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A descriptive survey of adult psychiatric day treatment centers in British Columbia Burstahler, Ruth Marie, 1936- 1973

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A DESCRIPTIVE SURVEY OF ADULT PSYCHIATRIC DAY TREATMENT CENTERS IN BRITISH COLUMBIA by RUTH MARIE BURSTAHLER B.N., University of Manitoba A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in the School of Nursing We accept this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA June, 1973  In presenting  this thesis in p a r t i a l fulfilment of the requirements for  an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t freely available for reference  and  study.  I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may by his representatives.  be granted by the Head of my Department or  It i s understood that copying or publication  of this thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission.  Department of The University of B r i t i s h Columbia Vancouver 8, Canada  ABSTRACT A DESCRIPTIVE SURVEY OF ADULT PSYCHIATRIC DAY TREATMENT CENTERS IN BRITISH COLUMBIA RUTH MARIE BURSTAHLER At the present time there i s very l i t t l e informational data available relating to the adult p s y c h i a t r i c day treatment centers in the province o f B r i t i s h Columbia. In recent years the trend i n psychiatric care has been to t r e a t people within their family and community s e t t i n g . Within the past f i v e years, four new day care centers have been established at various hospitals throughout the province o f B r i t i s h Columbia. The purpose o f this d e s c r i p t i v e survey was to provide a composite picture o f the currently functioning adult p s y c h i a t r i c day care centers. A total o f f i v e o f f i c i a l and two u n o f f i c i a l day care programs were surveyed and 290 patient records were examined. The s p e c i f i c areas of i n t e r e s t i n day care functioning centered around; the family and community involvement i n the treatment program, the types of treatment that were used, the type o f r o l e the s t a f f c a r r i e d out, the total program evaluation and a p r o f i l e of the patients who were treated by t h i s modality. To c o l l e c t the data, the researcher used; a questionnaire which was answered i n a taped interview, observational v i s i t s to each center, and an examination of the patients' records. The r e s u l t s of the questionnaire indicated that family involvement i n the total day program was generally l i m i t e d , group methods of treatment were used which gave the patients a sense of community, and patients were followed-up either by the day care center or by the r e f e r r a l source. Referral of patients to these centers were mainly from in-patient wards, other p s y c h i a t r i s t s and p s y c h i a t r i c c l i n i c s . The c r i t e r i a that was used to terminate a patient's treatment was on the basis of his actual performance i n  the program and his level o f functioning at home and i n the community. This was also the prevalent method used to evaluate the effectiveness of the total treatment program. S t a f f i n these day care centers were both permanent and rotating with t h e i r role function being both s p e c i f i c and generalized. An examination of the patients' records revealed that the average patient was 33 years o l d , generally female, s i n g l e , diagnosed as being depressed, above Grade 11 i n education and presently unemployed. Seventy-seven per cent of the patients had previously received p s y c h i a t r i c treatment and the length of stay i n the treatment program was 54 days. Findings from this study indicated that a wide v a r i e t y o f patients were treated i n day care, which, had these centers not been a v a i l a b l e , would have been admitted to an in-patient ward. Day care i s not only an a l t e r n a t i v e to h o s p i t a l i z a t i o n , but i t may be the choice method of treatment f o r many patients.  81  pages  ACKNOWLEDGEMENTS I would l i k e to express my sincere appreciation to the many people who have helped to make this study possible. To the directors and the s t a f f working i n each of the seven day care centers who so w i l l i n g l y gave their time, e f f o r t and f u l l co-operation during the data c o l l e c t i o n period of this study. To the members of my committee, Dr. A. Crichton and Mrs. E. Warbinek f o r the continued help and support that they provided throughout this study. I would e s p e c i a l l y l i k e to thank Miss M. Horrocks, the chairman of my committee f o r her continued interest and guidance i n the progression of this study.  TABLE OF CONTENTS CHAPTER I.  II.  III.  IV.  PAGE INTRODUCTION  1  The Choice of the Problem  1  The Problem  2  Significance of the Problem  2  D e f i n i t i o n of Terms Used  4  Limitations of the Study  4  REVIEW OF THE LITERATURE  6  H i s t o r i c a l Perspective  6  Day Treatment Centers  8  Aims of Day Treatment Centers  9  Evaluation of the Program  11  Disadvantages of Day Treatment Centers  12  Future Trends  13  DEVELOPMENT OF THE STUDY  14  Background of the Study  14  Personal Background  14  The Patient Population  15  The Day Center Setting  15  THE RESEARCH DESIGN  17  CHAPTER  PAGE The Questionnaire  17  Observational V i s i t s  19  Patient Records V.  VI.  METHOD OF ANALYSIS  ... 20 21  Description of Day Care A  21  Description of Day Care B  24  Description of Day Care C  26  Description of Day Care D  29  Description of Day Care E  31  Description of Program F  34  Description of Program G  36  Diagnostic Categories  38  INTERPRETATION OF FINDINGS  39  Premise of Day Care  39  Family Involvement  39  Staffing  41  Basis f o r Patient Discharge  41  Patient Follow-Up  42  Referrals  42  Patient Admission  43  Treatment  43  Program Evaluation  44  General Patient P r o f i l e  45  CHAPTER  VII.  PAGE Age of the Patients  47  Previous Hospital Treatment  49  Length of Time i n Treatment  50  Funding  50  SUMMARY, AREAS FOR FURTHER INVESTIGATION AND RECOMMENDATIONS  52  Summary  52  Areas f o r Further Investigation  53  Recommendations  54  APPENDIXES  56  Questionnaire  56  Taped Interviews  59  BIBLIOGRAPHY  79  LIST OF TABLES TABLE I. II. III. IV.  PAGE A Summary of the Tape Recorded Ansv/ers Received From the Five Day Care Centers In Response To the Questionnaire  40  A Summary of the Age Brackets of the Female and Male Patients Who Engaged i n the Day Care Programs in the Five O f f i c i a l Centers 48 The Number of Female and Male Patients Who Had Previously Received Psychiatric Treatment Within the Past Five Years  49  The Number of Days That Female and Male Patients Spent i n Day Care Treatment i n the Five Centers ... 50  CHAPTER I INTRODUCTION The concept of t r e a t i n g adult patients in a p s y c h i a t r i c day centre dates back to 1957 in B r i t i s h Columbia. Since that time, f i v e day treatment centres have been established. Four of these are located in Greater Vancouver and one i s located i n the Northern section of the province. Several other treatment centres are in the early planning stages. The p s y c h i a t r i c day treatment programs have generally evolved by two d i f f e r e n t methods. One, being the formalized planning and implementing of a program p r i o r to patients being admitted to i t , and secondly, where former patients return to the p s y c h i a t r i c v/ard on an informal basis, and are incorporated into the ward program. It i s when these " v i s i t i n g " ex-patients become quite numerous that a formal day program i s set up. At the present time there are several informal or u n o f f i c i a l programs operating in conjunction with an established p s y c h i a t r i c in-patient u n i t , within the general hospitals. Therefore, this present study was undertaken to provide a systematic body of knowledge relevant to the e x i s t i n g p s y c h i a t r i c day treatment centres in B r i t i s h Columbia. The Choice of the Problem At the present time there i s very l i t t l e informational data available relating to the adult p s y c h i a t r i c day treatment centres in the province of B r i t i s h Columbia. The design of this d e s c r i p t i v e survey was to generate a body of systematic knowledge to provide some basis f o r general statements to be made. Hyman states: Further the d e s c r i p t i v e survey by providing data on the r a r i t y or u n i v e r s a l i t y of some phenomenon and i t s d i s t r i b u t i o n s o c i a l l y gives guidance as to what type of , determinants might lead to the most f r u i t f u l hypotheses.  Herbert Hyman, Survey Design and Analysis (Glencoe: The Free Press, 1960), p. 78.  It was not f e a s i b l e to formulate a hypothesis, as the modest aim of t h i s study i s to describe objectively the phenomena of day treatment centres. I. THE PROBLEM Statement of the Problem. The purpose of this study was to provide a composite picture of psychiatric day treatment centres i n B r i t i s h Columbia as they relate to adult patient care. Increasingly, more people are seeking help and guidance f o r their problems i n d a i l y l i v i n g and a large number of these people are being seen and treated in psychiatric day treatment centres. How are these treatment centres set up so that maximum patient benefit can be derived? What categories of people are receiving this type of care? How are the patients referred to the day treatment centre? What family and community involvement i s there with the patient i n h i s treatment program? These are some of the questions which this survey attempted to answer i n providing a general d e s c r i p t i o n of the day treatment centres. The empirical g e n e r a l i z a t i o n i s a summary statement about facts derived by systematic methods...In many areas of health care research, i t i s necessary f i r s t to assemble such ordered facts before i t i s possible to move to more refinement o f meaning. Significance of the Problem. In recent years the trend i n psychiatric care has been toward treating people within the family and the community setting. One reason f o r this trend may be c i t e d as: "Community care extends the number of situations i n which r e l a t i v e l y normal social roles can be learned or resumed by the patient. Increasingly, more people are receiving out-patient treatment, day care treatment and follow-up treatment.  M.V. Batey, "Conceptualizing the Research Process," Nursing Research, Vol. 20, No. 4, 1971^ p. 296. 3  Mervyn Susser, Community Psychiatry (New York: House, 1968), p. 16.  Random  3 S p e c i f i c a l l y w i t h i n t h e l a s t 15 y e a r s , b o t h o f f i c i a l and u n o f f i c i a l treatment  c e n t r e s have been e s t a b l i s h e d a t v a r i o u s h o s p i t a l s  out t h e p r o v i n c e o f B r i t i s h C o l u m b i a .  through-  S e v e r a l a d v a n t a g e s have been  c i t e d by Cumming, f o r t h e u s e o f d a y t r e a t m e n t the " s i c k r o l e " i s u s u a l l y n o t as p r o m i n e n t l y p a t i e n t ; a value system i s adopted through  centres.  These a r e :  d i s p l a y e d by t h e  treatment  which g e n e r a l i z e s  t o t h e p a t i e n t s ' home s i t u a t i o n and t h e r e i s a l s o an e c o n o m i c f a c t o r i n v o l v e d , where l e s s monies a r e r e q u i r e d f o r t r e a t m e n t  facilities.^  T h e s e b a s i c a d v a n t a g e s f o r d a y c a r e have a l s o been c i t e d by Herz e t 5  al.  W i t h r e g a r d t o t h e e f f i c a c y o f a p s y c h i a t r i c day t r e a t m e n t  centre,  a s t u d y c a r r i e d o u t by W i l d e r e t a l . , t h e y c o n c l u d e t h a t : The f i n d i n g s o f t h e a p p l i c a b i l i t y s t u d y and t h i s two-year follow-up study i n d i c a t e t h a t the day h o s p i t a l was a f e a s i b l e t r e a t m e n t m o d a l i t y and was g e n e r a l l y a s e f f e c t i v e as the i n - p a t i e n t s e r v i c e i n the treatment o f a c u t e l y d i s t u r b e d p a t i e n t s f o r most o r a l l phases o f t h e i r hospitalization.6 A c c o r d i n g t o the l i t e r a t u r e , day treatment c e n t r e s operate on t h e p r i n c i p l e t h a t t h e needs o f t h e p a t i e n t a r e b e i n g met so t h a t t r e a t m e n t b e n e f i t s a r e d e r i v e d . How i s t h i s t r e a t m e n t m o d a l i t y e v a l uated? Unfortunately, there i s a s c a r c i t y o f l i t e r a t u r e p e r t a i n i n g t o t h e e v a l u a t i o n o f t h e s e t r e a t m e n t c e n t r e s i n terms o f p a t i e n t  J . Cumming and J . B a s s , "A Review o f t h e L i t e r a t u r e on P s y c h i a t r i c Day H o s p i t a l s w i t h S p e c i a l R e f e r e n c e t o E v a l u a t i o n , " Department o f H e a l t h S e r v i c e s and H o s p i t a l I n s u r a n c e , ( V i c t o r i a , B r i t i s h C o l u m b i a , May, 1 9 7 3 ) , p. 20. 5  M.I. Herz and J . E n d i c o t t e t a l . , "Day V e r s u s I n p a t i e n t H o s p i t a l i z a t i o n : A C o n t r o l l e d Study," American Journal o f P s y c h i a t r y , 127:10, A p r i l , 1971. *\].F. W i l d e r e t a l . , "A Two-Year F o l l o w - U p E v a l u a t i o n o f A c u t e P s y c h o t i c P a t i e n t s T r e a t e d i n a Day H o s p i t a l , " 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 , 122:1966, p. 1101.  4 benefits. Thus, one pre-requisite before evaluation can take place i s to be aware of the existing f a c i l i t i e s and how they operate. The purpose of this study was to become f a m i l i a r with these treatment centres as they relate to adult patient care. II.  DEFINITION OF TERMS USED  Adult. This term designates a female or a male who i s 19 years of age or over. Psychiatric Day Treatment Centre. This i s defined as a formal, on-going program of a c t i v i t i e s and treatment which i s attended by patients who have emotional problems. "The service i s designated for patients with mental or emotional disorders who spend part of the twenty-four hours of any one day i n the program." ^ In t h i s study, the patient population attended the program f o r three or more days per week on a regular basis until they were discharged. U n o f f i c i a l . This term i s synonymous with informal, to designate a day care program which does not receive s p e c i f i c Governmental funding. The patients coming to these day care programs are incorporated into the total in-patient structure and a c t i v i t i e s . III.  LIMITATIONS OF THE STUDY  This study was limited by: a) the size of the sample, b) the type of questionnaire, c) the type of setting. The size of the sample. The decision to examine a sample of 50 patient p r o f i l e s from each of the f i v e o f f i c i a l treatment centres was an a r b i t r a r y one. This selected population may or may not have provided a representative picture of the type of patients and the centres under study. In the two informal day care programs that were  U.S. Department of Health, Education and Welfare, Community Mental Health Centers Act of 1963, T i t l e 2. Public Law 88-164. Regulations (Federal Register) 1964.  5 studied, a total of 20 patient profiles were examined, as the total number of attending day patients was greatly reduced. The type of questionnaire.  The questionnaire that was used  in this study covers many complex areas of the functional psychiatric day treatment centre.  In order to get the required informational data,  a broad generalized approach to each area was chosen instead of delving in-depth into only one or two areas. The type of setting.  The intent of this study was to deal  exclusively with the formalized adult psychiatric day treatment centres. This excludes treatment provided once or twice a week, or weekly maintenance groups.  The setting of this study took place in the five  o f f i c i a l l y designated day treatment centres in the province.  Two  of the existing unofficial programs were examined to provide an indication of the type of activities engaged i n , and the patient population using this treatment modality.  CHAPTER II REVIEW OF THE LITERATURE A.  