not being permitted, i t seems as i f in this age of 7 i n t e r n a t i o n a l communication and t r a n s p o r t a t i o n , such provis ions should he regarded as ant iquated. I n d i v i d u a l l y , i t penal izes the disabled Canadian who has r e l a t i v e s i n another country (often i n the U . S . A . ) who are w i l l i n g to of fer him accommodation, personal comfort and companionship, a l l v i t a l human ingredients i n l i v i n g which he must forego i f he wishes to remain e l i g i b l e for h i s allowance. The Regulat ions , s e c t i o n 2, subsect ion (2), prescr ibe what i s meant by t o t a l and permanent d i s a b i l i t y . . . . a person s h a l l be deemed to be t o t a l l y and permanently d isabled when s u f f e r i n g from a major p h y s i o l o g i c a l , anatomical or psycho log ica l impairment v e r i f i e d by object ive medical f indings which i s l i k e l y to continue i n d e f i n i t e l y without s u b s t a n t i a l improvement and, as a r e s u l t thereof , such person is severely l i m i t e d i n a c t i v i t i e s perta in ing to normal l i v i n g . Notwithstanding attempts at object ive d i s a b i l i t y assessment, a r b i t r a r y decis ions vary from province to prov ince . Terms such as "major. . • impairment", " l i k e l y to continue", "substant ia l improvement" and "severely l i m i t e d i n • • • normal l i v i n g " do not e a s i l y y i e l d to s tandard iza t ion . C r i t e r i a f or greater uni formity i n d e f i n i t i o n should be provided. Determining d i s a b i l i t y res ts not only with medical f i n d i n g s . The measurement of s o c i a l impairment should a l so be inc luded . This i s done to some degree i n the s o c i a l worker's s o c i a l h i s t o r y of the a p p l i c a n t , even i f t h i s i s not demanded 8 by l e g i s l a t i o n . Improvement i n th i s area might be made i f there was l e g i s l a t i v e encouragement to have the medical and s o c i a l evaluations performed by doctors and s o c i a l workers who were required to become f a m i l i a r with the programme and the r e h a b i l i t a t i o n services provided. There are s t i l l considerable v a r i a t i o n s among medical personnel and s o c i a l work personnel as to what const i tutes "tota l and permanent" d i s a b i l i t y w i th in the meaning of the A c t . The emphasis on d i s a b i l i t y i s misguided. One c r i t i c i s m of the Act might v a l i d l y be that i t encourages too much concern with the d i s a b l i n g c h a r a c t e r i s t i c s and not enough on the person's remaining a b i l i t i e s . Theory, but not necessar i ly p r a c t i c e , on r e h a b i l i t a t i o n today stresses the importance of focussing on "what the c l i e n t has remaining" that can enhance h i s l i f e . There i s a lso the cons iderat ion of the poss ible psycho log ica l e f fect on a person ca l l ed on to prove he i s t o t a l l y and permanently d i s a b l e d . B r . Leonard Marsh states that using standards of t o t a l i and permanent d i s a b i l i t y does serve a purpose.. The area where i t i s u se fu l is i n industry where d i s a b i l i t y may be considered as a debt or where compensation i s a possible remuneration, but as a s o c i a l measure i t i s inappropr ia te . It i s frequent ly questioned whether the demand for 1 D r . L . C . Marsh, "Socia l Secur i ty Planning i n Canada", In ternat iona l Labour Review. V o l . 47 pp. 591 - 6l6. 9 permanent and t o t a l d i s a b i l i t y fosters or creates convictions of d i s a b i l i t y where they should not e x i s t , An applicant may ea s i l y a l t e r his self-conception i f receipt of an allowance demands i t . Modification of t h i s extreme condition would narrow the gap wherein many people f a l l — these are the people who are rejected from d i s a b i l i t y allowance and yet do not q u a l i f y f o r r e h a b i l i t a t i o n . Mr. Bodlak, i n h i s thesis on t h i s t o p i c , provides int e r e s t i n g s t a t i s t i c s which indicate among other things, the lack of communication between personnel concerned i n establishing d i s a b i l i t y and those concerned with rehabilitation.* 1' (See Table I ) . TABLE I P r o v i n c i a l Percentage of Rejected Applications A^ril_l^_1955-t-0_Iar_ch_31-,_lt56 Province Accepted Rejected Percent Declined B r i t i s h Columbia 725 247 25.4 Newfoundland 659 326 33.0 Quebec 13,064 9,719 42.2 Ontario 1,854 1,545 45.4 Prince Edward Island 270 227 45.6 Nova Scotia 979 1,249 56.0 Saskatchewan 793 1,026 56.4 Alberta 1,185 1,584 57.2 New Brunswick 830 1,508 64.5 Manitoba 730 1,429 65.9 Total 21,097 18,860 Source: Bodlak, Master Thesis. Bodlak, OP.cit. p. 82. 1G A t o t a l of 39»957 persons considered themselves s u f f i c i e n t l y disabled to apply, whereas only 52.8 percent were accepted. What happened to the 47.2 percent that were rejected? Even admitting that a l l the rejected applicants would probably not benefit from r e h a b i l i t a t i o n , they should at least a l l have been referred and t h e i r p o t e ntial explored. Although Mr. Bodlak made h i s study shortly a f t e r the l e g i s l a t i o n was introduced, t h i s " s t a t i s t i c " has continued to be a meaningful figure i n reports. A separate study could be made to f i n d out who are the people whose e l i g i b i l i t y f o r Disabled Persons Allowance has been denied, yet who seem not e l i g i b l e f o r any of the r e h a b i l i t a t i o n services. Receipt of other s p e c i f i c allowances d i s q u a l i f i e s the disabled from benefits under the Disabled Persons A c t . 1 These are termed categorical allowances and they a l l provide better and have more comprehensive coverage than t h i s Act. In addition to a s i m i l a r maximum allowance the other acts, fo r example the Blind Persons Act, either permit a greater maximum allowable income or make some provision for h o s p i t a l and/or medical coverage. Some programs do not require a test of f i n a n c i a l e l i g i b i l i t y , others Include supplementary allowances often paid according to need. The Disabled Persons Act has the least l i b e r a l provisions yet the most r i g i d x These are Blind Persons Allowance, Old Age Assistance, Old Age Security, War Veterans Allowance, and varying p r o v i n c i a l Mothers Allowances. 11 q u a l i f i c a t i o n s . Despite e f f o r t s made at att a i n i n g as much commonness i n provision as possible f o r a recipient of any categorical allowance there i s considerable d i v e r s i t y . Much can be attributed to the fact that the programs developed i n i s o l a t i o n and according to p o l i t i c a l convenience rather than s o c i a l need. As campaigning platforms they may have great public appeal although the voter i s often uninformed of the i n j u s t i c e s and i n e f f i c i e n c i e s of t h i s "categorical" approach to the problem. Certainly some needs are being met through such l e g i s l a t i v e action, but i f the programs do not serve the e x i s t i n g demands and are lacking i n s u f f i c i e n t scope to cover the needs they were set up to meet, they should be reviewed, adjusted, or revoked to make room f o r better measures. Residence i n ce r t a i n i n s t i t u t i o n s , homes, and hospitals i s another d i s q u a l i f y i n g f a c t o r . The rec i p i e n t of an allowance may continue to receive the allowance up to four months of the year i n a private or public h o s p i t a l , and may r e t a i n e l i g i b i l i t y i n d e f i n i t e l y , as approved by the province, i f he i s i n the h o s p i t a l for treatment of hi s d i s a b i l i t y . 1 I f such residence i s provided free of charge to the patient some adjustment i n the allowance may be i n order. However, many private homes and i n s t i t u t i o n s not only charge high maintenance Canada, Department of National Health and Welfare, Research and S t a t i s t i c s D i v i s i o n , R e h a b i l i t a t i o n Services i n Canada. Part I . Health Care Series, No.8Ottawa, March, I960. 12 rates, but often additional fees are asked because the disabled person may require extra personal care. There are numerous instances where a disabled person already i n receipt of the allowance, and because of i t , regains some form of independency from h i s family. Should he desire to move to a nursing home t h i s allowance would be suspended, thereby returning the c l i e n t to his former dependent p o s i t i o n . The maximum allowable income, along with increases i n the allowance i t s e l f , has been Increased several times since 1955. Although i t i s controversial as to whether the t o t a l maximum allowable Income i s s u f f i c i e n t f o r maintenance, the r e a l weakness of the Act l i e s i n the fact that no consideration i s made of the individual's p a r t i c u l a r l i v i n g expenses nor of the national cost of l i v i n g index. Because of d i f f e r i n g f i n a n c i a l status of the disabled's parents, r e l a t i v e s or guardians (usually they themselves own l i t t l e or no property), the allowance granted may serve one recipient w e l l while another poorly. They may receive the same rate of allowance, yet the service i s not e g a l i t a r i a n . The present means test and maximum allowable income inv i t e s the recipient to earn only a nominal annual Income so as not to jeopardize h i s allowance. This may be a r e a l disincentive to r e h a b i l i t a t i o n and earning. Another problem created by t h i s l e g i s l a t i o n i s that of accurately calculating Income. Annual reinspections involve high administrative 13 costs whereas the allowance, once granted, seldom changes because of annual f i n a n c i a l reviews. An advantage of these reinspections i s that some patterned contaet i s kept with the disabled. Since more insistence may be placed on the monetary condition than exploring the c l i e n t ' s p o t e n t i a l , t h i s "check" should be performed by personnel who are " r e h a b i l i t a t i o n " oriented. A more feasible arrangement than the means t e s t , especially i f the d i s a b i l i t y allowance i s not desirable as an outright pension, would be to encourage earning by the c l i e n t under a " s l i d i n g s cale" where he could s t i l l benefit from the allowance, at the same time he has greater income by working. At no time would his earnings induce him to consider unemployment i n preference to purposeful employment. Human needs are constantly changing. So too should l e g i s l a t i o n be amended to incorporate these changing demands. Since the passing of the Act ten years ago, only very i n s i g n i f i c a n t alterations have been made. L i t t l e e f f o r t has been devoted to issues that are not monetary i n nature. Physical d i s a b i l i t y may not only impose greater f i n a n c i a l d i f f i c u l t y because of low earning capacity, but t h i s r e f l e c t s also i n the individual's s o c i a l and psychic functioning. The Disabled Persons Act i s l i m i t e d and inadequate i n t h i s regard. Categorization and i n f l e x i b i l i t y of the Act do not recognize that: . . • each ph y s i c a l l y handicapped person i s an i n d i v i d u a l problem of vocational (personal 14 and s o c i a l ) maladjustment* Yet he has never been regarded as an i n d i v i d u a l but rather..as a c l a s s , a permanently dependent class. In r e l a t i n g d i s a b i l i t y allowances to r e h a b i l i t a t i o n , Miss Whitton believes that a comprehensive s o c i a l assistance program may serve as an Immediate remedy u n t i l better 2 provisions can be established. The problem of d i s a b i l i t y cannot be met by increased pensions or allowances alone, but so f a r t h i s Act has been a base f o r neither a comprehensive assistance scheme nor a r e h a b i l i t a t i o n program for the group i t i s Intended to cover. Nor has the l e g i s l a t u r e accepted the suggestions of the Canadian Welfare Council. The Council recommends that a l l public assistance measures for the disabled be linked with some form of r e h a b i l i t a t i o n . Without t h i s l i a i s o n the disabled person has no hope of Improving his p o s i t i o n and may resort to maximizing his helplessness i n order to obtain as much f i n a n c i a l help as possible. When the Disabled Persons Allowance grant proves I n s u f f i c i e n t to meet the needs of a disabled person, various forms of s o c i a l assistance can be used to bridge the gap. Those are the programs at the p r o v i n c i a l and municipal l e v e l s which are the modern counterpart of the old " r e l i e f " giving 1 Henry Kessler, R e h a b i l i t a t i o n of the P h y s i c a l l y  Handicapped. New York, Columbia University Press, 1947, p.23. 2 C. Whitton, The Dawn of Ampler L i f e . Toronto. Macmillan Company of Canada Limited, 1943, p. 33. 15 programs of former years and which are s t i l l hedged about in many places within the shades of the old Poor Law and the status of "pauper". Social assistance programs are developed to meet short term financial need. They are not a provision for the chronically handicapped, but are directed toward persons who encounter temporary financial need. Their rates are predicated on the often erroneous assumption that the cr i s i s i s short term only and they provide assistance at a subsistence level only. While i t is true that i n some places, social assistance programs are administered less.harshly and can be instruments of rehabilitation when s k i l l f u l l y developed and used, i t is equally true that in many places they are neither viewed nor administered i n this light, with consequent detrimental effects on the recipients. Also, there are immense variations across Canada i n philosophy and practice in these programs and there are s t i l l municipalities which grant aid of this kind according to their "grace and favour" and do not grant a basic minimum allowance to a l l their needy as of right. These kinds of aid then are the only forms of assistance available to those disabled people for whom the Disabled Persons Allowance is inadequate to meet their basic human needs and to those people who are not disabled according to the Act, are not helped by existing rehabilitation agencies, and yet are not self supporting. Not only is this kind of aid often 15 p r o g r a m s o f f o r m e r y e a r s . a n d w h i c h CUP© s t i l l h e d g e d a b o u t i n m a n y p l a c e s w i t h i n t h e s h a d e s o f t h e o l d P o o r L a w a n d t h e s t a t u s o f " p a u p e r " . S o c i a l a s s i s t a n c e p r o g r a r a s a r e d e v e l o p e d t o m e e t s h o r t t e r m f i n a n c i a l n e e d , t h e y a r e n o t a p r o v i s i o n f o r t h e c h r o n i c a l l y h a n d i c a p p e d , h u t a r e d i r e c t e d t o w a r d p e r s o n s «*ho e n c o u n t e r t e m p o r a r y f i n a n c i a l n e e d . T h e i r r a t e s a r e p r e d i c a t e d o n t h e o f t e n e r r o n e o u s a s s u m p t i o n t h a t t h e c r i s i s i s s h o r t t e r m o n l y a n d t h e y p r o v i d e a s s i s t a n c e a t a s u b s i s t e n c e l e v e l o n l y . I h i l e i t i s t r u e t h a t i n s o m e p l a c e s , s o c i a l a s s i s t a n c e p r o g r a m s a r e a d m i n i s t e r e d l e s s h a r s h l y a n d c a n h e i n s t r u m e n t s o f r e h a b i l i t a t i o n w h e n s k i l l f u l l y d e v e l o p e d a n d u s e d , i t i s e q u a l l y t r u e t h a t i n m a n y p l a c e s t h e y a r e n e i t h e r v i e w e d n o r a d m i n i s t e r e d i n t h i s l i g h t v w i t h c o n s e q u e n t d e t r i m e n t a l e f f e c t s o n t h e r e c i p i e n t s * ftlso, t h e r e a r e i m m e n s e v a r i a t i o n s a c r o s s C a n a d a i n p h i l o s o p h y ' ' ' a n d p r a c t i c e i n t h e s e p r o g r a m s a n d t h e r e a r e s t i l l m u n i c i p a l i t i e s w h i c h g r a n t s i d o f t h i s k i n d a c c o r d i n g t o t h e i r " g r a c e a n d f a v o u r " a n d <3o n o t g r a n t a b a s i c l a l n l m u c ) a l l o w a n c e t o a l l t h e i r n e e d y a s o f r i g h t • T h o s e k i n d s of a i d t h e n a r e t h e o n l y f o r m s o f a s s i s t a n c e available t o t h o s e d i s a b l e d p e o p l e f o r w h o m t h e D i s a b l e d P e r s o n s A l l o w a n c e i s i n a d e q u a t e t o m e e t t h e i r b a s i c h u m a n n e e d s a n d t o t h o s e p e o p l e w h o a r e n o t d i s a b l e d a c c o r d i n g t o t h e A c t , a r e n o t h e l p e d b y e x i s t i n g r e h a b i l i t a t i o n a g e n c i e s , a n d y e t a r e n o t s e l f s u p p o r t i n g . H o t o n l y i s t h i s k i n d o f a i d o f t e n 16 inadequate for the needs of the disabled person, but the nature of i t s e l i g i b i l i t y requirements and the manner i n which i t i s administered often offend against the basic pr i n c i p l e s of human di g n i t y * Disabled people have enough to contend with without the addi t i o n a l stress of being subjected to humiliating experiences at the hands of those authorities who have been set up as public servants to extend aid and r e h a b i l i t i a t i o n whenever possible to the disabled i n the name of the community* F i n a l l y , the Act ignores a basic r i g h t of the c l i e n t . This i s the ri g h t of appeal. A l l decisions are made without consulting the c l i e n t . I f he i s d i s s a t i s f i e d with the decisions made, he has neither free l e g a l advice nor the opportunity to appeal. A rejected applicant may, afte r an undetermined time i n t e r v a l , reapply. Despite the unmet intermediate need between the applications, the subsequent applica t i o n i s again assessed by the same personnel that refused the i n i t i a l a p p l i c a t i o n . As has been seen, the Disabled Persons Act i s , at the most, only an aid to some disabled persons. I t i s not a preventive measure and has no corrective f a c i l i t i e s . The Act i s often administered by " l o c a l " a u t h o r i t i e s , either p r o v i n c i a l or municipal. While there i s nothing to prevent the administering authorities from taking a broad view of the Act, and administering i t not s o l e l y as an income-17 maintenance program involving determination of the e l i g i b i l i t y of the disabled person for a cash grant, but also as an opportunity to bring to the c l i e n t what K a r l de Schweinitz has c a l l e d i n many of h i s w r i t i n g s , the " c l i n i c a l services," which Involve i n d i v i d u a l diagnosis and treatment (both medical and s o c i a l ) . I t i s regrettable that for a number of reasons not always to do with a shortage of s o c i a l work s t a f f , the service brought to the c l i e n t under t h i s Act i s often l i t t l e more than determination of e l i g i b i l i t y f o r the allowance. This Act could be used as a responsive instrument f o r determining and meeting what have been called "the non-cash needs" of the disabled person. 1 CHAPTER VI I I CRITIQUE GF THE VOCATIONAL REHABILITATION OF DISABLED PERSONS ACT, 1961 An evaluation of the Acts which constitute the t o t a l r e h a b i l i t a t i o n program at the federal l e v e l i n the area of vocational r e h a b i l i t a t i o n w i l l also be an i n d i c a t i o n of what aid i s available to disabled people seeking to enter employment. A l l the issues raised by these Acts cannot possibly receive adequate atte n t i o n i n t h i s study, though perhaps the study may serve to heighten awareness of the issues and perhaps also stimulate hypotheses for subsequent studies. One of the implications of the Federal government's both assuming the leadership role and providing f i n a n c i a l aid would be that i t could and should act as a standard s e t t i n g body without i n f r i n g i n g on the basic rights of the provinces. In the area of vocational r e h a b i l i t a t i o n , the exercise of t h i s function by the Federal government i s c l e a r l y demonstrated. While the provinces generally accepted that some uniformity and coordination i n r e h a b i l i t a t i o n was desirable, they nevertheless wish to approach t h e i r own problems i n t h e i r own p a r t i c u l a r way, but look to the federal government f o r f i n a n c i a l aid i n doing so. A. A Vocational R e h a b i l i t a t i o n Act Under the federal Acts r e l a t i n g to Vocational 2 R e h a b i l i t a t i o n services, f e d e r a l aid has been l a r g e l y conditional upon the provinces entering into agreements with the provinces to share the costs of c e r t a i n services. These agreements are s u b s t a n t i a l l y the same for each province. The way i n which the programs under the agreements were announced was interesting i n the l i g h t of Canadian his t o r y * There was an announcement that the agreement was available f o r signature* Possibly the shades of the unsuccessful Dominion-Provincial Conferences of 1945-46 were s t i l l haunting the Federal government. While i t may be speculated that the Federal government consulted experts w i t h i n the provinces, there i s said to be no evidence that a l l the provinces were included i n the consultations. As a consequence, the r e s u l t i n g agreements may not have been equally suitable f o r the needs of a l l provinces. The objectives of the Act are: (1) to enable the Federal Government to enter into agreements with the provinces to share f i f t y percent of costs incurred by the provinces i n providing a comprehensive program of services f o r the vocational r e h a b i l i t a t i o n of disabled persons; (2) to provide f o r the co-ordination of federal a c t i v i t i e s i n the f i e l d of vocational r e h a b i l i t a t i o n ; (3) to enable research to be undertaken and published i n respect of vocational r e h a b i l i -t a t i o n of disabled persons; and (4) to e s t a b l i s h a National Advisory Council on the R e h a b i l i t a t i o n of Disabled Persons to advise the Government and to provide a forum of opinion on the f i e l d of r e h a b i l i t a t i o n i n Canada. 3 To r e a l i z e these objectives the federal government had to exercise some control over p r o v i n c i a l functions and organize a h i e r a r c h i a l j u d i c i a l and administrative structure. Table I I depicts how l i n e s of authority move downward, (which authority i s possible only because of the Acts and signed Agreement,) and how the l i n e s of service move from the l o c a l l e v e l upward. In t h i s way l o c a l and p r o v i n c i a l resources are combined with those of other provinces to f orm ta national aggregate, which, i n turn, receives standardization, support i n operation, benefits from research, and consultation from the t o t a l organization. I t i s apparent that the Act and the Agreement are geared s o l e l y toward employment. The purpose of t h i s r e h a b i l i t a t i o n i s to place the formerly disabled person i n t o the economic market. This i s evident i n the way i n which the Act defines two terms. 2. (d) "disabled person" means a person who because of physical or mental impairment i s incapable of pursuing regularly any su b s t a n t i a l l y g a i n f u l occupation; and (e) "vocational r e h a b i l i t a t i o n " means any process of restoration, t r a i n i n g and employment placement, including services related thereto, the object of which i s to enable a person to become capable of pursuing regularly a s u b s t a n t i a l l y g a i n f u l occupation. This insistence on employment would have more meaning i f a l l those who were disabled could be so re h a b i l i t a t e d and, i f those so r e h a b i l i t a t e d could compete ; successfully with the 4 TABLE I I Organization Chart - C i v i l i a n R e h a b i l i t a t i o n Program National Minister Advisory of Council Labour National Employment Service Canadian Vocational Training Provincial. Advisory Bodies Minister of National Health and Welfare T Int er-d apartmental Committee National Co-ordinator, C i v i l i a n R e h a b i l i t a t i o n Medical R e h a b i l i -t a t i o n and D i s a b i l -i t y Advisory Service Nat'l H l t h Grants! f P r o v i n c i a l Coordinators Disabled Persons Allowances National Employment Service Training Voluntary Agencies Hospitals and Health Services Other Community Resources Source: United Nations Study on L e g i s l a t i v e and Administrative Aspects of R e h a b i l i t a t i o n Programmes i n Selected Countries — National Coordinator. 5 non-disabled unemployed. Canada has d i f f i c u l t y employing a l l her able-bodied labour force; s p e c i a l placement cannot t o t a l l y remove an employer's preference i n h i r i n g others rather than the disabled. R e h a b i l i t a t i o n should be available fo r those disabled persons who are w i l l i n g and able to benefit from i t , but making employment pot e n t i a l a condition of acceptance i n t o the program r e s t r i c t s the service to only a percentage of the disabled persons. This would be acceptable i f other Acts covered those disabled people who w i l l not be able to meet the goal of employment, but i n Canada no such acts exist and the services available under general l e g i s l a t i o n and private agency auspices are not s u f f i c i e n t to meet the needs of t h i s comparatively large group. Cybernetic expansion and Increased human replacement by automation w i l l reduce the d a i l y working hours and also the demand f o r employment. Instead of exclusively s e l e c t i n g and r e h a b i l i t a t i n g the p o t e n t i a l l y employable disabled where he w i l l contribute to the labour supply, the program might be altered to include the unemployables and t r a i n them to appreciate pursuits other than the s t r i c t l y commercial type. Many of the disabled who w i l l never be able to compete on the labour market could s t i l l be "usefully" occupied i n areas of l i t e r a t u r e , music, and so on. This would include many of those presently considering themselves useless because they have been rejected by both Disabled Persons and Vocational 6 R e h a b i l i t a t i o n * Furthermore, while attaining a sense of worthiness, they might be performing i n a f i e l d that t r u l y interests them and no competition i s necessary i n order to r e t a i n the job* The national ideology of equal rights to employment extends beyond t h i s to include the right to "the pursuit of happiness", or at least of s e l f development* Such an approach to r e h a b i l i t a t i o n would recognize t h i s human value* When automation changes the patterning of our use of "work" time and " l e i s u r e " time, and the a c t i v i t i e s appropriate to each, some of the d i s t i n c t i o n s we currently make between the two w i l l lose t h e i r meaning. One of the goals of the Agreement i s to remove the disadvantages suffered by the disabled person, Surely t h i s should not be r e s t r i c t e d to employment disadvantages but should Include a l l l i v i n g disadvantages. This r e h a b i l i t a t i o n program could be more comprehensive and v a l i d i f i t were to consider also the " r e h a b i l i t a t i o n " of persons who could benefit, even i f only to a degree, from improvement or rest o r a t i o n of capacities helping them enjoy such diversionary and s e l f -expressive a c t i v i t i e s as hobbies, s e l f - c a r e , a more active s o c i a l l i f e , and pursuing many of the a c t i v i t i e s that are a part of normal contemporary l i f e * These are personal values and, being so, have perhaps greater meaning to the disabled who are deprived of them. This program could be extended to include those disabled 7 who could reach only l i m i t e d goals because they may ac t u a l l y be handicapped i n r e l a t i o n to the ''ideal" goal of employment. To the disabled person, h i s own r e h a b i l i t a t i o n goal i s a l l important even i f i t i s , as cited e a r l i e r , l i m i t e d . The r e h a b i l i t a t i o n goal should always be i n d i v i d u a l l y set according to the p a r t i c u l a r capacities. Each disabled person has the ri g h t to help through government and private agency aid i n ar r i v i n g at what i s the best r e h a b i l i t a t i o n goal for him. The determining e l i g i b i l i t y factor would then not be the p o t e n t i a l for earning a substantial wage and "to contribute to Canada" through income taxation. While those who are able would s t i l l continue under the current t r a i n i n g f a c i l i t i e s , an expanded and more i n c l u s i v e service would include a larger segment of the disabled population. Dunlop describes the pligh t of many disabled persons: There are tens of thousands of disabled Canadians l i v i n g i n despair and f r u s t r a t i o n , who can neither f i n d nor keep work, who are unable to lead happy and useful l i v e s . These are the people who could be restored through r e h a b i l i t a t i o n — the people f o r whom _ r e h a b i l i t a t i o n services are not now avail a b l e . R e h a b i l i t a t i o n other than, but i n addition t o , vocational i s needed. The eventual f i n a n c i a l return of the re h a b i l i t a t e d person i s not a proper condition of receiving the help — many 1 Edward Dunlop, "Rehabilitation for the Disabled i n Canada", Toronto, September, 1958. Writing based on working papers prepared f o r the national Advisory Committee on the Re h a b i l i t a t i o n of Disabled Persons. 