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A community support system for the chronically mentally disabled of Vancouver Island Tomlinson, Peter Brook 1979

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A COMMUNITY SUPPORT SYSTEM FOR THE CHRONICALLY MENTALLY DISABLED OF VANCOUVER ISLAND by Peter Brook Tomlinson B.A., Simon Fraser U n i v e r s i t y , 1973 THESIS SUBMITTED IN PARTIAL FULFILLMENT THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN THE FACULTY OP GRADUATE STUDIES (Health Services PlanniHg) We accept t h i s t h e s i s as conforming t o the req u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA August, 1979 © Peter Brook Tomlinson, 1979 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department Of Ifealt-h f a r s anri ttpi r t eTTn nlorjy The University of British Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date Oct-nhPr l U h , 1 Q 7 Q D E - 6 B P 7 5 - 5 1 1 E i A b s t r a c t The c h r o n i c a l l y m e n t a l l y d i s a b l e d need to be d e f i n e d as a s p e c i a l needs group i n o r d e r t o r e c e i v e the s o c i a l and h e a l t h s e r v i c e s they r e q u i r e f o r community s u r v i v a l . T h e i r needs can be i d e n t i f i e d by rev i e w i n g the r e l a t i o n -s h i p s between c h r o n i c mental d i s a b i l i t y and s c h i z o p h r e n i a , poor s o c i a l margin, long term use o f treatment f a c i l i t i e s , and poor s o c i a l and v o c a t i o n a l f u n c t i o n i n g . Before the 1950*s, s e r v i c e s t o the c h r o n i c p a t i e n t were p r o v i d e d mainly w i t h i n the asylum system. Although some i n n o v a t i o n s i n p s y c h i a t r i c s e r v i c e s were developed e a r l i e r , these were d i r e c t e d t o p a t i e n t groups o t h e r than the c h r o n i c a l l y m e n t a l l y d i s a b l e d . T h i s t r a d i t i o n o f a t t e n t i o n t o other p a t i e n t groups has i n f l u e n c e d the com-munity mental h e a l t h movement o f the l a s t 25 y e a r s . T h i s movement was expected to p r o v i d e f o r the needs o f the chro-n i c a l l y d i s a b l e d i n the community as the mental h o s p i t a l s were reduced i n p o p u l a t i o n . Recognizing t h a t community c e n t e r e d care o f the former asylum p o p u l a t i o n s i s a t e c h n i c a l l y f e a s i b l e g o a l , the N a t i o n a l I n s t i t u t e o f Mental H e a l t h (N.I.M.H.) has proposed a model community system o f s e r v i c e s f o r t h i s p a t i e n t group. T h i s model addresses t h e i r s p e c i a l needs, but i t s a p p l i c a -t i o n r e q u i r e s a concert e d and c o o r d i n a t e d e f f o r t by s e v e r a l separate agencies. Recent changes i n Canadian h e a l t h care f i n a n c i n g allows a r e a l i s t i c look a t the American model. i i T h i s paper uses Vancouver I s l a n d , B r i t i s h Columbia, as a p l a n n i n g area f o r s e r v i c e s to the c h r o n i c a l l y men-t a l l y d i s a b l e d . The p o p u l a t i o n o f the area i s 441,000. The mental h e a l t h s e r v i c e s a v a i l a b l e t o these p a t i e n t s are reviewed i n o r d e r t o determine the exte n t o f t h i s a v a i l a b i l i t y . C r i t i c i s m s o f community s e r v i c e s i n o t h e r j u r i s d i c t i o n s were found t o be r e l e v a n t i n the p l a n n i n g r e g i o n . Recommendations are made based on the model s e r -v i c e system developed by N.I.M.H. A comparison o f the co s t s o f the e x i s t i n g s e r v i c e s t o c h r o n i c p a t i e n t s and the i d e a l system shows t h a t the r e q u i r e d improvements c o u l d be made w i t h l i t t l e e x t r a c o s t . i i i T a b l e o f C o n t e n t s P a g e I n t r o d u c t i o n 1 C h a p t e r 1 . D e f i n i n g t h e C h r o n i c a l l y M e n t a l l y D i s a b l e d 5 C h a p t e r 2 . P r e v a l e n c e o f t h e C h r o n i c a l l y M e n t a l l y D i s a b l e d 21 C h a p t e r 3 . S e r v i c e T r e n d s a n d I s s u e s 31 A . G e n e r a l T r e n d s a n d I s s u e s 31 B. C a n a d i a n a n d B r i t i s h C o l u m b i a 44 T r e n d s C h a p t e r 4 . A M o d e l C o m m u n i t y S e r v i c e s S y s t e m 53 C h a p t e r 5 . M e t h o d o f A n a l y s i s a n d S o u r c e s o f D a t a 65 C h a p t e r 6 . The P l a n n i n g A r e a : C u r r e n t S i t u a t i o n 74 C h a p t e r 7 . T h e P l a n n i n g A r e a : R e c o m m e n d a t i o n s 98 Summary: A S y s t e m W i t h i n F i v e Y e a r s 118 T a b l e s a n d F i g u r e s 123 B i b l i o g r a p h y 133 iv Table 2.1 Table 2.2 Table 2.3 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 6.1 Table 7.1 L i s t o f Tables One Year Prevalence Rates f o r S e l e c t e d Disorders i n Three R e g i s t e r Areas Monroe County One Year Expected Preva-lence Rates f o r Schizophrenia A p p l i e d to Vancouver I s l a n d P o p u lation Prevalence Rates of Psychosis from F i e l d Surveys Expected One-Year Prevalence of Treated Schizophrenia f o r Vancouver I s l a n d Regions: C a l c u l a t e d from Rochester R e g i s t e r Prevalence Rates f o r Population over 15, by Age and Sex Range Estimates of Treated Prevalence of Schizophrenia (number of cases) General H o s p i t a l Separations f o r P s y c h i -a t r i c Care i n 1977 f o r Vancouver I s l a n d School D i s t r i c t s by H o s p i t a l U t i l i z a t i o n Data f o r Vancouver I s l a n d General H o s p i t a l P s y c h i a t r i c I n p a t i e n t U n i t s Vancouver I s l a n d Admissions to Riverview by Mental Health Centre Catchment Area: With Rates per 100,000 over 15 years of age Vancouver I s l a n d P a t i e n t s , by Mental Health Centre Area, Resident i n R i v e r -view by Assessed L e v e l of Care Required C h a r a c t e r i s t i c s of Vancouver I s l a n d P a t i e n t s Resident i n Riverview A l l o c a t i o n of C l i n i c a l P o s i t i o n s and P s y c h i a t r i s t Sessions i n Vancouver I s l a n d Mental Health Centres C a l c u l a t i o n f o r D i s t r i b u t i o n of Expected Prevalence of Schizophrenia by C a p i t a l Region School D i s t r i c t s Estimated Capacity of Community S e r v i c e Components Page 26 27 29 123 69 124 125 126 127 128 129 130 131 V L i s t of Figures Page Figure 1. Vancouver Island Planning Regions 132 1 I n t r o d u c t i o n S e r v i c e s t o the c h r o n i c a l l y m e n t a l l y i l l have developed over time through s e v e r a l d i s t i n c t phases. The c u r r e n t phase i s c h a r a c t e r i z e d by concern f o r adequate community support s e r v i c e s to p a t i e n t s who f i f t e e n years ago would have been long-term r e s i d e n t s of c e n t r a l i z e d mental h o s p i t a l s . A d d i t i o n a l l y , the l i t e r a t u r e c o n t a i n s e x p r e s s i o n s of concern over the apparent fragmentation of e x i s t i n g s e r v i c e s and the f a i l u r e o f any one agency to accept r e s p o n s i b i l i t y f o r t h i s p a t i e n t group. Although these w r i t i n g s have been i n t e r n a t i o n a l , there i s evidence t h a t B r i t i s h Columbia has g e n e r a l l y f o l l o w e d p a t t e r n s o f s e r v i c e h i s t o r y f o r the me n t a l l y i l l s i m i l a r t o t h a t i n B r i t a i n and the Un i t e d S t a t e s . There have been some d i f -f erences i n s e r v i c e development which have c o n t r i b u t e d to the l o c a l p a t t e r n o f fragmentation and n e g l e c t . Awareness of some of these problems has r e s u l t e d i n s e v e r a l unpub-l i s h e d papers i d e n t i f y i n g s e r i o u s d e f i c i e n c i e s i n the e x i s t -i n g system. One o f these papers (Cumming, 1972) has r e s u l t e d i n the development o f a community c l i n i c a l and a f t e r c a r e s e r v i c e i n Vancouver, with the s p e c i f i c mandate to care f o r the s e r i o u s l y and c h r o n i c a l l y m e n t a l l y i l l . There has not been a s i m i l a r e f f o r t i n the p r o v i n c e s i n c e . While s e r -v i c e s i n Vancouver meet some of the needs o f the c h r o n i c a l l y i l l , s e r v i c e s i n the r e s t o f the pro v i n c e have been l e s s responsive t o the needs o f t h i s p a t i e n t group. 2. There has not been a s y n t h e s i s o f evidence put forward r e g a r d i n g gaps i n s e r v i c e f o r the c h r o n i c a l l y m e n t a l l y i l l f o r any major r e g i o n o f the P r o v i n c e . Such an attempt should be combined with r e c e n t knowledge of the needs and c h a r a c t e r i s t i c s of t h i s p a t i e n t p o p u l a t i o n and i n n o v a t i o n s e r v i c e developments i n other j u r i s d i c -t i o n s . Any s e r v i c e development i n the l o c a l s i t u a t i o n should be c o n s i d e r e d w i t h i n the framework of an o v e r a l l p l a n f o r meeting the s e r v i c e needs o f the c h r o n i c a l l y i l l . In the l a s t few years there have been some attempts t o s y n t h e s i z e r e c e n t l i t e r a t u r e i n t o models o f complete com-munity care systems. These models have been developed on the experience i n oth e r j u r i s d i c t i o n s and t h e i r a p p l i c a b i l -i t y t o the l o c a l s i t u a t i o n s h o u l d be examined i n d e t a i l . The scope of t h i s paper w i l l be t o propose the key elements o f a system o f care f o r the c h r o n i c a l l y m e n t a l l y i l l and d i s a b l e d f o r a s p e c i f i c r e g i o n o f the P r o v i n c e . The r e g i o n s e l e c t e d f o r t h i s paper i s Vancouver I s l a n d where there has not been any s i g n i f i c a n t s e r v i c e p l a n n i n g f o r the c h r o n i c p a t i e n t . Recommendations f o r a comprehensive community care system f o r a s p e c i f i c p l a n n i n g r e g i o n must f o l l o w f o u r b a s i c s t e p s : a) d e f i n i t i o n of the p o p u l a t i o n t o be served, i n c l u d i n g t h e i r c h a r a c t e r i s t i c s and numbers; b) development o f a p l a n n i n g model based on an assessment o f c u r r e n t trends and a v a i l a b l e technology; 3 c) examination of the s p e c i f i c planning region and an assessment of e x i s t i n g services used by the i d e n t i f i e d population; d) application of the model plan with recommenda-tions to improve the e x i s t i n g service system. Chapter 1 of t h i s thesis works through several d e f i -n i t i o n s of the terms, 'chronically mentally i l l ' and 'chronically mentally disabled*, while drawing the d i s -t i n c t i o n between the two. Also provided i n the f i n a l d e f i n i t i o n i s an outline of the patients' c h a r a c t e r i s t i c s and needs. Chapter 2 reviews some epidemiological l i t e r a -ture with the objective of selecting appropriate prevalence rates of demand for service by the chronically mentally disabled. A chronological examination of service develop-ments for the mentally i l l shows how the disabled group have become a recent concern. These developments i n Chap-ter 3 are presented as general, or international trends, with the discussion concluding on the B r i t i s h Columbia si t u a t i o n . In Chapter 4, recent published and unpublished l i t e r a t u r e i s examined to formulate a model plan df a system of services for the chronically mentally disabled. Chapter 5 focuses on the planning region, Vancouver Island, with an examination of e x i s t i n g mental health services and t h e i r u t i l i z a t i o n by the target population. A discussion of. the adequacy of t h i s region's services concludes t h i s chapter. Chapter 6 proposes required services i n order to bring the e x i s t i n g s i t u a t i o n closer to the model system. 4 The services required are proposed both in functional and organizational terms. This f ina l chapter concludes with a statement of the costs of the proposals. 5 Chapter 1 D e f i n i n g the C h r o n i c a l l y M e n t a l l y D i s a b l e d  An A d m i n i s t r a t i v e D e f i n i t i o n The l i t e r a t u r e o f the l a s t twenty y e a r s has r e l i e d on ' a d m i n i s t r a t i v e ' d e f i n i t i o n s which r e l a t e c h r o n i c i t y t o a p a t i e n t ' s c o n t a c t w i t h a s e r v i c e . Former w idespread use o f h o s p i t a l s as p r i m a r y care f a c i l i t i e s i s r e f l e c t e d i n the use o f the c r i t e r i o n ' d u r a t i o n o f s t a y ' . Sommer and Whitney (1961), Wing (1962), and Brown e t a l . (1966), among o t h e r s , c o n s i d e r e d t h a t menta l i l l n e s s was c h r o n i c i f l e n g t h o f h o s p i t a l s t a y was g r e a t e r than two y e a r s . Brandon and G r u e n -b e r g (1966) and Hogarty (1971) r e g a r d e d a one y e a r s t a y i n d i c a t i v e . The r e d u c t i o n from a two y e a r t o one y e a r s t a y c o u l d be a r e f l e c t i o n o f the p r o g r e s s i v e l y s h o r t e r h o s p i t a l i -z a t i o n p e r i o d f o r a l l admiss ions throughout the 1960 's . As w i l l be shown i n the next c h a p t e r , h o s p i t a l p o p u l a -t i o n s were b e i n g reduced as w e l l , even i n the face o f a r i s i n g admis s ion r a t e ( M a r t i n e t a l . 19 76) . Lamb e t a l . (1976), p a r t i c u l a r l y no ted a d r a m a t i c s h i f t o f f o r m e r l y l o n g - t e r m p a t i e n t s from the h o s p i t a l s t o the community. P u b l i c a t i o n s s i n c e the m i d - s i x t i e s have r e c o g n i z e d these t r e n d s . The phenomenon o f r i s i n g h o s p i t a l r e a d m i s s i o n s as a p r o p o r t i o n o f t o t a l admiss ions i s r e f l e c t e d i n the c r i t e r i a o f c h r o n i c i t y used by K r a f t e t a l . (196 8) , i . e . two y e a r s cont inuous h o s -p i t a l i z a t i o n o r c u m u l a t i v e h o s p i t a l i z a t i o n s o v e r s e v e r a l a d m i s s i o n s . Smith (19 74) c o n s i d e r e d r e a d m i s s i o n s a lone as 6 i n d i c a t i v e of a c h r o n i c s t a t e i f the p a t i e n t had one or two admissions a year. Eaton (19 75) saw the n e c e s s i t y o f l o o k i n g at both d u r a t i o n of episode ( l e n g t h o f h o s p i t a l i z a -t i o n ) and r e c u r r i n g episodes (number of h o s p i t a l i z a t i o n s ) . Todd (19 76) used s i m i l a r c r i t e r i a o f continuous h o s p i t a l i z a -t i o n o f three y e a r s , three readmissions, o r f i f t e e n years h i s t o r y o f p s y c h o t i c i l l n e s s . A l l o f the above s t u d i e s u t i l i z e d h o s p i t a l p o p u l a t i o n s when d i s c u s s i n g c h r o n i c p a t i e n t s . But as the r o l e o f the mental h o s p i t a l has been changing s i g n i f i c a n t l y over the yea r s , i t i s q u i t e p o s s i b l e t h a t c h r o n i c a l l y m e n t a l l y i l l persons do not use t h i s type o f f a c i l i t y as they might have perhaps f i f t e e n years ago. Lamb and G e o r t z e l (19 77) hypo-t h e s i z e d t h i s s i t u a t i o n and, by u s i n g o t h e r c r i t e r i a , d e f i n e d a c h r o n i c p a t i e n t group and then looked f o r i t s h o s p i t a l u t i l i z a t i o n p a t t e r n s . These c r i t e r i a were: being 18 t o 64 years o f age and i n r e c e i p t o f a s o c i a l allowance d i s a b i l i t y pension f o r a p e r i o d o f 18 months because of a m e d i c a l l y c e r t i f i e d d i a g n o s i s o f f u n c t i o n a l psychoses, i . e . s c h i z o -p h r e n i a and manic-depressive i l l n e s s . ' Lamb and G e o r t z e l found t h a t 39 o f t h e i r sample of 99 had no pr e v i o u s h i s t o r y o f s t a t e h o s p i t a l i z a t i o n and t h a t 6 3 persons had no h o s p i -t a l i z a t i o n i n the pr e v i o u s two years. As w e l l , 2 3% o f the sample were r e c e i v i n g no o u t p a t i e n t s e r v i c e s , which i s s u r -p r i s i n g , as the s e v e r i t y o f i l l n e s s o f the sample was con-firmed through i n t e r v i e w s . These r e s u l t s i n d i c a t e t h a t use of e s s e n t i a l l y a d m i n i s t r a t i v e c r i t e r i a would not adequately 7 d e s c r i b e the c h r o n i c a l l y m e n t a l l y i l l . A D i a g n o s t i c D e f i n i t i o n Brown e t a l . (1966) s t a t e d t h a t o n e - h a l f of a l l p a t i e n t s i n B r i t i s h mental h o s p i t a l s were l o n g - s t a y s c h i z o -p h r e n i c s , i . e . over two years o f h o s p i t a l i z a t i o n . These p a t i e n t s had accumulated from former decades when 35% t o 70% of p a t i e n t s admitted with a d i a g n o s i s o f s c h i z o p h r e n i a had stayed i n d e f i n i t e l y . Wing (196 8) found t h a t i n the Camberwell area of London, England, 6 4% of the l o n g - s t a y ( i . e . l e s s than two years) beds were occupied by s c h i z o p h r e -n i c s versus 29% of the s h o r t and medium stay beds and o n l y 13% of o u t p a t i e n t p l a c e s . K r a f t e t a l . (1967), r e p o r t e d from the F o r t Logan Mental H e a l t h Centre t h a t 14% o f t h e i r admitted i n p a t i e n t s r e q u i r e d a continuous stay o f over two years and t h a t 9 4% of these were s c h i z o p h r e n i c s . Schizophre-n i c s not d i s c h a r g e d w i t h i n the f i r s t few months had a .5 p r o b a b i l i t y o f becoming c h r o n i c h o s p i t a l p a t i e n t s . K r a f t e t a l . (1968) u n f o r t u n a t e l y d i d not p r o v i d e d i a g n o s i s f o r the c h r o n i c p a t i e n t s who were d e f i n e d by two years or more cumulative h o s p i t a l s t a y over s e v e r a l admissions: these p a t i e n t s accounted f o r 22% of a l l readmitted p a t i e n t s . How-ever, Winston e t a l . (1977) d i d review the a f t e r c a r e h i s t o r y o f a sample o f d i s c h a r g e d h o s p i t a l p a t i e n t s and found t h a t s c h i z o p h r e n i c s were r e h o s p i t a l i z e d i n l a r g e r numbers (34.6%) than o t h e r d i a g n o s t i c c a t e g o r i e s (11.4%). Many s t u d i e s have used the d i a g n o s i s o f f u n c t i o n a l psychoses, p a r t i c u l a r l y s c h i z o p h r e n i a , to d e f i n e a c h r o n i c 8 p o p u l a t i o n and, l i k e Hogarty (1971), c o n s i d e r e d t h i s group o f i l l n e s s e s as " u s u a l l y c h r o n i c and r e f r a c t o r y to t r a d i -t i o n a l treatment". The use o f t h i s d i a g n o s t i c c r i t e r i a by Lamb and G e o r t z e l (19 77) has a l r e a d y been mentioned. Others who used the same c r i t e r i a were Wing (196 8) , Wienman e t a l . (1970), Smith (1974), and Todd (1976). K e i t h e t a l . (19 76) gave a d d i t i o n a l support t o the co n t e n t i o n t h a t s c h i z o p h r e n i a i s perhaps the most e x t e n s i v e and d i s a b l i n g c h r o n i c mental i l l n e s s . They maintained t h a t the l i t e r a t u r e r e v e a l s s c h i z o p h r e n i c s u s u a l l y have longer s t a y s as i n p a t i e n t s than do persons w i t h o t h e r d i s o r d e r s , and t h a t 62% of known s c h i z o p h r e n i c s r e q u i r e some form of i n p a t i e n t s e r v i c e w i t h i n any given year. F u r t h e r they r e p o r t t h a t o n l y 15% to 4 0% of persons with t h i s d i s o r d e r are able t o f u n c t i o n at average l e v e l s of d a i l y l i v i n g , accounting f o r the f a c t t h a t 50% of economic p r o d u c t i o n l o s t as a r e s u l t of mental i l l n e s s i n the Un i t e d S t a t e s , i s because o f s c h i z o -p h r e n i a . The use of d i a g n o s t i c c a t e g o r i e s , such as s c h i z o p h r e n i a , t o d e f i n e a c h r o n i c p a t i e n t group, does not c o n t r i b u t e to an understanding o f the f u n c t i o n a l d i s a b i l i t i e s a s s o c i a t e d w i t h these i l l n e s s e s . A B e h a v i o u r a l D e f i n i t i o n Another way o f l o o k i n g at c h r o n i c i t y i s as a process or p a t t e r n o f behaviour, as e x p l a i n e d by Wing and Brown (1970) i n t h e i r dynamic model of the psychopathology of p s y c h o s i s . Before the onset o f i l l n e s s the i n d i v i d u a l w i l l have c e r t a i n d i s a b i l i t i e s or disadvantages t h a t w i l l i n f l u e n c e the 9 course of the i l l n e s s . These are termed pre-morbid d i s a b i l i -t i e s and can i n c l u d e poor e d u c a t i o n , low i n t e l l i g e n c e , phy-s i c a l d i s a b i l i t y , l a c k of s o c i a l p o s i t i o n , and poor s e l f - i m a g e . A second l e v e l of d i s a b i l i t i e s occurs w i t h i n the morbid p e r i o d . These are termed primary handicaps and r e f l e c t a concept borrowed from g e n e r a l medicine, although i n mental i l l n e s s , handicaps do not l e n d themselves to as r e l i a b l e o r v a l i d a measurement. Primary handicaps f o r s c h i z o p h r e n i a i n c l u d e the d i s o r d e r s o f a f f e c t which sometimes are termed n e g a t i v e symptoms. These are s o c i a l withdrawal, f l a t n e s s of a f f e c t , poverty o f speech, l a c k of i n i t i a t i v e , u n d e r - a c t i v i t y , and low l e v e l of m o t i v a t i o n . D i s o r d e r s of a s s o c i a t i o n or f l o r i d symptoms are another c a t e g o r y . o f primary handicaps and i n c l u d e d e l u s i o n s , h a l l u c i n a t i o n s , i n c o h e r e n t thought and speech, o v e r - a c t i v i t y , and o t h e r forms of odd behaviour. The t h i r d l e v e l of d i s a b i l i t i e s seen i n p s y c h o s i s i s termed secondary handicaps, and i s not c o n s i d e r e d t o a r i s e d i r e c t l y out of the d i s e a s e process but out of the p a t i e n t ' s own r e a c t i o n t o being i l l and the r e a c t i o n o f others t o the i l l n e s s . While r e c o g n i z i n g the o v e r l a p p i n g nature of the three l e v e l s o f d i s a b i l i t y , Wing and Brown c o n s i d e r e d t h a t the c h r o n i c behaviour seen i n mental h o s p i t a l s was a d i s p l a y of secondary h a n d i c a p s , n o t the handicaps a s s o c i a t e d w i t h the morbid l e v e l o f i l l n e s s . They termed the c h r o n i c behaviour p a t t e r n ' i n s t i t u t i o n a l i s m ' , which was a l o g i c a l behaviour given the environment o f the h o s p i t a l and i t s l a c k of expec-t a t i o n s of the p a t i e n t . 10 The b a s i c i d e a t h a t m a n i f e s t a t i o n s o f m e n t a l i l l n e s s w e r e a f u n c t i o n o f t h e i n d i v i d u a l ' s i n t e r a c t i o n w i t h h i s e n v i r o n m e n t g o e s b a c k a s f a r as t h e p h i l o s o p h y o f t h e m o r a l t r e a t m e n t p e r i o d . N o t w i t h s t a n d i n g t h e d e v e l o p m e n t o f s o c i a l p s y c h i a t r y i n t h e 19 3 0 ' s , t h e c o n c e p t t h a t much p a t i e n t b e h a v i o u r and i l l n e s s was i a t r o g e n i c was n o t p o p u -l a r i z e d u n t i l t h e p u b l i c a t i o n s o f t h e o p e n - d o o r h o s p i t a l p o l i c i e s i n E n g l a n d , a n d S t a n t o n a n d S w a r t z ' s c l a s s i c , The M e n t a l H o s p i t a l i n 1 9 5 4 . C h a n g e s i n a d m i n i s t r a t i v e a n d c l i n i c a l p o l i c i e s t h r o u g h o u t t h e 1 9 5 0 ' s r e s u l t e d i n b e h a v i o u r c h a n g e s i n many l o n g - t e r m p a t i e n t s w h i c h i n t u r n l e d t o a p e r i o d o f t h e o r y d e v e l o p m e n t a s o u t l i n e d b y Zusman ( 1 9 6 6 ) . B a r t o n (1959) o b s e r v e d l o n g - s t a y h o s p i t a l p a t i e n t s a n d s u g g e s t e d t h a t t h e i r p e r s o n a l i t y c h a r a c t e r i s t i c s w e r e a r e c o g n i z a b l e s y n d r o m e w h i c h he t e r m e d " i n s t i t u t i o n a l n e u r o -s i s " . T h e s y n d r o m e was p r o d u c e d b y t h e i s o l a t i n g e f f e c t s o f h o s p i t a l i z a t i o n a n d c o u l d be c o n f u s e d w i t h t h e l a t t e r s t a g e s o f s c h i z o p h r e n i a . The d i f f e r e n c e s w o u l d be a p p a r e n t f o l l o w -i n g a p r o g r a m o f s o c i a l r e h a b i l i t a t i o n d e s i g n e d t o e r a d i c a t e t h e e f f e c t s o f p r o l o n g e d h o s p i t a l i z a t i o n . Sommer ar id W h i t n e y (1961) d e s c r i b e d a s i m i l a r s y n d r o m e t e r m e d " c h r o n i c i t y " . T h i s was t h o u g h t t o s t a r t b e f o r e h o s p i t a l i z a t i o n when t h e p a t i e n t was g r a d u a l l y r e m o v e d f r o m c o m m u n i t y r o l e s a s h i s b e h a v i o u r became p r o g r e s s i v e l y p r o b l e m a t i c a l . C h r o n i c b e h a -v i o u r f o l l o w i n g h o s p i t a l i z a t i o n was c h a r a c t e r i z e d , b y a p a s s i v e d e p e n d e n c y a n d t o t a l a c c e p t a n c e o f h o s p i t a l a u t h o r i t y . T h e s y n d r o m e was a s e l f - f u l f i l l i n g p r o p h e c y a s s t a f f w o u l d e x p e c t 11 t h i s behaviour from p a t i e n t s . Any p a t i e n t h o s p i t a l i z e d f o r a prolonged p e r i o d was at r i s k of c h r o n i c i t y , p a r t i c u -l a r l y s c h i z o p h r e n i c s . M a r t i n (1955) observed c h r o n i c i t y i n other d i a g n o s t i c c l a s s e s and presumed other v a r i a b l e s than the i l l n e s s alone i n i t s e t i o l o g y . The f a c t o r s he suggested which predispose c h r o n i c i t y were inadequate p r e -morbid p e r s o n a l i t y , unfavourable economic circumstances, and l a c k of i n t e r e s t s and s o c i a l r e l a t i o n s h i p s . A mono-graph by the American P u b l i c H e a l t h A s s o c i a t i o n (1962) presented the c h r o n i c behaviour process as a " s o c i a l l y determined r e a c t i o n p a t t e r n " o f the p a t i e n t t o h i s e n v i r o n -ment's response t o h i s i l l n e s s . Termed, the " s o c i a l break-down syndrome", t h i s r e a c t i o n p a t t e r n c o n s i s t e d of w i t h -drawal from s o c i a l r o l e s , l o s s o f p e r s o n a l hygiene standards, and an i n c r e a s e i n anger or h o s t i l i t y . E r n e s t Gruenberg r e c o g n i z e d the s o c i a l breakdown syn-drome as an understandable s o c i a l b e h a v i o u r a l response t o oth e r s who are attempting t o d e a l w i t h the i l l n e s s . The syndrome c o u l d be prevented i f the p a t i e n t was giv e n a p o s i t i v e concept of h i s c o n d i t i o n and a s e l f - r e s p e c t i n g r o l e i n h i s treatment (Gruenberg, 196 7). Although the syndrome i s p r e s e n t w i t h many d i a g n o s t i c c a t e g o r i e s i t i s p a r t i c u l a r l y a s s o c i a t e d w i t h the psychoses (Brandon and Gruenberg, 1966). C h r o n i c i t y as Inadequate S o c i a l Roles Cumming (196 3) d e s c r i b e d a syndrome of s i m i l a r e t i o l o g y t o Gruenberg 1s, but emphasized not the c l i n i c a l m a n i f e s t a -t i o n s , but the s o c i a l and economic m a n i f e s t a t i o n s . Data 12 t h a t show a h i g h concordance between unemployment, l a c k o f job s k i l l s , and mental h o s p i t a l i z a t i o n are seen as evidence of the syndrome and, de f a c t o , as symptoms of mental i l l -ness. Cumming saw the syndrome as an inadequate o r g a n i z a -t i o n of the p a t i e n t ' s s k i l l s f o r everyday community r o l e s . Inadequate l i f e s k i l l s , as they are sometimes l a b e l l e d , are as much a c h r o n i c c o n d i t i o n as apathy and annoying behaviour. Many s t u d i e s and r e p o r t s have d e s c r i b e d c h r o n i c a l l y m e n t a l l y i l l p o p u l a t i o n s by u s i n g s o c i a l and demographic v a r i a b l e s . These d e s c r i p t i v e data support the c o n t e n t i o n t h a t c h r o n i c p a t i e n t s perform inadequate, o r at b e s t , mar-g i n a l s o c i a l r o l e s . The c h r o n i c p o p u l a t i o n s i n these s t u d -ies have u s u a l l y been s e l e c t e d by h o s p i t a l u t i l i z a t i o n d a t a , d i a g n o s i s , observed symptom p a t t e r n s such as s o c i a l break-down syndrome, or a combination of these. Many of the s o c i a l and demographic d e s c r i p t i o n s of c h r o n i c p a t i e n t groups seem t o f o l l o w from the process o f c h r o n i c i t y as hyp o t h e s i z e d i n the s o c i a l breakdown and inadequacy syndrome concepts. The p r o g r e s s i v e s o c i a l withdrawal and l o s s o f l i f e - s k i l l s i n t h i s group are seen as permeating the process o f pre-morbid d e t e r i o r a t i o n , the treatment phases, and a f t e r c a r e . The s t a t e o f pre-morbid adjustment, i . e . ego-strength and s o c i a l attachment, can be a mediating v a r i a b l e a f f e c t i n g the nature and e x t e n t o f the secondary d i s a b i l i t y p e r i o d of i l l n e s s i n the c h r o n i c p a t i e n t (Segal e t a l . , 1977). C h r o n i c p a t i e n t s have almost c o n s i s t e n t l y been d e s c r i b e d as being d e - s o c i a l i z e d , ( K r a f t e t a l . , 1967), s o c i a l l y d i s a b l e d 13 (Brown e t a l . , 1966) , and s o c i a l l y withdrawn (Wing and Brown, 1970). T h i s i s i n t e r p r e t e d as meaning t h a t there are few s o c i a l supports such as f r i e n d s (Wienman e t a l . , 19 70) or f a m i l y (Rada, 1969). S o c i a l withdrawal can be p a r t l y due t o s o c i a l l y i n a p p r o p r i a t e behaviour (Todd e t a l . , 19 76) or a diminished c a p a c i t y f o r making s o c i a l adjustments (Smith, 19 74) . There i s a s i m i l a r i t y between these f i n d i n g s and those o f Lamb and G e o r t z e l (19 77) who, i n the p r e v i o u s l y mentioned study, found t h a t o n l y 20% o f t h e i r sample were married. Wing and Brown found t h a t the d i v o r c e r a t e f o r t h e i r c h r o n i c p a t i e n t s was 3 to 4 times h i g h e r than t h a t of the g e n e r a l p o p u l a t i o n . F u r t h e r evidence of marginal s o c i a l attachment i s given by Lamb and G e o r t z e l who found t h a t 61% of t h e i r sample had no s o c i a l a c t i v i t i e s o u t s i d e t h e i r r e s i -dence and 56% had no s t r u c t u r e d a c t i v i t y such as employment, v o l u n t e e r work, or home r e s p o n s i b i l i t i e s . Unemployment r a t e s among c h r o n i c p a t i e n t s can be used as support f o r Hogarty's (1971) c o n t e n t i o n t h a t c h r o n i c s c h i z o p h r e n i c s are o v e r l y r e p r e s e n t e d i n the lower s o c i o -economic c l a s s e s i n s o c i e t y . Only 2% o f Lamb and G e o r t z e l ' s sample had f u l l - t i m e employment and 13% had p a r t - t i m e employ-ment. Smith (1974) found t h a t c h r o n i c p a t i e n t s , at the F o r t Logan Mental He a l t h Centre i n Colorado, had emotional problems which " l e f t them wi t h long-term d i m i n i s h e d c a p a c i t y f o r i n t e r p e r s o n a l r e l a t i o n s h i p s , v o c a t i o n a l adjustment, edu-c a t i o n a l p u r s u i t s , and s o c i a l i n t e r a c t i o n " . The marg i n a l community attachments o f c h r o n i c p a t i e n t s , d e s c r i b e d by 14 Cumming (1963) and o t h e r s , can be viewed as a m a n i