H i s t o r i c a l Perspective  H i s t o r i c a l l y , the f i r s t day treatment centre in Canada was established in Montreal, in 1947 by Cameron. This unit treated both convalescent in-patients and patients who would normally be admitted to the hospital wards. The diagnostic categories of the patients cared for in this day treatment centre ranged from "early schizophrenia," "depressed" and " h y p o m a n i c s . I n i t i a l l y , there were twenty patients attending the program, six days a week. In 1954 the e x i s t i n g f a c i l i t i e s were enlarged so that 40 patients could be accommodated. The writer was able to gain f i r s t hand knowledge and experience by working in this day care program in 1968. The successful results of this day centre may have helped to i n i t i a t e the e s t a b l i s h ment of psychiatric treatment centres in other areas and to hasten i t s acceptance as a treatment modality. In England, Bierer in 1951, i s credited with describing the f i r s t day hospital, which was e n t i r e l y independent of the e x i s t i n g mental hospitals. This Marlborough Day hospital functioned with a community orientation and the length of patient attendance varied. The types of treatments rendered to the patients included both physical and group care. By 1959 there were "...45 psychiatric day-hospitals 3  and day centres of a l l types..." In 1958-9 the passage of the Mental Health B i l l indicated a s h i f t i n g of p s y c h i a t r i c care from mental D.E. Cameron, "The Day Hospital," Modern Hospitals, 69:40, (1947). o  J. Bierer, The Day Hospital (London: H.K. Lewis, 1951); see also J. Bierer, "Theory and Practice of Psychiatric Day Hospitals," Lancet I I , (1959). 3  G.F. Rehin and F.M. Martin, Patterns of Performance in Community Care (Toronto: Oxford University Press, 1968), p.11.  7 i n s t i t u t i o n s to the community. "One of the main principles...(was) the re-orientation of the mental health service away from i n s t i t u t i o n a l care towards care in the community."^ This B i l l gave further impetus to the establishment of day centers within the community, whereby the patient received treatment but was not separated from his family and social s e t t i n g . In the United States, the Menninger C l i n i c established a day hospital in 1949. The patients who attended t h i s day hospital came from a wide geographical area and f o s t e r homes were provided while 5  they were under treatment. By 1959 there were approximately 25 day hospitals in f u l l operation. Since that time, t h i s form of treatment modality has increased very r a p i d l y in a l l areas of the United States. Guy and Gross c i t e one reason for this rapid expansion as: "The awareness of, and the d i s s a t i s f a c t i o n with, the l i m i t a t i o n s of huge custodial hospitals makes us seek eagerly f o r a l t e r n a t i v e s . " In the province of B r i t i s h Columbia, a day hospital was established i n 1957 at the Mental Health Center in Burnaby. Treatment was afforded to a diverse group of patients who were categorized as acutely disturbed, schizophrenic'and character disorders. A structured program was carried out which emphasized communication patterns, behavioural s k i l l s and patient r e s p o n s i b i l i t y . G.F. Rehin and F.M. Martin, Patterns of Performance i n Community Care (Toronto: Oxford University Press, 1968), p. 18. 5 M. C r a f t , " P s y c h i a t r i c Day Hospitals," American Journal of Psychiatry. 116, (1959), p. 251. ^W. Guy and G.M. Gross, "Problems in the Evaluation of Day Hospitals, " CommunityMental Health Journal, Vol. 3, No. 2 (1967), p. 111.  8  B. Day Treatment Centres A recurring d e f i n i t i o n of a psychiatric day hospital i s the one that i s given by C r a f t : ...as one where f u l l hospital treatment i s given under medical supervision...It i s suitable f o r those o f the mentally i l l who are well enough to travel and to spend the night with their families.7 This a r t i c l e reviewed the l i t e r a t u r e pertaining to day hospitals and i t was found that "a wide variety" of mental disorders were being treated with s i m i l a r treatment modalities as that on the i n patient wards. Craft also found that there were two l i m i t i n g factors to day care. These being: a) the patients' geographical location b) the "quality" and receptiveness of the patient's family or r e l a t i v e s i n the home. In an attempt to overcome the f i r s t l i m i t a t i o n of geographical d i s tance, foster homes have been used to lodge the patients. An i n herent draw-back to the use of foster homes i s that the patient i s removed from his family and community setting, " . . . a f t e r a prolonged absence, the patient cannot re-enter the community and s t a r t again Q  exactly where he l e f t o f f . " The patient, h i s family and the community may become accustomed to a separation and they may adopt a s a t i s f y i n g l i f e s t y l e which i n h i b i t s disruption. In this regard Gove and Lubach further state: Thus, i f the patient has an extended stay i n the h o s p i t a l , the s k i l l s he needs f o r performing e f f e c t i v e l y i n the-community w i l l gradually atrophy and he w i l l develop a new set of s k i l l s which are adapted to a s e t t i n g . . .  ^Craft, loc. c i t . g  W. Gove and J.E. Lubach, "An Intensive Treatment Program for Psychiatric Inpatients: A Description and Evaluation," Journal of Health and Social Behavior, Vol. 10 (1969), p. 225. >  9  Ibid.  9 The attitudes and responses of the r e l a t i v e s o f patients who were treated in a day hospital was the focus of a study by Odenheimer. The sample of the r e l a t i v e s that were studied was small — a total of seven. The results showed that a l l but one of the r e l a t i v e s voiced d i s s a t i s f a c t i o n when the patient was admitted to a day hospital and not to an inpatient ward. This treatment modality was experienced by the r e l a t i v e s as being "unwanted and anxietyprovoking."^ This would indicate that i n order f o r the day hospital to be a successful community based service, guidance and support must also be given to the family members of the patient. In summing up this study Odenheimer stated: 0  A survey of r e l a t i v e s ' statements about the admission procedure, t h e i r interaction with the day hospital s t a f f and t h e i r family members in treatment at the time of admission and during the f i r s t week a f t e r admission, has shown that c e r t a i n , a l b e i t unstructured, supportive measures on the part of s t a f f can m a t e r i a l l y minimize the r e l a t i v e s ' resistance. 11  The attitude of the general public indicates that inpatient treatment is more acceptable f o r emotional i l l n e s s , than i s day care treatment. Suchman s t a t e s : "The value system of a s o c i e t y helps to shape the public's a t t i t u d e s , b e l i e f s and behaviour in regard to health and illness." 1 2  C. Aims of Day Treatment Centers In common with a l l other organizations, day treatment centers have been established to perform a primary task or objective. Set within a broad framework this task i s to help the patient cope with  J.F. Odenheimer, "Day Hospital as an Alternative to the Psychiatric Ward," Archives of General Psychiatry, Vol. 13, (July, 1963), p. 53. 1 1  12  York:  Ibid.  E.A. Suchman, Sociology and the Field of Public Health (New Russell Sage Foundation, 1963), p. 15.  10 his emotional problems.  Astrachan et a l . presented four objectives  around which day hospitals may be designed.  The day hospital may  provide: a)  "an alternative to 24 hour inpatient hospitalization  b)  a transitional care setting whose task is to facilitate the re-entry into the community of previously hospitalized patients  c)  a treatment and rehabilitative f a c i l i t y for the chronically mentally disturbed  d)  a structure which delivers those psychiatric services which a specified community defines as an over-riding 13 public need."  Thus each day treatment center would be established on the basis of the specific task or objective which is deemed most appropriate to that specific environmental situation and community need.  Since  the day hospital operates in an open system, a working relationship with the community and the environment is essential  for total day  care functioning. The length of time that a patient would spend in the day treatment center would depend on such factors as:  the type and  severity of his illness; his past coping patterns and his outside supportive resources.  Meltzoff and Blumenthal in their description  of a day treatment center state that: If we are to have a significant impact on a patient, succeed in breaking up long established behaviour patterns, and give opportunities for learning a new repertory, sufficient interaction time with the patient is essential.14  B.M. Astrachan et a l . , "Systems Approach to Day Hospitalization," Archives of General Psychiatry, Vol. 22, (June, 1970), p. 550.  14  J. Meltzoff and R.L. Blumenthal, The Day Treatment Center (Springfield: Charles C. Thomas, 1966), p. 32.  11 D.  Evaluation of the Program  Evaluation or the extent to which the program achieves the stated objectives i s a d i f f i c u l t process. Craven approaches evaluation of a program in terms of goal achievement. The basic and distinguishing c h a r a c t e r i s t i c of program evaluation i s that program goals or objectives are stated and the evaluation i s then designed to determine the degree to which the goals were reached.15 Increasingly, the cost of health care is r i s i n g at a rapid rate. Thus the cost-benefit factor for a l l programs need to be evaluated to see i f the objective of adequate patient care has been met. Therefore, on a cost-benefit basis, day care i s one of the most economical forms of psychiatric treatment. This economy extends to space requirements, e f f i c i e n t use of s t a f f and retention of community ties which shorten the r e h a b i l i t a t i o n period.16 In terms of evaluation of a day treatment program, Guy and Gross state that two types of assessment procedures are necessary. These being: a) a terminal assessment which would measure the immediate treatment effects or r e s u l t s b) a follow-up assessment to evaluate the permanency of the treatment e f f e c t e d . This would indicate the necessity of stating a d e f i n i t e c r i t e r i a for success of a treatment program. This c r i t e r i o n may deal with the amount or slope of observable patient improvement, length of hospital stay or the rate of remission. 17  15  R.B. Cravens, "Evaluation of Community Mental Health Center Programs," Journal of Operational Psychiatry, Vol. 3, No. 2, (1967), p. 117. ^R.G. Congdon, " P a r t i a l H o s p i t a l i z a t i o n , " Canadian Psychiatric Association Journal, Vol. 16, (1971) p. 243-244. 17  Guy and Gross, op. c i t . , p. 117.  12 Service programs have progressed much more r a p i d l y than evaluation and research on the programs and effectiveness of centers, but the l a t t e r are being planned.18 E. Disadvantages of Day Treatment Centers The day treatment center, along with the many advantages as a treatment modality, also has some recognized disadvantages and inherent problems. Some of the negative aspects include the following: a) the center can be under-utilized, this may be due to the s e l e c t i o n procedure or that the referring agencies are not aware of this treatment f a c i l i t y b) the patient and his family may not view the program as an acceptable treatment modality, since the concept of day care does not conform to the inpatient model. Thus the neededfamily support may be lacking. c) there may be a higher r i s k with suicidal or homocidal patients d) i t may be more mentally f a t i g u i n g f o r the working s t a f f in the center, because of the structure of the program, to help the patient cope with his problems e) the drop out rate could be higher than i t i s f o r inpatient care, "...one possible explanation f o r the high, e a r l y drop out rate could be, of course, that the patient simply does not find anything i n the program that seems useful 19 and worthwhile to him." f) the geographical distance between the patient and the treatment center. D.N. Wiener, "Problems and Directions f o r the Day Treatment Mental Hygiene, 47, (1963), p. 411.  Center," 19  R.M. Glasscote, et a l . , Partial Hospitalization f o r the Mentally 111 (Washington: The J o i n t Information Service, 1969), p. 30.  13 F.  Future Trends  "During the l a s t hundred years psychiatric care of patients has changed from almost complete i n s t i t u t i o n a l i z a t i o n to a d i v e r s i t y 20 of treatment forms." In the future, w i l l the day treatment center replace the inpatient wards f o r psychiatric care? The s h i f t i n g trend is such that the patient, the family and the community share a greater r e s p o n s i b i l i t y in the care and treatment of emotional i l l n e s s . "More recently the emphasis has been on independent day-care centers 21 existing separately from inpatient psychiatric f a c i l i t i e s . " The advantages and the disadvantages of day treatment centers which provide care to patients with emotional problems, have been the topic of many a r t i c l e s and books. As yet, no d e f i n i t i v e conclusion has been reached. Cumming, in his summation stated: It seems l i k e l y , at least i n the f i e l d of the delivery of services, that we are seldom going to find new ways of d e l i v e r ing care which w i l l e n t i r e l y supersede a previous mode... For the present we w i l l have to act on the basis of informed good sense.22  20 Congdon, op. c i t . , p. 244. 21  J.A. Morgenstern and J.T. Ungerleider, "Integration of a Day-Care Program Into a General Psychiatric Hospital," American Journal of Psychiatry, 122, (1966), p. 1178. . 22 Cumming, op. c i t . , p. 32-33.  CHAPTER III DEVELOPMENT OF THE STUDY A.  Background of the Study  The l i t e r a t u r e r e l a t i n g s p e c i f i c a l l y to the p s y c h i a t r i c day treatment centers in B r i t i s h Columbia was scanty. Two recent papers by Cumming were relevant to this study, but the objective of these papers was not to provide a d e s c r i p t i v e summary of the a v a i l a b l e centers. One i n i t i a l problem encountered by the w r i t e r , was to discover the location of each adult p s y c h i a t r i c day care center i n this province. A contributing f a c t o r here may have been, that within the past year or two, there has been an increased i n t e r e s t in establishing this type of treatment modality. A f t e r the day care centers were located, they were then contacted by mail and in Greater Vancouver by a personal v i s i t , as to their willingness to participate i n this study. Numerous p s y c h i a t r i c wards which are located within general hospitals had u n o f f i c i a l programs, where former patients came to the ward during the day and were incorporated into the ward structure and a c t i v i t i e s . One important assumption here i s that; these former patients may be maintained outside of the hospital because the s t a f f devotes time and attention to the people and their problems. A possible re-admission into the in-patient f a c i l i t y may therefore be prevented. This type of u n o f f i c i a l program does not receive Governmental funding. B.  Personal Background  The researcher has been a c t i v e l y involved i n the d e l i v e r y of p s y c h i a t r i c care f o r the past four years. During this time the trend toward day care, out-patient care, and the prevention of i n -  15 patient admissions has been more and more evident. The i n i t i a l contact with day care treatment for p s y c h i a t r i c patients was in 1968 at the Allan Memorial in Montreal. The basic assumption that many patients do not require the s p e c i a l i z e d services of an in-patient ward and that other resources were able to provide a continuity of patient care, stemmed from this personal experience. In 1971, t h i s writer was fortunate to p a r t i c i p a t e in the planning and implementing of a day care program in another province. The resultant i n t e r e s t in t h i s method of d e l i v e r i n g health care to p s y c h i a t r i c patients in B r i t i s h Columbia seemed to be a natural outcome. C.  The Patient Population  In this study, informational data was c o l l e c t e d on 50 patients from each of the f i v e o f f i c i a l day treatment centers. In the two u n o f f i c i a l centers, a total of 20 patient records from each center, were examined. This reduction in number was due to a reduced patient intake who did not meet the c r i t e r i a of attending f o r three days on a regular basis. The total number of patient records that were sampled was 290. The patients included those who were a c t i v e l y involved in the treatment program at the present time, and to make up the total compliment of 50 patients from each area, data were obtained on the most recently discharged patients. The c r i t e r i a that was used for inclusion in t h i s study f o r the patient population was: a) female or male adult b) attendance at the program for three or more days per week on a regular basis c) a total attendance in day care f o r s i x or more consecut i v e treatment days d) presently involved in the program and the most recently discharged patients. D.  