8 helping services cannot possibly serve the public w e l l when structured on the premise that they must return at least as much to the economy as was spent on the beneficiaries of the program. Some services do not y i e l d the monetary return that i s necessary to sponsor the service. The returns i n human values cannot be so e a s i l y measured, but are nonetheless r e a l and v a l i d . Even on the s t r i c t l y f i n a n c i a l l e v e l , there i s s t a t i s t i c a l evidence supporting the low cost of r e h a b i l i t a t i o n . Non-vocational r e h a b i l i t a t i o n as an economical measure does not lend i t s e l f e a s i l y to s t a t i s t i c a l evidence, but such Involvement may reduce l a t e r costs of public assistance, ps y c h i a t r i c and medical care. Speaking on vocational r e h a b i l i t a t i o n , the Royal Commission of Health Services of 1964 reported a study of nearly 10,000 r e h a b i l i t a t e d persons, done by the C i v i l i a n R e h a b i l i t a t i o n Branch of the Department of Labour. The findings were* On the basis of what i t would have cost to maintain those r e h a b i l i t a t e d i n 1961-62, and on the assumption that those r e h a b i l i t a t e d i n e a r l i e r years earned at least as much as those r e h a b i l i t a t e d i n 1961-62, i t i s estimated that i n that year the savings i n maintenance expenditures approached $60 m i l l i o n , while the earnings of those employed amounted to over $180 m i l l i o n . 1 H a l l Report, "Royal Commission of Health Services", v o l . 1 , Ottawa, Queen's P r i n t e r , 1964, p. 515. 9 Figures f o r Saskatchewan, l i s t e d i n conduction with those above, indicated that i t cost $54,580 annually to support 71 people who, afte r r e h a b i l i t a t i o n , each earned an average of about $2,000 a year. The rate at which the re h a b i l i t a t e d persons contributes to the national economy by way of taxes soon pays for the cost of t h e i r r e h a b i l i t a t i o n and, at the same time, reduces public assistance expenditures. Dunlop1' gives comparable figures on Vocational R e h a b i l i t a t i o n costs and returns i n the United States. Table I I I provides information on e a r l i e r years and compares costs of support before r e h a b i l i t a t i o n to annual earnings a f t e r r e h a b i l i t a t i o n . TABLE I I I Re h a b i l i t a t i o n Gases and Cost of Support Compared to Incomes Period Number of Cases Males Females Number of Dependents Estimated Annual Cost For Support Annual Earn-ings After Rehabilitation Up to March 31, 1957 n 1957 - 1958 , 1958 - 1959 1959 - I960 1960 - 1961 1961 - 1962 1962 - 1963 1,001 1,055 1,174 1,462 1,614 1,669 1,818 686 683 745 941 1,044 1,079 1,186 315 372 429 5 a 570 590 628 610 826 877 1,146 1,276 1,300 1,400 450,532 984,460 1,232,040 923,240 954,304 902,919 1,118,891 1,750,753 1,860,165 2,219,380 2,683,403 2,730,502 3,198,547 3,401,979 Total 9,789 6,364 3,425 7,435 6,530,386 17,844,729. 1 Sources Canada, Department of Labour, Annual Report,Queen's P r i n t e r , Ottawa, 1963, p.54. Dunlop, o n . c i t . p.4. 10 Federal-provincial agreements have a duration of s i x years. They may be amended or e a r l i e r terminated by mutual consent of the parties and with the approval of the Governor i n Council. This combines the q u a l i t i e s of program s t a b i l i t y with flexibility to adapt r e a d i l y to new and immediate needs. The federal government w i l l share costs incurred by a province i n providing a r e h a b i l i t a t i o n service which includes: (4) (a) assessment and counselling services f o r disabled persons; (b) services and processes of restoration, t r a i n i n g and employment placement designed to enable a disabled person to dispense with the necessity for i n s t i t u t i o n a l care or the necessity for the regular home service of an attendant; (c) providing f o r u t i l i z i n g the services of voluntary organizations that are carrying on a c t i v i t i e s i n the province i n the f i e l d of vocational r e h a b i l i t a t i o n of disabled persons; (d) the t r a i n i n g of persons as counsellors or administrators to carry out programs for the vocational r e h a b i l i t a t i o n of disabled persons; (e) the coordination of a l l a c t i v i t i e s i n the province r e l a t i n g to vocational r e h a b i l -i t a t i o n of disabled persons; and (f) such other services and processes of restoration, t r a i n i n g and employment placement i n respect of disabled persons as are specified i n the agreement. Relating these provisions to the e a r l i e r part of t h i s study wherein a comprehensive program i s outlined, one may observe that, generous though the provisions are on some respects, 11 t h i s does not meet the t o t a l r e h a b i l i t a t i o n need of disabled people, even from the vocational aspects. No e x p l i c i t provision i s made to incorporate new services and to expand existing ones. The Act i s constricting because i t does not allow cost-sharing for services that are not already i n existence and provinces therefore receive no help i n the development of new programs nor with many kinds of needed f a c i l i t i e s . Since services may soon become obsolete i n a rapidly changing world, changes In programs must be allowed f o r and provisions made to include the development of new resources f o r the disabled. Otherwise the service becomes inappropriate because i t lags behind the changes i n society. At present the p r o v i n c i a l coordinator may "purchase" any necessary service which exists i f i t i s to benefit the cl i e n t i n reaching his vocational goal. However, i f the resource, though necessary, does not e x i s t , f o r example, use of a sheltered work shop f o r t e s t i n g work tolerance, he i s powerless under the Act to f a c i l i t a t e i n any way the inauguration of such a ser v i c e . Both the Act and Agreement request the provinces to define t h e i r programs by o u t l i n i n g the services, the process and by submitting annual reports and s t a t i s t i c s . The federal authorities are thus well informed of what happens on l o c a l administrative levels and t h i s i s also a means where suggestions f o r improvements may be made. Two-way communication i s v i t a l 12 i f the necessary changes are to be incorporated and i f they are to be appropriate to the situation. Sections 5 and 6 state that the Minister "may" undertake federal coordination, do research alone or in conjunction with a province, and assemble material for publication. In a l l these areas the Act does not make clear what the Federal government " w i l l " do as opposed to what i t "may" do. Nor is i t clear what specifically is expected of the provinces. This vagueness does not make for a stable base for future planning. Provincial activity in the f i e l d of rehabilitation would probably have greater security i f the provinces had some assurance of certain mandatory rather than optional federal support. To make maximum u t i l i z a t i o n of existing resources the Agreement, which makes provincial coordination a condition of federal participation, is the means by which this is done. Provinces have a Provincial Coordinator or Director of Vocational Rehabilitation whose duties are tos 7 (a) establish appropriate means of seeking out disabled persons. . . . (b) encourage the provision of adequate remedial and educational services for disabled children and to ensure continuity for services on their reaching adolescence. . (c) encourage voluntary agencies to define their role. . . . (d) establish a committee of representatives of those departments of the provincial government concerned. . .(with rehabilitation); 13 and to create on a p r o v i n c i a l and l o c a l basis, advisory coucils or committees where deemed appropriate. Acceptance of these s t i p u l a t i o n s brings together the need and the f a c i l i t y available to treat the need, but says nothing about the means of accomplishing these ends. The f i r s t step i n seeking out disabled persons i s for doctors to report d i s a b i l i t y at b i r t h . Records of t h i s sort are"kept with optional d i v e r s i t y . Kessler, making recommendations for the American States, suggests t h i s as both a method of early intervention and a preventative measure. Perhaps we can take a cue from one of the most constructive pieces of l e g i s l a t i o n i n t h i s regard. I r e f e r to the compulsory r e g i s t r a t i o n of deformed children at b i r t h . I t provides public r e s p o n s i b i l i t y f o r the detection of the deformity at an early date . when so much more can be done to correct i t . He also advocates that records be kept throughout the disabled's l i f e t i m e . Awareness and timing of Intervention would be f a c i l i t a t e d ; there would be greater assurance of a continuity of service so that appropriate intervention, made at s p e c i f i c stages of the individual's development, would be most e f f e c t i v e . Case f i n d i n g i n the individual's l a t e r l i f e could be more complete with improved r e f e r r a l arrangements. There i s very l i t t l e communication between authorities administering Disabled x Henry H. Kessler, R e h a b i l i t a t i o n of the P h y s i c a l l y  Handicapped. New York, Columbia University Press, 1947, p. 236. 14 Persons Allowance and rehabilitation o f f i c i a l s . Assuredly, many potential rehabilitation clients are lost i n the shuffling of them from one discipline to another. The Act expounds the principle that services may be purchased from private agencies on behalf of- the disabled person. This emphasizes the federal view that the appropriate division of responsibility i n Canadian rehabilitation i s the t r i n i t y of Federal-Provincial-Voluntary source. There i s s t i l l strong conviction i n Canada, as i n many other countries, that the day of the private agencies is by no means done. Both successive federal governments and the Royal Commission on Health Services see the voluntary agencies combining to play a v i t a l role i n rehabilitation. This is seen as necessary even i f the government implements a comprehensive program, as has been the experience i n countries like Britain and Sweden. It is most d i f f i c u l t to provide extensive services to a l l persons and for a l l d i s a b i l i t i e s . There are many voluntary agencies serving selected groups and, because they are already established, recognition of them w i l l avoid overlapping. Also, there are some dis a b i l i t i e s that are so Infrequent or affect only a very few people that i t does not warrant an elaborate governmental organization. The client might receive an adequate, perhaps a more personal, service from a private agency and the government may find i t more economical to purchase rather than provide for this intermittent need. 15 R e h a b i l i t a t i o n cannot be Isolated from health, welfare and education. That the provinces have a committee of representatives of various d i s c i p l i n e s i s imperative. Advisory councils, too, play an important part. Information supplied by these groups i s not only pertinent but serves as a public voice. The Act speci f i e s the composition of a National Advisory Council. Four members are to be employees of Her Majesty; representing the Department of National Health and Welfare, the Department of Veterans A f f a i r s , the Department of Labour, and the Unemployment Insurance Commission. Apart from t h i s , the i d e n t i t y of the other members i s not we l l specified except that ten s h a l l be chose upon the j o i n t recommendation of the Minister of Labour and the Minister of National Health and Welfare. The ten provinces s h a l l each have a member. F i n a l l y , one member i s to serve as chairman. It i s a f a i r d i s t r i b u t i o n that the various departments and the ten provinces be represented, but i t i s also important that public services other than those mentioned and the medical profession, voluntary agencies, r e l i g i o u s , and other groups be represented, and th i s granted to them by l e g i s l a t i o n . Lay people, and most of a l l , the handicapped themselves should be included. While the provinces may be considered accountable to the Ministers of Labour and National Health and Welfare (the l a t t e r , i n turn, are responsible to Parliament) by having to 16 submit reports, accounts and s t a t i s t i c s they do have some degree of autonomy* The federal government, within l i m i t a t i o n s , w i l l permit provinces to d i r e c t t h e i r spending as they see f i t * P r i o r approval of plans are usually demanded, but cost-sharing expenditures are submitted f o r reimbursement after the actual spending has taken place* In some instances there i s a c e i l i n g to federal f i n a n c i a l p a r t i c i p a t i o n , but p r o v i n c i a l freedom i s seen i n cases where, once the program i s accepted, the Federal government seems to do l i t t l e more than pay the province i t s share of the costs. In the development or i n i t i a t i o n of p a r t i c u l a r areas the province seems to have to take the f i r s t steps, but then may not do less than i s demanded by federal standards. B. The Individual Schedules Forming part of the Agreement (and which becomes as binding as any other part of the Agreement) are Schedules that set out the services, the methods, and the arrangements under which the provinces administer the service to the pub l i c . Schedule I l i s t s the conditions of assessment and councelling services to the c l i e n t . Previous chapters of t h i s study explain the various components of a comprehensive r e h a b i l i t a t i o n service and, when compared to the provisions under t h i s Schedule, indicates that an i d e a l program i s much more inclusiv e than that which i s outlined i n the Agreement. The goal toward which the e x i s t i n g assessment and counselling 17 services are geared i s employment, whereas the c l i e n t has many other needs that are important to him. S o c i a l services, psychological help, and r e h a b i l i t a t i o n f a c i l i t i e s are a few of those which now receive i n s u f f i c i e n t a ttention. Assessments should take into consideration c l i e n t values and the c l i e n t as a person rather than evaluating him i n r e l a t i o n to his capacity to reach goals which may seem i r r a t i o n a l , mechanical, and unreal to him. More recently there has been increased awareness i n placement considerations of recognizing the "trainee's" l i f e experiences, c u l t u r a l and r e l i g i o u s background, preferences, and of those things that have meaning to that p a r t i c u l a r person. At the same time there i s understanding of the person's physical and mental l i m i t a t i o n s . Services and Processes of Restoration are dealt with In Schedule 2. Here again, the instructions are vague, sta t i n g only that reimbursement to the provinces s h a l l be made at the rate set out i n the Agreement for remedial or restorative treatment and related services. Once more the c o n f l i c t of national standards and p r o v i n c i a l d i s c r e t i o n a r i s e s . I f the s p e c i f i c processes are not outlined i n the Agreement and Schedules then, even on the l e v e l of p r o v i n c i a l functions, there i s no guarantee that a c l i e n t w i l l receive as comprehensive a service as i s needed or as a s i m i l a r l y disabled person i n another province. 18 Schedule 3 says that t r a i n i n g of the disabled may-be provided under the terms of the Technical and Vocational Training Assistance Act or other t r a i n i n g , including u n i v e r s i t y courses i f approved by the Minister* Some of the prominent t r a i n i n g opportunities available w i l l be discussed i n subsequent sections* Employment placement services (Schedule 4) are provided through the National Employment Services* This necessitates close cooperation and good communication between p r o v i n c i a l r e h a b i l i t a t i o n o f f i c e s and federal employment o f f i c e s . The Act and Agreement state that services extended by the National Employment Office be coordinated on the federal l e v e l ; there i s also coordination by the provinces* Nowhere i s there reference to how the p r o v i n c i a l agencies; should cooperate with the national o f f i c e s * This remains confusing because i t involves two l e v e l s of government and there must be a bridge between these two* Using follow-up as an example, does the trainee's p r o v i n c i a l worker or the federal placement o f f i c e r r e t a i n contact with the c l i e n t ? Does the National Employment personnel share r e s p o n s i b i l i t y or assume f u l l control \after assessment and t r a i n i n g ends? What part does each play while r e h a b i l i t a t i o n i s i n process? Greater c l a r i t y i s needed as to who i s allocated r e s p o n s i b i l i t y to do what and when. Included i n Schedule 5 i s the t r a i n i n g of s t a f f that carries out the process of r e h a b i l i t a t i o n . More mention w i l l 19 be made of t h i s when the Training Act i s reviewed. Possible s t a f f t r a i n i n g varies from short courses to academie degrees. Not a l l s t a f f can be professionally t r a i n e d , nor need they perhaps be, and the range of t r a i n i n g i s quite appropriate to the d i v e r s i t y of functions carried out by the s t a f f . Quality of the s t a f f w i l l r e f l e c t on the t r a i n i n g received by the disabled person and should therefore be taken into account i n planning the t r a i n i n g curriculum. C. Other Considerations of the Act Costs that the federal government w i l l share with provinces includes s a l a r i e s and t r a v e l l i n g expenses of s t a f f and personnel involved i n r e h a b i l i t a t i o n as well as other administrative expenses approved by the Minister; expenses of disabled persons such as tools and clothing, t r a i n i n g , transportation and maintenance; costs of t r a i n i n g s t a f f ; costs of research; approved p u b l i c i t y ; medical fees; and services that are not free of charge to the pub l i c . For services other than counselling, guidance or assessment, the individual's a b i l i t y to contribute i s taken into consideration. There i s no consensus as to what c r i t e r i a to use i n c l i e n t p a r t i c i p a t i o n and c l i e n t contributions may vary without any set minimum rate at which he would not be expected to reduce his personal assets. Some provinces aid the trainee i n establishing himself, but the trainee i s not 20 certai n of s u f f i c i e n t c a p i t a l resources to i n i t i a t e a private business a f t e r h i s r e h a b i l i t a t i o n . Security i s a major psychological factor inducing the c l i e n t to r e h a b i l i t a t i o n . Apart from c a p i t a l funds, i f the trainee i s indigent his needs may be met. This does not necessarily include the maintenance of h i s family while he i s t r a i n i n g . P a r t i c u l a r l y i f the head of the household i s taking t r a i n i n g , services should be extended to h i s dependents as w e l l , and t h i s should not be at the subsistence l e v e l of s o c i a l assistance standards as i s the case i n some provinces. The Agreement does not enable cost sharing for several things even though they are basic to the o v e r a l l program. In the Appendix of the Agreement i s stated that 10. Except as otherwise s p e c i f i c a l l y provided f o r i n t h i s Agreement, shareable costs do not include p r o v i n c i a l expenditures incurred f o r any of the following items: (a) acquisitions of lands and buildings; (b) purchase or r e n t a l of o f f i c e equipment and supplies; (c) a l t e r a t i o n s , repairs or rentals f o r o f f i c e accommodation; (d) damage or compensation r e s u l t i n g from in j u r y to persons except the cost of f i r s t a i d ; (e) l e g a l , advisory or consulting fees and s a l a r i e s ; and • ( f ) overhead expenses added to the cost of materials supplied by the Province or any municipality from e x i s t i n g stores. 21 The Federal government proposes to help the provinces improve and provide r e h a b i l i t a t i o n services but, i n f a c t , only aids i n those areas that have already been i n i t i a t e d by the province. One of the recurring themes i n t h i s study has been the frequency with which the Federal government, i n r e h a b i l i t a t i o n l e g i s l a t i o n , throws the onus back on the provinces and the voluntary agencies f o r I n i t i a t i n g the services and meeting many, and sometimes a l l , of the c a p i t a l costs involved. The federal p o s i t i o n seems to be that i f the provinces and private agencies w i l l develop a service and play the major rol e i n i t s operation then the Federal government w i l l support i t . The role played by the federal authorities i s perhaps not f u l l y r ealized by the average c i t i z e n . The e a r l i e r mentioned r e h a b i l i t a t i o n " t r i n i t y " makes a t r i p l e demand on the c i t i z e n . He i s required to contribute to federal and p r o v i n c i a l taxes while expected to make a generous donation to private agency programs. A possible fourth demand might be made by the municipality, which may foster a r e h a b i l i t a t i o n project of i t s own. Allowing f o r d i f f e r i n g rates of cost sharing, i f the Federal government desires to help the provinces, especially as i t has national authority, i t should extend i t s aid to a l l those elements that make up the general program and to help i n supplying those elements that the provinces l a c k . In i n i t i a l establishment and subsequent expansion the provinces receive least support, yet these are the areas of most 22 Importance i n providing adequate services to the disabled person and are most expensive to the province. Combining the National Department of Labour's 1963 s t a t i s t i c s of payments made to the provinces with the 196l population Census (see Table IV) gives some i n d i c a t i o n of the rate at which each province u t i l i z e s federal monies. The variations between p r o v i n c i a l expenditures may depict that the Act and Agreement do not affect each province s i m i l a r l y . There may be many reasons why one province spends more, per capita, than another. A r e a l problem remains: that i s to f i n d a s o l u t i o n between national uniformity at a "basic minimum l e v e l " and meeting s p e c i a l p r o v i n c i a l demands at the same time. The Table may also be interpreted as some provinces requiring a d i f f e r e n t kind of help that has so f a r been extended by the federal government. Indicative, however, i s that each province's r e h a b i l i t a t i o n expenditure i s at a d i f f e r e n t pace. A comparison of the f i n a n c i a l and occupational status of the disabled before r e h a b i l i t a t i o n and that of t h e i r new status following r e h a b i l i t a t i o n w i l l be one way of evaluating what the program has done for those persons who have been accepted. Table V shows a marked change i n the f i n a n c i a l status. This means that the program does enable f i n a n c i a l independence f o r many disabled people. P r i o r to r e h a b i l i t a t i o n the majority were dependent on r e l a t i v e s and public assistance, af t e r r e h a b i l i t a t i o n the largest group earned between $1000 and 23 TABLE IV Payments to Provinces and P r o v i n c i a l Populations Province Federal ': P r o v i n c i a l Payment x Population xx Newfoundland Prince Edward Island Nova S c o t i a New Brunswick Ontario Manitoba Saskatchewan Alberta B r i t i s h Columbia 10,596.78 3,142.18 23,737.97 52,290.88 75,890.62 84,232.17 47,597.23 21,940.08 13,717.13 457,853 104,629 737,007 597,936 6,236,092 921,686 925,181 1,331,944 1,629,082 Total i - - . . 333,145.04 12,946,410 Source: s Canada, Department of Labour, Annual Report, 1962-63. SEX 1961 Canadian Census "TABLE V Fi n a n c i a l Status Before and After R e h a b i l i t a t i o n Groups At Acceptance 1962 1963 Total Dependent on Relatives 718 M P u b l i c Assist'ce 437 D i s a b i l i t y & other A l l . 42 Earnings: under 500 8 501 - 1000 52 1000 - 2000 122 2000 - 3000 80 3000 - over 30 Old Age Sec.Savings,etc 87 Unemployment Insurance 93 No Information Totals 1669 756 480 35 1 35 101 65 33 116 187 5 1809 1474 917 77 9 8? 223 145 63 203 280 5 3478 After R e h a b i l i t a t i o n 1962 1963 Total 63 198 445 650 221 1577 36 99 189 387 499 944 657 1307 247 468 1628 3205 Source: Canada, Department of Labour, Annual Reports, 1962- 1963. 24 $3000 per year* The s e l e c t i v i t y of trainees makes t h i s possible* Should services be extended t o include the disabled who do not have t h i s good employment prognosis, these s t a t i s t i c s might be r a d i c a l l y d i f f e r e n t . What might not be s t a t i s t i c a l l y indicated then, because i t would be more d i f f i c u l t to measure, would be the returns i n human s a t i s f a c t i o n and happiness• Table VI indicates movement i n coccupational status because of r e h a b i l i t a t i o n . This might be a better yard-stick fo r measuring Improvement i n " h a b i l l t a t i o n " of some c l i e n t s . Outstanding i s the movement from No Occupation (and Unskilled Occupation) to Sales and C l e r i c a l and the Serice Occupation group. The discrepancy i n the t o t a l number of persons before r e h a b i l i t a t i o n and that a f t e r i s accounted for by the fact that r e h a b i l i t a t i o n may not have been successful f o r a l l those who were accepted. Here, as In r e h a b i l i t a t i o n workshops, a good test of program scope i s the rate of f a i l u r e . 