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Role of the mental hospital in the provision of service to the adult psychotic patient by the Government… Colls, Muriel Helen 1976

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THE ROLE OF THE MENTAL HOSPITAL IN THE PROVISION OF SERVICE TO THE ADULT PSYCHOTIC PATIENT BY THE GOVERNMENT OF BRITISH COLUMBIA by M. HELEN COLLS B.A., The University of British Columbia, 1947 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA June, 1976 M. Helen Colls, 1976 / In p re sent ing t h i s t he s i s in p a r t i a l f u l f i l m e n t o f 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 t ha t permiss ion f o r ex tens i ve copying o f t h i s t he 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 ep re sen ta t i ve s . It i s understood that copying or p u b l i c a t i o n of t h i s t he s i s f o r f i n a n c i a l ga in s h a l l not be a l lowed without my w r i t t e n permi s s ion . Depa rtment The U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 Date i ABSTRACT T i t l e of the Thesis: The Role of the Mental Hospital In the Provision of Service to the Adult Psychotic Patient by the Government of British Columbia. Name of the Author: M. Helen Colls Submitted to the Department of Health Care and Epidemiology in partial fulfillment of the requirements for the degree of Master of Science. The dissertation discusses the provision of mental health care delivery by the Government of British Columbia, and the role and focus of Riverview Hospital i n a changing organizational environment. The developing policy of regional and community service necessitates reorganization of the hospital's programs, in order to integrate and coordinate the components of the system. The question of the optimal organization for delivery of service in Riverview is examined through a discussion of the theoretical background for the provision of care to the mentally disordered, the development of mental health services i n the province, and the alternatives and external-i t i e s which impinge on the provision and operation of the hospital's services. The intra-hospital planning, designed to effect an organizational response to environmental pressures, i s outlined. i i Thesis Advisory Committee: Dr. V.F. Mitchell (Chairman) Professor, Faculty of Commerce and Business Administration Dr. A.O.J. Crichton Professor, Department of Health Care and Epidemiology Mr. M.M. Warner Assistant Professor, Department of Health Care and Epidemiology i i i TABLE OF CONTENTS Page ABSTRACT i TABLE OF CONTENTS i i i LIST OF TABLES v i i LIST OF FIGURES . ix ACKNOWLEDGMENTS x PREFACE . x i CHAPTER I. Introduction . 1. The Classification of Mental Abnormality 1'. Provision of Services for the Mentally Disabled . . . . . . . . 4 The Role of the Mental Hospital . . \ • 8 Riverview Hospital . . 10 Organization of Provincial Mental Health Services . 11 I The Organization of the Institution: Riverview Hospital . . . 13 CHAPTER II. Provincial Government Mental Health Services . . . . 16 Asylums and Hospitals . . . . . . 16 Provincial Mental Health Services 19 Provincial Mental Health Services in the Community 20 Mental Health Planning Regions in British Columbia . . . . . . 28 CHAPTER III. Regionalization and the Community Approach to Treatment of Mental Illness in British Columbia 35 Community Mental Health Centres 38 Mental Health Centre Catchment Areas 41 Mental Health Centre Caseloads, and the Population of Mental Health Centre Catchment Areas . 45 iv TABLE OF CONTENTS (Continued) Page Comparison of Admission Rates and Caseloads of Mental Health Centres and Riverview Hospital 48 Discussion of Tables VII and VIII 61 The Greater Vancouver Mental Health Service . . . 64 Organization of the Greater Vancouver Service . . . . . . 66 Objectives and Operation of Community Care Teams . . . . 68 Admissions and Caseloads of Community Care Teams . . . . 69 CHAPTER IV. . Riverview Hospital: An Institution in Transition . 78 Growth and Development: 1904 to 1960 78 1960 to 1975: Fifteen Years of Transition . . . 81 Regionalization in Riverview Hospital 82 Riverview's Regionalization Committee 83 The Fraser Valley Pilot Regionalization Project . . . . . 86 Regionalization of Centre Lawn Unit 87 The C.A.P.S. Program . 90 Regionalization in Crease Unit . . . . . . 90 Organization of Riverview Hospital . 92 Structure 92 Management 95 Reorganization of the Hospital , 96 Development of a Proposal for Reorganization 98 Constraints on the Hospital and on Program Development . 102 Organizational Model . . . . . . 103 Proposed Programs 104 V TABLE OF CONTENTS (Continued) Page The Forensic Program 104 Vancouver Psychiatric Service 110 Provincial Psychiatric Service 114 Programs Four and Five 116 Extended Care and Medical Service 117 An Acute Medical and Surgical Service 118 A Specialized Continuing Psychiatric Care 118 A Continuing Care Service for Geriatric Patients . . . . . 118 A Social Rehabilitation Program 118 Program Four: Medical/Surgical 1 Health Services Interim Program Advisory Committee ... • 119 The Interim Advisory Committee, Program Five 120 Other Input to the Core Committee 121 Possibilities for the Future 121. CHAPTER V. Conclusion 124 Reorganization of the Health Department . . 126 The Altered Treatment Process 131 APPENDICES Appendix 1. Mental Health Legislation and Patients' Advocacy . . 141 Mental Health Legislation 141 Patients' Advocacy 143 The Mental Patients' Association 143. Mental Patients B i l l of Rights 144. Report of the Committee Considering Committal and Review Procedures . . . 146 Appendix 2. Inservice Staff Development at Riverview Hospital . . 150 v i TABLE OF CONTENTS (Continued) Page Appendix 3. Psychiatric F a c i l i t i e s in British Columbia, 1975 159 REFERENCES CITED 162 v i i LIST OF TABLES Table Page I Numbers of Patients, and Operating Costs, of Community and Residential Treatment: 1966 and 1974 . . . . . . . . . 27 II Mental Health Planning Regions . . . 29 III Inpatient F a c i l i t i e s . . . . . 33 IV Outpatient F a c i l i t i e s . . . . . . . . . . . . . . . . . . . 34 V Mental Health Centres and the School Districts Making up ; the Catchment Area of Each (1974) 42 VI Mental Health Centre Caseloads at- End of September, 1971 1974 - Mental Health Centre Population Projections, 1971-74, 78, 86 (1972, 73 pro-rated) • : . .- 46 VII Provincial Mental Health Regions, Service Areas, and School Districts. Mental Health Centres and Hospital Admissions, Admission Rates per 100,000 population, and Caseloads, 1972 . . 49 VIII Admissions, Rates of Admissions (per 100,000 population) and Caseloads of Patients by School District, Mental Health Centre, and Riverview Hospital, 1973 . . 55 IX Districts Included in the Metropolitan Vancouver Area . . . 68 X Admissions of Patients by Age, Sex and F a c i l i t y , 1973 . . . 71 XI Patients on Caseload by Age, Sex and F a c i l i t y , December 31, 1973 72 XII Admissions of Patients, Diagnosis by F a c i l i t y for the Mentally 111, 1973 . 73 XIII Patients on Caseload, Diagnosis by F a c i l i t y for the Mentally 111, December 31, 1973 74 XIV Riverview Outpatient Department. Admissions of Patients by Age and Sex, 1973 76 XV Riverview Outpatient Department. Patients on Caseload by Age and Sex, 1973 76 XVI Community Care Team Trends, September, 1974 . . . . . . . . 77 Continued. y i i i LIST OF TABLES (Continued) Table Page XVII Riverview Hospital Statistics from Each Mental Health Planning Region, 1968 . . 85 XVIII Riverview Hospital Statistics from Region 5: Greater Vancouver, 1968 . 91 XIX Adult Psychiatric F a c i l i t i e s in Vancouver Region General Hospitals, 1971 and 1975 136 ix LIST OF FIGURES Figure Page 1 Comparison of Admission Rates per 100,000 Population from Mental Health Planning Regions, to Mental Health Centres and to Riverview Hospital, 1972 and 1973 63 2 Proposed Organizational Model . . 105 3 Health Department Organizational Structure, 1974 . . . . 128 4 Organization of "Hospital Programs" 130 5 Health Sciences Centre Hospital: Diagrammatic Scheme of Current Operation 134 6 B.C. Hospitals: Beds Set Up for Use by Mental Service 135' i ACKNOWLEDGMENTS I am grateful to the members of my Thesis Committee, Dr. V.F. Mitchell, Dr. A.O.J. Crichton, and Mr. M.M. Warner, for their advice and patience during the preparation of the proposal and manuscript of this dissertation. I am also indebted to Dr. J.C. Johnston, Dr. W.J.G. MacFarlane, and the administration and staff of Riverview Hospital, for the support and encouragement offered me during the period of my employment by the provincial government Mental Health Branch. I appreciate the conscientious and excellent job which Mrs. Carole Szabo has done in typing the fi n a l text. x i PREFACE Issues about the way to provide services for the mentally i l l do not often surface to confront the public conscience, although they may be the subject of considerable debate among agencies and practitioners who are directly associated with those in need of these services. Occasionally the layman hears about what is needed, and what is not available, because a newsworthy event, usually with criminal overtones, involves an "ex-mental patient", or someone who obviously requires psychiatric evaluation. From time to time a crusading columnist w i l l decry the apparent lack of adequate f a c i l i t i e s ; or a particular group w i l l publicize the need for alternatives to those already in existence, or offer solutions or suggestions for what should be provided. These outbursts sometimes bring action in the specific areas to which they are directed, but the whole issue of what to do with society's mentally disabled members remains pretty far down the l i s t of priorities for the public conscience and purse. The layman accepts mental disability as a medical problem i f i t appears to require medical treatment; as a "welfare" problem i f the i n f l i c t e d person is not capable of supporting himself; and as a j u d i c i a l problem i f this person runs afoul of the law. While governments, psychiatrists, social agencies and volunteer organizations directly involved with the mentally i l l are cognizant of some of the needs, public pressure is seldom strong enough to e l i c i t a demand for sufficient funds and f a c i l i t i e s to provide adequate resources over the long run. What allocation i s available, therefore, must be spread over the whole spectrum of mental d i s a b i l i t i e s , and must be utilized to provide a great number of services for a great number of conditions. The issue of defining the magnitude and range of mental health x i i problems in the community, and how many of them governments should be prepared to take care of, must be faced. The British Columbia provincial government, having settled on a policy directed toward decentralized community treatment of mental i l l n e s s , finds i t s e l f s t i l l the proprietor of a centralized provincial f a c i l i t y -Riverview Hospital at Essondale. The question of the means to integrate and coordinate Riverview's services with those of developing community f a c i l i t i e s has been explored extensively by various government-appointed agencies and committees over the past ten to fifteen years. Recommendations, reports and proposals have been submitted, and organizational changes, in varying degrees, have been introduced. With more than thirty mental health centres established province-wide, and a metropolitan Vancouver network of mental health community care teams, as well as a growing number of psychiatric beds in general hospitals, the services of Riverview are expected to respond to the pressures generated by this provincial system of mental health care delivery. Rather than a single institutional organization for the delivery of service, this expanded system now includes a number of systems with interactions and interrelation-ships that compound the environmental forces acting on Riverview. The hospital's a b i l i t y to respond is constrained by i t s lack of autonomy to manage i t s own operations and control i t s own boundaries. Policy formulation, resource allocation, integration of services, and even some aspects of direct administration have in recent years been determined for the hospital by the Mental Health Branch of the Department of Health. Now that this Department has been reorganized into Hospital and Community x i i i Programmes, the direction of Riverview Hospital presumably l i e s with Hospital Programmes. The focus of the mental hospital is certainly changing: ten years ago Riverview had a much larger chronic patient population, whereas now many of these patients (although not a l l by any means) have been trans-ferred to other f a c i l i t i e s . The demand for admission of acutely psychotic patients continues,,-and the need for their adequate accommodation is apparent. Government sees the hospital's priority to l i e in i t s adaptation to the community model of care: the directives given Riverview to plan to "unitize", "regionalize" and "reorganize" i t s services imply that these services w i l l eventually be taken over or replaced by local regional services. The most recent excursion into.reorganization of the mental hospital began in 1973, when the Mental Health Branch Deputy Minister, Dr. Tucker, directed that Riverview was to be divided into five separate programs, each with i t s own administrative structure headed by a program-administrator and a c l i n i c a l director. These programs were: Greater Vancouver psychiatric services; psychiatric services for the rest of the province; medical/surgical health service; intermediate/personal care service; and a forensic service. Dr. Tucker appointed Riverview's Assistant Executive Director of Medical Services and i t s Director of Social Service as a hospital "Core Committee" to investigate and develop this reorganization. In so doing, the committee ran into opposition from the prevailing hospital hierarchy, _ xiv particularly the nursing organization, who saw themselves losing professional autonomy and control under the proposed administrative arrangement. Confronted with this opposition, the Deputy Minister relaxed the conditions for Unit reorganization, and offered the hospital an opportunity to participate in planning, through Unit Advisory Committees made up of a cross-section of the hospital staff and an expanded Core Committee. The Core Committee was now composed of the Assistant Executive Director, Medical Services, Dr. W.J.G. MacFarlane (chairman); the Director of Social Service, Mr. R.M. Ross; the Assistant Executive Director, Patient Services, Miss Marilyn Carmack; the Assistant Executive Director, Admin-istration, Mr. W.O. Booth; the Director of Psychology, Dr. Alan Clark; and to provide liaison with the Mental Health Branch, Dr. J.S. Bland, Co-ordinator of Mental Retardation and Children's Psychiatric Services. Dr. Vance Mitchell of the U.B.C. Faculty of Commerce and Business Administration, was appointed consultant to the Core. Committee. The Committee was to receive proposals from the Unit Advisory Committees and "other concerned organizations", and was to prepare a report on reorganization for the hospital Executive Director, Dr. J.C. Johnston, to forward to the government. The revised frame of reference was given to the hospital in February, 1974. At this time I was hired as Administrative Assistant to the Core Committee, and spent the next seven months coordinating the background and production of the Core Committee's report. As I was employed on a temporary basis, and was not a member of the Riverview staff, nor did I have any previous association with the Mental Health Branch, I was a relatively unbiased observer. The time spent on this project gave me a first-hand opportunity to observe the role of the hospital from the perspective of X V provincial health services, and the place i t occupies in the provision of mental health care. I acted as liaison between the Unit Advisory Committees and the Core Committee, and so could benefit from the points of view of both administration and staff. The constraints and physical limitations imposed by insufficient funds and centralized control, and their effect on the provision of care, were made abundantly clear. Clear, also, was the gap between possibility and actuality in the plans that had been laid down for the future provision of service. As the Core Committee's report progressed towards completion, i t became evident that most of the input was directed towards a delineation of the resources that each Unit, and the hospital as a whole, believed were necessary to meet the objectives of patient service. A l l the committees were goal-oriented in their analysis of the organization. The resulting "Proposal for the Reorganization of Riverview Hospital"^ describes the optimal organization of the hospital as seen from within the boundaries of the hospital and of each component. A broader perspective, based on the over-all system of provincial services for the mentally i l l , seems to be required in order to establish the future orientation of the hospital. Core Committee of Riverview H o s p i t a l . Proposal f o r the reorganization of  Riverview H o s p i t a l . Mimeo. August, 1974. 1 CHAPTER I Introduction The Classification of Mental Abnormality The historical development of mental health services in Canada has followed much the same process as in Britain and the United States. Canada inherited from Britain a number of concepts about insanity and criminal behavior, and federal and provincial responsibilities for the insane are delineated by the British North America Act. Jones (1960, 1966, 1972) ittraces the development of services in Britain, and notes the "growing acceptance of the idea of a diversified system of care,"''' while Deutsch 2 (1949) charts the history of the care and treatment of the mentally i l l , particularly from colonial times in the United States. The kind of attention given to people who exhibit mental disorder and deviance has been a function of the way in which their behavior has 3 been classified. Crichton (1974) suggests that the term "mental disorder" is diagnostic and treatment oriented, but in attempting to control the residual deviance of mental disorder, society has had great d i f f i c u l t y in sorting, out and labelling i t , and in distinguishing between the limits of tolerable and deviant behavior, and between the criminal and the insane. As Jones, K. Mental health and social policy: 1845-1959. London: Routledge and Kegan Paul, 1960. Deutsch, A. The mentally i l l in America. New York: Columbia University Press, 1949. Crichton, A.O.J. Mental health and social policies. In press, 1975. 2 4 Mercer (1973) points out, "Persons have no names and belong to no class un t i l we put them in one." The sick r o le—the "mentally i l l " — a n d i t s accompanying disability lends i t s e l f to a concept of medical treatment, but this does not extend to the impairment that is shown in retardation and long-term chronicity. Mercer examines the models of labelling the retarded from a c l i n i c a l and social system perspective, and discusses the divergence between the two. O'Conner (1973)^, in a bibliography on the sociology of mental illn e s s , gives fifty-one references on labelling, covering o f f i c i a l labels, nosologies, classification and ideology, normality and abnormality, disease models, interactional models and 'others, and meanings of mental health. Studies dealing with the development, manifestations, distribution and treatment of diagnosed mental illness, as related to social class, were undertaken by Hollingshead and Redlich (1958) , and followed up by Meyers and Bean (1968), who attempted "to determine whether or not social class i s related to the outcome of psychiatric treatment and to the adjustment of former patients in the community."^ The question of whether the condition Mercer, J.R. Labelling the mentally retarded. Berkeley: the University of California Press, 1973. O'Connor, J. Bibliography on sociology of mental ill n e s s . Vancouver: University of British Columbia, Dept. of Sociology, 1973. (Unpublished.) 'Hollingshead, A.B., & Redlich, F.C. Social class and mental ill n e s s . New York: "John Wiley & Sons, 1958. Meyers, J.K., & Bean, L.L. A decade later: a follow-up of social class  and mental i l l n e s s . New York: John Wiley & Sons, 1968. 3 i s r e a l l y one of i l l n e s s , or i s based on moral issues and normative standards i s examined by Szasz (1961), who considers "the concept of mental g i l l n e s s to be unserviceable." That the problem of coping with mental abnormality has been one of c l a s s i f i c a t i o n i s demonstrated by the changes i n treatment over time, from a condition of control to one of support. In an e a r l i e r day, society considered those who exhibited mental disorder as possessed, or relegated them, with a l l i t s unacceptable deviants, into gaols. Later i t attempted to d i f f e r e n t i a t e on the basis of perceived i n d i v i d u a l r e s p o n s i b i l i t y , by constructing asylums for mental incompetents and developing a profession (psychiatry) to r e l a t e to them, a l b e i t i n a c o n t r o l l i n g r o l e . The treatment r o l e of the p s y c h i a t r i s t progressed concurrently with d i f f e r e n t i a t i o n of c l i e n t s into the si c k , the disabled, and the impaired, and under a medical model of i l l n e s s , moved from a c u s t o d i a l to a therapeutic image. While the medical model i s l e s s stigmatizing, p a r t i c u l a r l y when the treatment and h o s p i t a l image i s projected, protection of the s o c i a l order and the need for s o c i a l regulation are s t i l l i n t e g r a l parts of the system. Cumming (1968), discussing systems of s o c i a l regulation, notes that " i t i s more d i f f i c u l t f o r the s p e c i a l i z e d agent to be at once ov e r t l y supportive and c o n t r o l l i n g g because support and co n t r o l require d i f f e r e n t s k i l l s . " Szasz, T. The myth of mental i l l n e s s . New York: Hoeber-Harper, 1961. Cumming, E. Systems of s o c i a l regulation. New York: Atherton Press, 1968. 4 Provision of Services for the Mentally Disabled Concepts such as educational support for the mentally disabled, particularly the retarded, were advanced when efforts were made to segregate them in separate f a c i l i t i e s . Segregation of retarded children allowed implementation of programs to train and teach, as impairment in children can be seen as responsive to training, and new ideas are li k e l y to be adopted more readily. The impaired in mental hospitals.f however, were not -seen as capable of being helped under the medical model, and tended to remain as long-term chronic patients on back wards. The activity of voluntary agencies, and reports such as the Canadian Mental Health Association's "More for the Mind" ( 1 9 6 3 ) ^ , and that of the Commission on Emotional and Learning Disorders in Children (1970), gave attention to the supportive needs of the mental patient by suggesting coordination and integration of a total program of "psychiatric services" related "to the whole spectrum of organized social l i v i n g . " ^ The CELDIC Report proposed that there should be decentralization of decision-making to local levels, with an accompanying coordination of community services and an emphasis on supportive education programs for the mentally disabled child. More for the mind: a study of psychiatric services in Canada. Toronto: The Canadian Mental Health Association, 1963. Commission on Emotional and Learning Disorders in Children. One million  children: the CELDIC report. Leonard Crainford (Ed.). Toronto: Canadian Mental Health Association, 1970. With the developing focus on supportive mental health services has come a change i n the r o l e of the p s y c h i a t r i s t , from that of providing only p s y c h i a t r i c medical services to being a part of an i n t e r - d i s c i p l i n a r y 12 team (Laycock, 1971). Further, services should be provided i n and by the community. The concept of an integrated community agency which would under-take to serve the needs of the mentally i l l has been developing i n B r i t i s h 13 Columbia since the Ross Report (1961) paved the way with i t s recommendations fo r community-based services. At present t h i r t y mental health centres are operating i n the province, and a service i s under development i n Vancouver. The "Vancouver Plan" i s aimed at resolving some of the most pressing problems i n dealing with mental i l l n e s s i n the c i t y (Cumming, Coates and Bunton, 14 1973), and i t s Community Care Teams would take "primary r e s p o n s i b i l i t y f o r the care of serious mental i l l n e s s " ^ (Cumming, 1972). Kyle (1973), i n describing the Vancouver Project, notes that community mental health services 16 "can be t a i l o r e d to the sdciography of a geographical area". As i t i s planned, however, the service i s directed only to the disabled mentally i l l adult. 12 Laycock, S.R. Reflections on f i f t y years i n Canadian mental health. I I . Canada's Mental Health. Jan.-Feb. 1972, 26^29. 13 American P s y c h i a t r i c Association. Survey of mental health needs and  resources of B r i t i s h Columbia. Mathew Ross (Ed.). O f f i c e of the Medical Dire c t o r , American P s y c h i a t r i c Association, 1961. 14 Cumming, J . , Coates, D., & Bunton, P. Community cafe services i n Vancouver:  planning and implementation. Unpublished paper, June, 1973. (Available from the Vancouver Mental Health Service.) ^Cumming, J . Plan for Vancouver. 1972, unpublished. ^ K y l e , J.D. Presentation to the Canadian Mental Health Association. Paper presented at a meeting of the Canadian Mental Health Association, November 1, 1973. 6 D i f f i c u l t i e s encountered in community acceptance of i t s mentally disabled members have been studied by the Cummings (1957), ' ' ' ' ' but developing 18 emphasis on the community health centre concept (Hastings, 1972; Foulkes, 19 1974) suggests a diminution of the reluctance to accept community-based mental health care. Foulkes emphasizes equity and removal of stigma by integrating f a c i l i t i e s and support services into proposed Human Resource and Health Centres. The Hastings Report, however, has been cri t i c i z e d by Freeman 20 (1973) for i t s lack of recommendations on mental health services. In light of the suggestion that less stigma i s attached to mental abnormality by treating i t in an integrated health centre, i t might be noted that Goffman (1963), discussing information control and personal identity, makes the point of "the mental patient who gratefully finds that his place of committment i s 21 far out of town, and hence somewhat cut off from his ordinary contacts." [Emphasis added.] Cumming, E., & Cumming, J. Closed ranks: an experiment in mental health  education. Cambridge: Harvard University Press, 1957. Hastings, J.E.F. The community health centreain Canada. Report of the Community Health Centre Project to the Conference of Health Ministers, 1972. Foulkes, R.G. Health security for British Columbians. Report to the Minister of Health, Province of British Columbia. Victoria: Queen's Printer, March, 1974. Freeman, S.J.J. Mental health and the Hastings report. Canada's Mental  Health, XXI, 3 & 4, May-Aug., 1973. Goffman, E. Stigma. Englewood C l i f f s , New Jersey: Prentice-Hall, 1963. 7 Wharf (1974), writing on the delivery system of mental health services in urban communities, identifies some of the problems which have arisen because of the fragmented existing service and the way agency boundaries have been fixed. He suggests how the pattern of service might be improved by analysing the inadequacies of present services, evaluating, 22 and experimenting with "carefully planned and monitored diversity." Fragmentation of mental health services and lack of comprehensive system 23 management are further c r i t i c i z e d by Clarkson (1974) in his paper on Canadian systems in transition. Decentralization of f a c i l i t i e s and provision of community mental health services ahs been a developing concept in other provinces. The changes and developments which have taken place in Saskatchewan, Ontario, Nova Scotia and British Columbia, and trends which are apparent in Quebec are outlined by Crichton (1975). Alberta i s in the throes of reorganization of i t s Mental Health Division and of regionalization. Proposals for an integrated and coordinated delivery system are set out in the report of a two-year study of 24 mental health in Alberta (Blair, 1969). Wharf, B. The organization of mental health services i n the l o c a l community. Canada's Mental Health. 22, June, 1974, 12-15. 'clarkson, G. Systems i n t r a n s i t i o n . Canada':'' a c r i t i q u e . Paper, presented at the 98th annual meeting of the.American Association on Mental Deficiency, 1974. B l a i r , W.R.N. Mental health i n Alberta. Government of Alberta, 1969. 8 The Role of the Mental Hospital The developing community-based orientation for the delivery of mental health services, designed to enhance the scope of care and treatment and, as Bockoven ( 1 9 7 2 ) says, predicated on the "fundamental striving of 25 democratic peoples for social orientation," places the function of the mental hospital and the medical model of scie n t i f i c psychiatry in a transitional situation. The significance of "total l i f e experience in the treatment of mental illness " (Bockoven, 1 9 7 2 ) and studies of the environ-26 ment in which patients are treated (the Cummings, 1 9 6 2 ) , as well as external pressures brought to-bear on mental hospitals, necessitates a conceptual reorganization of the hospital's value in the mental health care system. Many of the population i t has served in the past are to be cared for by other resources, with the aim of treating the mentally sick, the disabled,, the retarded, and the aged and infirm as much as possible in community f a c i l i t i e s , thus providing a less stigmatized and labelled environment. This leaves the mental hospital to care for the most impaired: the institution-alized, those with severe organic brain damage, and those who are considered a danger to themselves and to society, and are not easily distinguished by legal and medical c r i t e r i a . The care of people in this residual group presents problems of classification that need to be c l a r i f i e d so that pro-fessionals can relate to them and help them. What should be done for them Bockoven, J.S. Moral treatment in community mental health. New York: Springer Publishing Co., 1 9 7 2 . Cumming, J., & Cumming, E. Ego and milieu. New York: Atherton, 1 9 6 2 . 9 by the institution and by the professions, and how can their condition be improved? The legal c r i t e r i a , for example, under which a patient is kept in the mental hospital may be inconsistent with psychiatric treatment; the anti-therapeutic effects of prolonged institutionalization have been well documented. Alternatives to the objectives, organization, management, limitations of treatment and anti-therapeutic environment presented by the large, isolated institutions have been proposed or implemented along a spectrum which' extends from reorganizing the hospital so that i t reaches out into the community 27 (Bockoven, 1972; Fisher, Mehr and Trukenbrod, 1974), to dismantling i t 28 completely and tearing i t down (Foulkes, 1974). A more objective purview places the hospital as one part or f a c i l i t y in a comprehensive system of mental health services. In this context, i t s overcentralization must be corrected so as to bring i t into closer interaction with community resources. Decentralization of the operations of mental hospitals "requires significant 29 and d i f f i c u l t administrative changes," as discussed in the Milbank Memorial Fund quarterly publication devoted to.this topic (1964). Fisher, W., Mehr, & Trukenbrod. Power, greed and stupidity in the mental  health racket. Philadelphia: Westminster Press, 1974. 