Day Care Setting  There are four day care centers located i n Greater Vancouver and one center i s located in the northern i n t e r i o r section of B r i t i s h  16 Columbia. Two u n o f f i c i a l centers, which are located in central B r i t i s h Columbia were also examined. This survey i s not a sampling of the available psychiatric day care centers, as a l l of the e x i s t i n g programs participated in this study. The respondants f o r the taped interview varied with the centers, but a l l were in d i r e c t control and a c t i v e participants in the total treatment program. These respondants included; a nurse, a psychologist, two p s y c h i a t r i s t s , and an occupational therapist. In the two u n o f f i c i a l programs, the nurse in charge of the i n - p a t i e n t ward was interviewed. I n i t i a l l y the writer had planned to interview j o i n t l y the two people d i r e c t l y in charge of each program, f o r example, the p s y c h i a t r i s t and the nurse. But this plan was revised when the time factor was taken into consideration. Since each of the centers functioned with a limited number of s t a f f , i t was not deemed equitable to request the time of two s t a f f members at the same time.  CHAPTER IV THE RESEARCH DESIGN The aim of this survey was to provide a composite picture of the current functioning of the e x i s t i n g adult psychiatric, day care centers in B r i t i s h Columbia. Therefore, the use of a descriptive survey was deemed to be the most f e a s i b l e method of focusing attention on the natural d i s t r i b u t i o n and the r e l a t i o n s h i p of the variables found within these day care centers. " N a t u r a l i s t i c methods attempt to extract the elements of a naturally occurring complex of variables without the intrusions of d i r e c t manipulation or constraining controls." The survey procedures used to c o l l e c t data in these centers consisted of a questionnaire, observational v i s i t s and the patient records. A.  The  Questionnaire  The construction of this questionnaire was based on the assumption that the existing psychiatric day care centers have many commonalities. One assumption here, i s that family and community support i s essential before a patient can a t t a i n and maintain a higher level of functioning. This formed the basis f o r the question relating to family involvement in the patient's t o t a l treatment program. Lamb, in an a r t i c l e on chronic patients states: It was also found that the patients' level of functioning in the community had a much higher c o r r e l a t i o n with the expectations of the s i g n i f i c a n t people of t h e i r environment rather than with symptomatic expression of their i l l n e s s . 2  Theodore Mi 11 on and H.I. Diesenhaus, Research Methods in Psychopathology (Toronto: John Wiley and Sons, 1972), p.48. H. Richard Lamb, "Release of Chronic Psychiatric Patients Into The Community," Archives of General Psychiatry, Vol. 19, J u l y , 1968 , p. 42.  18 Several other assumptions relevant to the construction of this questionnaire were: a) that day care i s an e f f e c t i v e treatment modality b) long term care i s not e s s e n t i a l , nor i s i t always desirable, in helping people cope with l i f e situations or to learn new r e l a t i o n s h i p patterns c) an on-going evaluation of any type of health care delivery system or organization i s imperative d) each individual person has a r e s p o n s i b i l i t y f o r his own behaviour and actions This questionnaire was designed to provide an i n d i c a t i o n of the current functioning of the day care center. Prior to the data c o l l e c t i o n each respondant was given a copy of t h i s questionnaire f o r t h e i r perusal. The questionnaire was then answered v i a an hour long tape recorded interview with the writer. The use of a scheduled l i s t of questions was deemed necessary to ensure that the relevant information was obtained during each interview. But these interviews were not so r i g i d l y structured as to prevent elaboration on any topic related to the functional operation of the center. Unscheduled questions were also asked of the respondant, which added to the writer's understanding of that center. "Interviewing is both a d i r e c t source of information on b e l i e f and knowledge systems and a form of vicarious observation to increase case examples of 3  various types of overt behavior." Some of the questions were more relevant to some centers than to others. For example; the question of who referred the Marion P e a r s a l l , " P a r t i c i p a n t Observation As Role And Method In Behavioral Research," Nursing Research, Vol. 14, No. 1, 1965 , p. 40.  19 patient to the center, was more related to a large c i t y center, than i t was to a town where the hospital was the only medical f a c i l i t y . The questionnaire that was used in these interviews i s included in Appendix A. The use of a tape recorder in each interview was necessary so that the obtained information would be an accurate representation of the conversation. These taped interviews yielded an average of eleven pages f o r each center, which proved too lengthy to be included in t h e i r e n t i r e t y . Therefore, each answer was selected and a shortened version of the t r a n s c r i p t f o r each center has been included in Appendix B. Due to the l i m i t e d number of adult p s y c h i a t r i c day care centers in the province, a pre-test of the questionnaire in one of the centers was not c a r r i e d out. B.  Observational V i s i t s  Two observational v i s i t s were made to six of the p s y c h i a t r i c day care centers, the other center received one v i s i t of a six hour duration. These v i s i t s normally varied from one to four hours in length. The purpose of the v i s i t s were two-fold; one, to enable the writer to become f a m i l i a r and to gain a c e r t a i n degree of knowledge about these centers, and secondly, to obtain the informational data from the taped interview with the respondant. It was not the intent to a c t i v e l y p a r t i c i p a t e in a l l the patient a c t i v i t i e s that were c a r r i e d out in each center. The writer d i r e c t l y observed some of the patient a c t i v i t i e s , but this varied with each center dependent upon the a c t i v i t y in progress, the time period and the s t a f f that was involved. With regard to observational v i s i t s Blau and Scott state: "...the observer would do well to keep constantly in mind that he i s playing a social r o l e in a social 4  situation and to adapt his role to his research objectives." Peter Blau and W. Richard Scott, Formal Organizations (San Francisco: Chandler Publ. Co., 1962), p. 25.  20 C. Patient Records To provide a patient p r o f i l e of the patients who attended each day care center, certain variables were obtained from the charts that are kept on each person. The records of the patients presently engaged i n treatment plus the most recently discharged were used to equal a total of 50. A structured form was used to ensure that the relevant information was obtained from each record. Throughout this study, a l l the s t a t i s t i c a l calculations were taken to the nearest decimal point. In the two u n o f f i c i a l day programs, a patient p r o f i l e was obtained from examining the records of 20 of the patients who were presently coming up to the ward, and those who had attended i n the f i r s t three months of 1973. Complete records were not always kept on these patients, therefore areas such as education or written objectives were not readily a v a i l a b l e . In each center, the records that were kept on the individual patients varied a great deal i n the format that was used. In one area the recorded focus was on past performance and behaviour, i n another center the goals of the patient were emphasized and the progress he made to achieve those goals. This variance i n record keeping gave credence to the question that i s often cited i n the l i t e r a t u r e regarding the r e l i a b i l i t y of the records that are kept on the patients, e s p e c i a l l y when they are l a t e r used f o r informational purposes.  CHAPTER V METHOD OF ANALYSIS A d e s c r i p t i v e analysis w i l l be given f o r each of the seven day centers that were examined in this survey. This will provide the essential background information and introduction to each of these areas before proceeding to make generalizations from this data. This survey generated informational data relevant to: a) the patient population that attended the day care centers b) the type of treatments provided c) the involvement of family members d) the s t a f f i n g pattern i n the centers e) the present functioning of the centers f) the physical f a c i l i t i e s of the centers The time period f o r this data c o l l e c t i o n commenced on March 26, 1973 and i t was completed on April 27, 1973. Description of Day Care "A" A.  General Description  This day care program began operating two years ago in the hospital p s y c h i a t r i c ward, with l i m i t e d physical f a c i l i t i e s . In February, 1973, the day care program moved into a separate house, which i s located about two blocks from the h o s p i t a l . This building presently provides spacious areas f o r the various a c t i v i t i e s that take place. At the time of this survey, the day care program was s t i l l in the process of " s e t t l i n g i n " with regard to a c t i v i t i e s and remodeling the f a c i l i t i e s . Operational costs are covered by Governmental funding. Patients attend e i t h e r a f u l l time program or a part time one (Monday to Wednesday) dependent upon their s p e c i f i c needs.  22 The average age of the patients attending this program was 33.0 years, with males being s l i g h t l y older. The average number of treatment days per patient was 29.2. The largest marital category for both female and male was; s i n g l e , being 46 per cent of the population. The category of unemployed comprised a total of 45 per cent of the patients. About one-third of the day patients had been hospitalized previously within the past f i v e years, a s i m i l a r number had previously seen a p s y c h i a t r i s t and the remaining one-third had not received previous psychiatric treatment. Transportation to this area i s f a i r l y adequate. The present day care f a c i l i t y provides several large rooms and also smaller areas in which program a c t i v i t i e s can take place. This writer attributed the more relaxed atmosphere and group a c t i v i t i e s to the f a c t that this program did not occur in the medically orientated hospital s e t t i n g . Some recreational a c t i v i t i e s take place within the total community. The hours of operation are from 9:00 a.m. to 4:00 p.m., on a Monday to Friday basis. The s t a f f consists of three registered nurses, a part-time s o c i a l worker, occupational therapist and a p s y c h i a t r i s t . The average number of patients in t h i s program was twelve, when this survey was conducted there were nine patients. B.  Objectives  The theoretical aims which govern the operation of this day care program were taken from a 1972 Report. These were stated as; a) To provide the patient with simultaneous exposure to a rather intensive therapeutic a r t i f i c i a l and natural environment. b) To provide a non-medical therapeutic s e t t i n g . c) To provide a therapeutic community which stresses the general c h a r a c t e r i s t i c s of i n d i v i d u a l i t y , trustworthiness, p o s i t i v e reinforcement, r e s p o n s i b i l i t y , the provision of a c t i v i t y and a proper working day structure.  23 d) To provide a multiple i n t e r l o c k i n g group therapy, which provides the potential f o r learning and i n t e r a c t i o n . C. Patient P r o f i l e A d e s c r i p t i v e patient p r o f i l e of day care "A" v/hich was gleaned from 50 patient records can be shown by: a) Average number of patients in treatment - twelve. For the f i r s t three months of 1973, there were a total of 50 patients or 16.7 patients per month. In 1972, the average number of patients was 7 per month. b) Mean age of patients - 33.0 years. Female - 30.7 years, with the range being 19 to 58 years. Male - 35.4 years, with the range being 20 to 59 years. c) Sex - Female, 72 per cent Male, 28 per cent d) Marital status can be shown by: Single Married Separated Divorced Widowed Female 32% 20% 4% 10% 6% Male 14% 8% 4% 2% 0 e) The mean days of treatment was - 29.2 days. Female - 29.1 days, with the range being 9 to 48 days. Male - 29.3 days, with the range being 6 to 44 days. The 9 patients presently engaged i n treatment were not included i n these s t a t i s t i c s . f) The educational categories can be shown by: Grade 11 Below University and above Grade 11 Unknown Female 14% 12% 10% 36% Male 10% 6% 2% 10% g) The occupational categories can be shown by:  24 Female Male  Professional Working Unemployed 2% 4% 34% 4% 8% 12% h) Diagnostic category: Depression -. 48% Personality Disorder - 36% Others - 16%  Homemaker 24% 0  Student 8% 4%  Description of Day Care "B" A.  General Description  Day Care "B" was the f i r s t one to be established i n this province, and has been i n operation f o r the past 16 years. A unique aspect of t h i s program i s that the physical f a c i l i t i e s were e s p e c i a l l y constructed to house a day care h o s p i t a l . The physical layout i s quite spacious with s u f f i c i e n t areas f o r meetings and relevant a c t i v i t i e s . This day care i s not attached t o , or located i n close proximity to e i t h e r a p s y c h i a t r i c or a general h o s p i t a l . I n i t i a l l y , t h i s day hospital provided l a r g e l y somatic types of treatment. Funding f o r this program i s provided through the Mental Health Branch of Government. Transportation to t h i s f a c i l i t y presents a problem and a car i s a d e f i n i t e asset, i f not a necessity. The average patient stay at this day care program was 73.0 days with males staying predominantly longer. The female to male ratio was f a i r l y equal in number. The mean age of the patients was 29 years. The educational level was usually above Grade 11, (66%) and 50% of the patients were unemployed p r i o r to coming f o r treatment. Once again, the s i n g l e status was the highest f o r both female and male at 56%. This day care operates from 8:45 a.m. to 3:45 p.m., on a Monday to Friday basis. Each day i s f u l l y structured with group  25 a c t i v i t i e s , occupational or recreational therapy. One period a week is spent in a community a c t i v i t y . The permanent s t a f f consists of one registered nurse, four p s y c h i a t r i c nurses, a p s y c h i a t r i c aide, three occupational therapists and a p s y c h i a t r i s t - d i r e c t o r . B.  Objectives  The written aims as outlined in the information sheet which is given to the patients f o r this day h o s p i t a l , can be shown in the following four functions. a) We believe that human beings are responsible f o r t h e i r behaviour,that i s , they must accept the consequences of that behaviour. b) We concentrate on problems in the here and now, rather than trying to deal with the past since we believe that people can change t h e i r present behaviour and thus a l t e r t h e i r future. c) We encourage d i r e c t honest communication between a l l members both of ideas and feelings as they a r i s e . d) We encourage the development of s k i l l s and interests as this increases the capacity to gain competence and s a t i s f a c t i o n and use time e f f e c t i v e l y . C.  Patient P r o f i l e  A descriptive patient p r o f i l e of day care "B" which was gleaned from 50 patient records can be shown by: a) Average number of patients in treatment - 30. For the f i r s t three months of 1973, the average number of patients was 32.6 per month. In 1972, the average number of patients was 33.0 per month. b) Mean age of patients - 29 years. Females - 29.5 years, with the range being 19 to 48 years. Males - 28.5 years, with the range being 20 to 59 years.  26 c)  Sex - Female, 56 per cent Male, 44 per cent This female to male r a t i o was also observed by those patients presently involved in the treatment program. d) The marital status can be shown by: Si ngle Married Separated Divorced Widowed Female 24% 20% 8% 4% 0 Male 32% 6% 4% 2% 0 e) The mean days of treatment was - 73.0 days. Female - 55.0 days, with a range of 7 to 146 days. Male - 91.0 days, with a range of 6 to 162 days. The 21 patients presently engaged in treatment were not included in these s t a t i s t i c s . f ) The educational categories can be shown by: Grade 11 Below and above Grade 11 University Unknown 4% Female 28% 24% 0 12% Male 22% 10% 0 g) The occupational categories can be shown by: Professional Working Unemployed Homemaker Student ll Female 0 12% 26% Male 6% 24% 0 h) Diagnostic category: Personality Disorder 32% Schizophrenic - 36% Depression - 24% Others - 8% Description of Day Care "C" A.  