1 I f there i s l i t t l e f a i l u r e then the program i s l i k e l y very selective and does not accept "high r i s k " cases — those usually requiring help the most. Despite the success of r e h a b i l i t a t i o n , i t s t i l l does not meet the requirements of a comprehensive program because i t extends services only to a small segment of the disabled group, rather than being universal i n coverage. 1 A l i c e E l a r t , R e h a b i l i t a t i o n Coordinator, P r o v i n c i a l Mental Hospi t a l , Essondale, B.C. Speaking on "A Comprehensive Workshop -The Goodwill Approach", at:tbe Annual Meeting of Vancouver D i v i s i o n f o r Guidance of the Handicapped, March 29, 1965* 25 TABLE VI Occupation Before and After R e h a b i l i t a t i o n Occupation Before 1961 1962 !l963 i Total Occupation After 1961 1962 1963 Total P r o f f l and 49 Managerial 63 51 163 P r o f ' l and 85 Managerial 121 114 320 Sales and 222 C l e r i c a l 170 208 600 Sales and 410 C l e r i c a l 395 457 1262 Service 279 Occupations 177 150 606 Service 364 Occupations 266 299 929 AgrL, Fishery 134 Forestry,etc. 129 118 381 A g r i . Fishery 64 Forestry,etc. 80 68 212 S k i l l e d Oc- 103 cupation 145 158 406 S k i l l e d Oc- 114 cupat ion 235 201 550 Semi-skilled 123 Occupation 88 118 329 Semi-skilled 131 Occupation 123 154 408 Unskilled 307 Labour 317 332 956 Unskilled 214 Labour 233 246 693 Housewife and x Homemaker 113 117 230 Housewife and 1 Homemaker 126 124 250 No Previous 397 Occupation 465 560 1422 S e l f Care x 90 151 241 Retired K 2 2 4 Total 5097 4865 K Not l i s t e d f o r those years. Source: Canada, Department of Labour, Annual Reports. 26 TABLE VII D i s a b i l i t y Groups By Age, Sex and Location Group 1960-61 1961-62 1962-63 Total Under 20 186 197 255 638 2 0 - 2 9 616 663 1980 30 - 39 331 344 328 1003 40 - 49 231 225 228 784 50 - 59 129 144 177 450 Over 60 139 96 125 360 Total 1632 1669 1814 5215 Male_ 1044 1079 1186 3309 Female 570 590 628 1788 Dependents 1276 1300 1400 3976 Total 2890 2969 3214 9073 Urban 1009 1055 1179 3243 Rural 605 614 635 1854 Total 1614 1669 1814 5097 Sources Canada, Department of Labour, Annual Reports. The 5097 disabled persons who were accepted for r e h a b i l i t a t i o n during the three years i s c e r t a i n l y only a small portion of the people who are disabled. Not only i s there need to re-examine what needs and how many, or few, people are served, but the kinds of people presently served 27 offers direction for the future and should therefore be studied. Table VII shows that those people who were given a service f e l l primarily between the ages 20 and 4G. This i s the most potential labour force and perhaps indicative only of the program scope rather than of public conditions. Similarly, almost twice as many males as females and nearly twice as many urban as rural persons were e l i g i b l e . Only to a degree is this representative of dis a b i l i t y distribution, but i f so, then program focus should naturally adjust accordingly and gear rehabilitation services where greatest need exists* On the other hand, this could be Interpreted as the program having a limited purpose and restricted training f a c i l i t i e s * If the latter is correct, i t is time that rehabilitation be revised to consider universal coverage. 1 CHAPTER IX CRITIQUE OF THE TECHNICAL AND VOCATIONAL TRAINING ACT, i960 This Act, l i k e the Vocational R e h a b i l i t a t i o n of Disabled Persons Act, places great import on "gainful employment" as i t s end and purpose. Unlike i t s counterpart, i t does not devote i t s e l f e n t i r e l y to the physically disabled. I t serves the unemployed, those employed who wish to advance and improve t h e i r p ositions, and other sections of the "healthy" population. I t can therefore be used for the r e h a b i l i t a t i o n of many kinds of people, including the s o c i a l l y disadvantaged. The Agreement of the Act defines p r o v i n c i a l a c t i v i t y much better, with greater c l a r i t y and d i r e c t i o n , than the Vocational R e h a b i l i t a t i o n of the Disabled Persons Agreement. The services offered are more comprehensive, with provisions f o r trainees more adequate. As with the previous two Acts, t h i s Act and Agreement w i l l be evaluated conjunctively as they complement and overlap one another. Again, the approach w i l l be a c r i t i c i s m of i t s weaknesses, but th i s does not make the whole program inadequate. Despite the fact that more negative than positive c r i t i c i s m s may be recorded, t h i s Act i s perhaps Canada's best Federal-P r o v i n c i a l piece of l e g i s l a t i o n . I t s inclusiveness extends 2 not only to the physically and vocationally disabled, but to those who have no overt handicap and i t recognizes the s o c i a l l y and psychically distressed person, the unemployed and the poorly employed. The Vocational R e h a b i l i t a t i o n of Disabled Persons Act allows for the services necessary f o r r e h a b i l i t a t i o n ; t h i s Act enables the actual t r a i n i n g . A» The Training Act In the Agreement, section I , subsection (b), by technical and vocational t r a i n i n g i s meant . . . any form of i n s t r u c t i o n , the purpose of which i s to prepare a person f o r g a i n f u l employment i n any primary or secondary industry or i n any service occupation or to increase h i s s k i l l or proficiency therein, and without r e s t r i c t i n g the generality of the foregoing, includes i n s t r u c t i o n f o r that pur-pose i n r e l a t i o n to any of the following industries or occupations: a g r i c u l t u r e , f o r e s t r y , f i s h i n g , mining, commerce, construction, manufacturing or communications, or generally, any primary or secondary industry or service occupation requiring an understanding of the pr i n c i p l e s of science or technology and the applica t i o n thereof, except where such i n s t r u c t i o n i s designed f o r un i v e r s i t y c r e d i t . This i s , quite appropriately, general and therefore allows fo r p r o v i n c i a l d i s c r e t i o n i n developing along l i n e s of demand. The t r a i n i n g offered i s l i m i t e d to a degree and applies only to a c e r t a i n type of l i v e l i h o o d * While choice wit h i n t h i s confine i s l i b e r a l , i t excludes many people who could take t r a i n i n g i n courses other than these. In one sense, the 3 provisions made for training are indeed good. In another sense, because we have l i t t l e other supplementary rehabilitation legislation, the total opportunities available to the Canadian citizen are very limited, especially as education for the many types of workers needed in the health f i e l d is s t i l l met primarily, i f not exclusively, out of provincial education budgets. Other forms of rehabilitation, even in the vocational f i e l d , must be developed before Canada can claim to have a truly comprehensive range of rehabilitation opportunities open to a l l who can qualify for them without prohibitive cost to the individual or the province. The Agreement spells out the major purpose. It i s , f i r s t , to enable federal-provincial cost sharing according to some uniform standard. Second, to meet the need for trained workers i n our increasing and dynamic technological society. Third, to aid the economy by increasing s k i l l s and knowledge on the labour force. Fourth, to meet the need of newly trained and retrained workers. F i f t h , to aid and encourage industry which is an important element of our economy and which, in turn, contributes toward development of manpower s k i l l s . Sixth, to assist i n the development and operation of programs for the training of manpower. A subsequent mention of the specific Programs w i l l show that these goals are being realized. Even so, the achievement of the proposed goals is insufficient i f these 4 goals are l i m i t e d i n scope. Thus, even though a program f u l f i l l s i t s intent, i t can s t i l l be lacking as a good public service. Coordination occurs on p r o v i n c i a l and federal l e v e l s separately as w e l l as p r o v i n c i a l - f e d e r a l j o i n t l y . I t operates on a base comparable to "cooperative Federalism" where a c t i v i t i e s are shared and delegated rather than proceeding according to a s t r i c t separation of powers. Governments have found t h i s acceptable and workable as long as there Is no confusion of residual powers and r e s p o n s i b i l i t i e s . Superior to the Vocational R e h a b i l i t a t i o n of Disabled Persons Act, the National Advisory Council, section 9 of t h i s Act, represents equally employers and employees with other interested sections of the community. P r o v i n c i a l advisory or consultive committees are mandatory. Representation permits a f a i r d i s t r i b u t i o n of labour, education, s o c i a l services, c i v i l i a n , and other interested groups. Training f o r which the federal government w i l l accept cost-sharing and the varying rates of the sharing are set f o r t h i n section 3 of the Act, but are made much clearer i n the iAgreement with i t s attached Schedules and Appendixes. Any cost that i s not specified under these subsections may f a l l under section 3, providing i t i s not an expenditure f o r which the federal government has outlined as not being a cost-sharing item. 5 B. The Programs (i) Program I, Vocational High School Training (V.H.S.) Courses given as part of the high school education in Ttfxieh the greater part of time is devoted to preparing the student for employment through technical, commercial and other vocational subjects are part of the program. The annual federal contribution does not exceed three million dollars with allotments of thirty thousand plus an extra adjustment based on the percentage of persons between the ages 15-19 i s paid to each province. In no instance is the federal share more than 50$ of t o t a l costs up to this maximum. The money is used at provincial volition but not for capital expenditures. I n i t i a l l y , provinces must submit for approval the l i s t of schools and courses that w i l l play a part i n the training. Excluded are courses that may be termed as general subjects or those that do not contribute toward the students future employment. The same criticisms of limited scope apply here. ( i i ) Program 2, Technician Training (T) It is possible under this cost-sharing scheme to take training at a post-High School stage i n the fields of science or technology and other related fields with emphasis on the application of such training. This does extend to training designed for university credit. The time and type of training may be long-term (three years), part-time, or $ by correspondence and may be preceded by advanced t h e o r e t i c a l and p r a c t i c a l t r a i n i n g . The t r a i n i n g possible can hardly be distinguished from regular university classes and there i s a lack of overt c r i t e r i a as to who can receive university credit under the program and who, even i f indigent, i s expected to sponsor h i s own education. Why un i v e r s i t y education i s included under t h i s section and not under others seems to be a matter of p r i v i l e g e . I t i s somewhat of a r a d i c a l advancement to o f f e r a u n i v e r s i t y type of education within r e h a b i l i t a t i o n programs. While t h i s i s to be advocated, e l i g i b i l i t y requirements should be more e x p l i c i t . In t h i s area i t i s not easy to separate a r i g h t from a p r i v i l e g e i n education and why the regular student pays h i s fees while the student of t h i s program has these extra advantages without there being d e f i n i t i o n of who i s to be accepted. In previous years the scope of t r a i n i n g on educational and professional le v e l s varied greatly from one Schedule to another. Since May, 1963, the Second Meeting of the National Advisory Council on R e h a b i l i t a t i o n of the Disabled, the provinces may, at t h e i r own d i s c r e t i o n , provide any type of t r a i n i n g that i s considered f e a s i b l e . 1 This permission places the provinces i n a p o s i t i o n where they have to decide what range of academic t r a i n i n g f or the disabled i s j u s t i f i e d . 1 Canada, National Advisory Council on R e h a b i l i t a t i o n of Disabled Persons, Second Meeting, Appendix C, National Coordinator's Report, May 13-14-, 1963, p. 1. 7 The d i f f i c u l t question remains as whether some types of d i s a b i l i t i e s are favored and whether the disabled receive better opportunities than the student who assumes r e s p o n s i b i l i t y f or financing h i s own education. 2 ( i i i ) Program 3, Trade and Other Occupational Training(T.O.) Cost-sharing of 50$ supports pre-employment t r a i n i n g , upgrading or r e t r a i n i n g f o r persons over the school age who have l e f t before elementary school but require such t r a i n i n g to develop or increase t h e i r competence. The effect of t h i s type of t r a i n i n g acts as an equalizer between the educated and the uneducated employee. That person who discontinues his education when i n grade school often ends up as a "common labourer". Modern trends In industry and commerce demand specialized t r a i n i n g . Through t r a i n i n g the employee can Increase not only his wage but h i s standard of l i v i n g and thus better meet the increased costs of a contemporary comfortable l i f e . As i s seen In Table V I I I t h i s program i s Important i f the amount spent Is any i n d i c a t i o n of the people served. There are thousands of employees who are w i l l i n g and able to improve t h e i r competencej t h i s program enables them to r e a l i z e t h e i r p o t e n t i a l . The nation as w e l l as the i n d i v i d u a l benefits from t h i s t r a i n i n g . * Writer's notes of meeting with P r o v i n c i a l Coordinator of R e h a b i l i t a t i o n , B r i t i s h Columbia, March, 1965. TABLE VIII Federal Payments and Program Breakdown Program 1961 - 62 1962 - 63 Vocational High School Training 1,927,453.03 1,901,569.88 Technician Training 3,351,895.85 5,766.622.60 Trade and Other Occupational Training 5,415,028.83 7,446,179.61 Training i n Cooperation With Industry 29,398.51 52,732.84 Training of Unemployed 3,451,554.41 6,760,901.90 Training of the Disabled 363,716.39 582,837.00 Technical and Vocational Teacher Training 212,595.69 191,332.75 Training Programs for Federal Departments 26,711.43 41,258.09 Student Aid 301,953.75 299,719.74 Apprentice Training 1,969,588.64 2,160,484.84 Source: Canada, Department of Labour, Annual Beports. 9 ( i v ) Program 4, Training i n Cooperation with Industry (T.I.) Training i n t h i s f i e l d i s undertaken and developed conjointly by the province and a p a r t i c u l a r industry. The federal government shares $0% of costs of the approved programs and, since February 1964, 75% of approved programs. This includes apprenticeship, supervisory and management. An employee may receive t r a i n i n g i f , f o r some reason, he cannot obtain such from an established shcool or other i n s t i t u t i o n . The t r a i n i n g applies d i r e c t l y to the employee's work p o s i t i o n - and.thus the theory and s k i l l s acquired have maximum p r a c t i c a l value. "Training on the job" opportunities are a very important source f o r disabled people, who often could not be placed i f some such plan were not a v a i l a b l e . Training i s , however, not uniformly available to a l l employees even though they may be i n s i m i l a r employment. Much rests on the employer, who may consider personal gain as a condition to employee advancement. There i s nothing to prevent an employer from refusing to p a r t i c i p a t e i f he receives no great return from entering into an agreement with the province. Since cooperation of the employer determines whether t h i s program w i l l be used, the decision rests i n the wrong hands as employee's decision to t r a i n i s contingent upon the pr i o r decision of his employer. The employee has no claim to u nfair treatment, he can only resign from h i s work though i t i s not e a s i l y done a f t e r roots have been established. 1G Either because the combination of a l l other programs i s quite i n c l u s i v e , or because employers are not w i l l i n g to involve themselves, t h i s resource has not been too a c t i v e . Table VII shows that spending under t h i s program has remained second lowest. (v) Program 5, Training of Unemployed (M) The federal government contributes 75% of costs for t r a i n i n g of the unemployed, and 90% of costs of allowances paid to unemployed persons while i n t r a i n i n g . The higher rate of contribution i s not surprising when considering that had not these persons accepted t r a i n i n g they might remain on public assistance or unemployment insurance, both of which i n v i t e s i m i l a r public spending. The National Employment Service recommends the trainee but the f i n a l s e l e c t i o n includes the decisions of p r o v i n c i a l r e h a b i l i t a t i o n o f f i c i a l s . Hours and content of t r a i n i n g programs vary. The p r o v i n c i a l advisory committee, representing employers, labour, and federal and p r o v i n c i a l governments, w i l l advise on the kind of t r a i n i n g needed, the nature and length of the courses offered• Apart from the issue of whether the unemployed employable has employment p r i o r i t y over the unemployed disabled, the employable can be returned to work faster and with less cost. The stigma attached to the i d l e able-bodied person may not be as great an incentive to employment as t r a i n i n g 11 which w i l l make h i s labour more productive, perhaps more in t e r e s t i n g , under improved conditions, and y i e l d a humane l i v i n g wage. Training-on-the-job may be arranged f o r trainees. The employer stipulates the conditions of t r a i n i n g and submits regular reports to the province. E s p e c i a l l y for people who, for any reason, cannot take the time or afford the money to discontinue work to accept t r a i n i n g , t h i s offers an excellent opportunity. Arrangements are usually made to maintain the employee's wage while h i s t r a i n i n g continues, with the employer contributions on a percentage or scale basis• Relating t h i s to s i m i l a r arrangements for the disabled person, training-on-the-job precautions need be taken against errors mentioned by Linden. Thus, although i n some circumstances the type of l e g i s l a t i o n (to compel! employers to hire a percent of disabled persons on s t a f f ) may be required i n order to secure some work for disabled people who could not otherwise be employed, i t should be used sparingly and c a r e f u l l y . I t Is recognized that where a disabled person i s unable to compete with other workers i n a given task, i t might be preferable to pay him a smaller hourly wage and keep him working than ( s i c ) to require equal pay which would necessitate his dismissal. However, i t must be made clear that disabled people mut not be exploited merely because they are handicapped where they are able to do the job s a t i s f a c t o r i l y . Where v a r i a t i o n from minimum wages are necessary i t should be done only with safeguards f o r the disabled person.l A, M. Linden, "Labour L e g i s l a t i o n and the Disabled 1*, Material submitted to the Canadian R e h a b i l i t a t i o n Council f o r the Disabled, p. 7. 12 While disagreeing with the enforced employment of the disabled, the handicapped or untrained person should always be protected from e x p l o i t a t i o n * I t i s recommended that persons, whether i n t r a i n i n g or employed, when s t i l l p a r t i a l l y disabled, be assured of a minimum wage. This minimum should be the same as that of the general wage structure, and under certain circumstances where i t i s lower i n the case of a severe d i s a b i l i t y , there should be careful safeguards against e x p l o i t a t i o n . This i s a question that recurs with increasing fervor i n r e h a b i l i t a t i o n c i r c l e s . It i s s t i l l debated and never appears to have been s e t t l e d to the point where i t i s possible to say there i s a majority or a minority opinion for or against i t . Part of the d i f f i c u l t y i s that some disabled people want to work and are w i l l i n g to accept lower rates than the minimum wage because they are conscious of the fact that t h e i r production, or at least t h e i r agile pace, i s slower i n comparison to the non-disabled worker performing the same Job. Under t h i s program a minimum wage i s assured, with employers being reimbursed on a " s l i d i n g - s c a l e " rate which is separately negotiated i n each instance depending on the l i m i t a t i o n of the employee.^ (vi) Program 6, Training of the Disabled (R) This program, s p e c i f i c a l l y , l i n k s the Technical and ^ G. A. Roeher, "Progress and Needs of R e h a b i l i t a t i o n i n Canada", R e h a b i l i t a t i o n and World Peace, (ed.) E.J. Taylor, New York, International Society for R e h a b i l i t a t i o n of the Disabled, 8th World Congress, I960, p. 67. 13 Vocational Training Assistance Act with the physically disabled person and therefore with the Vocational R e h a b i l i t a t i o n of Disabled Persons Act. I t outlines the terms and conditions under which disabled persons receive the vocational t r a i n i n g . The physically handicapped person may receive assessment counselling, and physical r e h a b i l i t a t i o n under the Vocational R e h a b i l i t a t i o n of Disabled Persons Act, but the actual vocational t r a i n i n g for most people f a l l s under t h i s program. Here the two Acts complement one another. Placement of the r e h a b i l i t a t e d person i n suitable employment i s the r e s p o n s i b i l i t y of the Special Placement Section of the National Employment Service. This department operates under the authority of the Unemployment Insurance Act, Part 11, 1955. 1 The work of the Special Placement Section i s closely co-related with r e h a b i l i t a t i o n agencies and, though p o l i c i e s may vary from province to province with regard to c r i t e r i a of actual placement, the service i s a v i t a l part of r e h a b i l i t a t i o n . The f e d e r a l government shares 50% of the cost of t r a i n i n g for those selected by the p r o v i n c i a l s e l e c t i o n committee. Without prior approval, t r a i n i n g may not exceed two years but within t h i s period i t may take next to any form, including training-on-the-job. Such t r a i n i n g i s subject to the same 1 The National Coordinator's submission for "Study on Le g i s l a t i v e and Administrative Aspects of R e h a b i l i t a t i o n of the Disabled i n Selected Countries", New York, United Nations, 1964. 14 comments as i n the previous section. There seems to be some discrepancy between t r a i n i n g of the unemployed and t r a i n i n g of the disabled. In the f i r s t category the federal government accepts cost-sharing of 7% and 90$ of expenditures whereas, and perhaps for sim i l a r t r a i n i n g , only 50% of p r o v i n c i a l expenditures f o r the disabled. Nor does the difference i n federal rates account e n t i r e l y f o r the large difference i n the t o t a l money spent annually on these two programs. (See Table V I I I ) . The f i r s t of these two arguments indicates that the unemployed receive more support than the disabled and the federal government does not concentrate s u f f i c i e n t l y on d i s a b i l i t i e s . The second argument of t o t a l annual expenditures indicates that the provinces are f a l l i n g into the same er r o r . I f there are more disabled people i n Canada than unemployed, i t would be assumed that, receiving equal r e h a b i l i t a t i o n opportunities, the expenditures f o r t r a i n i n g of the disabled would be higher than f o r the unemployed. Furthermore, because of the d i s a b i l i t y , per capita t r a i n i n g costs f or t h i s group would be much higher than for the unemployed. ( v i i ) Program 7j Technical and Vocational Teacher Training (T.T.) It follows that i f adequate t r a i n i n g services are desirable, there must be provision made to t r a i n the s t a f f that provides the service. Each province and t r a i n i n g 15 i n s t i t u t i o n decides what quality of service w i l l be extended to the trainee by set t i n g standards of i n s t r u c t i o n and determining the q u a l i f i c a t i o n s of the teaching s t a f f . The schedule makes possible the r e a l i z a t i o n of these di f f e r e n t and numerous p r o v i n c i a l t r a i n i n g courses. ( v i i i ) Program 8, Training Programs for Federal Departments and Agencies (G) Training f o r members of the Armed Services or for t r a i n i n g f o r employment i n a federal government department w i l l be paid f o r up to 100% of the t o t a l cost of that t r a i n i n g . Those joining the Armed Forces i n Canada do so v o l u n t a r i l y , they can make i t t h e i r career and receive just wages. I f they require vocational or other r e h a b i l i t a t i o n t r a i n i n g , there i s no reason for them to have any advantage over any other c i v i l i a n person. ( i x ) Program 9, Student Aid (S.A.) P r o v i n c i a l aid to a s s i s t u n i v e r s i t y students and nurses may be given as a grant, a loan, or a combination of both, and the federal government w i l l reimburse 50% of these costs. The amount of and purpose for t h i s assistance i s determined by the province. I t i s not clear how t h i s program i s to operate i n conjunction with the functions of the Department of Education. Also confusing i s what c r i t e r i a i s used to determine who may 16 receive t h i s a i d . There must be a d i v i d i n g l i n e between the e l i g i b l e and the i n e l i g i b l e and there i s danger of unfairness to those grouped near t h i s marginal l i n e . (x) General Provisions under the Agreement Arrangements, separate and i n addition to the Schedules, may be entered into i n order to i n i t i a t e correspondence courses i n technical and vocational areas. Provinces, however, must make such courses available even to non-residents of the province at rates charged i t s own residents• Contrary to other s t i p u l a t i o n s , under certain circumstances the federal government w i l l accept cost-sharing for c a p i t a l expenditures and t r a i n i n g f a c i l i t i e s . This i s an encouraging po s i t i v e step which aids i n t r a i n i n g f a c i l i t i e s including buildings, physical equipment, machinery and other physical needs f o r t r a i n i n g . C a p i t a l expenses cover costs of approved construction, pruchase, addition or a l t e r a t i o n of buildings or physical plant, but excludes purchase of land, taxes, l e g a l fees, f a c i l i t i e s f o r I n d u s t r i a l Arts classes, and costs r e s u l t i n g from damage to property. A l l projects of t h i s nature where cost-sharing may occur requires the p r i o r approval of the Mi n i s t e r . The Minister may reject any project and there i s no appeal. On the other hand, he cannot impose any changes on the projects presented f o r approval* Especially i n t h i s respect, t h i s Agreement i s much 17 more adapted to expanding r e h a b i l i t a t i o n services than i t s counterpart under Vocational R e h a b i l i t a t i o n of Disabled Persons. Several minor, but no less important, sections deal with the National Advisory Council which i s to advise i n matters pertaining to t r a i n i n g Canada's manpower. The Council's consultative a c t i v i t y can be of value i n d i r e c t i n g the r e h a b i l i t a t i o n and t r a i n i n g programs. This e f f o r t , combined with coordination, can influence the quality of r e h a b i l i t a t i o n through analysis of courses taught, study of needs, providing information, and giving advice. Provinces agree to p u b l i c i z e t h e i r t r a i n i n g programs. An awareness of a public sercice i s not only a determinant of i t s use but, being a public service, i t i s a right to be informed. Needed i s s p e c i f i c information of the d i f f e r e n t kinds of t r a i n i n g available so that the p o t e n t i a l c l i e n t can select by comparison and that which i s most appropriate to his own p a r t i c u l a r case. This p u b l i c i t y must make mention of the role played by the federal government. This i s presumably so that the c l i e n t , as tax payer, w i l l know that the federal government i s Interested enough to spend money i n t h i s area. The federal government also provides occupational t r a i n i n g information to be d i s t r i b u t e d throughout secondary schools and other t r a i n i n g i n s t i t u t i o n s . E a r l i e r information may supply continuity of vocational preparation u n t i l vocational "establishment" i s attained and perhaps i n t h i s way, 18 at an e a r l i e r age, help curb " d r i f t i n g " into "dead-end" jobs. C. General Conclusions In some instances the Agreement i s e x p l i c i t as to what costs w i l l be shared, but no mention i s made whether maintenance of the c l i e n t includes that of h i s family and dependence. Even i f the t r a i n i n g f a c i l i t i e s are comprehensive for the vocationally handicapped person, he cannot accept t h i s t r a i n i n g i f t h i s means leaving behind a destitute family. The t o t a l provisions possible under the Acts mentioned comprise a reasonably good range of vocational t r a i n i n g and some physical r e h a b i l i t a t i o n . However, they do not provide for meeting the general need f o r developing new services or expanding ex i s t i n g ones. P r o v i n c i a l governments tend to regard assured f i n a n c i a l p a r t i c i p a t i o n by the federal government as a condition precedent to establishing new tr a i n i n g and r e h a b i l i t a t i o n f a c i l i t i e s , when these are the very areas i n which the federal government offers least assistance. This expectation and possibly reliance on the part of the p r o v i n c i a l governments when support i s not forthcoming, hinders new developments and expansion of services so that the lag between service and needs may tend to increase. Dunlop has three major c r i t i c i s m s of these Acts, which are summaries of what has already been pointed out while s p e c i f i c sections of the Acts were reviewed. 