f e s t a t i o n of c h r o n i c i t y i n the community, as can Wing's ' i n s t i t u -t i o n a l i s m ' be viewed as a m a n i f e s t a t i o n of c h r o n i c i t y i n the h o s p i t a l . Chronic D i s a b i l i t y as a D e f i n i t i o n o f S p e c i a l Heeds The f o u r p r e v i o u s headings t o g e t h e r can be seen as b e s t d e s c r i b i n g the c h r o n i c group, and i n c l u d e s the most d i s a b l i n g and s e r i o u s c h a r a c t e r i s t i c s of a number o f per-sons w i t h i n and without the s e r v i c e system. T h i s group has needs; some l o g i c a l l y f o l l o w from the p r e v i o u s d e f i n i -t i o n s and others are r e f e r r e d to elsewhere i n the l i t e r a -t u r e . I t i s apparent t h a t the c h r o n i c a l l y m e n t a l l y i l l u t i l i z e p s y c h i a t r i c i n p a t i e n t s e r v i c e s t o a l a r g e e x t e n t . T h i s s i t u a t i o n e x i s t s i n s p i t e of the p e r s i s t e n t d e i n s t i -t u t i o n a l i z a t i o n t r e n d of the 1960's and e a r l y 1970's which, i n p a r t , was designed t o i n h i b i t i n p a t i e n t admission of new c l i e n t s (Bachrach, 1976). The readmission data presented suggest t h a t some p o r t i o n of the o l d l o n g - s t a y p a t i e n t group, i . e . i n h o s p i t a l b e f o r e d e i n s t i t u t i o n a l i z a t i o n , r e q u i r e s p e r i o d i c h o s p i t a l s e r v i c e s . The work of K r a f t e t a l . , (1967, 196 8) suggests a g r a d u a l b u i l d - u p o f p a t i e n t s r e q u i r i n g con-tinuous i n p a t i e n t s t a t u s . T h i s t r e n d has been v e r i f i e d by Todd (19 76) who d e s c r i b e s a 'new l o n g - s t a y ' group, which i s l a r g e l y s c h i z o p h r e n i c . Lamb and G e o r t z e l (1972) s t u d i e d l o n g - s t a y p a t i e n t s i n C a l i f o r n i a and concluded t h a t there e x i s t s a 'hard-core' group of p s y c h o t i c s who w i l l never 15 f u n c t i o n o u t s i d e o f the h o s p i t a l environment. They e s t i -mated t h a t f i v e beds per 100,000 p o p u l a t i o n are r e q u i r e d f o r t h i s segment. Discharged h o s p i t a l p a t i e n t s need c l i n i c a l a f t e r c a r e s e r v i c e s i n the community i n order t o f u n c t i o n a t adequate l e v e l s and t o prevent readmission; or at l e a s t t o maximize the i n t e r v a l between readmission (Winston e t a l . , 1977). The psychopathology model of s c h i z o p h r e n i a p r e v i o u s l y p r e -sented mentions two c l a s s e s of primary symptoms r e l a t e d to the d i r e c t d i s e a s e p r o c e s s , i . e . n e g a t i v e and f l o r i d symp-toms. Cumming (19 77), although using d i f f e r e n t terminology, s t a t e s t h a t the two symptom p a t t e r n s make up the ' b i - p a r t i t e nature' o f s c h i z o p h r e n i a and act i n t e r d e p e n d e n t l y from each other on seperate continuum. Chemo-therapy has been i n s t r u m e n t a l i n c o n t r o l l i n g the f l o r i d symptoms, and c o n t r o l l e d s t i m u l a t i o n and ego-s t r e n g t h e n i n g t h e r a p i e s i n h i b i t the withdrawal and low-m o t i v a t i o n aspects of the n e g a t i v e symptoms ( G r e e n b l a t t , 1975) . These treatment i n t e r v e n t i o n s , among others, have been shown to be e f f e c t i v e i n c o n t r o l l i n g the d i s e a s e process and i n m i n i m i z i n g h o s p i t a l u t i l i z a t i o n ( S t e i n and T e s t , 1976) . In an unpublished paper, r e p o r t e d by Sheets (19 76), Mechanic attempted to e x p l a i n h i g h readmission r a t e s of c h r o n i c p a t i e n t s . He suggested t h a t the h i g h - r i s k group lacked m a t e r i a l l i v i n g s upports, a p p r o p r i a t e l i v i n g s k i l l s , coping mechanisms and defenses a g a i n s t s t r e s s s i t u a t i o n s , 16 i n d i v i d u a l and s o c i a l group supports,and s u s t a i n e d m o t i -v a t i o n . Chemo-therapy c o n t r o l of the flamboyant aspects of p s y c h o s i s , and t r a d i t i o n a l psychotherapy, does l i t t l e t o a s s i s t the p a t i e n t s i n a c q u i r i n g the s k i l l s and supports he needs f o r community l i v i n g (Cumming, 19 77). The needs d e s c r i b e d by Mechanic are h i g h l y s u g g e s t i v e o f the secon-dary d i s a b i l i t i e s o f p s y c h o s i s r e f e r r e d to by Wing and Brown. The secondary d e t e r i o r a t i o n wrought from the l o n g -term i l l n e s s , whether termed s o c i a l breakdown syndrome or inadequacy syndrome, r e q u i r e s a r e h a b i l i t a t i o n e f f o r t d i -r e c t e d t o i t alone. Ch r o n i c p a t i e n t s , whether i n the community or h o s p i t a l , have c e r t a i n b a s i c needs s i m i l a r t o those of the g e n e r a l p o p u l a t i o n . Sheets (1976), r e c a l l i n g C a s s e l l , the eminent e p i d e m i o l o g i s t , p o i n t s out t h a t any person has t o f u l f i l l c e r t a i n psycho-emotional needs i n order t o b u f f e r a g a i n s t p h y s i c a l and p s y c h o l o g i c a l s t r e s s . These a r e : s e c u r i t y , a f f e c t i o n , t r u s t , i n t i m a c y , nurturance, belongingness, a f f i l i a t i o n , and ap p r o v a l . These needs would u s u a l l y be met through p a r t i c i p a t i o n i n a s o c i a l support system encom-p a s s i n g primary and secondary r e f e r e n c e groups. The evidence presented by Lamb and G e o r t z e l (19 77), among o t h e r s , demonstrates t h a t many c h r o n i c p a t i e n t s do not adequately p a r t i c i p a t e i n b a s i c s o c i a l support systems. For p r a c t i c a l purposes, i t i s d i f f i c u l t t o c o n s i d e r the needs o f the p a t i e n t s e p a r a t e l y from those o f the person. For i l l u s t r a t i o n , one study r e p o r t e d t h a t the d e c i s i o n f o r 17 h o s p i t a l i z a t i o n i s more o f t e n based on the p a t i e n t ' s s o c i a l s i t u a t i o n r a t h e r than h i s symptomatology ( O z a r i n , 19 76). A d d i t i o n a l l y , o t h e r r e p o r t s have found r e l a t i o n s h i p s between community tenure and type of l i v i n g arrangment, employment, s o c i a l s i t u a t i o n , occurrence of b i z a r r e beha-v i o u r , and the degree p a t i e n t s ' f a m i l i e s t o l e r a t e manage-ment problems (Paul and L e n t z , 1977). J u d i t h Turner (19 77), i n a working paper based on a NIMH ( N a t i o n a l I n s t i t u t e of Mental Health) conference, l i s t e d the s p e c i a l needs of the c h r o n i c a l l y d i s a b l e d . T h i s l i s t i n c l u d e s needs r e l a t e d t o f u n c t i o n a l d e f i c i t s , depen-dency needs i d e n t i f i e d by S t e i n e t a l . (19 75), and b a s i c human needs. These a r e : "- Access t o decent housing, n u t r i t i o n , t r a n s p o r -t a t i o n , e d u c a t i o n , h e a l t h s e r v i c e , income maintenance and r e c r e a t i o n . - A p e r s o n a l support system c o n s i s t i n g of o t h e r people who care about them as i n d i v i d u a l s . - A comprehensive e v a l u a t i o n of s t r e n g t h s and weaknesses, and an o p p o r t u n i t y t o p a r t i c i p a t e i n s e t t i n g g o als and de v e l o p i n g a p l a n f o r ap p r o p r i a t e s e r v i c e s . - A p p r o p r i a t e and c o n t i n u i n g m e d i c a l and p s y c h i -a t r i c - p s y c h o l o g i c a l treatment as necessary, i n c l u d i n g p e r i o d i c review and r e g u l a t i o n of medi c a t i o n . - A p l a c e t o go or a person to c a l l f o r h e l p i n d e a l i n g with acute b e h a v i o r a l , e m o t i o n a l , or p h y s i c a l d i s t r e s s . - T r a i n i n g i n "coping s k i l l s " t o a s s i s t the c l i e n t i n t a s k s o f d a i l y l i v i n g , and, when a p p r o p r i a t e , a s s i s t a n c e i n performing these t a s k s . - A dependable resource person t o whom t o t u r n when a s s i s t a n c e i s needed o r a c r i s i s a r i s e s , who w i l l p r o t e c t the c l i e n t from e x p l o i t a t i o n , r e p r e s e n t the c l i e n t as necessary, and espouse the c l i e n t ' s cause i n necessary c o n t a c t s w i t h s e r v i c e agencies. 18 - O p p o r t u n i t i e s f o r v a l i d a t i o n of p e r s o n a l worth, f o r being a p p r e c i a t e d and v a l u e d as a human being. - A r e s i d e n t i a l s e t t i n g which p r o v i d e s reason-able s a f e t y , emotional support, a s s i s t a n c e i n d a i l y l i v i n g , and which resembles o t h e r community l i v i n g arrangements as n e a r l y as p o s s i b l e . - A s s i s t a n c e t o f a m i l y and s i g n i f i c a n t others i n r e l a t i o n to any d i f f i c u l t i e s they may experience as a r e s u l t o f the c l i e n t ' s p r e -sence i n t h e i r midst. - A s s i s t a n c e t o neighbors and employers i n coping a p p r o p r i a t e l y w i t h any unusual, annoy-i n g o r d i s t u r b i n g aspects of the c l i e n t ' s b e h a v i o r . - V o c a t i o n a l guidance, t r a i n i n g and a s s i s t a n c e i n s e c u r i n g and h o l d i n g a j ob. - P r o v i s i o n o f work or o t h e r u s e f u l d a i l y a c t i -v i t i e s f o r those i n d i v i d u a l s who are i n c a p a b l e of h o l d i n g a r e g u l a r j o b . - A s s i s t a n c e i n o b t a i n i n g and making a p p r o p r i a t e use of e n t i t l e m e n t s as c i t i z e n s or r e s i d e n t s of t h e i r r e s p e c t i v e communities. - A c l e a r l y d e f i n e d and a c c e s s i b l e grievance procedure." Summary Up to t h i s p o i n t the terms " c h r o n i c a l l y m e n t a l l y i l l " and " c h r o n i c a l l y m e n t a l l y d i s a b l e d " have been used i n t e r -changeably,, P a r t l y t h i s i s due t o a l a c k of c l e a r d i s t i n c -t i o n s i n the l i t e r a t u r e . T h i s i n c o n s i s t e n c y has been noted by Nagi (1966). An attempt has been made i n t h i s chapter t o d i s t i n g u i s h between the acute pathology or d i s e a s e process o f s c h i z o p h r e n i a and i t s long-term b e h a v i o u r a l , s o c i a l , and f u n c t i o n a l e f f e c t s . These l a t t e r e f f e c t s o f the d i s e a s e are r e f e r r e d t o as d i s a b i l i t i e s . The l i t e r a t u r e 19 supports a high c o r r e l a t i o n between p a t i e n t s diagnosed as s c h i z o p h r e n i c s and the prevalence o f c h r o n i c d i s a b i l i -t i e s r e s u l t i n g from mental i l l n e s s e s . The c h r o n i c a l l y d i s a b l e d w i l l have p e r i o d i c episodes of acute i l l n e s s r e q u i r i n g i n t e n s i v e c l i n i c a l s e r v i c e s , u s u a l l y i n an i n p a t i e n t s e t t i n g . During these episodes the p a t i e n t w i l l e x h i b i t an e x a c e r b a t i o n of Wing and Brown's d i s o r d e r s o f a s s o c i a t i o n or f l o r i d symptoms, which may a l s o be a s s o c i a t e d with d i s o r d e r s of a f f e c t . T r e a t -ment w i l l focus on a r e d u c t i o n o f these symptoms p r i m a r i l y with the use of p s y c h o a c t i v e drugs. Chemotherapy w i l l continue f o r an extended p e r i o d subsequent to the acute phase. These aspects of c h r o n i c mental d i s o r d e r , r e f e r r e d to as i l l n e s s , may be adequately d e f i n e d by the a d m i n i s t r a -t i v e or d i a g n o s t i c d e f i n i t i o n s . The b e h a v i o u r a l and s o c i a l d e f i n i t i o n s of c h r o n i c i t y p e r t a i n to the d i s a b l i n g s i d e of c h r o n i c mental i l l n e s s . The d i s a b l i n g p r o c e s s , evidenced by what Segal e t a l . r e f e r to as "poor s o c i a l margin", i s continued through l a c k of s o c i a l s k i l l s , t i m e - s t r u c t u r i n g and coping mechanisms. A l -though the i l l n e s s and d i s a b l i n g aspects of the c h r o n i c d i s o r d e r have t o be s e p a r a t e l y d e a l t w i t h by a s e r v i c e system, they cannot be c o n s i d e r e d independent of each o t h e r . The l i t e r a t u r e s t r o n g l y suggests t h a t mental h e a l t h systems which f a i l t o meet the needs of the d i s a b l e d w i l l i n e v i t a b l y r e s u l t i n an o v e r - u t i l i z a t i o n of the s e r v i c e s designed to 20 t r e a t the i l l n e s s . The f o l l o w i n g chapter w i l l i d e n t i f y the f a i l u r e o f e x i s t i n g systems to meet the needs o f the chro-n i c a l l y d i s a b l e d . In Chapter 4 , a model system i s p r e -sented which i s designed t o overcome the d e f i c i e n c i e s of most e x i s t i n g systems. 21 Chapter 2 Prevalence of the C h r o n i c a l l y M e n t a l l y D i s a b l e d As the o b j e c t i v e o f t h i s paper i s to propose a p l a n of community s e r v i c e s f o r the c h r o n i c a l l y d i s a b l e d , estimates o f expected u t i l i z a t i o n must be prepared. U t i -l i z a t i o n can be estimated once the prevalence o f d i s a b l i n g mental i l l n e s s i s determined. T h i s chapter c o n t a i n s a review o f some e p i d e m i o l o g i c a l l i t e r a t u r e t h a t w i l l p r o v i d e prevalence r a t e s t h a t can be a p p l i e d t o the Vancouver I s l a n d p o p u l a t i o n . As seen below, care must be e x e r c i s e d i n s e l e c t -i n g a p p r o p r i a t e r a t e s as they vary depending on the source and methodology of data c o l l e c t i o n . Sources o f Prevalence Data 1. Treatment F a c i l i t i e s Some e a r l i e r s t u d i e s used the f i r s t admission r a t e s to p u b l i c mental h o s p i t a l s as a method o f c a l c u l a t i n g i n c i d e n c e and p r e v a l e n c e , but these are u n r e l i a b l e without s p e c i f i c i n f o r m a t i o n on what f o r c e s b r i n g the s i c k i n t o the h o s p i t a l (Richman, 19 70). Goldhammer and M a r s h a l l (195 3) a l s o looked at f i r s t admissions, but i n c l u d e d a l l i n p a t i e n t f a c i l i t i e s , i n c l u d i n g p r i v a t e s a n a t o r i a and g e n e r a l h o s p i t a l s . The r a t e s from these sources are a c t u a l l y p a t i e n t prevalence r a t e s . As care f o r the m e n t a l l y i l l was s h i f t i n g from h o s p i t a l t o community i n the 1950's, the h o s p i t a l s as a source of data were becoming inadequate (Kramer e t a l . , 19 72). 22 H o l l i n g s h e a d and R e d l i c h (1958) attempted to overcome t h i s by s u r v e y i n g a l l treatment f a c i l i t i e s , i n c l u d i n g p r i v a t e p r a c t i t i o n e r s and o u t p a t i e n t s e r v i c e s . Surveys o f community treatment s e r v i c e s expand the d e f i n i t i o n of p a t i e n t i n e s t i -mating r a t e s o f mental d i s o r d e r , but s t i l l assume t h a t a l l the m e n t a l l y i l l w i l l e n t e r care. 2. P s y c h i a t r i c Case R e g i s t e r s Richman (1970) d e f i n e d p s y c h i a t r i c case r e g i s t e r s as "systems whereby records from a s p e c i f i e d s e t o f p s y c h i a t r i c f a c i l i t i e s are c o l l e c t e d f o r i n d i v i d u a l persons from a de-f i n e d p o p u l a t i o n and accumulated over time". They are de-signed t o r e c o r d the h i s t o r y of admissions, d i s c h a r g e s , and d u r a t i o n o f s t a y over the l i f e t i m e s of a group of u n d u p l i -cated i n d i v i d u a l s . Although based on a s p e c i f i e d p o p u l a t i o n u s u a l l y d e f i n e d g e o g r a p h i c a l l y , there are s t i l l problems o f m i g r a t i o n and comprehensiveness of r e p o r t i n g . For example, the Rochester R e g i s t e r i n Monroe County, New York, i s the only one i n the U n i t e d S t a t e s t h a t i n c l u d e s r e p o r t i n g from p r i v a t e p s y c h i a t r i s t s ( B a b i g i a h , 19 76). Although case r e g i s -t e r s have been used e x t e n s i v e l y (Bahn e t a l . , 1966; Wing et a l . , 196 7) i n r e p o r t i n g c r o s s - n a t i o n a l r a t e s o f mental i l l n e s s , they do have some disadvantages. There i s s t i l l a d i s c r e p a n c y between t r u e m o r b i d i t y and t h a t which i s r e p o r t e d , even though a more comprehensive r e p o r t i n g i s a v a i l a b l e . Comparison between areas i s sometimes d i f f i c u l t f o r there w i l l e x i s t v a r y i n g i n t e r p r e t a t i o n s o f d i a g n o s t i c c l a s s i f i c a -t i o n as i n v e s t i g a t e d by Cooper (19 70) between the U n i t e d 23 S t a t e s and England.' A l s o the paths t h a t determine the e x t e n t o f p a t i e n t c o n t a c t s w i l l vary (Bahn, 1966). Case r e g i s t e r s do, however, p r o v i d e the b e s t r e c o r d i n g of p a t i e n t c o n t a c t s . 3. F i e l d Surveys F i e l d surveys are an attempt t o measure t r u e m o r b i d i t y p r o v i d i n g p o i n t and p e r i o d prevalence r a t e s . Incidence r a t e s are r a r e l y forthcoming from f i e l d d ata (Dohrenwend and Dohrenwend, 1969) . Some o f the r e c e n t major s t u d i e s have been r e p o r t e d by L e i g h t o n et a l . (1959, 196 3) i n Nova S c o t i a , S r o l e (1962) i n Manhatten, and Ryan (1969) i n Boston. I n v e s t i g a t o r s t y p i c a l l y s e l e c t a d e f i n a b l e community and with a r e p r e s e n t a t i v e sample or an e n t i r e p o p u l a t i o n , i n t e r -view d i r e c t l y o r seek data from informants. The i n f o r m a t i o n i s assessed a c c o r d i n g to a s e t of predetermined c r i t e r i a t o d e f i n e cases which are u s u a l l y c a t e g o r i z e d from " l e a s t " t o "most s e v e r e l y d i s o r d e r e d " . In t h i s manner both t r e a t e d and u n t r e a t e d cases, as d e f i n e d by the i n v e s t i g a t o r s , are counted i n m o r b i d i t y r a t e s . Dohrenwend and Dohrenwend (1969) reviewed 44 f i e l d s t u d i e s and found t h a t the "short-term" p e r i o d prevalence r a t e s f o r p s y c h o l o g i c a l d i s o r d e r ranged from a r e p o r t e d 1% to over 60%, The r a t e e x i s t e d i n both urban and r u r a l s t u d i e s and i n North American, European, and A s i a n . These r a t e s , with t h e i r emphasis on g l o b a l c a t e g o r i e s o f d i s e a s e , are u n r e l i a b l e and almost u s e l e s s f o r p l a n n i n g purposes (Mechanic, 1970) . 24 There i s another i s s u e to be c o n s i d e r e d i n u s i n g prevalence r a t e s from the three sources d e s c r i b e d above. Should s e r v i c e s be planned on the b a s i s o f m o r b i d i t y estimates from f i e l d surveys or from r e p o r t s of e x i s t i n g u t i l i z a t i o n p a t t e r n s ? Ryan (196 4), i n Boston, demonstrated t h a t few people i n h i s category of " s e r i o u s l y impaired' were a c t u a l l y i n c o n t a c t w i t h any k i n d of mental h e a l t h s e r v i c e . A l s o , the h i g h r a t e s of s e r i o u s d i s o r d e r found i n S t i r l i n g County by L e i g h t o n suggests t h a t a s e r v i c e system should be designed on the b a s i s o f t r u e r a t e s — y e t there i s h e s i t a t i o n to do so. Dohrenwend (19 70), i n the New York borough of Washington He i g h t s , s u p e r v i s e d p s y c h i a t r i s t s conducting p e r s o n a l i n t e r -views with a l a r g e sample of the g e n e r a l p o p u l a t i o n . They i n t e r v i e w e d both t r e a t e d and u n t r e a t e d cases and, as i n o t h e r s t u d i e s , found s e r i o u s l y d i s t u r b e d i n d i v i d u a l s i n each group. But they a l s o found, t h a t f o r many, the symptom p a t t e r n s between the u n t r e a t e d and t r e a t e d s e r i o u s l y d i s t u r b e d were not the same. Dohrenwend reviewed r e s u l t s of some o t h e r prevalence s t u d i e s and p r e d i c t e d t h a t t h e i r m o r b i d i t y r a t e s c o u l d be reduced. Dohrenwend suggests a p a r t i a l e x p l a n a t i o n f o r an important query, i . e . whether un t r e a t e d and t r e a t e d cases of the same d i s o r d e r are fundamentally d i f f e r e n t . He does concede t h a t h i s e x p l a n a t i o n does not o b v i a t e the g e n e r a l f i n d i n g t h a t the a c t u a l m o r b i d i t y of s e r i o u s mental i l l n e s s i s g r e a t e r than r e p o r t e d . 25 Another i n t e r p r e t a t i o n of these f i n d i n g s i s t h a t e p i d e m i o l o g i s t s may be r e p o r t i n g d i f f e r e n c e s between need and demand. Rates o f t r e a t e d d i s o r d e r s are obvious measures of the l a t t e r , w h i le t r u e r a t e s , u s i n g measurement c r i t e r i a developed by h e a l t h p r o f e s s i o n a l s , are estimates of need as they d e f i n e i t . P o l i c y makers and funding bodies may not agree t h a t s e r v i c e s be p r o v i d e d t o meet a l l needs d e f i n e d i n t h i s way. The remainder of t h i s chapter w i l l f o l l o w Mechanic's (19 70) advice t h a t f o r p l a n n i n g , l i m i t e d c a t e g o r i e s o f i l l n e s s should be c o n s i d e r e d . These d i a g n o s t i c c a t e g o r i e s w i l l be d e r i v e d from case r e g i s t e r s as they p r o v i d e the b a s i s f o r e s t i m a t i n g u t i l i z a t i o n from demand. A compari-son of these r a t e s w i l l be made t o r a t e s from f i e l d s t u d i e s . Estimates o f Chronic Mental I l l n e s s As presented i n a p r e v i o u s chapter, a paper concerned w i t h the c h r o n i c a l l y m e n t a l l y d i s a b l e d i s mainly concerned w i t h the psychoses, p a r t i c u l a r l y the s c h i z o p h r e n i a s . The o r g a n i c psychoses, such as those a s s o c i a t e d w i t h dementia, make up a s i g n i f i c a n t p r o p o r t i o n of the long-term d i s a b l e d . These c o n d i t i o n s , however, are q u a l i t a t i v e l y d i f f e r e n t than the o t h e r psychoses (Mechanic, 1969) and p r e s e n t unique problems f o r management. S e r v i c e t o t h i s group deserves s p e c i a l and separate a t t e n t i o n , and would not be j u s t i f i a b l y s erved i n a paper devoted t o o t h e r major d i s a b i l i t i e s ; t h e r e f o r e they are excluded from the d i s c u s s i o n i n t h i s t h e s i s . 26 R a t e s f r o m C a s e R e g i s t e r D a t a W i n g e t a l . (196 7) c o m p a r e d t h e one y e a r p r e v a l e n c e f i g u r e s o f " s c h i z o p h r e n i a , m a n i c d e p r e s s i v e a n d o t h e r f u n c t i o n a l p s y c h o s e s " f r o m t h e c a s e r e g i s t e r s o f B a l t i m o r e , C a m b e r w e l l a n d A b e r d e e n . T h e s e r a t e s a r e s u m m a r i z e d i n T a b l e 2 . 1 . T a b l e 2 . 1 One Y e a r P r e v a l e n c e R a t e s f o r S e l e c t e d D i s o r d e r s i n T h r e e R e g i s t e r A r e a s ( R a t e s p e r 1 0 0 , 0 0 0 p o p u l a t i o n a g e d 15+) B a l t i m o r e C a m b e r w e l l A b e r d e e n S c h i z o p h r e n i a 6 85 435 246 M a n i c D e p r e s s i v e a n d O t h e r F u n c t i o n a l P s y c h o s e s 135 377 225 T o t a l P r e v a l e n c e R a t e 820 812 471 The l o w r a t e i n A b e r d e e n c a n be e x p l a i n e d b y W i n g ' s d e s c r i p t i o n o f t h e t h r e e c i t i e s . A b e r d e e n , u n l i k e t h e o t h e r s , i s a s m a l l e r c i t y w i t h l i t t l e m a j o r s o c i o - e c o n o m i c c l a s s d i f f e r e n c e s , v i r t u a l l y n o s l u m s o r u r b a n b l i g h t . T h e s e c o n d i t i o n s a r e s i g n i f i c a n t i n e x p l a i n i n g v a r i a n c e i n r e p o r t e d r a t e s o f s e r i o u s m e n t a l d i s o r d e r ( R o s e n b e r g a n d R a y n e s , 19 7 6 ) . T h e l o w e r s c h i z o p h r e n i a a n d h i g h e r m a n i c -d e p r e s s i v e r a t e s i n B r i t a i n , a s c o m p a r e d t o B a l t i m o r e , r e f l e c t s d i f f e r i n g d i a g n o s t i c p r a c t i c e s o f p s y c h i a t r i s t s a n d t r u e m o r b i d i t y d i f f e r e n c e s ( C o o p e r , 19 7 0 ) . A p p l i c a t i o n o f t h e B a l t i m o r e r a t e f o r s c h i z o p h r e n i a t o t h e 1976 V a n c o u -v e r I s l a n d p o p u l a t i o n o v e r 15 y e a r s o f a g e , i . e . 3 4 0 , 5 3 0 , w o u l d i n d i c a t e a one y e a r p a t i e n t p r e v a l e n c e o f 2 332 p e r s o n s . There i s h e s i t a t i o n to accept crude r a t e s r e a l i z i n g the impact of age and sex on the d i s t r i b u t i o n of mental i l l n e s s . Looking at o n l y U n i t e d S t a t e s s t u d i e s , B a b i g i a n (19 76) r e p o r t e d t h a t the one year prevalence f o r s c h i z o -p h r e n i a was between .2 3% and .4 7% o f the t o t a l p o p u l a t i o n . The h i g h e r f i g u r e was d e r i v e d from the Monroe County Case R e g i s t e r i n New York S t a t e . Table 2.2 shows the age and sex s p e c i f i c r a t e s f o r s c h i z o p h r e n i a , from the Monroe County R e g i s t e r , as a p p l i e d t o the Vancouver I s l a n d popu-l a t i o n . T h i s t a b l e uses only the Monroe County r a t e s f o r whites so t o make a p p l i c a t i o n r e p r e s e n t a t i v e r a c i a l l y . Monroe County i s an area of mixed economy wit h some r u r a l areas, s i m i l a r t o many s e c t i o n s o f Vancouver I s l a n d . Table 2.2 Monroe County One Year Expected Prevalence Rates f o r S c h i z o p h r e n i a A p p l i e d t o Vancouver I s l a n d P o p u l a t i o n ( r a t e per 100 ,000 population) Age Group Male Pop. Rate Cases Female Pop. Rate Cases 15-24 41,455 699 277 40,590 411 167 25-34 33,910 874 296 31,970 913 292 35-44 23,440 9 30 218 22,155 1144 253 45-54 23,550 616 145 24,860 753 187 55-65 21,170 2 75 58 24,465 445 67 65+ 23,290 63 15 29 ,685 113 34 T o t a l s 166,805 1009 173,725 1000 28 The Monroe County r a t e s p r o v i d e one year p a t i e n t prevalence and count on l y those s c h i z o p h r e n i c s who came i n t o s e r v i c e i n t h a t p e r i o d o f time. The r a t e s do not account f o r a l l the s c h i z o p h r e n i c s i n the p o p u l a t i o n as some would have r e c e i v e d s e r v i c e the pr e v i o u s year or not at a l l . I t i s i n t e r e s t i n g t o note the age d i s t r i b u t i o n i n the Monroe County r a t e s . There i s a n e g l i g i b l e r a t e f o r the o l d e r groups, perhaps r e f l e c t i n g an i n a b i l i t y of the s e r v i c e system t o t r e a t them and consequent l a c k o f demand. Bab i g i a n a l s o r e p o r t e d t h a t some American s t u d i e s quoted one year i n c i d e n c e r a t e s o f s c h i z o p h r e n i a between .043% and .069% o f the t o t a l p o p u l a t i o n . These r a t e s , a p p l i e d t o the Vancouver I s l a n d p o p u l a t i o n , would suggest t h a t there are 189 and 304 new cases of s c h i z o p h r e n i a a n n u a l l y . A c c o r d i n g t o the formula, Prevalence Duration = I n c i d e n c e > the d u r a t i o n o f s c h i z o p h r e n i a i s between 7 and 12 y e a r s . T h i s should be i n t e r p r e t e d c a r e f u l l y ; i . e . t h i s i s the leng t h o f time a s c h i z o p h r e n i c may seek a c t i v e treatment, s i n c e the r a t e s are d e r i v e d from p a t i e n t prevalence data. Rates from F i e l d Surveys Dohrenwend and Dohrenwend (1969) reviewed 44 i n t e r -n a t i o n a l prevalence s t u d i e s completed over a t h i r t y year p e r i o d . These f i e l d s t u d i e s took p e r i o d measures o f s h o r t d u r a t i o n — i n t e r p r e t e d as one to thr e e years — f o r a l l p s y c h o l o g i c a l d i s o r d e r s . The Dohrenwends e x t r a c t e d where 29 p o s s i b l e the r a t e s f o r p s y c h o s i s , i . e . s c h i z o p h r e n i a and other f u n c t i o n a l psychoses. Table 2.3 shows the d i s t r i -b u t i o n o f t h i r t e e n prevalence s t u d i e s by percent o f p o p u l a t i o n found w i t h p s y c h o t i c d i s o r d e r s . The male and female r a t e s of the s t u d i e s are separated. Table 2.3 Prevalence Rates o f P s y c h o s i s from F i e l d Surveys % Rate Reported No. o f S t u d i e s Reporting t h i s Rate; f o r Males f o r Females .23% - .50 6 8 .51 - .75 4 2 . 76 - 1.2 3 3 The narrow range o f r a t e s r e p o r t e d and the s i m i l a r i t y o f these r e s u l t s to those from case r e g i s t e r data i s note-worthy. While acknowledging d i f f i c u l t i e s mentioned above i n i n t e r p r e t i n g prevalence f i g u r e s from f i e l d s t u d i e s , i t may be safe to s t a t e t h a t the t r u e prevalence o f the major p s y c h o s i s , i s w i t h i n 50% o f the r e p o r t e d r a t e . Compared t o the v a r i a b i l i t y found i n s t u d i e s r e p o r t i n g a l l psycho-l o g i c a l d i s o r d e r , the d i f f e r e n c e between r e p o r t e d and t r u e prevalence o f p s y c h o s i s i s q u i t e s m a l l . The narrow range would support the c o n t e n t i o n of Goldhammer and M a r s h a l l (1953), and Mechanic (1969) t h a t t r u e m o r b i d i t y o f s e r i o u s p s y c h o s i s has not s i g n i f i c a n t l y changed over time and i s e s s e n t i a l l y the same between Western s o c i e t i e s . A d d i t i o n a l l y , Rosenberg and Raynes (19 76) proposed t h a t the concept o f p s y c h o t i c d i s o r d e r has not been s i g n i f i c a n t l y expanding i n 30 c o n t r a s t to expanding concepts o f o t h e r p s y c h o l o g i c a l d i s o r d e r . Oedegaard (1952) argued t h a t of a l l p s y c h o l o g i c a l d i s o r d e r s , the psychoses, and p a r t i c u l a r l y s c h i z o p h r e n i a , w i l l show up i n h o s p i t a l i z a t i o n r a t e s e v e n t u a l l y . He r e c o g n i z e d t h a t i n v e s t i g a t o r s f o r f i e l d surveys have shown 25 t o 30 per cent more n o n - h o s p i t a l i z e d p s y c h o t i c s than admission s t a t i s t i c s , but he concluded most of these would seek treatment w i t h i n one o r two years of onset. Summary There has been s u f f i c i e n t evidence presented i n Chapter 1 to suggest t h a t a prevalence estimate o f s c h i z o -p h r e n i a approximates t h a t o f c h r o n i c mental d i s a b i l i t y , o t h e r than those a s s o c i a t e d w i t h o r g a n i c psychoses. The prevalence o f s c h i z o p h r e n i a can be b e s t e s t i m a t e d from p s y c h i a t r i c case r e g i s t e r s , which r e f l e c t e x i s t i n g demand f o r treatment s e r v i c e s . An important v a r i a b l e to be con-s i d e r e d i s case d e f i n i t i o n , as d i a g n o s i n g p r a c t i c e s v a r y between case r e g i s t e r areas. T h i s v a r i a n c e w i l l be accounted f o r i n Chapter 5 where the estimates of a c t u a l prevalence f o r the d i f f e r e n t areas o f the p l a n n i n g r e g i o n , i . e . Vancouver I s l a n d , w i l l be presented. 