General Description  Day care "C" i s located in a semi-isolated, b a s i c a l l y a ,ne industry supported, i n t e r i o r community. This semi-isolation  27 may provide f e r t i l e ground f o r emotional problems that are not encountered i n a large populated c i t y . The psychiatric i n - p a t i e n t service and the day care program at the h o s p i t a l , serves people from the surrounding geographical areas. The only additional service for patients with emotional problems i s provided by the Mental Health Center located i n this community. Transportation to these two f a c i l i t i e s does present a problem, not only to people l i v i n g i n the outlying areas of the town, but also f o r people from the smaller surrounding towns. This day care was i n i t i a l l y started i n 1969. The program presently operates from about 9:00 a.m. to 4:00 p.m., on a Monday to Friday basis. Governmental funding provides for the d a i l y operational costs. This day care program i s c l o s e l y aligned with the in-patient services, as there i s a sharing of the s t a f f and the available physical space. This program i s loosely structured as s t a f f i n g , and the physical f a c i l i t i e s are l i m i t i n g factors. There i s one practicing p s y c h i a t r i s t i n this community. Some recreational a c t i v i t i e s take place within the community setting. When this survey was conducted there were 17 patients i n the program, which was more than the average number. Most of the patients i n this program are referred from the in-patient ward, as a t r a n s i t i o n a l phase before the patient returns f u l l y to community l i v i n g . B. Objectives The objectives of this day care program were expressed verbally as being: a) To help people cope with their emotional problems and to return to family and community l i v i n g . b) To treat people without admission to the hospital wards. c) To help a l l e v i a t e the acute bed shortage.  28 C. Patient P r o f i l e A d e s c r i p t i v e patient p r o f i l e of day care "C" which was gleaned from the 50 patient records can be shown by: a) Average number of patients in treatment - 10. For the f i r s t three months of 1973, there were a total of 10. patients per month. In 1972, the average number of patients was 7 per month. b) Mean age of patients - 38.4 years. Female - 37.7 years, v/ith the range being 19 to 64 years. Male - 39.2 years, with the range being 19 to 53 years. c) Sex - Female, 74 per cent Male, 26 per cent d) The marital status can be shown by: Single Married Separated Divorced Widowed Female 4% 54% 16% 0 0 Male 14% 6% 4% "0 2% e) The mean days of treatment was - 28.5 days. Female - 23.0 days, with the range being from 7 to 94 days. Male - 34.0 days, with the range being from 6 to 103 days. The 17 patients presently engaged i n treatment were not included i n these s t a t i s t i c s . f) The educational categories can be shown by: Grade 11 Below and above Grade 11 University Unknown 4% 10% Female 24% 36% 0 Male 2% 18% 61 g) The occupational categories can be shown by: Professional Working Unemployed Homemaker Student 0 10% 0 Female 12% 52% 0 14% Male 0 10% h) Diagnostic category: Depression - 62% Schizophrenic - 16% Anxiety Reaction - 8! Others - 14%  29 Description of Day Care "D" A.  General Description  Day care "D" was one of the resultant programs which occurred in 1971, when a re-organization of the day care services took place at one of the hospitals. I n i t i a l l y , a day care follow-up program had been established on each of the three in-patient wards. From t h i s , day care "D" and "E" were set up. Day care "D" operated within the hospital setting for one and a half years, p r i o r to moving into i t s separate present f a c i l i t y two months ago. This f a c i l i t y consists of a large house, located about one block from the h o s p i t a l . Governmental funding provides for d a i l y operational costs of t h i s program. The mean age of the patients attending day care "D" was 27.8 years, with females being s l i g h t l y older. The educational level of the patients was 90% in the Grade 11 and above category. The largest occupational bracket was the unemployed, which totaled 42% of the female - male population. Females out-numbered males 2 to 1 in t h i s program. The average length of stay f o r each patient was 6 weeks. The marital status of 50% was in the single category, with married patients t o t a l i n g 36%. Transportation, at selected times, i s better i n t h i s area than i t i s to some other areas of the c i t y , but a car i s s t i l l a d e f i n i t e asset to reach this f a c i l i t y . Patient a c t i v i t i e s take place i n a spacious house, which has several large rooms and several smaller areas. The patients are responsible for the d a i l y maintenance of the house and of the surrounding grounds. Recreational a c t i v i t i e s take place i n the community s e t t i n g . The hours of operation are from 9:00 a.m. to 4:00 p.m., on a Monday to Friday basis. The s t a f f consists of a psychiat r i s t , a psychologist, a nurse, an occupational technician and two rotating Medical Residents. The average number of patients in t h i s program was 20. When this survey was conducted there were 17 patients engaged i n the program.  30 B.  Objectives  The written objectives for this day program are six in number. These are: a) To assess neurotic patients who demonstrate good motivation for treatment, by intensive group psychotherapy, in the day care program. b) To form a therapeutic community comprised of c l i n i c a l s t a f f and patients which is a model of real l i f e . c) To involve the patients' marital partners, family members and friends in family and " s i g n i f i c a n t others" therapy. d) To o f f e r discharged day care patients out-patient psychotherapy when appropriate. e) To study o b j e c t i v e l y the results of the treatment in day care, aiming towards a steady increase in the e f f i c i e n c y and (time) economy of treatment, by developing and testing new treatment methods. f ) To share our knowledge with mental health professionals as well as community agencies and those who contribute towards enhancing the standards of mental health care in the community. C.  Patient P r o f i l e  A d e s c r i p t i v e patient p r o f i l e of day care "D" which was gleaned from 50 patient records can be shown by: a) Average number of patients in treatment - 20. For the f i r s t three months of 1973, there were a total of 24.0 patients per month. In 1972, according to the Hospital S t a t i s t i c a l Report, the average number of patients was 20.2 per month. b) Mean age of patients - 27.8 years. Female - 30.4 years, with range being 20 to 49 years. Male - 25.3 years, with the range being 21 to 41 years. c) Sex - Female, 66 per cent Male, 34 per cent This female to male r a t i o was also observed by those patients presently involved i n the treatment program.  31 d)  The marital status can be shown by: Single Married Separated Divorced Widowed Female 22% 32% 2% 8% 2% Male 28% 4% 2% 0 0 e) The mean days of day care treatment was - 34.6 days. Female - 34.3 days, with the range being 7 to 46 days. Male - 35.0 days, with the range being 23 to 49 days. The 17 patients presently engaged in treatment were not included in these s t a t i s t i c s . f) The educational categories can be shown by: Grade 11 Below Universi ty and above Grade 11 Unknown Female 20% 40% 2% 2% Male 8% 22% 4% 2% g) The occupational categories can be shown by: Professional Worki ng Unemployed Homemaker Student Female 4% 18% 22% 18% 4% Male 0 12% 20% 0 2% h) Diagnostic category: Depression - 58% Personality Disorder - 30% Others - 12% Description of Day Care "E" A.  General Description  The h i s t o r y of day care "E" and "D" are unique in their o r i g i n . I n i t i a l l y , i n 1968, separate day care programs were established f o r patient follow-up on each of the three in-patient wards. These programs were p a r t i a l l y incorporated into the total ward structure and p a r t i a l l y they were maintained as a separate program of a c t i v i t i e s . Numerous changes i n the programs and the s t a f f structure took place over the ensuing three years. In 1971, two separate day care programs  32 were established within t h i s hospital s e t t i n g . Day care "E" was one of these programs. O r i g i n a l l y t h i s program served as a t r a n s i t i o n a l phase for patients who came from the in-patient wards, p r i o r to t h e i r complete return to t h e i r family and the community. Governmental funding provides f o r d a i l y operational costs of t h i s present program. Day care "E" serves a r e l a t i v e l y selected patient population, where the majority (72%) are i n an educational level of Grade 11 and above. The largest marital category for both female and male was; s i n g l e , y i e l d i n g 54%. Unemployed i s the largest single occupational category, also 54%. The average stay in the program was about 10 weeks per patient. Transportation, at selected times, i s better in t h i s area, than i t i s to some other areas of the c i t y , but a car is s t i l l a d e f i n i t e asset to reach this f a c i l i t y . Day care program "E" is located within the hospital s e t t i n g . Patient a c t i v i t i e s take place within one large comfortable room, a large occupational area and several smaller areas within the hospital. Many recreational a c t i v i t i e s take place within the total community s e t t i n g . The hours of operation are from 9:00 a.m. to 4:00 p.m., on a Monday to Friday basis. The s t a f f includes two r e g i stered nurses, one occupational t h e r a p i s t , a medical supervisor, a part-time Resident and access to a-social worker. The average number of patients i n t h i s program is 12. When this survey was conducted there were also 12 patients in the program. This day care program serves almost e x c l u s i v e l y patients who are categorized as schizophrenic and post-psychotic. B.  Objectives  The written objectives f o r this day care program are six in number. These being: a) To assess and treat mainly post-psychotic and borderline patients who demonstrate some degree of motivation for change i n t h e i r behaviour and interpersonal r e l a t i o n s h i p s .  33 b) To continue to maintain a structured, d a i l y program which is supervised by a m u l t i - d i s c i p i i n a r y team. c) To achieve r e - i n t e g r a t i o n into the community by various means, in addition to pharmacotherapy. d) To involve r e l a t i v e s and friends in bi-monthly therapeutic group sessions and when indicated,to engage individual families i n b r i e f conjoint family therapy. e) To provide a more adequate follow-up program f o r patients and t h e i r f a m i l i e s upon discharge from the day care program. f ) To teach students from various d i s c i p l i n e s , the means of recognizing and u t i l i z i n g an individual patient's human potential as implemented in this day care s e t t i n g . C.  Patient P r o f i l e  A d e s c r i p t i v e patient p r o f i l e of day care "E" which was gleaned from 50 patient records can be shown by: a) Average number of patients i n treatment - 12. For the f i r s t three months of 1973, there were a total of 12 patients per month. In 1972, according to the Hospital S t a t i s t i c a l Report, the average number of patients per month was 20.2. b) Mean age of patients - 29.5 years. Female - 31.4 years, with the range being 19 to 64 years. Male - 27.6 years, with the range being 19 to 54 years. c) Sex - Female, 54 per cent Male, 46 per cent This female to male r a t i o was also observed by those patients presently involved i n the treatment program, d) The marital status can be shown by: Single Married Separated Divorced Widowed Female 24% 16% 2% 8% 4% Male 30% 10% 4% 2% 0  34 e) The mean days of day care treatment was - 52.7 days. Female - 28.8 days, with the range being 6 to 63 days. Male - 76.6 days, with the range being 7 to 68 days. The 12 patients presently engaged i n treatment were not included in these s t a t i s t i c s . f ) The educational categories can be shown by: Grade 11 Below University and above Grade 11 Unknown 8% 28% 12% 6% Female 14% 24% 8% 0 Male g) The occupational categories can be shown by: Professional Working Unemployed Homemaker Student 20% 2% Female 10% 20% 0 34% Male 2% h) Diagnostic category: Schizophrenia - 54% Depression - 32% Others - 14% Description of Program "F A.  1  General Description  Program "F" was one of the u n o f f i c i a l areas that was surveyed regarding day patient v i s i t s . This survey took place about two months a f t e r the p s y c h i a t r i c ward moved from a separate house into the hospital setting. The present ward provides a f a i r l y large lounge area and several smaller rooms which could be used for patient a c t i v i t i e s or interview rooms. In 1972, the day patients v i s i t e d the ward on the average of 227 v i s i t s per month. In the f i r s t three months of 1973, the monthly patient v i s i t s averaged 264. When this survey was conducted there were a total of 12 in-patients on the ward, this below capacity number was due to an inadequate number of s t a f f to care f o r 23 patients. Both patients and s t a f f were s t i l l  35 engaged i n a " s e t t l i n g i n " process i n this new area. The average age of the patient on day care was 33.5 years, with females being i n an older age bracket. A l l patients had previously been hospitalized, with a diagnosis of schizophrenia being s l i g h t l y higher at 35% than the remaining diagnostic categories. The average number of v i s i t s per patient was 17.0, with females maki predominantly more v i s i t s . The day patients are incorporated into the structure and a c t i v i t i e s of the ward patients. At the present time the ward s t a f f consists of nine nurses and a part-time occupational therapist. B. Patient P r o f i l e A d e s c r i p t i v e patient p r o f i l e of the people v i s i t i n g the psychiatric ward which was gleaned from 20 patient records can be shown by: a) Mean age of the patients - 33.5 years. Female - 36.1 years, with the range being 21 to 63 years. Male - 31.0 years, with the range being 19 to 64 years. b) Sex - Female, 70 per cent Male, 30per cent c) Marital status: Single Married Separated Divorced Widowed Female 20% 45% 5% 0 0 Male " 5% 10% 5% 10% 0 d) The mean v i s i t s to day care was - 17.0 per patient. Female - 25.6 v i s i t s , with a range of 3 to 66 v i s i t s . Male - 8.5 v i s i t s , with a range of 4 to 17 v i s i t s . e) The educational level v/as unknown. f) The occupational categories can be shown by: Professional Working Unemployed Homemaker Student Female 5% 15% 15% 35% 0 Male 0 20% 10% 0 0  36 g)  Diagnostic category: Schizophrenia - 35% Anxiety Reaction - 20% Depression - 30% Others - 15% h) Previous h o s p i t a l i z a t i o n of patients - 100%. Description of Program "G" A.  General Description  Program "G" was one of the two u n o f f i c i a l programs that was studied i n this survey.. The eight bed p s y c h i a t r i c i n - p a t i e n t unit was opened in March 1971, and overcrowding of this f a c i l i t y has been a common problem. In 1972 there were 366 patients admitted to the ward, an unknown number of day care patients came to the ward and 123 home v i s i t s were made. In the f i r s t 3 months of 1973, a conservative estimate of day care v i s i t s was 80 patients per month. The ward i s located at the end of a c o r r i d o r , o f f one of the medical wards. One f a i r l y large comfortable looking room serves as a dining area, lounge, meeting area, and a l i m i t e d recreational area. Several small windowless rooms are located o f f the ward, which also serve as multi-purpose rooms, besides being used as interview rooms. A large physiotherapy and occupational area i s located near the p s y c h i a t r i c ward, which contains a ping pong table and a punching bag, that the p s y c h i a t r i c patients can use i n the evening. The average age of the patient attending this u n o f f i c i a l day care was 37.6 years, with females being in a younger age bracket. This f i g u r e is s l i g h t l y higher than the average would be; as there was one female aged 79 years and one male aged 69 years attending. A l l patients had previously been h o s p i t a l i z e d , with depression (70%) being the most common diagnostic category. The average number of v i s i t s was 10.9 per patient, with females making predominantly more  37 v i s i t s . Unless the day patient had a s p e c i f i c problem which he d i s cussed with a s t a f f member, he was incorporated into the total treatment program and a c t i v i t i e s which were planned f o r the in-patients. A nursing s t a f f of s i x , manages both the in-patient a c t i v i t i e s and the day care v i s i t s . B. Patient P r o f i l e A d e s c r i p t i v e patient p r o f i l e of the people v i s i t i n g the psychiatric ward which was gleaned from 20 patient records can be shown by: a) Mean age of patients - 37.6 years. Female - 35.8 years, with the range being 19 to 79 years. Male - 40.3 years, with the range being 19 to 69 years. b) Sex - Female, 60 per cent Male, 40 per cent c) Marital status: Single Married Separated Divorced Widowed Female 35% 10% 5% 10% 0 Male 30% 0 5% 5% 0 d) The mean v i s i t s to day care was 10.9 per patient. Female - 13 v i s i t s , with a range of 3 to 31 v i s i t s . Male - 8.9 v i s i t s , with a range of 1 to 29 v i s i t s . e) The educational level was unknown. f) The occupational categories can be shown by: Professional Working Unemployed Homemaker Student Female 0 10% 15% 20% ' 15% Male 5% 25% 10% 0 0 g) Diagnostic category: Depression: 75% Adolescent Reaction: 25% h) Previous h o s p i t a l i z a t i o n of patients - 100%.  