1 1 Edward Dunlop, "Rehabilitation for the Disabled i n Canada", Toronto, September 1958. Writing based on working papers prepared for the National Advisory Committee on the Re h a b i l i t a t i o n of Disabled Persons, p. 19. 19 1 P r o v i n c i a l governments have no assurance that federal support w i l l continue at the same rate, nor have they any assurance they w i l l receive adequate help i n development of new programs. 2 In many instances the conditions of cost sharing i s vague and there i s no clear-cut statutory authority delineating the s p e c i f i c services, the costs that are shareable, nor the conditions under which they w i l l be shared. 3 There i s not only divided administrative r e s p o n s i b i l i t y and authority on the federal l e v e l , but also confusion on the f e d e r a l -p r o v i n c i a l l e v e l . Since t h i s was wri t t e n , some changes have been made, especially i n o u t l i n i n g short-term cost-sharing and under what conditions they w i l l be shareable. At the same time much confusion remains and no conclusive decisions have been made on what government w i l l be responsible for each part i n the t o t a l of r e h a b i l i t a t i o n . Throughout the review of the Acts and Agreements the observation that the c l i e n t has no recourse from the decisions of o f f i c i a l s responsible f o r the programs has been made. Since there i s no o f f i c i a l allowance for appeals, t h i s i s a basic lack i n a democratic country. I t i s a p r i n c i p l e of English law that the c i t i z e n should always have a l e g a l remedyj t h i s the Acts f a i l to provide. In t h i s view, i t could be argued that the omission i s a v i o l a t i o n of the Canadian B i l l of Rights. In the increasing bureaucratic tendencies of modern s o c i e t i e s , i t i s more than ever necessary that a l e g a l 20 recourse of some kind be provided. Many suggestions have been made as to the best way of s t a r t i n g an ef f e c t i v e system of appeal« The Scandinavians have r e l i e d on the use of ombudsmen, while the French, with t h e i r " c o n s e i l " approach are said to have the most ef f e c t i v e recourse system of a l l . This lack i n the Canadian system deserves deep consideration. As seen i n Table VI, r u r a l i n a c c e s s i b i l i t y i s s t i l l a serious problem. While many disabled persons may move to urban centers to better care for themselves, there remain many disabled i n the r u r a l areas that are neglected. These people must cry out to receive recognition, yet t h e i r residence should not place an ad d i t i o n a l hinderance i n t h e i r path toward improvement„ More generous provisions should be made for these people, even i n the form of h a b i l i t a t i o n so that they may remain where they are. In t h i s respect, homebound services and other modes of r e h a b i l i t a t i o n , other than s t r i c t l y employment, would serve a great need. Drawing most of the comments to t h i s section of the study together, one could state that Canada has a very good r e h a b i l i t a t i o n program for physical treatment and vocational t r a i n i n g . Considerations f o r including the disabled's s o c i a l and personal needs are being slowly incorporated into the general program, but are s t i l l lacking i n scope. A t r u l y comprehensive r e h a b i l i t a t i o n program would need to have greater awareness of the p a r t i c u l a r needs and values of the 21 individual. In rehabilitation, we can successfully return to employment many disabled people, but the conditions of acceptance should be the possibility of a more meaningful l i f e for the disabled rather than only financial independence through employment. 22 BIBLIOGRAPHY Bodlak, Stanley. D i s a b i l i t y Allowance. Master of S o c i a l Work Thesis, University of B r i t i s h Columbia, Vancouver,B.C.,1957• Bradbury, W . and Hatcher, F. Interview with w r i t e r , March 1965. Canada, Department of National Health and Welfare. Research and S t a t i s t i c s D i v i s i o n . R e h a b i l i t a t i o n Services i n Canada. Part I . Health Care Series Memorandum No.8, Ottawa, March, I960. Canada, Statutes. Disabled Persons Act. 1953*-54, c.55j as amended by 1957, c. 14; 1957-587 c . 5 ; 1962, c.3? 1963, c. 26. Canada, National Coordinator's Report. National Advisory Council on R e h a b i l i t a t i o n of Disabled Persons, Second Meeting, Appendix C. 13-14 May 1963. Canada, National Coordinator's Submission f o r the United Nations' Study on L e g i s l a t i v e and Administrative Aspects  of R e h a b i l i t a t i o n of the Disabled i n Selected Countries. Department of Economic and S o c i a l A f f a i r s , New York, United Nations, 1964. Canada, Royal Commission on Health Services. Ottawa, Queen's P r i n t e r , Vol.1 1964. Canada, Statutes. Technical and Vocational Training Assistance Act. 1960-61, c. 6. Canada, Statutes. Vocational R e h a b i l i t a t i o n of Disabled  Persons Act. 1960-61, c. 26. 23 Dunlop, Edward. R e h a b i l i t a t i o n f o r the Disabled i n Canada. Toronto, September 1 9 5 8 . W r i t i n g based on working papers prepared f o r the National M v i s o r y Committee on the R e h a b i l i t a t i o n of Disabled Persons. E l a r t , A l i c e . Speaking on A Comprehensive Workshop - The  Goodwill Approach at Annual Meeting of Vancouver D i v i s i o n f or Guidance of the Handicapped, 29 March, 1965. Kessler, Henry. R e h a b i l i t a t i o n of the P h y s i c a l l y Handicapped. New York, Columbia University Press, 1947. Linden, A. M. Labour L e g i s l a t i o n and the Disabled. M a t e r i a l submitted to the Canadian R e h a b i l i t a t i o n Council for the Disabled• Marsh, L. C. " S o c i a l Security Planning i n Canada." International Labour Review. V o l . 47. Roeher, G. A. "Progress and Needs of R e h a b i l i t a t i o n i n Canada". R e h a b i l i t a t i o n and World Peace. Ed. E.J. Taylor. New York, International Society f or R e h a b i l i t a t i o n of the Disabled, I 9 6 0 . SECTION IV PROFILE OF REHABILITATION SERVICES IN A PARTICULAR PROVINCE - BRITISH COLUMBIA i TABLE OF CONTENTS Page British Columbia - Background Factors 2 General Provincial Legislation as 5 i t affects the Disabled The use of the Coordinator of Rehabilitation 5 of Agreement Act i n British Columbia The Role of the Provincial Division of Rehabilitation 7 The Role of the Provincial Coordinator $ Experiments i n Coordination i n i t i a t e d by the 10 Coordinator's Office Establishment of Local Community Rehabilitation Councils 12 Observations on the use of these Coordinating Devices 17 The Disabled Persons Allowance Act as interpreted i n 19 Bri t i s h Columbia The Vocational Rehabilitation of the Disabled Act 27 The Technical and Vocational Training Act Use of the Hospital Insurance and Diagnostic Services Act 33 Use of Federal Grants 33 Provincial Services for Specific Categories 39 Mentally 111 40 Services to Children 45 Role of the Voluntary Agency 55 G.F. Strong Rehabilitation Centre 55 Canadian Arthritis and Rheumatism Society 63 Paraplegic Association 68 Poliomyelitis and Rehabilitation Society 74 Geriatric and Chronic Services 80 Division for the Guidence of the Handicapped of the Community 86 Chest and Council Summary and Conclusions 93 X 1 CHAPTER X PROFILE OF A PROVINCE Patterning of Services i n British Columbia with Special  Reference to the Legislative Base As previous sections of the study hav indicated, the function of federal aid is to assist the provinces to carry out their responsibilities i n the fields of health, education and welfare, a l l of which areas are concerned to some degree with services which come within the rehabilitation f i e l d . Many factors enter into a consideration of whether a province has an adequate social policy towards the disabled and how much continuity or change i n this policy might be detected, depending on which p o l i t i c a l party was i n power. This section attempts to do no more than make a beginning review of the effects which the present legislative structure for the division of responsibilities in Canada would seem to have on the patterning and provisions of services at the provincial and local level, where they are or should be available to the individual Canadian who needs them. Long before the federal government extended aid to the provinces i n these three f i e l d s , each province, under the British North America Act had made its own interpretation X - 2 of its responsibilities i n these fields and had developed its own unique pattern of services. The patterns developed in British Columbia were influenced by many factors, some of which w i l l be briefly reviewed. British Columbia - Some Background Factors British Columbia is Canada's westernmost province, reaching from the Rockies to the Pacific and from the American broder to the Yukon. Early i n the development of British Columbia, more than mountains separated i t from Canada. Until 1871 the province was a Crown Colony and only reluctantly gave up its status i n exchange for the promise of a railway which would open up an area which already had seen one gold rush and was yet to see another. In 1871 British Columbia had an estimated population of 36,247. A l l but between 8,500 and 9,000 of these souls were Indians. In the last 1961 census B.C. had a population of 1,629,082 ( i t is now estimated at 1,738,000 for 1964). Of this number 38,814 are Indian and Eskimo. Most of the population is squeezed into the south western portion of the province in the delta of the Fraser River. Vancouver, the third largest city in Canada and the only large Canadian port on the Pacific coast, had a metropolitan population of 790,165 in 1961; Victoria, the X - 3 the second largest city i n B.C., had 154,152. Vancouver's population is 4 8 . 5 $ of the total with Victoria 9.5$ of the total. Together, these urban areas make up almost 60$ of British Columbia's population. This is a different population distribution form than that of its two neighbouring provinces of Alberta and Saskatchewan and has had considerable effect on the patterning of services. Although British Columbia has an area of 366,255 square miles and the third largest provincial area in Canada, many of these miles represent mountain tops. It has been variously estimated that between less than 10 to 20$ of the land is usable, although there i s untold mineral wealth, as yet largely undeveloped. Certainly much of i t is vast mountain tracts of forest with the exception of the Great Interior Plateau with its f e r t i l e Okanagan Valley and the Peace River d i s t r i c t further north. While i t might be over-simplifying, one has only to leave the Fraser River Valley behind to have a sense of the primeval spendour that is s t i l l B r i t i s h Columbia. And one does not need to go beyond one's front door step to sense the s p i r i t of a frontier society with its emphasis on individualism, innovation and an isolated approach to situations which seems as characteristic i n rehabilitation as in other areas of civic responsibility. While the growth of secondary industries i n the province looks impressive from the latest s t a t i s t i c s , the main industries are s t i l l the X - 4 primary ones of logging, mining and f i s h i n g , and from the point of view of r e h a b i l i t a t i o n there are s t i l l far too few available jobs that can be c l a s s i f i e d as of a " l i g h t " or "sedentary" nature. B r i t i s h Columbia has a plethora of services offered by both government and voluntary agencies, most of them located w i t h i n the lower mainland area. In Vancouver alone, there are more than eighty agencies i n the Vancouver Community Chest and Council. General P r o v i n c i a l L e g i s l a t i o n as i t Affects the Disabled There i s need for a s p e c i f i c study of the general p r o v i n c i a l l e g i s l a t i o n as i t affects the disabled. There has been some concern expressed that p r o v i n c i a l labour l e g i s l a t i o n discriminates against the disabled. A separate study would seem to be indicated to investigate t h i s area. While the general p r o v i n c i a l taxation l e g i s l a t i o n does allow some concessions to the disabled, the picture i n t h i s area would appear to be s i m i l a r to what the Canadian R e h a b i l i t a t i o n Council f o r the Disabled study found to be true at the Federal l e v e l - that the (provincial) "government w i l l help some of the disabled i n some ways some of the time." An example of t h i s inconsistency may be given here. Under the Motor Vehicle Act and the Gasoline Tax Act, c e r t a i n "categories" x 5 of disabled, such as paraplegics, amputees and those confined to wheelchairs may claim exemption from automobile and gasoline taxation. However, the exemption does not cover a l l handicapped people who cannot use public transportation. The provincial government extends aid to the disabled in four additional ways. It ut i l i z e s federal provincial legislative agreements to help provide certain services. It takes direct responsibility for certain services and groups. It extends financial aid to some voluntary societies i n the rehabilitation f i e l d and sometimes purchases their services. It delegates certain responsibilities to the municipalities and offers varying kinds of assistance to them to carry out their designated responsibilities, especially i n relation to what are usually called the "welfare services" some of which, as has been seen, have a direct bearing on rehabilitation. It is proposed to select certain aspects of these services to examine the prevailing Canadian division of legislative responsibilities and how i t affects patterns i n rehabilitation services i n British Columbia. It is appropriate to begin with the u t i l i z a t i o n and interpretation of federal legislation pertaining to rehabilitation by the province. Use of the Coordination of Rehabilitation Agreement Act in British Columbia. X - 6 In 1953 federal funds were made available to the provinces through t h i s Act to pay for the services of a p r o v i n c i a l co-ordinator and his s t a f f on a f i f t y - f i f t y basis. In A p r i l 1954, B r i t i s h Columbia signed the Co-ordination of R e h a b i l i t a t i o n Agreement to qualify f o r federal assistance. The i n i t i a l agreement, which ran to 1958, was signed for a s i x year period to March 1964, and has now been re-signed to 1970. Under the terms of t h i s agreement the province agreed to appoint a P r o v i n c i a l Co-ordinator of R e h a b i l i t a t i o n , to e s t a b l i s h an interdepartmental r e h a b i l i t a t i o n committee and to develop a coordinated p r o v i n c i a l plan which w i l l " c l a r i f y and coordinate the role of a l l aspects of r e h a b i l i t a t i o n , including Vocational Training Placement Services as w e l l as the service provided under National Health Grant Program".^ Federal-provincial funds can be used to pay for s t a f f i n g of the Coordinator's o f f i c e f or s t a f f t r a i n i n g , for research and demonstration projects and f o r "expenses incurred on behalf of disabled individuals f o r r e h a b i l i t a t i o n services not otherwise available under the Vocational Training Co-ordination Act, Federal Health Grants or l o c a l p resources." 1 R e h a b i l i t a t i o n Services i n Canada. Part 1. General Review Health S e r i e s , No. 8, Research and S t a t i s t i c s D i v i s i o n Dept. of National Health and Welfare, March I960, p. 30. L o c . c i t . X - 7 In September 1954 the p r o v i n c i a l coordinator was appointed and the newly set up D i v i s i o n of R e h a b i l i t a t i o n was attached to the Health Branch of the P r o v i n c i a l Department of Health Services and Hospital Insurance. The R e h a b i l i t a t i o n D i v i s i o n i s administered through the Bureau of Special Preventative and Treatment Services. There i s an Assistant P r o v i n c i a l Health O f f i c e r d i r e c t i n g the Bureau who i s a doctor and who i s responsible for the broad co-ordination of the P r o v i n c i a l Health Units as w e l l as other governmental departments concerned and the work of voluntary health agencies, both i n l o c a l and province-wide f i e l d s . The Co-ordinator of R e h a b i l i t a t i o n , who i s under the d i r e c t o r , works closely with him to provide f o r the bringing of vocational services to the handicapped. In addition the Registry of Handicapped Children and Adults i s under the administration of the Bureau. These offices are i n a building w i t h i n the complex of buildings surrounding Vancouver General Hospital, and therefore, t h e o r e t i c a l l y at l e a s t , e a s i l y accessible to doctors and public a l i k e . The Role of the P r o v i n c i a l D i v i s i o n of R e h a b i l i t a t i o n This i s o f f i c i a l l y defined i n i t s own policy manual as follows: 1. Consultation i n the f i e l d of vocational r e h a b i l i t a t i o n t o : X - 8 a. l o c a l r e h a b i l i t a t i o n committees; b. public and private medical, s o c i a l and vocational agencies. 2. Administration of regulations concerning vocational r e h a b i l i t a t i o n under the Disabled Persons Act. 3. Development of standards i n r e h a b i l i t a t i o n services and f a c i l i t i e s . 4. Co-ordination of a l l a c t i v i t i e s i n the province r e l a t i n g to vocational r e h a b i l i t a t i o n of disabled persons. 5. Compilation of reports and s t a t i s t i c s concerning vocational r e h a b i l i t a t i o n . 6. Development of educational programs i n rehab-i l i t a t i o n f o r professional community and other groups. The Role of the Coordinator A broad d e f i n i t i o n of his role i s stated as follows: "To act as a consultant on problems of r e h a b i l i t a t i o n of individuals and to coordinate a l l departments and agencies p working i n the r e h a b i l i t a t i o n f i e l d . " It i s the p r o v i n c i a l r e s p o n s i b i l i t y of the co-ordinator to create a broad co-operative program with the p r o v i n c i a l Departments of S o c i a l Welfare, Education, and the Federal Departments of 1 B r i t i s h Columbia, "Manual for Vocational R e h a b i l i t a t i o n i n B r i t i s h Columbia," D i v i s i o n of R e h a b i l i t a t i o n , Health Branch, Department of Health Services and Hospital Insurance, Vancouver, p. 6. 2 Directory of Health. Welfare and Recreation Services i n  Metropolitan Vancouver, prepared and issued by the Community Chest and Council of Greater Vancouver, 1958, p. 24. X-9 Health and Labour as well as the National Employment service, in order to administer the Vocational Rehabilitation of Disabled Persons Act and the agreement signed. Co-ordination on a policy-making level is done through an interdepartmental committee which includes the Deputy of Ministers of the Health and Social Welfare branches, the Department of Education, Department of Labour, the Chairman of the Workmen's Compensation Board and the Provincial Secretary. The Health Branch Program is primarily geared to the vocational rehabilitation of the handicapped; however, the disabled can be rendered any service which w i l l result i n improved self-care and thus better social functioning. The Co-ordinator of Rehabilitation, who provides for the use of services by payment, must give approval before any rehabilitation services w i l l be paid for. He functions somewhat in the role of agent on behalf of those disabled people who are accepted for service. Although clients may not be seen by the Co-ordinator, he functions on their behalf, following up on the treatment processes through reports and carrying through financially u n t i l a case is closed, either through vocational rehabilitation, or through achievement of increased self-care and improved functioning. So although the emphasis is l a i d upon vocational i&abilitation in the legislation, this has not prevented a broad interpretation of the Coordinator's r o l e with emphasis on his power to authorize "expenses incurred on behalf of disabled individuals . . • not otherwise a v a i l a b l e . " Improved functioning and greater capacity for independence may be of as much importance to the i n d i v i d u a l . In other areas of the province screening w i l l increasingly be done through the l o c a l r e h a b i l i t a t i o n committees being set up through out the province. Experiments i n Coordination I n i t i a t e d by the P r o v i n c i a l Coordinator In February 1959, the Coordinator's Office and the National Employment Service commenced an experimental program to provide a steady contact between the l o c a l and regional o f f i c e s of the National Employment Service and the Co-ordinator's O f f i c e . As t h i s resulted i n improved co-ordination, a senior placement o f f i c e r of the National Employment Service's S p e c i a l Placement Section, was seconded to the Co-ordinator's O f f i c e to provide consultative services to both o f f i c e s and to help i n the improvement of job-placing services f o r those who are handicapped. 1 He regularly handles a l l r e f e r r a l s from the Vancouver General Hospital regarding academic up-gradings, r e - t r a i n i n g under the Vocational Training Agreement or those disabled x B r i t i s h Columbia, Department of Health and Unemployment Insurance Public Health Services Annual Report, V i c t o r i a , 1961, p. U 112. X - l l who are ready for job placement. This also includes any of the h o s p i t a l s ' patients who are to be referred to other agencies f o r vocational r e h a b i l i t a t i o n such as the P o l i o m y e l i t i s and R e h a b i l i t a t i o n Foundation or the Canadian Paraplegic Association. The h o s p i t a l f a c i l i t a t e s the r e f e r r a l of the disabled person through i t s r e h a b i l i t a t i o n conference set up by the hospital's S o c i a l Service Department. This conference meets twice monthly to discuss cases. Present when possible i s the patient's doctor. Present also i s a representative of the Co-ordinator's O f f i c e , and the Supervisor of the Out-Patient Department. I t i s the r e s p o n s i b i l i t y of the patient's s o c i a l worker to have written up the s o c i a l h i s t o r y , obtained the medical history from the doctor i n w r i t i n g and, i f required, a psychiatric and psychological evaluation from the Department of Psychiatry i n order to guage the patient's motivation, tolerance, p o t e n t i a l i n t e l l i g e n c e and i n t e r e s t s . The s o c i a l worker also presents: the case at the conference. I f the patient i s accepted by the Co-ordinator's Office and there s t i l l needs to be further vocational assessment which cannot be performed by the h o s p i t a l , the Co-ordinator 1s Office can buy these services elsewhere. For instance, there i s the P o l i o m y e l i t i s and R e h a b i l i t a t i o n Foundation Assessment Centre or the Youth Counselling Services which also give vocational assessment and counselling although t h e i r services are d i f f i c u l t f or the X - 12 physically handicapped to gain physical access to, as they are i n a downtown building on an upstairs f l o o r . A close l i a i s o n i s being maintained with various community agencies on a two-fold basis, to offer, i n d i r e c t l y through co-ordination, required r e h a b i l i t a t i o n services to the handicapped and to seek out and u t i l i z e the services available i n order to help i n d i v i d u a l disabled persons who seek help through the p r o v i n c i a l r e h a b i l i t a t i o n department. Demonstration Projects i n Establishment of Local Community  Re h a b i l i t a t i o n Councils. In i960 a p i l o t study was undertaken by the P r o v i n c i a l R e h a b i l i t a t i o n Consultant of the Co-ordinator*s Office to see i f handicapped people and individuals i n receipt of welfare allowances could become self-supporting. This project, shared between the S o c i a l Welfare Branch and the Health Department and supported by National Health Grant Funds, u t i l i z e d the l o c a l National Employment Service. From a t o t a l of 375 cases 167 were i d e n t i f i e d as having health problems; 48 of these people were selected to demonstrate the p o s s i b i l i t y of r e h a b i l i t a t i v e procedures. A year l a t e r , i n 1961, 26 of the 48 cases had either been r e h a b i l i t a t e d or were i n the process; the remaining 22 were found unsuitable for a r e h a b i l i t a t i o n program.1 1 B r i t i s h Columbia, Public Health Services, Annual Report of the Department of Health and Unemployment Insurance, V i c t o r i a , 1961, p. U 113 X - 1 3 As a consequence of t h i s study, i n Nanaimo, a further p i l o t demonstration was set up i n Chilliwack u t i l i z i n g the procedures and methods of the Nanaimo study. A program devoted to s e t t i n g up l o c a l r e h a b i l i t a t i o n teams has been undertaken by a research consultant o r i g i n a l l y on the t r i a l project and now seconded to the Co-ordinator fs Office to effected a co-ordinated approach i n the development of a program for vocational r e h a b i l i t a t i o n . The procedures set up were workable. Three add i t i o n a l committees were set up i n other communities using the same procedures, under the consultative services of the D i v i s i o n of R e h a b i l i t a t i o n i n Vancouver. 