'Foulkes, R.G. Health security for British Columbians. Report to the Minister of Health, Province of British Columbia. Victoria: Queen's Printer, March, 1974. Mental Hospitals join the community. New York: Milbank Memorial Fund, 1964. 10 Riverview Hospital • British Columbia has i t s mental hospital in transition: a typical "campus" of isolated, monolithic, outdated buildings, which at one time provided the only service available to most of the mentally i l l of the province. Now, with mental health centres f i l l i n g at least some of the needs, with psychiatrists in private practice, with a growing number of psychiatric beds in general hospitals? and with a government committed to local development of mental health services, what place should Riverview Hospital f i l l ? How may i t s f a c i l i t i e s and services be used to best advantage? This question—the optimal organization for delivery of service by Riverview H o s p i t a l — i s the central topic of this thesis. Riverview in 1974 found i t s e l f in a .transitional state; a position given to i t uni-laterally by policy determined and implemented by the provincial government, specifically the hospital's governing authority, at the time, the Mental Health Branch. The hospital i t s e l f can be f i t t e d into the typography of 30 organizations which Etzioni (1965) outlines. Its control structure is coercive, in i t s custodial role, and u t i l i t a r i a n , in i t s therapeutic context. Rules used to control the activities of patients and staff are predicated on c r i t e r i a of orderliness and usefulness. The degree to which these roles vary Etzioni, A. Organizational control structure. In J.G. March (Ed.), Handbook of Organizations. Chicago: Rand McNally, 1965. 11 within different areas of the hospital are governed to a large extent by social license and by attitudes of the external environment. As Etzioni points out, coercive organizations cannot be selective, and have to accept whomever i s sent to them. He notes, "When efforts are made to reduce coercion, as when...a therapeutic program is launched in a mental hospital, one of the f i r s t steps taken is to reselect the inmates and to increase the selectivity of prospective ones." The power indigenous to Riverview i s very, slight, as i t is defined by the Mental Health Act, and so i t i s d i f f i c u l t for the hospital to behave as a u t i l i t a r i a n organization, and even more d i f f i c u l t for i t to behave as a normative one. Instrumental control, by orders and rules, and participant alienation i s high in a coercive organization. The mental hospital, Etzioni says, i s low in pervasiveness in that the "formal authority limits i t s e l f to setting norms for activities i t has an interest in controlling." In i t s therapeutic context as a part of British Columbia's system of mental health services, however, Riverview must attempt to present a normative direction.. Riverview Hospital, then, may be defined as a quasi-coercive, quasi-normative institution. It i s s t i l l , to a large extent, the inpatient component of the provincial mental-health delivery system, but the number of patients, the method of their admission, their condition and the treat-ment they require, and their disposition on release are changing variables. Organization of Provincial Mental Health Services Developments in the external environment are also influencing the way the mental hospital's services are delivered. An appropriate perspective from which to examine the organization of the hospital can be formed by a 12 review of the development of mental health services i n the province, with s p e c i a l reference to t h e i r d i v e r s i t y of content and geographic d i s t r i b u t i o n . From t h i s h i s t o r i c a l background, the focus i s narrowed to a look at the present p r o v i s i o n of services by the p r o v i n c i a l government to the adult psychotic patient. The f a c i l i t i e s included i n t h i s context are Riverview H o s p i t a l , community mental health centres, and the Vancouver Service. (The Vancouver Service, while not under d i r e c t p r o v i n c i a l authority, i s included because i t i s developing under the auspices of the p r o v i n c i a l government. Valleyview Hospital and i t s s a t e l l i t e s , Skeenaview and Dellview, are not included, as they are s p e c i f i c a l l y f a c i l i t i e s f o r the "aged psychotic"; nor are Woodlands and T r a n q u i l l e , separate f a c i l i t i e s f o r the retarded, and now under the authority of the Department of Human Resources. Woodlands, however, i s noteworthy because i t i s moving ahead with the development of restructured programs and s t a f f training.) Community mental health centres and the Vancouver Service are cl o s e l y integrated with, and impinge on, the function of Riverview H o s p i t a l . The mental health centres and Centre Lawn Unit, and the Vancouver Service and wardsi-in Crease Unit, are intended by government p o l i c y to be interconnected, both i n a. patient-care and i n a s t a f f i n g continuum. Information about these components—Riverview Hos p i t a l , community mental health centres, and the Vancouver Ser v i c e — a r i d t h e i r present status i s a v a i l a b l e from o f f i c i a l p ublications and h o s p i t a l f i l e s . The p o l i c i e s determining p r o v i s i o n of community services, inpatient services, and the coordination of these with other agencies and f a c i l i t i e s (general h o s p i t a l p s y c h i a t r i c beds, r e h a b i l i t a t i o n u n i t s , forensic services, boarding home programs and other " l e v e l s of care" f a c i l i t i e s ) can be found i n government 13 publications and statements, legislative Acts, Riverview Hospital f i l e s , submissions from voluntary agencies, such as the Canadian Mental Health Association and the Mental Patients' Association, and writings on the objectives and development of the Vancouver Service by Cumming, Coates, Bunton and Kyle. Another level from which to look at policy formulation i s through reports such as those of the American Psychiatric Association (Ross, 1961), and Foulkes (1973), with their recommendations for British Columbia; reports dealing with the organization of services i n other provinces; and writers concerned with the Canadian health scene, such as Hastings (1972) 31 and Lalonde (1974). In addition, the Canadian Mental Health Association's More for the Mind (1963) and the CELDIC Report (1970),. had considerable impact on the direction of mental health policy. The Organization of the Institution ;of Riverview Hospital As a result both of the developing spectrum of mental health services in the province, and of the conditions under which i t operates, Riverview Hospital has been undergoing a period of reassessment and reorgan-ization designed to optimize i t s services relative to the overall provincial organization. From a "closed" system, l i t t l e affected?by pressures or alternatives in the external environment, i t has been directed to reorganize i t s structure into units which have the capability of integrating with other components of the system. Lalonde, M. A new perspective on the health of Canadians. Government of Canada Dept. of National Health and Welfare white paper. Ottawa: Queen's Printer, 1974. 14 From the original development and long-standing differentiation of i t s various buildings (acute and chronic, medical, and male and female divisions), the hospital was instructed in 1970 to "regionalize" i t s services, so as to coordinate with the regionalization of the province into 32 mental health planning areas. The suggestion implicit in this policy was to replace in the regions the services i n i t i a l l y assigned to Riverview. In 1973, while regionalization of one unit of the hospital had been partially implemented, the deputy minister directed that the hospital was to be reorganized into five relatively self-sufficient programs, "to f a c i l i t a t e more precise program planning and development on a functional basis" (memorandum from the Deputy Minister of Mental Health to Dr. J.C. Johnston, Executive Director, Riverview Hospital, November 13, 1973). Such restrictions on policy implementation as budgetary and staff-ing limitations, authority conflicts and p o l i t i c a l considerations commonly delay progress, and the hospital has encountered considerable d i f f i c u l t y in attempting to develop the f l e x i b i l i t y necessary to adapt to the terms of reference received from the Branch. The hospital's "Proposal for the Re-organization of Riverview Hospital" (1974) recommends development of programs with stated objectives and assigned resources which w i l l serve defined populations, and points out in i t s introduction, "We see the central issue of reorganization relating to the degree of functional autonomy which can be r e a l i s t i c a l l y vested in the designated Programs. We recognize that the Although the direction towards regional provision of services began in the nineteen-sixties, the present government committment is to increased impetus in the development of community services. 15 degree of autonomy which can be delegated Is directly proportionate to the amount of autonomy available." (Introduction to the Proposal, 1974.) The reorganization model outlined in the report is intended to permit,central direction while allowing functional autonomy within the proposed programs. Contributions to the planning which culminated in the report were made by a l l levels of staff, by a l l hospital departments, and by concerned organizations. Constrained by the terms of reference imposed, and cognizant of the potential for conflict inherent in proposed changes in management structure, the report represents a consensus. Since i t s completion and delivery to the deputy minister, no action towards i t s acceptance or implementation has been apparent. No doubt the present re-organization of the Health Department into Community Health and Hospital Programs w i l l necessitate a new perspective on the organization and operation of mental health f a c i l i t i e s in the province. In view of the confused state of program development in Riverview, i t seems important to investigate some of the forces operating in the hospital and in the larger community, and to outline the relationship between them and the proposed hospital reorganization. The future delivery of service by Riverview w i l l be affected by the emerging pattern of care in the province, which (correctly or incorrectly) is directed toward a four-tiered structure of community health centre, closed f a c i l i t y (day hospital or halfway house) for acute episodes, regional hospital psychiatric beds, and long-term care f a c i l i t y . 16 CHAPTER II Provincial Government Mental Health Services The history of mental health services in British Columbia i s a short one, as i t covers only the past hundred years. Perspectives and methods of treating the mentally disabled in the province have followed the cyclic trends typical of those elsewhere i n North America, although there are differences in the stage's of development that have been realized. Asylums and Hospitals "During the colonial period of the history of British Columbia, the only f a c i l i t y available for the mentally i l l was the common gaol."* (Foulkes, 1961) A building to contain and house the insane was f i r s t established by the British Columbia government in 1872, when the Royal Hospital (formerly a pest house) in Victoria accommodated seven patients. The following year an Insane Asylum Act was proclaimed, and in 1878 the Provincial Asylum was built in New Westminster, on the site where Woodlands now stands. A Royal Commission enquiry in 1894 into conditions at the Provincial Asylum reported that the institution was using cruel and inhuman methods that Foulkes, R.G. British Columbia mental health services: historical  perspective to 1961. Paper presented to the Annual Meeting of the Canadian Medical Association - B.C. Division, Section of Neurology and Psychiatry, April 24th, 1961. had been discarded in Great Britain more than a generation before. This report was followed by efforts to humanize the asylum, and improve the quality of i t s care. In 1897 i t was renamed the Public Hospital for the Insane, and an era of "Moral Treatment" began, marked by a therapeutic and humane atmosphere responsive to the patients' needs, and by emphasis on a medical model of diagnosis, treatment and care. This was accomplished under the direction of Doctors G.H. Manchester and C.E. Doherty, and the Provincial Secretarym' Dr. Henry Esson Young. (Provincial mental health services were established under the Provincial Secretary's Department, and remained so unt i l 1959, when they were transferred to the Department of Health Services and Hospital Insurance.) Moral Treatment in British Columbia lasted only from the beginning of the twentieth century u n t i l the f i r s t World War, when lack.of staff and over-crowding resulted in a return to merely custodial care. This concept, of providing the mentally disabled with a humane and supportive environment, was implemented f i r s t in 1793, by Philip Pinel, who released the insane at the Bicetre from their chains, and i t spread through Europe and America. The milieu therapy that i s advocated today invokes the principles of moral treatment; principles that are well-justified by the results obtained. It is unfortunate that the necessity to contain large and increasing numbers of social misfits within the limitations of government budgets caused this form of treatment to be neglected in British Columbia for nearly half a century. Other pressures on the use of public funds, and opposition to increased expenditures relegated the treatment of the mentally disabled to a low priority. Serious overcrowding at the Public Hospital for the Insane was 18 alleviated somewhat by planning a new hospital, and opening the f i r s t of i t s buildings in 1913. The hospital was named Essondale, after Dr. Henry Esson Young. It was situated on 1,000 acres in Coquitlam, and was planned as a series of buildings, each specialized in function, with adjacent residences for staff. This gave the province dual institutions, together called the Provincial Mental Hospital, but each new building completed at Essondale was immediately overcrowded. By 1950 there were more patients than beds, crowding out areas needed for therapy, and forcing a return to seclusion and restraints. In 1919, a prison at Saanich on Vancouver Island had been taken over to house the criminally insane. This was Colquitz, the Provincial Mental Home. In the same year, the Hollywood Sanitorium in New Westminster (70 beds) was started, and was the only recognized private treatment centre for mental disease un t i l psychiatric beds were established at the Vancouver General Hospital and at the. Royal Jubilee Hospital in Victoria. In 1936 the buildings of the Boys' Industrial School, adjacent to Essondale, were acquired for the aged psychotic. The problem of providing separate f a c i l i t i e s for the acute mental patient, the mentally defective, and the tubercular, was not solved un t i l the nineteen-fifties, but solutions were sought earlier: the Royal Commission of 1925, which dealt in great detail with mental deficiency, pointed out that the emphasis in this area should be educational rather than medical. In 1930 400 mental defectives were in residence at Essondale, and in 1932 a transfer of mentally retarded inmates to the Public Hospital for the Insane in New Westminster was begun, although the Schools for Mental 19 Defectives Act did not come into being un t i l 1953. Tubercular patients were not isolated until 1940, when two wards at Essondale were formed, and accommodated 300 cases, 200 of whom were classified "active". Provincial Mental Health Services Nineteen f i f t y marked the beginning of a new phase in the treatment of mental illness in the province. The various, government agencies were amalgamated into the Provincial Mental Health Services. Mental Health Divisions, governed by a "Hospital Council", were formed: the Active Treat-ment Services, Geriatrics Division, Preventative Services, Rehabilitation, and Research Divisions. The New Westminster mental hospital (P.H.I.) was renamed Woodlands School, direct admissions began there in 1953, and increased f a c i l i t i e s were bu i l t . Also provided were homes for the aged at Vernon and Terrace, a rehabilitation centre in Vancouver for discharged female patients, and the Crease Clinic of Psychological Medicine, dedicated to the intensive treatment of the acutely i l l and to education and research, was opened. The operation of Crease Clinic was facilitated by the 1951 Clinics of Psychological Medicine Act, which made voluntary admissions, and certified admissions without the loss of c i v i l rights, possible for a maximum period of four months. During the f i r s t year of operation, 791 of the 963 patients admitted were returned to the community within this four month statutory period. These encouraging figures promoted a degree of community involvement, with volunteer groups, the Canadian Mental Health Association, the Woodlands Auxiliary, and outpatient services gaining strength. The Burnaby Mental Health Centre opened in 1957, as did Venture, 20 a Vancouver rehabilitation centre for men. Further expansion included the building of Valleyview, an infirmary at the Home for the Aged, and the acquisition of Tranquille Sana-torium at Kamloops for retardates. At Essondale, the North Lawn building was opened in 1955 for tuberculosis treatment, and operating f a c i l i t i e s were provided in Crease Cl i n i c . ProvinciallMental Health Services in the Community Provincial mental health services policy changes which were directed towards the provision of community services began in the nineteen-forties. A considerable impetus was provided later by many studies and publications, such as the Canadian Mental Health Association's "More for the Mind" and the CELDIC Report, the Hastings Report, and the Foulkes Report on "Health Security for British Columbians", which a l l strongly recommended the concept of an integrated community f a c i l i t y to treat the mentally i l l . Early implementation of the changes dictated by government policy 2 was carried out in three phases, as described in the 1957 Annual Report by Dr. A.M. Gee, Director of Mental Health Services at the time: Phase I: "An effort was made to segregate into appropriate areas the mentally i l l , the aged mentally i l l , and the mentally retarded." These three groups had previously been housed together at the Provincial Mental 'Report of the Director of Mental Health Services. Annual Report, 1957, Mental Health Services, Province of British Columbia. Queen's Printer. 21 Hospital, made up of buildings in New Westminster (the original "asylum") and at Essondale, and extremely overcrowded. The segregation of the retarded was.made to the Woodlands School (the New Westminster building), which became a separate f a c i l i t y ; the aged mentally i l l went to the "Home for the Aged" at Port Coquitlam, and the mentally i l l remained at the Mental Hospital at Essondale. It was f e l t that, without the retarded and aged in the mental hospital, a more active treatment program, with a higher discharge rate, could be undertaken. Phase II; was to provide earlier treatment, oriented towards a 3 medical model of care. The new legislation, simplifying admission and discharge procedures, and the opening of the Crease Clinic of Psychological Medicine in 1951, decreased the average period of hospitalization substantially. .This, set the.stage for a closer integration of' a treatment service with the community. Phase III; The opening of the Mental Health Centre in Burnaby in 1957 offered out-patient, follow-up, and day-care service to patients in the community. In the ensuingg years the policy direction towards community orientation of mental health services continued. In 1959 the American Psychiatric Association was requested by the provincial government to conduct a survey of the mental health needs and resources of the province. This Clinics of Psychological Medicine Act, Government of B.C., 1951. 22 survey, known as the 'Ross Report' (edited by Mathew Ross, M.D., Medical Director of the American Psychiatric Association), "influenced the govern-ment in confirming i t s decision to effect regionalization of services..." (Statement in a forward to the Ross Report, by Eric Martin, Minister of Health Services and Hospital Insurance.) Pertinent recommendations on regionalization i n the Ross Report are: Recommendation 42: "The two major service levels should be recognized by the establishment of a Division of Hospital Services and a Division of Community Services, each directed by a psy-chiatrist, wwithin thepoffice of the Deputy Minister of Mental Health." Recommendation 44: "Mental health d i s t r i c t s should be.designated coterminous with the existing seventeen health d i s t r i c t s . At the outset, in view of the scattered nature of the population in some of the health d i s t r i c t s , i t might be deemed advisable to combine two or three health di s t r i c t s into one mental health d i s t r i c t . " The direction offered by Recommendation 42 was partially implemented by Mental Health Services in 1962, when the Branch was divided into four divisions; Mental Hospital, Geriatric, Schools for Mental Defectives and Community Services. Recommendation 44 was not f u l f i l l e d u n t i l 1967. In that year the province was divided into eight mental health planning regions, American Psychiatric Association. Survey of mental health needs and  resources of British Columbia. Mathew Ross (Ed.). Office of the Medical Director, American Psychiatric Association, 1961. 23 each containing a group of school d i s t r i c t s , but not, however, entirely coterminous with Public Health Districts. A comparison of the school d i s t r i c t s enclosed by Mental Health Planning Regions with those making up Public Health Districts is given on page 29; In 1961 the Burnaby Mental Health Centre was extending i t s services into the community, by providing professional help directly to health and welfare agencies "in Vancouver, and by a travelling c l i n i c which provided diagnostic and consultative services to many outlying areas of the province. It visited the health units at Kelowna and the upper Fraser Valley, aiding in the development of regional mental health c l i n i c s . The Provincial Mental Hospital introduced an after-care program in 1962—a follow-up service to patients discharged into the metropolitan Vancouver area. A mental retardation travelling c l i n i c , founded under the federal mental health grant, worked out of Woodlands School. A boarding-home care program located 180 patients from hospital in the lower mainland area and 119 patients lived in Venture and Vista, rehabilitation residences in Vancouver. Therapeutic activities at Essondale over the past ten years had resulted in a plethora of patients who could be cared for on an outpatient basis i f the community was prepared to undertake such a responsibility. Because treatment of mental illness is. a provincial responsibility, the provincial government was forced to bear the financial load of such care (apart from an annual Federal Mental Health Grant of less than one million dollars), and plans were formulated to set up Community Mental Health Centres. 24 As this policy of community mental health services.-, proceeded to develop, numerous other changes occurred in organization and legis-lation. During the years from 1962 to 1967, the following developments had particular impact: 1962: In the f i r s t establishment of psychiatric personnel outside of Vancouver and Victoria, a regional' mental health c l i n i c opened at Kelowna, located In an addition to the community Public Health Centre. This was to serve the major centres in the South Okanagan, North Okanagan, and South-Central Okanagan Health Units. Because the services of a psychiatrist were now available, a new psychiatric ward was built at the Kelowna General Hospital, and this greatly enhanced the scope of mental health services in the area by providing inpatient psychiatric beds in the local community. In assessing the impact of providing inpatient psychiatric hospital beds in the v i c i n i t y of community mental health centres, i t is notable that, by 1972, the admission rate of psychiatric patients from the Kelowna area (School District 23) to the Kelowna Mental Health Centre was 551.6 per 100,000, while the admission rate from this d i s t r i c t to Riverview Hospital was 12.8"*—a far lower proportion of inpatient admissions to Riverview than from any other mental health centre. Obviously, the supply of inpatient psychiatric beds in the local hospital was providing accommodation for a large proportion of the population which required i t . It is probable that the patients from this d i s t r i c t who were admitted to Riverview were those who could not be 1972 S t a t i s t i c a l Report. Victoria: Mental Health Branch. 25 looked after elsewhere, due partly to provisions of the Mental Health Act or the Criminal Code. In 1964 a new Mental Health Act was passed, and came into force on April 1, 1965. This was largely written by Dr. A.E. Davidson, for many years superintendent of the Provincial Mental Hospital, and later Deputy Minister of Mental Health Services. The new Act consolidated the features of the Clinics of Psychological Medicine Act, the Mental Hospitals Act, Schools for Mental Defectives Act, and Provincial Child Guidance Clinics Act.' Its main emphasis was to eliminate much of the legal involvement in Sommittals to mental institutions; admissions, whether informal or involuntary, were to be made on the basis of medical need, and this encouraged the development and use of locally operated mental health services. Admissions to Essondale in 1964 were 4,569, the highest number up to that time. In 1964, the Provincial Mental Home at Colquitz was closed, and the Riverside Unit at Essondale designated as a maximum security area, to accept " a l l psychiatric patients requiring security measures because of their dangerous propensities" (1964 Annual Report). During that year, Crease Unit and the Provincial Mental Hospital were combined and called Riverview Hospital. Also in 1964, the Victoria Mental Health Centre and aftercare c l i n i c was built adjacent to the Royal Jubilee Hospital; the Vancouver Island Mental Health Act. Government of B.C., 1964. Victoria, Queen's Printer. See Appendix 1 for amplification of this legislation. 26 Mental Health Centre opened in Nanaimo, to provide service to Central Vancouver Island and Upper Island Health Units; and the Kootenay Mental Health Centre opened in T r a i l , servicing the West Kootenay, East Kootenay, and Selkirk Health Units. In 1966 the Fraser Valley Mental Health Centre opened at Chilliwack, the North Okanagan Mental Health Centre at Vernon, and the Prince George Mental Health Centre at Prince George. At Riverview Hospital, patients from the metropolitan Vancouver area were, after 1966, admitted directly to Crease Unit, and patients from the rest of the province to Centre Lawn Unit./ As approximately f i f t y percent of admissions were from the Vancouver area, and as the two hospital units are nearly equal in size, this resulted in a relatively even distribution of admissions. Another Branch reorganization in 1966 saw Dr. F.G. Tucker become Deputy Director, responsible for Community and Nursing Divisions, and Dr. H.W. Bridge, Assistant Director, responsible for Inpatient Services. Earlier, the Branch office had been moved out of Essondale and located in the Public Health Building in Vancouver. By 1966, ten community mental health centres were operating in British Columbia. A comparison of the number of patients treated, and the cost of operating Mental Health Branch f a c i l i t i e s , in 1966 and 1974 (with 31 centres established) shows the changing aspect of delivery of services:^ Mental Health Branch. Annual report, 1966, Annual report, 1974. Victoria: Queen's Printer. 27 TABLE I NUMBERS OF PATIENTS, AND OPERATING COSTS, OF COMMUNITY AND RESIDENTIAL TREATMENT: 1966 AND 1974 1966: Total number of persons who received treatment at community mental health centres = 5877 1974: Caseload of a l l outpatient programs = 12,950* Total number of inpatients at Mental Health Branch residential programs during the year: 1966 =12,029 1974 = 4,152 Inpatients at: Riverview Hospital: 1966 = 7554 1974 = 1643 Schools for the Mentally Retarded: 1966 = 2328 1974 = 1495 Geriatric Division: 1966 = 2127 1974 = 987 Operating Expenses: Community mental health centres: 1966 = $1,144,195.00 1974 = $4,211,218.00 Inpatient institutions, Mental 1966 = $22,699,611.00 Health Branch: 1974 = $45,982,392.00 Daily institutional per 1966 = $10.48 capita cost: 1974 = $28.15 28 While these figures show the increased delivery of service by community mental health centres rather than by the centralized institutions, the obvious lesser operating costs per patient do not necessarily, reflect a true saving. Instead, the difference more probably demonstrates the lack of sufficient services available to the mental health centres' patients: adequate staff, services for the acutely psychotic, day hospitals, rehabilitation pro-grams, child and geriatric needs. These services are either not available at a l l , or are provided by other f a c i l i t i e s , with the cost absorbed by other budgets. Whether the community mental health centre concept w i l l progress to eventually providing an optimum method for delivery of service has yet to be evaluate. Mental Health Planning Regions in British Columbia Nineteen sixty-seven and sixty-eight was attime of conceptual change in philosophy and goals i n the Mental Health Branch, which was again re- ' organized, with a stated policy of decentralization and regionalization. Dr. Tucker was appointed Deputy Minister, located in Victoria with a staff of consultants whose aim was to promote the development of community programs. Dr. Bridge, Director of Mental Health Services in Vancouver s t i l l had the responsibility for inpatient institutions and the Mental Health Centre in Burnaby. ' The 1967-68 Report of the Deputy Minister of Mental Health notes the "...reorganization of the Branch to assume over-all aspects of mental health planning in order to f a c i l i t a t e the decentralization and regionalization of mental health programmes throughout the Province. For the purpose of mental health planning, the Province has been divided into eight regions, based upon clusters of health units. As the basic unit of these regions is 29 the school d i s t r i c t , r i g i d adherence to the proposed boundaries is not g essential should change be considered desirable in the future." The eight mental health planning regions, and the health units and school d i s t r i c t s 9 which are included in each region, are as follows: TABLEIII MENTAL HEALTH PLANNING REGIONS Mental Health Planning Region 1. Kootenay 2. Okanagan-Thomp s on 3. Fraser Valley 4. Skeena 5. Greater Vancouver 6. Cariboo-Peace River 7. Georgia Strait 8. South Vancouver Island Health Unit School District l(part) 1, 2\ 3, 4, 86 2 7, 10 3 9, 11, 12, 13 l(part) 18 4 19, 89, 21, 22 5 14, 15, 16, 17, 23, 77 6 24, 26, 29, 30, 31 7 32, 33, 34 8 35, 42, 75, 76 9 36, 37 10 40, 43 15 (part) 49 16 50, 52, 54, 80, 87, 88 . 