31 Chapter 3 S e r v i c e Trends and Issues A. General Trends and Issues  The Asylum P e r i o d Before the e i g h t e e n t h century most o f the m e n t a l l y i l l l i v e d i n the community s u f f e r i n g p o v e r t y , i n d e n t u r e and r i d i c u l e . Treatment s e r v i c e s as we know them were n o n - e x i s t e n t although a v e r y few asylums e x i s t e d such as Bethlehem H o s p i t a l i n London. The s o l u t i o n f o r the many i n d i g e n t ' l u n a t i c s ' was conceived o f i n i n s t i t u t i o n a l terms as they were lumped w i t h the poor and the c h r o n i c a l l y s i c k under the E l i z a b e t h a n Poor Laws which r e q u i r e d commu-n i t i e s t o house paupers i n almshouses and workhouses. Some of these f a c i l i t i e s came to house predominantly the m e n t a l l y i l l . C e n t r a l government r e g u l a t i o n o f these i n s t i t u t i o n s was f e l t n ecessary i n England by 1774 w i t h the A c t Reg u l a t i n g Madhouses. By t h i s time the i n s t i t u t i o n a l model was f i r m l y e s t a b l i s h e d throughout Europe and had been t r a n s p l a n t e d t o North America i n 1773 a t W i l l i a m s b u r g , V i r g i n i a (Mora, 1976). Mora s t a t e d t h a t the growth o f i n s t i t u t i o n a l care c o i n c i d e d w i t h the abandonment of moral ide a s o f the cause o f i l l n e s s such as p o s s e s s i o n , w i t c h c r a f t and s i n , and the r i s e o f modern medicine from the p e r i o d of W i l l i a m Harvey onward. By the mid-eighteenth century a smal l group of p h y s i c i a n s pre-occupied w i t h the workings of the mind were working w i t h i n asylums. 32 Some o f these p h y s i c i a n s were i d e n t i f i e d w i t h the "moral treatment" p e r i o d which began i n the 1790's a t the B i c e t r e i n France and the York Re t r e a t i n England. The approach o f moral treatment was to i n c r e a s e the s e l f - e s t e e m and s e l f - c o n t r o l o f the a f f l i c t e d through "the a p p l i c a t i o n o f r a t i o n a l l y determined rewards and punishments w i t h i n the context of a t r u s t i n g p a t i e n t -d o c t o r r e l a t i o n s h i p " (Schneck, 1960). Bockover (1962), among o t h e r s , h e l d t h a t moral treatment was the dominant mode o f p a t i e n t management i n the e a r l y asylum p e r i o d and a p r e c u r s o r o f modern community p s y c h i a t r y . However, as David Mechanic (1969) argued, moral treatment, although p r a c t i c e d i n t e r n a t i o n a l l y was not p r a c t i c e d u n i v e r s a l l y , as very few p a t i e n t s were exposed t o i t s approach and those who were, were more l i k e l y the a f f l u e n t . The l i m i t e d use o f moral treatment and because i t was not e s t a b l i s h e d on s c i e n t i f i c p r i n c i p l e s , d i d l i t t l e t o ensure i t s s u r v i v a l i n the s c i e n t i f i c age. A d d i t i o n a l l y , the p o p u l a t i o n p r e s -sures o f the 19th century became predominant i n shaping a c u s t o d i a l approach towards the m e n t a l l y i l l , and moral treatment was l e f t a t the wayside. England responded t o pr e s s u r e s f o r i n s t i t u t i o n a l care with the County Asylums A c t (1808) which empowered l o c a l governments t o c o n s t r u c t i n s t i t u t i o n s s p e c i f i c a l l y f o r the insane. E v e n t u a l overcrowding and d e t e r i o r a t i n g c o n d i t i o n s o f the asylums c o n t r i b u t e d t o a s h o r t - l i v e d reform movement. In 1845, the L u n a t i c Asylums Act p r o v i d e d f o r i n s p e c t o r s and f o r a process o f medi c a l c e r t i f i c a t i o n f o r commitment. 33 However, as Katheleen Jones (1960) has documented, there was a growing public fear of the insane and of wrongful committal. The r e s u l t was the 1890 Lunacy Act which re-quired a magistrate's order for a l l asylum admissions. As a l e g i s l a t i v e attempt to protect the pu b l i c , the Lunacy Act ensured the continuation of a custodial system of care. Citizens i n a f i n a n c i a l p osition to avoid asylums did so, using commitment only u n t i l absolutely necessary. The institutions came to be i d e n t i f i e d with the poor and hopelessly i l l , and removed from s o c i a l reform movement in other f i e l d s such as mental retardation and s o c i a l welfare. State governments i n the United States responded to the campaigning e f f o r t s of Dorothea Dix (1802-1887), who lobbied state l e g i s l a t u r e s to b u i l d asylums for the indigent mentally i l l . Her campaign l a i d the foundation for the ex-tensive state asylum system which was the predominant mode of care u n t i l the 1950's. These asylums l i t e r a l l y i s o l a t e d the mentally i l l from t h e i r communities as they were almost always b u i l t i n r u r a l areas. One reason was to a l l a y the general public fear of dangerous behaviour and secondly, that i t was b e n e f i c i a l to remove the a f f l i c t e d from a stress-f u l environment to a more peaceful, i d y l l i c one. Development of the knowledge and the profession of psychiatry contributed to the continuing i s o l a t i o n of the asylum from the mainstream of society. Psychiatry and related d i s c i p l i n e s such as neurology attempted to keep pace with the tremendous advances being made in other medical 34 f i e l d s , p a r t i c u l a r l y those based on biology. Interest grew i n the somatic origins of mental i l l n e s s to the detriment of environmental causes (Weston, 1976). The deterministic aspects of theories of evolution and heredity further influenced psychiatry i n the l a t t e r decades of the 19th century. The re s u l t was a pessimistic prognosis for mental i l l n e s s , which largely precluded consideration of alterna-tives of custodial care. For over two-thirds of those persons with serious mental i l l n e s s e s , asylum committal usually meant l i f e - l o n g incarceration. Many early p s y c h i a t r i s t s , i n h i b i t e d from expecting cures, became preoccupied with nosology and description of mental i l l n e s s . Some of the c l a s s i f i c a t i o n schema developed i n the late 19th and early 20th century has survived to the present r e l a t i v e l y i n t a c t . Korsakov described alcohol psy-chosis and Kraepelin studied and named 'dementia proecox' which Blueler renamed schizophrenia. Illnesses such as these were accounting for a majority of asylum populations. Early Community Alternatives In order for alternatives to the asylum system to evolve i t was necessary to broaden the explanation of mental i l l n e s s . This was a long and uneven process that involved the i n t e r -action of medicine with other d i s c i p l i n e s and schools of thought. Freud's developmental theory of personality was the f i r s t methodological attempt to integrate the o r i g i n of 35 mental pathology within the context of t o t a l personality development. His work stressed that normality and patho-logy were on a continuum, thus allowing for a more f l e x -i b l e approach to mental disorder that lent i t s e l f to i n t e r -vention strategies as an alternative to asylum committal. This approach had a l a s t i n g e f f e c t on the attitudes of professional groups working with the mentally i l l (Mora, 1976). Additionally, Freud's theories brought attention to the prevention of mental disorder through working with children. This was the s t a r t of the c h i l d guidance movement with psychologists as the main proponents, and with community c l i n i c s as t h e i r work settings. These c l i n i c s set a pattern for experimentation for adult outpatient c l i n i c services (Ridenour, 1961) which f i r s t appeared between 1900 and 1910, i n i t i a l l y providing h o s p i t a l admission, screening,and a f t e r -care. However, many of these c l i n i c s came to serve new types of c l i e n t s and not those who were being admitted to the mental hospitals. Another important l i n e of development for alternative services were the smaller "psychopathic" hospitals located i n the community with active treatment rather than custodial functions•. The f i r s t such unit opened i n 1902 i n Albany, New York, and the f i r s t unit a f f i l i a t e d with a university opened four years l a t e r i n Michigan. Several such univer-s i t y a f f i l i a t e d units followed, r e s u l t i n g i n further i n t e r -action of psychiatry with other professional and academic 36 groups. One such p r o f e s s i o n a l group was s o c i a l work, which f i r s t secured a p o s i t i o n i n p s y c h i a t r y a t the Boston Psychopathic H o s p i t a l i n 1909 (Ewalt and Ewalt, 1969). A mental h o s p i t a l i n Maryland e s t a b l i s h e d the f i r s t a f t e r -care department i n 1912 w i t h a p s y c h i a t r i s t and s o c i a l worker. The i n c l u s i o n o f s o c i a l work i n p s y c h i a t r i c s e r -v i c e s was permanently r e c o g n i z e d by 1920 when Smith C o l l e g e e s t a b l i s h e d " p s y c h i a t r i c s o c i a l worker" t r a i n i n g ( R o s s i , 1962). These i n n o v a t i o n s , however, d i d not s i g n i f i c a n t l y a f f e c t the continued growth o f the asylum system u n t i l much l a t e r . Ewalt and Ewalt (1969) l a r g e l y c r e d i t the union o f p s y c h i a t r y w i t h the s o c i a l s c i e n c e s t o the e f f o r t s o f Harry Stack S u l l i v a n (1892-1947), who with s o c i a l s c i e n t i s t s such as Lawrence Frank, H a r o l d L a s s w e l l , and Edward S a p i r worked through the 19 30's to develop a d e f i n i t i o n o f p s y c h i a t r y i n r e l a t i o n t o i n t e r p e r s o n a l r e l a t i o n s . S u l l i v a n (1947, 1949)' claimed t h i s approach was founded on the view o f man as a s o c i a l being with mental pathology a product o f b i o l o -g i c a l , p s y c h o l o g i c a l and s o c i a l f a c t o r s . T h i s i n c r e a s e d emphasis on s o c i a l f a c t o r s gave r i s e t o the term " s o c i a l p s y c h i a t r y " . S u l l i v a n a d d i t i o n a l l y saw psychotherapy i n s c h i z o p h r e n i a , a d i s e a s e r e s p o n s i b l e f o r many asylum admis-s i o n s , as an attempt to c o r r e c t f a u l t y communication p r o c e s s e s . T h i s would be accomplished i n a h o s p i t a l as the primary treatment f a c i l i t y , although a f t e r c a r e or home treatment was more s u i t a b l e f o r l a t e r stages o f therapy. C l i n i c a l management 37 of s e r i o u s d i s o r d e r s was now conceived as being p a r t i a l l y p o s s i b l e o u t s i d e the t r a d i t i o n a l asylum environment. S o c i a l p s y c h i a t r y up t o the 1940's h e l d p o t e n t i a l f o r new a t t i t u d e s t o be i n t r o d u c e d i n t o p a t i e n t care. T h i s d i d not occur immediately, f o r , i n America, at l e a s t , the e a r l y f u s i o n between p s y c h i a t r y and the s o c i a l s c i e n c e s was c h a r a c t e r i z e d by the u t i l i z a t i o n of p s y c h o a n a l y t i c concepts i n s o c i a l s c i e n c e r e s e a r c h (Dunham, 1955). I t was not u n t i l the s o c i o l o g i s t s examined the t r a d i t i o n a l t h e a t r e of p s y c h i a t r y - the asylums - t h a t p e r s p e c t i v e s of treatment began t o change (Gr e e n b l a t t e t a l . , 1955). These e a r l y s t u d i e s focused on the h o s p i t a l power and s o c i a l s t r u c t u r e s , and the ward s o c i a l environment; both o f which i n f l u e n c e p a t i e n t care. An important i n f l u e n c e was the i n t r o d u c t i o n of c h l o r -promazine, r e s e r p i n e , a n d other p s y c h o a c t i v e drugs i n t o the s t a t e h o s p i t a l s , beginning i n New York i n 1955. B r i l l and Patton (1962) r e p o r t e d t h a t almost immediately the mental h o s p i t a l p o p u l a t i o n and l e n g t h o f s t a y s t a r t e d to d e c l i n e , although the number o f admissions continued to r i s e . There has been some d i s c l a i m e r s (Baldwin, 196 3) of the importance giv e n t o p s y c h o a c t i v e drugs i n r e v e r s i n g mental h o s p i t a l census i n the 1960's as G r e e n b l a t t e t a l . (1955) r e p o r t e d t h a t the s o c i a l m i l i e u t h e r a p i e s were red u c i n g l e n g t h o f stay at Boston Psychopathic H o s p i t a l by the l a t e 1940's. Whatever the r e l a t i v e importance of the new chemo-t h e r a p i e s , the v a r i o u s developments i n t h i s p e r i o d brought 38 a t t e n t i o n t o the r e a l i s t i c o p p o r t u n i t i e s of m a i n t a i n i n g the s e r i o u s l y m e n t a l l y i l l i n t h e i r own communities. G r e e n b l a t t , L e v i s o n and W i l l i a m s (1957) r e p o r t e d on the r e h a b i l i t a t i o n p o s s i b i l i t i e s o f p s y c h o t i c s u t i l i z i n g h o s p i t a l and community programs. The Massachusetts Mental H e a l t h Centre i n 195 7 experimented wi t h emergency s e r v i c e s f o r o u t p a t i e n t s i n l i e u o f h o s p i t a l i z a t i o n . Harry Solomon (195 8) was c a l l i n g f o r the a b o l i t i o n o f the s t a t e h o s p i t a l s as a l t e r n a t i v e s e r v i c e s were showing h o p e f u l pos-s i b i l i t i e s of c a r i n g f o r the long-term m e n t a l l y i l l . There were important developments t a k i n g p l a c e o u t s i d e the U n i t e d S t a t e s . Some of these i n c l u d e d s t r u c t u r a l reforms, i n care systems and developments i n s e r v i c e technology. H o l l a n d had developed a comprehensive p s y c h i a t r i c s e r v i c e w i t h i n i t s p u b l i c medical insurance system by 19 36 which i n c l u d e d h o s t e l s and twenty-four hour emergency s e r v i c e s f o r the me n t a l l y i l l i n l o c a l communities. The E n g l i s h Mental Treatment A c t (1930) p r o v i d e d f o r l o c a l a u t h o r i t i e s t o e s t a b l i s h o u t p a t i e n t c l i n i c s f o r e a r l y d i a g n o s i s and treatment. More i m p o r t a n t l y t h i s l e g i s l a t i o n i n c o r p o r a t e d the concept o f v o l u n t a r y admission which was an e a r l y attempt t o make p s y c h i a t r i c care a v a i l a b l e on the same b a s i s as other m e d i c a l c a r e . T h i s p o l i c y was made e x p l i c i t i n the 19 39 Mental Treatment Act which a l s o f u r t h e r e d the expan-s i o n of the community s e r v i c e s necessary t o f u l f i l l the concept. The N a t i o n a l H e a l t h S e r v i c e s A c t (1946) p l a c e d a l l mental h e a l t h f a c i l i t i e s under newly c r e a t e d r e g i o n a l boards, 39 thus i n the next twenty years b r i n g i n g about an i n t e g r a t i o n w i t h o t h e r h e a l t h ..services s t i l l not achieved i n North America. McKerracher (1966) r e p o r t e d t h a t t h i s i n t e g r a t i o n brought marked improvement i n h o s p i t a l and community s e r -v i c e s f o r the m e n t a l l y i l l . Communication of these and s i m i l a r e f f o r t s were en-hanced by annual conferences and p u b l i c a t i o n s sponsored by the M i l l b a n k Memorial Fund s t a r t i n g i n 1949. I n t e r e s t grew i n such a l t e r n a t i v e s as p a r t i a l h o s p i t a l i z a t i o n , the f i r s t day h o s p i t a l being r e p o r t e d i n Moscow i n 19 33. North Americas*s f i r s t was the Day H o s p i t a l at A l l e n Memorial H o s p i t a l i n Montreal (Cameron, 1947). Community Mental Health Programs D i r e c t e d by C o n g r e s s i o n a l L e g i s l a t i o n i n 1955, the N a t i o n a l I n s t i t u t e of Mental Health s e l e c t e d a commission to "analyze and e v a l u a t e the needs and resources of the mentally i l l . . . and make recommendations f o r a n a t i o n a l mental h e a l t h program" ( J o i n t Commission, 1961). The J o i n t Commission f o r Mental I l l n e s s and H e a l t h p u b l i s h e d i t s summary r e p o r t and recommendations i n A c t i o n f o r Mental Health (1961), and r e c o g n i z e d t h a t "major mental i l l n e s s i s the core problem" and t h a t p a t i e n t s i n t h i s category "should have f i r s t c a l l on . . . the mental h e a l t h p r o f e s s i o n s " i n " v a r i o u s treatment f a c i l i t i e s " . These f a c i l i t i e s i n c l u d e d Community Mental H e a l t h C l i n i c s t o be ". . . a main l i n e of defense i n r e d u c i n g the need . . . f o r prolonged and repeated h o s p i -t a l i z a t i o n " . "A n a t i o n a l mental h e a l t h program should s e t as 40 i t s o b j e c t i v e one f u l l y s t a f f e d , f u l l time mental h e a l t h c l i n i c a v a i l a b l e to each 50,000 of p o p u l a t i o n . " Every community g e n e r a l h o s p i t a l over 100 beds should p r o v i d e "a p s y c h i a t r i c u n i t or beds", and s t a t e h o s p i t a l s under 1000 beds "should be converted as r a p i d l y as p o s s i b l e i n t o i n t e n s i v e treatment ce n t r e s f o r p a t i e n t s w i t h major mental i l l n e s s i n the acute stages". A l l l a r g e r s t a t e h o s p i t a l s , i t was recommended, should be "converted i n t o c e n t r e s f o r the long-term and combined care of c h r o n i c d i s e a s e s , i n -c l u d i n g mental i l l n e s s . Known techniques of r e h a b i l i t a t i o n , s o c i a l i z a t i o n , group l i v i n g and r e l e a r n i n g should be a p p l i e d t o the c h r o n i c a l l y i l l i n these i n s t i t u t i o n s " . These t e c h -n i q u e s , i t was s t a t e d , should be o f f e r e d t o a l l p a t i e n t s o f major mental i l l n e s s e s i n the community through the medium of v a r i o u s "day or n i g h t h o s p i t a l s , a f t e r c a r e c l i n i c s , p u b l i c h e a l t h n u r s i n g s e r v i c e s , f o s t e r f a m i l y c a r e , convalescent n u r s i n g homes, r e h a b i l i t a t i o n c e n t r e s , work s e r v i c e s and ex-p a t i e n t groups". The American Congress passed The Community Mental H e a l t h Centres Act o f 196 3, which a u t h o r i z e d up t o t w o - t h i r d s f e d -e r a l f i n a n c i n g of community mental h e a l t h c e n t r e s . F e d e r a l money was a v a i l a b l e c o n t i n g e n t t o the mental h e a l t h centre p r o v i d i n g f i v e b a s i c s e r v i c e s : i n p a t i e n t s e r v i c e s , out-p a t i e n t s e r v i c e s , p a r t i a l h o s p i t a l i z a t i o n , 24-hour emergency s e r v i c e s and c o n s u l t a t i o n and e d u c a t i o n f o r community agen-c i e s and p e r s o n n e l . F i v e o p t i o n a l s e r v i c e s were recommended: d i a g n o s t i c s e r v i c e s , r e h a b i l i t a t i o n ( i n c l u d i n g ' v o c a t i o n a l and 41 e d u c a t i o n a l programs), pre c a r e and a f t e r c a r e ( i n c l u d i n g h o u s i n g ) , t r a i n i n g , r e s e a r c h and e v a l u a t i o n (Cumming, 1974). L a t e r events showed the weakness i n community care f o r the c h r o n i c p a t i e n t by p l a c i n g these l a t t e r s e r -v i c e s on recommended s t a t u s . While the growth of i n t e r e s t i n community mental h e a l t h s e r v i c e programs s i n c e 196 3 has been accompanied by much support; t h e r e has been some c r i t i c i s m . Some c r i t i c s have spoken a g a i n s t the g e n e r a l t r e n d as seen i n A r n o f f (19 75) and r e f l e c t s a b a c k l a s h a g a i n s t the d e i n s t i -t u t i o n a l i z a t i o n movement of the l a t t e r 1960's and e a r l y 1970*s. Most Canadian p r o v i n c e s and American s t a t e s de-creased t h e i r asylum p o p u l a t i o n s by over f i f t y p e r c e n t without p l a n n i n g f o r community r e s i d e n t i a l a l t e r n a t i v e s . A mental h e a l t h s e r v i c e consumer ( A l l e n , 19 74) i n C a l i f o r n i a and a p s y c h i a t r i s t i n Montreal (Murphy, 1972) d e p l o r e d the care e x - h o s p i t a l p a t i e n t s were r e c e i v i n g i n community boarding homes, p a r t i c u l a r l y the l a c k of r e s o c i a l i z a t i o n and r e h a b i l i t a t i o n programs. Mechanic (1969) a l s o p o i n t e d out t h a t the care of s e r i o u s l y i l l p a t i e n t s i n the com-munity was p l a c i n g i n c r e a s i n g burden on the f a m i l i e s . A r n o f f (19 75) argued t h a t t h i s was a s o c i a l c o s t l a r g e l y i g n o r e d by supporters of community care. C r i t i c i s m such as t h a t of Mechanic and Murphy was d i r e c t e d a t s p e c i f i c shortcomings o f the community mental h e a l t h movement. Mechanic observed t h a t the i d e o l o g y o f t h i s movement has spread f a s t e r than the s e r v i c e s r e -q u i r e d f o r i t s adequate implementation. He claimed t h a t 42 community s e r v i c e s were p r o v i d e d t o p a t i e n t s on a s p o r a d i c and fragmentary b a s i s . Chu and T r o t t e r (1974), Cumming (1975), and others r e v e a l e d t h a t the c h r o n i c s e r i o u s l y m e n t a l l y i l l were not being g i v e n adequate s e r v i c e i n the community f o r p r o f e s s i o n a l s were disposed t o t r e a t i n g the more a t t r a c t i v e non-serious cases where p o s i t i v e r e s u l t s of i n t e r v e n t i o n c o u l d be r e c o g n i z e d i n a f i n i t e time p e r i o d . C r i t i c i s m appears to be focused on v a r i o u s aspects of community centered s e r v i c e s intended f o r the more chro-n i c a l l y s e r i o u s l y i l l , such as the s c h i z o p h r e n i c . Are the modes of community treatment f o r t h i s group as e f f e c t i v e as h o s p i t a l care? G o t t e s f i e l d (1975) and Townsend (1977) reviewed the l i t e r a t u r e on t h i s q u e s t i o n and concluded t h a t when community programs were c o o r d i n a t e d and o b j e c t i v e s s p e c i f i e d , community a l t e r n a t i v e s were more e f f e c t i v e than h o s p i t a l programs i n p r e p a r i n g long-term p a t i e n t s f o r l i v i n g i n the community. The r e c u r r i n g themes o f c o o r d i n a t i o n and c o n t i n u i t y of s e r v i c e , a n d c l e a r o b j e c t i v e s f o r community pro-grams i s echoed i n Feldman (19 73), Cumming (1974) and o t h e r s . Bachrach (19 76), summarizing Bertram Brown, saw as an i d e a l system one which i s c o o r d i n a t e d t o prevent h o s p i t a l admissions; t o r e s o c i a l i z e e x i s t i n g h o s p i t a l i z e d p a t i e n t s ; and which develops community support systems f o r n o n - h o s p i t a l p a t i e n t s . Turner (19 76) and Sheets (19 77) have proposed a f u l l range of components f o r a community support system. These components meet b a s i c needs of s h e l t e r , food, s o c i a l support and meaningful a c t i v i t y , as w e l l as the need f o r 43 medical and p s y c h i a t r i c s e r v i c e s . The work o f Turner and others w i l l be used t o develop a model of care l a t e r i n t h i s paper. The systems approach, perhaps most thoroughly deve-loped by Gerhard and M i l e s i n the Balanced S e r v i c e System (19 77) , encompasses the i n g r e d i e n t s of i n p a t i e n t and out-p a t i e n t programs as w e l l as c o o r d i n a t i o n w i t h o t h e r h e a l t h and s o c i a l s e r v i c e s i n the community. The concept o f an i n t e g r a t e d s e r v i c e s approach t o meeting the needs o f the c h r o n i c a l l y i l l c o u l d p o s s i b l y be seen as p a r t o f the com-munity mental h e a l t h movement, but Sheets saw i t as a f u r t h e r stage i n e v o l u t i o n , c a l l i n g i t the " f o u r t h r e v o l u -t i o n i n p s y c h i a t r y " . The t h i r d r e v o l u t i o n was the community mental h e a l t h movement wit h i t s emphasis on improving the mental h e a l t h o f a g i v e n geographic catchment area. Borus (19 78) r e c e n t l y focused a t t e n t i o n on the c r i t i c i s m t h a t t h i s movement has t r i e d t o be " a l l t h i n g s to a l l people and has embarrassed the mental h e a l t h p r o f e s s i o n s by becoming i n v o l v e d i n areas where i t has no e x p e r t i s e " , w h i l e " a v o i d i n g the d i f f i c u l t task of p r o v i d i n g the t h e r a p e u t i c s e r v i c e s necessary t o m a i n t a i n s e v e r e l y i l l and d i s a b l e d p s y c h o t i c p a t i e n t s i n the community". Borus warned t h a t the funding r e s t r i c t i o n s i n the mid-seventies on community mental h e a l t h would continue u n l e s s the movement e s t a b l i s h e d c r e d i b i l i t y w i t h the p u b l i c and the p o l i t i c i a n s . The work of Sheets, Turner, Gerhard and M i l e s seems to be an attempt t o rescue the community movement by s h o r i n g up i t s weakest f r o n t . I f adequate support systems f o r the 4 4 s e v e r e l y i l l and d i s a b l e d were developed,then some degree of c r e d i b i l i t y would be a t t a i n e d . Community mental h e a l t h may or may not be rescued by the " f o u r t h r e v o l u t i o n i n p s y c h i a t r y " . I t s value w i l l be i t s a b i l i t y t o p r o p e r l y p i c k up where the d e i n s t i t u t i o n a l i z a t i o n movement l e f t o f f . I t has been seen how the s e v e r e l y m e n t a l l y i l l have been d e a l t w i t h f o r over two hundred y e a r s . I n c a r c e r a t i o n and c u s t o d i a l care has s l o w l y g i v e n way t o o t h e r models o f i n t e r v e n t i o n and treatment which view long-term h o s p i t a l i -z a t i o n as u n d e s i r a b l e and unnecessary. While undoubtedly more humane, t h i s view has r e s u l t e d i n the n e g l e c t of many b a s i c needs of p a t i e n t s f o r m e r l y i n s t i t u t i o n a l i z e d . B. Canadian and B r i t i s h Columbia S e r v i c e Trends and Issues The Canadian experience with s e r v i c e s t o the c h r o n i c a l l y m e n t a l l y d i s a b l e d has been s i m i l a r t o the g e n e r a l trends d i s c u s s e d e a r l i e r , but with a few important v a r i a t i o n s . In the e a r l y 1900's,service p r o v i d e r s were f a m i l i a r w ith e a r l y community s e r v i c e s such as psychopathic h o s p i -t a l s and c h i l d guidance c l i n i c s . These s e r v i c e s were recom-mended f o r B r i t i s h Columbia i n 1920 i n a r e p o r t by the N a t i o n a l Committee f o r Mental Hygiene. T h i s r e p o r t made the d i s t i n c t i o n between acute and c h r o n i c mental " d i s e a s e " . Acute c o n d i t i o n s were c o n s i d e r e d t o be b e s t t r e a t e d i n a psychopathic s e c t i o n of a g e n e r a l h o s p i t a l w i t h ongoing care p r o v i d e d i n a convalescent home so as t o a v o i d lengthy h o s p i t a l i z a t i o n . The authors recog-n i z e d the d i f f i c u l t y i n t r e a t i n g p a t i e n t s r e c o v e r i n g from 45 mental d i s e a s e i n an asylum. There was l i t t l e mention, however, of what t o do wit h p a t i e n t s a l r e a d y i n s t i t u -t i o n a l i z e d o t h e r than p r o v i d i n g humane c o n d i t i o n s . Un-f o r t u n a t e l y , the i d e a presented i n t h i s r e p o r t o f prevent-i n g c h r o n i c i t y d i d not have any e f f e c t on the system of care as the p r o v i n c i a l government continued t o expand the mental h o s p i t a l . I n s t i t u t i o n a l care was the dominant mode of meeting the problem o f c h r o n i c p a t i e n t s and was r e i t e r a t e d a t a 1952 Montreal conference e n t i t l e d "Meeting the Needs o f the C h r o n i c a l l y 111". Dr. D. G. McKerracher, D i r e c t o r of P s y c h i a t r i c S e r v i c e s i n Saskatchewan was r e p o r t e d as s t a t -i n g : "the o b j e c t i v e s o f the programs, as f a r as the chro-n i c s are concerned, are p r i m a r i l y good n u r s i n g care and s u i t a b l e o c c u p a t i o n and r e c r e a t i o n " . Dr. McKerracher s t a t e d t h a t 4000 o f 4500 p a t i e n t s i n the p r o v i n c e ' s i n s t i -t u t i o n s were c o n s i d e r e d t o be c h r o n i c a l l y i l l . These p a t i e n t s were housed i n i n s t i t u t i o n s w i t h a c a p a c i t y o f 2900 beds. The B.C. c o n t r i b u t i o n t o t h i s conference d i d not even mention the c h r o n i c m e n t a l l y i l l o t h e r than t o say the government had r e s p o n s i b i l i t y f o r them. The emphasis at the conference was on medical i l l n e s s e s ; an emphasis which ap-pears i n most p u b l i c a t i o n s on the c h r o n i c p a t i e n t . Mental i l l n e s s has u s u a l l y a t t r a c t e d secondary a t t e n -t i o n . The B.C. government r e f l e c t e d t h i s view i n a p o s i t i o n paper to the 195 7 f e d e r a l - p r o v i n c i a l conference on h o s p i t a l 46 i n s u r a n c e . E n t i t l e d Proposed New Chronic Treatment and  Convalescent Coverage Programme, the p o s i t i o n paper e x p l a i n e d b e n e f i t s t h a t should be a v a i l a b l e t o the chro-n i c a l l y i l l e x c l u d i n g those persons w i t h " t u b e r c u l o s i s , mental d i s e a s e o r a l c o h o l i s m " . T h i s p o s i t i o n was c o n s i s -t e n t w i t h B r i t i s h Columbia's p o s i t i o n i n r e s p e c t t o i t s 1949 h o s p i t a l insurance program which p r o v i d e d coverage f o r a l l except those w i t h "nervous, mental c o n d i t i o n s , and t u b e r c u l o s i s which have gone beyond the acute stage". P a r t i c u l a r l y , "persons r e c e i v i n g treatment i n a P r o v i n c i a l mental i n s t i t u t i o n " were not covered under the program, as these were the r e s p o n s i b i l i t y o f the P r o v i n c i a l S e c r e t a r y and not the H e a l t h Department. The r e s u l t o f the above p o l i c y d e c i s i o n s and s i m i l a r ones i n r e s p e c t to f e d e r a l h o s p i t a l i n s u r a n c e , was two systems o f p s y c h i a t r i c i n p a t i e n t care w i t h a widening gap of resources a v a i l a b l e to each. The H o s p i t a l Insurance and D i a g n o s t i c S e r v i c e s Act (1957) excluded the p r o v i n c i a l men-t a l h o s p i t a l s from r e c e i v i n g the f i f t y per cent c o s t - s h a r i n g a v a i l a b l e to g e n e r a l h o s p i t a l s . T h i s was a mixed b l e s s i n g as the Act encouraged the development o f acute p s y c h i a t r i c treatment u n i t s i n g e n e r a l h o s p i t a l s ( T a y l o r , 1978). The g e n e r a l h o s p i t a l p s y c h i a t r i c u n i t s performed the f u n c t i o n of the p s y c h o p a t h i c wards proposed i n the 1920 r e p o r t mentioned above. The u n i t s were a v a i l a b l e to pa-t i e n t s w i t h acute c o n d i t i o n s and n e u r o t i c d e p r e s s i o n s , but not to those p a t i e n t s a l r e a d y i n the mental h o s p i t a l s . 