1 During 1964 they provided vocational r e h a b i l i t a t i o n services to 214 cases and 31 were placed i n employment during the year. Five new l o c a l r e h a b i l i t a t i o n committees were established during 1964 throughout the province to undertake vocational r e h a b i l i t a t i o n planning; so with a t o t a l of eight l o c a l active committees, there were 278 cases under assessment for vocational r e h a b i l i t a t i o n through the l o c a l organizations set up. Organization of the Local R e h a b i l i t a t i o n Committees Administratively the r e h a b i l i t a t i o n committees on a l o c a l l e v e l w i l l function w i t h i n the e x i s t i n g Health Unit 1 Unpublished report of Mr. F. Hatcher. X - 1 4 areas of the P r o v i n c i a l Health Department u t i l i z i n g the resources of other p r o v i n c i a l government departments on a l o c a l l e v e l , such ass S o c i a l Welfare, Education and the National Employment Service. In i t s manual, "Vocational R e h a b i l i t a t i o n i n B r i t i s h Columbia" the p o l i c y i s l a i d down that the Health Unit Director, the D i s t r i c t Supervisor of Welfare and the Special Services o f f i c e r or l o c a l manager of National Employment Service form a committee. The Health Unit Director has administrative r e s p o n s i b i l i t y for the continuing work of the committee on the l o c a l l e v e l . 1 The purpose of the Local R e h a b i l i t a t i o n Committee i s t o : Select and screen possible r e h a b i l i t a t i o n cases. Effect the establishment of comprehensive r e h a b i l i t a t i o n assessment and evaluation. Co-ordinate services i n r e h a b i l i t a t i o n planning, case a c t i v i t y and handling. Determine the requirements for vocational r e h a b i l i t a t i o n and physical restoration. Use consultative and s p e c i a l r e h a b i l i t a t i o n -services through the D i v i s i o n of R e h a b i l i t a t i o n . Referrals w i l l come from h o s p i t a l s , private doctors, the Medical Health o f f i c e r or h i s s t a f f , the Registry, l o c a l S o c i a l WelfareJServices, l o c a l National Employment Services, 1 B r i t i s h Columbia, Manual for Vocational R e h a b i l i t a t i o n i n B r i t i s h Columbia, D i v i s i o n for R e h a b i l i t a t i o n , Health Branch, Department of Health Services and Hospital Insurance, Vancouver, January 1965, p. 2. 2 L o c . c i t . community agencies and i n d i v i d u a l s . It i s hoped through these measures to provide early r e h a b i l i t a t i o n services before f i n a n c i a l and emotional resources are so depleted that a person becomes chronically dependent and unable to emotionally participate i n a r e h a b i l i t a t i o n program. The Local Committee on R e h a b i l i t a t i o n , once a r e f e r r a l i s made, w i l l decide upon the f e a s i b i l i t y of service after a medical, s o c i a l and vocational assessment. When a person i s accepted the committee can then, on a continuing basis, help the i n d i v i d u a l achieve h i s goal of vocational r e h a b i l i t a t i o n through a continuity of planning. I t i s hoped that each l o c a l committee w i l l help f i f t e e n handicapped people i n a year to achieve employment with another f i f t e e n cases benefitting from vocational r e h a b i l i t a t i o n procedures. The expectation i s that approximately 225 cases w i l l be helped to employment each year through the a c t i v i t i e s of the l o c a l r e h a b i l i t a t i o n committees. This may, of course, vary and w i l l be dependent not only upon the degree of motivation i n the in d i v i d u a l but also on the economic s i t u a t i o n and employment p o s s i b i l i t i e s . Another advantage i s that the l o c a l r e h a b i l i t a t i o n councils w i l l be h e l p f u l i n returning the disabled to t h e i r own communities a f t e r they have been to the r e h a b i l i t a t i o n center or other treatment f a c i l i t i e s offered i n the Vancouver area. The P r o v i n c i a l Co-ordinator i s concerned with the X 16 numbers of handicapped who stay In the Vancouver area with few or no social contacts, often without their vocational rehabilitation hopes being realized but not without hope that they someday w i l l be. They often live lives of isolation and hopelessness. The Co-ordinator's view is that they should be returned i f possible to be cared for by the people they know and with whom they have daily associations. It is natural, however, that some people with severe physical handicaps should elect to remain in Vancouver where there are like companions, more service clubs available, and a milder climate that makes i t less d i f f i c u l t to manoeuver outside i n the winter. With Councils established and operating in Cranbrook, Abbotsford and Port Alberni since 1963, the Co-ordinator's Office is planning to establish councils in four new areas during 1965. The f i r s t Rehabilitation Field Consultant who has recently been appointed i s now functioning i n the central and northern part of Vancouver Island where he w i l l be responsible for vocational rehabilitation and consultation to the local committees. It i s planned that a second w i l l be appointed to free the Rehabilitation Consultant for planning further local committee services in new areas of the province. The value of these co-ordination projects at the local level cannot yet be estimated as they are so recent, but their development augurs well for the future. Local responsibility is given to local organizations and units — a most important concept. A predictable and formal procedure has developed in terms of inter-agency co-ordination with the functions of each agency clearly defined as to their responsibilities and authority. To date there has been no effort to co-ordinate the services i n the Vancouver area, an admittedly gargantuan task because of the number of specialized services. Instead the Co-ordinator's Office has picked out usable services within the community for clients referred to his office. This has often meant that co-ordination i s not smoothly effected for the individual concerned. Yet the task is not easy because Vancouver is such a mosaic of agencies with varying attitudes of cooperation. The Provincial Co-ordinator's Office has decided that the larger areas of Vancouver and Victoria should be l e f t u n t i l sufficient experience had been gained in setting up rehabilitation co-ordinating committees in smaller towns and communities, so that workable methods and procedures can be originated before attempting organization i n these two complex urban centres. Observations on the Coordinating Devices Used As co-ordinating devices are such a notoriously d i f f i c u l t task in the f i e l d of rehabilitation i t is important X - 18 to document and follow up a l l attempts to pioneer i n this s t i l l largely unknown f i e l d . Research should be done as to the success of the newer devices, such as the local community councils. The inter-agency "case conference" device as used by the Rehabilitation department through the Vanoaiver General Hospital is an interesting and useful development. However, i t should be realized that only a fraction of the patients who could benefit from rehabilitation services are referred by their doctors to social service departments in hospitals, for a variety of reasons which i t is not appropriate to enter into here. The extension of a similar system to the other hospitals i n the area, such as St. Paul's (over 800 beds) and Sit. Vincent's would appear to be indicated. It should be noted that though there is an interdepartmental co-ordinating committee within the government rehabilitation services, there is not as yet a government sponsored general co-ordinating committee including both government sponsored agencies and voluntary agencies. The province of Saskatchewan has attempted such a development and this w i l l be referred to in the next chapter. There is a general planning and coordinating body for the rehabilitation f i e l d for British Columbia, which includes the groups mentioned above, but this is at the voluntary l e v e l . The agency which has taken this responsibility X - 19 has had an interesting history, f i r s t as the Vancouver Council for the Guidance of the Handicapped, established i n 1943, and currently as the Division for the Guidance of the Handicapped of the Vancouver Community Chest and Council. It was the f i r s t organization of its kind in Canada and w i l l be referred to i n a subsequent section of this chapter. The Disabled Persons Allowances Act As Interpreted in  British Columbia. The Disabled Persons Act which was federally enacted in January 1955, was implemented i n British Columbia the same year. Through an agreement i t provides for 50-50 sharing by the Federal and Provincial Governments of a basic monthly allowance now of $75 to a person who has been medically deemed to be totally and permanently disabled. In B.C. a supplementary allowance is given, dependent on outside income. The Disabled Persons Allowance is granted on a means test basis for persons between the ages of 18 and 69 for whom there are no therapeutic or vocational rehabilitative hopes as an alternative. For a single man the income limit may not be over $1,260 annually. For a married couple the limit is $2,220 annually except where the spouse is blind; then income may not exceed $ 2 , 5 8 0 . Allowances are not paid to recipients of the Blind Person War Veteran's Allowance Act, Old Age Assistance Act, or the Old Age Security Act. The Allowance X - 20 i s not issued to persons who are i n s t i t u t i o n a l i z e d for over four months of the year and e l i g i b i l i t y requires the person to have been i n the country for ten years Immediately p r i o r to a p p l i c a t i o n . The Federal Government administers i t s aspects of the Act under the Department of National Health and Welfare, the P r o v i n c i a l Government under the Department of S o c i a l Welfare. The Disabled Persons Act, along with the Blind Persons and Old Age Assistance Acts, are administered through a three-man board appointed by the Lieutenant Governor i n Council. The Old Age Assistance Board, which i s a d i v i s i o n of the Department of Welfare, has on i t three senior o f f i c i a l s of the Department. In addition to being charged with the administration of the Acts and t h e i r regulations, the Board considers applications and for t h i s purpose has created the Medical Advisory Board of the Disabled Persons Act. This consists of a p r o v i n c i a l l y appointed physician, a f e d e r a l l y appointed physician and a p r o v i n c i a l l y appointed medical s o c i a l worker. The screening on s o c i a l grounds i s done f i r s t by the medical s o c i a l worker from the Medical Services D i v i s i o n and then the medical decision i s based on the D i s a b i l i t y Evaluation Manual, which has been dis t r i b u t e d by the Federal Department of National Health and Welfare. The Medical Board may decide that a r e h a b i l i t a t i o n JC - 21 r e f e r r a l should be made. This, after clearance with the applicant's physician, i s done through the Disabled Persons Board to the P r o v i n c i a l Co-ordinator's Office of the Health Board. As the Disabled Persons Act provides income maintenance only for^those severely enough disabled to medically q u a l i f y , i t i s to be assumed that a f a i r number of people are referred fo r vocational r e h a b i l i t a t i o n to the Co-ordintor's Office for a decision. Those people who are not e l i g i b l e f o r the Disabled Persons Allowance w i l l presumably, i f f i n a n c i a l l y impoverished be on S o c i a l Assistance, which i s at a lower rate, allowing a single person $66, and i s not permanent, and which i n some places i s s t i l l administered with much of the old punitive poor law a t t i t u d e s . Observations on the Administration of the Disabled Persons  Allowance i n B r i t i s h Columbia The pattern which has been developed i n B r i t i s h Columbia i s s i m i l a r to that i n most other provinces. Not a l l other provinces however, grant a supplementary allowance. The fact that a province needs to do so i s an i n d i c a t i o n that the grant i s not s u f f i c i e n t to meet basic needs i n many instances. Although the manual i s an aid towards uniformity i n int e r p r e t a t i o n as to what constitutes a t o t a l l y and permanently disabling condition within the meaning of the Act, i t i s w e l l known that there are variations between provinces X 22 and even within the same province. While there i s bound to be a degree of subjectivity i n any interpretation, i t is important that there be proper provision for appeal against the decision of the Board. There is a fundamental problem of the administration of this Act. It has been shown that even very badly handicapped people are capable of independence through employment i n spite of the severe degree of physical dis a b i l i t y they seem to suffer, therefore i t is very d i f f i c u l t indeed to assess a person* employability where i t is a physical handicap that is being considered. In his thesis Mr. Bodlak points out how d i f f i c u l t i t is to assess the degree of physical d i s a b i l i t y and a person's employability. It would seem that the total and permanent disability is an elastic concept. He cites the case of one rejected applicant, a woman who did consider that she was totally and permanently disabled but who was advised by the examining committee that she was not eligible for a disability allowance. The grounds for rejection were that, according to the assessment by the G.F. Strong Centre, she would be able to manage with satisfactory employment. It was the opinion of the Co-ordinator of Rehabilitation that i t was "only a matter of time before a suitable job could be found." 1 She questioned the decision 1 Stanley Bodlak, "Disability Allowances", Master of Social  Work Thesis. University of British Columbia, Vancouver, B.C., 1957, P.106. X 23 particularly as she was then 38 years old, but there was no recourse open to her under the Act. In spite of the 1957 modifications to the Act, i t s t i l l tends to stamp a person as "totally disabled" and therefore "unrehabilitatable" when this may be so only in relation to employment goals but not i n relation to suitably set goals as set out in Chapter 2. If though^ both the Board and the Co-ordinator's Office may consider an applicant to be unemployable, i t should be remembered that his inabi l i t y to function independently may in some cases be due only to the fact suitable employment cannot be found for him. Once so classified his opportunities for rehabilitation are lessened. Although there is an annual medical review for the person on dis a b i l i t y allownce, once on for any time, the likelihood of rehabilitation is lessened. In the B.C. Social Welfare Annual Report for 1964 there were 402 new applications received! 190 new applications were granted; 235 were refused or withdrawn. By far the largest category for refusal was i n e l i g i b i l i t y on medical grounds. In 1963 there were 272 new applications; 221 or 8L24$ were refused; 17 or 6.24$ were rejected fcr having income in excess of that allowed by the Act. In 1964, out of 402 new applications of which 190 were accepted and 235 were refused, 202 or 86$ were not granted on medical grounds; the X 24 next highest percentage was the refusal of 3.4$ or 8 people on the basis of income1 in excess of that allowed by the Act. It is interesting to note that those people who applied either considered themselves seriously enough disabled, or were so considered by their families, their doctors, or 2 a social agency, to apply. It has been stated that most of the people who have applied for the Disabled Persons Allowance are already on Social Assistance and so their financial situtation w i l l not suffer i f they are turned down for Disabled Persons Allowance. Actually the Social Assistance amount is differently calculated and the disabled person may get less than i f he received Disabled Persons Allowance. The composition of the medical review boards varies i n the different provinces, but a l l contain both a federal and a provincial medical representative. It has been noted in an o f f i c i a l federal government publication that i n the provinces of British Columbia, Manitoba and Saskatchewan the provincial medical representatives on the Board are also staff members of the provincial rehabilitation boards, and that these provinces are among those with the smallest number of recipients of the allowance i n relation to the total 1 British Columbia Department of Social Welfare Annual Report, Queen's Printer, Victoria, 1964, p. 71. ^ Conversation with medical social worker, Department of Social Welfare Medical Division, Vancouver, April, 1965. X 25 population, 1 with British Columbia running lowest in number of recipients. It has been suggested that a smaller proportion of the disabled are applying for the allowance in British Columbia. However, when the number of applications received is compared with the number of allowances granted, the proportion of applicants granted the allowance has been consistently higher. A study of replies to the survey questionnaire made during the preparation of the Report on Needed Research i n Social Welfare in British Columbia for the Community Chest and Council revealed that most of the applicants for Disabled Persons Allowance learned about p the service through friends. It is interesting to note the most common medical conditions existing in people considered disabled enough to qualify for the allowance. The most frequent single cause is mental conditions, including mental ill n e s s , mental retardation and personality disorders, with neurological conditions running a close second as. the following table shows. This comment is made in Rehabilitation Services i n  Canada. Part I, published by the Department of National Health and Welfare, Ottawa, I960, p. 69. 2 Michael Wheeler, A Report on Needed Research in Welfare  in British Columbia. Community Chest and Councils of the Greater Vancouver Area, 1961, p. 194. X 26 TABLE IX Primary Causes of Disability i n Accepted Cases for Disabled Persons Allowance in Bri t i s h Columbia No. of Cases 384 299 289 206 1 190 Equal 100$ I960 1961 1962 1963 1964 Infective and Parasitic 3.16 4.4 4.8 3.89 4.7 Deseases Neoplasms 1.14 1.0 1.4 1.46 1.6 Allergic, Endocrine Sys. 3.45 2.0 3.5 .49 1.6 Metabolic & Ntrtiional Deseases Diseases of Blood & 0.28 0.3 0.4 .49 .5 Blood Forming organs Mental & Psychoneurotic 35.91 44.6 42.9 52.40 46.8 and Personality Disorders Diseases of the nervous system 29.60 26.5 25.3 26.20 21.1 circulatory " io:d6 6.7 10.4 2.43 6.8 respiratory »• 2.02 2.3 .07 1.46 3.2 digestive " .87 0.3 .04 -Genit o-ur inary .58 - - -skin & cellular tissues - 0.3 — 0.49 -bones & organs of mov't 9.48 8.4 7.3 7.29 8.9 Congenital Malformations 1.72 2.3 1.4 1.95 1.1 Symptoms of s e n i l i t y and _ _ _ 5. ill-defined conditions Accidents, poisoning and 1.72 0.7 1.7 1.46 .3 violence 100. 100. 100. 100. 100. Source: British Columbia, Department of Social Welfare Annual Reports, Queen's Printer, Victoria, 1960-1964. X 27 The Vocational Rehabilitation of the Disabled Act as  Interpreted i n British Columbia As demonstrated i n chapter eight, this is a broad and generous act as i t related to aid the group of the disabled i t is intended to aid, namely those capable of reaching substantially gainful employment, and has been discussed elsewhere i n this study. In Br i t i s h Columbia i t is given as broad an interpretation as possible. The Technical and Vocational Training Assistance Act as  Interpreted i n British Columbia This Act is to provide assistance for the development and operation of programs to train Canada's man-power as agreed between the Provincial and Federal Governments through the Technical and Vocational Training Agreement. The programs which are of most concern here are Program 5 (formerly known as Schedule M) and Program 6 (formerly known as Schedule R). Program 5 is for the training of the unemployed• . . .for training or retraining of unemployed persons to improve opportunities and increase trade or occupational competence. The Federal Government w i l l contribute 75 per cent of approved provincial costs except training allowances for training carried on i n accordance with regulations in Schedule 5* The Federal Government w i l l contribute beginning February 1, 1964, X 28 90 percent of approved p r o v i n c i a l t r a i n i n g allowances paid to unemployed persons while i n t r a i n i n g . 1 The purpose of Program 5 i s to provide some degree of f i n a n c i a l assistance to unemployed adults who have teen directed to t r a i n i n g by the National Employment Service. The intent of this program i s to enable a person to gain the p r a c t i c a l knowledge and s k i l l s of a trade that w i l l enable him to competes adequately on the labour market and obtain employment. The National Employment Service i s responsible for counselling and interviewing through the Special Section's O f f i c e r who decides i f t r a i n i n g i s warranted. He also d i r e c t s the applicant to the t r a i n i n g program. Under Program 6 i n B r i t i s h Columbia a person who has a physical, mental, s o c i a l or emotional d i s a b i l i t y can qualify by r e f e r r a l through the R e h a b i l i t a t i o n Service of the Department of Health. After approval his application i s processed by the Department of Education. In some situations the National Employment Service may be asked by the R e h a b i l i t a t i o n Services to act as t h e i r agent, otherwise there i s no need f o r the applicant to go through the National Employment Service. Following are the requirements 1 Canada, Agreements. Technical and Vocational Training Agreement Incorporating Amendments up to June 30, 1964, Queen's P r i n t e r , Ottawa, p. 4. X 29 laid out i n Program 6 for the training of the disabled: A program for the technical vocational training, retraining or vocational assessment of any disabled person who because of a continuing d i s a b i l i t y requires training to f i t him for employment in a suitable occupation. The Federal Government w i l l contribute %$ of provincial costs of approved programs in accordance with the regulations i n Schedule 6.1 For the programs of the Technical and Vocational Training Agreement the training f a c i l i t i e s and staffing are administered by the B.C. Vocational Schools, a Technical and Vocational Branch of the Department of Education. The program is run in co-operation with the Apprenticeship and Tradesman's Qualification Branch of the Provincial Department of Labour. An administrative organization has been set up consisting of the Provincial Director of Technical and Vocational Education, also the Regional Director of Canadian Vocational Training, both of the Department of Education, the Regional Supervisor, Special Services of the National Employment Services, the Provincial Co-ordinator of Rehabilitation and the Director of Apprenticeship and Tradesman's Qualification Branch, Department of Labour, B.C. Besides these key personnel there are also the Departmental Canada, Agreements, op.cit. p. 5. X 30 Assistant, Directors of the various federal and provincial services who are resource people. Under Program 6 requests for training assistance may come from any agency. However, a l l applications must be screened through the Rehabilitation Services who w i l l then decide upon presentation to the training selection committee. The regulations require that medical, social and vocational information is to be included with the application to substantiate sound planning for the disabled person and that i t is in his best interests. The regulations point out that where special provisions must be made because of a person's handicap these requirements should be specified medically before training begins. Referral for vocational assessment prior to a selection committee decision on a particular training course can be approved according to the regulations; but the assessment period cannot exceed three weeks without federal agreement. As pointed out i n the manual, the primary advantages of Program 6 are: 1. . . • the careful medical, social and vocational assessment which is made before the application is submitted to the committee. 2. The training period can be up to two years with additional training possible. British Columbia, Department of Education. The Technical and Vocational Branch Manual for Programs 5 and 6 , Queen's Printer, Victoria, p. x i i . X 31 In Br i t i s h Columbia, the provincial government has utilized federal aid i n a rapid expansion of vocational training f a c i l i t i e s . Vocational schools are now functioning i n Burnaby, Kelowna, Nanaimo, Nelson, Prince George and V i c t o r i a . 