38, 39(including Univer-sity Endowment Lands) 41, 44, 45, 46, 48 15 27, 28 17 59, 60, 81 18 55, 56, 57 13 65, 66, 67, 68, 69, 70 14 71, 72, 74, 85 .11 47 12 61, 62, 63 64 64 Mental Health Branch. Report of the Deputy Minister of Mental Health. Annual Report, 1967468. Victoria: Queen's Printer. ^1974 data. This information, as well as the Mental Health Centre addresses and code numbers, is obtained from the "Geographical Code Book - Mental Health Centres" used by Riverview Hospital. 30 Dr. Tucker stated the changing patterns of psychiatric care which should be included i n a regional mental health program (Annual Report 1967-68): "1. acute psychiatric care - in the psychiatric ward of a general hospital. 2. extended care - a responsibility of the Mental Health Branch, but the population would be better served in f a c i l i t i e s in i t s own community. 3. chronic care - in conjunction with the Department of Social Welfare, u t i l i z i n g the boarding house programme. 4. intermediate care - hospitals, group homes, outpatient and emergency f a c i l i t i e s . " At this time there were ten Mental Health Centres established in the province, with six more in the planning.stage. There were one hundred and forty-nine existing acute psychiatric beds in general hospitals., but a total of eight hundred thirty-one was planned for. The Eric Martin Institute, the Glendale Lodge (both in Victoria), and the Youth Development Centre in Burnaby were under construction. Problems in the Mental Health Regions centred around staffing. Recruitment of mental health professionalsnwas d i f f i c u l t , and there was a particular reluctance by psychiatrists to locate in remote areas. Salary levels of professionals in the provincial government service did not offer enough incentive, and professional staff turnover i n a l l areas was, and i s , high. In 1968, and again in 1973, a medical staff shortage caused a considerable reduction of available beds at Riverview Hospital, a situation that was remedied by opening the hospital to private psychiatrists, and later to sessional psychiatrists. The evolution of the Mental Health Branch's program of region-alization and decentralization continued. In 1970, the Vancouver office was closed, , and administration centred in Victoria. A l l inpatient services now reported directly to the Deputy Minister, and Dr. Bridge became Co-ordinator of Adult Psychiatric Services. Dr. J.S. Bland served as Co-ordinator of Mental Retardation and Child Psychiatric Services. In 1971 the Branch operation was organized into programs: Mental Retardation, Adult Psychiatry, Child and Adolescent Psychiatry, and Boarding-home Care. In 1972, Dr. Tucker began his Annual Report as follows. "The accelerating rate of social change and the attendant problems, together with mounting concern over the cost of health care, have had a particular impact upon the f i e l d of mental health. The complexity of devising and implementing a programme which crosses so many established boundaries increases' each year." The next year showed further the increase Dr. Tucker had noted -"a continuing readjustment and realignment of inpatient resources to comple-ment the regional programmes... staff had to assume new attitudes, roles and responsibilities as they pioneered programmes which, by their very nature, were often experimental and lacked the support of a well-tried administrative structure." (1973 Annual Report) Variations in the pattern of care in Vancouver and the lower Fraser Valley were begun. The Greater Vancouver Mental Health Project was initiated under the responsibility of the Metropolitan Board of Health and funded through the Provincial Community Care Services Society. This was viewed by government as a bed replacement project with an integration and coordination between community care teams and inpatient f a c i l i t i e s . To 32 effect this, a Joint Steering Committee was set up, representing Government, the Project, and Riverview Hospital. In the lower Fraser Valley, the Community Adult Psychiatric Service was a program planned to integrate mental health inpatient and community services through community psychiatrists, who were also to treat their patients on the wards of the Centre Lawn Unit, at Riverview. Centre Lawn and Crease Unit, at Riverview, were regionalized, so that patients from particular areas were admitted to specific wards. This, combined with the team concept of treatment, was expected to f a c i l i t a t e the revolving door concept of community integration and continuity in the care of the mentally i l l . In an effort to accommodate this-changingorole.Cof services, the Deputy Minister initiated a reorganization of Riverview into five programmes, with boundaries and administration more clearly defined than had been the case previously. To outline the Mental Health Branch situation in 1974 in regard to care and treatment of the mentally i l l , the following f a c i l i t i e s came under i t s direction: 33 TABLE III INPATIENT FACILITIES Riverview Hospital Components Patient Population Crease Unit . from Metropolitan Vancouver, Richmond and the North Shore Municipalities, also the Surgical ward and operating f a c i l i t i e s . Centre Lawn Unit; . . . . . . . patients from the remainder of the Province. Riverside Unit male patients classified as "Forensic". North Lawn Unit patients with a component to their illness requiring medical and nursing care. West Lawn Unit . . . . . . . . . long-term chronic male patients. East Lawn Unit long-term chronic female patients, one ward of male patients, accommodation for female forensic patients. Valleyview Hospital An extended care f a c i l i t y for the aged psychotic. Dellview A f a c i l i t y at Vernon, B.C., for the aged psychotic. By August, 1974 a transfer of f a c i l i t i e s from the jurisdiction of the Mental Health Branch to "private" societies, and to the Department of Human Resources had beenaaccomplished in the case of Skeenaview, Woodlands School, Tranquille, the Glendale Lodge, and i s underway in the forensic area. The Forensic Psychiatric Services Commission 34 Act*^ gives the Commission control of forensic f a c i l i t i e s , the inpatient component being the Riverside Unit at Riverview. 1 The future possibility of other inpatient psychiatric f a c i l i t i e s being transferred from the Department of Health to the Department of Human Resources appears l i k e l y . TABLE -/IV OUTPATIENT FACILITIES Community Mental Health Centres: thirty throughout the province. The Greater Vancouver Mental Health Services (under the Vancouver Metro-politan Board of Health and funded by the Community Care Services Society.) This now includes The Family and Children's Programme from the B.C. Youth Development Centre, The Riverview Outpatient Service in Vancouver, and nine Community Care Teams. Boarding Home Programs (administratively shared with the Department of Human Resources.) Forensic Psychiatric Services Commission Act. Government of B.C., 1974. Victoria: Queen's Printer. 35 CHAPTER III Regionalization and the Community Approach to Treatment of Mental Illness in British Columbia Development of a concept of regionalization of mental health services in British Columbia has followed the trend of recent years in the United States, Britain, Canada, and other countries, to a philosophy directed away from centralized institutional care and towards local community responsibility for the mentally i l l . Among the many factors influencing this change in government policy of providing mental health services were the growing d i f f i c u l t i e s in financing, maintaining and staffing the huge, ageing and obsolete buildings that had been erected on central but usually isolated sites, and served a vast catchment area; the large patient populations, with a high admission and low discharge rate; and the realization of the non-therapeutic and often deleterious effect on patients of prolonged institutionalization and custody. Also, advances in chemotherapy made the management of many patients, particularly the chronic schizophrenics, possible during the non-acute phases of their il l n e s s , i f alternate f a c i l i t i e s outside the hospital were available. In British Columbia, some of the indicators favoring the intro-duction of a regional concept for the provision of mental health services were: 1. A heavy patient load in the central provincial institution. Deutsch, A. The mentally i l l i n America. New York: Columbia Un i v e r s i t y , 1949. 36 2. An increase i n the number of i n s t i t u t i o n a l patients who could be returned and h a b i l i t a t e d i n the community i f f a c i l i t i e s were a v a i l a b l e there f o r t h e i r treatment and support. 3. An increase, with advances i n therapeutic techniques, i n the number of patients who do not require prolonged h o s p i t a l i z a t i o n . Because of the lack of l o c a l support f a c i l i t i e s , these patients are overhospitalized, and the c e n t r a l h o s p i t a l o v e r - u t i l i z e d . 4. The problems of increasing cost for the maintenance and s t a f f i n g of the aging i n s t i t u t i o n at Essondale. 5. The changing philosophy regarding the management of mental i l l n e s s and the p s y c h i a t r i c p a t i e n t . The p o l i c y of phasing out the mental h o s p i t a l i n favor of community p s y c h i a t r i c care has been a c o n t r o v e r s i a l issue wherever'if has been undertaken. Some of t h i s controversy has been generated by the process of decision-making, which many consider may be based more on p o l i t i c a l expediency than on geographic or population needs. In B.C., Dr. John Cumming has been instrumental i n the development of community services for the mentally i l l with, for example,.his "Plan for Vancouver" (1972), b a s i c a l l y a "plan for the s e r i o u s l y i l l adult psychotic", which stresses the decentralized nature of services to be provided i n the Greater Vancouver area. On the opposite side of the controversy, Dr. Winston Mahabir, i n a debate on "Dismantling the Mental H o s p i t a l " , at the Canadian P s y c h i a t r i c A s s o c i a t i o n convention i n Vancouver i n 1973, s a i d that while "the l a t e s t bandwagoners have stated that the locus of treatment should be the community, inventing charmingttheories to f i t t h e i r notions 37 2 and creating politically-pleasing models to promote them", i t i s the focus of psychiatry that needs to be changed, not the locus. Cumming's rationale for community treatment i s that the traditional approach towards treating the severely mentally i l l patient in a hospital environment i s expensive, inefficient, ineffective, and when prolonged, anti-therapeutic. A community-based and oriented mental health team would provide the assistance needed for the mentally disabled person to deal with the stresses in his l i f e , and alleviate the need for indefinite hospital-ization of the chronically i l l . It i s also aimed towards relieving some of the problems apparent in the present non-system: 1. Over-placement: a majority of patients in inpatient f a c i l i t i e s need neither the support and control of such a service, nor do they require the availability of the number of techniques as are usually found in a hospital environment. 2. Public and private psychiatry: a dichotomy which works against optimal patient care, since a complete range of resources is not available to either group. 3. Continuity of treatment, and finding treatment: using the premise that the. patient needing treatment most i s least able to seek i t independently the Cumming plan has as a central principle the organization and co-ordination of treatment f a c i l i t i e s . 'Mahabir, Winston. Dismantling the mental hospital. Paper presented to the Canadian Psychiatric Association Convention, Vancouver, 1973. 38 Community Mental Health Centres In 1974, thirty Mental Health Centres were operating in the following locations in British Columbia: Cranbrook Burnaby Nelson Saanich T r a i l Port Coquitlam Vernon Duncan Kelowna Penticton Kamloops Fort St. John Chilliwack Powell River Maple Ridge Whalley Surrey Prince Rupert New Westminster Port Alberni Victoria Williams Lake Nanaimo Abbotsford Courtenay Sechelt Terrace Langley Prince George Squamish In addition, nine community care teams are operating under the Greater Vancouver Mental Health Services project. The development and progress of most community mental health centres i s so recent that for many, their function and organization has not yet reached a point where they can define their prospective caseload and the boundaries or. limits of the populations they serve. Coordination with other provincial agencies, in particular the Public Health Units, i s not 39 articulated through policy, and appears to develop indiscriminately. However, when the Mental Health Branch decided on a policy of regional-ization and decentralization of mental health services for the province, i t s aim was to develop local services which would recognize and coordinate the mental health requirements of the population of each catchment area: that i s , a l l demand and need would be channelled through each local mental health centre, with the majority of services delivered in the area. i To l i s t a few of the d i f f i c u l t i e s blocking the way towards realizing this aim: 1. Cost of services: discussion of this subject breaks down into consideration of the cost of inpatient beds in local hospitals, funding sources and mechanisms, cost of ancillary services, such as day hospitals, sheltered workshops, halfway houses and boarding homes, and other such supportive programs which should .be developed. 2. Staffing problems: adequately trained and qualified staff people are particularly d i f f i c u l t to recruit for more remote areas. The provincial government salary and personnel policies f a i l to provide an adequate incentive to attract professional staff, as witnessed by the vacancies available for qualified psychiatrists at present. People who are recruited tend to go where they see the best opportunity, such as the CAPS program in the Lower Fraser Valley - a group of mental health centres strongly supported by the Branch. 3. Community acceptance: a subject which involves not only the socio-logical concepts of management of mental disorders, but also the legislation and medical c r i t e r i a which affect people who exhibit symptoms of such disorders. If adequate treatment i s available, i.e., professional staff, inpatient and outpatient f a c i l i t i e s ; and i f this has developed to a point 40 where i t i s serving the population's needs, in that the local professionals -doctors, police, and so on, are using i t rather than sending patients to Riverview, and the lay population i s also using i t directly to handle i t s needs when coping with mental disorder, then community acceptance has in fact arrived. Kelowna i s notable as an example of a properly functioning mental health centre, and others are developing - some rapidly, others more slowly. Those which, are geographically remote, where the;ppopulation i s scattered over a large area, and transportation i s d i f f i c u l t , where identification of need, and adequate means of f i l l i n g needs are hard to come by, such as in the north or in depressed areas, are naturally slow to produce the results the Mental Health Branch hopes for. To return to the development of mental health centres from the point of view of the population served, there are two areas which deserve elaboration. One i s the school d i s t r i c t s which provide the catchment areas for the mental health centres at present, the other i s the growth, in terms of patient admissions and caseloads, of mental health centres in comparison with corresponding decreases in admissions and caseloads at Riverview Hospital. It should be remembered that, un t i l the mental health centres came into being, the the exception of Greater Vancouver and Victoria, a l l patients who required intervention by treatment and hospitalization for mental illness were sent to Riverview. 41 Mental Health Centre Catchment Areas Table V shows the present mental health centres and the school d i s t r i c t s they serve. Not a l l compare equally with the school d i s t r i c t s enclosed by boundaries of Mental Health Planning Areas, as shown in Chapter II (Table I I ) . There are at least two reasons for this; f i r s t , Mental Health Planning Areas were devised by the Branch as a convenient means of sorting out school and public health d i s t r i c t s into manageable planning areas, and were never intended to be inflexible in terms of serving population needs. Accessibility of the mental health centre to the population at risk obviously w i l l tend to determine the boundaries and extent of i t s catchment area. For example, School District 86 includes the towns of Creston and Kaslo, and while this school d i s t r i c t i s part of the Cranbrook Mental Health Service Area, the Nelson Mental Health Centre serves Kaslo, and the Cranbrook Mental Health Centre looks after Creston's needs. This arrangement i s based on practical geographic considerations (distance by road and ferry across Kootenay Lake from Kaslo to Cranbrook) rather than adherence to school d i s t r i c t boundaries. A second reason for the v a r i a b i l i t y of mental health centre catchment areas is that the mental health centres were installed and developed on c r i t e r i a which were based on more than geographic considerations and population numbers: availability of staff and buildings, community demand and cooperation, and p o l i t i c a l considerations are examples of the variables affecting their establishment. 42 TABLE V MENTAL HEALTH CENTRES AND THE SCHOOL DISTRICTS MAKING UP THE CATCHMENT AREA OF EACH (1974) M.H.C. Code No. Mental Health Centre School Districts 1. Cranbrook 1. 2. 3. Fernie Cranbrook Kimberley 4. 86. Windermere Creston-Kaslo (part) 2. Nelson 86. 7. 10. Creston-Kaslo (part) Nelson Arrow Lakes 3. T r a i l 9. 11. Castlegar T r a i l 12. 13. Grand Forks Kettle Valley 4. Vernon . 89, 18. 19. 89. Golden Revelstoke Shuswap 21. 22. Armstrong Spillimacheen Vernon 5. Kelowna 23. Kelowna . . . 6. Kamloops 24. 26. 29. Kamloops Birch Island Lillooet 30. 31. South Cariboo Merritt 7. Chilliwack 32. 33. Fraser Canyon (Hope) Chilliwack 76. Agassiz 8. Maple Ridge 42. Maple Ridge 75. Mission 9. Surrey 36. Surrey 37. Delta 10. New Westminster 40. New Westminster 43. Coquitlam (Maillardville only) 11. Victoria 61. Greater Victoria 62. Sooke 12. Nanaimo 68. Nanaimo 69. Qualicum Continued... 43 TABLE V (CONTINUED) M.H.C. Mental Health School Districts Code No. Centre 13. Courtenay 71. 72. 84. Courtenay Campbell River Vancouver Island West 85. Vancouver Island North 14. Terrace 88. 54. Skeena-Cassiar Smithers 80. 87. Kitimat Stikine 15. Prince George 55. 56. Burns Lake Vanderhoof (Nechako) 57. Prince George 16. Burnaby 41. Burnaby 17. Saanich 61. Greater Victoria (with no. 11) 63. 64. Saanich Gulf Islands 18. Port Coquitlam 43. Coquitlam (except Maillardville) 19. Duncan 65. 66. .Cowichan (Duncan) Lake Cowichan 20. Penticton 14. 15. South Okanagann (Osoyoos) Penticton 16. 17. 77. Keremeos Princetpnr: Summerland 21. Fort St. John 81. 59. Fort Nelson Peace River South (Dawson Creek) 60. Peace River North (Fort St. John) 22. Powell River 47. Powell River 23. Whalley 36. Surrey (northern portion only) 24. Prince Rupert 49. 50. Ocean Falls Queen Charlottes 52. Prince Rupert 25. Port Alberni 70. Alberni Continued. TABLE V (CONTINUED) M.H.C. Code No. Mental Health Centre School D i s t r i c t s 26. Williams Lake 27. Williams Lake 28. Quesnel (Cariboo-C h i l c o t i n ) 27. Abbotsford 34. Abbotsford 28. Sechelt 46. Sechelt 29. Langley 35. Langley 30. Squamish 48. Howe Sound Greater Vancouver 38. 39. 44. 45. Richmond Vancouver North Vancouver West Vancouver 45 Mental Health Centre Caseloads, and the Population of Mental  Health Centre Catchment Areas Table VI i l l u s t r a t e s the caseload of each Mental Health Centre, at the end of September, f o r the years 1971 to 1974, and the population of the catchment area Cfound by t o t a l i n g the populations of school d i s t r i c t s included i n each) of each Mental Health Centre, projected from 1971 to 1986. It would be unwise to compare variances i n caseloads with population trends i n catchment areas so early i n the development of mental health centres. Caseloads r e f l e c t only the number of cases ascertained and accepted by each centre, and are dependent on many intervening v a r i a b l e s . However, the population'trends serve to point out future demands on mental health centres, and the need f or p r i o r i t i e s to be set for t h e i r development. TABLE iVI MENTAL HEALTH CENTRE CASELOADS AT END OF SEPTEMBER, 1971-1974. MENTAL HEALTH CENTRE CATCHMENT AREA POPULATION PROJECTIONS, 1971-74, 78, 86 (1972, 73 PRORATED.). Mental Health Centre Caseload Catchment Area Population Projections 1971, 1972 1973 1974 1971197. L 197231:2 197397'i 1974/4 1978 ; 1986 1. Cranbrook 155 332 144 63 51,300 52,604 53,908 55,213 61,375 76,920 2. Nelson 240 246 471 672 33,995 33,722 •33,449 33,175 34,237 37,565 3. T r a i l 157 198 218 225 42,082 41,807 41,532 41,257 41,837 46,959 4. Vernon 449 601 733 1097 64,720 66,277 67,834 69,392 77,003 94,985 5. Kelowna 313 350 399 634 50,225 53,356 56,487 59,620 70,926 88,298 6. Kamloops 255 227 343 392 79,496 83,250 87,004 90,760 106,766 143,155 7. Chilliwack 313. 384 465 333 45,995 46,372 46,749 447,128 49,355 58,988 8. Maple Ridge 404 371 687 768 . 40,067 41,024 41,981 42,938 47,553 62,467 9. Surrey 164 227 411 535 155,150 164,536 173,922 183,308 223,141 303,661 10. New Westminster 98 136 263 258 42,835 43,278 43,721 44,165 46,136 50,742 11. Victoria - 520 605 374 220^645 223,383 226,121 228,860 195,528 219,419 12. Nanaimo 145 160 296 447 53,205 54,836 56,466 58,097 64,565 79,119 13. Courtenay 178 172 126 281 34,520 35,734 36,948 38,162 44,406 59,079 14. Terrace 197 147 124 202 49,120 551,718 54,316 56,914 69,004 97,338 15. Prince George 692 129 133 257 180,705 85,649 90,593 95,538 117,240 165,661 16. Burnaby 572 576 567 776' 125,635 127,766 129,897 132,030 143,366 170,795 'Mental Health Centre caseload figures: Mental Health Branch Annual Reports, 1973, 1974. Catchment area population projections: B.C. Research Council, Population Projections by School Distr i c t s , 1974. Continued... TABLE VI(CONTINUED) Mental Health Centre Caseload 1971 1972 . 1973 1974 17. Saanlch 368- 444 458 512 18. Port Coquitlam 338 178 210 230 19. Duncan .32 199 315 523 20. Penticton 171 241 260 21. Fort St. John 1 119 74 199 22. Powell River 94 294 • 366 23. Whalley • - 116 258: 398 24. Prince Rupert - - 667 149 25. Port Al b e r n i - - 247 286 26. Williams Lake - - 12 11 27. Abbotsford - - 15 231 28. Sechelt - - - 74 29. Langley - - 210 30. Squamish - - - 58 Greater Vancouver (Community Care Teams-Total) 936 Catchment Area Population Projections 1971 1972 1973 1974 1978 1986 180,990 183,148 84,495 90,142 33,766 34,375 42,765 43,295 44,050 45,099 18,540 18,703 109,195 113,071 26,540 26,676 31,730 31,833 39,020 40,229 31,390 32,530 9,645 9,865 26,705 27,999 9,395 9,869 620,205 $626,184 185,306 187,466 95,789 101,436 34,984 35,595 43,825 44,355 46,148 47,199 18,866 19,029 116,947 120,825 26,812 26,947 31,936 32,042 41,438 42,647 33,670 34,812 10,085 10,306 29,293 30,587 10,343 10,819 632,163 638,142 196,396 216,707 123,770 184,591 38,713 47,171 47,370 52,665 53,849 71,564 21,875 28,406 139,684 185,036 29,214 37,022 33,354 39,056 48,883 66,103 38,480 47,303 11,473 14,084 35,604 46,987 13,012 17,561 673,288 761,116 48 Comparison of Admission Rates and Caseloads of Mental Health  Centres and Riverview Hospital It i s notable-that the inpatient population of Riverview Hospital has been decreasing rapidly in recent years. This decrease may undoubtedly be attributed, at least in part, to the increased development and capabilities of mental health centres; and the provision of alter-native community f a c i l i t i e s . A comparison of admissions, admission rates, and caseloads, from each Mental Health Planning Region, by school d i s t r i c t and Mental Health Centre, and by school d i s t r i c t and Riverview Hospital, follows. This comparison is for 1972 (Table VII) and for 1973 (Table VIII). The data is extracted from the Mental Health Branch 1972 St a t i s t i c a l Report, and the Mental Health Programs 1973 Sta t i s t i c a l Report. TABLE._V11 PROVINCIAL MENTAL HEALTH REGIONS, SERVICE AREAS, AND SCHOOL DISTRICTS Mental Health Centres and Hospital Admissions, Admission Rates 9perC106].0Q0spopulation, " " and Caseloads, 1972 Mental Health MHC MHC MHC Riverview Hospital Centre admis. rate caseload admis. rate caseload (Dec.31/72) (Dec.31/72) ALL REGIONS 6647 294.3 6666 2400 1063 2068 REGION 1 - KOOTENAY Cranbrook . 1 Fernie Cranbrook 32 270.4 28 6 50.7 10 2 Cranbrook II i t 201 1269.1 111 7 44.2 6 3 Kimberley II II 68 743.0 52 4. 43.7 4 4 Windermere II i i 10 195.9 7 - 1 19.6 3 86 Creston-Kaslo Cranbrook & 41. 348.9 27 9 76.6 17 Nelson Nelson 7 Nelson Nelson 125 675.1 235 9 48.6 17 10 Arrow Lakes II f j 12 314.4 21 2 62.7 2 T r a i l -9 Castlegar Tr a i l 43 408.6 ' 45 14 ! 37.8 2 11 T r a i l II 120 521.4 97 10 43.4 19 12 Grand Forks II 27 470.2 27 5 87.1 9 13 Kettle Valley II 30 1105.4 20 - - 2 Total for Region 1: 709 603.2 670 57 48.5 91 Continued... IAB'L1ELVT I^(.C0N3E&MED) REGION 2 - OKANAGAN  THOMPSON Vernon 18 Golden 19 Revelstoke 21 Armstrong-Spallumcheen 22 Vernon 89 Shuswap Kelowna 14 Southern Okanagan 15 Penticton 16 Keremeos 17 Princeton 23 Kelowna 77 Summerland Kamloops 24 Kamloops 26 Birch Island 29 L i l l o o e t 30 South Cariboo 31 M e r r i t t Total: Mental Health C sntMHC MHC MHC Riverview Hospital Centre admis. rate caseload admis. rate caseload (Dec.31/72) (Dec.31/72) 1308 524.8 1450 68 27.3 134 Cranbrook 10 149.8 15 3 44.9 Vernon II 68 747.2 80 6 ; 65.9 7 28 692.0 48 5 123.6 8 II 310 1116.0 443 9 32 .'5 13 II 114 582.8 146 5 25.6 19 Penticton 83 842.1 53 7 71.0 8 » 119 547.0 57 ' 5 23.0 10 II 20 693.2 10 1 34.7 3 it 4 10677 4 1 26.7 7 Kelowna 301 551.6 364 7 12.8 16 Penticton 16 266.6 15 — — 4 Kamloops 175 297.6 174 11 18.7 19 ii 4 112.6 6 3 5.1 1 8' 210.9 5 - — 7 u 23 270.1 12 2 23.5 5 u 25 267.5 18 3 32.1 7 Continued... o TABLE VIIC(('GQNTINUED) Mental Health MHC MHC ' MHC Riverview Hospital Centre admis. rate . caseload admis. rate caseload (Dec.31/72) (Dec.31/72) REGION 3— FRASER VALLEY Total 1750 368.2 1714 672 148.3 414 *i"**••>, "I" " " F v c h i i r i w a l t r 32 Fraser Canyon Chilliwack 33 501.2 31 19 288.6 10 33 Chilliwack II 249 1 272 35 96.6 36 34 Abbotsford Abbotsford 119 112 30 89.5 18 Mission 35 Langley Langley 65 226.6 65 28 97.6 19 42 Maple Ridge Maple Ridge 258 897.2 299 64 222.6 50 75 Mission II 89 682.8 95 44 337.6 26 76 Agassiz Chilliwack 19 . 425.5 19 3 67.2 1 Cloyerdale 36 Surrey Surrey 314 276.6 337 142 125.1 88 37 Delta II 98 177.9 106 51 • 94.5 24 New Westminster 40 New Westminster New West- 158 360.1 130 107 243.9 83 43 Coquitlam minster (Maillard- 351 387.7 248 149 165.0 59 v i l l e only) Continued.. TABLED V/I I{C('.GONfMNUED ) Mental Health MHC MHC MHC Riverview Hospital Centre admis. rate caseload. admis. rate caseload -- (Dec.31/72) (Dec.31/72) REGION 4 - SKEENA Total: 363 464.0 172 75 95.9 46 Terrace i 50 Queen Charlotte Prince Rupert 31 691.0 10 3 66.9 3 52 Prince Rupert it 19 105.5 2 25 138.8 17 54 Smithers Terrace 71 697.6 39 6 59.0 5 80 Kitimat Terrace 78 536.4 40 8 55.0 2 88 Skeena-Cassiar it 163 653.9 81 25. 100.3 12 Ocean Falls i 49 Ocean Falls Prince Rupert - 7 16223 • '5. A t l i n 87 Stikine Terrace 1 56.3 - 1 56.3 2 REGION 5 - GREATER VANCOUVER Total: 494! 63.0 541 1117 143.4 1026 Richmond 38 Richmond ' 4 6.2 4. 83 128.2 40 Vancouver* 39 Vancouver Vancouver 74 17.1 124 829 191.2 851 Burnaby Service 41 Burnaby Burnaby . 406 315.8 393 116 90.2 76 North Vancouver 44 North Vancouver 4 4.2 17 43 45.7 31 West Vancouver 45 West Vancouver 2 5.2 2 18 47.0 15 Squamish 46 Sechelt Sechelt ; 1 10.1 - 13 131.2 5 48 Howe Sound Squamish — - — 15 153.9 8 *Including University Endowment Lands Continued... TABLE yIInt(t,e0NWiENIJED), Mental Health MHC MHC MHC Riverview Hospital Centre admis. rate caseload admis. rate Caseload (Dec.31/72) (Dec.31/72) REGION 6 - CARIBOO-PEACE RIVER Total: 245 245 143.4 251 134 78.4 88 Williams Lake 27 Williams Lake Williams Lk. 14 60.6 12 14 60.6 14 28 Quesnel II 1 5.7 2 22 126.5 12 Dawson Creek 59 Peace River South Ft. St. John 54 252.3 55 18// 84.1 16 .60 Peace River North II •74 385.4 66 17 88.5 7 81 Fort Nelson it 1 23.5 1 8 188.0 -Prince George 55 Burns Lake Pr. George - 3 44.7 - 8 119.1 7 56 Vanderhoof II 3 26.1 3 10 87.0 5 57 Prince George t i 95 141.2 112 37 55.0 27 REGION 7 - GEORGIA STRAIT To t a l : 979 487.2 803 140 69.7 117 Nanaimo 65 Cowichan Duncan 197 807.8 243 9 36.9 17 66 Lake Cowichan i i 16 270.5 18 1 16.9 3 67 Ladysmith Duncan & Nanaimo 11 112.4 13 5 51.1 4 68 Nanaimo Nanaimo 112 272.6 142 34 82.8 29 69 Qualicum II 22 249.3 25 7 79.3 6 70 A l b e r n i Port Alberni 90 277.4 54 34 104.8 19 Courtenay 71 Courtenay Courtenay 192 762.6 97 17 67.5 14 72 Campbell River i t 53 271.8 21 19 97.4 5 84 Vancouver Is. West II 11 254.6 1 - - -85 Vancouver Is. North II 76. 722.1 43 8 76.0 9 Powell River 47 Powell River Powell River 199 1048.9 146 6 31.8 11 Continued... TA-BEE: v/iI';C(:GONT€NUED) REGION 8 - SOUTH VANCOUVER ISLAND T o t a l : V i c t o r i a 61 Greater V i c t o r i a 62 Sooke 63 Saanich 64 Gulf Islands Mental Health Centre MHC admis. MHC rate MHC caseload (Dec.31/72) R i v e r v i admis. ew Hosp rate i t a l caseload (Dec.31/72) ' r.v v.-+ Saanich V i c t o r i a II Saanich i t 796 379.3 1060 60 28.6* 112 542 85 142 27 347.0 336.1 604.2 555.0 711 105 201 43 49 4 5 2 31.4 15:8 21.3 41.1 98 4 7 3 TABLE Will ADMISSIONS,.RATES OF ADMISSIONS (PER 100,000 POPULATION), AND CASELOADS OF PATIENTS BY SCHOOL DISTRICT, MENTAL HEALTH CENTRE, AND RIVERVIEW HOSPITAL, 1973 MENTAL HEALTH MENTAL HEALTH CENTRES RIVERVIEW HOSPITAL PLANNING REGION Centre Admis- Admission Caseload Admis- Admission Caseload Service Area and sions rate (Dec.31/72) sions srate o c n o o i U I S O L X C O ALL REGIONS* 8763 378.5 9132 2134 92.2 1912 REGION 1 - KOOTENAY 686 576.2 85.6 -41 34.4 82 Cranbrook 11 Fernie Cranbrook 7 54.4 5 4 31.1 8 2 Cranbrook n 84 493.1 51 6 35.2 5 3 Kimberley II 29 337.9 15 8 93.2 4 4 Windermere ii 15 291.6 12 2 38.9 4 86 Creston-Kaslo Cranbrook & 62 532.6 67 5 43 .0 14 Nelson Nelson 7 Nelson Nelson 223 1177.4 431 3 15.8 16 10 Arrow Lakes II 36 885.6 . 54 1 24.6 2 T r a i l 9 Castlegar T r a i l 90 810.9 93 2 18.0 3 11 T r a i l II 95 433.2 98 5 22.8 14 12 Grand Forks II 33 575.9 27 4 69.8 9 13 Kettle Valley ti 12 447.7 6 1 37.3 3 ft includes 'other'. On On TABLE V-I-I-I (GONT-I-NUED) MENTAL HEALTH MENTAL HEALTH CENTRES RIVERVIEW HOSPITAL PLANNING REGION Service Area & School Centre Admis- Admission Caseload Admis- Admission Caseload sions rate (Dec.31/72) sions District rate REGION 2 - OKANAGAN-THOMPSON 1579 615.8 2013 54 21.1 124 Vernon Gr stab-rook 18 Golden Cranbrook 4 56.2 9 - - -19 Revelstoke Vernon 74 760.7 . 