47 I t was not u n t i l the mid-19 70's, i n B r i t i s h Columbia at l e a s t , t h a t g e n e r a l h o s p i t a l u n i t s were being u t i l i z e d by many p a t i e n t s who would have entered the mental hos-p i t a l i n former y e a r s . T h i s t r e n d was not e s t a b l i s h e d u n t i l the p r o v i n c i a l mental h o s p i t a l , Riverview, had de-creased i t s census from 35 38 i n 1959 t o 1600 i n 19 74, and admissions from 2 760 t o 1724. P s y c h i a t r i c beds i n B r i t i s h Columbia's g e n e r a l h o s p i t a l s i n c r e a s e d from 107 t o over 400 i n the same p e r i o d . The e f f e c t o f n a t i o n a l h o s p i t a l insurance i s e v i d e n t i n these f i g u r e s . During the p e r i o d o f the J o i n t Commission on Mental I l l n e s s i n the Un i t e d S t a t e s there was a major review of p s y c h i a t r i c s e r v i c e s i n Canada, sponsored by the Canadian Mental H e a l t h A s s o c i a t i o n . The f i n a l r e p o r t , More f o r the  Mind appeared i n 196 3, the year o f the Community Mental Health Centre l e g i s l a t i o n i n the U n i t e d S t a t e s . While both the American and Canadian reviews attempted t o seek s o l u -t i o n s t o s i m i l a r problems — poor c o o r d i n a t i o n o f e x i s t i n g s e r v i c e s , d i f f i c u l t y i n e s t a b l i s h i n g new community s e r v i c e s , and l a r g e asylum p o p u l a t i o n s — the p r o p o s a l s were funda-me n t a l l y d i f f e r e n t . The American f e d e r a l government, with d i r e c t g r a n t s , e s t a b l i s h e d a new s e r v i c e system. The Canadian authors o f More f o r the Mind f a l l phy-s i c i a n s , proposed an ex t e n s i o n of p s y c h i a t r i c s e r v i c e s from the g e n e r a l h o s p i t a l s . These s e r v i c e s would i n c l u d e care from non-medical p r o f e s s i o n a l s , c onvalescent c a r e , and r e -h a b i l i t a t i o n , and would be i n c l u d e d i n any n a t i o n a l h e a l t h insurance scheme. T h i s message was g i v e n to the H a l l Royal 48 Commission which was c o n s i d e r i n g , among oth e r matters, medical i n s u r a n c e . The N a t i o n a l M e d i c a l Care Insurance Act (1966) had two major e f f e c t s on p s y c h i a t r i c s e r v i c e s . F i r s t , t here was the a s s o c i a t e d d e c i s i o n to phase out the N a t i o n a l H e a l t h Grants Program o f 194 8 which had p r o v i d e d the o n l y f e d e r a l funds t o p r o v i n c i a l mental h e a l t h programs. Se-condly, medical s e r v i c e s , i n c l u d i n g those of p r i v a t e psy-c h i a t r i s t s , were a v a i l a b l e t o a l l c i t i z e n s . T h i s had the e f f e c t of i n c r e a s i n g needed p h y s i c i a n manpower. Yet the p r o p o s a l of More f o r the Mind, i . e . t h a t non-medical p r o f e s s i o n a l s e r v i c e s be i n c l u d e d i n the h e a l t h insurance scheme, was not accepted. M u l t i - p r o f e s s i o n a l approaches to mental i l l n e s s were not encouraged w i t h i n the m e d i c a l care system un l e s s the p a t i e n t was w i t h i n the boundaries of the g e n e r a l h o s p i t a l . Community mental h e a l t h s e r v i c e s j o i n e d the mental h o s p i t a l s as being s e t apart from the i n s u r e d , and f e d e r -a l l y c o s t - s h a r e d , medical system. Most p r o v i n c e s responded t o t h i s s i t u a t i o n by expanding the mental h e a l t h centre model of s e r v i c e , of which a l i m i t e d number were i n p l a c e before the m i d - s i x t i e s . The mental h e a l t h c e n t r e s had t o compete a t a disadvantage w i t h c o s t - s h a r e d h e a l t h s e r v i c e s f o r p r o v i n c i a l funds. B r i t i s h Columbia, however, was a b l e to e s t a b l i s h 30 c e n t r e s by 1978. A second major p u b l i c insurance measure i n the 1960's had an e f f e c t on s e r v i c e s f o r the c h r o n i c a l l y d i s a b l e d . The 49 Canada A s s i s t a n c e A c t (1966) allowed the f e d e r a l government to cost-share p r o v i n c i a l s o c i a l w e l f a r e programs. These i n c l u d e d income a s s i s t a n c e , c h i l d w e l f a r e , and s o c i a l r e -h a b i l i t a t i o n programs. Under the l a t t e r emerged s o c i a l c e n t r e s and s h e l t e r e d workshops f o r marginal groups such as the disadvantaged, me n t a l l y retarded,and the p h y s i c a l l y d i s a b l e d . S u b s i d i e s f o r the care o f the i n d i g e n t and the c h r o n i c a l l y i l l and d i s a b l e d i n boarding homes were a l s o e l i g i b l e f o r f e d e r a l funds. The Canada A s s i s t a n c e P l a n (CAP), i . e . the a d m i n i s t r a t i v e arm o f the Ac t , was intended f o r "persons i n need". Need was d e f i n e d as f i n a n c i a l need, thus many o f the ment a l l y d i s a b l e d were a u t o m a t i c a l l y e l i g i b l e f o r the co s t - s h a r e d s e r v i c e s and a few were deve-loped f o r them. Some s e r v i c e s were developed by v o l u n t a r y a s s o c i a t i o n s w i t h grants r e c e i v e d from p r o v i n c i a l w e l f a r e departments. Only p r o v i n c i a l w e l f a r e departments had a u t h o r i t y t o r e c e i v e the CAP c o s t - s h a r i n g . Hence the community boarding homes, programs which a s s i s t e d d e i n s t i t u t i o n a l i z a t i o n , arid s o c i a l c e n t r e s f o r the me n t a l l y d i s a b l e d were developed o u t s i d e of the mental h e a l t h departments. As a r e s u l t , the system was f u r t h e r fragmented, although i n B.C. an agreement was reached between the w e l f a r e and mental h e a l t h departments t o co o r d i n a t e . t h e a d m i n i s t r a t i o n o f the boa r d i n g home placements from Riverview h o s p i t a l . No i n t e r - d e p a r t -mental agreement was e s t a b l i s h e d t o co o r d i n a t e the develop-ment of s o c i a l r e h a b i l i t a t i o n s e r v i c e s e l i g i b l e f o r CAP c o s t -s h a r i n g . 50 The mental h e a l t h c e n t r e s e s t a b l i s h e d i n B r i t i s h Columbia were s i m i l a r i n name onl y t o those developed i n the U n i t e d S t a t e s . They were not p a r t o f a f e d e r a l p r o-gram, as the involvement o f the Canadian government i n f i n a n c i n g mental h e a l t h programs s i n c e 196 8 has been non-e x i s t e n t . B r i t i s h Columbia mental h e a l t h c e n t r e s d i d not have the same comprehensive mandate to p r o v i d e the ' f i v e b a s i c s e r v i c e s ' , as most of these, such as i n p a t i e n t c a r e , day h o s p i t a l s , and emergency s e r v i c e s , were p a r t of the c o s t - s h a r e d g e n e r a l h o s p i t a l system. Lack o f centres' i n t e g r a t i o n w i t h the e x i s t i n g m e d i c a l and h o s p i t a l system r e s u l t e d i n t h e i r having d i f f i c u l t y i n a t t r a c t i n g p s y c h i a t r i s t s , e s p e c i a l l y i n t o the s m a l l e r com-m u n i t i e s . M e d i c a l insurance guaranteed r e f e r r a l s t o psy-c h i a t r i s t s ' p r i v a t e p r a c t i c e s . Not having an a b i l i t y to perform a major medical treatment r o l e , most c e n t r e s e s t a -b l i s h e d c l o s e working r e l a t i o n s h i p s w i t h s c h o o l s , s o c i a l agencies, and w e l f a r e departments, i n programs of p r e v e n t i o n , c o n s u l t a t i o n , and e d u c a t i o n . L a c k i n g c l e a r l e g i s l a t i v e mandate, the mental h e a l t h centres* o p e r a t i o n s have been guided by a s e r i e s o f memo-randa developed by the p r o v i n c i a l department r e s p o n s i b l e f o r t h e i r a d m i n i s t r a t i o n . Foulkes (1974) quoted from one de-partmental statement o f 1967, which emphasized the c e n t r e ' s r o l e t o "'assume i n c r e a s e d r e s p o n s i b i l i t y f o r the o v e r a l l aspects o f mental h e a l t h p l a n n i n g . . . . •". Another s t a t e -ment, dated 19 70, s t a t e s t h a t "the Centre must g i v e p r i o r i t y t o the more s e r i o u s mental, emotional and b e h a v i o u r a l 51 problems. These i n c l u d e major c h r o n i c mental i l l n e s s . . . ". A s p e c i f i c l i n k a g e o f the two r e s p o n s i b i l i t i e s , d i r e c t s e r v i c e and s e r v i c e s p l a n n i n g , was a l s o mentioned i n the 19 70 statement. T h i s r e f l e c t s r e c e n t American and Canadian l i t e r a t u r e which s t a t e s t h a t the agency w i t h the r e s p o n s i b i l i t y f o r d i r e c t s e r v i c e t o the c h r o n i c a l l y men-t a l l y i l l should have an e x p l i c i t mandate f o r the c o o r d i -n a t i o n of l o c a l s e r v i c e s f o r these c l i e n t s . Recent i n t e r n a l p o l i c y statements (see appendices) of the department have g r e a t l y expanded the s p e c i f i c r e -s p o n s i b i l i t i e s o f the centres t o i n c l u d e : c o n s u l t a t i o n s t o o t h e r agencies, community e d u c a t i o n , f a m i l y c o u n s e l l i n g , and o t h e r s e r v i c e s . Concurrently, the former e x p l i c i t man-date t o serve the persons w i t h major c h r o n i c mental i l l n e s s have been reduced t o a "concern". T h i s comes a t a time when Riverview h o s p i t a l has reduced i t s p o p u l a t i o n by over one-rhalf between 19 70 and 19 78. More o f the s e r i o u s l y impaired p a t i e n t s are i n the community than ever b e f o r e . In 19 75, one e f f o r t was made to encourage the mental h e a l t h centres t o care f o r the c h r o n i c a l l y i l l . P s y c h i a t r i c nurses were p l a c e d i n t w o - t h i r d s o f the cen t r e s w i t h the s p e c i f i c r e s p o n s i b i l i t y o f c a r i n g f o r t h i s c l i e n t group. The nurses have s i n c e reached t h e i r maximum caseloads w i t h -out f u r t h e r p o s i t i o n s being added. The review o f the cen-t r e s ' c a s e l o a d s , i n Chapter 5, w i l l demonstrate the l i m i t s o f r e s p o n s i b i l i t y t h a t c e n t r e s have assumed f o r the chro-n i c a l l y i l l and d i s a b l e d . 52 A model f o r a comprehensive community s e r v i c e f o r the d i s a b l e d i s presented i n the next chapter. The model i s borrowed from the N a t i o n a l I n s t i t u t e o f Mental H e a l t h i n the United S t a t e s where there are d i f f e r e n t f i n a n c i a l s t r u c -t u r e s . As d i s c u s s e d p r e v i o u s l y , Canadian mental h e a l t h s e r -v i c e s have been at a disadvantage when competing w i t h o t h e r medical and h o s p i t a l s e r v i c e s f o r p r o v i n c i a l funds w i t h i n the f e d e r a l f i n a n c i a l system. The American f e d e r a l govern-ment can fund s e r v i c e s d i r e c t l y , so p l a n s , such as t h a t out-l i n e d i n the next chapter, are more r e a l i s t i c . There has been, however, a r e c e n t change i n Canadian f i n a n c i n g o f h e a l t h and s o c i a l s e r v i c e s . F i r s t , the med-i c a l and h o s p i t a l insurance plans were r e p l a c e d i n 19 77 by the E s t a b l i s h e d Programs F i n a n c i n g Act which t r a n s f e r r e d f u l l funding r e s p o n s i b i l i t y t o the P r o v i n c e s . C o s t - s h a r i n g was r e p l a c e d by n o n - s p e c i f i c grants and i n c r e a s e s i n the amount o f income taxes t h a t p r o v i n c e s can r a i s e f o r h e a l t h s e r v i c e s . Secondly, changes i n the Canada A s s i s t a n c e P l a n allowed p r o v i n c i a l h e a l t h departments t o a d m i n i s t e r c o s t - s h a r e d w e l f a r e programs. Under t h i s arrangement the B r i t i s h Columbia h e a l t h a u t h o r i t i e s p r e s e n t l y a d m i n i s t e r and fund boarding homes. The h e a l t h department, r e c e n t l y termed a M i n i s t r y , a l s o has the p o t e n t i a l o f funding c o s t - s h a r e d s o c i a l c e n t r e s and s h e l t e r e d work programs. Comprehensive mental h e a l t h programs f o r the d i s a b l e d now have the c a p a b i l i t y o f competing on the same terms as o t h e r h e a l t h s e r v i c e s s i n c e none are competing f o r c o s t -shared d o l l a r s . 53 Chapter 4 A Model Community Support System Since the 196 3 Community Mental Health Centre l e g i -s l a t i o n there has been appearing an i n c r e a s i n g volume o f l i t e r a t u r e concerned with the development o f community s e r v i c e s f o r the c h r o n i c a l l y m e n t a l l y d i s a b l e d . Many d e s c r i p t i o n s of these s e r v i c e s have been i n c o r p o r a t e d i n t o subsequent American l e g i s l a t i o n . The preceeding chapter l i s t e d some o f these s e r v i c e s as f i v e a d d i t i o n a l b a s i c s e r v i c e s r e q u i r e d t o be i n p l a c e b e f o r e f e d e r a l funding can be approved f o r a Community Mental Health Centre. The N a t i o n a l I n s t i t u t e f o r Mental Health has gone a f u r t h e r step as o u t l i n e d i n s e v e r a l r e c e n t working papers. I t has i n c o r p o r a t e d a system approach to p r o v i d i n g s e r v i c e s to the s e r i o u s l y m e n t a l l y i l l and c h r o n i c a l l y d i s a b l e d , such as presented i n the work of Gerhard and M i l e s , and Sheets. A u s e f u l statement o u t l i n i n g the i d e a l community sup-p o r t system f o r the c h r o n i c a l l y m e n t a l l y d i s a b l e d i s found i n the p r e v i o u s l y mentioned paper by J u d i t h Turner (1977). The s e r v i c e c a t e g o r i e s developed by Turner w i l l be used i n a s s e s s i n g the adequacy o f s i m i l a r s e r v i c e s on Vancouver I s l a n d . Turner's paper groups the components of a compre-hensive community support system under s i x headings: a) Mental Health S e r v i c e s b) P s y c h o s o c i a l R e h a b i l i t a t i o n S e r v i c e s c) Long-Term Support and Maintenance S e r v i c e s d) Community I n t e g r a t i o n and Acceptance S t r a t e g i e s e) P r o t e c t i o n of C l i e n t s ' Rights f) P l a n n i n g , C o o r d i n a t i o n , Case Management and Con-t i n u i t y of Care 54 These are presented below with s u p p o r t i n g evidence from o t h e r l i t e r a t u r e and r e f e r e n c e s t o a c t u a l need estimates developed by o t h e r s . F u r t h e r need e s t i m a t e s , more appro-p r i a t e to the l o c a l s i t u a t i o n , are developed i n Chapter 7. I t should be mentioned at t h i s time t h a t Turner's system i s based on a number o f b a s i c g u i d i n g p r i n c i p l e s . These are paraphrased f o r the sake of b r e v i t y . A human s e r v i c e should be based on p r i n c i p l e s of p e r s o n a l d i g n i t y f o r the c l i e n t and h i s r i g h t o f s e l f - d e t e r m i n a t i o n i n a t -t a i n i n g h i s own g o a l s . S e r v i c e s should be p r o v i d e d u s i n g c u l t u r a l l y normative and valued methods, and l o c a l e s t h a t reduce stigma and s e g r e g a t i o n . S e r v i c e s should be p r o v i d e d on an i n d i v i d u a l i z e d b a s i s where p o s s i b l e . S e r v i c e s should be e a s i l y a v a i l a b l e and a c c e s i b l e to a l l who need them r e g a r d l e s s o f income, r a c e , or r e l i g i o n . C l i e n t s should be t r e a t e d as d e v e l o p i n g i n d i v i d u a l s , who although capable of growth, may r e q u i r e the gradual t r a n s f e r from a depen-dent r e l a t i o n s h i p t o more independent f u n c t i o n i n g . S e r v i c e p r o v i d e r s should ensure t h a t wherever p o s s i b l e a c l i e n t ' s n a t u r a l support system should be enhanced and u t i l i z e d t o a s s i s t the c l i e n t . Components of a Community Support System a) "Mental H e a l t h S e r v i c e s . There should be a f u l l range o f mental h e a l t h s e r v i c e s , i n c l u d i n g but not l i m i t e d t o : d i a g n o s t i c e v a l u a t i o n ; 24-hour i n t e n s i v e c r i s i s s t a b i l i z a t i o n s e r v i c e s e i t h e r i n h o s p i t a l or i n a community-based s e t t i n g ; emergency s e r v i c e s ; p r e s c r i p t i o n , p e r i o d i c review and r e g u l a t i o n of m e d i c a t i o n ; and community-based p s y c h i a t r i c and p s y c h o l o g i c a l s e r v i c e s . " 55 M o r e e x p l i c i t m e n t i o n s h o u l d b e made f o r t h e a v a i l -a b i l i t y o f b e d s f o r s h o r t - t e r m h o s p i t a l i z a t i o n s . I n p a -t i e n t u n i t s a r e an i n t e g r a l c o m p o n e n t o f t h e M e n t a l H e a l t h S e r v i c e s s e c t i o n o f t h e c o m m u n i t y s u p p o r t s y s t e m , a s h o s p i t a l i z a t i o n i s n e c e s s a r y f o r some o f t h e c h r o n i c p a t i e n t p o p u l a t i o n (Lamb a n d G e o r t z e l , 1 9 7 2 ) . I n o r d e r t o m i n i m i z e t h e i s o l a t i o n o f t h e i n p a t i e n t s e r v i c e f r o m t h e r e s t o f t h e c o m m u n i t y s u p p o r t s y s t e m , t h e b e d s s h o u l d be l o c a t e d w i t h i n t h e i m m e d i a t e a r e a i t s e r v e s . A b e d t o p o p u l a t i o n r a t i o o f . 25 p e r 1 0 0 0 , t h e a v e r a g e r a t i o f o r t h e p r o v i n c e p r e s e n t l y , s h o u l d be a d e q u a t e f o r l o c a l p s y -c h i a t r i c b e d s . The c e n t r a l m e n t a l h o s p i t a l h a s n o t b e e n i n c l u d e d i n t h i s e s t i m a t e , a s i t i s o n l y r e q u i r e d f o r t h e f e w i n t r a c t a b l e p a t i e n t s e x h i b i t i n g g r o s s l y a n t i - s o c i a l b e h a v i o u r . L a m b ' s e s t i m a t e f o r t h i s g r o u p , m e n t i o n e d i n C h a p t e r 1 , was 5 b e d s p e r 1 0 0 , 0 0 0 . T h e l o w n u m b e r o f a l l i n p a t i e n t b e d s i s a d e q u a t e a s t h e e f f i c a c y o f s h o r t h o s p i -t a l i z a t i o n s , i . e . 3 t o 21 d a y s , h a s b e e n d e m o n s t r a t e d ( R e i s s m a n e t a l . , 1 9 7 7 ) . U t i l i z a t i o n o f i n p a t i e n t s e r v i c e s c a n be f u r t h e r m i n i m i z e d w i t h t h e a v a i l a b i l i t y o f p a r t i a l h o s p i t a l i z a t i o n s e r v i c e s a s d e s c r i b e d b y G l a s s c o t e e t a l . ( 1 9 6 9 ) . C o m m u n i t y - b a s e d o u t p a t i e n t c l i n i c a l s e r v i c e s s u c h a s g r o u p a n d i n d i v i d u a l t h e r a p i e s , c h e m o t h e r a p y , a n d f a m i l y i n t e r v i e w s a r e n e c e s s a r y i f c o m m u n i t y t e n u r e , i . e . t h e p e r i o d b e t w e e n h o s p i t a l i z a t i o n s , i s t o be m a x i m i z e d ( W i n s t o n e t a l . , 1 9 7 7 ) . C o m m u n i t y t r e a t m e n t o f t h e m o r e " m a r k e d l y 56 impaired'" can be a r e a l i s t i c expectation, as demonstrated by Test and Stein (1976) i n Wisconsin. As treatment of t h i s segment of the chron i c a l l y disabled i s centered more i n the community, there i s a necessity for the 24-hour c r i s i s s t a b i l i z a t i o n service mentioned by Turner. This service was shown by Polak and Kirby (1976) to be able to prevent many h o s p i t a l i z a t i o n s with the addit i o n a l advan-tage of o f f e r i n g opportunities to solve r e a l problems of c l i e n t s i n s i t u •-•- problems that may have been unreachable before. b) "Psychosocial Rehabilitation Services. There should be community-based psychosocial r e h a b i l i t a t i o n services which include but are not limi t e d t o: - Training or re t r a i n i n g of c l i e n t s i n community l i v i n g s k i l l s such as grooming, budgeting, shopping, housekeeping, etc. - Opportunities for c l i e n t s to assume and adjust to normal s o c i a l r o l e s , such as worker, club member, resident, etc. - A wide spectrum of s p e c i a l l i v i n g arrangements, o f f e r i n g varying degrees of supervision, a s s i s -tance and support, and linked with necessary mental health, s o c i a l r e h a b i l i t a t i o n and other such services. - Recreational and s o c i a l opportunities. - Vocational evaluation, t r a i n i n g and placement services." The community-treatment program i n Wisconsin reported by Stein et a l . (1975), and Test and Stein (1976) was "de-signed to help patients acquire the coping s k i l l s and auton-omy necessary for a reasonable community adjustment". They recognized that treatment techniques "frequently u t i l i z e d with h e a l t h i e r outpatients have been unsuccessful with . . . the markedly impaired . . . (i.e.) those patients 57 who t r a d i t i o n a l l y have been treated by public mental hospitals and aftercare programs". The Wisconsin patients lacked the following coping s k i l l s : " a c t i v i t y of d a i l y l i v i n g s k i l l s , vocational s k i l l s , l e i s u r e time s k i l l s , and s o c i a l or interpersonal s k i l l s " . Sheltered workshops were the primary locale used by Test And Stein f o r t r a i n -ing patients with these functional d e f i c i t s . Other na-t u r a l treatment locales were used such as: community l i v i n g arrangements fo r patients, l o c a l s o c i a l - r e c r e a t i o n a l f a c i l i t i e s , stores, laundromats, etc. In vivo approaches were u t i l i z e d , since the authors recognized that the chro-n i c a l l y mentally disabled had d i f f i c u l t y i n generalizing learned behaviours from one environment to another, and that patients had the ri g h t to be viewed as responsible adults i n normal s o c i a l r o l e s . The r e s u l t of the Wisconsin pro-gram was avoidance of h o s p i t a l i z a t i o n and increased com-munity functioning since the patients had learned " i n s t r u -mental and problem-solving behaviors". Fish (1962) has estimated that up to 70% of schizo-phrenic patients w i l l e x h i b i t some l a s t i n g deterioration or defect i n functioning. Half of these w i l l require long-term maintenance of varying degrees and kinds. The expectation for the remaining 30% w i l l be a complete or adequate s o c i a l cure, i . e . resumption of normal s o c i a l r o l e s . This epidemiological paradigm should provide an estimate of the extent of r e h a b i l i t a t i o n services needed within the care system. 58 c ) " L o n g - T e r m C o m m i i n i t y S u p p o r t a n d M a i n t e n a n c e S e r v i c e s . F o r t h o s e c l i e n t s who h a v e r e a c h e d t h e i r h i g h e s t l e v e l o f f u n c t i o n i n g a n d f o r t h o s e who b e c a u s e o f t h e i r age o r t h e n a t u r e o f t h e i r i l l n e s s a r e i n -e v i t a b l y d e c l i n i n g i n a b i l i t y t o f u n c t i o n , t h e r e s h o u l d b e s e r v i c e s a v a i l a b l e t o s u s t a i n f u n c t i o n a l c a p a c i t i e s o r t o r e d u c e t h e r a t e o f d e t e r i o r a t i o n . T h e s e s e r v i c e s i n c l u d e t h e same b a s i c e l e m e n t s a s p s y c h o s o c i a l r e h a b i l i t a t i o n s e r v i c e s , l i s t e d a b o v e , a n d i n a d d i t i o n , p r o v i d e t h e f o l l o w i n g : - A s p e c t r u m o f l o n g - t e r m s u p p o r t i v e l i v i n g a r r a n g e m e n t s . - O p p o r t u n i t i e s f o r l o n g - t e r m s h e l t e r e d e m p l o y -m e n t . - O t h e r f u l l o r p a r t t i m e d a i l y a c t i v i t i e s f o r p e r s o n s who may n o t be c a p a b l e o f c o m p e t i t i v e e m p l o y m e n t b u t who n e e d o p o r t u n i t i e s t o p a r -t i c i p a t e i n c o m m u n i t y l i f e a n d t o f u n c t i o n a s a member o f a s u p p o r t i v e g r o u p . " The i m p o r t a n c e o f m e a n i n g f u l s o c i a l a n d v o c a t i o n a l r o l e s f o r t h e c h r o n i c a l l y d i s a b l e d h a s b e e n m e n t i o n e d a b o v e . T h e s e r o l e s a r e i m p o r t a n t f o r p a t i e n t s w i t h p e r -m a n e n t f u n c t i o n a l d i s a b i l i t i e s w h i c h i m p a i r f u l l i n t e g r a -t i o n i n t o t h e ' n o r m a l ' s o c i a l a n d e c o n o m i c s y s t e m . S p e -c i a l l y d e s i g n e d s u p p o r t i v e s o c i a l s y s t e m s , w h i c h i n c l u d e a v a r i e t y o f h o u s i n g a r r a n g e m e n t s , w i l l b e r e q u i r e d f o r a p e r c e n t a g e o f t h e c h r o n i c p o p u l a t i o n f o r an i n d e f i n i t e p e r i o d o f t i m e . T h e r e a r e s e v e r a l m y t h s ( S h e e t s , 19 76) h e l d b y s e r -v i c e p r o v i d e r s w h i c h h a v e i n h i b i t e d t h e i r a c c e p t a n c e o f s p e c i a l l y d e s i g n e d s u p p o r t s y s t e m s f o r c h r o n i c p a t i e n t s u n a b l e t o f u r t h e r b e n e f i t f r o m r e h a b i l i t a t i o n e f f o r t s . T h e s e m y t h s f a i l t o r e c o g n i z e t h a t some c l i e n t s c h o o s e t o l e v e l o f f a t a p a r t i c u l a r s o c i a l , v o c a t i o n a l , a n d r e s i d e n -t i a l l e v e l , a t w h i c h p o i n t f u r t h e r i n s i s t e n c e t o move o n c a n b e d e s t r u c t i v e . A n o t h e r m y t h i s t h a t a l l c l i e n t s 59 should become i n d i v i d u a l l y independent; yet attaining a r e a l i s t i c l e v e l of functioning may be contingent upon a degree of dependence on some aspect of the designed sup-port system. The normalization myth precludes recogni-t i o n that some schizophrenics may choose, and benefit from, a f f i l i a t i o n with others l i k e themselves, where they may f e e l more comfortable and accepted. Several s o c i a l and housing programs have been operating success-f u l l y on a denial of these myths, such as Fountain House i n New York and Coast Foundation i n Vancouver. Reporting on the experience of the Ft. Logan Mental Health Centre, Kraft et a l . (1971) show that 8.7% of a l l admissions to the Centre required i t s services f o r a period longer than f i v e years, and 2.7% of admissions were s e r i -ously enough impaired to require 24-hour supervision ranging from inpatient care to half-way house accommodation. The 8.7% of admissions requiring services for longer than two years consumed 48.5% of a l l patient days for the 24-hour supervised range of services. The considerable amount of resources consumed by t h i s group should indicate the impor-tance of designing a support system, for the long-term disabled, that guarantees placement at a l e v e l of care com-mensurate with optimal functioning. Lack of sophi s t i c a t i o n i n assessment and service design w i l l ultimately r e s u l t i n o v e r - u t i l i z a t i o n of valuable resources by a small number of people. d) "Community Integration and Acceptance Strategies. As c l i e n t s move to less r e s t r i c t i v e settings, there should be a planned and sustained e f f o r t to help the community accept, integrate and relate appro-p r i a t e l y to chronically mentally disabled persons. Approaches to t h i s include, but are not limited to the following: - Systematic planning for dis p e r s a l of c l i e n t s to avoid oversaturating certain neighborhoods or communities. - Family or s o c i a l systems counseling services. - Emergency backup services to family, fri e n d s , landlords, employers. - Opportunities for concerned community members to p a r t i c i p a t e i n program planning, to volun-teer t h e i r services or resources, to provide jobs and housing, and to see c l i e n t s function-ing i n normal s o c i a l r o l e s . - Community education. - Training, consultation, and backup services to community agencies who share; responsibi-l i t y for providing services to people with p s y c h i a t r i c problems." The organized community support system cannot expect to d i r e c t l y look a f t e r a l l the needs of the chron i c a l l y disabled. Ideally, the system should only intervene to provide housing, employment, and s o c i a l supports when these components are not normally available. Short of providing these components d i r e c t l y , the care system should encourage community members to assume t h e i r respon-s i b i l i t i e s i n coping with, and managing the functional d e f i c i t s of the disabled. Families, landlords, schools, and employers w i l l f e e l more comfortable i n accepting com-munity members with chronic d i s a b i l i t i e s i f they have the support and backup of service agencies. Community acceptance strategies are important i n en-suring that the disabled are able to obtain t h e i r r i g h t f u l place i n the mainstream "markets" of housing, income support, 61 s o c i a l services, health services, and recreation f a c i l i -t i e s . The h o s p i t a l i z e d patient, e s p e c i a l l y the chro-n i c a l l y disabled, c a r r i e s a stigmatizing l a b e l . This goes back to the days when asylums were for the " f u r i -ously mad" and "manifestly dangerous" (Overholser, 1955). This stigma may i n t e r f e r e with a chronic patient's r i g h t to access community f a c i l i t i e s , work places, and housing. The care system has the r e s p o n s i b i l i t y to advocate on the patient's behalf when access i s blocked. e) "Protection x>f C l i e n t Rights. There should be c l e a r l y defined mechanisms to protect c l i e n t r i g h t s , both i n and outside of mental health f a c i l i t i e s . " The l i t e r a t u r e concerned with the r i g h t s of the men-t a l l y i l l (Katz et a l . , 1967: Jackson, 1970; Rock, 1968; Overholser, 1955; and others) primarily examines issues of involuntary commitment, ri g h t to refuse or receive treatment, and procedures for release from mental hospi-t a l s . These are substantive issues, and cannot be ad-dressed within t h i s paper, as thorough examination of s o c i a l p o l i c y and medical-legal jurisprudence i s required. However, for the chronic patient, there are three areas which should be considered within t h i s model. For patients deemed incapable of making decisions i n respect to treatment, some l e g i s l a t i o n requires that consent to treatment be obtained from the next-of-kin, and i f unavailable, the i n s t i t u t i o n takes the responsi-b i l i t y (Jackson, 1970). As presented i n Chapter 1, many c h r o n i c a l l y d i s a b l e d persons lack s i g n i f i c a n t contacts w i t h f a m i l y and may not have an advocate from t h i s source. In these cases, the system has the r e s p o n s i b i l i t y t o de-velop procedures t o p r o t e c t the p a t i e n t ' s r i g h t s and d i g n i t y . Chronic p a t i e n t s tend t o A s i l t - u p ' i n mental h o s p i -t a l s and re c e i v e l i t t l e more than c u s t o d i a l care. Ameri-can courts have r e c e n t l y set precedents which r e q u i r e State h o s p i t a l a d m i n i s t r a t i o n s to place these p a t i e n t s i n the " l e a s t r e s t r i c t i v e s e t t i n g p o s s i b l e " . This p r i n -c i p l e should be inc o r p o r a t e d i n t o the p r a c t i c e s of com-munity s e r v i c e agencies as chronic p a t i e n t s a l s o ' s i l t - u p ' i n community boarding homes and other f a c i l i t i e s . F i n a l l y the system should be developed, w i t h a com-prehensive network of s e r v i c e s and supports, t o prevent s e r v i c e p r o v i d e r s and community members from using h o s p i -t a l commitment i n a l l but the most necessary s i t u a t i o n s . Over-reliance on i n v o l u n t a r y commitments, and unnecessar-i l y long h o s p i t a l stays on commitment, i s d i r e c t l y pro-p o r t i o n a t e t o the a v a i l a b i l i t y of a l t e r n a t i v e s t o h o s p i -t a l i z a t i o n s (Rock, 1968). f) "Planning, C o o r d i n a t i o n , Case Management, and Con- t i n u i t y of Care. The f o l l o w i n g c o n d i t i o n s are necessary t o c o n s t i t u t e an e f f e c t i v e system of care f o r the c h r o n i c a l l y d i s a b l e d : - At the State ( P r o v i n c i a l ) l e v e l , there must be an inter-agency c o l l a b o r a t i v e e f f o r t t o develop a d m i n i s t r a t i v e , f i n a n c i a l and other arrangements t o assure a v a i l a b i l i t y and ac-c e s s i b i l i t y to the p o p u l a t i o n of r e l e v a n t high q u a l i t y s e r v i c e s . 