38 VIII.  Diagnostic Categories  Throughout this survey the s i g n i f i c a n c e attached to the diagnostic categories into which the patients have been placed, was viewed to be of l i t t l e importance. The v a l i d i t y of placing a diagnostic label on a patient has been questioned by many medical professionals. Scheff, i n one of his statements on l a b e l i n g , comments that; "...the physician and others inadvertently cause the patient to display symptoms of the i l l n e s s the physician thinks the patient has."^ Several of the centers surveyed also reported that often an accurate diagnosis could not be made until the patient had completed a course of treatment, but that a diagnostic label was required for s t a t i s t i c a l purposes. Not a l l diagnostic labels were acceptable for these s t a t i s t i c s , f o r example; the term a l c o h o l i c , even though this may have been the major presenting symptom of the patient. This may help to explain why the diagnostic label of "Depression" was used f o r 47% of the total patients surveyed.  Theory  Thomas J . Scheff, Being Mentally 111: A Sociological (New York: Aldine Publ". Co., 1966), p. 84.  CHAPTER VI INTERPRETATION OF FINDINGS In this d e s c r i p t i v e survey of the day care centers the aim was to obtain complete and accurate information in several spec i f i c areas of day care functioning. A summary of the basic commona l i t i e s and divergencies of each center can be seen in Table 1. These answers have been selected and shortened f o r easier reference. This table deals only with the f i v e o f f i c i a l , Government funded centers, as many of the questions were not d i r e c t l y applicable to the two informal programs. Only one of the day treatment centers was not d i r e c t l y a f f i l i a t e d with a p s y c h i a t r i c ward of a h o s p i t a l . A.  Premise of Day Care  The premise that was used to e s t a b l i s h each center varied, thus providing a diverse range of areas f o r patient care. The basic premises that were given included: a) to provide an out-patient program b) providing a center to t r e a t a l l types of patients c) to r e l i e v e the bed shortage d) to provide a therapeutic community e) to increase e f f i c t i v e relationships and s k i l l s The basic difference between i n - p a t i e n t care and day care was that more r e s p o n s i b i l i t y was a l l o t e d to the patient while he was s t i l l in a semi-protected environment. B.  Family Involvement  In one center, "D", i t was mandatory f o r family members or s i g n i f i c a n t others to be involved with the patient's treatment program. In this center the patient group also interviewed the prospective patient before he was admitted into that program. Two other centers provided family therapy i n s e l e c t cases when the patient's  A surwaav or Tuf i n p f B f c o a o c o A m w m  pretivn) FBOH THE rive  40  OFFICIAL DAT CARt CEriTCBS 1W PCSPOflSE TO THE OUtSTlOWAIRE  To provide ton* type Of Out-patient program.  Host severely U l psychiatric patlentt could be tre*ted In • day h o s p i u l In their community.  To find an answer to the bed shorUge And to keep tor* people from being admitted.  To provide the concept of a therapeutic ilty.  Our program H for pattentl who hate d i f f i c u l t y with inter-personal relationi m p * and social s k i l l s .  How does this differ from In-patient care?  Oay car* get* away from the old structure. It puts the patient In t unique position; half woy between a protected environment and r e a l i t y .  Does not apply.  Ooet not apply  The self-regulation and the responsibility can bt taken by the patient.  Patients have more experience In taking responsibility and for the decision making process,  2.  Involver-ent of family meefcer or significant other.  Sera families are Involved, but not many. Mainly with the social worker In teltet eases.  Depends on the nature of the problem. Minimal Involvement at ninthly open house when Indicated family therapy Is carried out.  They are not realty Involved very ouch.  A family group i t run every week and patient* bring members and work on their problems together.  We have a relatives group, and ione fatally therapy with tt 1 acted families.  3.  Who Initiates this tnvolvenent?  Treatment teem.  Patient's therapist.  Docs not apply.  The patient Initiates this.  Staff to day care,  Head nurse, occupational therapist and social worker are permanent. T»o nurses and psychiatrist are routed.  S U f f Is permanent.  Occupational therapist 1s pe ma rent, nursing S U f f work r o u t i n g shifts.  S U f f i s permanent.  S U f f I t permanent.  No volunteers.  Four ex-pat1ent volunteers.  One volunteer.  One c l e r i c a l volunteer and drama volunteers.  Five volunteers, working ta specific arias.  Each staff has a specific function as well as a generalized one.  I. Premise on which day treatrent center was tsublished.  4. Is staff permanent or c n they routed?  Are volunteers used?  L  Specific or general role function for s u f f f  Specific function, not much blurring of rotes at a l l .  Very l i t t l e d i f f e r entiated role functioning.  t t ' l pretty well a generalized r o l e .  C.  Occlslon on which patient 1s discharged.  He know what the patient's problems are, and we stack up what he has done against the problem. If we can see M n raking headway In a l l areas, we support aim and he Is discharged.  Patients are conferenced regularly, and 1t is decided on the basts of reports when to terminate.  A l l patients' progress is discussed tn weekly rounds, i f they can cope at home or In the coosunity, then they are discharged.  Use of behavioural scale or questionnaire?  We expect stay 6 to I t Is the behaviour time,  patients w i l l 8 weeks, and change tn during this  Roles blur very much i n that we participate In a l l parts of the program. Patients have a problem l i s t fctilch they work on. Conrrlt.'^erts are a weekly on these proaleca and we observe changes i n behaviour.  Ro. I t is through the A chart which measures problem l i s t rating. the severity of the patient's problem and a weekly questionnaire that measures happiness, neurotic symptoms and harmful t r a l u .  No. Evaluation consists of the patient's actual performance.  A discharge suirmary goes to the referring doctor and the patient Is encouraged to make a follow-up appointment.  By patient's principal therapist, private psychiatrist, Mental Health Centers, private doctors or out-patient department here.  The psychiatrist or HenUl Health C l i n i c .  Attend for 3 weeks one of the group meetings.  Patient returns at 3.S. g, and 12 eonth Intervals. Also referring source.  Psychiatrists,' private doctors, and the hospiul ward.  Psychiatrists 1n the community, own outpatient staff. Inpatient resources from other hospitals.  Coorunlty, and the in-patient ward.  Out-patient c l i n i c at h o s p i u l , in-patient u n i t , other hospitals, and psychiatrists tn the coonunlty.  In-patient wards, agencies and psychiatrists In the community.  Exclusion of patient*? Specifically drug addicts or alcoholics.  It works Out that there 1s very l i t t l e exclusion. Do exclude organic brain syndrome and chronic schizophrenics. Each case Is comldercd on Its own merits.  Alcoholics, drug No , we do not exclude rpatients ... the basis addicts, and psychoon of that kind of symptom. P*ths. are excluded.  Exclude alcoholics, drug addicts, clearly psychotic patients.  Addicts, alcoholics, severe personality disorder!, suicidal or honocidal patients are excluded.  10.  Types of treatment used.  Croup methods, role playing, psychodrana, expressive groups, patient evaluation of the program, occupational and recreational therapy, video taping of One group a week. The methods are a l l group ortentatrd, not only psychological, but also physical.  Focus Is on providing a n l l l e u therapy type Of situation. Group therapy. Individual sessions, role playing, psychodrana, theatre games, relaxation.  11.  Methods used to evaluate th* progran.  Rely on feed-back regarding how the patient Is dolm). Tearly effort to Jud<je progress of program.  Suppltr«ntary Question: Is this d4/ care u<*d primarily a i a transitional phaie?  No, not as standard procedure,  7.  Follow-up care.  1. Where do referrals from?  12.  come  On what the patient It able to do when they tet out. Cope tn the corrvjnlty, able to work, c i r c l e of associates.  Intensive group therapy, Group discussions, occupational therapy and role playing, Gestalt. encounter groups. A recreational confronting and demandactivities. ing therapy program.  To see If people i r e re-adnltted and to see i f they can cope at home and tn the cur.munlty.  Tes, for about 751 of the patients.  We have not yet structured our c r i t e r i a of how to reiearcn the effectiveness, We believe there is improvement Of people who com here.  Reality orientated. Group therapy, discussions, non-verbal techniques, theatre techniques, work projects, occupational and recreational therapy.  Relates to the patient's problem l t u , the patient's weekly srlf-evaluatlon and progress notes.  41 problem indicated t h i s . Family involvement in these two centers was also obtained through a regularly scheduled Open House and a Relatives Group. The other two centers provided l i t t l e , i f any, family involvement. This degree of involvement of family members may r e f l e c t the treatment philosophy, the a v a i l a b i l i t y of s t a f f and the type of patients selected in each s p e c i f i c center. C.  Staffing  In three of the centers the s t a f f were permanent, and in the other two, there was a combination of permanent and rotating s t a f f . It was d i f f i c u l t to obtain an accurate s t a f f to patient r a t i o , as many of the centers engaged s t a f f on a p a r t i a l or irregular basis. An approximation of this r a t i o could be 1 s t a f f to every 4 patients. This included a l l levels of s t a f f involved in that program, also in some centers there were more s t a f f members employed than in others. The range of the role functioning of the s t a f f included: a) s p e c i f i c functions b) s p e c i f i c and generalized functions c) generalized functions The type of s t a f f role functioning did not form a pattern which was dependent upon the category of s t a f f found within that center. A l l but one of the centers used volunteers in some aspect of the functioning program. Drama volunteers were used in two centers and volunteers were generally involved with escorting patients, and in one center, with c l e r i c a l a c t i v i t i e s . From this study i t cannot be concluded whether the volunteers were used because s t a f f was not available f o r these a c t i v i t i e s or whether these volunteers were more adept at the s p e c i f i c duties they carried out. D.  Basis f o r Patient Discharge  One general c r i t e r i a that was used by a l l of the f i v e centers to discharge a patient was on the basis of that patient's actual performance in the d a i l y program and his level of functioning at  42  home and i n the community. Two o f the centers stated that regular s t a f f conferences were held and the decision to discharge the patient was made at that time. One center included the patient i n these conferences whenever this was f e a s i b l e . A chart was used i n one center which weekly measured the severity of the patient's problem, but this was not s p e c i f i c a l l y used as the c r i t e r i a f o r discharge. Two of the centers stated that the treatment program i s terminated when progress has been made by that patient to cope with the problems that he had i n i t i a l l y voiced. E.  Patient Follow-Up  In each center the patients were generally followed-up by the r e f e r r a l source. Two of the centers required the patient to return to the day care center f o r a varied time period a f t e r discharge. The f i v e respondants i n these centers were i n agreement that some type of follow-up care was essential f o r continued patient functioning and patient maintenance. One of the inherent d i f f i c u l t i e s with followup care, i s that often the patient feels i n excellent health on leaving the treatment program, and therefore does not feel any need for followup care. This i s one problem that confronted a l l o f the centers. Dependent upon the patient s i t u a t i o n , perhaps i t may not be required or even desirable to have follow-up care. F.  Referrals  The r e f e r r a l of the prospective patients to day care centers came from several sources, most o f which included other medical resources. These were, in-patient wards, other p s y c h i a t r i s t s and psychiatric c l i n i c s . Three of the respondants i n three centers stated that they were working out the d i f f i c u l t i e s that were encountered when patients were referred from community agencies or from psychiat r i s t s who were not a f f i l i a t e d with that s p e c i f i c center. Two of the centers were being used as a t r a n s i t i o n a l phase for patients  43 coming from an in-patient ward and back into f u l l family l i f e . was one of t h e i r stated objectives. G.  This  Patient Admission  The present limited treatment f a c i l i t i e s in B r i t i s h Columbia for drug addicts and alcoholics prompted the question of whether this category of patient was excluded from day care treatment. Three of the centers stated that they did not admit these two categories of patients, while the other two centers stated that the admission policy was determined by each individual s i t u a t i o n . The l a t t e r two centers also mentioned that they had had very few drug addicts in t h e i r treatment programs, while alcoholics were more numerous and were treated in these programs. A frequent secondary diagnosis that was found on the 290 patient records that were examined was both alcoholism and a drug problem. But these accounted for only 3% and 2% respectively of the o f f i c i a l l y reported diagnostic categories. Each of the centers stated that they did adhere to some form of admission p o l i c y , which ranged from a selected patient population to one which was less s e l e c t i v e . For example; one center selected a neurotic patient population and another center admitted schizophrenic and post-psychotic patients. H.  Treatment  In the f i v e o f f i c i a l centers that were surveyed, group methods of treatment were used with individual sessions being infrequent. Occupational and recreational therapy played an important part in the total treatment program of each center. This group method of treatment was in keeping with: . . . i n the hospital s e t t i n g , task groups with patient leadership and group cohesion have a more beneficial influence  44 on social behaviour and performance than do individual tasks and workshop a c t i v i t y directed by staff.1 The importance that was placed on the use of prescribed medications varied from the expectation that every patient i s required to take the medication, to one, where medications were prohibited, except f o r medical purposes such as diabetes or s i m i l a r physical ailments. Four of the centers did use or prescribe medications. One factor in the use or the non-use of medications i s that t h i s may r e f l e c t the category of the patients that were admitted into each s p e c i f i c program or the selected method of treatment. For example; a schizophrenic person may need to be maintained with the use of medications. I.  Program Evaluation  The methods that were used to evaluate the effectiveness of the total program ranged from: a) feed-back b) patient performance c) re-admission rate The most prevalent method being used was based on the patient's actual performance both in the program and his a b i l i t y to cope in his family and the community s e t t i n g . Often i t may be d i f f i c u l t to evaluate or measure the q u a l i t y of the patient's functioning or coping a b i l i t y , since the patient spends two-thirds of his time with family members and s i g n i f i c a n t others. Here the patient's own assessment of his p a r t i c u l a r l i f e s t y l e is„ used to gauge his progress. One of the problems that plagues a l l the present methods of the delivery of health care i s the lack of concrete objective evaluative procedures.  