88 1 10.3 7 21 Armstrong- V! Spallumcheen II 35 819.7 47 3 70.3 5 22 Vernon II 410 LI414.5 560 10 34.5 11 89 Shuswap 11 101 50990 145 4 20.2 15 Kelowna 14 Southern PaEenticton 29 290.3 65 8 80.1 9 Okanagan •605 o 2 15 Penticton II 131 605.2 147 4 18.5 13 16 Keremeos II 18 622.8 23 - - 2 17 Princeton II 16 392.6 17 • 2 49.1 6 23 Kelowna Kelowna 385 673.8 491 3 5.3 13 77 Summerland Penticton 33 546.5 40 1 16.6 5 Kamloops : -> 24 Kamloops Kamloops 255 408.0 290 7 11.2 18 26 Birch Island II 8 217.7 10 1 27.1 1 29 Lillooet i t 12 , 315.0 10 4 105.0 9 30 South Cariboo II 28 334.0 27 2 23.9 5 31 Merritt II 40 418.4 44 4 41.8 5 Continued... TABLE Vli»IOI(CONTINIJED) MENTAL HEALTH MENTAL HEALTH CENTRES RIVERVIEW HOSPITAL PLANNING REGION Service Area & School Centre 1 Admis- Admission Caseload Admis- Admission Caseload D i s t r i c t sions rate (Dec.31/72) sions rate REGION 3 - FRASER VALLEY 2340 514.8 2475 603 132.7 386 Chilliwack 32 Fraser Canyon Chilliwack 39 . 577.2 32 17 251.6 3 33 Chilliwack II 386 1049.9 374 30 81.6 41 34 Abbotsford Abbotsford 168 483.8 101 25 • 70.8 17 Mission 35 Langley Langley 69 224.3 86 39 126.8 21 42 Maple Ridge Maple Ridge 344 1190.2 494 56 193.8 45 75 Mission n 95 681.2 159 41 294.0 25 76 Agassiz Chilliwack 20 460.8 19 I- 23.0 1 Cloverdale -36 Surrey Surrey 549 477.6 569 142 123.5 79 37 Delta it 141 251.0 159 46 82.1 24 New Westminster New,^  40 New Westminster Westminsters te208 463.8 221 94 209.6 77 43 Coquitlam ii ' 321 356.3 261 112 124.3 : 53 ( M a i l l a r d v i l l e only) Continued. lAJBLE 8 (CONTINUED) MENTAL HEALTH PLANNING REGION Service Area & School District MENTAL Centre HEALTH Admis-sions CENTRES Admission rate t t i Caseload '•(Dec. 31/72) Admis-sions RIVERVIEW Admission rate HOSPITAL Caseload REGION 4 - SKEENA Total: 522 662.0 : 235 90 114.3 49 Terrace 50 Queen Charlotte -52 Prince Rupert 54 Smithers 80 Kitimat 88 SKeenaaCassiar Pr. Rupert II Terrace II II -29 134 39 74 234 633.1 716.9 379.5 509.9 2087.3 12 107 6 31 75 8 22 8 10 31 174.6 117.7 77.8 68.9 276.5 4 17 6 1 15 Ocean Falls 49 Ocean Falls Pr. Rupert 2 57.1 2 7 200.0 4 A t l i n 87 Stikine Terrace 10 645.2 2 4 258.1 2 REGION 5 - GREATER VANCOUVER Total: 812 105.6 810 1024 133.1 937 Richmond 38 Richmond 25 38.5 22 40 61.6 32 Vancouver* 39 Vancouver Vancouver Service 300 66.0 241 807 177.5 787 Burnaby 41 Burnaby Burnaby 459 3353.4 514 91 70.1 .70 North Vancouver 44 North Vancouver 7 7.4 12 45 47.7 27 West Vancouver 45 West Vancouver 2 5.2 3 16 41.9 13 Squamish 46 Sechelt 48 Howe Sound Sechelt Squamish 19 189.4 18 12 13 119.6 131.8 4 4 *inc l u d i n g University Endowment Lands Continued... TA'BDE tVI'iHOi!CCONtTrIiNUED) MENTAL HEALTH MENTAL HEALTH CENTRES RIVERVIEW HOSPITAL PLANNING REGION Service Area & School Centre Admis- Admission Caseload Admis- Admission Caseload sions rate (Dec.31/72) sions rate Dis t r i c t REGION 6 - CARIBOO-PEACE RIVER Total: 262 146.7 189 92 51.5 80 Williams Lake 27 Williams Lake Williams 23 89.0 1-7 10 38.7 14 28 Quesnel Lake 2 10.9 2 8 43.7 8 Dawson Creek 59 Peace River South Ft. St. John 28 128.0 - 8 36.6 16 60 Peace River North 52 269.9 2 9 46.7 5 81 Fort Nelson II 1 25.3 - 3 75.8 -Prince George 55 Burns Lake Pr. George 1 13.6 1 3 40.9 6 56 Vanderhoof II 4 33.5 3 11 92.2 6 57 Prince George II 151 219.0 164 40 58.0 25 Continued. • - T A B L Q l I t ^ MENTAL HEALTH MENTAL HEALTH CENTRES RIVERVIEW HOSPITAL PLANNING REGION Service Area & School Centre Admis- Admission Caseload Admis- Admission Caseload (Dec.31/72) sions rate D i s t r i c t sionse- rate REGION 7 - GEORGIA STRAIT Tot a l : 1670 818.3 1459 132 64.7 117 Nanaimo 65 Cowichan Duncan 243 974.4 351 20 80.2 21 66 Lake Cowichan II 32 514.6 34- 2 32.2 3 67 Ladysmith Duncana& Nanaimon o 2 20.3 3 1 10.'1 3 68 Nanaimo Nanaimo 209 495.3 235 27 64.0 27 69 Qualicum t i 61 702.1 63 5 57.6 6 70 A l b e r n i Port Alberni 498 1513.9 272 24 73.0 16 Courtenay 71 Courtenay Courtenay 201 777.8 135 16 61.9 12 72 Campbell River II 47 240.6 26 18 92.2 9 84 Vancouver Island i t 13 307.7 2 4 94.7 2 West 85 Vancouver Island II 39 348.7 8 10 ' 89.4 9 North Powell River 47 Powell River Powell River 325 1657.5 '. 330 5 25.5 9 REGION 8 - SOUTH VANCOUVEI ISLAND Total': 885 413.2 1092 • 61 28.7 101 V i c t o r i a -61 Greater V i c t o r i a V i c t o r i a & 608 338320 738 53 33.4 87 Saanich 62 Sooke V i c t o r i a 82 312.4 92 3 11.4 •"•6 63 Saanich Saanich 182 738.9 225 3 12.2 6 64 Gulf Islands i t 13 272.0 37 2 41.8 2 OTHER* 7 N.A. 3 37 N.A. ;"36 Unorganized t e r r i t o r y , ex-province, not known 61 Discussion- of Tables VII and VIII Most mental health centres are so recently established that their admission and caseload stat i s t i c s do not yet reflect population trends or rates of mental illness in their catchment areas, but are more li k e l y to show that most have not begun to serve the population in the manner which is envisioned by their frame of reference. The Kelowna centre has already been mentioned as an example of a properly functioning mental health centre which adequately serves the population demands, and this is partly because of the presence of inpatient psychiatric beds in the Kelowna General Hospital. The admission rate to Riverview (in 1972) from Kelowna was only 12.8 per 100,000, while the rate to the Kelowna Mental Health Centre was 551.6. As well, the Kelowna centre's caseload reflects the population growth, and shows a f a i r l y stable increase each year. The large or erratic increases shown for many centres are probably due to need and demand generated by the presence of such a f a c i l i t y , and which previously was served by other sources or not identified. Decreases in numbers may be caused by staff losses or other internal factors in the mental health centre, thus reducing the centre's ascertainment capability. A more suggestive c r i t e r i a of the function of the centres is shown by a decrease in Riverview admissions from school d i s t r i c t s served by established mental health centres, as noted above in the example of Kelowna. However, other areas do not follow this trend. The Riverview admission rate from the Kootenay region school d i s t r i c t s was an average of 48.5 per 100,000, and the rate of admissions to local mental health centres 524.8, although inpatient psychiatric beds are provided in the T r a i l General Hospital. It 62 must be remembered that the program of mental health centres is in too early a stage of development to lend i t s e l f to adequate over-all evaluation. A comparison of admissiom.rates by Mental Health Planning Regions to Mental Health Centres and to Riverview Hospital, for 1972 and 1973, is shown by Figure 1. The developing increase in ascertainment by Mental Health Centres, even in the space of one year, shows clearly. However, the caseload of Mental Health Centres must be examined before attempting to demonstrate the vali d i t y of. any correlation with declining admission rates to Riverview. To examine in detail regional populations and their effect on f a c i l i t i e s and manpower requirements of mental health centres would require indepth study of the populations making up the regions and the variables involved. Some of these variables are: 1. Age and sex of the population. 2. Stability or transience of the population. 3. Ethnic or regional characteristics of the population. 4. Economic structure and future economic development of the region. 5. Present f a c i l i t i e s and services available. 6. Accessibility of the mental health centre: location, staffing, referral patterns, and services provided. 7. Acceptance of the mental health centre and of the concept of local community care of the mentally i l l . Such an indepth study is beyond the scope of this paper, and i t i s not practical using the figures available. However, i t would be very interesting to investigate the population characteristics of a specific area and trace their effect on the development of a community mental health centre. 63 '72 '73 •72 '73 ...•72; '73 •72!, .'73 •72 '7 3 .'72! '73 ; Kootenay Okanagan- Fraser Skeena Greater. Cariboo._-r > Thorapson Valley • • Vancouver Peace Riv j •72 '73 Georgia^ S t r a i t •72 «73| South Vancouver] Island Mental Health Centres: Riverview Hospital: | Figure 1: Comparison of Admission Rates per 100,000 population from Mental Health Planning Regions, to Mental Health Centres and to Riverview Hospital, 1972 and 1973. 64 The Greater Vancouver Mental Health Service While the Mental Health Branch was developing community Mental Health Centres throughout the province, provision of mental health services in Greater Vancouver remained fragmentary at best, with an acute shortage of hospital psychiatric beds and with services provided only through the resources of Riverview Hospital, private psychiatrists, the Metropolitan Board of Health, and voluntary social agencies. This fractionated non-system produced a chaotic situation in an area which has exceedingly high rates of attempted suicide, heroin and alcohol addiction, and other indicators of high pathology. To provide an alternative to this situation and to respond to community mental health needs, a Mental Health Advisory Committee to the Metropolitan Board of Health was established in 1972. Its mandate was to coordinate and plan a composite community mental health program for the Greater Vancouver Regional Di s t r i c t , with special emphasis on alternative 3 methods of care and provision of back-up resources. Dr. Gerry Bonham, Vancouver's Chief Medical Health Officer, and Dr. Roberta McQueen, Director of Mental Health Services, spearheaded the formation of the Advisory Committee. Impetus was given by the appointment of Dr. John Cumming as Program Consultant, and by the interest of the newly-elected N.D.P. provincial government in the concepts of community care centres. Mental Health Branch. Annual Report, 1972. Victoria: Queen's Printer. 65 4 Dr. Cumming's 'Plan for Vancouver' was developed as a position paper to present the committee's view of basic community services to the Mental Health Branch, and provides the Basis- and direction for the project. Dr. Cumming points out that the plan i s not complete; i t does not include specifications for integration of inpatient beds for the mentally i l l . It is basically a plan for the management of the seriously i l l adult psychotic, and does not deal adequately with services for children and the elderly. The core elements of the Plan for Vancouver provided for community mental health services, through teams correlated to the sociography of an area and taking the primary responsibility for the acutely psychotic patient. Community involvement was considered basic in the planning and delivery of services. The need for development towards a system was emphasized by the Cumming plan, as well as a coordination and sharing with the existing 'non-system'—i.e., with hospital f a c i l i t i e s , preferably in the community, and with other community services, such as professional psychiatric treatment, c r i s i s centres, hostels, sheltered work-shops, and so on. For this reason Cumming advocated that the complete system be introduced region by region, rather than by introducing one service after another. The i n i t i a l emphasis was toward more efficient u t i l i z a t i o n of f a c i l i t i e s , based on the theory that more serious psychotic conditions (crisis situations) may be alleviated by early inter-vention, and therefore this should be the f i r s t element in the direction of the system. Cumming states, "The most common reason for non-acceptance w i l l be that the person i s not sick enough." Cumming, John. Plan for Vancouver. Unpublished paper. 66 Organization- of the Greater Vancouver Service The community mental health program which has been organized to provide services to the Greater Vancouver area—the Greater Vancouver Mental Health Services—is funded by the provincial government, through the Community Care Services Society, and is managed under the auspices of the Greater Vancouver Metropolitan Board of Health. Dr. J.D. Kyle is Executive Director of the Service, and his office i s responsible for administration, research and planning. Nine Community Care teams are now operating in various areas in Greater Vancouver, with more planned. In 1974 the staff of the Family and Children's Programme of the B.C. Youth Development Centre was transferred to the Vancouver Service, and in 1975 Riverview Hospital's Outpatient Department and i t s caseload of more than 750 patients followed suit. The framework of Community Care teams requires support services in order to work towards the goal of a comprehensive mental health system. Patient housing, in the form of short-term hostels or boarding homes, is an urgent need, as are rehabilitative services, such as sheltered workshops, a psychogeriatric centre, and a day hospital. Development of an active communication network with community professionals and voluntary social agencies, as well as with hospitals in the area, is an essential component •> of the strategy required to the Service to f u l f i l l i t s purpose. The Greater Vancouver Regional Hospital District's Psychiatric Planning Group, in a 1974 review of psychiatric f a c i l i t i e s in the Region, comments: "The Community Care Teams which have come into operation in the last two to three years are playing an important part in provision of psychiatric services. They are considerably hampered by the lack of easily accessible in-patient, day care f a c i l i t i e s and intermediate and long-term care places. The Psychiatric Planning Group is of the opinion that the following new recommendations should be made at this time. 'IN DEVELOPING ADEQUATE PSYCHIATRIC SERVICES FOR THE IMMEDIATELY ADJACENT COMMUNITY THE GENERAL HOSPITAL PSYCHIATRIC UNIT SHOULD BE INVOLVED IN CLOSE LIAISON WITH THE APPROPRIATELY LOCATED COMMUNITY CARE TEAM WITH SOME SHARED STAFF APPOINTMENTS AT VARIOUS PROFESSIONAL LEVELS.' The Psychiatric Planning Group is of the opinion that the functional integration of Community Care teams with acute general hospital services w i l l not detract from the availability of necessary one to' one therapy which w i l l continue to constitute a major part of acute psychiatric treatment. Such integration w i l l require clear funding guidelines among B.C.H.I.S., M.S.C., the Metropolitan Board of Health and other community agencies.""' Dr. Kyle l i s t s the specific short-term objectives of the Vancouver Service as follows: "1. To treat in the community patients who would ordinarily Psychiatric Planning Group, Professional Practices Sub-committee, Greater Vancouver Regional Hospital Di s t r i c t . 1974 review of 1971 guidelines for planning acute psychiatric f a c i l i t i e s in the greater Vancouver Region. Unpublished. Nov. 22, 1974. 68 require hospitalization. 2. To shorten hospital stays of those who require inpatient care. 3. To prevent rehospitalization of those who are discharged from hospital. 4. To provide an organizational focus for a variety of community mental health programs, and for the necessary pre-planning of these programs. 5. To assist other agencies to deliver better care to the mentally, disturbed."^ Objectives 9bje6t-jtyesij.tt^ Care Teams Metropolitan Vancouver is now divided into twenty-two d i s t r i c t s , plus Richmond and the North Shore. It is intended that a community team w i l l serve each d i s t r i c t . TABLE I X Burrard DISTRICTS INCLUDED IN THE METROPOLITAN VANCOUVER AREA 1. West End 2. Kitsilano 3. Fairview 4. Mount Pleasant 5. CGentraliBusinessDDistr.-ict North 6. Strathcona 7. Grandview-Woodland 8. Hastings-Sunrise East 9. Cedar Cottage-Kensington 10. Renfrew-Collingwood West 11. West Point Grey 12. Dunbar 13. Arbutus Ridge 14. Shaughnessy 15. South Cambie 16. -Riley Park 17. Kerrisdale 18. Oakridge 19. Marpole South 20. Sunset 21. Victoria-Fraserview 22. Killarney Kyle, J.D. Paper presented to the Canadian Mental Health Association, B.C. Branch. Nov. 1, 1973. 69 The terms of reference of the Service are based on the Cumming 'Plan for Vancouver', and the functions of the community care teams are f i r s t , "problem-solving help" aimed at alleviating a c r i s i s situation, and' second, a "learning situation" where either the patient is made more competent and thus less subject to c r i s i s , or the patient's reaction to c r i s i s i s changed. It i s the goal of the community care team to see that the patient's problems are solved, by his own efforts i f that is possible, and by whatever guidance and assistance is necessary., The team operates in the community through the following steps: 1. Contact with the patient: assessment by the senior mental health worker (a qualified and experienced social worker, psychologist, or graduate-level trained psychiatric nurse) or psychiatrist, to determine the nature of the problem and formulate a treatment plan. 2. If an acute episode, necessary steps are taken to reduce the causal c r i s i s situation. 3. A decision whether the situation can be treated in the community, or i f i t should be referred to a more specialized treatment resource. 4. Participation by a team mental health worker throughout the patient's course of treatment, u n t i l his return to the community. -'Ad^lj^G^nA^ Teams The following tables, taken from the 1973 St a t i s t i c a l Report^ (issued in 1975), show admissions and caseloads of the four Community Care Mental Health Programs. 1973 s t a t i s t i c a l report. Victoria: available from The Statisticians's Office, Mental Health Programs. Dept. of Health. 70 teams whose figures were available when this data was collected: Mount Pleasant, Richmond, Strathcona, and West End. Tables- X and XI show that the developing caseload i s composed predominantly of adults, as envisaged by the Cumming 'Plan for Vancouver'. Tables XII and XII, however, (Admissions and Caseloads by Diagnosis) show a chronic:acute proportion of admissions of 115:89, and a similar proportion of caseload of 75:88, indicating the lack of alternative support f a c i l i t i e s . TABLE XO ADMISSIONS OF PATIENTS BY AGE, SEX AND FACILITY, 1973 AGE GROUPS Vancouver Community Tot a l 0-9 10-14 15-17 18-24 25-44 45-69 70-80 81+ Not known Care Teams TOTAL 261 _ 1 2 35 107 98 7 2 9 male 97 - • 1 . 1 10 55 25 - 1 4 female 164 - 1 25 . 52 73 7 1 5 Mt. Pleasant 43 _ 1 9 21 12 (October/73) male 15 - - - 3 10 2 - - -female 28 - • - - 1 •6 11 10 - - -Richmond (Dec/73) 19 _ _ _ 1 12 6 — — _ male . 6 - - - • 1 3 2 - - -female 13 - - - - 9 4 - — -Strathcona 24 _ 3 11 7 1 2 (November/73) male 8 - - - 1 5 1 - 1 -female 16 - - - 2 6 6 - - 2 West End 175 _ 1 1 22 63 73 7 1:. 7 (March/73) male 68 - 1 1 5 37 20 - - 4 female 107 - - - 17 26 53 7 1 3 ( ) Date of f i r s t reporting. TABLE XI. PATIENTS ON CASELOAD BY AGE, SEX AND FACILITY, DECEMBER 31, 1973 AGE GROUPS Vancouver Community Total 0-9 10-14 15-17 18-24 25-44 45-69 70-80 81 & Care Teams Over TOTAL 202 _ 1 2 28 83 76 10 2 male 75 - 1 1 8 40 20 4 1 female 127 - • - 1 20 43 56 6 1 Mt. Pleasant (Oct/73) 39 _ — 1 7 19 12 - -male 14 - - - 3 9 2 - -female 25 - - 1 4 10 10 — -Richmond (Dec/73) 19 — — - 1 12 6 - -male 6 - - - 1 3 2 - -female 13 - - - - 9 4 — -Strathcona.: (Nov/73) 22 _ — - 2 10 7 2 : l male 7 - - - - 5 1 - 1 female 15 - - - 2 5 6 2 -West End (Mar/73) 122 _ 1 1 18 42 51 8 1 male 48 - 1 1 4 23 15 4 -female 74 - - - 14 19 36 4 1 ( ) Date of f i r s t reporting. ~ J to H-1 -C» ON Ul VO CO I—1 Ul I—' 00 ^4 ON VO VO CO I I H -P-h-1 >—' ro CO I—1 O * Ul u i to I I I I I I I co co to CO I to ^ I I I I I I I I I I Ul H" CO I vo Total Adult/Acute Mental or Emotional Child/Adolescent Problem Chronic Mental : Illness Geriatric Mental Illness Mental Retardation Personality Disorder Learning Disorder Marital Problem Other > H > H w o TJ ?0 o bd tr1 W S X! H s H GO GO H O oo o o Co rt fD Hi H-l-i CO rt t-c (D o ri rt H-3 OQ s: s fD rt H- rt CO i-( O • rt CO S4 rt 0 M 0* o I-1 0 o 0 fD P-on as • N •—s s tt 0 p y—s fD rt H No O < ~J o OO o >—' Co v ' t/73) M O O H C5 M < > M n H S ro to i—* oo o ro ro vo vo ro ON ~J ON Ov On OO I I J> H H M 8) ON M O O 00 to ro I I -C-I I I I I ro to ro ro I to ON I I I I I I I I I I oo i oo I I Total Adult/Acute Mental or Emotional Child/Adolescent Problem Chronic Mental Illness Geriatric Mental Illness Mental Retardation Personality Disorder Learning Disorder Marital Problem Other m 2! H 1% o pd O W c-1 M x< fctl M H hd H H 5! H CZ) O O > CO w t-< o a M > O 2! O w n H tr1 o ?d H 2! H H tr1 t- 1 a o ?d VO 00 IL 75 Similar tables and s t a t i s t i c s f o r 1974 and 1975, when a v a i l a b l e , may show v a r i a t i o n s i n trends, due to increased numbers of acute p s y c h i a t r i c beds i n general h o s p i t a l s , and p s y c h i a t r i c boarding homes i n the area, As w e l l , the i n c l u s i o n of the Riverview Out-Patient Department and i t s large caseload, w i l l have a considerable e f f e c t , as w i l l the Family and Children's Program. Tables XIV and XV show the numbers of 8 admissions, and caseloads, of the Out-Patient Department i n 1973. 1973 S t a t i s t i c a l Report. TABLE XIV RIVERVIEW OUT-PATIENT DEPARTMENT. ADMISSIONS OF PATIENTS BY AGE AND SEX, 1973 Total AGE GROUPS 0-9 10-14 15-17 18-24 25-44 45-69 70-80 81+ not known Riverview Out-Patient Department male female 549 — — • 1 74 234 235 5 - -293 — — 1 47 149 194 2 *- -256 . - - - 27 85 141 3 ' -TABLE XVj RIVERVIEW OUT-PATIENT DEPARTMENT. PATIENTS ON CASELOAD BY AGE AND SEX, 1973 Total AGE GROUPS 0-9 10-14 15-17 18-24 25-44 45-69 70-80 81+ not known Riverview Out-Patient Department male female 772 374 398 44 284 414 24 6 30 174 158 8 4 -14 110 256 16 2 Community Care team entries and caseloads for 1974 are shown in Table XVI, extracted from data in the 1974 Annual Report of the Mental 9 Health Branch. •„ TABLE Xyi COMMUNITY CARE TEAM TRENDS, SEPTEMBER 1974 Greater Vancouver Community Care Teams Yearly Sum of Entries to September, 1974 Caseload at End of September, 1974 Total 1280 943 Mount Pleasant (from October 1973) 279 150 Richmond (from December 1973) 185 145 Strathcona (from November 1973) 178 142 We'st End (from March 1973) 274 247 Kitsilano (from February 1974) 215 156 West Side (from February 1974) 149 103 ( ) Date reporting from. Mental Health Branch. Printer. 101st Annual Report 1974. Victoria: Queen's CHAPTER IV Riverview Hospital: An Institution in Transition 78 Growth and Development: 1904 to I960 Riverview Hospital had i t s origin in 1904, when the provincial government purchased one thousand acres of land near the junction of the Fraser and Coquitlam Rivers for the purpose of expanding the mental hospital f a c i l i t y , which at that time was the Public Hospital for the Insane at New Westminster. Dr. R.G. Foulkes (1961) describes the building of the new hospital: "The plans for the new hospital at Coquitlam, obtained by staging a competition between the architects of the Province, received the highest commendation of psychiatrists in Eastern Canada and the Lunacy Commission of New York State. They called (for) the building, in stages, of a number of structures, each specialized as to function: an administration building, an acute building, sick and infirm buildings, an epilepsy building, a pair of chronic buildings, and adequate living quarters for nurses. It was decided that one of the chronic buildings should be constructed f i r s t so that i t could be used to house the overflow from the PHI, and the building now known as West Lawn was begun. The f i r s t building on the new grounds, named Essondale after Dr. Henry Esson Young, the Provincial Secretary, was opened on April 1st, 1913. 1 , 1 Foulkes, R.G. British Columbia mental health services: historical perspective to 1961. 79 At Essondale, the planned new buildings were gradually completed and opened, and were immediately overcrowded: the f i r s t "acute" building, Centre Lawn, in 1924; East Lawn, for women, in 1930, and by 1950 there were more patients than beds, crowding out areas needed for therapy, and "forcing a return to the use of seclusion and restraints. The construction and design of the site and buildings was typical of state-operated mental hospitals in Canada and the United States at the time: dark, imposing multi-winged brick structures, surrounded by cottage-style nurses' quarters and houses for administrative and medical staff, a l l set among spacious lawns and flowerbeds, reached by winding drives, and giving an over-all impression of remoteness, removed from a l l contact with the normal world. Solutions to the problem of separate f a c i l i t i e s for the acute mental patient, the mentally defective, the tubercular, and the aged psychotic were gradually developed, as outlined in Chapter II. In 1932 four hundred mental defectives were transferred from Essondale to the Public Hospital for the Insane and later that institution was renamed Woodlands School. In 1936 the buildings of the Boys' Industrial School, adjacent to Essondale, were acquired for the aged psychotic, and in 1955 the North Lawn building was opened as a tuberculosis treatment unit. During this period various hospital departments, such as Occupational Therapy, Social Service, Psychology, Pathology, X Ray and Foulkes. op. c i t . 80 Pharmacy were developed but these were severely hampered by overcrowded conditions and lack of staff. Although a Nurses' Training School was estab-lished in 1930 , the standards of nursing staff were drastically reduced during the war years, when untrained aides had to be hired. These limitations also diluted application of advances in treatment which developed: malarial therapy, bismuth, sulpha and p e n i c i l l i n for General Paresis, insulin shock, metrazol, electroconvulsive therapy and lobotomy. For example, in 1940 there were only 540 patients under treatment (insulin shock and metrazol) out of a total population of 3,836. Because of the intense overcrowding and untrained staff")" the Provincial Mental Hospital was providing l i t t l e more than minimal custodial care, but a medical therapeutic model appeared with the construction in 1948 of the Crease Clinic of Psychological Medicine, built by adding a wing to the recently vacated Veteran's Building. Other improvements included the installation of surgical f a c i l i t i e s , a new Department of Neurology, a policy of unlocked wards and absence of physical restraints, a remotivation program for the patients in the "chronic" buildings, a recreation centre—Pennington Hall, two rehabilitation houses in Vancouver for recently discharged patients, and 25 beds in Centre Lawn for alcoholics.. The hospital had also been unitized, in an effort to provide specific forms of treatment, each unit having a unit director with functional control of staff. These units were Crease Clinic, Centre Lawn (the "acute" buildings), West Lawn and Riverside for male patients, East Lawn for females, and North Lawn, the medical unit. In 1960 the hospital received f u l l accreditation by the American Psychiatric Association. * In 1972, the responsibility for training psychiatric nurses was transferred to the B.C. Institute of Technology, under the auspices of the Provincial Department of Education. +Inservice nursing staff development at Riverview is outlined in Appendix 2. 81 1960 to 1975: Fifteen Years of Transition In the nineteen sixties, the orientation of government policy towards development of community health services became apparent. The Provincial Mental Hospital and Crease Clinic were extremely overcrowded, and with recent advances in chemotherapy, and a therapeutic model of care, were prepared to return increasing numbers of patients to the community. The necessity for follow-up care for discharged patients, and the lack of psychiatric personnel, particularly in rural areas, provided the rationale for attention to this area. As community services progressed, in the form of mental health centres which were to provide service to health units, the hospital was also increasing i t s community involvement in the Vancouver area with an after-care program; a boarding home project; Venture and Vista, the two rehabilitation houses; and volunteer services sponsored by the Canadian Mental Health Association. During the years that mental health services have been developing in the community, the v i a b i l i t y and effective operation of the mental hospital has become more and more dependent on the constraints necessitated by i t s coordination with community f a c i l i t i e s . The rapidity of the changes in accepted concepts, and in government policy, concerning the best way to provide service and to control the mentally disordered, have required the hospital to constantly reassemble i t s resources as best i t can. Its guidelines and the boundaries of i t s function were set by the Mental Health Branch, so that i t must operate as a component of an open system of provincial mental health services. After originating, and functioning, u n t i l this conceptual change, as a single and solitary institution, with organizational boundaries 82 as defined and stringent as the formidable isolation of i t s physical structure, these readjustments,called for complex adaptations of the hospital's resources. To summarize the changes in organization at Essondale vafter the 1964 Mental Health Act, during that year the Provincial Mental Hospital and Crease Clinic were combined and called Riverview Hospital. Crease was to take new admissions from the greater Vancouver area and Centre Lawn Unit those from the rest of the province. In 1964 also the Riverside Unit (opened in 1950) was designated as a maximum security area, to accept " a l l psychiatri patients requiring security measures because of their dangerous propensities. From this time u n t i l the present the environmental demands on Riverview Hospital have been towards itsscoordination with community services, while s t i l l maintaining and f u l f i l l i n g i t s role as provider of a therapeutic inpatient f a c i l i t y for a l l patients who meet i t s admission c r i t e r i a . Regionalization in Riverview Hospital After the Mental Health Branch delineated provincial Mental Health Planning Regions in 1968, with the objective of eventually decentralizing a l l mental health services, plans for allocating Riverview Hospital!s services on a regional basis developed. In 1969 the Minister of Health, the Honorable Ralph. Loffmark, expressed interest in such a concept. P r . H.W. Bridge, Director of Mental Health Services, presented a proposal which suggested that certain services at Riverview should be Mental Health Branch. Annual Report 1964-65. Victoria: Queen's Printer. 