63 - A t t h e c o m m u n i t y l e v e l , t h e r e m u s t b e a c l e a r l y d e f i n e d c a s e management s y s t e m t o i d e n t i f y a n d r e a c h o u t t o t h e p o p u l a t i o n ; t o a s s e s s t h e i r s e r v i c e n e e d s , t o p l a n f o r d e l i v e r y o f s e r v i c e s i n t h e l e a s t r e s t r i c -t i v e s e t t i n g a n d t o f o l l o w - a l o n g t o a s s u r e t h a t s e r v i c e s a r e d e l i v e r e d a n d p l a n s a r e u p d a t e d a s r e q u i r e d . - A t t h e c l i e n t l e v e l , s e r v i c e s s h o u l d be o r g a n i z e d t o p r o m o t e c o n t i n u i t y o f s u p p o r - t i v e r e l a t i o n s h i p s . A s f a r a s c a s e -management i s c o n c e r n e d , t h i s means t h a t t h e r e s h o u l d b e one p e r s o n o r t e a m r e s p o n - s i b l e f o r e s t a b l i s h i n g a n d r e m a i n i n g i n c o n t a c t w i t h t h e c h r o n i c a l l y d i s a b l e d i n d i v i d u a l o n a c o n t i n u i n g b a s i s , r e g a r d l e s s o f how many a g e n c i e s g e t i n v o l v e d . The t o -t a l n u m b e r o f c l i e n t s a s s i g n e d t o t h i s p e r -s o n o r t e a m s h o u l d be s m a l l e n o u g h s o t h a t e a c h c l i e n t i s r e g a r d e d a n d t r e a t e d a s a u n i q u e i n d i v i d u a l , a n d s o t h a t a s u p p o r t i v e , c a r i n g r e l a t i o n s h i p i s p o s s i b l e . - F i n a l l y , a l l s e r v i c e s s h o u l d be o r g a n i z e d t o h e l p c l i e n t s become o r r e m a i n p a r t o f a n e t w o r k o f c a r i n g r e l a t i o n s h i p s , i . e . , a p e r s o n a l s u p p o r t s y s t e m . I n t h i s w a y , c l i e n t s c a n d e v e l o p c a p a c i t i e s f o r m u t u a l a n d s e l f -h e l p . A t t h e same t i m e , u n n e c e s s a r y d e p e n d e n c y o n t h e o r g a n i z e d s e r v i c e s y s t e m c a n b e r e d u c e d . ' * T h e N a t i o n a l I n s t i t u t e o f M e n t a l H e a l t h , i n a s u b s e -q u e n t p o l i c y p a p e r (N IMH, 1977) , i d e n t i f i e d t w o n e c e s s a r y c o n d i t i o n s f o r c o m m u n i t y s e r v i c e s t o be c o n s i d e r e d an i n t e g r a t e d s y s t e m . F i r s t , t h e r e m u s t b e a " c o r e s e r v i c e s a g e n c y " w h i c h i s s p e c i f i c a l l y i d e n t i f i e d a s h e l p i n g t h e s e v e r e l y m e n t a l l y d i s a b l e d . T h i s a g e n c y w i l l p r o v i d e o n e o r mo re o f t h e b a s i c s e r v i c e c o m p o n e n t s , o u t l i n e d i n t h i s c h a p t e r , a n d t a k e r e s p o n s i b i l i t y f o r e s t a b l i s h i n g l i n k a g e s w i t h a g e n c i e s p r o v i d i n g t h e o t h e r c o m p o n e n t s . L i n k a g e s m u s t a l s o be e s t a b l i s h e d w i t h " m a i n s t r e a m " a g e n c i e s i n c l u d i n g w e l f a r e , h e a l t h , a n d h o u s i n g . S e c o n d l y , t h e r e n e e d s t o 64 be r e c o g n i t i o n b y d e s i g n e r s o f t h e s y s t e m t h a t a s i n g l e p e r s o n o r t e a m h a s t o be r e s p o n s i b l e f o r l i n k i n g t h e c l i e n t t o t h e v a r i o u s s e r v i c e c o m p o n e n t s . T h i s r e s p o n -s i b i l i t y i s t h e " c a s e m a n a g e m e n t " f u n c t i o n w h i c h c o u l d b e c a r r i e d o u t b y t h e p a t i e n t ' s a s s i g n e d p r i m a r y t h e r a -p i s t o f t h e c o r e a g e n c y . A s i m i l a r f u n c t i o n was b u i l t i n t o t h e d e s i g n o f t h e G r e a t e r V a n c o u v e r M e n t a l H e a l t h S e r v i c e ( Cumming , 1 9 7 2 ) . The r e m a i n i n g c h a p t e r s o f t h i s t h e s i s w i l l e x a m i n e V a n c o u v e r I s a l n d s e r v i c e s w i t h t h e o b j e c t i v e o f r e c o m -m e n d i n g a c o m p r e h e n s i v e s y s t e m s i m i l a r t o t h e m o d e l p r e s e n t e d i n t h i s c h a p t e r . R e i t e r a t e d b y N e u f e l d t ( 1 9 7 9 ) , t h i s w i l l r e q u i r e an e x a m i n a t i o n o f t h e r a n g e o f s e r v i c e s p r o v i d e d , t h e r e g i o n a l i z a t i o n ( o r d i s p e r s a l ) o f t h e s e , a n d t h e l o c a t i o n o f t h e e m p o w e r e d a u t h o r i t y t o c o o r d i n a t e t h e m t o m e e t t h e n e e d s o f i n d i v i d u a l c l i e n t s . Chapter 5 Method of A n a l y s i s and Sources o f Data The p l a n n i n g r e g i o n s e l e c t e d f o r t h i s paper i s Vancouver I s l a n d i n the p r o v i n c e o f B r i t i s h Columbia. The 19 76 Canada Census r e p o r t s a p o p u l a t i o n f o r the area o f 441,407 w i t h i n an area of 22,000 square m i l e s . A l l major towns and c i t i e s have g e n e r a l h o s p i t a l s o f which f o u r have s p e c i f i c a l l y d e s i g n a t e d p s y c h i a t r i c u n i t s . S i x communities have mental h e a l t h c e n t r e s . V o l u n t a r y agencies p r o v i d e half-way houses, a c t i v i t y c e n t r e s , and workshops f o r the m e n t a l l y i l l i n some communities. R i v e r -view h o s p i t a l and p s y c h i a t r i c wards i n g e n e r a l h o s p i t a l s i n the C i t y o f Vancouver a l s o serve the I s l a n d p o p u l a t i o n . A l l of these s e r v i c e s , i n a d d i t i o n t o p r i v a t e m e d i c a l p r a c t i c e , make-up the p s y c h i a t r i c s e r v i c e system f o r Van-couver I s l a n d . As s t a t e d i n the I n t r o d u c t i o n , a necessary step r e -q u i r e d i n t h i s paper i s the assessment o f the s e r v i c e s c u r r e n t l y a v a i l a b l e t o the c h r o n i c a l l y m e n t a l l y d i s a b l e d i n a s p e c i f i c r e g i o n . Questions t h a t would be asked d u r i n g t h i s assessment a r i s e from the model community s e r v i c e system o u t l i n e d i n the preceeding chapter. These q u e s t i o n s a r e : a) Are a l l components of the model system a v a i l a b l e t o the d i s a b l e d i n each area o f the p l a n n i n g r e g i o n ? 66 b) To what extent are e x i s t i n g service system components being u t i l i z e d by the chron i c a l l y disabled i n the d i f f e r e n t areas? c) Is there s u f f i c i e n t organization of services to provide continuity of care at the c l i e n t l e v e l , and services planning at the area and regional level? At the beginning of Chapter 2, i t was stated that u t i l i z a t i o n of services by the chronically disabled could be estimated once t h e i r expected prevalence was known. The same chapter concluded that expected preva-lence derived from p s y c h i a t r i c case registers provide the best estimates. As stated i n Chapter 1, not a l l the chronically mentally disabled can be diagnosed as schizo-phrenic, nor do a l l persons with schizophrenia become chronically disabled. The c o r r e l a t i o n , however, between them i s high enough to consider the two c l a s s i f i c a t i o n s as one for planning purposes. A review of p s y c h i a t r i c services u t i l i z a t i o n w i l l include both inpatient and outpatient services used by the planning region residents. Where possible, the u t i l i -zation of these services by patients considered to be chronically mentally disabled w i l l be extracted. These figures w i l l be compared to the expected prevalence of schizophrenia. The types of data that w i l l be examined are: a) separation data from acute care general hospitals; 67 b) admission data from p s y c h i a t r i c u n i t s i n acute g e n e r a l h o s p i t a l s ; c) Riverview H o s p i t a l p a t i e n t movement r e p o r t s and p a t i e n t p r o f i l e s ; d) c l i e n t movement r e p o r t s from p r o v i n c i a l mental h e a l t h c e n t r e s ; and e) attendance r e p o r t s o f workshops and a c t i v i t y c e n t r e s . F i n a l l y , an assessment w i l l be made of the s e r v i c e s a v a i l a b l e to the c h r o n i c p a t i e n t s and the degree of co-o r d i n a t i o n among these s e r v i c e s . Judgements were a r r i v e d a t on the b a s i s o f i n f o r m a t i o n s u p p l i e d from i n t e r v i e w s with s e r v i c e p r o v i d e r s . The p l a n n i n g area of Vancouver I s l a n d has been d i -v i d e d i n t o three regions f o r e a s i e r examination. These r e g i o n s , as shown i n Fi g u r e 1 on page 132, a r e : a) North I s l a n d which i n c l u d e s School D i s t r i c t s 71, 72 , 84 and 85; b) C e n t r a l I s l a n d which i n c l u d e s School D i s t r i c t s 65, 66, 68, 69 and 70; and c) C a p i t a l Region which i n c l u d e s School D i s t r i c t s 61, 62, 63 and 64. There are advantages i n using these three r e g i o n s . Each r e g i o n i s comprised of d i s t i n c t catchment areas of mental h e a l t h c e n t r e s , h o s p i t a l d i s t r i c t s , and p u b l i c h e a l t h u n i t s . The re g i o n s are a l s o composites of Canada Census d i v i s i o n s . 68 V a r i a t i o n s i n Prevalence Estimates There i s an i n h e r e n t degree o f u n c e r t a i n t y i n f o r e -c a s t i n g u t i l i z a t i o n of a h e a l t h s e r v i c e ( M a r t i n , 1975). T h i s would be p a r t i c u l a r l y t r u e w i t h a mental h e a l t h s e r v i c e , w i t h much o f the u n c e r t a i n t y accounted f o r by the d i f f i c u l t i e s i n case d e t e r m i n a t i o n . Wing e t a l . (196 7) a t t r i b u t e d d i a g n o s t i c p r a c t i c e s as accounting f o r the d i f f e r e n c e s i n r a t e s of s c h i z o -p h r e n i a between the B a l t i m o r e and two B r i t i s h case r e g i s -t e r s from Camberwell and Aberdeen. The crude r a t e s of t r e a t e d s c h i z o p h r e n i a from the Baltimore Case R e g i s t e r and t h a t from Monroe County i n New York are s i m i l a r . Cooper (1970) examined the d i a g n o s t i c p r a c t i c e s of B r i t i s h and American p s y c h i a t r i s t s and found a c o n s i s t e n t d i f f e r e n c e i n t h e i r r e s p e c t i v e d e f i n i t i o n s o f s c h i z o p h r e n i a . The B r i t i s h d e f i n i t i o n i s much t i g h t e r s i n c e the B r i t i s h psy-c h i a t r i s t s tend t o exclude twenty to t h i r t y p e r c e n t o f cases t h a t American p s y c h i a t r i s t s would diagnose as s c h i z o -p h r e n i a . S t u d i e s comparing Canadian d i a g n o s t i c p r a c t i c e s to the B r i t i s h or American were not searched. I t i s q u i t e reasonable t o assume t h a t the Canadian d e f i n i t i o n l i e s some-where i n between the American and B r i t i s h , as both i n f l u e n c e s are prominent i n Canadian p s y c h i a t r y . As M a r t i n suggests, a f o r e c a s t e d range of u t i l i z a t i o n i s more r e a l i s t i c , g iven u n c e r t a i n t y , than a s i n g l e number f o r e c a s t . The range w i l l use an upper and lower bound, and a mean. I f a s i n g l e number i s to be used at a l l , the mean would be the most reasonable. Given the i n t e r n a t i o n a l 6 9 d i f f e r e n c e s i n case d e t e r m i n a t i o n , the r a t e s from the Monroe County case r e g i s t e r * w i l l p r o v i d e the upper bound, and the Camberwell r e g i s t e r , the lower bound. Table 5.2 below shows the expected one-year t r e a t e d prevalence of s c h i z o p h r e n i a f o r the d i f f e r e n t r e g i o n s of Vancouver I s l a n d , c a l c u l a t e d from these r a t e s . Table 5.2 Range Estimates o f T r e a t e d Prevalence of S c h i z o p h r e n i a (number of cases) Vancouver I s l a n d Regions Upper Bound Mean Lower Bound % D e v i a t i o n from Mean North I s l a n d 336 277 219 21% C e n t r a l I s l a n d 653 553 456 18% C a p i t a l Region 1059 9 31 803 14% Vancouver I s l a n d T o t a l 2048 1761 1478 16% The expected prevalence from the Monroe County age and sex s p e c i f i c r a t e s are shown i n Column (1) and i s c o n s i d e r e d the upper bound e s t i m a t e . The Camberwell crude r a t e (435 per 100,000) was a l s o a p p l i e d t o the p o p u l a t i o n , the r e s u l t i n g prevalence i s shown i n column (3), and i s c o n s i d e r e d the lower bound. Column (2) shows the mean expected p r e v a l e n c e . A l l these f i g u r e s w i l l be u t i l i z e d t o estimate the a c t u a l c a p a c i t y of s e r v i c e s f o r t h i s p a t i e n t group. One minor source of e r r o r i n Table 5.2 i s t h a t column (1) i s c a l c u l a t e d from age and sex s p e c i f i c r a t e s , and * These r a t e s a p p l i e d t o the Vancouver I s l a n d p o p u l a t i o n by age and sex are shown i n Table 5.1 on page 123. column (3) from a crude r a t e . T h i s e r r o r should not be s i g n i f i c a n t enough to a f f e c t the p r e s e n t a t i o n i n t h i s chapter. Column (4) shows the percentage d e v i a t i o n from the mean prevalence f i g u r e f o r each I s l a n d r e g i o n . The d i f f e r e n c e s i n these percentages are a t t r i b u t e d t o the d i f f e r e n t age s t r u c t u r e s of the r e g i o n s . Sources o f S e r v i c e U t i l i z a t i o n Data a) General H o s p i t a l S e p a r a t i o n Reports S e r v i c e r e p o r t s from g e n e r a l h o s p i t a l s p r o v i d e c e r -t a i n i n f o r m a t i o n on separated p a t i e n t s which i n c l u d e s : age, sex, diagnoses, days o f c a r e , treatment r e c e i v e d , and s c h o o l d i s t r i c t of p a t i e n t ' s r e s i d e n c e . T h i s i n f o r -mation i s submitted f o r f i n a n c i a l reimbursement from the p r o v i n c i a l i nsurance p l a n . The 19 77 h o s p i t a l s e p a r a t i o n of a l l p a t i e n t s , over 15 years of age, who r e c e i v e d psy-c h i a t r i c care are reviewed i n t h i s chapter. T h i s group of s e p a r a t i o n s i n c l u d e s p a t i e n t s with a primary p s y c h i -a t r i c diagnoses (ICDA-8 codes 290.0 t o 315.99), and pa-t i e n t s with s e l f - i n f l i c t e d wounds w i t h a secondary p s y c h i -a t r i c d i a g n o s i s . These s e p a r a t i o n s , f o r r e s i d e n t s of Vancouver I s l a n d , are presented i n Table 5.3. (Table 5.3 and subsequent t a b l e s i n t h i s chapter f o l l o w the Summary at the end of t h i s paper.) There are some disadvantages i n using h o s p i t a l sepa-r a t i o n s f o r p l a n n i n g . Diagnosis of p a t i e n t s may be u n r e l i a b l e . The number of s e p a r a t i o n s per y e a r , and not the a c t u a l number of i n d i v i d u a l s separated, i s r e p o r t e d . Diagnosis f o r s e p a r a t i o n s by s c h o o l d i s t r i c t i s not a v a i l a b 7i o n l y d i a g n o s i s f o r a l l s e p a r a t i o n s i n the p r o v i n c e . S e p a r a t i o n data w i l l be used p r i m a r i l y to assess where r e s i d e n t s o f Vancouver I s l a n d seek treatment. b) P s y c h i a t r i c U n i t Data General h o s p i t a l s do not r e p o r t p a t i e n t s e p a r a t i o n s from designated p s y c h i a t r i c u n i t s d i s t i n c t from a l l acute p a t i e n t s e p a r a t i o n s . T h e r e f o r e , a q u e s t i o n n a i r e was sent t o the f o u r Vancouver I s l a n d h o s p i t a l s c o n t a i n i n g d e s i g -nated p s y c h i a t r i c u n i t s . I t was requested t h a t each u n i t d e s c r i b e i t s s e r v i c e s , and r e p o r t admissions and occupancy r a t e f o r 19 77. These data are shown on Table 5.4 and w i l l be compared t o the s e p a r a t i o n data f o r a l l acute beds i n the h o s p i t a l s . From the two data s e t s , i t w i l l be p o s s i b l e to c a l c u l a t e the percentage o f p s y c h i a t r i c care s e p a r a t i o n s t h a t were t r e a t e d i n the h o s p i t a l ' s p s y c h i a t r i c u n i t s . c) Riverview H o s p i t a l Data Riverview H o s p i t a l i s the o n l y p r o v i n c i a l l y owned and operated mental h o s p i t a l i n B.C. I t i s l o c a t e d on the mainland and i s s e v e r a l hours t r a v e l l i n g time from most p o i n t s on the I s l a n d . However, a-number of I s l a n d r e s i -dents are admitted to Riverview each year. T h i s h o s p i -t a l ' s 1978 p a t i e n t movement r e p o r t p r o v i d e s the number of admissions from Vancouver I s l a n d by the p a t i e n t ' s area of r e s i d e n c e . These data are presented i n Table 5.5. P a t i e n t prevalence i n f o r m a t i o n was o b t a i n e d from a survey o f I s l a n d r e s i d e n t s who were on the wards as of June 25th, 19 78. The survey i n c l u d e d an assessment of the l e v e l of care i n which each p a t i e n t c o u l d be most a p p r o p r i a t e l y 72 p l a c e d . The l e v e l s ranged from " l i v i n g i n d e p e n d e n t l y " t o "acute p s y c h i a t r i c s e t t i n g " . C r i t e r i a f o r the e i g h t l e v e l s o f care are found i n the A p p e n d i c e s . The r e -s u l t s >of the assessments are shown i n T a b l e 5.6. A d d i -t i o n a l i n f o r m a t i o n o b t a i n e d from the survey i s found i n T a b l e 5.7. T h i s i n c l u d e s l e n g t h o f s t a y i n R i v e r v i e w , age , s ex , d i a g n o s i s and r e f e r r a l s o u r c e , d) M e n t a l H e a l t h C e n t r e s Data There are s i x p r o v i n c i a l l y funded and a d m i n i s t e r e d menta l h e a l t h c e n t r e s on Vancouver I s l a n d . Two are i n the C a p i t a l R e g i o n , t h r e e i n the C e n t r a l Region and one i n the N o r t h Reg ion . On most c l i e n t s s e r v e d , c e r t a i n i n f o r m a t i o n i s c o l l e c t e d upon opening and c l o s i n g t h e i r f i l e s . T h i s d a t a i s p r o c e s s e d i n the c e n t r a l o f f i c e i n V i c t o r i a , from which v a r i o u s s t a t i s t i c a l r e p o r t s are a v a i l -a b l e . These r e p o r t s do not c o n t a i n a r e l i a b l e count o f the numbers o f s c h i z o p h r e n i c s s e r v e d by the c e n t r e s , as d i a g n o s i s i s not r e c o r d e d . The term " c h r o n i c m e n t a l i l l -ness" i s sometimes r e c o r d e d f o r cases opened, so w i l l be used i n t h i s paper i n l i e u o f d i a g n o s i s . The numbers o f cases r e p o r t e d h a v i n g a " c h r o n i c menta l i l l n e s s " , as a p r o p o r t i o n o f the c e n t r e s ' t o t a l c a s e l o a d , are p r e s e n t e d i n the t e x t o f the nex t c h a p t e r . Between October 19 78 and January 19 79 v i s i t s were made t o a l l the menta l h e a l t h c e n t r e s except the one i n the N o r t h R e g i o n . C e n t r e s t a f f were asked about t h e i r ca se loads and s e r v i c e s a v a i l a b l e i n the community to the 73 c h r o n i c a l l y d i s a b l e d . Estimates o f the numbers o f chro-n i c a l l y i l l were c o n s t r u c t e d from the i n t e r v i e w i n f o r m a t i o n where p o s s i b l e , and compared to the 1976 annual r e p o r t o f the p r o v i n i c a l mental h e a l t h c e n t r e s . Table 5.8 shows a l l o c a t i o n of c l i n i c a l p o s i t i o n s and p s y c h i a t r i s t s e s s i o n s i n the mental h e a l t h c e n t r e s w i t h r a t e s o f coverage f o r the catchment area p o p u l a t i o n . The number of these c l i n i c a l p o s i t i o n s s p e c i f i c a l l y d e s i g n a t e d t o care f o r the c h r o n i c a l l y i l l are presented i n the t e x t of the next chapter. A number o f assumptions have to be made i n i n t e r p r e -t a t i n g the data sources d e s c r i b e d above. One o f these i s the problem o f d u p l i c a t e d p a t i e n t counts. A p a t i e n t may use the s e r v i c e s o f a mental h e a l t h c e n t r e , g e n e r a l h o s p i t a l and Riverview i n the same year, and be counted t h r e e times. T h e r e f o r e , t o t a l l i n g p a t i e n t counts from these sources can be m i s l e a d i n g and.therefore are avoided. Another problem i s t h a t each s e r v i c e uses d i f f e r e n t terms, and probably d i f f e r e n t c r i t e r i a , t o d e s c r i b e cases, i n t e r p r e t e d f o r t h i s paper, as c h r o n i c a l l y m e n t a l l y d i s a b l e d . T h i s type o f problem i s i n h e r e n t i n u s i n g secondary data sources and cannot be avoided. 74 Chapter 6 The P l a n n i n g Area; Current S i t u a t i o n Vancouver I s l a n d i s l o c a t e d o f f s h o r e from the mainland of B r i t i s h Columbia and i s approximately two and a h a l f hours t r a v e l l i n g time from the c i t y of Vancouver. The I s l a n d has an economy r e p r e s e n t a t i v e o f the P r o v i n c e w i t h f o r e s t r y , f i s h i n g , mining, a g r i c u l t u r e and mixed manufac-t u r i n g . Much o f the area i s r e l a t i v e l y u n i n h a b i t e d w i t h over t h r e e - q u a r t e r s of the p o p u l a t i o n c l u s t e r e d along the major highway on the south-east and south c o a s t . Some areas are q u i t e i s o l a t e d w i t h i n h e r e n t d i f f i c u l t i e s i n d e l i v e r i n g s e r v i c e s . The p o p u l a t i o n i n these areas i s r e -l a t i v e l y s m a l l , but with a l a r g e p r o p o r t i o n o f n a t i v e Indians. The North I s l a n d Region The North I s l a n d i n c l u d e s the s c h o o l d i s t r i c t s o f Courtenay (#71) , Campbell R i v e r (#72) , Vancouver I s l a n d West (#84) and Vancouver I s l a n d North (#85) which are r e c o g n i z e d as the catchment area o f the Courtenay Mental He a l t h Centre. School d i s t r i c t s #72 and #85 i n c l u d e por-t i o n s o f the p r o v i n c e ' s mainland but most of the p o p u l a t i o n of these d i s t r i c t s are on the I s l a n d p o r t i o n s . Thus, the e n t i r e area o f these two d i s t r i c t s w i l l be i n c l u d e d i n the p l a n n i n g r e g i o n . The four s c h o o l d i s t r i c t s have a combined p o p u l a t i o n of 69,930 a t a d e n s i t y of 3.57 persons per square 75 m i l e . School D i s t r i c t #85 i s the l e a s t populated w i t h 1.5 4 persons per square m i l e and School D i s t r i c t #71 i s the most, wi t h 42.99 persons per square m i l e , a) S e r v i c e s There are three h o s p i t a l s over 10 beds i n s i z e i n the r e g i o n . These are i n A l e r t Bay (S.D. #85) with 53 beds, i n Campbell R i v e r (S.D. #72) with 92 beds, and i n Comox (S.D. #71) wit h 145 beds. The l a t t e r c o n t a i n s the o n l y p s y c h i a t r i c i n p a t i e n t u n i t i n the r e g i o n . The 20 beds i n t h i s u n i t p r o v i d e s .28 p s y c h i a t r i c beds per 100 0 p o p u l a t i o n which i s .03 beds per 1000 over the p r o v i n c i a l average f o r t h i s category of p s y c h i a t r i c i n p a t i e n t f a c i l i t y . The Comox h o s p i t a l does not p r o v i d e o t h e r p s y c h i a t r i c s e r v i c e s such as a day h o s p i t a l o r o u t p a t i e n t s e r v i c e s . The North I s l a n d i s served by a Mental Health Centre i n the c i t y o f Courtenay which has 6.5 f u l l - t i m e e q u i v a l e n t s o f p r o f e s s i o n a l s t a f f . T h i s i s a r a t i o of 9.3 s t a f f t o 100,000 p o p u l a t i o n (see Table 5.8). However, the Mental H e a l t h Centre mainly serves i t s immediate area of Courtenay and Comox which c o n t a i n s 29,415 p o p u l a t i o n . T h i s would i n e f f e c t g i v e i t 22.1 s t a f f per 100,000. The Centre had plans to p o s i t i o n c l i n i c a l s t a f f i n o t h e r communities i n the near f u t u r e . The Centre has a pa r t - t i m e nurse d e s i g -nated s p e c i f i c a l l y to care f o r the c h r o n i c a l l y m e n t a l l y i l l . There are 2 p s y c h i a t r i s t s i n Courtenay s e r v i n g the e n t i r e r e g i o n . They pr o v i d e 1 h a l f - d a y per week each t o the Courtenay Mental Health Centre w i t h the remainder of 76 t h e i r time spent i n p r i v a t e p r a c t i c e . They a l s o p r o v i d e c o n s u l t a t i o n i n the Campbell R i v e r H o s p i t a l once a week. There are v i r t u a l l y no p s y c h o - s o c i a l r e h a b i l i t a t i o n or long term maintenance programs for*-'the c h r o n i c a l l y d i s -abled. The Mental Health Centre s u p e r v i s e s a boarding home program which has 85 beds i n the area, most o f these are i n the Courtenay s c h o o l d i s t r i c t . There i s a home with 12 beds f o r ' b u r n t out' s c h i z o p h r e n i c males and another home wit h 8 beds f o r a younger s c h i z o p h r e n i c group needing a s h o r t t o medium s t a y . The remainder o f the boarding home beds i n the area are oc c u p i e d by the m e n t a l l y r e t a r d e d . There i s a s h e l t e r e d workshop f o r the r e t a r d e d but not f o r the m e n t a l l y i l l , and there i s no a c t i v i t y or s o c i a l c e n t r e . Both the h o s p i t a l and the Mental H e a l t h Centre use the l o c a l community centre f o r a r e c r e a t i o n group one day a week, and a few c h r o n i c p a t i e n t s p a r t i c i p a t e . b) U t i l i z a t i o n of S e r v i c e s The mean expected one year prevalence f o r s c h i z o p h r e -n i a f o r the North I s l a n d i s 277 (+ 58) persons. T h i s number should r e p r e s e n t the number of persons who w i l l seek and r e c e i v e some form of treatment i n a one year p e r i o d . Some w i l l be t r e a t e d i n the h o s p i t a l , some i n the Mental H e a l t h Centre, and others i n f a m i l y p r a c t i t i o n e r s ' o f f i c e s . A c e r t a i n number o f p a t i e n t s may be t r e a t e d i n two or more of these s e r v i c e s , and some w i l l seek treatment out o f the r e g i o n . The p s y c h i a t r i c u n i t i n Comox had 52 3 admissions i n 19 77, of which 16 to 2 0 per cent are estimated t o be f o r 77 s c h i z o p h r e n i a . Included i n t h i s number are readmissions. Table 5.3 shows 9 74 s e p a r a t i o n s f o r p s y c h i a t r i c care f o r the p o p u l a t i o n over 15 years o f age i n the North I s l a n d Region. Much o f t h i s d i f f e r e n c e i s a t t r i b u t a b l e to sepa-r a t i o n s from the Campbell R i v e r and A l e r t Bay h o s p i t a l s . Although d i a g n o s i s i s not a v a i l a b l e f o r these s e p a r a t i o n s , i t i s probable t h a t the s m a l l n o r t h e r n h o s p i t a l s t r e a t a l a r g e number o f a l c o h o l r e l a t e d d i s o r d e r s . Out-of-area h o s p i t a l s which admitted some o f the r e g i o n ' s cases were Nanaimo Regional H o s p i t a l (32 separa-t i o n s ) , Vancouver area h o s p i t a l s (31 s e p a r a t i o n s ) and Royal J u b i l e e / E r i c M a r t i n I n s t i t u t e (9 s e p a r a t i o n s ) . I t i s obvious t h a t the l a t t e r i s not a prominent r e g i o n a l r e f e r r a l c e n t r e f o r the North I s l a n d . The number of p s y c h i a t r i c cases han-d l e d o u t s i d e the r e g i o n ' s h o s p i t a l s amounted t o 8.1 per cent o f the t o t a l s e p a r a t i o n s , and o f t h e s e , 3 per cent were t r e a t e d o f f the I s l a n d . A d d i t i o n a l l y , the Riverview admissions should be con-s i d e r e d . In 19 78, 17 admissions from the r e g i o n were r e -corded i n t o Riverview H o s p i t a l . H a l f o f these were readmis-s i o n s . The r a t e o f admission f o r the area was 33.69 per 100,000 p o p u l a t i o n over 15 years of age. T h i s i s above the average f o r the I s l a n d which i s 17.91 per 100,000. I t i s q u i t e p o s s i b l e t h a t some of the 17 admissions to Riverview would be accounted f o r i n g e n e r a l h o s p i t a l s e p a r a t i o n data as they would be t r a n s f e r r e d from these h o s p i t a l s . But, as 78 seen i n Table 5.7, many Riverview p a t i e n t s have been ad-m i t t e d d i r e c t l y on a do c t o r ' s r e f e r r a l and have bypassed the l o c a l u n i t . As o f June 19 78 there were 11 r e s i d e n t s from the North I s l a n d area i n Riverview H o s p i t a l . Seven of these p a t i e n t s r e q u i r e d i n t e n s i v e o r longterm p s y c h i a t r i c c a r e ; some, i n a d d i t i o n , r e q u i r e d m e d i c a l care. The 4 o t h e r p a t i e n t s c o u l d have been cared f o r i n l o c a l f a c i l i t i e s i f these had been a v a i l a b l e . The Courtenay Mental He a l t h Centre had 32 8 open cases at year end 1976. Of t h i s number, 48 had a c h r o n i c mental i l l n e s s . The Centre D i r e c t o r r e p o r t s t h a t many o f the c h r o n i c p a t i e n t s are c a r r i e d by the p r i v a t e p s y c h i a t r i s t s . The g e n e r a l p r a c t i t i o n e r s a p p a r e n t l y r e f e r these cases to them r a t h e r than t o the Mental He a l t h Centre. The C e n t r a l I s l a n d Region The C e n t r a l I s l a n d r e g i o n c o n t a i n s the f o l l o w i n g s c h o o l d i s t r i c t s w i t h t h e i r p o p u l a t i o n and d e n s i t y per square m i l e , and one year mean expected pr e v a l e n c e o f s c h i z o p h r e n i a : School D i s t r i c t P o p u l a t i o n D e n s i t y Prevalence A l b e r n i (#70) 32,170 10.76 153 Qualicum (#69) g l 8 8 Q ? 