Susser, op. c i t . , p. 145.  45 J.  General Patient P r o f i l e  A patient p r o f i l e that was obtained from the 290 patient records that were examined would include: Average Age: 33 years. This included the seven centers. Sex: Generally female, (ratio of 2:1). This included the seven centers. Marital Status: 45% being s i n g l e , with 34% being married. Treatment Days: 54. The average days f o r females were 34 days, and males 73 days. This included the f i v e o f f i c i a l centers only. Education: 60% above Grade 11, with 38% being unemployed. Previous Psychiatric Treatment: 77%, females 50% and males 27%. Largest Diagnostic Category: Depression and Schizophrenia. This p r o f i l e may be likened to the p r o f i l e expressed by Susser when he described patients in mental hospitals. He stated: "Because single patients lack social support and mental hospitals provide social support, these rates could be more an index of response to a social rather than a psychological s t r a i n . " In t h i s d e s c r i p t i v e survey the r a t i o of single females to single males was equal and i t was found to be the largest marital category. In the married category the female patients out-numbered the male by a r a t i o of 5 to 1. Whether these l a t t e r patients lacked the "social support" or i f family involvement in the treatment program was lacking, cannot be f u l l y determined by this study, since only one day care center stipulated family involvement as a condition of treatment. But i t may indicate that the male who i s married received more family and social support than the female who was married. Loeb wrote: ...these intimates must be involved i n the treatment process from the beginning, or else they probably w i l l not be there when the person, now an ex-patient, i s ready  Susser, op. c i t . , p. 88.  46 to return...and i f they (intimates) do not understand the nature of his d i s a b i l i t y they cannot help him.3 There i s mounting evidence that social and family support i s necessary for the ex-patient to maintain an appropriate level of i n t e r personal functioning. It i s noted that interactions outside of the family m i l i e u a l s o have an important effect on the quality of patient behaviour. In t h i s survey more than one-third of the people were unemployed p r i o r to entering treatment. It cannot be decided here whether the patient's emotional d i f f i c u l t i e s prevented him from working, or whether these d i f f i c u l t i e s prompted his discharge from employment. An assumption here i s that an a c t i v i t y or employment which the person feels i s worthwhile and he i s capable of doing, w i l l increase his own confidence and self-worth. "Mental patients who obtain regular work 4  on leaving the hospital tend to s e t t l e successfully in the community." Places of employment are often more apt to keep a job open f o r a professional person than they would f o r a person working in a lower occupational l e v e l . There were two findings that were common to the two u n o f f i c i a l programs and the one o f f i c i a l day care center located i n the i n t e r i o r of B r i t i s h Columbia. The f i r s t being, a greater percentage of females gave t h e i r occupation as homemaker, 52% in the towns, than did the ones in the c i t y where homemaker was given as 18%. Secondly, in the towns there were less patients c l a s s i f i e d as students than there were in the centers located in Greater Vancouver. In the towns t h i s may r e f l e c t lessened job opportunities f o r females, t r a i n i n g programs ° Leight M. Roberts, S.L. Halleck and M.B. Loeb ( E d i t . ) , Community Psychiatry (London: The University of Wisconsin Press, 1966), p. 227-229. 4  Susser, op, c i t . , p. 58.  47 may not be as r e a d i l y a v a i l a b l e or emotional problems of people who would be c l a s s i f i e d as adult student may not become as evident or be as prevalent as they are in a larger c i t y . K.  Age of the Patients  Table II indicated that there i s a gradual decrease in the number of patients as t h e i r age increases. This inverse e f f e c t may r e f l e c t current s o c i e t a l values which place a great deal of emphasis on the younger population or i t could r e f l e c t the attitude of the medical s t a f f , where i t may be more i n t e r e s t i n g and rewarding to modify the behaviour of a younger age group. Thirty-one per cent of the patients were i n the 19 to 23 age bracket, which may also indicate that t h i s i s a d i f f i c u l t age period i n which one seeks to discover a s a t i s f a c t o r y l i f e s t y l e . Jourard states: "...that one's attitude toward l i f e and s e l f are factors both in the onset of 5  i l l n e s s and i n the recovery therefrom." This table also indicated that female patients out-numbered males in each of the age brackets. This gives r i s e to the unanswered question of whether a higher r a t i o of the female population succumbs to emotional i l l n e s s than do males, or i f females are more apt to seek treatment.  Sidney M. Jourard, The Transparent S e l f (Toronto: Reinhold Co., 1971), p. 76.  Van Nostrand  TABLE II A SUMMARY OF THE AGE BRACKETS OF THE FEMALE AND MALE PATIENTS WHO ENGAGED IN THE DAY CARE PROGRAM IN THE FIVE OFFICIAL CENTERS Age i n Years Day Care Center  19-23  24-28  29-33  3k - 38  39 - 43  44 - 50  F M  F M  F M  F M  F M  F M  A  13  3  6 3  5 2  4 1  4  B  11  7  5 8  1 3  7 2  2 0  C  6.1  D  9  7  E  8  11  47  29  Total  2  1  6  10  6  4 4 6 3  7 5 30  23  22  2  14  4  F  over 60 M  F  M  1 2  3  3  0  0  2 1  0  1  0  0  5  2  6  3 0  .2  1  4 0  O  O  O  O  0 0  1 2  2 1  2  1  1  0  18  3  0  51 - 60  6  14  5  15  2  6  6  11  3  8  1  2  0  0  00  49  TABLE III THE NUMBER OF FEMALE AND MALE PATIENTS WHO HAD PREVIOUSLY RECEIVED PSYCHIATRIC TREATMENT WITHIN THE PAST FIVE YEARS Day care center  Hospital or day care treatment F  M  A  13  4  B  20  C  26  D  27  E  24  Total  F  M  9  6  14  4  4  4  4  7  0  0  11  4  12  0  0  6  5  19  3  2  0  2  9  55  L.  F  No previous treatment  M  11  no  V i s i t to a psychiatrist  16  12  35  22  Previous Hospital Treatment  One assumption that was hot borne out in this study was that a higher percentage of males than females would f i n d i t more acceptable to v i s i t a p s y c h i a t r i s t in his o f f i c e than to be admitted to a hospital f a c i l i t y . Table III indicated that 5% of the male population had previously v i s i t e d a p s y c h i a t r i s t versus 6% of the female population. This table indicated that 66% of the patients had been treated either in a hospital ward or in a day care center previous to this present admission to a day care center. A t o t a l of 23% had not received p r i o r psychiatric treatment. The two u n o f f i c i a l day programs of "F" and "G" were not included in this table since a l l of the people who returned to the ward had been previously hospitalized.  50 M.  Length of Time in Treatment  The length of time the patients spent in the day care treatment program ranged from 6 to 162 days. In three of the f i v e centers male patients stayed in treatment predominantly longer than females, this was e s p e c i a l l y evident in day care "B" and "E". Two speculations concerning this may be made. One, i s that i t may require a longer time period f o r the male patient to learn d i f f e r e n t behavioural methods, and secondly, the male patient may be kept in the treatment program longer so as to balance the female to male r a t i o . TABLE IV THE NUMBER OF DAYS THAT FEMALE AND MALE PATIENTS SPENT IN DAY CARE TREATMENT IN THE FIVE CENTERS Average days of treatmentt  Day Care Centers C D  A  B  E  Females  29.1  55.0  23.0  34.3  28.8  Males  29.3  91.0  34.0  35.0  76.6  +The patients who were presently engaged in treatment were not included in these f i g u r e s . N.  Funding  The funding that the f i v e o f f i c i a l centers received varied from 14 to 23 d o l l a r s per patient per day, with the average being 18 d o l l a r s per day f o r each center. One center which received the highest amount of 23 d o l l a r s per day also provided a l l of the patients' medications. In four of the centers, this money was not paid d i r e c t l y to the day care center, but i t was paid to the hospital which the  51 center was a f f i l i a t e d with. The hospital budget then bore the expenses of the day care center. The f i v e o f f i c i a l day care centers have a combined capacity to treat approximately 90 patients per day, and presently a total of one-third of these patients are being treated by one center. The average cost of 18 d o l l a r s per patient i n the day care center could be contrasted with an average hospital cost per patient day of about 72 d o l l a r s . It i s recognized that many other factors enter into t h i s cost comparison which may make i t i n v a l i d . But the entire cost-benefit factor i s an important issue i n the health care d e l i v e r y system.  CHAPTER VII SUMMARY, AREAS FOR FURTHER INVESTIGATION AND RECOMMENDATIONS At the present time there i s very l i t t l e informational data available r e l a t i n g to the adult p s y c h i a t r i c day treatment centers in the province of B r i t i s h Columbia. In recent years the trend i n psychiatric care has been to treat people within their family and community s e t t i n g . Many people who require help and guidance f o r their emotional problems are being treated i n p s y c h i a t r i c day care centers and they are not being admitted to a p s y c h i a t r i c ward. Within the past f i v e years, four day care centers have been established at various hospitals throughout the province of B r i t i s h Columbia. The purpose of this d e s c r i p t i v e survey was to provide a composite picture of the currently functioning adult p s y c h i a t r i c day care centers. A total of f i v e o f f i c i a l and two u n o f f i c i a l day care programs were surveyed and 290 patient records were examined. The s p e c i f i c areas o f i n t e r e s t i n day care functioning centered around; the family and community involvement i n the treatment program, the types of treatment that were used, the type of role the s t a f f c a r r i e d out, the total program evaluation and a p r o f i l e of the patients who were treated by this modality. To c o l l e c t the data, the researcher used; a questionnaire which was answered i n a taped interview, observational v i s i t s to each center, and an examination of the patients' records. The r e s u l t s o f the questionnaire indicated that family involvement i n the total day program was generally l i m i t e d , group methods of treatment were used which gave the patients a sense of community, and patients were followed-up either by the day care center or by the r e f e r r a l source. Referral o f patients to these centers were mainly from in-patient wards, other p s y c h i a t r i s t s and p s y c h i a t r i c c l i n i c s . The c r i t e r i a that was used to terminate a patient's treatment was on the basis of h i s actual performance i n the program and h i s level o f functioning at home and i n the community. This was also the prevalent method used to evaluate the effectiveness of the total  53  treatment program. Staff i n these day care centers were both permanent and rotating with t h e i r role function being both s p e c i f i c and generalized. An examination o f the patients' records revealed that the average patient was 33 years o l d , generally female, s i n g l e , diagnosed as being depressed, above Grade 11 i n education and presently unemployed. Seventy-seven per cent of the patients had previously received psychiatric treatment and the length o f stay i n the treatment program was 54 days. Findings from this study indicated that a wide variety of patients were treated i n day care, which, had these centers not been available, would have been admitted to an i n - p a t i e n t ward. In the two u n o f f i c i a l centers that were surveyed, the number o f patient v i s i t s to the ward indicated that there was a need at these two centers for this type of treatment modality. Day care i s not only an alternative to h o s p i t a l i z a t i o n , but i t may be the choice method o f treatment f o r many patients. AREAS FOR FURTHER INVESTIGATION As t h i s study progressed there were several areas relevant to day care functioning which would warrant f u r t h e r investigation. These included: a) The patients' perception of his emotional problem and what areas o f day care treatment were most b e n e f i c i a l to him. Many times the same patient has been treated i n both a hospital ward and in day care, thus h i s perceptions of what has helped him could be a guide f o r program i n i t i a t i o n . b) To study the a t t i t u d e s and acceptance o f the patient's family or s i g n i f i c a n t others when the patient i s treated i n a day care center and then returns to h i s family s e t t i n g i n the evening. c) To determine the e f f e c t of day care treatment on the patient regarding his short term and long term level o f functioning and h i s social adjustment within the community. This would involve following the patient i n h i s community setting a t various time periods.  54  RECOMMENDATIONS Descriptive surveys generate many unanswered questions as to why an event should occur, and this survey i s no exception. The recommendations that could be drawn from this study include: a) That greater family involvement be i n i t i a t e d i n a l l of the programs so that there would be a greater sharing and understanding of goals and r e s p o n s i b i l i t i e s between the family, the patients and the treatment team. b) A l i a i s o n be established with various community agencies so that the day center can r e f e r people f o r job placements or t r a i n i n g and that these same agencies could r e f e r people d i r e c t l y to the day treatment center. c) The s t a f f in the day care center should be permanent, so that they w i l l have the r e s p o n s i b i l i t y of planning and implementing changes within the treatment program. In this way the s t a f f member would also become more adept at carrying out their roles which would benefit the patient. d) The present public r e l a t i o n s campaign should be expanded so that day care as a treatment modality became more acceptable. This campaign would not only be aimed at the general p u b l i c , but also at private and public agencies and the medical profession. e) There should be a continued concern i n each day care center i n providing written l i t e r a t u r e pertaining to the objectives and philosophy of the program, the methods of d e l i v e r i n g the treatment program, and to determine the program p o l i c i e s . This material could form a basis f o r an i n i t i a l o r i e n t a t i o n of new s t a f f members and to supply the community agencies with the information they would require to enable more co-operation between the agency and the day care center. f ) The cost of the program i n each day care center should be determined with regard to what is the total cost to achieve the  55  stated objectives of the program and are there a l t e r n a t i v e methods of reaching these objectives. g) Since each center has s p e c i f i c goals which guide i t s function, an in-depth study of each area should be made, as to the effects of treatment, q u a l i t y of patient functioning a f t e r treatment and an evaluation in terms of f u l f i l l i n g the stated objectives. This would include an on-going continuous evaluation.  APPENDIX A  57  A QUESTIONNAIRE TO PROVIDE INFORMATION REGARDING THE PSYCHIATRIC DAY TREATMENT CENTERS IN BRITISH COLUMBIA 1. I n i t i a l l y , on what premise or basis was the p s y c h i a t r i c day treatment center established? In what way does this d i f f e r from the premise used to provide inpatient care? 2. In what way are the patient's family or s i g n i f i c a n t others involved i n the patient's total treatment program? 3.  Who i n i t i a t e s t h i s involvement?  4.  In the day treatment center, i s the s t a f f permanent or are they rotated, for example, the doctors, nurse, s o c i a l worker or the occupational therapist? Do you have any volunteers i n the program?  5.  Does each s t a f f member have a d i s t i n c t or s p e c i f i c role function or i s there a generalized role function f o r a l l members?  6.  On what basis i s the decision made to discharge the patient, that i s , how i s i t ascertained that the patient has achieved maximum benefit from the program?  7.  On discharge of the patient, how i s his follow-up care planned?  