83 available to the entire population of the province, but have a s t r i c t l y limited function, while other services would be more comprehensive in function, but would be confined to a definitely specified and limited population: "For example, a comprehensive psychiatric inpatient service to members of one particular Mental Health Planning Region only. Such a i regionally assigned service would, of course, require to have a close liaison with and ramifications into the region concerned. Each of these regional services should be gradually phased out by the replacement in the regions of those services i n i t i a l l y assigned in the Riverview Hospital... As each region developed adequate services to replace those available to i t at Essondale, the service at Essondale could be phased out and converted to 4 a more appropriate use." Riveryiew jRifr.er-v.ijewi.sz;Regi'oria.l'yzatii'on ' Commi 11ee Regionalization of services at Riverview was approved by the Minister of Health in March of 1970, and in May of that year a Regionalization Committee composed of hospital staff was set up, for the purpose of adapting the programs within the hospital to the requirements of Mental Health Planning Regions. It noted that the boundaries of Riverview catchment area should coincide with the boundaries of the Mental Health Centres, the Public Health Units, and the Social Service Districts. In November, 1970, the committee issued a position paper on "Regionalization of the Hospital". This outlined the objectives as follows: Information and data on the development of a concept of regionalization within Riverview i s obtained from hospital f i l e s . 84 "To divide Riverview Hospital into a number of self-contained c l i n i c a l programmes aimed at: 1. meeting specific patient needs (e.g., medical unit, extended care unit, maximum security unit); 2. division of the Province into particular geographical regions to meet the c l i n i c a l needs of these regions;"^ and anticipated results: "1. Improved communications with the areas served. 2. C l i n i c a l programmes appropriate to the need of the region. 3. Greater awareness in the regions and in the hospital of the f a c i l i t i e s and resources available. 4. More involvement of regional agencies in the care and habilitation of their psychiatric patients. (Emphasis included.) 5. More continuity of patient care. 6. Better defined division of labor, both within the hospital and community agencies.""' In correspondence with the committee, the Deputy Minister, Dr. Tucker, pointed out that his main concern.in developing some type of regionalization " i s with producing a community based service, even i f a proportion of i t is to be rendered in the institution.""' His feeling was that the regionalized staff - largely doctors and social workers - should be primarily tied to the community and only secondarily tied to a given physical location in the hospital. Dr. Tucker added that i t was "imperative that the Riverview Hospital f i l e s . 85 regional team ensure that their services are an integral part of the community service for the mentally i l l . " "Regionalization" was defined as: a) geographical regions b) admission of patients from one geographical area to one particular hospital unit offering services to that geographical area. The following population figures and statistics are taken from the minutes of the Riverview Regionalization Committee, and comprise the data used by the committee in planning and discussing the project. Consultation and direction were provided by Mental Health Branch representatives, as the aim was to implement Branch policy. TABLEXXVII RIVERVIEW HOSPITAL STATISTICS FROM EACH MENTAL HEALTH PLANNING REGION, 1968: Region Population Admissions Rates Caseload* Caseload Rates 1. Kootenay 110,000 92 84 130 : 118 (per 100,000) 2. Okanagan-Thompson 191,600 119 62 178 93 3. Fraser Valley 355,000 654 184 . 424 120 4. Skeena 65,000 95 147 68 105 5. Greater Vancouver 740,800 1582 .214 1353 183 6. Cariboo-Peace 150,000 149 99 100 66 River 7. Georgia Strait 176,000 183 104 171 97 8. S. Vancouver Is. 190,000 103 54 157 83 Total of a l l Regions: 1,977,000 2,977 150 2,626 133 *as of Dec. 31, 1968 Riverview Hospital f i l e s . 86 The Fraser Valley Pilot Regionalization Project After several attempts to develop a model or pilot project which would accommodate patients from a specific catchment area, the Regionalization Committee decided upon an area which included the school di s t r i c t s making up Mental Health Planning Region Three (Fraser Valley) with the exclusion of New Westminster, and decided to c a l l this the "Fraser Valley Pilot Project". The committee li s t e d the following points as c r i t e r i a for adapting the hospital to a concept of regionalization for this area: 1. A l l patients from Region Three, excepting those from New Westminster, would be admitted to a designated number of beds in the Centre Lawn Unit of Riverview Hospital, and specific staff would be assigned. 2. It would be necessary to regionalize new admissions only, and not attempt regionalization of the present residents of the hospital from Region Three, because of the inadequacies of the hospital's long-term areas. 3. Only acute treatment services would be regionalized, for example: inpatient services would treat only new admissions in the hospital area designated for each part of the Region (i.e., in Centre Lawn). In the community, patient assessment and out-patient treatment would be referred to an appropriate agency - in other words, the hospital committee did not feel inclined to accept responsibility for provision of community services. 4. A l l Mental Health Branch personnel - members of the "team" in the hospital and in the mental health centres, should be responsible to a regional director. Pending the appointment of such an authority, the team wouldrreport to the hospital's C l i n i c a l Director, rather than to the Unit Director of Centre Lawn. To implement the team and regional director concept, Dr. Bridge would act as an extra-mural director, to provide directional 87 r e s p o n s i b i l i t y to the mental health centres and to the treatment teams. Dr. Tucker and Mr. R. Mclnnes, Coordinator of Mental Health Centres, were to provide l i n e authority to the mental health centres. 1 The Regionalization Committee minutes give the^'following figures which were used i n planning the a l l o c a t i o n of space i n Riverview's Centre LawnnUriit: Number of possible admissions per year from the designated area: 700. Average length of patient stay i n h o s p i t a l : 42 days. Patient days per year: 700 x 42 = 29,400 days. Number of beds required: ^355 ' ^ ~ ^5 beds. Regionaiiz£fogc£ibril£ii^^^^ Lawn Unit" The r e g i o n a l i z a t i o n program appears to have dragged i t s feet f o r some time, as several d i f f i c u l t i e s i n planning and implementation impeded i t s progress. Motivation, support and d i r e c t i o n , and expertise i n planning were more d i f f i c u l t to generate because of the i s o l a t i o n of Riverview, the dichotomy i n treatment concepts between the h o s p i t a l and mental health centres, and a lack of communicatiohrtbetween the h o s p i t a l , the centres, and the Branch i n V i c t o r i a . Implementation was impeded, due to lack of funds and s t a f f , adequate accommodation, and i n the h o s p i t a l , lack of any control or autonomy overffunds, s t a f f , and f a c i l i t i e s . In May, 1972, a Mental Health Branch task force, c o n s i s t i n g of Dr. Bridge as chairman, Dr. Cumming, Mr. R. Goodacre (consultant i n sociology), and Mr. Mclnnes was appointed. This group was to develop regional services which would t i e i n the a c t i v i t i e s of s p e c i f i c mental health centres with " c e r t a i n s e r v i c e s " i n Riverview. 88 Three c l i n i c a l teams were set up in Centre Lawn Unit, each headed by a psychiatrist who was also director of a mental health centre (appointed as Medical Specialist 3). The team which served both the hospital and the centre was to be a discrete entity, and the Deputy Minister envisioned the whole hospital eventually operating with such teams. Regionalization of Centre Lawn Unit o f f i c i a l l y took place on July 4, 1972. Each floor in Centre Lawn admitted patients from specific geographical regions of British Columbia. As the regions designated were more numerous than Centre Lawn floors, each floor took patients from both specific local and remote areas. It was planned to have the Riverview teams travel to their catchment areas, in an effort to improve communications and patient follow-up, but, although this was a directive from the Deputy Minister, re a l i t i e s of staff shortages and lack of funds did not allow the volume of travel that was anticipated,/. At present patient follow-up procedure is that Riverview sends a notice of separation to the local mental health centre when a patient i s separated from the hospital into the mental health centre's catchment area. Only selected patients are specifically referred to a mental health centre for continuing care. Other areas that demand further consideration are: Channels of communication Referral patterns Preadmission service Aftercare Participation of the mental health centre staff in hospital treatment and discharge planning Community organization and resource development Community placement f a c i l i t i e s . 89 A report from Mr. R. Mclnnes, Coordinator of Mental Health Centres and Chairman of the Regional Planning Committee f o r Adult P s y c h i a t r i c Services, gives a review of Riverview r e g i o n a l i z a t i o n to A p r i l 2, 1973.^ He noted that i n the nine months since the o f f i c i a l s t a r t of the program, i t had been hampered by severe s t a f f shortages, and the Riverview s t a f f had been unable to make f i e l d journeys. However, he wrote that no opposition and no problems had been encountered within the h o s p i t a l . He believed there was also an increased l e v e l of communication between the h o s p i t a l and the mental health centres, although very inadequate long-distance telephone service hampered t h i s considerably. Other negative factors l i s t e d were: Inadequate s t a f f to bring medical records up to date and summaries of release sent out, i . e . , slow release notices and discharge summaries. D i f f i c u l t i e s encountered i n obtaining medical opinions when r e f e r r a l s or preassessment of patients are required. The transportation of patients from other areas and regions to Riverview Hospital by the R.C.M.P.: a th e r a p e u t i c a l l y damaging procedure. "Suitcase therapy": the tendency of communities, faced with the problem of t r e a t i n g t ransients, to send them on t h e i r way and l e t some other area assume r e s p o n s i b i l i t y f o r t h e i r treatment.. A much-needed spectrum of treatment for a l c o h o l i c patients i s not av a i l a b l e . The admission p o l i c i e s of general h o s p i t a l p s y c h i a t r i c u n i t s , and the quantity and t r a i n i n g of t h e i r s t a f f (with d i s c r i m i n a t i o n against p s y c h i a t r i c nurses) does not provide the needed inpatient a l t e r n a t i v e to Riverview Hospital f i l e s . 90 Riverview Hospital, nor do hospital emergency room services. There i s , so far, not enough staff to provide teams which can work both in the community and in the hospital. • • ' A---- T: hg -Q*?AgB>S. Program A further development in the community-oriented policy of provision of psychiatric care is the C.A.P.S. Program - Community Adult Psychiatric Services. In this program, at present, psychiatrists attached to mental health centres in the lower Fraser Valley - Whalley, Port Coquitlam, Maple Ridge, Surrey, New Westminster, and Langley are also on.staff at Riverview (in Centre Lawn) and admit and supervise treatment of their patients in hospital as well as in the mental health centre. This arrangement partially provides the organization of service envisioned by the Deputy Minister, although supervision and funding by areas of the Mental Health Branch which are removed from Riverview Hospital produce management d i f f i c u l t i e s . This problem is only one of many which has developed from the "absentee landlord" situation, i.e., lack of local autonomy and management because of decision-making and authority functions based at Branch level. A further problem is in. the lack of psychiatrists to provide after-hour and weekend coverage on a regional basis, delaying the f u l l implementation of the program. on a l 1 zf Re^i'dhaliz^jjgnjJiri. tCr eas e Uni t Patients from the Greater Vancouver area are admitted to Crease Unit, while Centre Lawn takes patients from the rest of the province. With Centre Lawn admissions organized on a regional basis, a similar arrangement was conceptualized between the area served by Crease and by the developing Vane ouver Mental Health Service. 1968 admission and caseload stat i s t i c s for 9 1 Riverview from the Greater Vancouver area are shown in Table XVIII. TABLE XVIII RIVERVIEW HOSPITAL STATISTICS FROM REGION 5: GREATER VANCOUVER, 1968 •-' 'i-Population Riverview Admission Resident Resident Rate (by School'District) Admissions Rate Dec.31/68 (per 100,000) (in thousands) 38: Richmond 58 92 159 40 69 39: Vancouver 429 1182 276 1132 264 41: Burnaby 119 176 148 99 84 44: North Vancouver..84 . 6 3 75 47 56 45: West Vancouver...35 23 67 18 52 46: Sechelt 9 25 294 7 92 48: Howe Sound 8 21 277 10 118 TOTAL: 740. 1582 214 1353 183 In September ..off 1973fe.according to policy established by the Deputy Minister, part of Crease Unit was regionalized into three c l i n i c a l teams and wards, to provide service to patients residing in defined geographic regions within Metropolitan Vancouver, excluding Burnaby. This program was expected to result in an amalgamation of the services provided by Crease Unit and the Riverview Outpatient Department, which would be combined and known as the Vancouver Service. The North and East Units of the city were assigned to one team, the West and South units to another, and the Burrard Unit to a third team. Patients resident in Richmond were assigned to the West-South team, and Northe:Shore and Burnaby patients distributed among the various teams. When the "Burnaby Project", with inpatient beds, commenced f u l l operation, patients from Burnaby would be referred to that 92 8 s e r v i c e . In the implementation of t h i s concept of the r e g i o n a l i z a t i o n of three wards and c l i n i c a l teams i n Crease Unit, the d i f f i c u l t i e s that arose were due i n part to communication gaps between s t a f f and records of the Vancouver Mental Health Project and of the Riverview "Vancouver Service", and i n part to p h y s i c a l pressures from 'the numbers of patients admitted. The Burrard area, for example, which contains a very dense and transient population as w e l l as the c i t y gaol, produced what at times became an unmanageable load of grossly psychotic patients, a t h e r a p e u t i c a l l y unsatis-factory s i t u a t i o n . An overlap of service between.the Riverview Outpatient Department and the Vancouver Project teams, i n that both were looking a f t e r patients i n the same context and i n the same area, needed to be resolved. So as to contain the increasing discrepancy i n number and condition of patients admitted from the d i f f e r e n t Vancouver areas, r e g i o n a l i z a t i o n per se i n Crease was discontinued i n 1974, to the extent that patients were admitted to each of the three ward s oh the basis of f a c i l i t i e s a v a i l a b l e , and the decision of the admitting physician on duty, rather than on the a r b i t r a r y basis of the area from which they came. Organization of Riverview Hospital Structure Riverview Hospital today i s a complex of buildings of varying u t i l i t y . The patient population i s s t e a d i l y decreasing (at present i t i s i n Dr. W.J.G. McFarlane: Staff Memorandum. Riverview Hospital f i l e s . 93 the neighbourhood of 1600), few of the staff l i v e on the site, and the education of psychiatric nurses has been moved to the British Columbia Institute of Technology, leaving some of the wards and residences empty. The original building, West Lawn, is s t i l l used to house male chronic patients, but the wards on i t s "C"•side have been closed, as this area was considered too dilapidated for renovation, and some seventy patients have been transferred to East Lawn and others to Tranquille and Valleyview. Seven "minicare homes" are part of West Lawn: these were originally individual staff residences, and are now rehabilitation houses for small groups of male patients. . East Lawn contains chronic female patients, a number of whom are retarded. Many of i t s elderly patients are becoming increasingly infirm. As well, female forensic patients are located on ward F4a, which also has the more grossly psychotic of East Lawn's population. An "Activities of Daily Living" home, and one of the original nurses' residences, Brookside, are rehabilitation extensions of East Lawn. North Lawn, the medical unit, looks after patients who have a major physical component to their illness which necessitates medical treatment and nursing care. In addition, one 32 bed ward is devoted to the diagnosis, evaluation, and treatment of patients whose mental illness i s caused by organic disease, i.e., organic brain syndrome. The Riverside Unit is now specifically for the containment of male forensic patients: those admitted under Warrants of Committal, Orders-in-Council, or some other provision of the Criminal Code. Such patients who require inpatient psychiatric treatment after the expiry of their sentence are transferred to other areas of the hospital. 9 4 The organization of Centre Lawn Unit on a regionalization concept has been described previously. As well as wards which admit and treat patients from specific regions of the province, ward D5 in Centre Lawn provides an operant (behavior modification) program, to which patients are referred from other hospital areas. Crease Unit has three acute wards for patients from the Metro-politan Vancouver area, as well as a number of .chronic psychotics, and a nine-bed Intensive Care Unit. The operating room and surgical ward are also in Crease, as well as other c l i n i c a l and diagnostic f a c i l i t i e s , administrative and departmental, offices, the main medical records office and the library. The hospital's Rehabilitation Department operates Hillside, a 52 bed separate residential rehabilitation and training building on the hospital grounds, and Venture and Vista, two half-way houses in Vancouver. Also under hospital direction is Pennington Hall, the recreation centre; and industrial, transport, and laundry f a c i l i t i e s . The Outpatient Department at 9 6 East Broadway, as noted earlier, was a part of Crease Unit's Vancouver Psychiatric Service un t i l taken over by the Greater Vancouver Mental Health Services. On the grounds, but not under the management of the hospital, are an education building, public works and f i r e department units, CMHA volunteer services and tuck shop, Mental Health Branch pharmacy and stores, and the Department of Agriculture's Colony Farm. In addition, approximately 450 patients are supervised by the hospital in a special boarding home program . under the joint direction of the Mental Health Branch and the Department of Human Resources. 95 Management The administration of Riverview Hospital is carried out through a departmentalized structure, governed by a board composed of o f f i c i a l s of the Mental Health Branch, and headed by the Executive Director, Dr. J.C. Johnston. The various departments are directed by assistant executive directors and department heads. Activities in the six hospital units are directly administered by departmental supervisors of the larger departments, such as nursing, social service, occupational therapy, medical records, dietetics, housekeeping, and so on. Each unit also has a medical Unit Director, although in 1974-75 these positions were vacant in Crease, East Lawn and Riverside. The medical staff, under the direction of the Assistant Executive Director, Medical Services, is composed of both salaried staff and sessional physicians,, with consultants available when required. The staff at Riverview are employees of the provincial government. With the exception of physicians, Registered Nurses and Registered Psychiatric Nurses, who bargain with the employer through their professional organizations, the staff certified bargaining agent is the British Columbia Government Employees' Union. Hospital standards and quality are monitored by administrative and medical staff committees, the latter including the Medical Advisory Committee, Credentials Committee, Medical Records Committee, Medical/Surgical Audit Committee, Psychiatric Audit Committee, Programme Committee, Pharmacy and Therapeutic Committee, Therapeutic Abortion Committee, and an Ad Hoc Committee for Amendment of the Medical Staff By-Laws. The management of the hospital was, u n t i l mid-1975, under the 96 direction of the Mental Health Branch of the provincial Department of Health. The rapid changes in the organization of a system of mental health services in British Columbia, however, have resulted in a somewhat anomalous position for the hospital, a state imposed unilaterally by policy determined and implemented by the Mental Health Branch and By government. The problems Riverview faces are associated with i t s institutional role-set, the functional autonomy and resources available to i t , and the demands made on i t . Reorganization of the Hospital In 1973, while regionalization of the Centre Lawn Unit had been partially implemented, the Deputy Minister directed that the hospital was to be reorganized into five relatively self-sufficient programs, "to f a c i l i t a t e 9 more precise program planning and development on a functional basis." These programs were: " 1 . Greater Vancouver psychiatric services - providing care to Vancouver, Burnaby, Richmond and the North Shore. 2. Psychiatric services providing care for the balance of the Province. 3. Forensic service - for the entire Province. 4. Medical/Surgical Health Service - providing medical and nursing care, also c l i n i c a l support services such as radiology, laboratory and dentistry, to a l l five program areas. 5. Intermediate/Personal Care Service - for the mentally disordered. Entrance to this program w i l l only be from Programs 1 and 2, due to lack of Memorandum from the Deputy Minister of Mental Health to Dr. J.C. Johnston, Executive Director, Riverview Hospital, November 13, 1973. 97 suitable community resources. It w i l l be understood that such resources are to be developed at the community level. "*^. Restrictions on policy implementation, such as budgetry and staffing limitations, authority conflicts and p o l i t i c a l considerations commonly delay progress, and the hospital has encountered considerable d i f f i c u l t y in attempting to develop the f l e x i b i l i t y necessary to adapt to the terms of reference received from the Branch. The hospital's "Proposal for the Reorganization of Riverview Hospital" (1974) recommends development of programs with stated objectives and assigned resources which w i l l serve defined populations, and points out in i t s introduction,' "We see the central issue of reorganization relating to the degree of functional autonomy which can be r e a l i s t i c a l l y vested in the designated Programs. We recognize that the degree of autonomy which can be delegated is directly proportionate to the amount of autonomy available."'''* The reorganization model outlined in the hospital report is intended to permit central direction while allowing functional autonomy within the proposed programs. Contributions to the planning which culminated in the report were made by a l l levels of staff, by a l l hospital departments, and by concerned organizations. Constrained by the terms of reference imposed, and cognizant of the potential for conflict inherent in proposed changes in management structure, the proposal represents a concensus. Since Memorandum from the Deputy Minister of Mental Health to Dr. J.C. Johnston, Executive Director, Riverview Hospital, November 13, 1973. Core Committee of Riverview Hospital. Proposal for the reorganization of  Riverview Hospital. Mimeo. August, 1974. 98 i t s completion and d e l i v e r y to the Deputy Min i s t e r , no action towards i t s acceptance or implementation has been apparent. No doubt the present reorganization of the Health Department w i l l necessitate a new perspective .on the organization and operation of mental health f a c i l i t i e s i n the province. As the Mental Health Branch 1974 Annual Report puts i t : "This report i s 12 cu r r e n t l y under consideration i n the l i g h t of Departmental reorganization." DevelopmsniPey^elioprmenfoLO.fL a:rRro7p.o:s:aferfio-rj.tReorganization The o r i g i n a l terms of reference, p r i n c i p l e s and procedures f o r implementation of reorganization of the h o s p i t a l into f i v e programs, as determined by the Mental Health Branch, and outlined in.a memorandum, November 13, 1973 from the Deputy M i n i s t e r , did not meet with unanimous approval from some of the affected groups. The proposed administrative structure for each of the f i v e programs c a l l e d f o r a Program Administrator and a C l i n i c a l D i r e c t o r , with both c l i n i c a l and n o n - c l i n i c a l s t a f f assigned to each program, and c e n t r a l support services a v a i l a b l e to each. Staff p a r t i c i p a t i o n i n program development was to be ensured and implemented by advisory committees and councils. The implications of the l i n e s of authority designated by the p r i n c i p l e s of reorganization and by an organizational chart which had been prepared, raised serious concerns and objections by both nursing and medical s t a f f . These concerns were with regard to the p o s s i b i l i t y that nurses would be rec e i v i n g d i r e c t i o n i n nursing matters from non-nurses, s p e c i f i c a l l y the " C l i n i c a l D i rectors"; that a t r u l y 'Mental Health Branch. 101st Annual Report 1974. V i c t o r i a : Queen's P r i n t e r . 99 decentralized scheme would require a decentralized resource allocation, and would not involve the amount of structure above the program level that was indicated in the organizational chart. To resolve the impasse concerning the administrative structure that had been reached, the Deputy Minister issued a further memorandum on February 14, 1974, outlining new terms of reference regarding reorganization. While this specified the same five proposed programs, i t did not tie them to any specific organizational or administrative model. An expanded hospital committee, formed to plan and develop the reorganization, was composed of: the Assistant Executive Director, Medical Services (Chairman) the Assistant Executive Director, Patient Services the Assistant Executive Director, Administration the Director of Social Service the Director of Psychology a Representative of the Branch, to provide liaison. This was known as the Core Committee, and was responsible to the Executive Director, and through him to the Deputy Minister. To seek broad group involvements, creativeness and originality, participation from staff involved in each of the programs had been encouraged. Five "Interim Program Advisory Committees" were formed, made up of represent-atives from the various departments and disciplines present in each unit: Crease, Centre Lawn, Riverside, North Lawn, and East and West Lawn combined, and each produced valuable contributions. A l l of these, as well as inputs from the hospital departments and from concerned organizations, were taken 100 into consideration, and were included as appendices in the Core Committee's f i n a l report. As the Proposal for the Reorganization of Riverview Hospital was developed within the terms of reference defined by the Deputy Minister, the model proposed by the Core Committee did not exceed these guidelines. The position taken by the Committee, as stated in the Introduction to the Proposal, i s "that what is needed is a model which would change the focus of control from precedent to problem-solving based on rational planning" and i t s recommendations are as follows: 13 "1. The Forensic Program (Program Three) of Riverview Hospital be removed administratively from Riverview Hospital, and placed under the Forensic Psychiatric Services Commission. 2. The Vancouver Psychiatric Service (Program One) be either, (a) removed administratively from Riverview Hospital, and placed under a Vancouver Health Board, or, alternatively, (b) designated as one Program within Riverview Hospital. 3. Riverview Hospital be brought under a governing board, empowered to act in a fashion similar to the governing boards of general hospitals. 4. Program management be decentralized with departmental structure maintained, to ensure the development of acceptable standards of care. 5. The following Programs, serving defined populations, and with Program numbers in brackets refer to those Programs originally described in the Deputy Minister's memoranda of Nov. 13, 1973 and February 14, 1974. 101 stated objectives and assigned resources, be developed: (a) Vancouver Psychiatric Service (Program One). Alternatives are stated in Recommendation 2, above. (b) Provincial Psychiatric Service (Program Two). (c) Extended Care and Medical Service (Program Four). (d) Acute Medical and Surgical Service (Program Four). (e) Specialized Continuing Psychiatric Care (Program Five). (f) Continuing Care for Geriatric Patients (Program Five). (g) Social Rehabilitation Program (Program Five). A Program Committee be established in each Program, responsible for the management of that Program. An Inter-Program Coordinating Committee be established, responsible for coordinating the activities of the various Programs and Central Departments, and providing advice and consultation to the Executive Director. The responsibilities of the senior administrative officers of the Hospital be as follows: (a) An Assistant Executive Director shall be responsible for certain designated departments. (b) The Assistant Executive Director, Administration, shall be responsible for certain designated departments. (c) The Medical Director shall be administratively responsible for medical staff, and for designated medical resource departments. (d) The Director of Nursing shall be administratively responsible only for the Department of Nursing. The Assistant Executive Director, the Assistant Executive 102 Director, Administration, the Medical Director, the Director of Nursing, the.Director of Personnel, the Director of Psychology, the Director of Social Service, and the Coordinator of Volunteers report directly to the Executive Director. 10. The role and relationship of the Medical Staff Organization continued as at present. 11. Suitable provision for staff to transfer between Programs be made between the Departments concerned and the Programs involved, and such provision be communicated to the appropriate union or professional association." The Core Committee defined the term "Program" as "the sum of small planned functional services and programs available to a given population." The populations were defined in a number of ways: on a geographic basis, on a legal basis, and on a c l i n i c a l basis. Following the definition of the 14 population, objectives and components (i.e., wards) were outlined. Constraint Pons t r a i n s While the terms of reference for proposing a model for reorganization of the hospital were contained in the February 14 memorandum from the Deputy Minister, the Core Committee exceeded these to point out in i t s Report some of the areas where constraints on Program development were most apparent. These can be itemized as: Details of proposed Programs, organizational and administrative models, are to be found in the text of the "Proposal for the Reorganization of Riverview Hospital." 