8 5 2 2 Q 6 Nanaimo (#68) Cowichan (#65) Lake Cowichan (#66) 47,095 36.10 214 141,145 553 79 The f i v e s chool d i s t r i c t s are shown above i n three group-ings as each group i s served by a major h o s p i t a l and a mental h e a l t h c e n t r e . S e r v i c e s and t h e i r u t i l i z a t i o n have to be d i s c u s s e d w i t h r e f e r e n c e t o these three sub-areas, a) S e r v i c e s There are 3 major h o s p i t a l s i n the r e g i o n , although o n l y 2 of them have a designated p s y c h i a t r i c u n i t . P s y c h i a t r i c Beds  H o s p i t a l T o t a l Beds Number per 1000 Port A l b e r n i 139 0 0 Nanaimo 2 74 24 .35 Cowichan 141 10 .21 Only the Nanaimo h o s p i t a l p r o v i d e s a p s y c h i a t r i c day program. No other p a r t i a l , h o s p i t a l i z a t i o n or o u t p a t i e n t s e r v i c e s are a v a i l a b l e through the h o s p i t a l s . The P o r t A l b e r n i h o s p i t a l has made a p p l i c a t i o n t o the p r o v i n c i a l government f o r an 8 bed p s y c h i a t r i c u n i t . T h i s h o s p i t a l a l s o has t e n t a t i v e plans f o r a day h o s p i t a l program. There are 3 Mental Health Centres s e r v i n g the C e n t r a l r e g i o n w i t h a t o t a l o f 13.5 c l i n i c a l p o s i t i o n s . Two o f these p o s i t i o n s have been des i g n a t e d s p e c i f i c a l l y f o r nurses to work wi t h the c h r o n i c a l l y i l l and d i s a b l e d . The 3 Centres are: C l i n i c a l P o s i t i o n s  Number per 100,000 f o r Chronics Por t A l b e r n i 4.0 12.4 1.0 Nanaimo 5.5 8.1 1.0 Duncan (Cowichan) 4.0 11.3 0 80 There are 5 p r a c t i c i n g p s y c h i a t r i s t s i n the r e g i o n . One i s i n P o r t A l b e r n i , and p r o v i d e s a l l h i s time t o the Mental H e a l t h Centre which i n c l u d e s c o n s u l t i n g at the h o s p i t a l . There are 3 p s y c h i a t r i s t s i n Nanaimo; a l l p r o v i d e s e s s i o n a l time to the h o s p i t a l , but onl y 1 p r o v i d e s a h a l f - d a y per week t o the Mental Health Centre. The Cowichan area has 2 p s y c h i a t r i s t s . One works at the hos-p i t a l and the o t h e r p r o v i d e s 7 h a l f - d a y s per week to the Duncan Mental H e a l t h Centre. P s y c h - s o c i a l r e h a b i l i t a t i o n and long-term maintenance programs are a l i t t l e b e t t e r developed here than i n the North r e g i o n . The Duncan Mental H e a l t h Centre i n the Cowichan area s u p e r v i s e s a boarding home program which has beds f o r the m e n t a l l y i l l . These are a l l c h r o n i c p a t i e n t s . No r e h a b i l i t a t i o n occurs i n these homes but some r e s i d e n t s a t t e n d an a c t i v i t y program i n a church h a l l 2 or 3 days a week. In a d d i t i o n , 4 r e s i d e n t s a t t e n d a workshop which mainly serves the me n t a l l y r e t a r d e d . There are onl y 18 p l a c e s f o r the m e n t a l l y i l l i n designated mental h e a l t h boarding homes i n the Nanaimo area. A d i v i s i o n o f the h o s p i t a l ' s day program i s attended by 18 to 25 c h r o n i c s c h i z o p h r e n i c p a t i e n t s who p a r t i c i p a t e i n s o c i a l and r e c r e a t i o n a l programs. The Mental Health Centre nurse p r o v i d e s a h a l f - d a y per week t o t h i s program. The Canadian Mental Health A s s o c i a t i o n , a v o l u n t a r y o r g a n i -z a t i o n , a l s o operates a r e c r e a t i o n program f o r c h r o n i c p a t i e n t s and many of i t s p a r t i c i p a n t s a l s o a t t e n d the 81 h o s p i t a l day program. While t h i s area has a wider community program than the North I s l a n d , s t a f f at the h o s p i t a l and the Mental H e a l t h Centre s t a t e d t h a t t h e r e were s t i l l p r o -gram shortages r e s u l t i n g i n a g r e a t e r use o f the i n p a t i e n t u n i t than was necessary. Readmission r a t e s were r e p o r t e d as being e s p e c i a l l y h i g h among the younger s c h i z o p h r e n i c s . Community program components mentioned as needed were a r e h a b i l i t a t i o n - o r i e n t e d half-way house, a more s t r u c t u r e d t r e a t m e n t - o r i e n t e d day program, and follow-up o f h o s p i t a l d i s c h a r g e s . The above o p i n i o n s p r o v i d e d by the Nanaimo s t a f f were echoed i n P o r t A l b e r n i which has no p s y c h o - s o c i a l r e h a b i l i t a t i o n s e r v i c e s , i n c l u d i n g housing programs, f o r the c h r o n i c a l l y d i s a b l e d . The degree of c o o r d i n a t i o n among the s e r v i c e s i n the r e g i o n v a r i e s . Each o f the sub-areas of P o r t A l b e r n i , Nanaimo, and Cowichan are d i s t i n c t and t h e r e are no pro-grams c o o r d i n a t e d between them. The P o r t A l b e r n i Mental Health Centre has i n i t i a t e d s e v e r a l measures t o f a c i l i t a t e c o o r d i n a t i o n and communication between l o c a l s e r v i c e s , i n c l u d i n g meetings, feedback to r e f e r r i n g agents, and con-s u l t a t i o n s . Centre s t a f f i n Duncan are i n v o l v e d i n s e v e r a l community o r g a n i z a t i o n s i n c l u d i n g the P s y c h i a t r i c P l a n n i n g Committee at the h o s p i t a l . The .focus o f these c o o r d i n a t i n g e f f o r t s , however, i s p r i m a r i l y f o r p a t i e n t groups o t h e r than the c h r o n i c a l l y d i s a b l e d . Even with a p s y c h i a t r i s t working at the Nanaimo Centre and the h o s p i t a l day program, 82 there was lack: o f c o o r d i n a t i o n o f d i s c h a r g e p l a n n i n g from the ward and follow-up i n the community. No formal agree-ment e x i s t s between these s e r v i c e s t o develop l i n k a g e mechanisms. b) U t i l i z a t i o n of S e r v i c e s L o c a l h o s p i t a l s i n the C e n t r a l I s l a n d Region were able to t r e a t most of t h i s r e g i o n ' s s e p a r a t i o n s f o r p s y c h i a t r i c care from g e n e r a l h o s p i t a l s . L o c a t i o n o f Treatment f o r P s y c h i a t r i c Care f o r General H o s p i t a l Separations Number of P s y c h i a t r i c Care Separations Discharged from  Region v i c t o r i a Vancouver Sub-Area H o s p i t a l s H o s p i t a l s H o s p i t a l s % n o n - l o c a l Ccwichan 537 42 9 8.7 Nanaimo 620 11 11 3.5 P o r t A l b e r n i 418 17 7 6.0 The p s y c h i a t r i c u n i t s i n Cowichan and Nanaimo were able to t r e a t about 70 per cent and 9 0 per cent, r e s p e c t i v e l y , of the p s y c h i a t r i c cases separated from t h e i r h o s p i t a l s . The Port A l b e r n i h o s p i t a l does not have a p s y c h i a t r i c u n i t , but t r e a t e d 337 o f the 442 p s y c h i a t r i c s e p a r a t i o n s f o r the p o p u l a t i o n i n t h i s s c h o o l d i s t r i c t . The Nanaimo h o s p i t a l i s the second p r e f e r r e d s i t e f o r admissions by P o r t A l b e r n i r e s i d e n t s . The p s y c h i a t r i c u n i t s i n Duncan and Nanaimo r e p o r t e d 277 and 612 admissions r e s p e c t i v e l y f o r 1977. S t a f f i n the Duncan u n i t r e p o r t e d t h a t 10 to 15 per cent of t h e i r 83 admissions had a d i a g n o s i s o f psychoses. Nanaimo s t a f f r e p o r t e d a f i g u r e o f 2 3 per cent f o r s c h i z o p h r e n i a . Even though Port A l b e r n i i s without a p s y c h i a t r i c u n i t , the h o s p i t a l s t a f f thought t h a t about 15 per cent o f t h e i r p a t i e n t s were s c h i z o p h r e n i c . P o r t A l b e r n i s t a f f d i d say t h a t many p a t i e n t s are sent d i r e c t l y but o f the ar e a f o r treatment. Riverview admitted 35 p a t i e n t s from the C e n t r a l I s l a n d r e g i o n i n 1978. Table 5.5 shows the admission r a t e s f o r the 3 sub-areas v a r i e s c o n s i d e r a b l y . P o r t A l b e r n i has the h i g h e s t r a t e i n the r e g i o n , and the e n t i r e I s l a n d , at 65.10 per 100,000 over 15 years o f age. The Cowichan area has the lowest r a t e f o r the I s l a n d at 14.46 per 100,000 over 15. The average admission r a t e f o r the I s l a n d i s 17.73 per 100,000 over 15. The C e n t r a l I s l a n d r e g i o n had 42 p a t i e n t s on the R i v e r -view wards as of June 1978. F o r t y - f i v e per cent of these were assessed as r e q u i r i n g l e v e l s o f care which c o u l d be p r o v i d e d i n community s e t t i n g s , but as d e s c r i b e d above, there are few f a c i l i t i e s to care f o r the c h r o n i c a l l y d i s a b l e d i n the r e g i o n . The 3 Mental H e a l t h Centres r e p o r t e d 1076 e n r o l l e d cases at year end 1976. Of t h i s number, 87 were r e p o r t e d as having a c h r o n i c mental i l l n e s s . The three Centres and numbers o f r e p o r t e d cases are shown below. 84 A l l E n r o l l e d Chronic % C h r o n i c / Centre Cases Cases A l l Cases Duncan 452 24 5. 3% Nanaimo 361 40 11. 1% P o r t A l b e r n i 255 2 3 9.0% Recent i n t e r v i e w s with the Duncan Centre s t a f f r e v e a l e d a t o t a l a c t i v e c a s e l o a d o f approximately a t h i r d of the above number with even fewer c h r o n i c cases being c a r r i e d . On the other hand, P o r t A l b e r n i s t a f f p r o v i d e d a v e r b a l updated ca s e l o a d count o f 334 cases o f which approximately 65 are c h r o n i c s c h i z o p h r e n i c s . I t was not unexpected t o f i n d t h a t the p s y c h i a t r i c nurses i n the P o r t A l b e r n i and Nanaimo Mental Health Centres were c a r r y i n g most of the c h r o n i c cases. The C a p i t a l Regional D i s t r i c t The C a p i t a l Region i n c l u d e s 4 s c h o o l d i s t r i c t s and 2 Mental Health Centre catchment areas. The s c h o o l d i s t r i c t s w i t h t h e i r p o p u l a t i o n are as f o l l o w s : School D i s t r i c t P o p u l a t i o n Greater V i c t o r i a (#61) 163,934 Sooke (#62) 31,437 Saanich (#6 3) 2 8,800 G u l f I s l a n d s (#64) 6,421 230,592 85 a) S e r v i c e s The C a p i t a l Region i s served by 4 acute care h o s p i t a l s : 1 each f o r the G u l f I s l a n d s and North Saanich, and 2 r e g i o n a l h o s p i t a l s i n the C i t y o f V i c t o r i a . The Royal J u b i l e e H o s p i t a l i n V i c t o r i a i s the l a r g e s t w i t h 695 beds, and has the o n l y p s y c h i a t r i c u n i t i n the r e g i o n . C a l l e d the E r i c M a r t i n I n s t i t u t e (E.M.I.), the u n i t i s the l a r g e s t g e n e r a l h o s p i t a l p s y c h i a t r i c u n i t i n the pro-v i n c e with 100 a d u l t care beds. The C a p i t a l Region a l s o has the h i g h e s t b e d - t o - p o p u l a t i o n r a t i o i n the p r o v i n c e with .43 p s y c h i a t r i c u n i t beds per 1000 p o p u l a t i o n . E r i c M a r t i n should have o n l y 57 beds i f the d i s t r i c t were p r o v i d e d w i t h the p r o v i n c i a l standard (.25 beds per 1000) f o r t h i s type o f f a c i l i t y . To a l i m i t e d e x t e n t , as seen i n Table 5.3, the h o s p i t a l serves as a secondary r e f e r r a l centre f o r the I s l a n d . In t h i s c a p a c i t y , E.M.I, cou l d support 3 more beds. A symptom o f a system problem i n the C a p i t a l Region i s the i n a c c e s s a b i l i t y o f i n p a t i e n t c a r e . Although the re g i o n has p r o p o r t i o n a t e l y 70 per cent more beds than any ot h e r r e g i o n on the I s l a n d , there i s a constant demand f o r access. As a r e s u l t the h o s p i t a l has implemented s e v e r a l b u f f e r i n g mechanisms which r e g u l a t e flow and f r u s t r a t e r e f e r r i n g agents. These agents are f o r c e d t o r e s o r t to ad-m i s s i o n through the Royal J u b i l e e H o s p i t a l Emergency, and t o i n v o l u n t a r y committal procedures. About 25 per cent o f admissions t o E r i c M a r t i n are i n v o l u n t a r y ; a f i g u r e much 86 h i g h e r than o t h e r p s y c h i a t r i c u n i t s . I t i s no t a b l e t h a t E r i c M a r t i n has not found adequate means to cut average length o f s t a y which i s almost twice the average f o r other p s y c h i a t r i c u n i t s i n the p r o v i n c e . Many p a t i e n t s s t a y s e v e r a l months on the wards when they c o u l d be p l a c e d a t lower l e v e l s o f c a r e . Conversely, there are numerous complaints from community sources t h a t some p a t i e n t s are be i n g d i s c h a r g e d too e a r l y and without s u f f i -c i e n t d i s c h a r g e p l a n n i n g t o guarantee community tenure. The I n s t i t u t e does not have s t a f f p s y c h i a t r i s t s as a l l treatment and discharge o r d e r s are given by those i n p r i v a t e p r a c t i c e . T h i s system, while a p p r o p r i a t e f o r medi-c a l wards where c r i t e r i a f o r c l i n i c a l p r a c t i c e i s more c l e a r l y d e f i n e d , i s not a p p r o p r i a t e f o r a p s y c h i a t r i c ward. Without s t r o n g d i r e c t i o n governing admission c r i t e r i a , l e n g t h of treatment p e r i o d , and d i s c h a r g e p l a n n i n g , the i n p a t i e n t s e r v i c e cannot guarantee t h a t i t s s e r v i c e i s going to be used a p p r o p r i a t e l y and i n accordance to the t o t a l community's needs. E r i c M a r t i n I n s t i t u t e makes a v a i l a b l e 2 n i g h t beds to the p h y s i c i a n s i n the emergency wards o f the 2 V i c t o r i a hos-p i t a l s . P s y c h i a t r i c emergencies are i n i t i a l l y handled by these p h y s i c i a n s who attempt t o get a p s y c h i a t r i c c o n s u l t a -t i o n when i n d i c a t e d . D i f f i c u l t i e s have been r e p o r t e d i n o b t a i n i n g c o n s u l t s a f t e r normal working hours and on weekends. A f t e r - h o u r s a v a i l a b i l i t y o f a p s y c h i a t r i s t i s arranged by those i n p r i v a t e p r a c t i c e , and i s p r i m a r i l y a coverage system 87 f o r p a t i e n t s a l r e a d y c a r r i e d by t h i s group. In. some s i t u a t i o n s t h i s s e r v i c e i s a v a i l a b l e on an emergency b a s i s , but c o n s u l t a t i o n , when ob t a i n e d , i s u s u a l l y over the phone. The r e s u l t i s t h a t d i s p o s i t i o n of emergencies i s l a r g e l y decided by c a s u a l t y o f f i c e r s who when pressed can use the 2 n i g h t beds at E.M.I, a f t e r 8 p.m. C l e a r l y a gap e x i s t s between 5 p.m. and 8 p.m. Approximately 130 p s y c h i a t r i c emergencies p r e s e n t them-s e l v e s t o Royal J u b i l e e H o s p i t a l each month, o f which 2 0 are admitted to the n i g h t beds. F o r t y per cent o f the n i g h t b e d " p a t i e n t s are subsequently admitted t o E.M.I, i n the morning and the remainder are sent home. The m a j o r i t y sent home from the emergency wards and the o v e r n i g h t beds are not f o l l o w e d f o r a f t e r c a r e . T h i s i s another gap i n s e r v i c e complained about by many f i e l d workers i n the V i c t o r i a area. There i s no arrangement with the Mental Health Centres to f o l l o w t h i s group of p a t i e n t s . The C a p i t a l r e g i o n i s served by 2 Mental H e a l t h Centres. The V i c t o r i a Centre serves p a r t of the Greater V i c t o r i a School D i s t r i c t which i n c l u d e s the m u n i c i p a l i t i e s o f E s q u i -malt and Oak Bay, and C i t y o f V i c t o r i a . The p o p u l a t i o n of t h i s area i s 9 8,743. To some ext e n t the Centre serves the Sooke School D i s t r i c t which has a p o p u l a t i o n of 31,437. There are 12 f u l l - t i m e Mental H e a l t h Centre c l i n i c a l p o s i -t i o n s or 9.23 per 100,000, f o r the e n t i r e catchment area. The second Mental Health Centre, i n Saanich, serves the G u l f I s l a n d s and Saanich School D i s t r i c t s , and the 88 p a r t o f Saanich m u n i c i p a l i t y which extends i n t o the Greater V i c t o r i a School D i s t r i c t . The t o t a l p o p u l a t i o n of t h i s catchment area i s 100,430 persons. With 5.5 f u l l - t i m e c l i n i c a l p o s i t i o n s , the Centre p r o v i d e s 5.4 8 per 100,000 p o p u l a t i o n . Both Mental H e a l t h Centres have s t a f f a v a i l a b l e to c h r o n i c p a t i e n t s . The V i c t o r i a Centre has 2 p s y c h i a t r i c nurses and the Saanich Centre has 1 p s y c h i a t r i c nurse. Three s t a f f s t a t i o n e d at the V i c t o r i a Mental H e a l t h Centre have been assig n e d the r e s p o n s i b i l i t y o f d e v e l o p i n g and s u p e r v i s i n g community boarding homes i n the r e g i o n . Each Centre r e c e i v e s s e s s i o n a l time from p s y c h i a t r i s t s ; Saanich r e c e i v e s 10 h a l f - d a y s per week and V i c t o r i a 15 h a l f - d a y s . The p s y c h i a t r i s t s a t the Centres do not admit t o the E r i c M a r t i n I n s t i t u t e . To g a i n admission f o r a Centre c l i e n t , a r e f e r r a l i s f i r s t made to a gen e r a l p r a c t i t i o n e r who i n t u r n gains admission. Some p s y c h o - s o c i a l r e h a b i l i t a t i o n programs e x i s t i n t h i s r e g i o n . Two o f the 6 boarding homes s u p e r v i s e d by Centre s t a f f p r o v i d e some p r e p a r a t i o n f o r community l i v i n g to 22 r e s i d e n t s , although one home i s u n d e r s t a f f e d because o f funding l i m i t a t i o n s . There are no s a t e l l i t e apartment programs or c o o p e r a t i v e housing. A v o l u n t a r y o r g a n i z a t i o n , Canadian Mental H e a l t h A s s o c i a t i o n , operates two programs f o r the c h r o n i c a l l y d i s a b l e d . One i s a r e c r e a t i o n / a c t i v i t y o r i e n t e d day program which has 50 to 70 p a r t i c i p a n t s , and the o t h e r attempts to teach s o c i a l and d a i l y l i v i n g s k i l l s 89 t o a s i m i l a r g r o u p . Some r e s i d e n t s o f t h e b o a r d i n g homes a t t e n d t h e s e p r o g r a m s . V o c a t i o n a l s e r v i c e s f o r t h e m e n t a l l y i l l a r e o p e r a t e d b y s e v e r a l n o n - p r o f i t a g e n c i e s . T h e A r b u t u s C r a f t s p r o g r a m t e a c h e s b a s i c j o b s k i l l s t o a b o u t 15 t o 20 m e n t a l l y i l l p e r s o n s . T h e G a r t h Homer p r o j e c t p r o v i d e s some v o c a t i o n a l c o u n s e l l i n g a n d t r a i n i n g . S t . V i n c e n t de P a u l t a k e s i n 10 m e n t a l l y i l l p e r s o n s a t a t i m e f o r p r e - e m p l o y m e n t a s s e s s m e n t a n d b a s i c t r a i n i n g . A l t h o u g h V i c t o r i a i s b e t t e r s e r v i c e d i n t h i s a r e a t h a n t h e r e s t o f t h e I s l a n d , m o s t p r o f e s s i o n a l c a r e - g i v e r s e x p r e s s e d a n e e d f o r m o r e c o m p r e h e n s i v e v o c a -t i o n a l p r o g r a m s i n c l u d i n g a s s e s s m e n t , t r a i n i n g , a n d p l a c e -m e n t . b) U t i l i z a t i o n T h e C i t y o f V i c t o r i a w i t h a p o p u l a t i o n o f 6 2 , 5 4 5 , h a s c h a r a c t e r i s t i c s o f m o s t c i t i e s ; s u b s t a n d a r d h o u s i n g , a s k i d roxv, h i g h r i s e d e v e l o p m e n t , c h a r i t y m i s s i o n s a n d s o c i a l s e r v i c e s f o r t h e d i s p o s s e s s e d , a n d s i n g l e r o o m o c c u p a n c y h o t e l s . I n s h o r t , t h e c i t y c o n t a i n s e l e m e n t s w h i c h c o r r e -l a t e w i t h a c o n c e n t r a t i o n o f p e o p l e m a r g i n a l l y a t t a c h e d t o t h e m a i n s t r e a m o f s o c i e t y . W i t h i n t h i s g r o u p w o u l d e x i s t a l a r g e n u m b e r o f c h r o n i c s c h i z o p h r e n i c s , many o f whom w o u l d h a v e d r i f t e d t o t h e c i t y c o r e f r o m t h e s u r r o u n d i n g a r e a . B e c a u s e o f t h e n a t u r e o f t h e r e g i o n , i . e . h a v i n g a n u r b a n c o r e a n d r u r a l p e r i p h e r y , i t i s l i k e l y t h a t t h e c a l -c u l a t i o n o f e x p e c t e d p r e v a l e n c e f o r s c h i z o p r e n i a , b y s c h o o l d i s t r i c t , may n o t r e f l e c t t h e a c t u a l d i s t r i b u t i o n o f m o r b i d i t y 90 w i t h i n the r e g i o n . A technique i s proposed here which allows f o r a r e c a l c u l a t i o n of p r e v a l e n c e d i s t r i b u t i o n . T h i s technique uses g e n e r a l h o s p i t a l s e p a r a t i o n d a t a , c o n t i n u i n g w i t h the assumption t h a t the p r o p o r t i o n of c h r o n i c mental i l l n e s s t o a l l h o s p i t a l s e p a r a t i o n s f o r p s y c h i a t r i c care i s r e l a t i v e l y constant from r e g i o n to r e g i o n . The h o s p i t a l s e p a r a t i o n s f o r the C a p i t a l Region's p o p u l a t i o n by s c h o o l d i s t r i c t have been reproduced on Table 6.1 (page 130). Column (1) shows the s e p a r a t i o n s f o r p s y c h i a t r i c care from a l l f o u r acute care h o s p i t a l s i n the r e g i o n . Column (2) shows these s e p a r a t i o n s as r a t e s . There are l a r g e d i f f e r e n c e s among the s c h o o l d i s -t r i c t s f o r h o s p i t a l s e p a r a t i o n r a t e s f o r p s y c h i a t r i c care. These d i f f e r e n c e s are shown as p r o p o r t i o n s to the average r a t e f o r the e n t i r e C a p i t a l Region i n Column (3). These p r o p o r t i o n s were used as weights and a p p l i e d t o column (4), i . e . the expected prevalence o f s c h i z o p h r e n i a i n each s c h o o l d i s t r i c t . The r e s u l t i n g c a l c u l a t i o n , i n column (5) shows the r e v i s e d number o f expected cases i n each s c h o o l d i s t r i c t . T h i s r e v i s e d d i s t r i b u t i o n o f cases should r e f l e c t the degree of d r i f t i n g towards the urban core. In keeping with the e a r l i e r p r e s e n t a t i o n o f a range estimate o f p r e v a l e n c e , the column (5) D i s t r i b u t i o n of s c h i z o p h r e n i a would appear as f o l l o w s : 91 Upper Bound Mean Lower Bound Greater V i c t o r i a 865 758 651 Sooke 82 72 62 Saanich 94 82 71 Gulf I s l a n d s 22 19 16 T o t a l s 1063 931 800 There were 190 8 g e n e r a l h o s p i t a l s e p a r a t i o n s f o r psy-c h i a t r i c care a t t r i b u t e d to the C a p i t a l Region•s p o p u l a t i o n i n 1977. A l l but 54 s e p a r a t i o n s (2.83%) were t r e a t e d w i t h i n the r e g i o n . T h i s i s the lowest p r o p o r t i o n of a l l I s l a n d r e g i o n s . The t o t a l p s y c h i a t r i c s e p a r a t i o n r a t e f o r g e n e r a l h o s p i t a l s i s a l s o the lowest f o r the I s l a n d . Of the 190 8 s e p a r a t i o n s , 75 per cent were t r e a t e d a t the Royal J u b i l e e / E r i c M a r t i n complex. I t i s i n t e r e s t i n g to note t h a t t h i s h o s p i t a l t r e a t e d 78 per cent of a l l p s y c h i a t r i c s e p a r a t i o n s f o r the V i c t o r i a and Sooke School D i s t r i c t s ' r e s i d e n t s , 56 per cent f o r Saanich r e s i d e n t s , and 2 3 per cent t o those o f the G u l f I s l a n d s . D i s t a n c e and a v a i l a b i l i t y o f l o c a l beds pro-bably a f f e c t s u t i l i z a t i o n o f the p s y c h i a t r i c f a c i l i t i e s at the c e n t r a l h o s p i t a l . I t can be suggested t h a t l o c a l hos-p i t a l s have a c a p a c i t y to t r e a t many of t h e i r communities p s y c h i a t r i c problems. I f 16 per cent, the province-wide average, of a l l the p s y c h i a t r i c s e p a r a t i o n s were f o r s c h i z o p h r e n i a , then 305 s e p a r a t i o n s i n t h i s r e g i o n would be a t t r i b u t e d to t h i s i l l n e s s . 92 The Royal J u b i l e e / E r i c M a r t i n complex t r e a t e d 1551 p s y c h i a t r i c care s e p a r a t i o n s i n 1977. A l l but 113 of these were a t t r i b u t e d t o the r e g i o n ' s p o p u l a t i o n . Only 6 4 (4 per cent) of the s e p a r a t i o n s were a t t r i b u t e d t o r e s i d e n t s from the r e s t o f the I s l a n d . More than twice t h i s number o f I s l a n d r e s i d e n t s were t r e a t e d i n Riverview and Vancouver h o s p i t a l s . E.M.I., w i t h i t s high bed-to-p o p u l a t i o n r a t i o , and more than twenty a d m i t t i n g p s y c h i a -t r i s t s , has not managed t o f u l f i l l the r o l e of a secondary treatment c e n t r e f o r Vancouver I s l a n d . E.M.I, a l s o draws on the l o c a l area f o r i t s out-p a t i e n t s e r v i c e and day program. Approximately 25 t o 35 c h r o n i c p a t i e n t s are a t t e n d i n g the o u t p a t i e n t s e r v i c e , p r i m a r i l y f o r m e d i c a t i o n s . V i r t u a l l y no s c h i z o p h r e n i c s at t e n d the day program as t h i s i s a program f o r n e u r o t i c s . The C a p i t a l Region has the lowest I s l a n d admission r a t e t o Riverview, w i t h 9 p a t i e n t s being admitted i n 1978. These were a l l admitted from the V i c t o r i a Mental H e a l t h Centre catchment area so r e p r e s e n t a r a t e o f 6.91 admissions per 100,000. In June 1978, Riverview had 5 8 p a t i e n t s whose home address was w i t h i n the C a p i t a l Regional D i s t r i c t . A l l but 1 of these were from the V i c t o r i a Centre's catchment area. S i x t e e n of these Riverview p a t i e n t s were assessed as r e q u i r i n g acute p s y c h i a t r i c care and 14 as r e q u i r i n g l o n g -term p s y c h i a t r i c and medical care. The remainder, o r 49 per cent, c o u l d be cared f o r i n l o c a l f a c i l i t i e s , but are not because o f a shortage of f a c i l i t i e s . Most of these 93 p a t i e n t s r e f e r r e d t o Riverview over the years have a d i a g n o s i s o f f u n c t i o n a l p s y c h o s i s (35 out of 58) and, secondly, o f o r g a n i c p s y c h o s i s (18 out o f 58). In 1976, the Saanich Mental H e a l t h Centre d e c l a r e d 54 or 9.2 per cent o f i t s 587 open cases as having a chro-n i c mental i l l n e s s . The V i c t o r i a Centre d e c l a r e d 45 8 open cases i n 19 76, of which 183 (39 per cent) were c l a s s i f i e d as having a c h r o n i c mental i l l n e s s . T h i s per-centage i s h i g h e r than any o t h e r I s l a n d Mental Health Centre. P a r t o f the reason i s t h a t the Centre has the p s y c h i a t r i c nurse p o s i t i o n s s p e c i f i c a l l y d e s i g n a t e d t o care f o r the c h r o n i c p a t i e n t . The nurses r e p o r t c a r r y i n g 100 c h r o n i c p s y c h o t i c s between them. The Saanich Centre has 1 p s y c h i -a t r i c nurse who c a r r i e s 40 c h r o n i c c l i e n t s . Some o f the casel o a d of the 3 nurses r e s i d e . i n the boarding homes which are s u p e r v i s e d by other Centre s t a f f . A l l o f the 85 r e s i d e n t s i n the mental h e a l t h boarding homes have me d i c a t i o n p r e s c r i b e d by the p s y c h i a t r i s t i n the V i c t o r i a Mental Health Centre. Most other c h r o n i c pa-t i e n t s have medications p r e s c r i b e d by p h y s i c i a n s and p s y c h i -a t r i s t s i n p r i v a t e p r a c t i c e . Only some of these p a t i e n t s r e c e i v e long-term follow-up,arid c o n t a c t by the 3 community p s y c h i a t r i c nurses i n the Mental H e a l t h Centres. Many more p a t i e n t s are r e f e r r e d but the nurses have r e f u s e d a d d i t i o n a l r e f e r r a l s because of t h e i r heavy e x i s t i n g c a s e l o a d . There e x i s t s at l e a s t f o u r separate means f o r maintaini-i n g the c h r o n i c p a t i e n t i n the community. The Mental H e a l t h 94 Centres support two of these. Only the community nurse's r o l e approaches the concept of case manager as o u t l i n e d i n Chapter 4. But t h i s f u n c t i o n i s l i m i t e d both because of h i g h caseloads and l a c k o f c o o r d i n a t i o n between the s e r -v i c e s they would need t o access f o r t h e i r c l i e n t s . Summary The mean one y e a r t r e a t e d prevalence f o r s c h i z o p h r e n i a has been es t i m a t e d t o be 1761 f o r Vancouver I s l a n d . As mentioned e a r l i e r , about two - t h i r d s of t h i s number w i l l e x h i b i t permanent d i s a b i l i t i e s o r d e f e c t s i m p a i r i n g f u l l s o c i a l f u n c t i o n i n g . The p o p u l a t i o n i n the three I s l a n d r e g i o n s produced 455 4 h o s p i t a l s e p a r a t i o n s which r e c e i v e d p s y c h i a t r i c c a r e . Approximately 16 per cent, or 730 s e p a r a t i o n s , were f o r s c h i z o p h r e n i a , although the percentage t r e a t e d i n l o c a l p s y c h i a t r i c u n i t s v a r i e d between 12 per cent i n Duncan t o 2 3 per cent i n Nanaimo. H o s p i t a l s e p a r a t i o n data cannot be compared to the expected prevalence o f s c h i z o p h r e n i a as h o s p i t a l s r e c o r d numbers of s e p a r a t i o n s , not numbers o f i n d i v i d u a l s t r e a t e d . However, i f i t were assumed t h a t some o f these s e p a r a t i o n s r e p r e s e n t the same person being admitted twice or more dur i n g the y e a r , and t h a t between 500 t o 600 i n d i v i d u a l s account f o r the 730 s e p a r a t i o n s f o r s c h i z o p h r e n i a , then, approximately o n e - t h i r d of the expected prevalence were pro-v i d e d i n p a t i e n t treatment d u r i n g 1977. 95 As seen i n Table 5.2 and 5.5, the areas of the I s l a n d vary i n t h e i r use o f Vancouver h o s p i t a l s and Riverview. The area w i t h the l e a s t u t i l i z a t i o n of o u t - o f - r e g i o n h o s p i t a l s i s the C a p i t a l Region by v i r t u e of having a s u r p l u s o f p s y c h i a t r i c beds, many being used f o r c h r o n i c care. The area with the next lowest percentage i s Nanaimo, which i s the o n l y h o s p i t a l p r o v i d i n g a day program f o r the c h r o n i c a l l y i l l . P o r t A l b e r n i has the h i g h e s t u t i l i z a -t i o n r a t e f o r Riverview h o s p i t a l and i s the o n l y r e g i o n without l o c a l p s y c h i a t r i c u n i t beds. C l i n i c a l o u t p a t i e n t s e r v i c e s f o r the c h r o n i c a l l y i l l are i n c o m p l e t e l y p r o v i d e d by Mental H e a l t h Centres. The p s y c h i a t r i c nurse p o s i t i o n s f o r the c h r o n i c p a t i e n t s are p r o v i d e d t o some Centres but not a l l . There i s a d i r e c t r e l a t i o n s h i p between n u r s i n g time a v a i l a b l e and percentage of t o t a l Centre c a s e l o a d t h a t i s c h r o n i c . While not s u r -p r i s i n g , t h i s r e l a t i o n s h i p suggests an a d d i t i o n a l need f o r the nurse p o s i t i o n s . A d d i t i o n a l l y , the p s y c h i a t r i s t s e s -s i o n s a v a i l a b l e to the Centres do not seem to be a l l o c a t e d on a c o n s i s t e n t b a s i s of need. Port A l b e r n i Centre has one nurse and a f u l l - t i m e p s y c h i a t r i s t a v a i l a b l e , w h i l e Nanaimo Centre has the nurse but o n l y a t e n t h of a f u l l - t i m e p s y c h i -a t r i s t . I f t w o - t h i r d s o f the expected 1761 s c h i z o p h r e n i c s r e -c e i v i n g treatment o r care i n one year have a l a s t i n g func-t i o n a l impairment, then many would show up i n Mental H e a l t h 96 Centre c a s e l o a d s . Yet only 371, (or 15 per c e n t ) , of the Centres' t o t a l c a s e l o a d were d e c l a r e d as having a c h r o n i c mental i l l n e s s , w i t h some having s c h i z o p h r e n i a . I f even one-half o f the expected s c h i z o p h r e n i c s with a permanent d i s a b i l i t y would r e q u i r e the Centres' s e r v i c e s at a p o i n t i n time, there would be about 610 cases at the Centres. L o c a l g e n e r a l p r a c t i t i o n e r s r e f e r more of the s e r i o u s mental pathology to p s y c h i a t r i s t s than to the C e n t r e s . P r i v a t e p r a c t i c e cannot b i l l the insurance p l a n f o r many s e r v i c e s t h a t c h r o n i c p a t i e n t s need and which c o u l d be p r o v i d e d by non-medical p e r s o n n e l . One r e s u l t o f t h i s s i t u -a t i o n i s an over-use of h o s p i t a l c a r e , which i s the most expensive component i n the t o t a l system. Comprehensive community-based p s y c h i a t r i c s e r v i c e s should be a v a i l a b l e as an a l t e r n a t i v e and a c o n t i n u a t i o n to i n p a t i e n t c a r e . A l t e r n a t i v e s should be a v a i l a b l e through the Mental H e a l t h Centres and s p e c i a l l y designed day p r o -grams. However, the emphasis o f p r o f e s s i o n a l time i n the Centres i s on s i t u a t i o n a l d i s o r d e r s , l i f e s t y l e c o u n s e l l i n g , and f a m i l y and m a r i t a l i n t e r v e n t i o n s . B a s i c l i n k i n g s e r -v i c e s such as emergency t r i a g e and r e g u l a r follow-up from i n p a t i e n t to o u t p a t i e n t care do not e x i s t . The community nurse program i s an attempt by the Mental H e a l t h Centres to p r o v i d e follow-up t o c h r o n i c pa-t i e n t s , but t h i s i s s t i l l inadequate. There are not enough o f them and they are not p a r t o f a system, as no r e a l system e x i s t s . The s e r v i c e s i n the I s l a n d r e g i o n show themselves as 97 elements s h a r i n g a s i m i l a r geography. The f a i l u r e t o develop i n t e r - a g e n c y c o l l a b o r a t i v e e f f o r t s , c o n t i n u i t y of c a r e , and case management can be a t t r i b u t e d to s e v e r a l f a c t o r s . No mental h e a l t h agency has been p r o v i d e d a mandate to e x e r c i s e l e a d e r s h i p . The Mental He a l t h Centres are p a r t of a p r o v i n c i a l system which h i s t o r i c a l l y has been unable to o p e r a t i o n a l i z e a c l e a r mandate. The p s y c h i -a t r i c u n i t s and E r i c M a r t i n p a r t i c u l a r l y are b a s i c a l l y workshops f o r p r i v a t e p r a c t i t i o n e r s , each f o l l o w i n g t h e i r p e r s o n a l p r a c t i c e s . The h o s p i t a l u n i t s have l i t t l e i n t e r -n a l i n t e g r a t i o n and l e a d e r s h i p , l e t alone p r o v i d i n g l e a d e r -s h i p o u t s i d e t h e i r w a l l s . Not enough resources have been p r o v i d e d t o v o l u n t a r y agencies d e a l i n g with the c h r o n i c a l l y s e r i o u s l y i l l , thus no o r g a n i z e d v o i c e has a r i s e n from t h i s s e c t o r . The f o l l o w i n g chapter w i l l address these s e r v i c e de-f i c i e n c i e s and o r g a n i z a t i o n a l problems, and g i v e s p e c i f i c re commendations. 