8. Where do you get your patient r e f e r r a l s from? 9. Do you exclude any category of patients from day care? Here I am thinking s p e c i f i c a l l y of drug addicts or the a l c o h o l i c . 10.  What methods of treatment are used i n the day care centers?  11.  What methods are used to evaluate the total effectiveness of the day treatment center?  12.  What are the written goals or objectives of the day treatment center?  The following information was taken from the patient's chart Age  Marital Status  Sex  Occupation  Education  Days of Treatment  Previous admission  Diagnosis  Average number of patients per day, month, and year.  APPENDIX B TAPED INTERVIEWS  60  Partial t r a n s c r i p t i o n of the taped interview with day care "A" Code: R - Respondant I - Interviewer I: On what premise or basis was the psychiatric day center established? R:  The premise of day care generally i s to provide some type of out-patient program f o r the patients. We wanted to get away from the old r i g i d ward setting and to get into something that's a b i t looser and a b i t less r e s t r i c t i n g f o r the patient.  I: How does this premise d i f f e r from that used f o r inpatient care? R:  Day care gets away from the old structure, i t puts the patient in a unique position; halfway between a protected environment and r e a l i t y . They come into day care, they hopefully learn things, they go home and they t r y them out and over a period of f i v e to eight weeks, they seem to change their habit of dealing with people. You provide a p r o t e c t i v e shield f o r the patient, while they are i n the program, i t ' s less pronounced here than on the ward. Because of our treatment philosophy, but i n a d d i t i o n , the patient goes home every night.  I:  In what way are the patient's family or s i g n i f i c a n t others involved i n the patient's total treatment program?  R:  We get some families involved, but not many. These families are involved mainly with the social worker and these are i n select cases.  I: Who would i n i t i a t e this involvement? R:  It would be by a decision made by the treatment team.  I:  Is the s t a f f here permanent or are they rotated?  R:  The s t a f f here i s the head nurse i s every six months. are permanent and  rotated. The p s y c h i a t r i s t stays f o r one year, permanent, and the other two nurses are rotated The social worker and occupational t h e r a p i s t work part-time.  I: Do you have any volunteers i n the program? R:  No, there are no volunteers i n the program.  61 I: Does each s t a f f member have a d i s t i n c t role function or i s there a generalized f o l e function f o r a l l members? R:  No, I don't f i n d much blurring at a l l . About the only place you could talk about b l u r r i n g , i s when we get together to talk about things. As f a r as roles are concerned, they are s t i l l pretty fixed and set. The thing that makes the difference, I think, is that everybody gets t h e i r say and people have a much more of an equal weight then, in most s i t u a t i o n s .  I: On what basis i s the decision made to discharge the patient, how do you ascertain that he has received maximum benefit? R:  We don't usually have too much trouble agreeing on when a patient is ready to go. We know what the patient's problems are, and we stack up what he has done against the problem. If we can see him making headway in a l l those areas, we support him and he i s discharged.  I:  Is there a behavioural scale or questionnaire that you use as a helpful c r i t e r i o n f o r discharge?  R:  No.  I: On discharge, how i s the patient's follow-up planned? R:  On discharge, a discharge summary goes to the r e f e r r i n g doctor and the patient i s encouraged to make a follow-up appointment with that doctor.  I: Where do you get most of your r e f e r r a l s from? R:  A l o t of the r e f e r r a l s are from p s y c h i a t r i s t s , private doctors and from the ward at the h o s p i t a l .  I: Would t h i s day care be considered primarily as a t r a n s i t i o n a l one, f o r patients from the ward to the community? R:  No, not as standard procedure. It couldn't be because of our program and the s u i t a b i l i t y of the people f o r this program.  I: Do you exclude any patients from day care? Here I'm thinking s p e c i f i c a l l y of drug addicts or a l c o h o l i c s . R:  A c t u a l l y i t works out that there isn't. Each case i s considered on i t s own merits. We have had a couple of addicts and quite a few a l c o h o l i c s . Somebody with a drug or alcohol problem we look at very c a r e f u l l y , but we c e r t a i n l y don't d i s p e l l them without  62  giving them a t r y . We do exclude organic brain syndrome and the chronic schizophrenics, as they would not benefit from this program. Our group i s s t i l l b a s i c a l l y a neurotic group with some personality disorders. I: What types of treatment are used i n the program? R: They are a l l group methods, and a l l the variations of group methods. We do role playing, psychodrama, we tape one group a week, expressive groups, patients evaluate the program, occupational and recreational therapy. The methods are a l l group orientated, they are not only psychological, but also physical. I: What methods are used to evaluate the t o t a l effectiveness of the day care program? R: We haven't done any research into this at a l l . We r e l y on feedback that we get from other patients, s t a f f and p s y c h i a t r i s t s . Once a year, we present our program to the other s t a f f and at this time, we make an e f f o r t to judge the progress of the program. This gives us some indication as to what type of patient i s doing well i n the program.  63  P a r t i a l t r a n s c r i p t i o n of the taped interview with day care B" 11  Code: R - Respondant I - Interviewer I:  I n i t i a l l y , on what premise was the p s y c h i a t r i c day treatment centre established?  R: The premise used was that most severely ill p s y c h i a t r i c patients could be treated i n a day hospital i n t h e i r own community, without having to be admitted to 24 hour care. The day hospital has moved from a position of providing l a r g e l y somatic treatment and occupational therapy to inter-personally focused treatment milieu. I:  In what way i s the patient's family or s i g n i f i c a n t others involved in the patient's total treatment program?  R: This involvement depends on the nature of the problem presented. This i s under the guidance of the patient's therapist; family group therapy sessions with the p r i n c i p a l therapist, as an ongoing part of the patient's treatment, may be indicated while they are i n the day hospital program. We try to i n d i v i d u a l i z e this according to the demands of the s i t u a t i o n . There i s minimal involvement b u i l t into the program where we have open house once a month. A l l patients are expected to attend and are asked to i n v i t e interested friends or members o f t h e i r family who wish to see what kind of treatment program they are involved i n . And to meet the s t a f f who are working with them. I:  In the day treatment centre, i s the s t a f f permanent or are the s t a f f rotated?  R: The s t a f f i s permanent. I: Do you have any volunteers i n the program? R: At the moment we have four ex-patient volunteers, they are engaged i n various a c t i v i t i e s such as: helping people get to the program, in the occupational therapy area or i n taking patients out into the community for b r i e f periods. I: Does each s t a f f member have a s p e c i f i c role function or i s there a generalized function f o r a l l ?  64 R: There i s r e a l l y very l i t t l e d i f f e r e n t i a t e d role functioning in the day hospital. A l l members o f the team are expected to function i n a l l parts of the program. However, the nurses dispense medications, physicians prescribe i t and occupational therapy arranges the patient's occupational program. A l l members of the s t a f f take part i n group therapy, recreation periods, and the other items i n the program. I: On what basis i s the decision made to discharge the patient, that i s , how i s i t ascertained that he has achieved maximum benefit from the program? R: Patients are conferenced regularly i n the program, at 1 - 4 week i n t e r v a l s , depending on the rate of t h e i r progress. I t i s decided on the basis of the reports from week to week i n these conferences when i s the appropriate time to terminate. I: There i s no s p e c i f i c behavioural scale or questionnaire that you use? R: No. Our evaluation of the patient, consists of t h e i r actual performance i n the program and t h e i r performance i n l i f e i n the community. I: On discharge of the patient, how i s h i s follow-up care planned? R: I am very reluctant to take a patient unless we can arrange an adequate follow-up program. This i s done by people such as: the patient's p r i n c i p a l therapist, private p s y c h i a t r i s t , Mental Health Centers, private doctors or from the out-patient department here. I: Where do you get most o f your r e f e r r a l s from? R: There are three major areas where we get r e f e r r a l s ; one i s from p s y c h i a t r i s t s i n the community, second, i s from our own outpatient s t a f f and t h i r d , i s from in-patient resources from other hospitals. I: Are there any types of patients that you do not admit? Here I'm thinking s p e c i f i c a l l y o f drug addicts and a l c o h o l i c s . R: No, we don't exclude patients on the basis of that kind o f symptom. We have f a i r l y r i g i d l y enforced rules about the abuse of alcohol and drugs, and a patient cannot continue to attend here and continue that kind of behaviour. We've had a much larger number o f alcoholics than addicts. I t r y not to have more than one-third of the people i n the program psychotic a t any given time.  65  I:  What t y p e s o f t r e a t m e n t s a r e c a r r i e d o u t  here?  R:  The f o c u s i s on p r o v i d i n g a m i l i e u t h e r a p y t y p e o f s i t u a t i o n . The p a t i e n t has an o p p o r t u n i t y t o engage i n t a s k s r e l a t e d t o w o r k i n g , p l a y i n g and r e l a t i n g t o o t h e r s . We have group t h e r a p y , i n d i v i d u a l s e s s i o n s , r o l e p l a y i n g , p s y c h o d r a m a , t h e a t r e games, r e l a x a t i o n and o t h e r t e c h n i q u e s . M e d i c a t i o n s a r e a l s o u s e d . We use two k i n d s o f t h e o r e t i c a l b a c k g r o u n d s ; one, p r o v i d e d by t r a n s a c t i o n a l a n a l y s i s and the o t h e r p r o v i d e d by l e a r n i n g t h e o r y .  I:  How do you e v a l u a t e the t o t a l e f f e c t i v e n e s s o f the program?  R:  B a s i c a l l y , on what the p a t i e n t i s a b l e t o do when t h e y g e t o u t o f i t . I f he i s a b l e t o cope i n the community, i f he i s a b l e t o work and has a r e a s o n a b l e c i r c l e o f a s s o c i a t e s .  66  Partial t r a n s c r i p t i o n of the taped interview with day care "C" Code: R - Respondant I - Interviewer I: On what premise was the day care program established? R:  We were very short of beds, we only had about seven in-patient beds at that time. We had a l o t of p s y c h i a t r i c patients who couldn't stay very long in the h o s p i t a l , so they kept returning. We were trying to find an answer to the bed shortage. We thought we might be able to discharge patients sooner, and we might also be able to keep some people from being admitted.  I:  In what way does t h i s d i f f e r from the premise of in-patient care?  R:  We've got a 14-bed capacity on the in-patient ward, but we usually have more patients.  I:  In what way are the patient's family or s i g n i f i c a n t others involved i n the patient's total treatment program?  R:  They are not r e a l l y involved very much. We t a l k to members of the family and sometimes home v i s i t s are made, but not very many. About 75 per cent of our day care are the r e s u l t of i n patients, and some family member may be c a l l e d i n . Our patients come from a l l over, so i f i t ' s f a r out or even 20 miles away i t complicates the case of t r y i n g to get everyone together.  I:  Is the s t a f f here rotated or are they on a permanent basis?  R:  The nursing s t a f f from the ward go down to the a c t i v i t i e s , the nursing s t a f f work rotating s h i f t s so i t ' s not the same s t a f f a l l the time. The occupational therapist is permanent.  I: Do you use volunteers in the program? R:  We have one volunteer who comes in for a c t i v i t i e s and there is a volunteer occupational therapist.  I: Does each s t a f f member have a s p e c i f i c or a generalized r o l e function? R:  It's pretty well a generalized r o l e . The groups are led by the social worker and usually a nurse, whenever she's free. People here don't have s p e c i f i c roles in which they don't dare step  67  outside of. Everybody seems to help everybody else and i t ' s a very good atmosphere. I:  On what basis i s the decision made to discharge the patient from the program?  R:  When people say they're perhaps ready f o r the step to go on, whether i t ' s to school or the home. We see i f they are able to cope i n the community or at home. A l l patients' progress i s discussed in weekly rounds, and t h e i r own doctor says e i t h e r they're doing fine or we should keep them longer.  I:  On discharge of the patient how is his follow-up care planned?  R:  Some see the p s y c h i a t r i s t and sometimes they go to the Mental Health C l i n i c . That's about a l l the follow-up care they have.  I:  So a large number of patients use the day care as a t r a n s i t i o n a l phase from in-patient care back to the community.  R:  Yes.  I:  Are there any types of patients that are excluded from day care? Here I'm thinking s p e c i f i c a l l y of drug addicts or a l c o h o l i c s .  R:  We made a rule not to take the a l c o h o l i c s and only special drug addicts that we f e l t we could do some work with. I feel the psychopaths destroy everything that's going on i n the program. But perhaps we wouldn't have this rule i f we had more than one room, where you could have more than one group, but when you have such small f a c i l i t i e s , you can't have everything and you do what is best.  I:  What methods of treatment are used i n the program?  R:  We have group discussions, occupational therapy and outside recreational a c t i v i t i e s . The time table seems to change every month.  I:  What methods are used to evaluate the total effectiveness of the day program?  R:  One way of evaluation i s to see the re-admissions, and see i f these people are able to cope, even f o r a couple of months. I could c i t e several cases where day care has seemed to help people cope and i t has kept them from being in-patients. So i t ' s more on how the person i s able to cope.  I:  In a town l i k e t h i s , where you pretty well know everyone, have you found this has hampered your treatment relationships?  Patients have mentioned this on occasion. I don't think i t bothers us so much, i t ' s j u s t the fears that they have, but we t e l l them (patients) that this is confidential and that they probably need help.  69  Partial t r a n s c r i p t i o n of the taped interview with day care "D". Code: R - Respondant I - Interviewer I: On what premise or basis was t h i s day treatment centre established? R: One of the major ideas behind this treatment program i s the concept of therapeutic community. A group of people come together and e s t a b l i s h t h e i r own r u l e s , or follow a set o f r u l e s , that they speak openly, that they e l e c t a committee among themselves to ensure the progress of a l l the patients. The progress of a l l the patients i s the concern of every member o f the community, and not only the s t a f f . That the maintenance o f the house and community and physical as well as the emotional needs are part o f the patient's r e s p o n s i b i l i t y . I:  In what way does t h i s d i f f e r from the premise used to provide in-patient care?  R: What we are trying to do here that i s d i f f e r e n t than a hospital based program i s that the s e l f regulation and the r e s p o n s i b i l i t y can be taken upon the patient. I t i s not necessary f o r them to be i n a hospital to be regulated by the hospital requirements and regulations. That patients can be more responsible f o r themselves than they are i n a hospital s e t t i n g . I:  In what way i s the patient's family or s i g n i f i c a n t others involved i n h i s treatment program?  