1 Aside from these a number of private schools which offer specific technical training such as stenographic training are l i s t e d . The one d i f f i c u l t y seen i s that most of these courses require at least a grade 10 education, although their manual implies there can be some exceptions based on emotional maturity. Many handicapped adolescents and adults have not managed to reach this level, not necessarily through lack of capacity, but because of lack of educational services suited to their needs being available to them at the primary and secondary levels. There are few provisions i n Vancouver to help the adult disabled person come up to a grade 10 education except at King Edward School which is unmanageable for the physically handicapped because of stairs. In Br i t i s h Columbia emphasis is upon primary industry in which there is much seasonal employment. Also those employed i n logging, fishing and construction tend to have poor educational backgrounds and a few s k i l l s vocationally. When they become disabled i t is hard for these people to The Vancouver School of Art and the Vancouver Vocational Institute are under the Vancouver Board of School Trustees. X 3 2 adjust to sedentary office or indoor jobs. Though they cannot a l l attend King Edward School, i t is true that correspondence courses are provided by the Provincial Department of Education, but these are often quite unsuited to a person with l i t t l e background i n the art of studying and who may need much individual attention and remedial help educationally to achieve the required standard for vocational school. The handicapped person who seeks training under the Technical and Vocational Training Agreement is not limited to vocational schools as are those applicants under Program 5« On the contrary, they can use a variety of educational institutions where applicable. As stated in the Agreement, these can be: a. Regular municipal or provincial vocational schools, or institutes of technology. b. Private trade schools or business colleges approved by the Province. c. Special training centres. d. Universities. e. In business or industry, when approved by the Federal Director of Vocational Training. On the job training can also be arranged when i t is in a disignated trade or occupation with a recognized 1 Canada, Regulations. Office Consolidation Technical and Vocational Training Agreement Regulations, Queen's Printer, Ottawa, p. 2 2 . X -33 apprenticeship plan and can accommodate a disabled person. There is actually very l i t t l e use of this provision i n British Columbia at present. This is another area where research needs to be done to ascertain the reasons. A reasonable hypothesis would be that one f a i r l y common reason would prove to be that buildings might not be suitable for access by physically disabled persons. Use of Hospital Insurance and Diagnostic Services Act Under this legislation, discussed earlier i n the study, various rehabilitation services to both inpatients and outpatients are included in shareable costs which the federal government w i l l allow. The inclusion of rehabilitation f a c i l i t i e s however, is at the option of the province. British Columbia did not include these at f i r s t , indeed not un t i l 1954 and s t i l l does not include outpatient services in its hospital insurance program. Needless to say, this is a great gap in the rehabilitation services, as so many treatments need to be given on an outpatient basis. Use of Federal Grants The use by British Columbia of the various federal grants would make a separate study i n i t s e l f . Many factors enter into this, and a good comparative study of the X 34 differing use of these grants "by the provinces has not yet been done. In relation to the medical rehabilitation grant, the questions arises as to why British Columbia has tended to use small amounts of the grant for tie purchase of specialist consultations, diagnostic tests and prostheses for clients not otherwise covered, as have Nova Scotia and Saskatchewan, while in contrast, New Brunswick and Manitoba have used i t extensively for the purposes of medical assessment, prostheses, and maintenance allowances for clients away from home. A more extended example of the use of a federal grant by the province of British Columbia w i l l next be discussed as an example of extremely useful developments in the rehabilitation f i e l d made possible by the use of these grants. Because comprehensive rehabilitation begins with good case-finding this development w i l l be discussed i n some d e t a i l . This registry was the f i r s t of its kind to be established in Canada. Its inauguration was an interesting use of the federal Health Grant for crippled children which was made available to B.C. i n 1948. At once, there arose the problem of how to make the best use of i t . This quickly led to the realization that there was very l i t t l e available information at the time as to just how many children there were in British Columbia who were suffering from handicapping ' X 35 d i s a b i l i t i e s , let alone the comparative incidence of each di s a b i l i t y . So i t was debided to use the grant to make a province-wide survey, as a result of which"some 20,000 handicapped children were found. The report on the survey recommended that a permanent Crippled Children's Registry be set up on a voluntary basis. This was done in 1952 and the Registry placed under the supervision of the Division of V i t a l Statistics Medical Statistics Section. At f i r s t , the response was slow but by 1955 more than 7,000 children had been registered. The Registry has a direct link to the Department of V i t a l Statistics — a l l birth defects which are reported within 48 hours of birth by the attending physician to the Department of V i t a l Statistics are referred automatically to the Registry. It removed its age restriction i n I960 so that adults over 21 have been registered since that time. It depends upon voluntary registrations from hospitals, doctors, agencies, and especially Public Health Services for the reporting of cases. It gives a detailed diagnostic classification of the total number registered. However, there is a concentration upon the under 21 statistics because the registry has now been receiving registration of handicapped children for 13 years and has become a valuable research resource as to the needs i n the younger age group. At the end of 1963 there were 21,951 people i n the registry. Of that number 82$ were under 21 and 18$ X 36 were 21 and over, 1 i n d i c a t i n g only that the Registry, which receives between 150-200 case registrations on children per month, has a more d i f f i c u l t time i n persuading agencies to report adult handicaps to them. The metropolitan areas of V i c t o r i a and Vancouver, presumably where the largest number of handicapped people l i v e , have decreased i n the numbers of r e g i s t r a t i o n s . It was noted that although the Public Health Units were consistent i n t h e i r r e g i s t r a t i o n s , there were not many from them i n the adult group. The Registry does much educational and l i a i s o n work i n order to increase i t s influence and effectiveness. I t defines a handicapped person ass • . • one who possesses a physical, mental and/or emotional problem which i s l i k e l y to be permanently d i s a b l i n g , interfere with hi s education, or prevent f u l l and open employment. This includes children with congenital malformations or f a m i l i a l conditions which may or may not be permanently disabling.- 2 I t has a three f o l d purpose: f i r s t , to show s t a t i s t i c a l l y the prevalence and incidence of handicapping and genetic conditions i n B r i t i s h Columbia; secondly to help with the management and r e f e r r a l of handicapped persons by providing a l i a i s o n with the various agencies and i n s t i t u t i o n s i n B r i t i s h Columbia, and t h i r d l y , to evaluate the s t a t i s t i c a l 1 B r i t i s h Columbia; Department of Health Services and Hospital Insurance, Health Branch "Registry for Handicapped Children and Adults Annual Report," D i v i s i o n of V i t a l S t a t i s t i c s Special Reports No. 8 3 , 1963, Forward, p. i . L o c . c l t . X 37 information registered so that the adequacy of the available f a c i l i t i e s can be determined and an indication of future needs and f a c i l i t i e s indicated. 1 The Registry cannot be regarded as a complete source of information at this point in time because the registrations are voluntary and dependent on the caliber and conscientiousness of the reporting. It i s , however, constantly increasing i t s scope as the advantages of registration become better known to the community, as individual or institutional agency prejudice is broken down and the research possibilities of the Registry are more widely comprehended. This w i l l be of future consequence in achieving r e l i a b i l i t y when doing specific incidence estimates of the prevalence of specific defects i n children. Two major criticisms are made of registries: that they deprive people of their right to privacy and that the returns are slow, so that i t i s d i f f i c u l t to build up such a registry and often the data cannot be made explicit enough i n i t i a l l y . One authority, Dr. J. Millar, answers both these charges as follows: f i r s t , that as the State assumes increasing responsibility for providing a number and variety of Health and Welfare Services to improve human i l l s , i t then should have both the moral and also the statutory right 1 Loc. c i t . 0 X 38 to learn the geneses of these i l l s . In answer to the second criticism he states that although the returns may be slow i n coming the British Columbia Registry has proven its use already by pointing to the need for rehabilitation and education in certain diseased groups of children."1" Secondly, Registries form a disability or disease index which can be consulted i n order to obtain i n a relatively short period of time basic Information on large numbers of 2 individuals with specific defects. Another authority, Dr. J.D. G r i f f i n , general director of the Canadian Mental Health Association, in his address to the Canadian Association of Retarded Children's Conference in Prince Edward Island i n 1959» said that a l l cases of handicapped children should be registered. He indicated that such a system would have to be implemented by the provinces in cooperation with the medical profession. Already the Registry is a valuable tool to the office of the Provincial Co-ordinator although the two serve different functions. Ihile the o f f i c i a l co-ordinator*s chief concern to date has been vocational rehabilitation, he must also concern himself with other needs of the handicapped. The Registry can help him in case finding . The 1 James R. Millar,Ph.D., "The Use of Registries and V i t a l Statistics in the Study of Congenital Malformations,Session VII, n.d. Loc.cit X 39 Registry also hopes to benefit from its close liaison with the Co-ordinator's Office by receiving registrations of the handicapped adult through the local rehabilitation committees that have been set up in several areas in the province. The Registry, while under the jurisdiction of the Division of V i t a l Statistics, has a Medical Director who serves i n a dual role as Director of the Division of Rehabilita-tion Services and Director of the Registry. This makes for a close and useful liaison with the government department which has the responsibility for the coordination of rehabilitation services. Provincial Services for Specific Categories of Clients Under the present division of powers the provincial government accepts direct responsibility for certain groups or "categories" of clients needing rehabilitation. These include injured workmen, the mentally i l l , those with tuberculosis, those with venereal disease and certain children's services. As i t would be impossible to examine a l l these programs, attention w i l l be focussed on il l u s t r a t i v e examples of operation of the present division of responsibility and its effects on the patterning of programs. Three programs w i l l be specifically referred to: the Workmen's Compensation, services for the mentally i l l , and services for children. X 40 The Workmen's Compensation Program Historically, this is one of the oldest provincial programs. It has often been cited as an example of what a "comprehensive" program can accomplish. From another viewpoint i t might equally serve as an example of the deficiencies of the categorical approach to rehabilitation. There are limitations for certain cases on the kind and amount of benefits and treatment that may be received, and this can adversely affect the rehabilitation process. A number of authorities have questioned whether there.should be a separate category for this group. It is not appropriate to enlarge on this here, but i t can be said that since this program was f i r s t established the approach to rehabilitation has changed. Lump sum settlements, compromise settlements, following l i t i g a t i o n , the signing of releases of l i a b i l i t y when the effects of an illness or accident may not show up t i l l years afterwards, emphasis on deciding degree of dis a b i l i t y according to rather complicated scales have a l l been mentioned by authorities as li k e l y to mitigate against the rehabilitation process. As in a l l categorical programs, some f a l l through the net and their rehabilitation needs may go unmet. Services for the Mentally 111 Services for the mentally i l l were chosen as an example of X 41 a program which has recently been re-evaluated and is in the process of reorganization. Many professional observers in the f i e l d of mental illness have commented favourably on the design of the pattern for these services projected for the province. Of course there are s t i l l lacks, such as overcrowding in hospitals, but in the main the pattern of services that i s emerging may be said to be i n line with many of most recent recommendations made by authorities in this f i e l d for improvement. The following description is intended to highlight the main characteristics of the pattern. With the introduction of the new Riverview Act of April 1965, i n British Columbia, the process of rehabilitation for the mentally i l l w i l l be commenced on a regional basis and i t is expected that the institutions at Essondale w i l l be reallocated on a geographical rather than, as has been, on a chronic or active treatment basis. The ultimate plan is to have no long term chronic patients in the institution. People w i l l be referred to regional or general hospitals i n their communities i f needing psychiatric help. This forward looking policy in the thinking of those i n the Mental Health Services is geared to catching acute illness at the onset. It is also a move to try to break down prejudice against mental illness i n the community. This move is a most necessary step as mental illness is the outstanding crippler in a l l age groups. X 42 Through the Canadian Mental Health Association, (British Columbia division) a voluntary organization, i t is planned that the patient who has been removed from his environment to one of the regional hospitals, w i l l return to the community and to the f a c i l i t i e s and services being set up through local chapters of the Mental Health Associations. The Canadian Mental Health Association is concerned withs ( 1 ) patient care in hospitals; ( 2 ) after care; ( 3 ) community psychiatric services; (4) mental health services for children. These services w i l l vary with the interest and concern of the local Canadian Mental Health Association but there w i l l be someone in the small communities to contact the returning patient and be a l i a i s o n with the community, a matter of great importance to a person who may feel different or unwanted. There are now 2 2 branches of the Canadian Mental Health Association actively involved in the province. The Mental Health Services of the Provincial Government have been concerned with providing a total rehabilitation program for the mentally i l l . In order to help with this complex problem they established a rehabilitation department early in 1 9 6 3 . One aspect of their program is to find suitable job placements for patients in the hospital work areas. A program of analysis of the work areas of the hospital was undertaken preparatory to classifying patient a b i l i t y for job assessment. The purpose X 4 3 was to determine the level of competency of the patient as well as the complexity of the task so that a job training and a payment plan could be worked out. This assessment is now used as a reference when patients are referred to the Special Placement Section of the National Employment Service. The program, which is run by the Co-ordinator of Rehabilitation, Mental Health Services, now has 6 0 $ of the patients engaged in occupational therapy. During the 19-64 year 1 , 2 2 6 men and 7 2 4 women were given tasks in the hospital setting suited to their a b i l i t i e s ; also 4 2 9 men and 2 0 3 women were reassigned tasks or work areas. This grading system, which also provides token payments, has interested the patients who have improved the level of their work performance and have become more interested i n work.1 It has benefited them in their eventual adjustment to the community. Vista and Venture are short stay rehabilitative homes used as resources by patients where they can stay while seeking suitable employment or additional training in the Vancouver area. It is planned that after discharge the social worker w i l l give personal counselling as well as the follow up work of encouraging the ex-patient to take further training to to use the Special Placement Section of the British Columbia, Mental Health Services Annual Report, Victoria, 1964, p. F 61. X 44 National Employment Service. A consultative council was established i n the f a l l of 1 9 6 3 in order that the Medical Superintendent could be advised of program developments for the benefit of the patient, the hospital and the community. This council is composed of senior representatives of the Mental Health Services, the Rehabilitation Services, the Social Welfare Department, the National Employment Service, the Public Health Units, the Vocational Training Schools and the Division for the Guidance of the Handicapped.1 To date there have been six meetings. In this way i t can be seen that there is an effort on the part of the government to co-ordinate its services and on the part of the community to provide rehabilitation. There are in addition to the f a c i l i t i e s at Riverview, Eastview, Westview and Northview, mental health services available at the Mental Health Centre with an adult outpatient and day hospital treatment program, and a children's c l i n i c with the diagnostic and treatment f a c i l i t i e s on an outpatient basis. In addition to this there are the Mental Health Centres i n Victoria and Kelowna,(Trail and Nanaimo offering both adult and children's clinics with the purpose of keeping people i n their own community and to reach them early i n British Columbia, Mental Health Services Annual Report, Queen's Printer, Victoria, 1964, p. F . 6 2 . X 45 their illness before the patterns of chronic illness become well established. It would be ironic indeed i f such a basically sound system of services were to be n u l l i f i e d because of lack of auxiliary rehabilitation services. Yet local surveys of lacks in this f i e l d plus interviews with personnel working in this f i e l d have a l l stressed that some of the main obstacles to the carrying through of the program are to be found not in the " c l i n i c a l " and "institutional" treatment phases (though i t is not disputed there are lacks here too) but rather in such factors as lack of suitable housing accommodation, hostels, and foster homes for adults, homemaker services, sufficient suitable jobs and recreational lacks. Many of these services are provided by voluntary agencies which may or may not get financial support from the provincial government. Rehabilitation Services for Children in British Columbia Services to children were chosen for review because in any community, they are usually a good indicator of the strengths and weaknesses of the patterns of services. This is because of the high consensus of opinion that these services should be given a high degree of priority, the strong emotional appeal of the unmet needs of children and the fact that "charitable" and private sources of funds are often more available for children than for other groups. A review of X 4 6 the rehabilitation services available to children i n the province reveals some interesting facets of the operation of the "tripartite division of responsibility" which is characteristic of the Canadian scene. The relative roles of federal, provincial and voluntary agencies are nowhere more closely intertwined than i n the children's f i e l d . The Federal Government has given grants to the provinces since 1948 to aid in the prevention, treatment and rehabilitation of illness or conditions that create crippling in children. In 1 9 5 3 the Medical Rehabilitation Grant was introduced and i n I 9 6 0 i t became the Medical Rehabilitation and Crippled Childrens' Grant. It is used for medical rehabilitation f a c i l i t i e s and services i n the training of medical rehabilitation personnel and for research studies in the f i e l d . Federal stat i s t i c s on expenditures under the National Health Grants were $109,403 i n 1 9 6 0 - 6 1 , $ 2 3 3 , 3 3 0 in 1 9 6 2 , $ 1 8 6 , 8 8 8 in 1 9 6 3 and $ 2 3 6 , 1 6 9 in 1 9 6 4 to British Columbia under the Medical Rehabilitation and Crippled Childrens* Grant. Services for physically impaired children in Br i t i s h Columbia are more closely connected with broad programs of child health than in many provinces There are several f a c i l i t i e s for pediatrics i n the 1 Report of the Medical Advisory Committee to the Minister of Health on Rehabilitation, Chronic Treatment and Convalescent Care, B.C. Division of the Canadian Medical Association, Vancouver, May 2 0 , 1 9 6 4 , p. 15. X 47 Vancouver area in which much rehabilitative work is done. The Child Health Centre at Vancouver General Hospital i s a 212 bed children's hospital which cares for in-patients and out-patients. It is a teaching and research centre for the Department of Paediatrics at the University of British Columbia, and is a mgjor referral centre for children in B.C. The provincial government contributes heavily to Vancouver General Hospital which is the main medical centre for the province though i t s t i l l goes by the name of^a "city" hospital. Unfortunately i t s out-patient department is particularly crowded and this limits rehabilitation work. In addition there are other provincially supported institutions such as the Children's Hospital which cares for long term cases of crippled children but is now becoming an acute hospital — 40$ acute and 60$ long term patients. The travelling c l i n i c of the Children's Hospital offers diagnostic services i n various parts of the province. "It was ascertained that over 99$ of those cases referred from the travelling c l i n i c are sent to the Chrildren's Hospital rather than to other paediatric f a c i l i t i e s within the province."! In addition there is also the Tra velling Speech and Hearing Services where they are not permanently attached to Health Units such as at Burnaby, Surrey, Victoria, Kelowna, Vernon and T r a i l . 1 Loc.cit. X 4 8 Jericho H i l l School is a provincially operated institution for the aurally or visually handicapped. It had a total of 3 3 6 day and resident pupils i n 1 9 6 3 - 1 9 6 4 , 2 2 7 of whom were deaf. It is a twenty roomed Home Economics -Industrial Arts building and the school is actively engaged in helping to plan a program for a vocational school for the handicapped i n order that the older children can receive vocational training to suit them to employment.1 The reason why these two groups of children were housed in the same f a c i l i t i e s was said to have been done originally to save the province money. Certainly, i t is not usual in western countries to find these two groups housed together, as their rehabilitation needs are i n some respects so different. It is interesting to note that there has been planning for the two groups i n the new premises for the school currently being b u i l t . There are other specialized f a c i l i t i e s for physically handicapped children such as the Sunny H i l l Hospital, previously the Vancouver Preventorium for Tuberculosis which, because of the drop in this disease, has had its program broadened and at present even a more comprehensive one is being sought to reach the needs of children. There is also the Queen Alexander Solarium on Vancouver Island which treats not only children with tuberculosis but also those with heart disease British Columbia, Department of Education, Victoria, Queen's Printer 1 9 6 3 - 1 9 6 4 p. N 1 1 5 . X 49 and congenital deformities. Its location, at a distance from the larger population centres, tends to isolate the children from participation in community l i f e , which is a fundamental principle of rehabilitation. The Registry for Handicapped Adults and Children has had as one of its major functions the co-ordination of services for disabled children. It has functioned as a ease referral and follow-up agency, especially for those requesting service from outside Vancouver, and has advised the Public Health Services to do follow-up in low income families i f there is no private family doctor. When older, the children w i l l be referred to the Provincial Co-ordinator for vocational rehabilitation. The provincial government does not operate alone in this f i e l d of services for physically disabled children. The pattern of services would not be complete without the work of the following "private" or "voluntary " agencies. Intensive therapy with children is done at the G.F. Strong Centre which has a special program for those with cerebral palsy, but handles a l l kinds of orthopedic d i s a b i l i t i e s . In addition to the Cerebral Palsy Association i n Vancouver, there is now the lower Fraser Valley Cerebral Palsy Association which established a Children's Treatment Centre in 1961. This Centre includes services to a l l handicapped children in the lower Fraser, Valley area. x 50 Children with special d i s a b i l i t i e s may be handled by privately organized societies which specialize in this, such as the Epileptic Society and the Arthritis and Rheumatism Society. (A surprising number of children suffer from the crippling effects of rheumatoid diseases). In cases which are not handled by other agencies either financially or because of their own policy, either the Poliomyelitis Foundation or the British Columbia Society for Crippled Children undertakes to help. Service is given the child up to the age of 16 by either buying such service on its behalf of the basis of proven need or by co-ordinating planning. This is done through the Lion's Club and Kinsmen's Club whose services are province-wide. The Crippled Children's Society runs a bus service in the lower mainland to the School for the Deaf and the Blind as well as to various treatment centres in the lower mainland, including Vancouver, Victoria and Campbell River. It provides a summer camp for physically handicapped children and the Easter Seal Residence in Vancouver is for parents and their handicapped children needing treatment. Together these public and privately sponsored services constitute a considerable range of rehabilitative aids. Again however, perusal of local surveys of the needs of handicapped children, plus interviews with workers in the f i e l d indicate that there are a number of gaps which there is x 51 d i f f i c u l t y i n f i l l i n g . Not even the agencies are agreed as to how these gaps should he f i l l e d . Three examples of these lacks w i l l be mentioned. First,lack of foster homes; secondly, lack of educational services such as nursery schools and home teaching for handicapped adolescents to enable them to reach grade X leveljand thirdly, lack of enough suitable and dependable transportation services. For the mentally retarded, there are provincially sponsored services and privately sponsored services, the latter mostly provided by strong parent groups who put pressure on the provincial government to grant the same "per capita" cost "per place" to responsible organizations to plan for retarded children as the government would be spending on them were they in regular schools. There are s t i l l many lacks for these children. For the badly retarded child there is s t i l l institutionalization and training offered i n the provincially run Woodland's School which has 400 beds for the multiple handicapped, 200 beds for retardates and 800 beds for residential accommodation. There were 1 , 3 1 6 pupils registered in March 3 0 , 1 9 & 4 , with 249 admissions, 245 separations and 6 1 transferred to Tranquille School which also has a retarded children's program now running. During 1 9 6 4 the Occupational Therapy Department at Woodlands organized a sheltered workshop in the evening as a X 52 pilot project. If- i t is successful i t w i l l be incorporated into the daytime program to simulate the conditions of an actual factory type of employment.1 The voluntary societies such as the Associations for Retarded Children are operative throughout the province. These associations operate kindergartens, schools, occupational f a c i l i t i e s and training programs for young adults as weel as being instrumental in drawing retarded children into the general school program through special classes. Vancouver's Association runs a sheltered workshop for teen-agers and young adults to occupy the retarded and tr a i n them for employment in a sheltered situation. In addition the Association is concerned to have the retarded educated i n the school system where possible, - a fundamental principle i n rehabilitation planning. Treatment f a c i l i t i e s for mentally i l l and emotionally disturbed children are far from adequate i n terms of quantity. Child guidance c l i n i c units have long waiting l i s t s . Travelling Child Guidance Clinics travel throughout the province with a psychiatrist, psychologist, trained nurse and psychiatric social worker, making diagnostic studies of children referred through the Social Welfare Branch or other social agencies or doctors, but there is l i t t l e treatment service available. ' IIIIII 1 British Columbia, Mental Health Services Annual Report, Queen's Printer, Victoria, 1964, p. F 6. x 53 There is also the Children's Foundation, a Community Chest agency which offers a Residential Treatment Centre to children from six to twelve who are emotionally disturbed. The program has twenty children and has opened a halfway house for those who are almost ready to move on. Treatment is from two years on. It does not begin to meet the needs of this group in terms of numbers though the quality of its services is undenied. St .Euphrasia's School at White Rock is run by Catholic nuns who have a residential treatment centre for pre-delinquent girls from twelve to fifteen years of age. The program carries over thirty teen-aged gir l s who stay for a period of one to two years and attend school within the institution. There are additional Provincial Government f a c i l i t i e s for the emotionally disturbed and mentally i l l teen-agers such as treatment at Riverview1'but no special program for the occasional teen-ager accepted for short stay treatment. The mixing of adults and teen agers does not lend i t s e l f to an ideal treatment situation for the emotionally disturbed youngsters. The Canadian Mental Health Association, concerned about the mental health needs of children i n British Columbia, Formerly Crease C l i n i c . X 54 prepared a questionnaire to be circulated throughout the province. It also prepared a report with twenty-four recommendations, the three most important being that before new services are developed, co-ordinated planning with the various departments and governmental levels as well as private agencies and professional and community organizations should occur. Training funds should be provided for professional staffing. The new mental Act should be implemented to regionalize services for children as well as general medical services. 