98 Chapter 7  The Planning Area; Recommendations The e x i s t i n g p s y c h i a t r i c services on Vancouver Island have been examined i n the previous chapter. The general h o s p i t a l p s y c h i a t r i c units and Mental Health Centres are the main components of the public intervention and t r e a t -ment system. The chronic patient shows up f a i r l y consis-t e n t l y i n the former service and less so i n the l a t t e r . Riverview hospital also serves as a treatment resource for psychotic patients, with a s i g n i f i c a n t number i n residence who could be returned to the community. The communities do not have the capacity to reintegrate these patients, nor the capacity to adequately maintain or r e h a b i l i t a t e those already resident l o c a l l y . As a r e s u l t , there are multiple readmissions to l o c a l p s y c h i a t r i c units. Not only do com-munities lack service capacity, the e x i s t i n g components show no properties of a coordinated system. A plan for the Island that i s intended to r e c t i f y these d e f i c i e n c i e s should be presented i n d e t a i l , as service providers need guidelines for implementing new components and for task coordination. Funding agencies and p o l i t i c i a n s need to know the extent of the system being proposed. System planners should have s u f f i c i e n t d e t a i l to estimate manpower a v a i l a b i l i t y , impact on other service systems, and demands on resource a l l o c a t i o n mechanisms. The communities that are asked to take r e s p o n s i b i l i t y for t h e i r disabled c i t i z e n s 99 should be helped t o r e a l i z e the extent of t h e i r r e s p o n s i -b i l i t y . A Procedure f o r E s t i m a t i n g S e r v i c e Demand Several references have been made i n Chapter 3 t o l i t e r a t u r e t h a t propose s e r v i c e systems. Only one of these (Townsend, 1977) attempts t o estimate the a c t u a l c a p a c i t y of system components f o r a chro n i c p a t i e n t p o p u l a t i o n . These c a p a c i t i e s should be e x t r a c t e d and d i r e c t l y a p p l i e d as estimates o f s e r v i c e requirements t o complete the l o c a l community support system on Vancouver I s l a n d . One s h o r t -coming o f t h i s procedure i s t h a t Townsend draws on American experience and although the s e r v i c e i s s u e s may be s i m i l a r , d i f f e r e n t s e r v i c e arrangements may have produced estimates not appropriate f o r l o c a l use. To guard against t h i s pro-blem, Townsend w i l l be used as a check on the r e s u l t s of a s e r v i c e u t i l i z a t i o n and need study completed on a l o c a l s e r v i c e ; the Greater Vancouver Mental Health S e r v i c e (Tomlin-son e t a l . , 1977). This survey r e p o r t attempted t o determine the extent the proposed S o c i a l S e r v i c e s Act (S.S.A.) would a f f e c t com-munity mental h e a l t h programs i n Vancouver. This l e g i s l a -t i o n was intended t o a i d the Provinces i n t h e i r response to the changing s o c i a l and personal needs of Canadians by attempting t o improve e x i s t i n g c o s t - s h a r i n g arrangements i n t h i s area. The B i l l was not passed however, f o r as p a r t of a cost-containment program i t was p u l l e d from the Order paper 100 of the House of Commons i n l a t e 1977. A number of s e r v i c e s were o u t l i n e d i n the B i l l as e l i g i b l e f o r f e d e r a l c o s t - s h a r i n g . The s e r v i c e a c t i v i -t i e s of the Greater Vancouver Mental Health Service were appraised using the c r i t e r i a f o r the sharable s e r v i c e s l i s t e d i n the B i l l . S e v e r a l o f these s e r v i c e d e s c r i p -t i o n s are quoted below. R e h a b i l i t a t i v e S e r v i c e s This s e c t i o n of the S o c i a l Services Act s e r v i c e s was d i v i d e d i n t o two p a r t s f o r the survey. The f i r s t p a r t r e t a i n e d the t i t l e R e h a b i l i t a t i o n Services and were described as those s e r v i c e s which " i n t e n d t o reduce or remove the e f f e c t s o f an impairment which s u b s t a n t i a l l y l i m i t s a d i s a b l e d person's a b i l i t y to o b t a i n or maintain employment and/or t o undertake the normal a c t i v i t i e s of d a i l y l i v i n g i n the community. These s e r v i c e s may i n c l u d e : assessment, s e r v i c e s t o a i d independent l i v i n g , c o u n s e l l i n g , s o c i a l i z a t i o n , p r e - v o c a t i o n a l t r a i n i n g , . . . p r o v i s i o n s f o r access t o places of r e s i d e n c e / t r a i n i n g / o r employment. For the purposes of the Act community mental h e a l t h s e r v i c e s of a r e h a b i l i t a t i v e nature provided i n the community are considered as r e h a b i l i t a t i v e s e r v i c e s . " For the survey, a p a r t of t h i s s e c t i o n was e x t r a c t e d and termed Employment Se r v i c e s which i n c l u d e d the phrases "employment pr e p a r a t i o n and work a c t i v i t y , employment sup-p o r t , a l t e r n a t i v e employment, ( i . e . s h e l t e r e d work s e t t i n g s ) " . 101 S o c i a l Integration Services S o c i a l Integration Services as outlined i n the S.S.A. were designed "to aid individ u a l s who are s o c i a l l y i s o -l a t e d , or members of groups f o r which there i s an unusually high incidence of i n d i v i d u a l s o c i a l i s o l a t i o n " and the intent was to "b u i l d or maintain p o s i t i v e interpersonal r e l a t i o n s h i p s , or to develop or engage i n personally sa-t i s f y i n g group a c t i v i t i e s , or to p a r t i c i p a t e meaningfully i n community l i f e . This service must include: "a) representational and f a c i l i t a t i v e services to remove or reduce obstacles preventing indiv i d u a l s and groups u t i l i z i n g goods and services. b) s o c i a l i z a t i o n services to i d e n t i f y problems and help integrate i n d i v i d u a l s i n a s o c i a l group. c) counselling services. d) outreach services, and may include reception services or supportive l i v i n g environments of a short term nature f o r individuals i n t r a n s i t i o n . " Day Care for Adults "Day Care for Adults i s intended to provide a super-vised program i n the community that must include a c t i v i -t i e s , personal care, and emergency f i r s t a i d , overseeing medication and l i a i s o n with the home s i t u a t i o n . I t may include one meal." This description of day care would include e x i s t i n g day h o s p i t a l programs. Residential Services f o r Adults "Residential Services for Adults are intended to pro-vide board and room, supervision, personal, nursing,, 102 p r o t e c t i v e / s u p p o r t i v e c a r e , o r s o c i a l r e h a b i l i t a t i o n s e r -v i c e s . " T h i s w o u l d i n c l u d e t h e c a r e p r o v i d e d i n t h e e x i s t i n g m e n t a l h e a l t h b o a r d i n g h o m e s . The S o c i a l S e r v i c e s A c t s u r v e y u s e d a l a r g e s a m p l e o f t h e G . V . M . H . S . e n r o l l e d c l i e n t s (402 o f 2 6 0 1 ) . A s u r v e y i n s t r u m e n t was a d m i n i s t e r e d t o t h e p r i m a r y t h e r a -p i s t o f t h e s a m p l e i n o r d e r t h a t t w o q u e s t i o n s be a n s w e r e d . 1. "How many c l i e n t s o f G . V . M . H . S . a r e c u r r e n t l y r e c e i v i n g t h e d i f f e r e n t s e r v i c e s a s d e s c r i b e d u n d e r S . S . A . ? " 2 . "How many c l i e n t o f G . V . M . H . S . s h o u l d r e c e i v e f u r t h e r s e r v i c e s s u c h a s t h o s e d e s c r i b e d u n d e r S . S . A . ? " The c u m u l a t i v e a n s w e r s t o t h e s e q u e s t i o n s , f o r t h e f i v e s e r v i c e s o u t l i n e d a b o v e , a r e shown b e l o w . S e r v i c e H e a d i n g Q u e s t i o n #1 Q u e s t i o n #2 B o t h Q u e s t i o n s R e h a b i l i t a t i o n 81% 3% 84% E m p l o y m e n t 3% 16% 19% S o c i a l I n t e g r a t i o n 26% 21% 47% Day C a r e 1% 6% 7% R e s i d e n t i a l 17% 3% 20% E r n e s t T o w n s e n d (1977 ) e v a l u a t e d t h e e c o n o m i c f e a s i -b i l i t y o f t r e a t i n g s c h i z o p h r e n i c p a t i e n t s w i t h i n a c o m m u n i t y -b a s e d s y s t e m a s o p p o s e d t o a h o s p i t a l - b a s e d s y s t e m . He e s t i m a t e d t h e p e r c e n t a g e o f c a s e s , b a s e d o n a o n e - y e a r e x p e c t e d p r e v a l e n c e o f s c h i z o p h r e n i a , t h a t w o u l d u s e v a r i o u s c o m p o n e n t s o f a c o m m u n i t y s y s t e m . Some o f T o w n s e n d s ' s c o m -p o n e n t s o f c o m m u n i t y c a r e c a n b e r e g r o u p e d t o a p p r o x i m a t e 103 the c l a s s i f i c a t i o n s of s e r v i c e s used i n the S o c i a l Ser-v i c e s Act. Townsend's estimates of u t i l i z a t i o n appear below. Category of S e r v i c e Townsend Estimate R e h a b i l i t a t i o n 40 - 81% Employment 12 - 18% S o c i a l I n t e g r a t i o n 24 - 40% Day Care R e s i d e n t i a l 1 4 - 1 8 % There are minor d i f f e r e n c e s between the u t i l i z a t i o n estimates of the two s t u d i e s . Townsend estimated u t i l i -z a t i o n w i t h i n a one-year p e r i o d w h i l e the Tomlinson survey reported u t i l i z a t i o n w i t h i n a three-month p e r i o d . Consi-d e r i n g the c h r o n i c nature of s c h i z o p h r e n i a , the d i f f e r e n t time periods should not adversely a f f e c t comparison. Town-send' s range of u t i l i z a t i o n f o r R e h a b i l i t a t i o n S e r v i c e s i s a t t r i b u t e d t o h i s d e t a i l e d estimates f o r d i f f e r e n t r e h a b i l i -t a t i o n t h e r a p i e s ; t h i s was not a v a i l a b l e i n the Tomlinson paper. The 81 per cent and 84 per cent f i g u r e s r e f e r to use o f chemotherapy, the lower f i g u r e to other t h e r a p i e s . The c a t e g o r i e s of s e r v i c e s described i n the S o c i a l S e r v i c e s Act survey are not i d e n t i c a l to the c a t e g o r i e s described i n the model system i n Chapter 4. They do, how-ever describe most s e r v i c e s under the model system headings of "Psycho-social R e h a b i l i t a t i o n S e r v i c e s " and "Long-term Support and Maintenance S e r v i c e s " . To a l e s s e r e x t e n t , they 104 describe s e r v i c e s w i t h i n the headings o f "Mental Health S e r v i c e s " and "Community Acceptance S t r a t e g i e s " . In s p i t e of d i f f i c u l t i e s i n c o m p a r a b i l i t y to the model, the s e r v i c e c a t e g o r i e s used i n the Tomlinson study do provide a q u a n t i f i c a t i o n of demand f o r some model system components. These demand estimates w i l l provide a s t a r t i n g p o i n t f o r l o c a l region planning. Estimates of Ser v i c e Capacity i n the Planning Region C a l c u l a t i o n s of s e r v i c e c a p a c i t y can be made once the expected u t i l i z a t i o n , or demand, f o r the s e r v i c e i s known. U t i l i z a t i o n can be considered t o be the number of persons at r i s k who would use a s e r v i c e i n a given time p e r i o d . A b e t t e r estimate o f u t i l i z a t i o n would r e s u l t i f i t was based on the number of cases expected t o be " a c t i v e " i n the s e r -v i c e system at any one time. Only a p r o p o r t i o n of the ex-pected prevalence of schizophrenics w i l l be " a c t i v e " i n the s e r v i c e system. Some cases w i l l be i n a s t a t e of r e m i s s i o n , others w i l l have not yet entered the system. Seventy per cent of the expected cases of sc h i z o p h r e n i a w i l l be c o n s i -dered t o be a c t i v e at one time. This i s the percentage of schizophrenics t h a t F i s h (1961) proposed would r e q u i r e some degree of i n d e f i n i t e supports f o r d a i l y l i v i n g . The c a p a c i t y o f a s e r v i c e i s defined as the number of c l i e n t s t h a t can be e n r o l l e d at one time. The ca p a c i t y of the s e r v i c e components, taken from the S o c i a l S e r vices Act survey, has been c a l c u l a t e d f o r each of the three sub-regions of 105 Vancouver I s l a n d . These c a l c u l a t i o n s are shown i n Table 7.1 on page 131. Al s o shown i n the t a b l e i s estimated c a p a c i t y f o r minimally supervised housing, as described by Tomlinson and Cumming (1976), and an estimate of the number of case managers r e q u i r e d f o r a l l cases e n r o l l e d i n the system o f s e r v i c e s . T h i r t y cases w i l l r e q u i r e one case manager. Column ( 2 ) , of Table 7.1, l i s t s : (a) the number of e n r o l l e d cases w i t h i n the s e r v i c e system at any one time, i . e . 70 per cent o f the one-year mean expected prevalence; (b) the mean number o f e n r o l l e d cases expected t o r e q u i r e the f i v e s e r v i c e c a t e g o r i e s at any one time, (some c l i e n t s would be using more than one s e r v i c e ) ; and (c) the mean number of primary workers r e q u i r e d f o r a l l e n r o l l e d cases. Column (3) shows the d e v i a t i o n from the mean i n order t h a t the upper and lower bounds on the u t i l i z a t i o n may be e s t i -mated. Column (4) l i s t s : (a) the number of ch r o n i c c l i e n t s c u r r e n t l y e n r o l l e d i n the f i v e c a t e g o r i e s at the time o f the survey of s e r v i c e s on the I s l a n d and; (b) the current number o f p r o f e s s i o n a l s (nurses and s o c i a l workers) i n the Mental Health Centres s p e c i f i c a l l y a v a i l a b l e to the chr o n i c p a t i e n t . The d e f i c i e n c i e s i n s e r v i c e c a p a c i t y f o r the c h r o n i c -a l l y mentally d i s a b l e d f o r the three sub-regions o f Vancouver I s l a n d i s apparent from comparison of columns (2) and (4) on Table 7.1. I t would be u s e f u l t o examine these areas i n 106 g r e a t e r d e t a i l i n order t h a t these s e r v i c e need e s t i -mates can be i n t e g r a t e d w i t h the s e r v i c e s already a v a i l -able. Because of the s i z e of the C a p i t a l Region r e l a t i v e t o the others , t h i s examination w i l l concentrate on t h i s area. S e r v i c e Recommendations f o r the C a p i t a l Region In Chapter 4, a s e r v i c e system model was presented as being able t o meet the needs of the c h r o n i c a l l y i l l and d i s a b l e d . S e r v i c e s were c a t e g o r i z e d under the f o l l o w -i n g headings: a) Mental Health S e r v i c e s b) Psycho-Social R e h a b i l i t a t i o n S e r v i c e s , c) Long-Term Support and Maintenance S e r v i c e s , d) Community I n t e g r a t i o n and Acceptance S t r a t e g i e s , e) P r o t e c t i o n of C l i e n t s * R i g h t s , and f) P l a n n i n g , Coordination,Case Management and C o n t i n u i t y o f Care. Estimates o f c e r t a i n s e r v i c e s have been made and presented i n Table 7.1. These w i l l be i n t e g r a t e d i n t o the model i n order t h a t s p e c i f i c recommendations can be made from i t s o u t l i n e . Mental Health Services I t i s proposed here t h a t a l l s e r v i c e s under "Mental Health S e r v i c e s " be provided by p u b l i c l y organized s e r v i c e s . P r i v a t e medical p r a c t i c e does not have the f i n a n c i a l mecha-nisms a v a i l a b l e t o provide comprehensive s e r v i c e s t o the 107 c h r o n i c a l l y m e n t a l l y i l l a n d d i s a b l e d . The t w o M e n t a l H e a l t h C e n t r e s i n t h e C a p i t a l R e g i o n do n o t p r e s e n t l y h a v e t h e c a p a c i t y f o r 574 t o 730 e n r o l l e d c h r o n i c c l i e n t s f o r t h e " d i a g n o s t i c e v a l u a t i o n . . . p r e s c r i p t i o n , r e v i e w a n d r e g u l a t i o n o f m e d i c a t i o n ; and c o m m u n i t y - b a s e d p s y c h i a t r i c a n d p s y c h o l o g i c a l s e r v i c e s " t h a t t h i s s e c t i o n o f t h e m o d e l r e q u i r e s . The a d d i t i o n o f t h e 18 ( r a n g e 1 5 . 5 - 2 0 . 5 ) c a s e m a n a g e r s i s i n t e n d e d t o g i v e t h e M e n t a l H e a l t h C e n t r e s t h i s c a p a c i t y . The c a s e m a n a g e r p o s i t i o n s a l s o p r o v i d e p r i m a r y m e n t a l h e a l t h s e r -v i c e s t o t h e c h r o n i c p a t i e n t . H e n c e t h e r e a r e t w o r o l e s b u i l t i n t o t h e j o b d e s c r i p t i o n : c a s e management a n d t r e a t -m e n t . W i t h t h e l a t t e r , t h e c a s e m a n a g e r i s c o n s i d e r e d a s t h e " p r i m a r y w o r k e r " f o r t h e c l i e n t . Some o f t h e s e s e r -v i c e s a r e c u r r e n t l y b e i n g p r o v i d e d w i t h i n t h e p r i v a t e p r a c t i c e s y s t e m a n d t o a d e g r e e t h i s w i l l c o n t i n u e . A p h a s i n g - i n o f t h e p r i m a r y w o r k e r p o s i t i o n s w i l l a l l o w f o r a g r a d u a l t r a n s f e r o f t h i s s e r v i c e f r o m t h e p r i v a t e t o p u b l i c s y s t e m . M o s t o f t h e c h r o n i c a l l y d i s a b l e d w i l l b e u s i n g p s y c h o -t r o p i c m e d i c a t i o n s f o r an i n d e f i n i t e p e r i o d . N u r s i n g s k i l l s w i l l t h e r e f o r e b e an i m p o r t a n t i n g r e d i e n t o f t h e c a s e m a n a -g e r p o s i t i o n . S o c i a l w o r k s k i l l s i n t h e p r o v i s i o n o f s u p -p o r t t o p a t i e n t s ' s o c i a l s y s t e m s a n d i n t h e m a n i p u l a t i o n o f t h e s e s y s t e m s a r e a l s o n e c e s s a r y . The c a s e m a n a g e r s c o u l d b e f r o m e i t h e r s o c i a l w o r k o r n u r s i n g d i s c i p l i n e s a n d w i t h 108 a team approach b u i l t i n t o the t a s k , each d i s c i p l i n e w i l l a s s i s t the other i n e s s e n t i a l l y a common task. One p h y s i c i a n should be a v a i l a b l e f o r c l i n i c a l support t o every 5 primary workers, or 150 c l i e n t s . Case managers should be a l l o c a t e d throughout the regi o n t o r e f l e c t the estimated d i s t r i b u t i o n o f t h e i r expected expected case loads. This d i s t r i b u t i o n was e s t i -mated i n Chapter 5. The a l l o c a t i o n of case managers, or primary workers, would be based on the assumption t h a t 70 per cent of the above range of cases would be e n r o l l e d i n s e r v i c e s at any one time. A l l o c a t e d on the b a s i s of one case manager t o t h i r t y cases, the case manager d i s t r i -b u t i o n by school d i s t r i c t would be: Maximum Mean Minimum Greater V i c t o r i a 20.0 17.7 15.2 Sooke 1.9 1.7 1.5 Saanich 2.1 1.9 1.6 Gulf I s l a n d s .5 .4 24.6 21.8 18.7 As the region already has f o u r nursing and s o c i a l work p o s i t i o n s a v a i l a b l e t o the c h r o n i c a l l y i l l , then a mean estimate o f 17.8 p o s i t i o n s i s a d d i t i o n a l l y r e q u i r e d . C r i s i s i n t e r v e n t i o n and s t a b i l i z a t i o n s e r v i c e s could be improved i f the p h y s i c i a n s i n the emergency wards of the two h o s p i t a l s i n V i c t o r i a has 24-hour access t o psy-c h i a t r i c beds f o r assessment and t r i a g e . These s e r v i c e s should be organized as p a r t of the p u b l i c system w i t h a 109 s p e c i a l s h o r t - t e r m a s s e s s m e n t a n d t r e a t m e n t u n i t ( u n d e r o n e week s t a y ) s e t up i n E r i c M a r t i n I n s t i t u t e . The V a n -c o u v e r p o p u l a t i o n i s u s i n g 12 b e d s i n a s i m i l a r a s s e s s m e n t u n i t , s o 6 b e d s s h o u l d b e a d e q u a t e f o r t h e C a p i t a l R e g i o n . T h e e m e r g e n c y c o m p o n e n t s h o u l d b e c o n t r a c t u a l l y l i n k e d w i t h o u t p a t i e n t s e r v i c e s f o r m a n d a t o r y f o l l o w - u p f o r p a t i e n t s n o t r e q u i r i n g c o n t i n u e d i n p a t i e n t c a r e . A s p a r t o f t h e p u b l i c s y s t e m , i t i s p r o p o s e d t h a t E r i c M a r t i n I n s t i t u t e b e r e d u c e d i n s i z e f r o m . 4 3 b e d s p e r 1000 p o p u l a t i o n t o . 2 5 p e r 1 0 0 0 . T h i s w o u l d p r o v i d e a u n i t o f 58 b e d s . A d d i t i o n a l l y b e d s w i l l b e n e e d e d f o r t h e I n s t i t u t e t o f u n c t i o n a s t h e s e c o n d a r y r e f e r r a l c e n t r e f o r o t h e r I s l a n d p s y c h i a t r i c u n i t s . E r i c M a r t i n i s c u r r e n t l y r e c e i v i n g a b o u t 64 c a s e s a n n u a l l y f r o m o t h e r I s l a n d r e g i o n s , w i t h V a n c o u v e r h o s p i t a l s a n d R i v e r v i e w r e c e i v i n g 147 a d m i s s i o n s a n n u a l l y . Some a d m i s s i o n s t o t h e m a i n l a n d w i l l c o n t i n u e t o b e a p p r o p r i a t e , b u t a s f u r t h e r c o m m u n i t y s u p p o r t s e r v i c e s a r e e s t a b l i s h e d i n t h e o t h e r I s l a n d r e g i o n s , some o f t h e p a t i e n t f l o w o f f t h e I s l a n d w o u l d b e r e d u c e d . I t i s p o s s i b l e t h e n , t h a t E . M . I , m i g h t p i c k up a r e s i d u a l 74 ( o n e - h a l f o f 147 ) a d m i s s i o n s . W i t h an a v e r a g e l e n g t h o f s t a y o f 30 d a y s , t h e s e s e c o n d a r y a d m i s s i o n s (64 p l u s 74) w i l l r e q u i r e 11 b e d s . E . M . I . ' s t o t a l b e d c o u n t w i l l t h e n b e : 11 b e d s f o r s e c o n d a r y r e f e r -r a l s f r o m t h e I s l a n d , 58 b e d s f o r p r i m a r y r e f e r r a l s f r o m t h e C a p i t a l R e g i o n a n d 6 b e d s f o r an a s s e s s m e n t u n i t , f o r a t o t a l o f 75 b e d s . 110 The c u r r e n t admission r a t e t o E.M.I, w i l l be reduced w i t h more e f f e c t i v e t r i a g e of emergencies, and by the a v a i l a b i l i t y o f a d d i t i o n a l p s y c h o - s o c i a l r e h a b i l i t a t i o n s e r v i c e s and long-term support and maintenance s e r v i c e s . Psycho-Social R e h a b i l i t a t i o n and Long Term  Community and Maintenance Se r v i c e s These two s e c t i o n s of the model Community Support System w i l l be discussed together as many programs w i l l provide both short-term t r a i n i n g and long-term support. I t has been shown t h a t 40 per cent to ,84 per cent of cases e n r o l l e d i n the system w i l l r e q u i r e r e h a b i l i t a t i o n s e r v i c e s . The higher f i g u r e a p p l i e s to the need f o r chemotherapy s e r -v i c e provided under Mental Health S e r v i c e s . We can conser-v a t i v e l y expect then, t o have 40 per cent o f the e n r o l l e d cases, i . e . 260 + 36, t o r e q u i r e s o c i a l and community l i v i n g s k i l l t r a i n i n g . This t r a i n i n g can be provided w i t h i n the e x i s t i n g v o l u n t a r y o r g a n i z a t i o n s such as the Canadian Mental Health A s s o c i a t i o n and Garth Homer Achievement Centre. These e x i s t i n g s e r v i c e s provide s k i l l t r a i n i n g to approximately 70 c l i e n t s . T h e i r c a p a c i t y should be increased three times. A f t e r s e v e r a l years o f working w i t h the c h r o n i c a l l y d i s a b l e d t h i s c a p a c i t y could be reduced as the c l i e n t s l e a r n t o func-t i o n more e f f e c t i v e l y i n the community. S o c i a l I n t e g r a t i o n S e r v i c e s are r e q u i r e d f o r 306 c l i e n t s '(+ 43). Some of these c l i e n t s need s p e c i a l l y designed s o c i a l centres such as the e x i s t i n g Cornerhouse which serves 50 to 70 c h r o n i c a l l y d i s a b l e d . Others need programs t h a t I l l i n v o l v e t h e m i n e x i s t i n g c o m m u n i t y r e c r e a t i o n a l a n d s o c i a l f a c i l i t i e s . T h e s e p r o g r a m s may b e r u n b y v o l u n t e e r s o r t h e c l i e n t s t h e m s e l v e s . Some c h r o n i c s n e e d e n c o u r a g e m e n t t o a c c e s s e x i s t i n g s o c i a l p o s s i b i l i t i e s t o p r e v e n t i s o l a -t i o n a n d d e t e r i o r a t i o n o f f u n c t i o n i n g . Some o f t h i s e n -c o u r a g e m e n t w i l l b e g i v e n b y t h e p r i m a r y w o r k e r . H o u s i n g f o r t h e m e n t a l l y i l l p r o v i d e s b o t h a l o n g -t e r m a n d s h o r t - t e r m f u n c t i o n . The e s t i m a t e f o r R e s i d e n t i a l S e r v i c e s i n T a b l e 7.1 i s f o r l o n g a n d s h o r t - t e r m c a r e f o r v a r i o u s l e v e l s o f c l i e n t f u n c t i o n i n g . T h e m i n i m u m s e r -v i c e t o b e p r o v i d e d i n t h e 124 (+ 17) b e d s e s t i m a t e d , i s d a i l y m e a l p r e p a r a t i o n a n d l i m i t e d s u p e r v i s i o n . T h e m a x i -mum s e r v i c e w o u l d b e 24 -hour n u r s i n g c a r e a n d s t r i c t t i m e -s t r u c t u r i n g . T h e c u r r e n t 85 b e d s i n t h i s c a t e g o r y o f s e r -v i c e s h o u l d be e x p a n d e d t o t h e e s t i m a t e d n u m b e r . I f t h e p s y c h o - s o c i a l r e h a b i l i t a t i o n s e r v i c e s w e r e d e v e l o p e d a s r e c o m m e n d e d , some o f t h e e x i s t i n g r e s i d e n t s w o u l d b e c a p a b l e o f p r o g r e s s i n g t o l e s s s u p e r v i s e d s e t t i n g s . T h e v a c a t e d b e d s a n d t h e a d d i t i o n a l c a p a c i t y w o u l d a l l o w f o r t h e r e p a -t r i a t i o n o f t h e 2 7 R i v e r v i e w p a t i e n t s who w e r e a s s e s s e d a s b e i n g c a p a b l e t o l i v e i n c o m m u n i t y s e t t i n g s . A n o t h e r l o n g - t e r m c o m m u n i t y h o u s i n g s t r a t e g y i s c o -o p e r a t i v e a p a r t m e n t s , s i m i l a r t o t h a t d e v e l o p e d b y C o a s t F o u n d a t i o n S o c i e t y i n V a n c o u v e r . Cumming a n d T o m l i n s o n (1976), i n a V a n c o u v e r s t u d y , e s t i m a t e d t h i s n e e d a t one a p a r t m e n t p e r one t h o u s a n d p o p u l a t i o n o v e r 15 y e a r s o f a g e . T h i s w o u l d r e s u l t i n a s i m i l a r p r o g r a m i n t h e C a p i t a l R e g i o n 112 f o r 170 c l i e n t s . A d e s c r i p t i o n o f t h i s p r o g r a m i s a v a i l -a b l e i n C a n a d a ' s M e n t a l H e a l t h ( T o m l i n s o n a n d Cumming , 1 9 7 6 ) . A c a p a c i t y o f 117 p l a c e s (+ 14) h a s b e e n e s t i m a t e d f o r e m p l o y m e n t o p p o r t u n i t i e s , b o t h o f a s h o r t - t e r m t r a i n -i n g a n d l o n g - t e r m p l a c e m e n t n a t u r e . The e x i s t i n g c a p a c i t y o f t h e s e s e r v i c e s i n t h e V i c t o r i a a r e a i s a b o u t 30 p l a c e s i n t w o s e t t i n g s . T h i s s h o u l d be e x p a n d e d a s i n d i c a t e d . E x i s t i n g n o n - p r o f i t o r g a n i z a t i o n s s h o u l d b e e n c o u r a g e d t o p r o v i d e e m p l o y m e n t s e r v i c e s u n d e r c o n t r a c t u a l a r r a n g e -m e n t . C o m m u n i t y I n t e g r a t i o n a n d A c c e p t a n c e S t r a t e g i e s The p r e s e n t s y s t e m w i l l h a v e t h e c a p a c i t y t o a s s i s t t h e d i s a b l e d * s i n t e g r a t i o n i n t o t h e c o m m u n i t y w i t h t h e a d d i t i o n o f t h e c a s e m a n a g e r p o s i t i o n s t o t h e M e n t a l H e a l t h C e n t r e s . C o m m u n i t y a c c e p t a n c e s t r a t e g i e s c a n a l s o b e t h e r e s p o n s i b i l i t y o f v o l u n t a r y a g e n c i e s w h i c h w o r k w i t h t h e d i s a b l e d . P e r h a p s t h e b e s t s t r a t e g y i s t h e a b i l i t y o f t h e s y s t e m t o d e v e l o p a q u i c k r e s p o n s e t o t h e n e e d s o f c o m m u n i t y members i n t h e i r r e l a t i o n s h i p s w i t h t h e c h r o n i c a l l y i l l a n d d i s a b l e d . E m p l o y e r s , l a n d l o r d s , a n d f a m i l y member s w i l l b e m o r e w i l l i n g t o p r o v i d e o p p o r t u n i t i e s i f t h e s y s t e m i s a b l e t o p r o v i d e s u p p o r t when r e q u i r e d . P r o t e c t i o n o f C l i e n t s ' R i g h t s I n t h e c u r r e n t s y s t e m , c l i e n t s ' r i g h t s a r e b e i n g a b u s e d b e c a u s e t h e s y s t e m w o r k s b a d l y . B e c a u s e a c o n t i n u u m o f c a r e i s n o n - e x i s t e n t , r e s p o n s e t o c l i e n t s i n c r i s i s i s o n l y 11.3 possible when the c r i s i s demands h o s p i t a l treatment. As t h i s i s d i f f i c u l t to obtain, committal procedures are invoked. A better, more comprehensive system would go a long way to preserving the r i g h t s of patients. However, since service providers are used to invoking committal procedures, the habit of not using them may be d i f f i c u l t to break. I t i s proposed that a patients' advocate o f f i c e be established within the public system. Such an advocate would be charged with investigating a l l committed cases and recommending alternative courses of action where possible. Planning, Coordination, Case Management  and Continuity of Care There are two necessary conditions for a set of ser-vices to operate as a coordinated system. F i r s t there must be a "core services agency" s p e c i f i c a l l y i d e n t i f i e d to helping the severely disabled. Such an agency must have a clear mandate to do so and the authority and resources to make contractual arrangements with other services i n the system. In t h i s plan i t i s proposed that the core services agency be the Mental Health Centre. The Mental Health Centres' administrative head o f f i c e i n the Ministry of Health w i l l have to redefine the role and function of the Centres i n t h e i r communities. An examination of e x i s t i n g function shows lack of leadership i n l o c a l communities for services to the c h r o n i c a l l y disabled. Clear p o l i c y established i n regulation i s required i n order for Centres to take the lead i n planning and coordinat-ing l o c a l services. 