103 1. A necessity for the "ultimate authority for the operation of Riverview Hospital to be vested in a lay governing board, composed of persons of stature from the community. Such a board would be empowered, under appropriate legislation, to act in a manner similar to that of general hospital boards." 2. The hospital management system should be aligned to the concept of management by objectives. 3. The hospital should have autonomy in the areas of purchasing and stores (presently under the authority of the Branch), and of plant maintenance (now a responsibility of the Department of Public Works). In a footnote, the Report states: "One of the most emphatic concerns voiced by several hospital disciplines has been directed towards the mobility to secure adequate plant maintenance and construction...The Core Committee also notes the efficacy of establishing separate funding arrangements which w i l l permit the hospital to secure tenders for work requirements, and set i t s own priorities for expenditure of funds." 4. A need for departments of public relations, and of research and staff development, as one of the detriments of the hospital in i t s public image, as well as i t s lack of research and staff training programe. The parameters of program development were constrained both by the terms of reference imposed and by the centralized management of the hospital. While the Interior Program Advisory Committees advocated a decentralized management model, the Department Directors in general favored a centralized scheme. Organizational Model After prolonged deliberation, including consideration of the points 104 of view of the Advisory Committees, department heads, representatives from "concerned organizations",^ and the position of a l l members of the Core Committee, an organization model was developed for the hospital. This model, shown in Figure 2 "permits central direction and, at the same time, allows for functional autonomy with planning and management responsibility within the Programs. Also, i n keeping with our terms of 16 reference, 'professional concerns are safeguarded.'" Proposed Programs The Forensic Program The f i r s t Program identified by the Core Committee in i t s Proposal i s the Forensic Program, and the Committee recommends that "The Forensic Program (Program Three) of Riverview Hospital be removed admini-stratively from Riverview Hospital, and placed under the Forensic Psychiatric Services Commission."''^ The Forensic Program would thus become The B.C. Government Employees' Union; the B.C.M.A., Section of Psychiatry; the Riverview Medical Staff Organization; the R.N.A.B.C. and R.P.N.A.B.C. Core Committee Report:' Introduction. ^Core Committee Report: Recommendations. |DIR ECTOR OF SOCIAL SERVICE CASEWORK (SUPERVISOR l/Pro^ram i@isi^ i (JOINT CONFERENCE] COMMITTEE iMEDICAL STAFF ORGANIZATION — tpOVERNINQ BOARDl [EXECUTIVE DIRECTORl' DIRECTOR OF ' [PSYCHOLOGY; IDIRECTOR OF NURSING PERSONNEL— VOLUNTEERSH jlNTER-PROGRAM C00RDINATIN3| COMMITTEE  MEDICAL DIRECT OR] IPHYSICIANSI jCONSUim ANTS CHIEF OF IMEDICAL STAFF*, l/Program COORDIN-ATOR ISTAFF DEVEL-OPMENT ASSOCIATE DIRECTOR OF NURSING: lASSISTANT DIRECTOR! OF NURSING EVENING ISUPERVISORSl NURSING COORDIN. ATOR* lASSISTANT DIRECTORl OF NURSING NIGHT ISUPERVISORSl -CHARGE NURSES (grouped according to Program) •Indicates possible new Department or Position (see text of Report for discussion) lASSISTANT EXECUTIVE! DIRECTOR* .DENTAL -E.E.Q. -PHYSIO-THERAPY LRADIOLOGY 1 HOSPITAL STANDARDS COMMITTEE ASSISTANT EXECUTIVE DIRECTOR. ADMINISTRATION (-ACTIVITY THERAPY (O.T..R.T.) •BARBER & BEAUTY SHOP UMEDICAL RECORDS -OPTOMETRY -PASTORAL CARE l-PODIATRY .RESPIRATORY THERAPY IACCOUNTANTI CENTRAL ADMINIS-i TRATION OFFICER* 1-BUSTNESS OFFICE i-PAY OFFICE PURCHAS-i - TNG & STORES* FIGURE 2 -REHABILITATION -SPEECH THERAPY -TEACHER • LPUBLIC RELATIONS* LRESEARCH 4 STAFF DEVELOPMENT* PROPOSED ORGANIZATIONAL MODEL LDTETETICS [.HOUSEKEEPING INFORMATION -INDUSTRIAL -LAUNDRY -LIBRARY .PHARMACY -POST OFFICE -SECURITY -SWITCHBOARD .TRANSPORT PROGRAM) ADMIN. 3FFICER 1/Program PLANNING PROGRAMMING BUDGETING OFFICER* PLANT _ MAINTENANCE* (HOSPITAL AUDIT ICOMMHTEEI VANCOUVER I- PSYCHIATRIC SERVICE PROGRAM COMMITTEE PROVINCIAL - PSYCHIATRIC PROGRAM COMMITTEE EXTENDED CARE MEDICAL SERVICE PROGRAM COMMITTEE ' ACUTE MEDICAL t-Sb SURGICAL SERVICE PROGRAM COMMITTEE SPECIALIZED CONTINUING PSYCHIATRIC CARE PROGRAM COMMITTEE CONTINUING CARE SERVICE TOR GERIATRIC PATIENTS PROGRAM COMMITTEE SOCIAL RE-L 1ABILTTATION PROGRAM PROGRAM COMMITTEE o Ln 106 the inpatient component of the Provincial Forensic Psychiatric Service. The population of the inpatient Forensic Psychiatric Service would be: 1. Accused persons remanded for psychiatric examination. 2. Persons held at the direction of the Lieutenant-Governor in Council, pursuant to the Criminal Code of Canada, or the Mental Health Act. 3. Persons held pursuant to a court order. 4. Persons in need of psychiatric treatment in a hospital setting while in custody. Passage of the Forensic Psychiatric Services Commission Act (1974) gives the Commission established under the Act the responsibility of providing forensic.psychiatric services to the population described above. The functions of the Commission, as outlined in the Act, are: "(a) to provide forensic psychiatric services to the courts in the Province and to give expert evidence in relation thereto; (b) to provide forensic psychiatric services for (i) accused persons remanded for psychiatric examination; ( i i ) persons held at the direction of the Lieutenant-Governor in Council pursuant to the Criminal Code (Canada) or the Mental Health Act; ( i i i ) persons in need of psychiatric care or assessment while in custody; and (iv) persons held pursuant to a court order; (c) to provide in-patient and out-patient treatment for persons referred to in Clause (b) and such other persons as the Minister may designate; (d) to plan, organize, and conduct, either alone or with other persons and organizations, 107 ( i ) research respecting the diagnosis, treatment, and care of forensic p s y c h i a t r i c cases; (e) to consult,with Federal, P r o v i n c i a l and municipal departments or agencies, mental health centres, and other persons or organizations with respect to the advancement of the objectives set out i n t h i s section; and (f) to perform other duties, r e s p o n s i b i l i t i e s , research, and education programmes respecting forensic psychiatry as directed by the Lieutenant-18 Governor i n Council." Assuming that the Forensic Program w i l l come under the j u r i s d i c t i o n of the Forensic P s y c h i a t r i c Services Commission, i t s inpatient p s y c h i a t r i c services w i l l require i n t e g r a t i o n with other agencies and f a c i l i t i e s dealing with t h i s p o p u l a t i o n — t h e courts, outpatient forensic services, c o r r e c t i o n a l i n s t i t u t i o n s , and post-confinement r e h a b i l i t a t i o n services: the Forensic Program boundaries w i l l i n t e r f a c e with components of the c o r r e c t i o n a l system as well as with the health system. While experts agree that the medical model of treatment should be applied to the mentally i l l f o r e n s i c patient, the c r i t e r i a f o r admission to and e x i t from the system i s con t r o l l e d and affected by l e g a l and j u d i c i a l , as well as medical, d e f i n i t i o n s . Adequate treatment and sec u r i t y components, and linkage mechanisms, must be given a major p r i o r i t y i n fo r e n s i c program development. Continuity of data, and of the methods of maintaining, s t o r i n g , l i n k i n g and accessing records i s an absolute necessity i f a system of fo r e n s i c mental health service i s to function. An evaluation of the degree of r e c o n c i l i a t i o n among the record-Forensic P s y c h i a t r i c Services Commission Act. 1974. Government of B.C. 108 keeping procedures of the various f a c i l i t i e s should be undertaken, with a mandate to develop and implement a policy which w i l l correct deficiencies. The c r i t e r i a adopted by authorities to designate an individual's requirement.for assessment or treatment for mental illness and his subsequent admission to the Forensic Program is not discussed here, Evaluation of the legal status of the population which is designated to the Forensic Unit, while a c r i t i c a l area, is preliminary to the content of this dissertation, which is concerned with the adaptation of the f a c i l i t i e s of Riverview Hospital in order to meet the needs of the mentally i l l . The emphasis is that such committals require both a custodial and a treatment environment. The image that the Riverside Unit has been directed to present has been that of a hospital unit, however, as both the staff and the patients are constrained by i t s custodial function, such an image appears to them as euphemistic, impractical, and a deceit. It is essential that attention be drawn to the multiplicity of roles which the staff of a unit such as Riverside are forced to play. These role complexities, and the conflict between the philosophy of psychotherapy and the custodial management of the inmates, deter and undermine any thera-peutic process. The mental health services available to persons committed to a mental hospital under an Order-in-Council, Court Order, or transferred from prison should be equal to those available to mentally disabled persons not in custody.^ The Law and Mental Disorder. Three: criminal process. Toronto. CMHA. 1969. 109 The Forensic Program requires adequate resources to allow i t to function as a therapeutic f a c i l i t y , while maintaining a custddial entity. The Interim Forensic Program Advisory Committee submitted recommendations intended to form the basis for the operation of a forensic hospital. These outline operating principles of a forensic hospital; improvements in medical record-keeping, and in housekeeping, dietary, security, occupational and recreational therapy; a work-rehabilitation program on the Colony Farm; and suggestathe optimal roles of a work supervisor, a nurse coordinator, a 20 rehabilitation consultant, and of the farm staff. The committee also addressed i t s e l f to the issue of the community and thefforensic patient. Sydney Baird, coordinator of volunteers, recommended that a coordinator of community services be hired for the Forensic Program. Mrs. Baird argues that: "Although we presently have the community somewhat involved with Riverside patients, the Forensic Programme presents unique challenges. While our society sees these particular patients as both bad and mad, our patients frequently see themselves as victims of society. To be faced with the possibility of indeterminate incarceration even though one has not been found guilty of anything, exacerbates anti-social reactions. Thus both the patients and the community see themselves as each other's victims. And both are correct. This most vexatious dilemma w i l l never be solved to the satisfaction of everyone, but un t i l the community becomes more involved, enlightened and concerned, the forensic patient and health care professionals dealing with them w i l l continue to be isolated. It i s my submission that a more dynamic rapport amongst patients, professionals and the community, is feasible and a necessary part of the Forensic Programme. While i t i s encouraging to report that both C.M.H.A. and Legal Aid Society, of-Core Committee Report. Appendix D. Program Three: Forensic Program. 110 Society of B.C. have recently adopted the problem of the mentally i l l involved with the law amongst their respective p r i o r i t i e s , i t is impossible...to either maintain continuity of community services or expand programmes to forensic patients with existing staff positions. I therefore recommend consideration be given to hiring a full-time Co-ordinator of Community Services for the Forensic Programme."21 The Core Committee, in dealing with the Forensic Program, anticipated that, with the passage of the Forensic Psychiatric Services Commission Act, and the establishment of a Provincial Forensic Psychiatric Service with i t s own executive director, the program, i.e., the Riverside Unit, wou'lid become the inpatient component of the service. For this reason, the Report delineates only those positions and resources of Riverview Hospital which have been designated for the Forensic Program and would be separated from the hospital. The staff and resources of a Forensic Psychiatric Service would depend on the nature and degree of integration with inpatient and outpatient services, and with court consultations and ju d i c i a l and correctional f a c i l i t i e s . Vancouver Psychiatric Service. The Vancouver Psychiatric Service was designated as Program One by the Core Committee, which recommended that i t "be either, (a) removed administratively from Riverview Hospital, and placed under a Vancouver Recommendation to the Interim Forensic Programme Core Committee Report, Appendix D. Baird, Sydney. Sub-Committee. Health Board, or, alternatively, (b) designated as one Program within 22 Riverview Hospital." Pointing out that patients served by this Program would be from Vancouver, Richmond, and the North Shore municipalities, the Core Committee enlarged on i t s recommendation: "The recommendations for the Vancouver Psychiatric Service (Program One) take into consideration the development of the Greater Vancouver Mental Health Services under the Metropolitan Board of Health of Greater Vancouver. They also consider the possible future development of a Vancouver Health Board, which might succeed both the Metropolitan Board of Health and the Greater Vancouver Regional Hospital Board. The Vancouver Psychiatric Service of Riverview Hospital, and the separately administered Greater Vancouver Mental Health Service, represent a certain duplication of services and a somewhat a r t i f i c i a l separation of inpatient and outpatient services. The development of a Vancouver Health Board would present an opportunity to bring both parts of what should be an integrated service under one governing board. This is similar to the way in which the Forensic Psychiatric Services Commission w i l l bring a l l i t s designated services under one governing board." The Core Committee outlined the components of the Vancouver Psychiatric Service as four wards in Crease Unit, as well as the Outpatient Core Committee Report. Recommendations. 112 Service at 96 East Broadway in Vancouver. The Interim Program Advisory Committee described i t s objectives as follows: "1. To provide general and comprehensive psychiatric treatment for patients meeting the admitting c r i t e r i a of Riverview Hospital f a c i l i t i e s , who reside in Vancouver city, the North Shore municipalities, and Richmond. 2. Such a service would include diagnosis, treatment, rehabilitation and/or confinement, and may be provided on an outpatient basis, on the basis of partial, acute, or chronic hospitalization, as is considered most appropriate for the individual patient concerned. 3. . The service would undertake to refer patients to specialized services of Riverview Hospital, e.g. Forensic, Organic Brain Syndrome, etc. or to other f a c i l i t i e s i f a patient is more suitably treated in such areas. 4. This service would cooperate with other agencies, such as Human Resources, in order to see that the total needs of the patients are met, but would not in i t s e l f provide such services as housing, employment, financial assistance, etc., not generally considered a hospital responsibility. 5. The service w i l l have a role in public education in mental health matters and in professional education in association with the relevant educational institutions. 6. This service w i l l foster research conducted by members of i t s staff and w i l l cooperate with duly approved research projects of 23 other qualified investigators." Core Committee Report. Appendix E l . Vancouver Psychiatric Service (Program One). 113 The Advisory Committee suggested that the best use of the hospital Outpatient Department was as a day hospital, which would accept patients from a l l areas of the hospital, from Community Care Teams, and from private practitioners. This day hospital would function as "1. An alternative to inpatient treatment. 2. As a transitional f a c i l i t y . 3. As a locus for intermediate-term rehabilitation of persons who have social and vocational deficits resulting from or related to mental illn e s s . 4. As a service for patients so seriously impaired that, but for the periodic support and/or maintenance of the day programme, long-term hospitalization would be required. 5. As a diagnostic method. 24 6. Pre-admission services." The senior personnel from the Outpatient Service and the Joint Steering Committee (made up of representatives from Riverview and the Vancouver Service) supported this day-hospital concept, and forwarded a recommendation to the Deputy Minister. In 1975, however, staff and f a c i l i t i e s of the Outpatient Service were seconded to the Greater Vancouver Mental Health Service. Coordination between the Vancouver Psychiatric Service (Program 1) in Riverview and the developing Community Care Teams in the Greater Vancouver area has been described earlier in this chapter. Increases in Core Committee Report. Appendix E l . Day Hospital - Day Care. 114 community f a c i l i t i e s have resulted in a change in the characteristics of patients newly admitted to Riverview, as the more seriously disturbed have been referred there for admission. In order to meet the needs thus generated, an intensive care unit and closed wards have been developed in Crease Unit. Provincial Psychiatric Service The population of this Service would consist of "patients with residence in parts of the Province of British Columbia other than Vancouver, 25 Richmond, the North Shore municipalities, and Burnaby." Its goals, equivalent to those of the Vancouver Psychiatric Service, were "to provide appropriatescaref. treatment and rehabilitation of mentally i l l persons for the designated population. To provide acute and generalized continuing inpatient care, limited outpatient and partial hospitalization services. So as to assure the best quality of service, continuous inservice, educational and research programs shall be carried out. Liaison with mental health centres and other appropriate community and educational 25 agencies w i l l be maintained." The Provincial Psychiatric Service in Centre Lawn Unit was expected to continue in the development of "regionalization", and coordinate i t s staff and services with those of provincial Mental Health Centres. The staff working in Centre Lawn experienced the same lack of adequate resources to cope with an increasingly acutely disturbed patient Core Committee Report. 115 population as did the members of the Vancouver Psychiatric Service. Their d i f f i c u l t i e s were compounded by their confusion as to the authority under which they were to operate. With a program of regionalization carried on concurrently in the community and in the hospital unit, coordination and direction came from the Mental Health Branch. Internal organization, however, was directed by hospital administration. As a result of this apparent dichotomy of direction, the Centre Lawn Advisory Committee experienced great d i f f i c u l t y and frustration in coming to grips with an organizational model. To quote excerpts from the Committee's minutes, "(The chairman raised) the issue of the difference in concept between what Branch through the Program Reorganization concept is 26 proposing and what Hospital Administration is saying..." In order to cl a r i f y i t s position, the Centre Lawn Advisory Committee made the following recommendations: "1. Recommended that Core Committee obtain information from Woodlands School relevant to the recent changes made there to serve as guideline to the Program Committees here. 2. Recommended that mental health f a c i l i t i e s be augmented so that: a) they could provide adequate follow-up for patients discharged from Riverview Hospital; b) they would accept responsibility for care of same. 3. Recommended that c l a r i f i c a t i o n be obtained regarding the term 'continuing inpatient care 1 stated as one of the objectives of "Program 26 Core Committee Report. Appendix E2. Program Two: Centre Lawn. 116 Program #2 as outlined in the draft memo of March 26, 1974 entitled 'Definitions of Programs, Program Objectives and Components',. (This c l a r i f i c a t i o n i s being requested in order to establish which Programs should accept responsibility for extended care type patients.) 4. Recommended that Public Works Department be contacted to determine why nothing has been done regarding the long promised structural changes required to make possible integration and a closed area in Centre Lawn. 5. Recommended that bed count in Centre Lawn be reduced to an acceptable level of nurse/patient ratio. 6. Recommended that provision be made for compulsory follow-up of 27 potentially dangerous patients." Programs Four and Five As outlined in the Deputy Minister's terms of reference for reorganization of Riverview Hospital, these programs were defined as: "4. Medical/Surgical Health Services, providing medical and nursing care, also c l i n i c a l support services such as physical medicine, radiology, laboratory and dentistry, etc,,(to a l l five programme areas.)•' 5. Intermediate/Personal Care Service (including rehabilitation) for the mentally disordered. Entrance to this programme from Programmes 1 and 2 w i l l occur only when there i s a lack of Core Committee Report. Appendix E2. Program Two: Centre Lawn. 117 suitable community resources. It is expected that there w i l l be an expansion of these Intermediate/Personal Care Services at 28 the community level." The Core Committee stated that these Programs, "as outlined in the terms of reference, presented certain problems. It was found that these two Programs had their physical components (wards) so scattered between buildings that a substantial interchange of patients would be required. In addition, i t is projected that the population of Program Four 29 may enlarge, while the population of Program Five may decrease." The Committee made an alternate recommendation^-s that these two Programs be divided into five - Extended Care and Medical Service, Acute Medical and Surgical Service, Spec-ial'-izedaEontinuing Psychiatric Care, Continuing Care Service for Geriatric Patients, and a Social Rehabilitation Program. Extended Care and Medical Service This service would "provide appropriate inpatient care, treatment and rehabilitation to extended care, mentally i l l patients, who have a major physical component to their i l l n e s s . " It would have "close liaison with, 30 and a ready exchange of patients from, the other Programs." Deputy Minister of Mental Health. Memorandum Re: Reorganization, Riverview  Hospital. Feb. 14, 1974. i Core Committee Report. Core Committee Report. 118 An Acute Medical and Surgical Service "would provide acute medical and surgical care to mentally i l l patients who require such service" 31 and would have "close liaison with other Programs." Its components would be a surgical unit, comprising the operating suite and surgical ward in Crease Unit; the organic brain syndrome ward, which would be moved from North Lawn to Crease Unit; and two medical wards, South .3 in North Lawn and J4 in East Lawn. A Specialized Continuing Psychiatric Care program had as i t s goal provision of "long-term care of a specialized nature, for patients selected from the other Programs. These patients should have a potential for 31 rehabilitation." The "operant project" would be included in this Program. A Continuing Care Service for Geriatric Patients was intended "to provide long-term care of a specialized nature, including experimental programs, for older patients on a selected basis from the other functional divisions. These patients have a potential to move into the Extended Care ..31 Program. A Social Rehabilitation Program's goal was "to provide continuing care and treatment, with emphasis on speia-llrehabilitation, for mentally i l l persons now under care in the long stay areas of Riverview Hospital, and for 31 patients referred on a selected basis from other programs." This program would u t i l i z e the "minicare" homes and vacant nurses' residences on the hospital grounds for patient accommodation. Core Committee Report. 1 1 9 Program Four: Medical/Surgical Health Services Interim Program Advisory  Committee This committee submitted a comprehensive report to the Core Committee, which i s included i n the Reorganization Proposal as Appendix E3. The Committee l i s t e d the objectives of the Services as: "1. To care for patients with acute medical or s u r g i c a l conditions. Surgical services w i l l be a v a i l a b l e to patients from the f i v e programs at Riverview Ho s p i t a l , Valleyview and The Woodlands School. Medical Services w i l l include the above areas except The Woodlands School. 2. To care f o r patients with Medical or Surgical pathology which require continuous medical and nursing supervision, e.g. b r i t t l e d i a b e t i c s , cardiac conditions i n advanced stages, patients who require p e r i o d i c c a t h e t e r i z a t i o n or have suprapubic catheters, gastrostomies, etc. 3. To care f o r patients who because of t h e i r p h y s i c a l conditions require extensive nursing care. 32 4. To admit and investigate patients with organic b r a i n syndrome." It outlined and defined i n considerable d e t a i l the p a r t i c u l a r services which should make up the Program: Medical Services Surgical Services Core Committee Report. Appendix E3. Prp.gram Four: Medical/Surgical Health Services. 120 Extended Care Programme Rehabilitation - Activity Therapy Physiotherapy Occupational Therapy Recreational Therapy. The Interim Advisory Committee, Program Five This was.a joint committee, with representatives from both East and West Lawn, the two chronic buildings, sStaff from these units f e l t strongly that their programs and patients had a large measure of potential that was unrecognized by the Mental Health Branch and hospital administration, and the Program Committee responded to the request for input to the Core Committee with a great deal of planning and endeavor. The reader is directed for reference to Appendix E4 of the Core Committee's Report for the submissions from the Program Committee for East and West Lawn. This contains a summary of the Committee's recommendations, and submissions on: j 1. Admission screening committee for Program Five. 2. Acute Psychiatric Care within Program Five. 3. Community Preparation Program. 4. Intermediate Care. 5. Behavior Modification Program. 33 6. Recommendations regarding Program organizational structure. Core Committee Report. Appendix E4. Program Five. 121 Other Input to the Core Committee The Proposal For the Reorganization of Riverview Hospital included i n i t s appendix, as w e l l as submissions from the Interim Program Advisory Committees, a l l information received through meetings and communications with the h o s p i t a l departments, and with concerned organizations; the B.C.G.E.U., the B.C.M.A. Section of Psychiatry, the h o s p i t a l medical s t a f f organization, the R.N.A.B.C. and R.P.N.A.B.C. P o s s i b i l i t i e s f o r the Future Mental Health Branch p o l i c y has been directed toward community de l i v e r y of mental health se r v i c e s . An i n t e g r a t i o n of mental health centres and Centre llawn Unit i s developing, a l i a i s o n i s set up between the Vancouver Service and Crease Unit, and i t i s very probable that Riverside w i l l come under the d i r e c t i o n of the Forensic P s y c h i a t r i c Services Commission. I t seems apparent that the acute areas of the h o s p i t a l are destined to become inpatient components of community services u n t i l such a l t e r n a t i v e s as day hos p i t a l s and p s y c h i a t r i c beds i n regional general h o s p i t a l s develop s u f f i c i e n t l y to replace them. The long-term and medical care f a c i l i t i e s may be integrated into 34 the typography of " l e v e l s of care" outlined by the Department of Health, as each l e v e l of care provides a d e f i n i t i o n f o r p s y c h i a t r i c and mental, as wel l as p h y s i c a l condition. Some of these l e v e l s are within the j u r i s d i c t i o n of the Department of Health, while others come under the d i r e c t i o n of the Acute, Extended, Intermediate, Personal, and R e h a b i l i t a t i v e Care. 122 Department of Human Resources. The mechanism for reallocation of f a c i l i t i e s i s provided by the Mental Health Act, and has already been activated. Skeenaview, the geriatric f a c i l i t y at Terrace, is under the direction of a local Society, and Woodlands and Tranquille are now part of the Department of Human Resources. Some referrals of patients from Riverview to Intermediate Care institutions have been accomplished. It seems unusual, therefore, that the terms of reference given for the reorganization of Riverview did not contain any directive for specific autonomous capabilities. As the Core Committee took pains to point out, "The degree of autonomy which can be delegated is directly proportional to the amount of autonomy available," and no prospect of any relaxation of the centralized direction of the Mental Health Branch was forthcoming. Dr. Foulkes, in one of his "Special Reports" (Psychiatry at the Crossroads: A Review. Working Paper XXV), gives the following criticisms, which may have relevance in explaning the anomaly: "In our study, the present mental health bureaucracy was given a hearing. It, collectively, presented a 'belief system' that included movement away from the large institutions towards a community orientation, the redefinition of the role of the psychiatrist and the granting to other health professionals and even citizen's groups, an opportunity to work with those who need help and to govern institutions of various kinds. "However, in spite of this, the organization proceeded with a l l haste to continue to speak of expansion and renovation of the existing institutions. They exhibited the 'circling' described by. Wm. A. Wine in his 123 35 paper ,...It i s possible to obtain a consensus of beliefs of those involved in planning and delivering but evaluation is so d i f f i c u l t that i t is virtually impossible to state whether programmes have been successful or have simply transferred problems from one agency to another... "Even with one expensive form, the Mental Health Centre, efficacy is not demonstrated in a satisfactory manner. Success of this institution is explained in terms of the increasing numbers that have been installed 36 over the years, as i f quantity alone is indicative of progress." With the 1975 reorganization of the Health Department, Riverview Hospital has been placed under the jurisdiction of Hospital Programs, and is combined with Valleyview, Pearson and Dellview in an organization of "Provincial Institutions" which has been given a new form of departmental structure. Wine, W.A. Community psychiatry: an approach to evaluation. Clarke . Institute, Dec. 1969. Mimeo. 36 Foulkes, R.G. Health security for British Columbians. Special Report:  psychiatry at the crossroads: a review (w. p.xxv). 1974. Victoria: QuQueen&s Printer. 