1 There is no unanimity as to the proper division of responsibility for the meeting of the "unmet" rehabilitation needs of these children. Certainly the "net" does not catch a l l children who need these services at present. Under the Social Assistance Act there is medical provision for children i f the parents are not able to work for medical reasons or are on social assistance for longer than three months. Children who are wards and also those who are wards of the three Children's Aid Societies i n B.C. have f u l l medical coverage. These provisions are important sources of the prevention of disability but they do not reach the children of low income families who do not quite qualify as "medical indigents" British Columbia Division of the Canadian Mental Health Association. The Mental Health of Children in British Columbia, Vancouver, April, 1964, p. 2 5 . x 55 The Role of the Voluntary Agency: Some Effects of the  Present Distribution of Responsibilities The brief review of the children's services has shown how important the role of the "private" or voluntary agency is i n the pattern of services. The next series of examples have been chosen to highlight the anomalous situation of the voluntary agencies i n the present pattern of services. The division of responsibility is by no means clear. Nor is the role of the provincial government. This is one of several basic questions that arise i n relation to the importance and effects of the present division of power; ie . , who shall say what the services shall be; who shall say who w i l l provide them; who shall say how they w i l l be provided; who is responsible for taking the in i t i a t i v e i n f i l l i n g well acknowledged gaps. G. F. Strong Rehabilitation Centre The f i r s t "voluntary" agency to be discussed with a view to highlighting some of the obstacles to the implementation of comprehensive services is the G.F. Strong Rehabilitation Centre. It is an example of a voluntary agency which could not exist without government financial support. 1 1 The Centre, a non-profit organization, depends i n part upon Health Grants from the Provincial Government as well as per day per patient funds from Hospital Insurance in order to operate. The revenue from Health Grants was 3 6 $ of revenue i n i 9 6 0 , 2 6 $ in 1 9 6 1 , 27% in 1 9 6 2 and 28$ in 1 9 6 3 . X 56 It was opened in 194-9 to give physical restoration services to paraplegics and poliomyelitis patients. With changing need i t has shifted focus and has how, with the decrease i n poliomyelitis victims, increased the varieties of disabled people on i t s program. The Centre provides a broad base of medical rehabilitation but because i t is geared to the more comprehensive aspects of rehabilitation i t includes in its integrated program medical, psychological, social, educational and vocational services and evaluation, both on an in-patient and out-patient basis. Nevertheless, i t has been described in some of the American literature on rehabilitation centres as "medically and orthopedically oriented". Included in the centre is a separate program for cerebral palsy children, run by the Children's Rehabilitation and Cerebral Palsy Association. This program has now been broadened to include non-palsied handicapped children. Most of the cerebral palsy children come to the centre on a day basis and have their schooling there. The Cerebral Palsy Program is co-ordinated toward the rehabilitation of children with a medical advisor, physiotherapists, psychological testing, psychiatric services of the Child Guidance Cli n i c and Centre physiotherapists as well as teachers provided by the school board and teaching x 57 at the centre. There Is a program for pre-schoolers which had 6 4 children i n 1 9 6 3 . This program treated 272 children in I 9 6 3 as compared to 275 in 1 9 6 2 . In addition to this, the Canadian Arthritis Society rents 9 beds for the use of their patients among whom there are stroke victims. The team approach is emphasized i n the G.F. Strong Centre as being the core of its program. It is an agency which must depend a great deal upon cooperation, not only within its team situation but also with the community, for it sees i t s e l f as being only one part of the total rehabilitation process. It actively pursuesssound and constructive community relationships because i t i s dependent upon them to help patients move on to another phase of rehabilitation once they have reached a maximum degree of self-care and ability to function within their handicap. Within the setting of the Centre a most important vocational rehabilitative service is that of the vocational counsellor who either on a consultation or treatment basis, w i l l , depending upon the need, make available vocational, educational or. psychological services for in-patients or out-patients. The vocational rehabilitation department is aware of the need to help the individual adjust and ideally would see the vocational eouncellor as being involved i n the person's situation from the beginning of the restorative phase X 58 throughout as a continuous process u n t i l the person leaves. The Centre's high standards are well regarded in the community and among the disabled who have benefited. According to the Annual Reports of the Centre, the degree of severity of the handicap of those admitted increases each year, in part because the procedures and casefinding methods of the Provincial Co-ordinator's Rehabilitation Service had uncovered a back log of chronic d i s a b i l i t i e s which previously had not had services. The Centre believes that this is now levelling o f f . 1 In addition, i t now accepts cases for rehabilitation that would have been regarded as hopeless but with current practice in physical rehabilitation plus the imaginative development of self-help devices and applicances, i t opens opportunities to the severely handicapped. In 1 9 6 3 there were 14 quadriplegic patients from cervical cord injuries. In 1 9 6 3 the Centre admitted 181 as new patients and 75 readmissions from previous years. The average length of stay per patient was 142 days. In total there were 297 from the lower mainland and 174 from elsewhere within the province; and five were from outside British Columbia. In reviewing cause of di s a b i l i t y 3 6 $ of the new patients were admitted 2 because of accidents, 3 5 $ because of automobiles. 1 G. F. Strong Rehabilitation Centre 16th Annual Report for the year 1 9 6 2 , Vancouver, p. 12. 2 i b i d . , p. 9. X 59 Tables X and XI illustrate in graphic form the nature of the d i s a b i l i t i e s of those admitted and the success of treatment procedures. TABLE X CAUSE OF DISABILITY IN NEW ADMISSIONS TO G.F. STRONG REHABILITATION CENTRE. I960 Disease I 9 6 0 1 9 6 1 1962 1963 1964 Vascular lesions CNS, 24 ' 23 6 0 24 4 6 21 3 2 18 40 " 19 Spinal Cord Trauma 24 8 20 8 2 8 13 30 17 2 9 14 Multiple Sclerosis 7 3 8 3 16 7 15 8 29 1 1 Bone and joint diseases 17 6 19 8 15 7 9 15 7 Fractures 7 3 1 1 4 1 0 5 6 3 1 3 6 Poliomyelitis 68 25 2 6 1 0 9 4 8 4 5 5 Head injury 9 3 8 3 9 4 7 4 8 4 Diseases of CNS 14 5 14 6 8 4 1 6 9 18 9 Speech disorders 5 2 7 3 8 4 1 1 6 6 3 Neoplasm of larynx 7 3 10 4 7 3 6 3 9 4 Arthritis 8 3 7 3 3 2 Congenital condition 17 6 12 6 7 3 Peripheral nerve injury 5 2 6 2 3 2 5 2 Traumatic amputations 4 1 6 2 5 2 10 5 1 0 5 Peripheral vascular 4 1 8 3 5 2 4 2 10 5 diseases Parkinson's disease 5 2 6 3 Adult Cerebral Palsy 7 3 3 1 3 ) •3 4 2 3 1 Muscular distrophy 3 ) •j 2 1 Tumours of CNS 3 1 5 2 Other neoplasms 6 2 4 2 Others 13 5 16 6 20. 10 7 4 10 5 Totals 2 7 6 100$ 250-100$ 217-100$ 181-100$ 211 -100$ Source: G. F. Strong Rehabilitation Centre, Annual Reports.1960-1964. X 60 TABLE XI PATIENTS. DISCHARGED AS TREATMENT COMPLETED INDICATING F.MPT.OYMF.TOT STATUS Occupation 1962 ; 1963 Pre-school 3 5 Student, attending 35 19 Student, not attending 5 2 Employment, s e l f supporting 41 30 R e t i r e d 26 9 Housewife, performing d u t i e s 45 26 Housewife, not performing 19 13 Unemployed, F u l l y employable 12 8 Unemployed, M a r g i n a l l y employable 24 25 Unemployable 17 24 T o t a l 227 161 Source: G. F. Strong R e h a b i l i t a t i o n Centre, Annual  Reports 1962 - 1963. This R e h a b i l i t a t i o n Centre has r e c e n t l y received a long awaited approval from the P r o v i n c i a l Government t o expand i t s f a c i l i t i e s . P r i o r t o t h i s , however, Dean McCreary, i n h i s report t o h i s Medical Advisory Committee on R e h a b i l i t a t i o n of June 16, 1963, t o the P r o v i n c i a l Government, made the recommendation that the G.F. Strong Centre be r e - l o c a t e d at X 61 the Vancouver General H o s p i t a l grounds. Such a move the committee f e l t would increase i t s e f f e c t i v e n e s s . The 1 report gives f i v e reasons f o r t h i s recommendation: a. An opportunity f o r general p r a c t i c t i o n e r s t o p a r t i c i p a t e i n the r e h a b i l i t a t i o n process. b. The ease and a v a i l a b i l i t y of consultant s e r v i c e s which are i n a general h o s p i t a l and are necessary f o r a complete program. c. The supportive d i a g n o s t i c f a c i l i t i e s a v a i l a b l e i n a general h o s p i t a l would mea n s e r v i c e s are not d u p l i c a t e d . d. Centre would be i n c r e a s i n g l y used as a teaching u n i t i n p h y s i c a l medicine and f o r the paramedical personnel, who r e q u i r e education. e. The p a t i e n t would r e c e i v e e a r l i e r r e h a b i l i t a -t i o n treatment than i f t r a n s f e r r e d t o a d i s t a n t centre. In answer to t h i s many of those f a m i l i a r w i t h the Centre and i t s program are persuaded that the Centre would be swallowed up In the l a r g e r complex of a general h o s p i t a l , that general p r a c t i c t i o n e r s are e i t h e r r e h a b i l i t a t i o n o r i e n t e d or else they are not, that i t i s t h e i r a t t i t u d e towards r e h a b i l i t a t i o n as such which impels them t o p a r t i c i p a t e i n a program and not the geographical l o c a t i o n of the r e h a b i l i t a t i o n f a c i l i t i e s . From the handicapped person's viewpoint there i s much 1 Report of the Medi c a l Advisory Committee t o the M i n i s t e r of Health on R e h a b i l i t a t i o n , Chronic Treatment and Convalescent Care, Vancouver, May 20, 1964, p. 8. X 6 2 to be s a i d f o r having a f r e e standing Centre. The i n d i v i d u a l does not f e e l that the Centre i s i n any way a h o s p i t a l , i n which he had l i k e l y had confinement before r e f e r r a l t o the Centre. He f e e l s that he i s moving out toward the community instead of being i n a medical maze which may i n t e n s i f y h i s f e e l i n g s of dependency and hence hamper h i s r e s t o r a t i o n of f u n c t i o n . I t might prove d i f f i c u l t t o m a i n t a i n the degree of morale and s p i r i t of unity present i n the Centre were i t to become one of the vast complex of b u i l d i n g s at Vancouver General H o s p i t a l which already are overcrowded and without "breathing" space. I t i s pointed out that the Centre i s already adjacent t o Shaughnessy, the Veterans' h o s p i t a l , which may a l s o l o s e i t s s t a t u s or at l e a s t change i f the Glassco report i s implemented. The d e c i s i o n as to where the Centre w i l l be has not been p u b l i c a l l y announced. This dilemma r e f l e c t s the d i f f i c u l t d e c i s i o n s involved i n changing or maintaining present patterns of s e r v i c e and i n weighing gains and l o s s e s which are by no means e x c l u s i v e l y f i n a n c i a l . I n February 1 9 6 2 , the G.F.Strong Centre presented i t s r e p o r t , "A Report on Comprehensive R e h a b i l i t a t i o n to the Royal Commission on Health S e r v i c e s . " In t h e i r 2 2 recommendations, of which a number are now out of date because of the new p r o v i n c i a l - f e d e r a l l e g i s l a t i o n , some are s p e c i f i c a l l y concerned w i t h t h e i r own long delayed plans to expand t h e i r over-crowded c e n t r e . The Centre i s very X 6 3 concerned about the w a i t i n g l i s t s f o r admission as each day without treatment can c o n t r i b u t e t o f u r t h e r d i s a b i l i t y . Some of the recommendations dea l with p h y s i c a l r e h a b i l i t a t i o n on a broad s c a l e and suggest ways of f i l l i n g i n the gaps i n a comprehensive program. The Report suggests t h a t the F e d e r a l and P r o v i n c i a l Governments j o i n t l y e s t a b l i s h , w i t h appropriate voluntary agencies, a p r o j e c t to develop c a s e f i n d i n g data f o r r e h a b i l i t a t i o n . Then a n a t i o n a l a s s o c i a t i o n of r e h a b i l i t a t i o n f a c i l i t i e s should be organized, using F e d e r a l Grants to e s t a b l i s h a nation-wide r e p o r t i n g system. I t i s recommended that a comprehensive program i s the most e f f e c t i v e method f o r using the a v a i l a b l e money and o f t e n l i m i t e d personnel r e q u i r e d i n r e h a b i l i t a t i o n . Therefore, programs which have l i m i t e d s e r v i c e should be discouraged except where they apply t o a need that i s a l s o l i m i t e d . I t i s proposed t o review next a voluntary agency which took a somewhat d i f f e r e n t approach and which would not even e x i s t today had "programs which have l i m i t e d s e r v i c e " been "discouraged" at the time i t was founded. The Canadian A r t h r i t i s and Rheumatism S o c i e t y T h i s S o c i e t y was founded almost single-handed by Miss Mary Pafik (now Executive D i r e c t o r of the B r i t i s h Columbia X 64 Arthritis and Rheumatism Society) i n 1948. At that time there were practically no f a c i l i t i e s for sufferers from the rheumatic diseases anywhere i n Canada apart from one or two expensive private hospitals. The agency has since become a model of what a private agency with high standards of service can achieve. From the f i r s t , the agency stressed a comprehensive range of services recognized the seven rehabilitation goals enumerated in Chapter II. • The agency rented X&m beds in the G.F. Strong Centre and from the f i r s t used a proportion of these for patients whose rehabilitation goal could be no more than a limited degree of self-care. At that time and probably s t i l l , there were people i n the community who did not hesitate to voice the view that the beds could be put to better use i f used for people who could reach a vocational rehabilitation goal. The organization provides an extensive, highly specialized series of services originally limited to patients suffering from rheumatic disease although i t i s now broadening it s program to include stroke and accident cases where no alternative can be offered the patient. In Vancouver, the Arthritis Society maintains ten beds in the G.F. Strong Rehabilitation Centre and six beds at the Holy Family Hospital, as well as the Canadian Arthritis Society's Medical Centre. X 65 A r t h r i t i s p a t i e n t s from anywhere i n B.C. can be admitted t o these three p l a c e s . I n - p a t i e n t treatment at the Medical Centre i s given by a r e h a b i l i t a t i o n team of medical c o u n s e l l o r , p h y s i o t h e r a p i s t , occupational t h e r a p i s t , nurse and s o c i a l worker. The period of residence i s u s u a l l y three months. In a d d i t i o n , at Vancouver General H o s p i t a l and St.Paul's i n Vancouver, the A r t h r i t i s and Rheumatism S o c i e t y runs out-p a t i e n t A r t h r i t i c C l i n i c s . There are a l s o these s e r v i c e s at S t . Joseph's H o s p i t a l , V i c t o r i a , and at the North Vancouver General H o s p i t a l . The Canadian A r t h r i t i c and Rheumatism Society o f f e r s home care s e r v i c e on an extensive basis throughout the province. There are more than 3 0 p h y s i o t h e r a p i s t s employed who work on an out-patient b a s i s , or i n the home t o help those who r e q u i r e physiotherapy treatments, whether i t i s a r t h r i t i s or another c o n d i t i o n r e q u i r i n g t h i s form of treatment. A home nursing s e r v i c e i s a l s o provided but i t i s l i m i t e d t o t a k i n g blood specimens, making s p l i n t s and ca r r y i n g out nursing orthopedic d u t i e s . There i s a l s o a t r a v e l l i n g medical c o n s u l t a t i o n s e r v i c e which goes throughout the p r o v i n c e . U n f o r t u n a t e l y as physiotherapy treatments are not covered by B r i t i s h Columbia H o s p i t a l Insurance unless the di s a b l e d person i s an i n - p a t i e n t , they must finance a l l t h e i r treatments t o p a t i e n t s i n t h e i r own homes from t h e i r own funds. This l i m i t s the r e h a b i l i t a t i o n work they could X 66 achieve. It should be pointed out however, that the Provincial Government does give a health grant to the Society. In 1964 i t received $111,635 or 26$ of its income from a grant. The Community Chest of Vancouver contributed 3 0 . 8 $ , treatment fees from the province were 17*3$ and other appeals and campaigns 22.9$. The Arthritis and Rheumatism Society has long advocated rehabilitative treatment services for chronically i l l patients in hospitals. It would require approximately 30 beds near the Vancouver General Hospital to carry out such a program. The Society is concerned about providing a co-ordinated out-patient and home care program and have asked for Br i t i s h Columbia Hospital Insurance financial coverage i n helping the individual to restoration of his faculties and a b i l i t i e s . The Society, i n i t s brief to the government of British Columbia1 pointed out that there are at least 15,000 cases of rheumatoid a r t h r i t i s . British Columbia has a total of 15 arthritis beds available. If the ratio of beds to the population were along the lines of more forward-thinking countries, British Columbia would be asking for a 120-130 bed hospital instead of the 30 bed hospital they are requesting. Hospitals serve approximately 3 ,500 a r t h r i t i c patients a year i n British Columbia but the Society 1 Canadian Arthritis and Rheumatism Society Brief to the Executive Council of the Government of Br i t i s h Columbia, Vancouver, August 1964, p. 3 . X 6 7 can only admit 1 6 at a time f o r in-care treatment. Doctors are r e f e r r i n g approximately 2,000 a d d i t i o n a l p a t i e n t s w i t h other d i s a b i l i t i e s a year; 3 3.6$ of the case load i s not a r t h r i t i c . This points out the many gaps i n r e h a b i l i t a t i o n , i n the pro v i n c e . P a t i e n t s under 40 comprise 2 2 $ of i t s case l o a d ; those from age 40 to 64 comprise 4 3 $ of the case l o a d . At l e a s t 2 1 3 of the people treated were i n the age group of the employables. The Canadian A r t h r i t i c S o c i e t y i s the only o r g a n i z a t i o n at t h i s time which i s attempting a co-ordinated h o s p i t a l , o u t - p a t i e n t and home treatment program i n the province, - another " f i r s t " i n the h i s t o r y of t h i s pioneering s o c i e t y . This s o c i e t y i s an e x c e l l e n t example of the s t r e n g t h and v i t a l i t y of the vol u n t a r y o r g a n i z a t i o n . I t has never f a i l e d to share i t s f a c i l i t i e s w i t h other groups of s u f f e r e r s whenever p o s s i b l e . I t has always shown i t s e l f w i l l i n g t o cooperate w i t h other agencies and i n general community planning f o r comprehensive r e h a b i l i t a t i o n s e r v i c e s . But i t has never surrendered i t s r i g h t t o do what i t could f o r s u f f e r e r s now t o prevent f u r t h e r d i s a b i l i t y without w a i t i n g f o r the " u t o p i a " of complete community s e r v i c e s , p e r f e c t l y coordinated t o become a r e a l i t y . In a democracy i n d i v i d u a l s and o r g a n i z a t i o n s must always have t h i s r i g h t and our s o c i e t y would be the poorer without t h e i r e f f o r t s . C e r t a i n l y the X 68 thousands of people who have been helped w i t h the d i s a b i l i t i e s caused by these extremely p a i n f u l and d i s t r e s s i n g c o n d i t i o n s and the ones who have been prevented from f u r t h e r disablement would have no doubt at a l l that t h i s was the r i g h t approach. I n the next s e c t i o n another agency which d i d not wait f o r "the government to do i t " w i l l be dis c u s s e d . The Canadian P a r a p l e g i c A s s o c i a t i o n This o r g a n i z a t i o n was chosen as r e p r e s e n t a t i v e of a h i g h c a l i b r e " s e l f - h e l p " group formed by the handicapped themselves to meet some of t h e i r own needs. Such org a n i z a t i o n s play an important r o l e i n the o v e r a l l network of s e r v i c e s . They f i l l needs which cannot be met so w e l l by government p r o v i s i o n s nor by any other type of community s e r v i c e . I n r e h a b i l i t a t i o n centres, p a t i e n t s say that one of the greatest sources of as s i s t a n c e t o them i n the various stages of " a d j u s t -ment" t o t h e i r d i s a b i l i t y (as o u t l i n e d i n Chapter I) i s the encouragement and help they get from other p a t i e n t s who have a l s o had t o l e a r n t o "cope". This o r g a n i z a t i o n provides t h i s s e r v i c e along w i t h others to paraplegics both while they are h o s p i t a l i z e d and when they are back i n the community. This growing volu n t a r y o r g a n i z a t i o n f o r people d i s a b l e d and classed as p a r a p l e g i c s , or quadraplegics, has a membership of over 600 i n B r i t i s h Columbia and has an X 6 9 increase of 6 0 members a year. The A s s o c i a t i o n i s concerned about the w e l l - b e i n g of i t s members and has been instru m e n t a l i n improving the s i t u a t i o n f o r them by keeping a close l i a i s o n w i t h newly impaired p a r a p l e g i c s and t h e i r f a m i l i e s , spending time e i t h e r v i s i t i n g i n h o s p i t a l s or at the G.P. Strong Centre, w i t h f i e l d t r i p s to paraplegics i n other parts of B.C. The purpose i s to create hope f o r the p h y s i c a l and v o c a t i o n a l r e h a b i l i t a t i o n of those who are newly pa r a p l e g i c and t r y to e l i m i n a t e emotional' problems that might prevent t h i s . The A s s o c i a t i o n was instrumental i n o b t a i n i n g a male nurse f o r the V i c t o r i a n Order of Nurses, the f i r s t time, J u l y 1 9 6 1 , such a program had been undertaken i n Canada. Because of the success a second male nurse was h i r e d . Together these two made over 2 , 0 0 0 home v i s i t s i n 1 9 6 1 . The nurses r e f e r many d i s a b l e d to the p a r a p l e g i c a s s o c i a t i o n . The development of t h i s service i s another good example of what a v o l u n t a r y agency can do while other groups may be able to do no more than recommend time and again that t h i s s e r v i c e should be s t a r t e d . There i s a l i m i t e d male nursing s e r v i c e i n Vancouver, quite i n s u f f i c i e n t t o meet the needs of a l l the p a t i e n t s who could b e n e f i t from i t . This includes p a t i e n t s w i t h g e n i t o - u r i n a r y d i s o r d e r s , some stroke p a t i e n t s and others. When t h i s s e r v i c e cannot be obtained i t o f t e n means that a p a t i e n t has to stay i n a h o s p i t a l or nursing home. With i t he can o f t e n f u n c t i o n i n X 