1 1 4 As t h e e s t a b l i s h e d c o r e s e r v i c e a g e n c y , t h e C e n t r e s w i l l p r o v i d e t h e s e r v i c e f u n c t i o n d e s c r i b e d u n d e r t h e h e a d i n g " M e n t a l H e a l t h S e r v i c e s " . I n p a t i e n t c a r e a n d 2 4 - h o u r e m e r g e n c y s e r v i c e w o u l d b e p r o v i d e d t h r o u g h t h e h o s p i t a l s u n d e r c o n t r a c t . O t h e r s e r v i c e s w o u l d a l s o be p r o v i d e d u n d e r c o n t r a c t . M o s t o f t h e s e w o u l d b e s p o n s o r e d a n d o p e r a t e d b y t h e n o n - p r o f i t a g e n c i e s a n d w o u l d i n c l u d e v o c a t i o n a l p r o g r a m s , r e c r e a t i o n a n d h o u s i n g . The s e c o n d n e c e s s a r y c o n d i t i o n i s a c a s e management f u n c t i o n . T h i s p r o v i d e s f o a s i n g l e p e r s o n t o b e r e s p o n -s i b l e f o r l i n k i n g c l i e n t s t o t h e a p p r o p r i a t e s e r v i c e s , e n s u r i n g c o n t i n u i t y o f c a r e , a n d u p d a t i n g c a r e p l a n s . I t h a s b e e n p r o p o s e d t h a t t h e c a s e management f u n c t i o n b e b u i l t i n t o t h e j o b d e s c r i p t i o n o f t h e p r i m a r y w o r k e r s i n t h e c o r e s e r v i c e s a g e n c y , i . e . t h e r e c o n s t i t u t e d M e n t a l H e a l t h C e n t r e s . U p p e r I s l a n d a n d C e n t r a l I s l a n d R e g i o n s R e c o m m e n d a t i o n s f o r t h e U p p e r I s l a n d a n d C e n t r a l I s l a n d s e r v i c e s w i l l b e s i m i l a r t o t h o s e p r o p o s e d f o r t h e C a p i t a l R e g i o n . The s m a l l e r p o p u l a t i o n c e n t r e s a n d r e m o t e c o m m u n i t i e s i n t h e t w o r e g i o n s w i l l p r o b a b l y r e q u i r e some d i f f e r e n c e s i n s e r v i c e o r g a n i z a t i o n . The f o u r M e n t a l H e a l t h C e n t r e s i n t h e c i t i e s o f C o u r t e n a y , N a n a i m o , P o r t A l b e r n i , a n d D u n c a n s h o u l d b e m a n d a t e d t h e r e s p o n s i b i l i t i e s o f a c o r e s e r v i c e s a g e n c y . T h e s e C e n t r e s c a n i n c r e a s e t h e i r c a p a c i t y o f p r o v i d i n g m e n t a l h e a l t h s e r v i c e s t o t h e c h r o n i c a l l y d i s a b l e d b y h i r i n g t h e 115 n u m b e r s o f c a s e m a n a g e r s i n d i c a t e d i n T a b l e 7 . 1 . T h e t w o C e n t r e s i n C o u r t e n a y a n d N a n a i m o w i l l r e q u i r e m o r e p s y c h i -a t r i s t s ' t i m e t o b e a v a i l a b l e t o t h e new p o s i t i o n s . S i g -n i f i c a n t s u p p o r t f r o m t h e C e n t r e s * c e n t r a l a d m i n i s t r a t i v e o f f i c e w i l l b e n e c e s s a r y i n o r d e r f o r t h e C e n t r e s t o d e v e l o p a f i r m m a n d a t e o f l o c a l s e r v i c e s l e a d e r s h i p . I t i s p r o b a b l y n o t f e a s i b l e i n t h e n e a r f u t u r e t o i n c o r p o r a t e t h e l o c a l p s y c h i a t r i c u n i t s i n D u n c a n , N a n a i m o , a n d Comox f u l l y i n t o t h e p u b l i c s y s t e m . T h e s e c o m m u n i t i e s do n o t h a v e t h e h i g h n u m b e r s o f p s y c h i a t r i s t s f o u n d i n t h e C a p i t a l R e g i o n . A m o r e s u i t a b l e s o l u t i o n w o u l d b e f o r t h e M i n i s t r y o f H e a l t h t o n e g o t i a t e , i n c o n j u n c t i o n w i t h t h e l o c a l M e n t a l H e a l t h C e n t r e s , w i t h t h e g e n e r a l h o s p i t a l s t o e s t a b l i s h a p r o p o r t i o n o f p s y c h i a t r i c u n i t b e d s a s " c l o s e d a d m i s s i o n " b e d s . T h e s e c l o s e d b e d s w o u l d be o p e r -a t e d u n d e r c o n t r a c t t o t h e M e n t a l H e a l t h C e n t r e s o t h a t a d m i s s i o n , t r e a t m e n t , a n d c o n t i n u i t y o f f o l l o w - u p w o u l d b e m a i n t a i n e d b e t w e e n t h e two s y s t e m s , i . e . i n p a t i e n t a n d o u t -p a t i e n t . A s t a f f p s y c h i a t r i s t s h a r i n g t i m e b e t w e e n t h e C e n t r e a n d t h e c l o s e d u n i t b e d s w o u l d be an e f f e c t i v e s e r v i c e - l i n k i n g s t r a t e g y . I n c o n j u n c t i o n w i t h t h i s j o i n t s e r v i c e , new d a y h o s p i t a l s e r v i c e s c o u l d o p e r a t e i n Comox a n d D u n c a n . T w e n t y - f o u r h o u r e m e r g e n c y s e r v i c e s h o u l d b e c o o r d i n a t e d b e t w e e n t h e h o s p i t a l s a n d C e n t r e s a s w e l l . P o r t A l b e r n i d o e s n o t h a v e a p s y c h i a t r i c u n i t , b u t n e v e r t h e l e s s t r e a t s many o f i t s h o s p i t a l a d m i s s i o n s f o r p s y c h i a t r i c c a r e . S e r i o u s c o n s i d e r a t i o n s h o u l d b e g i v e n t o 1-1-6. e s t a b l i s h i n g a d a y h o s p i t a l p r o g r a m i n t h i s c o m m u n i t y r a t h e r t h a n an i n p a t i e n t u n i t . T h e d a y h o s p i t a l s h o u l d b e l i n k e d t o t h e P o r t A l b e r n i M e n t a l H e a l t h C e n t r e s i m i -l a r t o t h e a r r a n g e m e n t b e t w e e n C e n t r e s and i n p a t i e n t u n i t s i n t h e o t h e r c o m m u n i t i e s . N a n a i m o h o s p i t a l c o u l d c o n t i n u e t o r e c e i v e i n p a t i e n t s f o r P o r t A l b e r n i a s t h e f o r m e r u n i t h a s a s u r p l u s o f b e d s . Remote c o m m u n i t i e s i n t h e n o r t h e n d o f t h e I s l a n d a n d t h e w e s t c o a s t s u c h a s P o r t M c N e i l l , P o r t H a r d y , G o l d R i v e r , a n d T o f i n o - U c l u e l e t , p r o v i d e a s p e c i a l p r o b l e m i n s e r v i c e d e l i v e r y . T h e s e c o m m u n i t i e s a r e n o t l a r g e e n o u g h t o s u p p o r t o r g a n i z e d p s y c h i a t r i c s e r v i c e s . T h e c h r o n i c a l l y i l l a n d d i s a b l e d c o u l d be s e r v e d b y p r o v i d i n g t h e l o c a l p h y -s i c i a n s w i t h p s y c h i a t r i c a l l y t r a i n e d n u r s e s on a p e r m a n e n t o r v i s i t i n g b a s i s . The n u r s e s w o u l d b e e m p l o y e d b y t h e n e a r e s t M e n t a l H e a l t h C e n t r e t o w o r k i n t h e p h y s i c i a n s ' o f f i c e s a n d b e r e s p o n s i b l e t o t h e m . T h e n u r s e s w o u l d a i d t h e p h y s i c i a n s i n f o r m u l a t i n g t r e a t m e n t p l a n s w i t h i n t h e l o c a l c o m m u n i t y a n d r e f e r r i n g a p p r o p r i a t e l y o u t s i d e t h e a r e a . P e r h a p s f o u r n u r s e s c o u l d b e p l a c e d i n i t i a l l y . The f o u r m a j o r c o m m u n i t i e s w i t h M e n t a l H e a l t h C e n t r e s s h o u l d h a v e an o r g a n i z e d s y s t e m o f p s y c h o - s o c i a l r e h a b i l i -t a t i o n a n d l o n g - t e r m m a i n t e n a n c e p r o g r a m s . E a c h c o m m u n i t y s h o u l d h a v e v o c a t i o n a l t r a i n i n g a n d s h e l t e r e d w o r k s e t t i n g s o p e r a t e d b y n o n - p r o f i t a g e n c i e s u n d e r c o n t r a c t t o t h e C e n t r e s . A s w e l l , t h e r e s h o u l d be o r g a n i z e d l i f e - s k i l l s t r a i n i n g p r o g r a m s a n d r e c r e a t i o n a l s e r v i c e s . E a c h o f t h e 117) f o u r c o m m u n i t i e s c o u l d s u p p o r t a v o c a t i o n a l p r o g r a m f o r t w e n t y c l i e n t s a t t e n d i n g d a i l y . A b o u t t h e same numbe r c o u l d b e s e r v e d d a i l y i n r e c r e a t i o n a l p r o g r a m s . I n t h e s m a l l e r c o m m u n i t i e s , l i f e - s k i l l s t r a i n i n g a n d r e c r e a t i o n a l p r o g r a m s s h o u l d b e c o m b i n e d i n t o one s e r v i c e a n d o p e r a t e d o u t o f g e n e r a l c o m m u n i t y r e c r e a t i o n f a c i l i t i e s . P e r h a p s v o l u n t e e r p r o g r a m s o r g a n i z e d f r o m l o c a l h o s p i t a l s c o u l d h e l p t h e d i s a b l e d i n p l a c e s s u c h a s P o r t H a r d y . R e s i d e n t i a l s e r v i c e s show o n e o f t h e b i g g e s t s e r v i c e g a p s i n t h e t w o r e g i o n s . H o u s i n g , b o t h s u p e r v i s e d a n d m i n i m a l l y s u p e r v i s e d , s h o u l d b e e x p a n d e d a s i n d i c a t e d i n T a b l e 7 . 1 . O v e r t i m e , t h e demand f o r s p e c i a l h o u s i n g s h o u l d d e c r e a s e a s t h e e x i s t i n g g r o u p o f d i s a b l e d p a t i e n t s l e a r n t o l i v e i n t h e c o m m u n i t y w i t h f e w e r s u p p o r t s . T h e r e -f o r e , f o r m s o f h o u s i n g s h o u l d b e s e l e c t e d t h a t c a n b e l e t o u t o f s e r v i c e r e l a t i v e l y e a s i l y . A l l h o u s i n g s e r v i c e s s h o u l d b e d e v e l o p e d b y n o n - p r o f i t a g e n c i e s a n d u n d e r c o n -t r a c t w i t h t h e c o r e s e r v i c e s a g e n c y . I n t h e s m a l l e r commu-n i t i e s , f o r m s o f f a m i l y , o r f o s t e r c a r e c o u l d b e u s e d , a s w e l l a s s a t e l l i t e a p a r t m e n t s , w h i c h c o u l d be s u s i d i z e d , i n o r d e r t o a l l o w t h e d i s a b l e d t o l i v e i n t h e i r own c o m m u n i t i e s . The p l a n p r o p o s e d i n t h i s c h a p t e r c o u l d b e i m p l e m e n t e d w i t h i n a f i v e y e a r p e r i o d a n d w o u l d c o s t n o m o r e t h a n t h e e x i s t i n g s y s t e m . C o m p a r i s o n o f p r e s e n t a n d e x p e c t e d c o s t s a r e shown i n t h e n e x t s e c t i o n . 118 Summary : A S y s t e m W i t h i n F i v e Y e a r s I n t h e f i r s t c h a p t e r s o f t h i s p a p e r , t h e c h r o n i c a l l y m e n t a l l y d i s a b l e d w e r e e s t a b l i s h e d a s a s p e c i a l n e e d s g r o u p w h i c h m u s t r e c e i v e an o r g a n i z e d r e s p o n s e f r o m t h e t r e a t m e n t a g e n c i e s . I t h a s b e e n p r o p o s e d t h a t w i t h i n a m o d e l c a r e s y s t e m , t h e s e a g e n c i e s s h o u l d d e m o n s t r a t e l e a d e r -s h i p among a w i d e r a n g e o f c a r e a n d s u p p o r t s e r v i c e s . T h e r e h a s b e e n , h o w e v e r , much c r i t i c i s m d i r e c t e d a t c o m m u n i t y m e n t a l h e a l t h s e r v i c e s , w i t h t h e c r i t i c i s m f o c u s e d o n t h e i r i n a d e q u a t e r e s p o n s e t o t h e n e e d s o f t h e l o n g - t e r m d i s a b l e d a n d s e v e r e l y m e n t a l l y i l l . V a n c o u v e r I s l a n d h a s b e e n c o n s i d e r e d a s a p l a n n i n g r e g i o n f o r s e r v i c e s t o t h e m e n t a l l y d i s a b l e d . The e x i s t i n g m e n t a l h e a l t h s e r v i c e s w e r e s u r v e y e d a n d u t i l i z a t i o n s t u d i e d . The r e s u l t s o f t h i s e x a m i n a t i o n s u p p o r t e d many o f t h e c r i t i -c i s m s f o u n d i n t h e l i t e r a t u r e . No s e r v i c e h a d a s s u m e d a l e a d e r s h i p r o l e . H e n c e c o m p r e h e n s i v e n e s s a n d c o n t i n u i t y o f s e r v i c e was n o n - e x i s t e n t . The m a j o r g a p s i n t h e t o t a l c a r e s y s t e m w e r e i n t h e a r e a s o f e m e r g e n c y r e s p o n s e , s o c i a l a n d v o c a t i o n a l r e h a b i l i t a t i o n , p a t i e n t a d v o c a c y a n d h o u s i n g . The o n l y s e r v i c e a r e a g e n e r o u s l y p r o v i d e d w e r e h o s p i t a l b e d s , w h i c h a r e a l s o t h e m o s t e x p e n s i v e p a r t o f t h e s y s t e m . I n C h a p t e r 7, i t was p r o p o s e d t h a t t h e M e n t a l H e a l t h C e n t r e s b e g i v e n t h e r e s p o n s i b i l i t y o f d e v e l o p i n g a c o o r d i n a t e d a n d c o m p r e h e n s i v e s y s t e m a t t h e l o c a l l e v e l . A d d i t i o n a l l y , w i t h t h e a d d i t i o n o f mo re p r i m a r y w o r k e r s f o r t h e d i s a b l e d , t h e C e n t r e s w i l l b e r e s p o n s i b l e f o r p r o v i d i n g b a s i c m e n t a l 119 h e a l t h s e r v i c e s a n d e n s u r i n g t h e i n d i v i d u a l c l i e n t a c c e s s t o t h e v a r i o u s s u p p o r t s e r v i c e s i n t h e c o m m u n i t y . I n o r d e r t o f u l f i l l t h e i r new r o l e t h e C e n t r e s w i l l r e q u i r e a c l e a r p o l i c y s t a t e m e n t f r o m t h e p r o v i n c i a l M i n i s t r y o f H e a l t h , and a d m i n i s t r a t i v e d i r e c t i o n a n d p l a n n i n g s u p p o r t f r o m t h e C e n t r e s ' h e a d o f f i c e . New f u n d i n g r e l a t i o n s h i p s w i l l h a v e t o b e e s t a b l i s h e d w i t h p r i v a t e n o n - p r o f i t a g e n c i e s , a s t h e s e a g e n c i e s c u r -r e n t l y r e c e i v e m o s t f u n d i n g f r o m t h e M i n i s t r y r e s p o n s i b l e f o r w e l f a r e s e r v i c e s . The n o n - p r o f i t a g e n c y h a s w o r k e d c l o s e l y w i t h p u b l i c a g e n c i e s i n t h e p a s t a n d s h o u l d c o n t i n u e t o do s o . I f p r o v i d e d a c l e a r r o l e i n a s e r v i c e s y s t e m f o r t h e m e n t a l l y d i s a b l e d , p r i v a t e a g e n c i e s s h o u l d b e a v a l u a b l e p a r t n e r i n a c o m p r e h e n s i v e s y s t e m o f s e r v i c e s . T h e new c o m m u n i t y c a r e s y s t e m s h o u l d h a v e c l e a r g o a l s t o b e a c h i e v e d o v e r a d e f i n i t e t i m e p e r i o d . I t i s p r o p o s e d h e r e t h a t t h e s e g o a l s b e : 1) e s t a b l i s h m e n t o f t h e s y s t e m l i n k i n g r e l a t i o n s h i p s w i t h i n o n e y e a r ; 2) d e v e l o p m e n t o f a l l s y s t e m c o m p o n e n t s w i t h t h e r e commended c a p a c i t i e s w i t h i n f i v e y e a r s ; 3) s y s t e m c o m p o n e n t s b e f u l l y d e v e l o p e d i n o n e a r e a f o l l o w e d b y a r e p e a t p r o c e s s i n t h e n e x t ; t h i s i s p r e f e r a b l e t o a s e r v i c e b y s e r v i c e d e v e l o p m e n t w i t h i n t h e e n t i r e r e g i o n ; 4) r e d u c t i o n i n i n p a t i e n t u t i l i z a t i o n w i t h a s u b s e -q u e n t r e d u c t i o n o f b e d s , p a r t i c u l a r l y i n t h e C a p i t a l r e g i o n ; 120 5) a 95 p e r c e n t r e d u c t i o n o f a d m i s s i o n s t o R i v e r v i e w h o s p i t a l w i t h i n one y e a r a n d a s i g n i f i c a n t r e d u c -t i o n i n a d m i s s i o n s t o V a n c o u v e r h o s p i t a l s ? 6) a l l s e c o n d a r y i n p a t i e n t c a r e b e p r o v i d e d t o V a n c o u v e r I s l a n d r e s i d e n t s b y t h e E r i c M a r t i n I n s t i t u t e ; a n d 7) a r e p a t r i a t i o n o f I s l a n d r e s i d e n t s f r o m R i v e r v i e w h o s p i t a l o v e r a f i v e y e a r p e r i o d , a s t h e l o c a l a r e a s d e v e l o p c o m m u n i t y f a c i l i t i e s . The c o s t o f d e v e l o p i n g t h e p r o p o s e d s y s t e m s h o u l d b e o f f s e t i n s a v i n g s f o r i n p a t i e n t c a r e . T h e s e s a v i n g s , a t $ 4 , 2 1 8 , 1 2 5 , w o u l d b e d e r i v e d f r o m : 1) r e d u c t i o n o f 25 b e d s a t t h e E r i c M a r t i n I n s t i t u t e f o r a s a v i n g o f $ 1 , 3 8 7 , 0 0 0 p e r y e a r (25 b e d s @ $152 p e r d i e m ) ; 2) d i s c o n t i n u e d u s e o f R i v e r v i e w h o s p i t a l f o r I s l a n d a d m i s s i o n s a t a s a v i n g o f $ 2 0 4 , 0 0 0 p e r y e a r (60 a d m i s s i o n s x 40 d a y s s t a y x $85 p e r d i e m ) ; a n d 3) r e p a t r i a t i o n o f I s l a n d r e s i d e n t s * f r o m R i v e r v i e w h o s p i t a l a t an a n n u a l s a v i n g o f $ 2 , 6 2 7 , 1 2 5 (85 p a -t i e n t s @ $85 p e r d i e m ) . • T h e s e p a t i e n t s w o u l d be r e l o c a t e d i n n e w l y d e v e l o p e d f a c i l i t i e s t h e c o s t o f w h i c h w i l l b e i n c l u d e d b e l o w . I t i s e x p e c t e d t h a t 25 t o 30 p a t i e n t s w i l l r e m a i n i n R i v e r v i e w a s t h i s i s t h e n u m b e r e s t i m a t e d t o r e q u i r e l o n g - t e r m p r o -t e c t i v e i n p a t i e n t c a r e . 121 The new s e r v i c e s f o r t h e I s l a n d w i l l h a v e an a n n u a l c o s t o f $ 3 , 9 0 2 , 0 0 0 . The a p p r o x i m a t e c o s t f o r e a c h s e r -v i c e w i l l b e : 1) 3 3 . 5 c a s e m a n a g e r p o s i t i o n s § $ 3 0 , 0 0 0 e a c h $ 1 , 0 0 5 , 0 0 0 2) S o c i a l I n t e g r a t i o n p r o g r a m s f o r 480 c l i e n t s @ $1300 e a c h 6 2 4 , 0 0 0 3) Day C a r e p r o g r a m f o r 72 p a t i e n t s @ $8000 p e r y e a r e a c h 5 7 6 , 0 0 0 4) E m p l o y m e n t p r o g r a m s f o r 197 c l i e n t s @ $3000 p e r y e a r e a c h 5 9 1 , 0 0 0 5) S u p e r v i s e d R e s i d e n t i a l s e r v i c e s f o r 104 c l i e n t s a t $4000 p e r y e a r e a c h 4 1 6 , 0 0 0 6) M i n i m a l l y S u p e r v i s e d a p a r t m e n t s f o r 260 c l i e n t s a t $1500 p e r y e a r e a c h 3 9 0 , 0 0 0 7) A d d i t i o n a l P s y c h i a t r i s t t i m e ; a p p r o x i -m a t e l y 5 @ $ 6 0 , 0 0 0 p e r y e a r e a c h 3 0 0 , 0 0 0 $ 3 , 9 0 2 , 0 0 0 A c o m p a r i s o n b e t w e e n t h e s a v i n g s a n d e x p e n d i t u r e f i g u r e s i n d i c a t e s a n e t s a v i n g t o t h e s y s t e m o f $ 3 1 6 , 0 0 0 p e r y e a r . T h i s w i l l n o t b e c l a i m e d h o w e v e r , s i n c e o t h e r p u b l i c c o s t s w i l l a c c r u e f r o m a s h i f t f r o m a h o s p i t a l - o r i e n t e d s y s t e m t o c o m m u n i t y - o r i e n t e d s y s t e m o f s e r v i c e s . The r e p a -t r i a t i o n o f R i v e r v i e w p a t i e n t s w i l l r e s u l t i n i n c r e a s e s o f s o c i a l a s s i s t a n c e p a y m e n t s . T h e s e h a v e n o t b e e n i n c l u d e d i n t h e e x p e n d i t u r e e s t i m a t e s . On t h e o t h e r h a n d , a p p r o x i -m a t e l y o n e - t h i r d o f t h e e x p e n d i t u r e s w o u l d b e e l i g i b l e f o r f e d e r a l c o s t - s h a r i n g u n d e r t h e V o c a t i o n a l R e h a b i l i t a t i o n f o r D i s a b l e d P e r s o n s A c t a n d t h e C a n a d a A s s i s t a n c e P l a n . 122 The c o s t c o m p a r i s o n i s o n l y r e l e v a n t when v i e w i n g t h e s y s t e m a s b e i n g f u l l y d e v e l o p e d . D u r i n g t h e t r a n s i t i o n a l p e r i o d o f f i v e y e a r s t h e r e w i l l b e a d u p l i c a t i o n o f e x p e n -d i t u r e s , a n d f o r some s e r v i c e s s t a r t - u p e x p e n s e s w i l l b e r e q u i r e d . I t h a s b e e n t h e p o l i c y o f s o c i e t y i n f o r m e r t i m e s t o h i d e away t h e m e n t a l l y i l l a n d d i s a b l e d i n a s y l u m s . T h e s e i n s t i t u t i o n s a r e n o t b e i n g u s e d i n t h i s f a s h i o n t o d a y . I n -s t e a d , t h e m e n t a l l y i l l a r e a t t e m p t i n g t o s u r v i v e i n t h e i r l o c a l c o m m u n i t i e s . T h e i r r e c o r d h a s n o t b e e n g o o d a s shown i n many r e p o r t s o f p o o r s o c i a l m a r g i n a n d r e p e a t e d u s e o f h o s p i t a l c a r e . The r e c o r d o f t h e p u b l i c s e r v i c e s y s t e m i n r e c o g n i z i n g t h e s e p a t i e n t s ' p l i g h t h a s n o t b e e n g o o d e i t h e r . T h e r e h a s b e e n a f a i l u r e i n p u b l i c p o l i c y t o r e c o g n i z e t h a t a p r o b l e m e x i s t s w i t h t h e c h r o n i c a l l y i l l a n d d i s a b l e d . T h i s p r o b l e m d i d n o t g o away w i t h t h e a s y l u m s . T h e s e p a -t i e n t s s t i l l h a v e t h e same n e e d s t o b e m e t . The f a i l u r e t o r e c o g n i z e t h i s f a c t h a s b e e n a f a i l u r e t o a c c e p t a c o n t i n u i n g r e s p o n s i b i l i t y . The r e c o m m e n d a t i o n s made i n t h i s p a p e r h a v e b e e n an a t t e m p t t o d e l i n e a t e some m e t h o d f o r p o l i c y m a k e r s t o r e -a s sume s o c i e t y ' s r e s p o n s i b i l i t y f o r a f o r g o t t e n g r o u p . Once t h i s r e s p o n s i b i l i t y h a s b e e n a c c e p t e d a n d p l a n s made f o r i t s o p e r a t i o n a l i z a t i o n , t h e n t h e s e r v i c e s y s t e m c a n c l a i m t o h a v e e n t e r e d t h e p e r i o d J o h n S h e e t s h a s c a l l e d " t h e f o u r t h r e v o l u t i o n i n p s y c h i a t r y " . 123 Table 5.1 Expected One-Year Prevalence of Treated Schizophrenia for Vancouver Island Regions: Calculated from Rochester Register Prevalence Rates for Population over 15, by Age and Sex Male Rate Expected Female Rate Prevalence Age Interval Male Female per 100,000 per 100,000 (cases North Island Region 15 - 24 6 ,900 6,530 .699 .411 72 25 - 34 6 ,450 5,845 .874 .913 109 35 - 44 4 ,650 3,835 .9 30 1.144 86 45 - 54 3,680 3,415 .616 . 753 48 55 - 64 2,640 2 ,440 .275 .445 18 65 + . 2,035 2,030 .063 .113 3 To t a l 15 to 65+ 26,355 24,095 336 Central Island Region 15 - 24 13,425 12,980 .669 .411 142 25 - 34 10,875 10,075 . 874 .913 186 35 . 44 7,745 7,215 .9 30 1.144 155 45 - 54 7,615 7,745 .616 .75 3 106 55 - 64 6 ,815 7,480 .275 .445 52 65 + 6,555 6 ,465 .063 .113 12 Total 15 to 65+ 53,030 51,960 653 Ca p i t a l Reqion 15 - 24 21,120 21,080 .669 .411 228 25 - 34 16 ,585 16 ,050 . 874 .913 291 35 - 44 11,045 11,105 .9 30 1.144 229 45 - 54 12,255 13,710 .616 .753 178 55 - 64 11,715 14,535 .275 .445 97 65 + 14,700 20,805 .063 .113 36 To t a l 15 to 65+ 87,420 97,285 1,059 Total Island Region 15 to 65+ 166,805 173,340 2,048 Table 5.3 General Hospital Separations for P s y c h i a t r i c Care in 19 77 for Vancouver Island School D i s t r i c t s by Hospital School D i s t r i c t North Island Vancouver Royal Port Island Vancouver T o t a l J u b i l e e Duncan Nanaimo Alberni Comox Hospitals Hospitals Separations 71 - Courtenay 72 - Campbell River 84 - Vancouver Is. North 85 - Vancouver Is. West sub-total Central Island 65 - Cowichan 66 - Lake Cowichan *67 - Ladysmith 68 - Nanaimo 69 - Qualicum 70 - Alberni sub-total C a p i t a l Region 61 - V i c t o r i a 62 - Sooke 63 - Saanich 64 - Gulf Islands 3 17 359 4 9 392 2 12 124 139 10 287 3 1 1 21 24 4 54 1 2 2 46 182 8 241 — — — 9 2 32 1 550 349 31 974 21 289 8 17 3 338 7 61 8 1 2 4 83 8 12 44 2 95 6 167 4 509 2 11 9 535 2 1 96 4 3 2 10 7 13 1 31 337 53 _7 442 55 364 696 342 6 183 27 16 72 1216 118 94 10 1438 sub-total Column t o t a l s 1502 374 14 1 _1 16 74 4 344 560 290 26 70 30 416 948 21 2 _2 25 83 1548 151 166 4_3 1908 4554 to Table 5.4 U t i l i z a t i o n Data f o r Vancouver I s l a n d General H o s p i t a l P s y c h i a t r i c I n p a t i e n t U n i t s P s y c h i a t r i c U n i t E r i c M a r t i n I n s t i t u t e ( V i c t o r i a ) Cowichan D i s t r i c t H o s p i t a l (Duncan) Average Approved P a t i e n t Length of Beds Admissions Days Stay 100 12 1475 277 32,120 2,737 22.0 9.9 U n i t Occupancy Rate % 88.0 75.0 St. Joseph H o s p i t a l (Comox) 20 523 6,010 11.5 82.3 Nanaimo Regional H o s p i t a l (Nanaimo) 24 156 612 2887 7,964 48,831 13.0 17.0 90.8 86.0 T a b l e 5 .5 V a n c o u v e r I s l a n d A d m i s s i o n s t o R i v e r v i e w b y M e n t a l H e a l t h C e n t r e C a t c h m e n t A r e a : W i t h R a t e s p e r 1 0 0 , 0 0 0 o v e r 15 y e a r s o f age R i v e r v i e w A d m i s s i o n s A l l F i r s t R e - R a t e p e r R e g i o n M . H . C . A r e a a d m i s s i o n s a d m i s s i o n s a d m i s s i o n s O t h e r * 1 0 0 , 0 0 0 N o r t h C o u r t e n a y 17 8 8 1 3 3 . 6 9 C e n t r a l D u n c a n 2 1 1 0 1 4 . 4 6 C e n t r a l N a n a i m o 18 7 10 1 3 7 . 8 6 C e n t r a l P o r t A l b e r n i 15 4 9 2 6 5 . 1 0 C a p i t a l S a a n i c h 0 0 0 0 1 I f 4 . 8 5 C a p i t a l V i c t o r i a _9 _1 _ 7 •I J 1 T o t a l 61 21 35 5 1 7 . 7 3 * < D t h e r : R e t u r n s f r o m E x t e n d e d L e a v e , e s c a p e , and t r a n s f e r s . 00 - J - J cn cn cn cn o CO in ui - • " - - ^ - 01 c CO « J Cn cn cn cn Ul NJ VO cn M n 0 c a t) Z C w < 0 0 e fll • 5 c •1 3 5 01 n rr 0) o 3 rr • <+ H- 01 H- 0 0 (D > 3 3 n r t 3 0 3" P-01 PJ C 01 > ro l-l >1 ro 3 0) H--J | >-> O O O Ul CO | O O Ul O h-1 ^ O | O O O O O O CO I O N> r & M O O VO | to )-• tvj O O ^ 03 NJ ' VO NJ O NJ I ui NJ co o on CO ~ J ~ J o o o ^ on Ul to NJ M NJ Ul O NJ Ul M NJ cn Ul on 03 ~J VO cn Independent L i v i n g Personal Care Intermediate Care Extended Care Mini-care Fernwood Pre-Infirmary Long Term North Lawn Psych. Unit Row T o t a l Row % Rate per 1 0 0 , 0 0 0 53 < ro oi co 3 a o ro c 3 < r r ffl 3 H CQ 33 H* H- 0> < 5 ro a H < -O H* 01 ffl r t * H» ro cr 3 •< r t ca > « 01 ca tr ca cr (0 !•< ro ca tn 3 UI ro ro . a 3 on r t t-i ni ro M < ro — >-• ro 0) o M Mi r t 3-n oi o fi ro ro 3 r t 73 n ro ro C > H- 11 I-I ro ro oi a » / -7 T J. «. \J T a b l e 5.7 C h a r a c t e r i s t i c s o f Vancouver I s l a n d P a t i e n t s R e s i d e n t i n Riverview North C e n t r a l C a p i t a l T o t a l C h a r a c t e r i s t i c s I s l a n d I s l a n d Region I s l a n d Source o f Admission P r i v a t e M e d i c a l P r a c t i c e 9 22 24 55 Mental H e a l t h Centre 1 5 1 7 General H o s p i t a l 4 8 10 22 Other 7 10 6 25 T o t a l R e s i d e n t P a t i e n t s 11 42 58 111 Diagnosis F u n c t i o n a l Psychoses 5 26 35 66 Organic P s y c h o s i s 4 9 18 31 Other 2 4 5 11 Length o f Stay Under 6 months 7 6 months - 2 y e a r s 12 2 years - 10 y e a r s 28 over 10 y e a r s 64 Age 21 - 30 16 3 1 - 4 0 8 4 1 - 5 0 17 5 1 - 6 5 46 66+ 24 Sex Male Female 64 47 T a b l e 5.8 A l l o c a t i o n o f C l i n i c a l P o s i t i o n s and P s y c h i a t r i s t S e s s i o n s i n V a n c o u v e r I s l a n d M e n t a l H e a l t h C e n t r e s F u l l - t i m e S e s s i o n s / w e e k # C l i n i c a l M e n t a l H e a l t h C e n t r e C l i n i c a l P o s i t i o n s f r o m P s y c h i a t r i s t P o p u l a t i o n S e r v e d P o s i t i o n s / 1 0 0 , 0 0 0 # S e s s i o n s / 1 0 0 , 0 0 0 V i c t o r i a 1 3 . 0 15 1 3 0 , 1 8 0 9 . 99 1 1 . 5 4 S a a n i c h 5 .5 10 1 0 0 , 4 3 0 5 . 48 1 0 . 0 0 D u n c a n 4 . 0 7 4 7 , 0 9 9 8 .49 1 4 . 8 6 N a n a i m o 5 .5 1 6 1 , 8 8 0 8 .89 1 .62 C o u r t e n a y 6 . 5 2 6 9 , 6 4 9 9 . 3 3 2 . 8 7 P o r t A l b e r n i 4 . 0 10 32 , 174 12 . 4 3 3 1 . 0 8 T o t a l 3 8 . 5 4 9 . 0 4 4 1 , 4 1 2 8 .72 1 1 . 1 0 T a b l e 6 .1 C a l c u l a t i o n f o r D i s t r i b u t i o n o f E x p e c t e d P r e v a l e n c e o f S c h i z o p h r e n i a b y C a p i t a l R e g i o n S c h o o l D i s t r i c t s S c h o o l D i s t r i c t S e p a r a t i o n f o r P s y c h i a t r i c C a r e S e p a r a t i o n R a t e p e r 1 0 0 , 0 0 0 R e v i s e d P r o p o r t i o n a t e E x p e c t e d E x p e c t e d W e i g h t i n g C a s e s C a s e s G r e a t e r V i c t o r i a (#61) S o o k e (#62) S a a n i c h (#63) G u l f I s l a n d s (#64) T o t a l s C o l . 1 1494 14 3 164 38 1839 C o l . 2 1106 6 32 735 719 990 C o l . 3 1.12 . 6 4 . 7 4 . 7 3 1 .00 C o l . 4 C o l . 5 774 128 12 7 30 1059 865 82 94 22 1064 y c 1 3 1 Table 7.1 E s t i m a t e d C a p a c i t y o f Community S e r v i c e Components C o l . 1 C o l . 2 Col . 3 C o l . 4 Mean # E x i s t i n g i n t h i s Range of # i n t h i s Region Type o f S e r v i c e S e r v i c e U t i l i z a t i o n S e r v i c e North E n r o l l e d Cases 194 + 41 ? I s l a n d R e h a b i l i t a t i o n 163 + 34 ? S o c i a l I n t e g r a t i o n 91 + 19 10 Day Care 14 + 3 0 Employment 37 8 0 R e s i d e n t i a l 39 + 8 20 Apartments 40 + 8 0 # o f Case Managers 6.5 + 1.5 1 1:30 C e n t r a l E n r o l l e d Cases 387 + 69 220 I s l a n d R e h a b i l i t a t i o n 325 + 58 ? S o c i a l I n t e g r a t i o n 181 + 32 32 Day Care 27 + 5 15 Employment 73 + 13 0 R e s i d e n t i a l 77 + 14 31 Apartments 80 + 15 0 # o f Case Managers 13 + 2.3 2.5 1:30 C a p i t a l E n r o l l e d Cases 652 + 91 178 Region R e h a b i l i t a t i o n 548 + 76 ? S o c i a l I n t e g r a t i o n 306 + 43 50 Day Care 46 + 6 0 Employment 117 + 14 30 R e s i d e n t i a l 124 + 17 85 Apartments 140 + 22 0 # o f Case Managers 22 + 3 4 1:30 132 F i g u r e 1. Vancouver I s l a n d P l a n n i n g Regions 133 B i b l i o g r a p h y A l l e n , P . " A C o n s u m e r ' s V i e w o f C a l i f o r n i a ' s M e n t a l H e a l t h C a r e S y s t e m " . 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" S o m e - C o n c e p t u a l I s s u e s i n D i s a b i l i t y a n d R e h a -b i l i t a t i o n " . I n S u s s m a n , M . ( E d . ) . S o c i o l o g y a n d  R e h a b i l i t a t i o n . W a s h i n g t o n , D . C . ; A m e r i c a n S o c i o l o g i -c a l A s s o c i a t i o n , 1 9 6 6 . N a t i o n a l I n s t i t u t e o f M e n t a l H e a l t h . The NIMH C o m m u n i t y  S u p p o r t P r o g r a m . M i m e o , N o v e m b e r 1 3 , 1 9 7 7 . N e u f e l d t , A . H . " Y o u n g A d u l t h o o d : T h e Age o f T r a n s i t i o n " . C a n a d a ' s M e n t a l H e a l t h , 2 6 ( 4 ) : 1 8 - 2 2 , 1 9 7 8 . O e d e g a a r d , 0 . " T h e I n c i d e n c e o f M e n t a l D i s e a s e s a s M e a s u r e d b y C e n s u s I n v e s t i g a t i o n v e r s u s A d m i s s i o n S t a t i s t i c s " . P s y c h i a t r i c Q u a r t e r l y , 2 6 , 1 9 5 2 . O v e r h o l s e r , D. " T h e P r e s e n t S t a t u s o f t h e P r o b l e m s o f R e l e a s e o f P a t i e n t s f r o m M e n t a l H o s p i t a l s " . P s y c h i a t r i c  Q u a r t e r l y , 2 9 ( 2 ) : 3 7 2 - 3 8 0 , J u l y , 1 9 5 5 . O z a r i n , L . " C o m m u n i t y A l t e r n a t i v e s t o I n s t i t u t i o n a l C a r e " . A m e r i c a n J o u r n a l o f P s y c h i a t r y . 1 3 3 ( 1 ) : 6 9 - 7 2 , J a n u a r y / 1 9 7 6 . - ' -138 P a u l , G . a n d L e n t z , R. P s y c h o s o c i a l T r e a t m e n t o f C h r o n i c  M e n t a l P a t i e n t s : M i l i e u V e r s u s S o c i a l L e a r n i n g "~" P r o g r a m s ^ C a m b r i d g e : H a r v a r d U n i v e r s i t y P r e s s , 1 9 7 7 . P e r r y , H. " I n t r o d u c t i o n " . I n S u l l i v a n , H . S . ( e d . ) . T h e  F u s i o n o f P s y c h i a t r y a n d S o c i a l S c i e n c e . New Y o r k : N o r t o n a n d Compnay , 1 9 6 4 . P o l a k , P . a n d K i r b y , M . 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