124 CHAPTER V Conclusion This thesis has endeavored to present a view of the development of services for the adult psychotic patient by the government of British Columbia, in the community as well as in the mental hospital. The premise offered here is that before any analysis.for planning for change can be undertaken, a f u l l appreciation of the present situation must be obtained. Through a focus on the existing parameters of government provision of mental health services, a basis for further investigation can be established. Application of a systems model of analysis to the organization of Riverview Hospital would demonstrate, in light of government policy directed to community provision of care, the constraints and pressures on the boundaries of the hospital organization. There is no doubt that the changing role of Riverview is due, in most part, to the hospital's turbulent environment, and only in a small extent to the results of changing treatment processes within i t . The hospital's response to environmental forces, however, is constrained by i t s lack of autonomy, particularly in i t s authority to manage i t s own operations and to control i t s own boundaries. When one examines the development of mental health services in this province, i t becomes apparent that the system of mental health -care"/.;: delivery i t s e l f , rather than the components of.organizations that make up the system, has been subjected to reorganization over a relatively short period of time - a s e l f - i n f l i c t e d turbulence, so to speak. To view the situation from another perspective, the environment has rapidly expanded to include, rather than a single institutional system for the delivery of service, a number of systems with interactions and interrelationships that 125 are compounding the environmental forces acting on Riverview. The main problem for the hospital l i e s in i t s inability to react appropriately. Until recently, the authority for provision of service was established, with the exception of the funding mechanism, within the hospital. Latterly, due to the expansion of services and p o l i t i c a l commitments, policy formulation, integration of services, resource allocation, and even some aspects of direct management were, vested in. the provincial Mental Health.Branch. As the Department of Health has undergone a reorganization, and has emerged as two branches, Community Health and Hospital Programs, rather than the previous four, the area or centralized control of mental health services appears to be bifurcated. The implication of directives to the hospital in recent years (1969 and later) to plan to regionalize and reorganize i t s services, is that services provided by Riverview w i l l eventually be replaced by local regional services. An analysis of the processes taking place in the over-all f i e l d of mental health service delivery, and of the adaptations developed or envisioned to enable the systems in this f i e l d to interact, would help to c l a r i f y some of the problems which are being encountered. If the independent variables affecting the components' or organizations' a b i l i t y to achieve the program objectives were measured and evaluated, perhaps a clearer and more direct route to an optimal delivery of mental health services would emerge. In searching for a policy that w i l l provide guidelines to the organization of health care delivery in the province, the provincial Health Department has, in addition to i t s centrally administered control mechanism, produced concepts of both the centralized B.C. Medical Centre and the 126 decentralized pilot community Health and Human Resource Centre. It is li k e l y that mental disorder w i l l in future relate to the system in conjunction with other types and classifications of illness, rather than as a separate and distinct anomaly. The implication that mental health care should be delivered in conjunction with physical health care leads to integration of the existing separate models. Reorganization of the Health Department In 1974, at the second session of the Legislative Assembly, the Department of Health Act^ was amended, so that a complete reorganization of the Health Department could take place. This amendment, the repeal of Section 12, removed the requirement that a medical qualification be held by the Deputy Health Ministers. A Reorganization Committee, with J.W. Mainguy, Assistant Deputy Minister of Hospital Insurance, as chairman, reported to the then Minister of Health, the Honorable Dennis Cocke. As a result of the committee's report, the four branches of the Department of Health, (Public) Health, Mental Health, Hospital Insurance, and Medical Services, were consolidated into two main programs: the "Medical and Hospital Programmes Branch" and the "Community Health Programmes Branch", each under the direction of a Deputy Minister. As outlined in the Mental Health Branch Newsletter, "The Medical and Hospital Programmes Branch w i l l be responsible for such services as: the Medical Insurance Programme; the Hospital Insurance Programme; the admin-.; Department of Health Act. Government of B.C. Victoria. Queen's Printer. 1960. 127 istration of government institutions; Emergency Health Services; Diagnostic Services and Forensic Psychiatric Services. The Community Health Programmes Branch w i l l have responsibility for: Community Mental Health Programmes (excluding institutional care); Community Public Health Programmes; special health services, such as VD Control, Occupational Health, etc.; such environmental control services as are delegated to the Health Department by the Executive Council; the Community Health Centre Development Programme and the Community Care F a c i l i t i e s Licencing Programme." The Minister announced three appointments: Mr. J.W. Mainguy as Senior Deputy Minister, Mr. W.J. Lyle as Deputy Minister (Medical and Hospital)*, and Dr. G.R.F. E l l i o t t , Deputy Minister, Community Health Programs. Dr. F.G. Tucker became the senior psychiatric consultant within the Departmental Planning and Support Services, as well as Chairman of the Forensic Psychiatric Services Commission. An organizational chart of this new Health Department Structure, 3 issued in 1974, is shown in Figure 3. 'Mental Health Branch Newsletter. Oct., 1974. Mental Health Branch. Victoria. "Medical and Hospital" Programs later became t i t l e d "Hospital Programs." ^British Columbia Hospital Insurance Service. 1974 Annual Report. Victoria. Queen's Printer. 128 HEALTH ADVISORY COUNCIL W. .). L y l e DEPUTY MINISTER MEDICAL * HOSPITAL PROGRAMS BRANCH SUPPORT SERVICES G. A. St e w a r t Chairman MEDICAL SERVICES COMMISSION J . G l e n w r i n h t Assoc.Dep.Min. HOSPITAL PROGRAMS Hon. l£(g£ MINISTER ellknd J.H. Mainquy Deputy M i n i s t e r o f H e a l t h EMERGENCY HEALTH SERVICES! COMMISSION FORENSIC PSYCHIATRIC SERVICES COMMISSION A. Porteous Assoc,Dep.Min. MENTAL HEALTH PROGRAMS DIAGNOSTIC • SERVICES AUTHORITY DEPARTMENTAL PLANNING 4 SUPPORT SERVICES 1 Dr. G.R.F. E l l i o t DEPUTY MINISTER COMMUNITY HEALTH PROGRAMS BRANCH SUPPORT SERVICES Dr. Benson f\ssoc. Dep. Min PUBLIC HEALTH . PROGRAMS BUREAU OF SPECIAL HEALTH SERVICES COMMUNITY HEALTH CENTRE DEVELOPMENT GROUP COMMUNITY CARE FACILITIES LICENCING BOARD * T h i s u n i t (Development Group f o r Community H e a l t h and Human Resources C e n t r e s ' i s r e l a t e d t o the Development o f H e a l t h and th e Department o f Human Resources R e p o r t i n q arrannements c u r r e n t l y under d i s c u s s i o n . Figure 3: Health Department Organizational Structure, 1974. 129 In the ensuing period, from the autumn of 1974 when the Health Department reorganization was f i r s t announced, unt i l the present (spring, 1976), processes of consolidation, restructuring and planning have been taking place. The inflated costs of both continuing and new programs, with increased government expenditures and resulting deficits, necessitated that spending be curtailed and operating costs reduced. As a result, overt reorganizational activities at the service delivery level have in general been held somewhat in abeyance. For mental health services, the immediate result of the reorganized departmental structure is to locate community mental health programs (under Mr. A. Porteous) with Community Health Programs, while Riverview Hospital now comes under the jurisdiction of Hospital Programs, as one of a group of government-operated hospitals which includes, as well as Riverview, Pearson and Valleyview Hospitals. A "Director of Government Health Institutes"* Mr. J. Bainbridge, was appointed in November, 1975, to administer this group of hospitals. This latter organization, under Hospital and Medical Services, is shown in Figure 4. With the formation of "Government Health Institutes" the executive directors of the three hospitals, a l l physicians, were located elsewhere, and these positions are at present vacant, although the intention is to make new appointments. An overview of the operation and direction of the hospitals is underway by the Hospitals Management Engineering Unit of the Hospital 1976 t i t l e ; originally named "Government Institutions". 130 Consultation and Inspection Division. At this time the Unit is examining previous reports from, and proposals concerning these hospitals, with a view towards discerning studies that may be used to promote reactivation in particular areas, or general concepts that may be applicable to future direction and development. The expectation is that recommendations can be developed that w i l l allow for the most profitable methods of implementing ft the organization and operation of the hospitals. Figure 4: Organization of "Hospital Programs" DEPARTMENT OF HEALTH I Minister I | Senior Deputy Minister | Deputy Minister| Hospital and Medical Services Associate Deputy Minister Associate Deputy Minister Hospital Programs  Medical Services -iRate Board 1 Other Hospital Programs  [Director Government Institutions! ("Board (s) of ManagementL [Government Hospitalsl Riverview Hospital, Valleyview Hospital, Pearson, Hospital Executive Directors! This information is based on a discussion with Mr. J. Reeve, a member of the Hospitals Engineering Unit, on March 30, 1976. Mr. Reeve informed me that he is currently looking at the "Core Committee Report" and examining it s recommendations, and the input that was obtained from various areas. 131 The Altered Treatment Process As the reorganized Health Department now locates Riverview within the structure of Hospital Programs, the treatment processes carried on there w i l l relate to those of other inpatient f a c i l i t i e s in the province. A review of the various organizational alternatives that have been implemented by inpatient mental health f a c i l i t i e s in British Columbia w i l l demonstrate models of psychiatric hospital care that have developed: 1. Mental health f a c i l i t i e s governed by private societies and boards: Under the Mental Health Act, Section 5, "The Lieutenant-Governor in Council may, by order transfer a Provincial mental health f a c i l i t y or service 4 or a part thereof to a society..." Glendale, built in 1971 in Victoria, and originally named Glendale Hospital, is an i n - and out-patient f a c i l i t y for the mentally retarded. It has the stated policy of "assessing every retarded person on Vancouver Island.""' Built and funded by the provincial government, i t is operated by the Glendale Lodge Society. The management of Skeenaview, an inpatient psychogeriatric f a c i l i t y in Terrace, B.C., was in 1974 transferred to a lay society (for a one year t r i a l period) and Bevan Lodge in Courtenay is operated by the Bevan Lodge Society. 2. Mental Health f a c i l i t i e s transferred to other government depart-ments: In 1974 the responsibility for services to the mentally retarded was transferred from the Department of Health to the Department of Human Resources. Mental Health Act, 1964. Dr. K. Martin, Medical Superintendent, Glendale. Personal communication. 132 Woodlands and Tranquille were the inpatient f a c i l i t i e s affected. 3. The University of British Columbia Health Sciences Centre Hospital: A 60 bed psychiatric unit, part of the Health Sciences Centre complex, under the direction of a university co-ordinating board, offers a broad spectrum of psychiatric c l i n i c a l , teaching and research services. While i t s admission policies are set under the Mental Health Act, the unit's a f f i l i a t i o n with the university medical school provides accommodation for teaching and research that was previously enjoyed by Riverview. In 1970, Riverview Hospital provided educational programs, in association with the University of British Columbia, for post-graduate residents in psychiatry, undergraduate medical students, and students in the faculties of nursing, law, social work, education and the School of Rehabilitation Medicine. These programs, while s t i l l viable, have for the most part been taken over by the university unit. Early in 1974, however, Riverview obtained formal a f f i l i a t i o n with U.B.C. and residents in psychiatry received training experience at the < hospital. The Health Sciences Centre Unit had as i t s f i r s t director Dr. Tyhurst, who was the principal author of the Canadian Mental Health Association's "More 6 7 for the Mind" and the CELDIC Report. The comprehensive mental health service model he advocated was not adopted by the provincial government, but did influence the development of psychiatric services at such hospitals as Vancouver General. Dr. Tyhurst was succeeded at the university unit by Store for the Mind: A Study of Psychiatric Services in Canada. C.M.H.A. ^Commission on Emotional and Learning Disorders in Children: One Million  Children: the CELDIC Report. C.M.H.A. 133 Dr. Milton H. Miller, head of the university Department of Psychiatry, who was also appointed, in 1972, to the Advisory Board of Riverview Hospital. The operation of the Health Sciences Centre Psychiatric Unit i s directed towards comprehensive community services, and seeks to encompass a f u l l spectrum of inpatient and outpatient care for a l l kinds of psychiatric disorders, a l l ages, and a l l concerned professional groups. A "Diagrammatic Scheme of Current Operation" of the hospital is shown in Figure 5. 4. Additional inpatient psychiatric beds in general hospitals: In 1975, there was a total of 527 psychiatric beds in public general hospitals. These were added to local hospitals in a rather eclectic fashion as acute care, short stay resources, with l i t t l e emphasis devoted to supporting f a c i l i t i e s . Figure 6 l i s t s the total number of hospital "mental" beds in 8'* the province in 1975. A l i s t of the psychiatric f a c i l i t i e s available in the province in 1973 is found in Appendix 3. In the Greater Vancouver Region, adult psychiatric f a c i l i t i e s in general hospitals in 1971, and in 1975, are 9 compared (see Table XIX). Canadian Hospital Directory. Vol. 23. July, 1975. Toronto. Canadian Hospital Assoc. 1975. i G.V.R.H.D. Professional Practices Sub-Committee Psychiatric Planning Group. 1974 Review of 1971 Guidelines for Planning Acute Psychiatric F a c i l i t i e s  in the Greater Vancouver Region. Mimeo. G.V.R.H.D. 1974. THE UNIVERSITY OF BRIIIbrl LULUHUIM Deportment o f P s y c h i a t r y H e a l t h Sc i ences Cent re H o s p i t a l 134 FIGURE 5 DIAGRAMMATIC SCHEME OF CURRENT OPERATION \\ OUSE NIT KNOBLdOH e r v i s o r up HOSPITAL DAY CARE \ \ DR. KlWBlspCH EAST 2 IN-PATI ENTj UNIT -Med i c a l Stud ir it is WEST 2 IN-PATIENT UNIT -R e s i d e n t s _ j L Own R e f e r r a l , S o u r c e WEST 1 SHORT-STAY UNIT -R e s J ^ i e n t s CHILD & FAMILY OUT-PAT I ENT( SERVICE <tf V \\WiJ7J7 PSYCHIATRIC CLINIC - EAST 1 ASSESSMENT, BRIEF TREATMENT & FOLLOW-UP UNIT G e n e r a 1 P r o c t i t i o n c r s S e l f - R e f e r r a ; DR. l.'ATTjERSCN Super v i i s o r Agency R e f e r r a l R. KRELL Superv i s o r Own F o l l o w - u 1. C r i s i s I n t e r v e n t i o n 2. B r i e f Psychotherapy 3- Group Psychotherapy k. Chemotherapy 5- E. C. T. 6. Home V i s i t s P r i v a t e P s y c h i a t r i s t s 135 Figure 6: B.C. Hospitals, Classified by Status or Licence and Controlling Body: Beds Set Up for Use by Mental Service* Hospital Classification "Mental" Beds Public General Lay Religious Municipal Provincial Public Special Lay Religious Provincial Total Public 445 40 42 527 60 4988 5048 5575 Beds list e d as "psychiatric" and "epileptic", and beds for the treatment of other nervous conditions. 136 TABLE XIX ADULT PSYCHIATRIC FACILITIES IN VANCOUVER REGION GENERAL HOSPITALS, 1971 AND 1975 (I = Inpatient Bed, D = Day Care Place, E = Emergency Observation Bed) JANUARY 1971 JANUARY 1975* 1 V.G.H. 40 I 40 I 16 E 2 U.H.S.C. 60 I 24 D 60 I 45 D 3 St. Vincent's None 20 I 30 D 4 Shaughnessy (40 I) (Closed) 20 I (20 closed) 5 Surrey Memorial 20 I 20 I 7 D 6 Lion's Gate 40 I 40 I 40 D 7 Burnaby + Mental Health Centre 30 D 25 I 60 D 8 Peace Arch None 10 I (undesignated) 9 Hollywood 70 I (70 I) (closed, 1975) 10 St. Paul's None 40 I + D 11 Royal Columbian None 20 D 12 Mount St. Joseph None None (20 I + D + E for 1976) 13 B.C.M.C. None None (85 I + D + E for .1978) 14 Richmond General None None 15 St. Mary's None None TOTALS 270 I 54 D 275 I 202+D 16 E TOTAL PLACES 324 493+ includes those clearly planned to be in operation in early 1975 137 In the opinion of the G.V.R.H.D.'s Psychiatric Planning Group, Riverview Hospital w i l l continue to "have important functions in the totality of psychiatric services for the Greater Vancouver Region."'"*' "On an interim basis, un t i l sufficient general hospital units are developed, i t w i l l have to carry a hopefully decreasing proportion of acutely i l l psychiatric patients from the metropolitan area. Riverview should not, however, be looked upon as continuing indefinitely a function in relation to the hospitalization of the vast majority of acutely disturbed individuals, other than those mentioned ..below, who can be handled in general hospital units nearer their homes and places of work. "On both an interim and long term basis Riverview could provide f a c i l i t i e s for the acute care and treatment of patients from the area adjacent to i t . It should also provide specialized back-up f a c i l i t i e s to general hospital units throughout the Region which would have d i f f i c u l t y in handling seriously aggressive patients and multiproblem patients such as those who are socially indigent or unpredictably mobile. Riverview could develop other specialized programs in fields such as long-term rehabilitation, potentially dangerous patients, chronic brain syndrome patients, research, etc., to mention only a few of the challenging possibilities.""'"''" Provision of community extended and intermediate care f a c i l i t i e s has not been implemented to a degree that w i l l provide space to allow Riverview . Hospital to transfer many of i t s chronically disabled patients. With the Psychiatric Planning Group. Op.. c i t . Ibxd. 138 increasing average age of the long-term inpatient population, there is a corresponding increase in the number of patients with physical infirmities. Some of the larger chronic wards at Riverview have been divided into infirmary areas, and six medical staff positions are allocated to general practitioners, to provide general medical care for these patients. In recommending an Extended Care and Medical Services Program, Riverview's Core Committee was cognizant of the lack of available community resources for the chronically disabled. The East and West Lawn Program Advisory Committee went to much effort to outline the demands on the hospital resulting from the lack of coordinated community endeavor to produce alternative f a c i l i t i e s . The present mental hospital, as a centrally managed and unified organization, contains a l l levels of institutional care for the mentally dis-ordered. It provides the levels of patient care compatible to those outlined under B.C. Hospital Programs c r i t e r i a , with the addition of custodial (forensic), i.e., acute and extended care (including medical and surgical), rehabilitative, intermediate, and personal care. In order to integrate the f a c i l i t i e s that the mental hospital now provides with health care resources in the community, the levels of care required by mentally disordered patients should be differentiated and specified in relation to equivalent levels of care in other health system components. A d i f f i c u l t y , however, in the community integration of the mentally i l l population, is that the general hospital psychiatric wards and community mental health centres tend to accommodate mostly the neurotic and voluntary patients, while the government institution receives the grossly psychotic. With the development of Community Care teams and more general hospital psychiatric 139 beds, there continues to be a noticeable reduction i n admissions to River-view, but at the same time, there i s a d i s t i n c t increase i n the numbers of " p o t e n t i a l l y dangerous" psychotic patients admitted, many a f t e r confrontations with the law. Integration of inpatient and outpatient f a c i l i t i e s i s an area that has been confused and has generated considerable antagonism. Because the Vancouver Service was set up under a d i f f e r e n t j u r i s d i c t i o n , continuity of service between i t s teams and Riverview Hospital has seldom been achieved; rather, there has been a d u p l i c a t i o n . The community mental health centres are understaffed and lacking the necessary support services. Ideological d i f f e r -ences also intrude between community services and h o s p i t a l f a c i l i t i e s , f o r ' example: the s o c i a l model of mental i l l n e s s as opposed to the medical model; pro f e s s i o n a l a c c o u n t a b i l i t y and j u r i s d i c t i o n s ; and the "dumping-ground syndrome" - w i l l society accept i t s m i s f i t s ? A further d i f f i c u l t y i n the organization of mental health services i s an apparent dichotomy i n p o l i c y . While committed to the concept of region-a l i z a t i o n and d e c e n t r a l i z a t i o n , the p r o v i n c i a l government retains close f i n a n c i a l and administrative c o n t r o l . While delegating autonomy, i t does not provide the means, and "the amount of autonomy which can be delegated i s d i r e c t l y 12 proportionate to the amount of autonomy a v a i l a b l e . " A d e f i n i t i o n of the objectives of a mental health d e l i v e r y system, and development of a model which w i l l accommodate evaluation of the components of the system, would provide badly needed c l a r i f i c a t i o n . Necessary also i s an i n v e s t i g a t i o n of the prevalence Core Committee Report. 140 of mental health problems, and "the issue of how they are spread i n the population and how many of them we must be prepared, i n some way or other, 13 to take care of." The future r o l e of the mental h o s p i t a l needs to be examined i n the context of i t s place, and the place of i t s programs, i n the health care d e l i v e r y system, and i n a system of human services. The administrative and func t i o n a l changes that may be required i n order to adapt to new frames of reference should be ascertained from a perspective that includes the onjectives of the t o t a l system, and that has determined the means necessary to reach those objectives. Lemkau, P.V. Basic Issues i n Psychiatry. S p r i n g f i e l d , 111. Charles C. •Thomas. 1959. 1 141 APPENDIX 1 Mental Health L e g i s l a t i o n and Patients' Advocacy Mental Health L e g i s l a t i o n B r i t i s h Columbia l e g i s l a t i o n which was repealed and superceded by the 1964 Mental Health Act was as follows:''' 1. Mental Hospitals Act: admission to a mental h o s p i t a l , under t h i s Act, was ei t h e r voluntary, or was made on a judge's order or an "urgency order". 2. C l i n i c s of Psychological Medicine Act: admissions made, with the signatures of two medical p r a c t i t i o n e r s , f o r four months only. A f t e r t h i s four month period the patient was to be either discharged or admitted under conditions of the Mental Health Act. 3. P r o v i n c i a l C h i l d Guidance C l i n i c s Act: allowed the establishment of c h i l d guidance c l i n i c s . 4. Schools f o r Mental Defectives Act: admissions were made under the same c r i t e r i a as i n the Mental Hospitals Act. 5. P r o v i n c i a l Mental Health Centres Act: admissions to p r o v i n c i a l mental health centres were voluntary^ or on r e f e r r a l by a physician. 2 The 1964 Mental Health Act, as consolidated i n December, 1973, allowed the Minist e r of Health to "designate any b u i l d i n g or premises a P r o v i n c i a l mental health f a c i l i t y " , "designate any public h o s p i t a l , or any part thereof...as an observation u n i t , or a p s y c h i a t r i c u n i t " (Section 4), and the Carrothers, A.W.R. A report on mental health l e g i s l a t i o n i n B r i t i s h Columbia. Faculty of Law, the Univ e r s i t y of B r i t i s h Columbia. 1959. 'Mental Health Act. (Consolidated f o r convenience only, Dec. 1973) Government of B.C. V i c t o r i a . Queen's P r i n t e r . 142 Lieutenant-Governor in Council may "transfer a Provincial mental health f a c i l i t y . . . t o a society..." (Section 5). The Act allows "a Director or person having authority to admit persons to a Provincial mental health f a c i l i t y ; shall not admit a person to a Provincial mental health f a c i l i t y i f a) suitable accommodation i s not available within the Provincial mental health f a c i l i t y for the care, treatment and maintenance of the patient; or b) in his opinion, the person is not a mentally disordered person or is a person who, because of the nature of his mental disorder, could not be cured or treated appropriately in the f a c i l i t y " (Section 21). This Section has been invoked by the hospital when staff shortages,,;or an influx of exceptionally d i f f i c u l t patients, have threatened i t s satisfactory performance. A voluntarily-admitted patient must be discharged within 72 hours of his request for discharge (Section 22). If admitted under Section 23 (admission based on two medical certificates) a patient must be discharged on the f i r s t anniversary of the date of his admission, or be examined and his detention renewed. After 30 days from the date a person was admitted under Section 23, he is entitled to receive a hearing "for the purpose,of determining whether or not he should be detained" (Section 24). The panel for such a hearing must consist of an appointed chairman, a staff physician, and a person "who is appointed by the patient" (Section 24). This Review Panel was established by a 1973 amendment to Section 24 of the Mental Health Act. A patient admitted under a "Form A" Magistrate's Warrant, or by only one medical certificate, must be discharged after 72 hours unless the detention becomes otherwise authorized. 143 Patients' Advocacy Pressure for the protection of c i v i l and legal rights of mental patients is noted with the inclusion i n this Appendix of the "Mental Patients 3 B i l l of Rights", and a copy of committee's report from a conference on 4 Mental Disorder and the Law held in May, 1974, at the University of B.C. It should also be noted, in regard to mental health legislation and patients' rights, that the determination and administration of patients' estates are governed by the Patients' Estates Act of 1962, superceding the Lunacy Act and Trustee Act, and that the Sexual Sterilization Act was repealed in 1973. The Mental Patients' Association The Mental Patients' Association, established in 1971, offers a contribution in self-help, housing, and support to patients discharged from psychiatric f a c i l i t i e s . Its negative attitude towards the traditional areas of treatment of mental patients is a deliberate policy, and i t sees i t s role as one of support and advocacy for patients. Funded originally by a federal LEAP grant, i t s funds were later provided by the provincial N.D.P. government, resulting in a co-optation of the association which brought i t under "establishment" auspices. Mental patients and the law. Mental Patients Liberation Project. New York. 1973. Report of the committee considering committal and review procedures for the conference on Mental Disorder and the Law. Working papers. Conference held at the University of British Columbia, May, 1974. 144 MENTAL PATIENTS BILL OF RIGHTS This B i l l of Rights was sponsored by the Mental Patients' Liberation Project, 56 East 4th St., New York, and is taken from Mental Patients and  the Law, 1st ed., 1973, p.95. 1. You are a human being and are entitled to be treated as such with as much decency and respect as is accorded to any other human being. 2. You are a (Canadian) citizen and are entitled to every right established by (common law) and guaranteed by,(the Canadian B i l l of Rights). 3. You have the right to the integrity of your own mind and the integrity of your own body. 4. Treatment and medication can be administered only with your consent and, in the event you give your consent, you have the right to demand to know a l l relevant information regarding said treatment and/or medication. 5. You have the right to have access to your own legal and medical counsel. 6. You have the right to refuse to work in a mental hospital and/or to choose what work you shall do and you have the right to receive the minimum wage for such work as is set by the state labor laws. ' 7. You have the right to decent medical attention when you feel you need i t just as any other human being has that right. 8. You have the right to uncensored communication by phone, letter, and in person with whomever you wish and at any time you wish. 9. You have the right not to be treated like a criminal; not to be locked up against your w i l l ; not to be committed involuntarily; not to be finger-printed or "mugged" (photographed). 10. You have the right to decent liv i n g conditions. You're paying for i t and the taxpayers are paying for i t . 11. You have the right to retain your own personal property. No one has the right to confiscate what is legally yours, no matter what reason i s given. That i s commonly known as theft. 12. You have the right to bring grievance against those who have mistreated you and the right to counsel and^a court hearing. You are entitled to protection by the law against retaliation. 13. You have the right to refuse to be a guinea pig for experimental drugs and treatments and to refuse to be used as learning material for students. You have the right to demand reimbursement i f you are so used. Continued... 145 14. You have the r i g h t not to have your character questioned or defamed. 15. You have the r i g h t to request an a l t e r n a t i v e to l e g a l commitment or inc a r c e r a t i o n i n a mental h o s p i t a l . 