70 the community. C e r t a i n l y he can l i v e at home. The P a r a p l e g i c A s s o c i a t i o n obtained i t f o r t h e i r own members, -another example of a vo l u n t a r y s o c i e t y which took the view that i t could do something now to help i t s members d e a l w i t h d i s a b i l i t y and that i t should without w a i t i n g f o r general community d e c i s i o n s to be reached as t o who should provide the s e r v i c e on an o v e r a l l b a s i s f o r a l l the people who could b e n e f i t from i t . Not only does the c l i e n t b e n e f i t but the cost t o the community i s considerably reduced. Fol l o w i n g i s a case t o i l l u s t r a t e t h i s p o i n t . A quadreplegic p a t i e n t , discharged from h o s p i t a l a f t e r being h o s p i t a l i z e d f o r nine years and now earning a l i v i n g , 1 e n t a i l e d the f o l l o w i n g c o s t s : h o s p i t a l care 15,000 a year or a t o t a l of $45,000. Because of'male nursing s e r v i c e provided by the V i c t o r i a n Order of Nurses he was able t o leave h o s p i t a l and have the required nursing care at home wi t h the necessary s p e c i a l equipment. The P a r a p l e g i c A s s o c i a t i o n runs a job placement s e r v i c e w i t h two r e h a b i l i t a t i o n o f f i c e r s . During 1963 these two o f f i c e r s contacted 40 new companies regarding employment f o r p a r a p l e g i c s . They made eleven permanent placements and many f u t u r e prospects. During a f i v e year p e r i o d , from 1959 when the s e r v i c e began, t o 1963, 84 permanent placements were Canadian P a r a p l e g i c A s s o c i a t i o n , Personal i n t e r v i e w w i t h Mr. D. Mowat, March, 1965. X 71 made. Ninety-five percent of the positions were f i l l e d by people who were confined to wheelchairs, five v percent to people with varying degrees of d i s a b i l i t y . Of the 84 placements 68 are s t i l l employed by the same company. The occupations most productive for the physically disabled have been so far electronic assembly woners, cardex clerks, dispatching PBX operators, typists, general office workers, packaging and bench assembly workers.1 In their experience they have found, as have rehabilitation officersdealing with the physically disabled elsewhere, that there are three main groups: (1) the top 25$ who need l i t t l e assistance to obtain re-employment; (2) the middle 50$ who need some retraining to become employable; and (3) the bottom 25$ who may be unemployable; bacaisa of the severity of their d i s a b i l i t y , lack enough formal education or a marginal work history. The Poliomyelitis Vocational and Rehabilitation workshop is a valuable service to the third group and three people were referred there i n 1963 for further vocational training. Three others, given on-the-job training-in-industry were ready for employment in 1964. The vocational officers of the Paraplegic Association have found that the employment of paraplegics in temporary 1 Canadian Paraplegic Association 7th Annual Report, British Columbia Division, Vancouver, 1963, p. 12 . X 72 work i s a valuable experience. I t i s b e t t e r close at home, or at the A s s o c i a t i o n o f f i c e or on the job. The work i s u s u a l l y t y p i n g and packaging. Aside from employment at an average of $1.00 an hour, i t i s t h e r a p e u t i c and gives the r e h a b i l i t a t i o n o f f i c e r an on the job assessment of the handicapped person. The need i s , however, f o r a place f o r more t r a i n i n g such as that provided by a s h e l t e r e d workshop. One c h a r a c t e r i s t i c of t h i s s o c i e t y has always been the close c o o r d i n a t i o n of a l l aspects of the r e h a b i l i t a t i o n process. I t involves c a r e f u l medical assessment, i n t e n s i v e r e s t o r a t i v e treatment, p a i n s t a k i n g v o c a t i o n a l assessment, training,placement, and follow-up w i t h the c o u n s e l l i n g r o l e a v i t a l one at each stage of the process. This i s an example of a comprehensive approach but l i m i t e d t o a s p e c i a l category and provided by a " p r i v a t e " agency. The A s s o c i a t i o n i s concerned about a h o s t e l f o r those attending the G.F- Strong Centre as outpatients and f o r those who may need a d d i t i o n a l t r a i n i n g such as that o f f e r e d by the P o l i o m y e l i t i s R e h a b i l i t a t i o n workshop. At one point they had hoped to b u i l d a h o s t e l w i t h t h e i r own funds, but have had to abandon t h i s as an A s s o c i a t i o n p r o j e c t . The p h y s i c a l l y handicapped are very concerned about accommodation as there i s no p r o v i s i o n f o r s p e c i a l accommodation f o r them through the N a t i o n a l Housing Act as administered by C e n t r a l Housing and Mortgage. E l d e r l y X 73 people do q u a l i f y but the handicapped do not although they c e r t a i n l y have s p e c i a l and sometimes expensive housing needs. The P o l i o m y e l i t i s and R e h a b i l i t a t i o n Foundation and the Canadian P a r a p l e g i c A s s o c i a t i o n have been s e t t i n g up a comprehensive housing r e g i s t e r of s u i t a b l e accommodation f o r wheelchair cases t o t r y t o e l i m i n a t e the problem of housing that c u r r e n t l y e x i s t s f o r them. I n a d d i t i o n to t h i s the A s s o c i a t i o n i s concerned, along w i t h the D i v i s i o n of the Handicapped, f o r the need t o design p u b l i c b u i l d i n g s so that they can be used by the handicapped who must use wheelchairs and by the aged who o f t e n cannot manage s t a i r s . The P a r a p l e g i c A s s o c i a t i o n r e c e i v e s an annual grant from the B.C. government. I n 19&3 i t r e c e i v e d from the province $ 7 , 3 5 0 . 0 0 and $12,500.00 from the head o f f i c e ; some of these funds were F e d e r a l Grants t o the N a t i o n a l A s s o c i a t i o n . The S o c i e t y continues to grow as the number of paraplegics i n the community i n c r e a s e s . The c h i e f source of pa r a p l e g i c a f f l i c t i o n s used t o be i n d u s t r i a l accidents but i s now automobile I n j u r y . The increased number of women d r i v i n g has increased the number of women paraplegics each year, from 5 t o 8$ up to 3 0 $ . I f the P a r a p l e g i c A s s o c i a t i o n has operated on the basis of "what can we do now t o meet the needs of our members", some non-self help groups have asked themselves X 74 the questions"where are we most needed now? How can we adapt ourselves t o meet the greatest amount of need now"? The next o r g a n i z a t i o n to be discussed i s an example of t h i s response by a p r i v a t e agency. The P o l i o m y e l i t i s and R e h a b i l i t a t i o n Foundation The P o l i o m y e l i t i s Foundation, which began i n 1944 as a p r o j e c t of the Kinsmen Club, had a r a p i d growth due to p o l i o epidemics w i t h i n the province of B r i t i s h Columbia. P o l i o was brought under c o n t r o l by S a l k v a c c i n e , but the c r i p p l i n g aftermath concerned the Foundation which developed a comprehensive province-wide program t o help the v i c t i m s "walk and work again." With the e x t e n s i o n of s e r v i c e s t o t h i s one group of handicapped, i t became apparent that there were many unmet needs of the handicapped w i t h i n the community which must be met. The Foundation thus decided that i t would f i l l i n the r e h a b i l i t a t i o n gaps f o r other groups of people w i t h d i s a b i l i t i e s and so i t has a very f l e x i b l e and v a r i e d group of s e r v i c e s t o p h y s i c a l l y handicapped adu l t s and c h i l d r e n . I t s t a t e s , i n i t s manual, that s e r v i c e s have been extended to a l l persons w i t h o r t h o p a e d i c a l l y d i s a b l i n g c onditions or p h y s i c a l d e f o r m i t i e s , where the s e r v i c e required i s not o f f e r e d by another e x i s t i n g agency.1 1 The P o l i o m y e l i t i s and R e h a b i l i t a t i o n Foundation of B r i t i s h Columbia Handbook of S e r v i c e s , Vancouver, 1963, p. 2. X 75 Their purpose i s to sponsor s e r v i c e s f o r the p h y s i c a l l y d i s a b l e d . I t does not operate i t s own medical centre but buys the s e r v i c e s of the G.F. Strong Centre, h o s p i t a l s or other agencies where r e q u i r e d . The second program of the Foundation i s speech and hearing s e r v i c e s . These are d i v i d e d i n t o two p a r t s : (1) a c e n t r a l c l i n i c l o c a t e d i n Vancouver f o r the d i a g n o s i s , c o u n s e l l i n g and therapy of c h i l d r e n , and (2) f i e l d s e r v i c e s of a t r a v e l l i n g speech t h e r a p i s t i n some areas of the province w i t h others attached t o Health U n i t s . The Foundation hopes to expand t h i s program throughout the province. A t h i r d and most s i g n i f i c a n t program from the viewpoint of meeting an important and as yet l a r g e l y unmet r e h a b i l i t a t i o n need, i s the V o c a t i o n a l Services Program of Vancouver. I t s purpose, as described i n i t s brochure, 1 i s t o provide a s k i l l e d v o c a t i o n a l assessment t r a i n i n g and work placement to a l l persons over the age of 18 who are handicapped and r e q u i r e the s e r v i c e s of the program because of t h e i r d i s a b i l i t y . There i s a l i m i t , as those who can e i t h e r be t r a i n e d through the Vancouver V o c a t i o n a l I n s t i t u t e or s i m i l a r p r o v i n c i a l i n s t i t u t i o n s and those who can be d i r e c t l y placed through the N a t i o n a l Employment Service w i l l not be e l i g i b l e . The Centre i s concerned w i t h handicapped people who are Handbook of S e r v i c e s , o p . c i t . pp. 9-11 X 76 r e h a b i l i t a b l e although i t w i l l accept those who are b o r d e r l i n e cases where assessment and aptitude t e s t i n g are required by the O f f i c e of the P r o v i n c i a l Co-ordinator. The f u n c t i o n of the program i s t o help people who are d i s a b l e d , e i t h e r e m o t i o n a l l y , mentally or p h y s i c a l l y , through v o c a t i o n a l a p p r a i s a l , t o be conditioned t o a work s i t u a t i o n and to b u i l d up work t o l e r a n c e s . The o b j e c t i v e i s t o t r a i n them at some r e l a t i v e l y simple s k i l l s and prepare them t o enter the working world. C u r r e n t l y f i f t e e n s e l e c t e d candidates are being given the s e r v i c e o f f e r e d by the Foundation and 45 a year are now being trained.To accommodate between 30 and 40 at a time the Foundation plans t o enlarge the f l o o r space. The program includes s p e c i a l i z e d v o c a t i o n a l t e s t i n g , c o u n s e l l i n g , a c o n t r o l l e d work s i t u a t i o n i n the workshop and c l e r i c a l sdhool and job placement s e r v i c e when t r a i n i n g i s completed. I t provides an e v a l u a t i o n and adjustment centre of the highest p o s s i b l e p r o f e s s i o n a l c a l i b r e . A s t a f f - c l i e n t r a t i o has been set up which gives comprehensive as w e l l as i n t e n s i v e s e r v i c e based on close s t a f f - c l i e n t r e l a t i o n s h i p s . This i s on the basis of seven c l i e n t s t o one s t a f f member and does not include a d m i n i s t r a t i o n . , C u r r e n t l y on s t a f f i s a p s y c h i a t r i s t who i s h i r e d on a one-day-a-week b a s i s . He sees c l i e n t s one week and holds s t a f f conferences the next. The philosophy i s to be a f u n c t i o n i n g and dynamic program X 7 7 of s e l f - e x a m i n a t i o n and s e l f - u n d e r s t a n d i n g upon the part of the s t a f f i f the centre i s t o be the "enabler" i t has set out t o be. Other s t a f f include a c o n s u l t i n g p h y s i c i a n , a s t a f f psychometrist, a teacher and c l e r i c a l i n s t r u c t o r , a shop s u p e r v i s o r , a placement offi c e r ( w h o i s a l s o contract s o l i c i t o r ) , and a d i r e c t o r who i s a t r a i n e d psychologist and p r e s e n t l y doing a l l the intake i n t e r v i e w i n g and c o u n s e l l i n g i n a d d i t i o n t o administering the program. Upon the expansion of t h e i r program to include from 3 0 to 40 c l i e n t s there w i l l be increased s t a f f s an a s s i s t a n t teacher and c l e r i c a l i n s t r u c t o r , an a s s i s t a n t shop s u p e r v i s o r , a s o c i a l w orker-vocational c o u n s e l l o r , a s t a f f s e c r e t a r y and a part-time bookkeeper. The opportunity t o o f f e r d i r e c t s u p e r v i s i o n i s the key to the program which i s e s s e n t i a l l y geared t o g i v i n g s o c i a l t r a i n i n g and s k i l l as being one of the most b a s i c requirements of any job s i t u a t i o n . Being on time, the l e a r n i n g of c o n s i d e r a t i o n and courtesy t o o t h e r s , i s of fundamental importance. The a t t i t u d e , of course, of the d i s a b l e d person to h i m s e l f and h i s handicap i s , t h e r e f o r e , of paramount importance i n terms of h i s adjustment to h i s s i t u a t i o n and a l s o , t h e r e f o r e , h i s adjustment t o o t h e r s . Often the emotional a t t i t u d e s of the handicapped person can be much more d i s a b l i n g than the p h y s i c a l causes of them. Because the emphasis i s upon the p s y c h o l o g i c a l and s o c i a l f a c t o r s , the d i r e c t o r has included i n the f i f t e e n X 7 8 people c u r r e n t l y on the program h a l f who have had problems of mental maladjustment. He has found i n h i s experience that t h i s r a t i o of p h y s i c a l t o mental d i s a b i l i t y works w e l l and that the two d i f f e r i n g types t h e r a p e u t i c a l l y complement each o t h e r . 1 The program f u n c t i o n s around the workshop s t r u c t u r e , using work t a s k s , not only as an e v a l u a t i v e method but a l s o as a way t o u t i l i z e developing work s k i l l s i n the handicapped. There i s a p r i n t i n g press and job contracts are u t i l i z e d , such as making paint samples f o r show room d i s p l a y . There are assessments and records kept on each d i s a b l e d person. When he has f i n i s h e d h i s t r a i n i n g — the period of time v a r i e s f o r each person — he w i l l be helped i n t o employment by the Foundation. The s e r v i c e s of the N a t i o n a l Employment S e r v i c e , S p e c i a l Placement S e c t i o n , are u t i l i z e d , e s p e c i a l l y the New Westminster S e c t i o n as a very close l i a i s o n has developed between there and the Foundation. There i s a l s o a close s e r v i c e between the P r o v i n c i a l Co-ordinator's Department and the Foundation as a l a r g e number of cases are r e f e r r e d by the Co-ordinator 1 s O f f i c e . R e f e r r a l s from other parts of B.C. are e i t h e r made through the P r o v i n c i a l R e h a b i l i t a t i o n Committee's r e p r e e n t a t i v e t o the P r o v i n c i a l Co-ordinator's O f f i c e , i f l o c a l committees have been 1 P e r s o n a l i n t e r v i e w w i t h Mr. A. Bowers, D i r e c t o r , V o c a t i o n a l and Services Program P o l i o m y e l i t i s and R e h a b i l i t a t i o n Foundation, March, 1 9 6 5 . X 79 e s t a b l i s h e d , o r , where government r e h a b i l i t a t i o n committees do not e x i s t from Kinsmen's groups, through the D i r e c t o r of the Foundation i n Vancouver. The S o c i a l Welfare Branch r e f e r s through the Co-ordinator's O f f i c e i f there are no l o c a l r e h a b i l i t a t i o n committees set up. The funds f o r the V o c a t i o n a l R e h a b i l i t a t i o n Centre are provided through the March of Dimes. Se r v i c e to the government i s paid f o r on a per case bas i s as no Health Grants are received from the p r o v i n c i a l government by the R e h a b i l i t a t i o n Centre. This s e r v i c e was chosen as an example of a p r i v a t e agency attempting t o provide three very expensive kinds of r e h a b i l i t a t i o n s e r v i c e s , and succeeding i n so doing. D i a g n o s t i c and t h e r a p e u t i c c l i n i c s , speech and hearing s e r v i c e s and s h e l t e r e d workshop f a c i l i t i e s are among the most expensive of a l l s e r v i c e s t o provide. The l a t t e r represents one of the greatest unmet r e h a b i l i t a t i o n needs i n the lower mainland. I t Is s i g n i f i c a n t that under the present d i v i s i o n of powers the f e d e r a l government would hot i n c l u d e as shareable costs any expenses incurred i n the s e t t i n g up of such a s e r v i c e , the p r o v i n c i a l government has so f a r not seen f i t t o i n i t i a t e i t , and t h e r e f o r e p o s s i b l y q u a l i f y under one of the agreements f o r aid i n maintaining i t , and i n the absence of i n i t i a t i o n by e i t h e r l e v e l of government, a p r i v a t e agency has gone ahead w i t h the i n a u g u r a t i o n of such a s e r v i c e . U n f o r t u n a t e l y , i t cannot meet a l l the chronic X 8 0 needs of the lower mainland f o r s e r v i c e s of t h i s k i n d . The D i v i s i o n f o r the Guidance of Handicapped has t r i e d t o point out community-needed s e r v i c e , such as a s h e l t e r e d workshop. I t has set up and studied a t h e o r e t i c a l s i t u a t i o n w i t h the hope that one agency w i l l undertake t h i s p r o j e c t as a badly needed community s e r v i c e . So f a r , the workshop s i t u a t i o n of the type seen as needed, has not had an agency backer, though a number would be i n t e r e s t e d i f they had s u f f i c i e n t funds. R e h a b i l i t a t i o n f o r the Aged and the C h r o n i c a l l y 111 This group of s e r v i c e s was chosen as exemplifying most of the weaknsses of the present d i v i s i o n of r e s p o n s i b i l i t y to the detriment of i n c r e a s i n g l y l a r g e numbers of the p o p u l a t i o n . I n B r i t i s h Columbia the f i g u r e f o r the aging p o p u l a t i o n i s higher than that of Canada g e n e r a l l y , due i n part t o the retirement of o l d people t o a milder c l i m a t e . The problem of aging i s one of concern t o the province as a whole but more p a r t i c u l a r l y t o the centres of p o p u l a t i o n such as Vancouver and V i c t o r i a where old people come and congregate because of a v a i l a b l e s e r v i c e s . There are three classes of people i n need of chronic care: the young with chronic diseases who need r e h a b i l i t a t i o n , but cannot always respond at the pace required i n the acute h o s p i t a l s ; the aging who s u f f e r from cancer, heart and blood X 81 v e s s e l and kidney d i s e a s e s ; and the aging who s u f f e r from chronic degenerative c o n d i t i o n s who w i l l need d o m i c i l i a r y care. There i s no doubt that those w i t h c h r o n i c diseases do not at the present time r e c e i v e the kind of care best s u i t e d t o them, and a l s o they b o t t l e - n e c k acute h o s p i t a l f a c i l i t i e s badly needed f o r the a c u t e l y i l l . Most of the h o s p i t a l c o n s t r u c t i o n i n the province has been of "acute 11 h o s p i t a l s , not f a c i l i t i e s f o r the c h r o n i c a l l y i l l . The problem at the present time i s how the c h r o n i c a l l y i l l can be best helped as a l l the f a c i l i t i e s i n the Vancouver area, i n c l u d i n g p r i v a t e nursing and boarding homes, are g r e a t l y s t r a i n e d and are inadequate. People may r e q u i r e nursing which cannot be given them at home. Sometimes they need only short periods i n h o s p i t a l but could be at home i f there was an adequate home-care program. In t h i s way not only would the c h r o n i c a l l y d i s a b l e d person b e n e f i t , but a l s o the community as a whole as acute care beds would not be overloaded w i t h chronic p a t i e n t s . There i s a t o t a l of 400 beds at the Holy Family H o s p i t a l , at Marpole I n f i r m a r y ( p r o v i n c i a l ) and Mount S t . Francis at Nelson ( a l s o p r o v i n c i a l ) that provide Infirmary care as w e l l as the Old Men's Home at Kamloops. The Infirmary at Marpole has a program of r e c r e a t i o n a l therapy t o improve the morale of the p a t i e n t s ; i t does not however, pretend to have a r e h a b i l i t a t i o n program as such. X 82 I n the Vancouver General H o s p i t a l there i s a 12 bed A c t i v a t i o n Ward. The p r o v i n c i a l government has agreed t o the need f o r a chronic h o s p i t a l f o r sometime and one has been promised f o r a number of years but there has been no a c t i o n . Consequently the s e r v i c e s , few as they are i n Vancouver, such as Glen, Grandview and Heather Annex, provide a t o t a l of 280 beds. These are f o r c u s t o d i a l care. There are no r e h a b i l i t a t i o n s e r v i c e s although i t has been estimated by a Community Chest and C o u n c i l survey that at l e a s t 36$ of the p a t i e n t s i n these three s i t u a t i o n s would b e n e f i t from a c t i v a t i o n and r e h a b i l i t a t i o n programs i f they were available-!-The Holy Family H o s p i t a l has an a c t i v a t i o n ward which has o f f e r e d s p e c i a l h e lp to over 700 p a t i e n t s since 1961. This i s a 52 bed h o s p i t a l w i t h a physiotherapy s t a f f as w e l l as an o c c u p a t i o n a l therapy s t a f f , a part-time speech t h e r a p i s t and a c r a f t worker. The average pa t i e n t i s 71 years of age and stays an average of 50 days i n the h o s p i t a l . - Most r e f e r r a l s come from the acute h o s p i t a l s and e s p e c i a l l y S t . P a u l s . Only p a t i e n t s who are good prospects f o r r e h a b i l i t a t i o n are r e f e r r e d ; i t i s now performing a very valuable and much needed p u b l i c s e r v i c e i n r e h a b i l i t a t i o n w i t h the aged. The Holy Family H o s p i t a l has asked the government f o r extensions to double i t s bed c a p a c i t y . I t i s u n l i k e l y that t h i s w i l l 1 Community Chest and C o u n c i l of the Greater Vancouver Area, D i v i s i o n f o r Guidance of Handicapped. B r i e f to the RQal Commission i n Health S e r v i c e s concerning the R e h a b i l i t a t i o n of the P h y s i c a l l y Handicapped. Vancouver, December 1 9 6 l , p. 7. X 8 3 be granted because the trend seems to be toward b u i l d i n g up t h i s type of s e r v i c e i n the General H o s p i t a l s and i n a futu r e chronic h o s p i t a l complex. I t i s hoped, however, that o u t - p a t i e n t s s e r v i c e s and community programs w i l l be extended from the Holy Family H o s p i t a l , otherwise those who have been t r e a t e d on an i n - p a t i e n t b a s i s wiithout follow-up work w i l l d e t e r i o r a t e and r e q u i r e f u r t h e r in-care treatment. At present these s e r v i c e s are not covered by e i t h e r f e d e r a l or p r o v i n c i a l f i n a n c i a l a i d and are q u i t e beyond the means of a p r i v a t e h o s p i t a l to pro v i d e . The recommendation of the medical advisory committee under Dr. McCrearyis that there should be a P r o v i n c i a l R e h a b i l i t a t i o n H o s p i t a l which would concentrate upon s p e c i a l r e h a b i l i t a t i o n s e r v i c e s of a comprehensive nature i n one geographical lco a t i o n . This would be an assessment and c o n s u l t a t i o n s e r v i c e f o r a l l p a t i e n t s r e q u i r i n g s p e c i a l r e h a b i l i t a t i o n anywhere i n the province. I t would not only be a f o c a l point f o r i n f o r m a t i o n and research regarding medical and paramedical r e h a b i l i t a t i o n but i t would a l s o be a teaching and t r a i n i n g centre f o r those i n r e s t o r a t i v e medicine. Such a h o s p i t a l would have the a d d i t i o n a l advantage of becoming the f o c a l point of a l l government and community p h y s i c a l and v o c a t i o n a l s e r v i c e s of a r e h a b i l i t a t i v e nature and would f a c i l i t i a t e c o - o r d i n a t i o n of s e r v i c e s . I t recommended that the P r o v i n c i a l R e h a b i l i t a t i o n H o s p i t a l should be adjacent to the Vancouver General H o s p i t a l . X 8 4 A d d i t i o n a l recommendat ions were that the nursing home f a c i l i t i e s be assessed; that the p a t i e n t should not have to pay f o r the cost of nursing home care h i m s e l f but should be covered under the B r i t i s h Columbia H o s p i t a l Insurance S e r v i c e — a f t e r assessing the need of the pa t i e n t on an i n d i v i d u a l b a s i s . The Committee f u r t h e r s t a t e d that although c e r t a i n r e h a b i l i t a t i v e and s p e c i a l s e r v i c e s are part of the h o s p i t a l complex and d i f f i c u l t to arrange outside the h o s p i t a l s i t u a t i o n , unless the B r i t i s h Columbia H o s p i t a l Insurance S e r v i c e gives out-patient coverage, then acute h o s p i t a l bed space w i l l continue to be used Unnecessarily by people w i t h chronic c o n d i t i o n s . One important aspect of a home care program i s the general p r a c t i c t i o n e r ' s need f o r r e g u l a r home, boarding home or nursing home v i s i t s i f the person i s to be maintained outside the h o s p i t a l or i n s t i t u t i o n a l s i t u a t i o n . The a d d i t i o n a l need i s f o r home c r a f t s and would r e q u i r e v i s i t i n g o c c u p a t i o n a l t h e r a p i s t s as w e l l as p h y s i o t h e r a p i s t s t o help the person t o p h y s i c a l l y and emotionally m a i n t a i n themselves. Home occu p a t i o n a l therapy f a c i l i t i e s are non e x i s t e n t except through the Canadian A r t h r i t i s and Rheumatism S o c i e t y . The V i c t o r i a n Order of Nurses i s attempting t o 1 Report of the Medical Advisory Committee on R e h a b i l i t a t i o n Vancouver, May 2 0 , 1964,pp. 2 7 - 8 . X 8 5 s t a r t a d i v e r s i o n a l program through the D i v i s i o n f o r the Guidance of the Handicapped. R e h a b i l i t a t i o n s e r v i c e s f o r the c h r o n i c a l l y i l l and the aged should include home-maker s e r v i c e s . Though f o r t u n a t e l y these s e r v i c e s are a v a i l a b l e i n s m a l l q u a n t i t y i n some of the i n t e r i o r communities such as P e n t i c t i o n , w h i c h has s i x permanent and twelve p a r t i a l (under mu n i c i p a l g r a n t ) , there are few homemakers a v a i l a b l e i n the Vancouver area. Nine are w i t h the Family Service Agency and some housekeepers are h i r e d by the C i t y S o c i a l S e r v i c e Department. The Family Service Agency has done some p i l o t p r o j e c t work i n home-maker se r v i c e f o r the aged, but i t i s of a demonstration nature and does not purport t o cover the need, only t o demonstrate t h i s as a sound program f o r the aged and f o r the d i s a b l e d . The inadequacy of t h i s degree of s e r v i c e f o r the lower mainland p o p u l a t i o n i s s e l f - e v i d e n t . I f a chronic and g e r i a t r i c program i s t o achieve any kind of success i t must be based on sound planning of a co-ordinated nature, developing a s