146 REPORT OF THE COMMITTEE CONSIDERING COMMITTAL AND REVIEW PROCEDURES FOR THE CONFERENCE ON MENTAL DISORDER AND THE LAW, MAY, 1974 ' In isolating the major problems which arise in a consideration or committal of the mentally i l l , and in proposing solutions which attempt, to some degree, to take account of the tensions which result from the conflict between the need to obtain treatment for sick persons, and the desire to prevent unjust deprivations of personal liberty, the committee was in considerable agreement. Although the principal issues in the area of committal and review were discussed in a theoretical way, the existing procedures and legislation governing committal of the mentally i l l in British Columbia, and Provincial f a c i l i t i e s for treatment in general, provided practical references for discussion. Although the committee recognizes that the ju s t i f i c a t i o n for involuntary hospitalization in any circumstances is under attack by various groups and individuals, the committee believes there is a need for compulsory committal in some instances. A theoretical model for determining the justification for compulsory committal might allow such committal where four c r i t e r i a are met. These are: (1) The individual is suffering from a disorder of the mind. (2) As a result of the disorder the individual's a b i l i t y to determine to seek or to refuse treatment i s impaired to the extent that he is unable to make a decision in his own interest to accept or reject treatment. (3) Care and treatment are required for the individual's own protection or for the protection of others. (4) Adequate alternative treatment resources other than involuntary committal are unavailable. In formulating these c r i t e r i a , i t i s important to note that dangerousness to oneself or others and need for care and treatment are them-selves insufficient to justify involuntary committal. It must be emphasized, that in the absence of a mental illness which impairs the individual's a b i l i t y to make a judgment regarding treatment, no just i f i c a t i o n for involuntary confinement exists outside of the criminal law. It seems important to emphasize, as well, that the justification for involuntary committal on the ' basis of a need for care and treatment does not extend/to compulsory confine-ment of an individual merely on the basis that treatment w i l l be of benefit to him, and the expenditure of funds for his benefit would be ju s t i f i e d . There must be some finding that in the absence of the care and treatment available, the individual would be a danger to himself or others, or because of his incapacity, would be liable to suffer substantial harm because of neglect, or exploitation by others. In determining whether the justifications for compulsory committal exist in an individual case, society is confronted with the related tasks of devising standards, either subjective or objective, to be applied in determining jus t i f i c a t i o n , and a committal procedure which is capable of assessing the interests at stake in a committal decision. H 7 A major problem i n determining whether a l l of the t h e o r e t i c a l c r i t e r i a j u s t i f y i n g compulsory committal are present i s the d i f f i c u l t y of i d e n t i f y i n g mental i l l n e s s by reference to any objective c r i t e r i a . A s i m i l a r problem a r i s e s i n assessing whether the mental i l l n e s s has impaired the i n d i v i d u a l ' s judgment to the extent that he i s incapable of making a reasoned decision to accept or r e j e c t treatment. A major d e s c r i p t i v e component a v a i l a b l e f o r determining the existence of a mental i l l n e s s i s the observable behaviour patterns which might lead to the determination that an i n d i v i d u a l was dangerous to himself and others. As a r e s u l t there would appear to be some danger that where the c r i t e r i o n of dangerousness alone i s s a t i s f i e d , a determination of mental i l l n e s s and r e s u l t i n g impairment of judgment might follow automatically without proper consideration being given as to whether the f i r s t two c r i t e r i a have been met. Because of the d i f f i c u l t i e s involved i n formulating an o b j e c t i v e l y applicable concept of mental i l l n e s s , i t seems appropriate to .question both the worth and d e s i r a b i l i t y of formulating standards to govern the bases of compulsory committal. The majority of the committee i s of the view that any attempt to devise standards f o r determining whether the c r i t e r i a j u s t i f y i n g compulsory committal are met would, of necessity, be imprecise, and, i n p r a c t i c e , have l i t t l e bearing on the d i s p o s i t i o n of any p a r t i c u l a r case, although there i s agreement that the onus ought to r e s t on the state to show that the c r i t e r i a j u s t i f y i n g involuntary committal have been met. A minority, however, are of the view that the deprivation of l i b e r t y cannot be j u s t i f i e d on generalized or i n t u i t i v e judgments that the c r i t e r i a j u s t i f y i n g confinement have.been met. Although, i n p r a c t i c e , i f involuntary admission to a mental health f a c i l i t y i s i n i t i a l l y a medical-administrative decision, i f u n j u s t i f i e d compulsory committal i s t o be susceptible to attack i n the courts there must be some basis upon which a court can determine whether the degree of impairment i s s u f f i c i e n t to j u s t i f y confinement and whether the determination of the degree of impairment has been made on the basis of s u f f i c i e n t evidence. One suggested test for determining j u s t i f i c a t i o n f o r involuntary committal would require that a l l the c r i t e r i a on which committal i s based be demonstrated by the State on a preponderance of evidence. The nature of the evidence required would, of course, d i f f e r f o r each of the elements required to be shown. In order to make involuntary committal of the mentally i l l consistent with compulsory confinement of those not mentally i l l , i t would be necessary that the c r i t e r i a j u s t i f y i n g committal be demonstrated beyond a reasonable doubt. However, i n view of the d i f f i c u l t i e s inherent i n formulating a d e f i n i t i o n of mental disorder which would be s a t i s f y i n g from a l e g a l point of view, and because a f i n d i n g of dangerousness can never be more than a mere p r e d i c t i o n , i t seems questionable whether i t could ever be demonstrated beyond a reasonable doubt that the c r i t e r i a j u s t i f y i n g involuntary committal had been met. The committee i s of the view that pre-admission assessment of the p o t e n t i a l involuntary patient by two physicians, one of which i s a p s y c h i a t r i s t , i s the most desirable c e r t i f i c a t i o n procedure. This procedure has the advantages of i n f o r m a l i t y and convenience, and d i r e c t s attention to the i n d i v i d u a l ' s emotional d i f f i c u l t i e s rather than the l e g a l j u s t i f i c a t i o n for committal. In addition, i t may be that a medical-administrative admissions committee i s better equipped to explore the a l t e r n a t i v e s to compulsory h o s p i t a l i z a t i o n . 148 Choice of a medical rather than a j u d i c i a l admissions procedure is based as much on the deficiencies of a j u d i c i a l process of admission as i t is on any advantages of a medical procedure. The committee feels that a primarily adjudicative process at the admissions stage may be unnecessarily traumatizing. More important, however, is the danger that a requirement for jud i c i a l adjudication of a l l involuntary committals would tend to diminish attentive-ness to the cases where the propriety of the committal was really questionable. In order to minimize the possibility of compulsory committal on inadequate grounds, the committee believes that an involuntary patient must have the right to challenge the sufficiency of the case for committal at any time after admission, or, where an involuntary application for admission is anticipated, before admission. Although the committee feels that the i n i t i a t i v e to challenge committal ought to rest with the patient, a require-ment should be placed on the mental health f a c i l i t y to advise the patient of the right to j u d i c i a l review of the committal and of the means to obtain review. The right to j u d i c i a l review i s , of course, largely meaningless unless, in practice, such a review is readily available. It i s noteworthy that, in British Columbia, to the knowledge of the committee, there has never been a ju d i c i a l review of an involuntary committal, despite the provision for such a review in the Mental Health Act. To the extent that failure to u t i l i z e this mode of review is due to the expense and cumbersomeness of a Supreme Court hearing, the failure may be overcome by providing that legal aid to available as of right to any patient wishing to. challenge his committal, regardless of any independent financial means the patient may have. In addition, the committee suggests that such an appeal be available, alternatively, to a Provincial Court Judge with a right of appeal to a Judge of the Supreme Court. Ifflengthy hospitalization i s necessary a j u d i c i a l determination of the need for continued compulsory hospitalization should take place one year after the i n i t i a l admission or last j u d i c i a l review of the committal. Under these circumstances counsel should be appointed, and independent psychiatric or other evidence as to the desirability of continued hospitalization and alternative treatment or custodial resources available should be ordered by the court where i t is considered necessary. Such reviews would be mandatory each year except in circumstances where the degree and permanence of the impairment was such that the court would have a discretion to postpone a review for a further three years. In addition to procedures and legislation permitting ready access to a j u d i c i a l review of involuntary committal, the committee supports an alternative method of review similar to that provided by the review panel set up under s.24 of the British Columbia Mental Health Act. This section provides for review of committal by a three, member review board on the request of an involuntary patient. However, although the committee is of the view that at least one member of the board ought to be a psychiatrist, to avoid the possibility of bias or the appearance of bias, i t is advisable that this member of the board not be associated with the mental health f a c i l i t y to which the patient has been admitted. To ensure that the members of the review panel are able to conduct an adequate investigation of the background of the patient and to properly consider whether continued confinement is necessary, the 149 committee feels that the panel members ought to be appointed to the panel, and paid, on the basis that their position on the panel, although i t w i l l not constitute the members' major employment, cannot be considered merely additional to other full-time employment. In addition, the committee believes that the provision in the British Columbia Act which permits one member of the review panel to be appointed by the patient creates ambiguity in the role of that member on the committee. Where the patient requires an advocate to press for his release, or wishes to c a l l evidence himself concerning the propriety of his continued committal, i t would seem appropriate that he elect for a jud i c i a l review of his hospitalization. The legislation creating the review panel should clearly state that a patient instituting this method of appeal w i l l not impair his right to discharge in any other authorized fashion. The committee feels that there may be some advantage to creating a position of ombudsperson to function within the mental health system. This o f f i c i a l would be independent of any mental health f a c i l i t y , and would be charged with the duty of arbitrating patients' minor complaints with the institution, and ensuring that patients were made aware of their right to review of their committal and the means to obtain such a review. Although the committee are of the view that some emergency power of apprehension of the mentally i l l , without a hearing, analogous to that contained in s.27(l) of the British Columbia Mental Health Act is necessary, the committee believes that permitting such apprehension on the basis of hearsay evidence as i s presently permitted under the B.C. Act, may result in an unjustifiable infringement of c i v i l l i b e r t i e s . This i s particularly so when no duty i s placed on the apprehending police officer to satisfy himself as to the veracity of the information and the r e l i a b i l i t y of the informant. Finally, the committee recognizes that the seriousness of the issues relating to involuntary committal diminishes to the extent that the mentally i l l seek assistance voluntarily. It i s apparent, therefore, that in conjunction with efforts to ensure that compulsory committal i s justi f i a b l e and proper, a concerted effort must also be exerted to ensure that adequate voluntary treatment alternatives are available which offer assistance to the mentally i l l which i s dignified and humane. 150 APPENDIX 2 INSERVICE STAFF DEVELOPMENT AT RIVERVIEW HOSPITAL 1 Inservice t r a i n i n g , education and development of Riverview's nursing s t a f f i s provided by the Department of Nursing, and c a r r i e d on under the d i r e c t i o n of the Coordinator of Nursing S t a f f Development. Nurse C l i n i c i a n s within each Unit organize and coordinate the o r i e n t a t i o n , t r a i n i n g and continuing education of nursing personnel. Included i n t h i s Appendix, and obtained from the h o s p i t a l Department of Nursing, as part of that Department's submission to the Core Committee, are: The Philosophy of Nursing S t a f f Development The D e f i n i t i o n of Nursing Staff Development Education The Objectives of Nursing S t a f f Development Education The Job Description of a Co-ordinator of Orientation and Staff Development Programmes The Job Description of a Nurse C l i n i c i a n , and a proposal to the Core Committee, from Nursing Staff Development personnel, o u t l i n i n g the organization of Nursing Staff Development and suggesting new roles i n a reorganized h o s p i t a l structure. Riverview Hospital:" Department of Nursing. 151 PHILOSOPHY OF NURSING STAFF DEVELOPMENT RIVERVIEW HOSPITAL The primary function of nursing staff development is to assist the nurse in the improvement of patient care. Nursing as a v i t a l service depends on the a b i l i t y of the nurse to incorporate new knowledge and s k i l l s into the daily patient care. Each nurse is a unique.individual who brings to the job strengths, weaknesses, education and experience. Each should be guided toward realizing his/her potential by stimulating the development of an open inquiring mind and a capacity for independent thought and action. An intrinsic part of staff development is to assist the nurse to identify his/her learning needs; to assist them to meet these needs and to apply the acquired knowledge and s k i l l s in f u l f i l l i n g his/her role. Continuing Education is a responsibility shared by employer and employee thereby improving the nursing care given to each patient. JW/mm May 7, 1973. 152 NURSING STAFF DEVELOPMENT EDUCATION RIVERVIEW HOSPITAL DEFINITION We define a Nursing Staff Development education program as a l l of the planned education and training provided by the Department of Nursing to assist the nursing personnel to learn and increase competence in the effective giving of good patient care. The programs conducted provide: ORIENTATION SKILL TRAINING CONTINUING EDUCATION To help the new, reassigned or recently promoted employee adjust to his/her environment and duties. To provide the opportunity for the employee to develop and u t i l i z e s k i l l s and attitudes required for the job and to keep the new employee abreast of changing methods and new techniques. To help the employee keep up-to-date with new concepts, to increase knowledge, understanding and competency, to develop a b i l i t y to analyze problems and to work with others. LEADERSHIP AND MANAGEMENT DEVELOPMENT To equip a selected group of employees for increased responsibilities and new positions. May 1973 JW/mm 153 NURSING STAFF DEVELOPMENT EDUCATION OBJECTIVES 1. To orient new personnel to the organization and p o l i c i e s of the h o s p i t a l — thereby reducing mistakes by providing necessary information, promoting acceptance of new employee, f o s t e r i n g the f e e l i n g of belonging, providing assistance i n sol v i n g i n i t i a l problems, and helping management personnel becomeracquainted with new employee's aptitudes, s k i l l s , personality, and p r o f e s s i o n a l needs. 2. To provide an environment conducive to learning, to promote increased job s a t i s f a c t i o n and personal growth of i n d i v i d u a l employees. 3. To a s s i s t i n e s t a b l i s h i n g opportunities f o r e f f e c t i v e group r e l a t i o n s h i p s . 4. To a s s i s t and encourage personnel to work together as members of the nursing team i n developing nursing care plans r e s u l t i n g i n improved patient care. 5. To a s s i s t personnel i n becoming more e f f e c t i v e members of the nursing team by recognizing t h e i r needs and using these as a basis for program planning. 6 . To a s s i s t management l e v e l personnel to become more competent as pro f e s s i o n a l p r a c t i t i o n e r s and as teachers and administrators. 7. To i d e n t i f y and provide resources which w i l l keep personnel informed of current trends, issues, and pra c t i c e s i n nursing service and a l l i e d f i e l d s . 8. To encourage and a s s i s t nursing s t a f f to assume r e s p o n s i b i l i t y as equal p a r t i c i p a t i n g members of.the health team to organize and coordinate f a c i l i t i e s , a c t i v i t i e s , and personnel f o r the purpose of achieving the aims and objectives of. the h'ospital and thus insure optimal patient care. October, 1972. JW/mm 154 JOB DESCRIPTION CO-ORDINATOR OF ORIENTATION AND STAFF DEVELOPMENT PROGRAMMES DEPARTMENT OF NURSING  RIVERVIEW HOSPITAL FRAME OF REFERENCE: Responsible to the Director of Nursing. FUNCTIONS: (a) Assesses educational needs of a l l nursing personnel; (b) Establishes and administers a variety of educational programmes and activities within the nursing department; (c) Establishes and administers orientation programmes to a l l nursing personnel; (d) Fosters public relations through collaboration with other disciplines and community agencies; (e) Interprets to v i s i t i n g groups the function of the Department of Nursing within the hospital. RESPONSIBLE FOR: (1) assessing, planning and administering nursing inservice educational programmes; (2) orientating a l l newly recruited and re-assigned nursing personnel; (3) evaluating orientation and inservice educational programmes; (4) interpreting the nurse's role to other disciplines and community groups; (5) collaborating with Unit Nursing supervisors in order to assess the educational needs of their programmes; (6) preparing programme progress reports; (7) coordinates a f f i l i a t e programmes. 155 JOB DESCRIPTION NURSE CLINICIAN DEPARTMENT OF NURSING RIVERVIEW HOSPITAL FRAME OF REFERENCE: Responsible to Co-ordinator of Staff Development FUNCTIONS: (a) To assist nursing staff to identify and meet their learning needs related to the improvement of patient care; (b) To promote a climate in which learning can take place. RESPONSIBLE FOR: (1) maintaining communication and collaborating with supervisors in the unit, in order to plan, assess and evaluate programmes; (2) participating, planning, developing, and implementing educational programmes for a l l members of the nursing staff; (3) planning and implementing programmes for staff development within one unit; (4) assisting in planning and implementing new programmes on individual wards within own unit; (5) orientating new and reassigned staff to the unit; (6) teaching new or revised procedures; (7) maintaining records of individual participation in staff development programme; (8) assisting in promoting favorable departmental and inter-departmental relationships; (9) promoting positive attitude of employee toward his/her own job; (10) serving on and guiding the activities of Task Committee within the unit; (11) interpreting to v i s i t i n g groups the function of the Department of Nursing within the hospital. 156 RIVERVIEW HOSPITAL DEPARTMENT OF NURSING TO: Core Committee FROM: Nursing Staff Development Reorganization Riverview Hospital Personnel. May 29, 1974. "So as to assure the best quality of service, continuous inservice educational and research programs shall be carried out." (Statement from the goals of Program 1 - 2 - 3 - 4 - 5 originating from the Core Committee). Nursing Staff Development - a planned educational experience provided in the job setting and closely identified with service in.order to help the person perform more effectively as a person and a worker. Nursing Service needs this planned educational experience for the following reasons. 1. Constant need to orient new, returning and current employees to new developments to keep the quality of care up to standards. 2. The need to train non professional personnel many of whom have never been in a hospital before commencing employment. 3. The high turn-over rate. 4. The lack of standardization among units and wards. 5. The divergent levels of training of staff. Nursing Service has authorized us to perform the following services - Orientation - Training for aide personnel - Continuing Education at ward level - Leadership Development Nursing Staff Development is involved in many other related functions. 1. Resolution of problems between job levels and across department. 2. Assisting in formulation and recommendation of c l i n i c a l procedures. 3. Assisting in formulating and recommendation of nursing administrative policies and procedures. 4. Testing of products and evaluate the need and recommendation of usage. 5. Resource for general information from other mental health f a c i l i t i e s . 6. Arranging tours and conducting same for nursing students from other hospitals. • 7. Liaison with professional organizations. 157 Nursing Staff Development personnel plan and participate in a l l of these functions. Many changes involving nursing personnel and patient care are initiated or investigated by nursing staff development. Putting out "brush f i r e s " can in i t s e l f become a f u l l time activity. Nursing Staff Development is an arm of Nursing Service - with a clinician in each unit responsible to the Supervision of Nursing Staff Development who in turn i s responsible to the Director of Nursing. We have considered the "Reorganization" from the aspects of five programs -one hospital, or five separate hospitals. Advantages of - Centralized Nursing Staff Development - sharing of knowledge, teaching s k i l l s , nursing s k i l l s , - as resource people. - less expensive - no duplication equipment, time, a c t i v i t i e s . - teach more people at one time, e.g. sharing orientation, workshop etc. - sharing of ideas -relevant to a l l programs. - expertise of one cli n i c i a n can be shared with other Programs. - having other clinicians involved with staff is more stimulating than always the same person. - peer group support provides - stimulation - validation and evaluation. - cl i n i c i a n seen as non threatening to staff (not part of super-visory unit staff) due to being responsible to someone outside the unit or program. - cl i n i c i a n f a c i l i t a t e s improved patient care by identifying and meeting staff learning. - clinicians responsible to a central Supervisor allows freedom +o to invest their s k i l l s and energy in educational functions for staff. Results and outcomes of inservice and Staff Development are commensurate with administrative interest in, understanding of and financial backing for inservice staff, equipment, f a c i l i t i e s . We have been strongly supported in the above by the Central Nursing office and at the ward level from the Charge Nurse down. Nursing Staff Development Personnel whether in five programs or five hospitals should be retained as a group with a special educational function. How can Inservice Education be restructured to retain our present focus on improvement of patient care through Nursing Staff Development? The need for Inservice Education is being increasingly f e l t by other Departments in the hospital. 158 A Department of Educational Resources may be the Answer. A comprehensive Department of Educational Resources could include the following positions and functions. A. Coordinator of Educational Resources - (ca t a l y s t - counselor - administrator l i a i s o n person). 1) crosses a l l h o s p i t a l l i n e s to promote and e l i c i t cooperation i n the development and u t i l i z a t i o n of educational resources. 2) consults with all-department heads i n planning to meet the educational needs of employees. 3) coordinates the scheduling of a l l Inservice Programs. The r o l e of the Coordinator of Educational Resources would be to coordinate e x i s t i n g resources which no s i n g l e program can a f f o r d , organize, or f u l l y u t i l i z e . B. Coordinator of Audio V i s u a l Resources. 1) . d i r e c t s , coordinates amd consults i n a l l matters pertaining to the u t i l i z a t i o n of Audio V i s u a l media i n the h o s p i t a l . 2) t r a i n s and a s s i s t s h o s p i t a l personnel i n the operation of Audio V i s u a l equipment. 3) advises and a s s i s t s others i n the preparation, production of any educational projects which includes the use of Audio V i s u a l equipment and used for i n s t r u c t u r a l purpose e.g. f i l m s . 4) provides f o r the maintenance, performance and u t i l i z a t i o n of the h o s p i t a l Audio V i s u a l equipment. C. Coordinator of Nursing Staff Development and A f f i l i a t e Programs - see job d e s c r i p t i o n . 1) function within the defined r o l e . 2) contributes c l i n i c a l expertise to problem solving and to' the develop-ment of i n s e r v i c e program relevant to patient care. 3) maintains close communication with Nursing Service Departments. D. Nurse C l i n i c i a n s (Instructors) function within the defined r o l e - see job d e s c r i p t i o n . E. Secretary -o r i g i n a l signed by Josephine Welsh Coordinator Nursing S t a f f Development 159 APPENDIX 3: PSYCHIATRIC FACILITIES IN BRITISH COLUMBIA, 1975 I. P s y c h i a t r i c In-Patient F a c i l i t i e s B r i t i s h Columbia, 1975 Location Name Category Type of I n s t i -t u t i o n Owner-ship Psych. Bed Capacity Burnaby Burnaby Mental pub. Ment. prov. 25 Health Centre Chilliwack Chilliwack Gen. pub. gen. p.u. lay 22 Hosp. Courtenay Bevan Lodge pub. f. retard lay Delta Peace Arch Hosp. pub. gen. p.u. lay 10 Essondale Riverview Hosp. pub. ment. prov. 2,000(approx.) Essondale Valleyview Hosp. pub. aged prov. 700(approx.) Kamloops Royal Inland Hosp. pub. gen. p.u. lay 39 Kelowna Kelowna Gen. Hosp. pub. gen. p.u. lay 8 Nanaimo Nanaimo Reg. Gen. pub. gen. p.u. lay 24 Hosp. 70 New Westminster Hollywood Hosp. p r i v . gen. p.u. prop. i. (closed 1975) New Westminster Woodlands pub. f. retard prov. 1,100(approx.) North Vancouver Lions Gate Hosp. pub. gen. p.u. lay 40 Penticton Penticton Hosp. pub. gen. p.u. lay 8 Prince George Prince George pub. gen. p.u. lay 10 Reg. Hosp. Prince Rupert Prince Rupert pub. gen. p.u. lay 9 Gen. Hosp. Saanich Glendale pub. f. retard lay 320 Surrey Surrey Memorial pub. gen. p.u. lay 20 Hosp. 220(approx.) Terrace Skeenaview, pub. aged lay T r a n q u i l l e T r a n q u i l l e School pub. f. retard prov. 450(approx.) Vancouver St. Paul's Hosp. pub. gen. p.u. lay 20 Vancouver St. Vincent's Hosp. pub. gen. p.u. lay 20 Vancouver Shaughnessy Hosp. pub. gen. p.u. lay 44 Vancouver U.B.C. Health •pub. gen. p.u. lay 60 Sciences Centre Vancouver 'Vancouver Gen. Hosp. pub. gen. p.u. lay 48 Vernon Vernon Jubilee pub. gen. p.u. lay 11 Hosp. 220(approx.) Vernon Dellview pub. aged prov. V i c t o r i a E r i c Martin Inst. pub. gen. p.u. lay 100 of Psych. aged: home for the aged ment: mental i l l n e s s gen: general h o s p i t a l l a y : lay ownership f. retard: f a c i l i t y f o r the retarded prop: proprietary ownership p.u.: p s y c h i a t r i c f a c i l i t y i n general pub: public h o s p i t a l prov: p r o v i n c i a l 160 II. Mental Health Centres and Out-Patient Departments British Columbia, 1975 Abbotsford Burnaby Chilliwack Courtenay Cranbrook Duncan Fort St. John Kamloops Kelowna Langley Mental Health Centres Maple Ridge Nanaimo Nelson New Westminster Penticton Port Coquitlam Powell River Prince George Saanich Sechelt Squamish Surrey Terrace T r a i l Vernon V i c t o r i a Whalley Williams Lake Burnaby New Westminster North Vancouver Prince George Richmond Surrey Tranquille Vancouver Vancouver Out-Patient Departments Located At: B.C. Youth Development Centre 'The Maples' Woodlands Lions Gate Hosp. Prince George Reg. Hosp. Vancouver Service Surrey Memorial Hosp. Tranquille School The Narcotic Addiction Foundation Victoria Vancouver Service (9 Community Care teams) St. Paul's Hosp. St. Vincent's Hosp. U.B.C. Health Sciences Centre Vancouver General Forensic Clinic Eric Martin Inst, of Psychiatry 161 III. F a c i l i t i e s for the Treatment of Emotionally Disturbed Children.and Youth* British Columbia, 1973 A. Intensive Treatment Centres Browndale: Vancouver The Children's Foundation: Vancouver Pacific Centre for Human Development: Victoria The Maples: Burnaby Secret Harbor Farm: Anacortes, Washington Youth Resources Society: Vancouver Laurel House Society: Vancouver B. Group Treatment Homes Central City Mission: Vancouver Elizabeth Fry Society: Vancouver Dr. Endicott Home for Retarded Children: Creston Nasaika Lodge Society: Vancouver South Okanagan Youth Resources Society: Kaleden Vanderhoof Group Living Home for Retarded C. Special Educational Residential Centres St. Euphrasia's School: Surrey Brannan Lake School: Nanaimo Cedar Lodge Residential Centre for Child Rehabilitation: Cobble H i l l New Denver Youth Centre: New Denver House of Concord: Langley D. Special Educational F a c i l i t i e s St. Christopher's School: North Vancouver Chrisholme Society: Langley E. Assessment F a c i l i t i e s South Okanagan Human Resources Society: Penticton *Includes also hospitals and units lis t e d in I and II. This l i s t i s at 1973, and numerous changes have developed since that time. 162 REFERENCES CITED American Psychiatric Assoc. Survey of mental health needs and resources  of British Columbia. Mathew Ross (ed.). Office of the Medical Director, American Psychiatric Assoc. 1961. Baird, Sydney. Recommendations to the Interim Forensic Program . Sub-Committee. Core Committee Report. Appendix D. Blair, W.R.N. Mental Health in Alberta. Government of Alberta. 1969. Bockoven, J.S. Moral treatment in community mental health. New York. Springer Publishing Co. 1972. British Columbia Hospital Insurance Service. 1974 Annual Report. Victoria. Queen's Printer. Canadian Hospital Directory. Vol.23, July, 1975. Toronto. Canadian Hospital Assoc. 1975. Carrothers, A.W.R. A report of mental health legislation in B.C. Faculty of Law, U.B.C. 1959. Clarkson, G. 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The organization of mental health services i n the l o c a l community. Canada's Mental Health. 22. June, 1974. 12-15. Wine, W.A. Community psychiatry; an approach to evaluation. Clarke I n s t i t u t e . Dec. 1969. Mimeo. 

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