R: We run a family group every week and a l l the patients bring family members or s i g n i f i c a n t others to the group and work on t h e i r problems together. Also they would bring family members during group meetings at other times during the week. So that we very much emphasize improving and working out r e l a t i o n s h i p s with other members. I: Who i n i t i a t e s this involvement? R: The individual has to be s e l f motivated but the patient i n i t i a t e s his family's own involvement. A l l patients are i n i t i a l l y i n t e r viewed by a Resident and also by the patient group. One of the questions the patients always ask new patients i s , are they w i l l i n g to bring t h e i r family members to the group. I f there i s resistance, they may not get into the program. I:  Is the s t a f f here permanent or are they rotated?  R: S t a f f i s permanent.  70  I: Do you use any volunteers in the program? R:  We have one volunteer who helps us with c l e r i c a l work and we use drama volunteers who run a theatre workshop once a week.  I: Does each s t a f f member have a s p e c i f i c role function or i s there a generalized role function f o r a l l members? R:  It i s both. Each s t a f f member has a s p e c i f i c function as well as a generalized one. The occupational therapist is responsible for co-ordinating a l l the work in the program. The nurse i s responsible f o r running an a f t e r care group, and I co-ordinate the program administratively. Weekly groups are conducted by the doctors.  I: On what basis i s the decision made to discharge a patient, how do you ascertain that he has achieved maximum benefit from the program? R:  The expectation i s that patients w i l l stay 6 to 8 weeks and i t ' s usually by the end of that time that we decide on discharge. So i n point, i t ' s a time f a c t o r , we feel that i t ' s an intensive group therapy experience and a f t e r 8 weeks often not much more can be accomplished at the moment. There i s very much an emphasis on the change in behaviour. One of the c r i t e r i a s on discharge is change in behaviour, probably much more so than resolving internal c o n f l i c t s .  I: Do you use a behavioural scale or a questionnaire in evaluating t h e i r progress? R:  Yes, we have a chart which we have just started using, where patients when they f i r s t enter measure the severity of t h e i r problem in the group. Each week they measure the change in the problem. We also have a questionnaire that the patients do weekly, which measures happiness, neurotic symptoms and harmful t r a i t s what people see as their harmful t r a i t s .  I: On discharge, how is the patient's follow-up care planned? R:  One of the commitments when a patient leaves the program i s that they are expected to attend f o r 3 weeks one of the regular group meetings back here. Following those 3 weeks, i f they are s u f f i c i e n t l y motivated, they may be invited to j o i n one of the weekly a f t e r care groups.  I: Where do you get most of your patient r e f e r r a l s from?  71 R: Most of our patients seem to come from the Out-Patient C l i n i c at the hospital. We also have a considerable number who come from the in-patient unit, from Emergency at another hospital and from p s y c h i a t r i s t s i n the community. I: Are there any types of patients that you exclude from the program, and here I'm thinking s p e c i f i c a l l y of drug addicts or a l c o h o l i c s . R: We exclude both categories. Nor do we take c l e a r l y psychotic patients. The patients are very c a r e f u l l y screened. No one is permitted into the program who i s taking drugs of any nature. I: There are no prescribed medications then? R: No,there are no prescribed medications, except f o r physical ailments. The expectation i s no drugs, and taking drugs can mean expulsion from the program. I: What methods of treatment are used i n the day program? R: It i s intensive group therapy. We use many techniques; role playing, encounter, G e s t a l t , i t ' s quite an e c l e c t i c approach and i t i s extremely confronting and a very demanding therapy program. We experiment with new techniques a l l the time. I: What methods are used to evaluate the total effectiveness o f the program? R: We have not y e t structured our c r i t e r i a of how to research exactly the effectiveness. We believe that there i s improvement of most people that come here, i t ' s been a successful program. Most people who come, almost everyone who comes, does make changes in a very short period of time.  72  Partial t r a n s c r i p t i o n of the taped interview with day care "E". Code: R - Respondant I - Interviewer I: On what premise was t h i s day care program established? R:  Our program was established for patients who have d i f f i c u l t y with interpersonal relationships and social s k i l l s . Our patients would be admitted from the in-patient services and this would largely be a t r a n s i t i o n period for them. It would be a supportive and r e h a b i l i t a t i v e kind of program that would help patients with problem solving and developing better s k i l l s . We focus on the here and now, along with r e a l i t y o r i e n t a t i o n . We try to provide a program that w i l l give the patient p o s i t i v e and helpf u l experiences in changing t h e i r unacceptable behaviour.  I: How does this d i f f e r from the premise of in-patient care? R:  In our program, patients have more experience in taking r e s p o n s i b i l i t y for themselves and the decision making process. On the wards, the program is planned f o r them. The patients r e a l l y do not have much decision about what they do, or how t h e i r problems are solved, or in actual f a c t , what t h e i r problems are.  I:  In what way are the patient's family or s i g n i f i c a n t others involved in the patient's total treatment program?  R:  Every other Wednesday we have a Relatives Group in the evening, which enables the family to f i n d out about the total treatment program. We have some family therapy with c e r t a i n selected f a m i l i e s . These are about one hour in length f o r four to f i v e weeks. We do not engage in intensive family therapy, but merely to point out to the family, that there is some pattern of behaviour that i s prompting and promoting i l l n e s s in the family member.  I: Who i n i t i a t e s this involvement? R:  S t a f f in the day care team i n i t i a t e s family  involvement.  I:  Is the s t a f f here rotated or are they on a permanent basis?  R:  S t a f f here i s permanently assigned to day care.  I: Do you use any volunteers i n the program? R:  We have f i v e volunteers working with us in s p e c i f i c areas in the program.  73 I:  Are any of the volunteers ex-patients?  R:  No, they are not.  I:  Does each s t a f f member have a s p e c i f i c or generalized role function?  R:  I believe that our roles blur very much i n that we participate in a l l parts of the program. I administrate and co-ordinate the program, besides working in i t , i n various areas. But in the program our work i s shared.  I:  On what basis i s the decision made to discharge the patient from the program?  R:  The patients have their problem l i s t , they are aware of what i t i s they want to work on, they t e l l us through committments that they make about these problems and working on them each week. Most of our assessment i s probably done on an objective and subjective basis; how does the patient f e e l , how does he feel about himself and his progress, and what have we observed as changes i n his behaviour.  I:  You don't use some scale or questionnaire that they f i l l i n on admission and then again on discharge?  R:  No. I t i s through the problem l i s t rating and t h e i r future plans.  I:  On discharge of the patient, how i s his follow-up care planned?  R:  In January of this year we i n i t i a t e d the plan of having each patient come back at 3, 6, 9, and 12 month i n t e r v a l s , to see us at the hospital here. Follow-up may a l s o be done by the r e f e r r a l source, the private doctor or the c l i n i c here.  I:  Where do you get most of your r e f e r r a l s from?  R:  We get r e f e r r a l s from the in-patient wards, from psychiatrists and d i f f e r e n t agencies i n the community. People can be referred d i r e c t l y to us.  I:  Are there any types of patients that are excluded from day care? Here I am thinking s p e c i f i c a l l y of drug addicts or a l c o h o l i c s .  R:  The addicts, a l c o h o l i c s , severe personality disorders, suicidal or homocidal patients would not be considered f o r this program.  I:  What methods of treatment are used i n this program?  74  R:  We try to make the program as r e a l i t y orientated and as every day as possible. We use group therapy, discussions and non-verbal techniques to develop self-awareness. Theater techniques, occupational therapy, medications, work projects and.recreational a c t i v i t i e s are also used.  I: What methods are used to evaluate the total effectiveness of the day care program? R:  B a s i c a l l y , i t relates to the patient's problem l i s t , that i s our major source of evaluation. Each patient writes a s e l f evaluation and a progress note on himself at the end of each week. He answers f i v e questions pertaining to his progress. It r e a l l y relates to the i n d i v i d u a l , how does he see himself and how does he see his progress. Our follow-up program w i l l also be another method of evaluation.  75  Partial t r a n s c r i p t i o n of the taped interview with day care "F". Code: R - Respondant I - Interviewer I: What would be the objective of starting an o f f i c i a l day care program here? R:  People, need more than j u s t a 15 minute interview for after-care. It i s our b e l i e f that the more someone can stay in the community and be involved with t h e i r f a m i l i e s , or be on the job, the better o f f they are. We feel that the further someone gets into a hospital set-up, the more d i f f i c u l t i t is f o r them to re-adjust to being back i n the world again.  I: The people that come i n f o r day care v i s i t s , what do they do? R:  They are incorporated into the d a i l y routine. I think that probably, because they are more able to assume more r e s p o n s i b i l i t y f o r themselves, this c e r t a i n l y is stressed and often they are quite helpful with the other patients who aren't as f a r along as they are.  I: What types of treatment are c a r r i e d out on the ward? R:  The main thing we t r y to focus on, so f a r we don't have a r e a l l y large number of patients, so we are able to spend a l o t of time i n d i v i d u a l l y with people and helping them to r e l a t e to others in more healthy kinds of ways. We also stress group therapy, along the l i n e of what's happening to you in the here and now, and how can we help you get more out of l i v i n g . With the idea that you have the same types of problems i n the hospital that you have outside, i n that you react in s i m i l a r kinds of ways and you can learn more about y o u r s e l f and each other. We do have occupational therapy, recreational therapy, medications, individual therapy and electro-therapy. It seems to me, that sometimes i f you r e a l l y j u s t provide a climate that i s secure and giving, that people w i l l r e a l l y come around. Sometimes we get so caught up i n what we are going to do f o r so and so, that we often leave the patient out of the planning process.  I: Are there any types of patients that you exclude from day care? Here I'm thinking s p e c i f i c a l l y of drug addicts or a l c o h o l i c s . R:  Yes, we have had a l c o h o l i c s and drug addicts on the day care program. Our dilemma i s that, not f o r the a l c o h o l i c because we r e a l l y do stress AA with them, and they start i n AA when  76  they are here. But the drug addict, p a r t i c u l a r l y the younger ones. There i s nothing a v a i l a b l e in town and there's no place for them to go. I:  Is there any family or community involvement i n the program?  R:  We are f a i r l y c l o s e l y involved with the s t a f f of the Mental Health C l i n i c here. There i s some family involvement, but there needs to be a l o t more work in this area. There i s also a volunteer club here where people who need to be with other people, and can't r e a l l y do this on t h e i r own, can congregate, and they have d i f f e r e n t a c t i v i t i e s . But d i r e c t family involvement in the program, there i s very l i t t l e of that.  I:  How are patients referred to t h i s unit?  R:  The Public Health nurse can r e f e r , and the private doctors are now admitting and the p s y c h i a t r i s t s , the patients themselves or r e l a t i v e s .  77  P a r t i a l t r a n s c r i p t i o n of the taped interview with day care "6". Code: R - Respondant I - Interviewer I:  Would you t e l l me about the unit here and s p e c i f i c a l l y about the day patients coming up to the ward?  R: Right from the very beginning, we realized that we r e a l l y couldn't function as a psychiatric unit without some follow-up of the patient. Now we have; because of no funds, because o f a lack of space and because of a l l kinds of things, we have not been able to s e t up any very high geared s p e c i f i c program. I t has been more on the basis of saying to patients, "come on back i f you r e a l l y feel you need to see somebody" i n terms o f educating them not to s l i p back too f a r . Now we have to be careful not to make people dependent too. By and large we have not set up s p e c i f i c times; i t i s more when they feel the need to come. Some have d e f i n i t e l y been referred to be here f o r certain hours of the day and to get involved i n whatever program we have set up. Here again, due to s t a f f shortage, space, and f a c i l i t i e s , we haven't had a l l that much a c t i v i t y for them to do when they do come. Depending on what the s i t u a t i o n is they may stay f o r 15 minutes or up to 8 hours, or even longer sometimes. We have three or four people coming i n regularly and we have set up s p e c i f i c outlines of what we expect of them while they are here. The rest of the people that come are on more o f an emergency basis. Today, one of the patients we've had since the ward opened, phoned and said she f e l t she was s l i p p i n g . So she came i n and I spent an hour talking with her. By the end of our conversation, her own self-confidence had returned. This i s the sort of thing that we do a l o t o f , i n f a c t , this is the majority o f what I would c a l l day care right now. I:  Where do you get most of your r e f e r r a l of patients from, besides the ones who come on their own?  R: Mostly our r e f e r r a l s come through the p s y c h i a t r i s t s and the general p r a c t i t i o n e r s . We usually decide a f t e r a patient gets here, j u s t how much follow-up they need. Or i t may involve us going out to v i s i t them i n their home. I:  What types of treatments are carried out here?  78  R: There i s some group therapy, recreational a c t i v i t i e s , c r a f t s , we use a l o t of medications, some electro-therapy, and we t r y to give people as much individual therapy as possible. I: Are there any plans for expanding the in-patient unit? R: There i s space that i s going to be u t i l i z e d , but I don't know i f i t w i l l be by psychiatry. I f we d i d expand, day care would also have to expand and we would need more s t a f f . We've- r e a l l y tried to assess the type of patients that we are dealing with and what does this community or area r e a l l y need. I'm beginning to feel that i f we can run a f l e x i b l e unit, i f we had more space, then maybe a s p e c i f i c day care program with day care beds f o r people to stay overnight and that type of thing. I: Do you have any volunteers i n the program? R: We have one who comes up to the ward for about four hours a day and she does various errands. We r e a l l y do need volunteers. I would prefer to try and use ex-patients i f that's possible. It has been my experience that these people do very well and you can get some very good volunteers. I:  Is there any community involvement with the program here?  R: We're presently working on a l i a i s o n with several community agencies. There has been some progress. I t i s obvious that everyone has been working i n their own sphere and not r e a l l y r e a l i z i n g what others are doing and there i s a l o t o f duplication. We've got to get that sorted out f i r s t and get working as a team. This i s a right sized community where we could do some r e a l l y good things. Any program that i s set up has to be unique to the area i t i s serving.  BIBLIOGRAPHY A. BOOKS Bierer, J . The Day Hospital.  London: H.K. Lewis, 1951.  Blau, Peter and W. Richard Scott. Formal Organizations. San Francisco: Chandler Publ. Co., 1962. Fox, David J. Fundamentals of Research in Nursing. New York: Century-Crofts, 1970.  Appleton-  Glasscote, R.M., and others. P a r t i a l H o s p i t a l i z a t i o n f o r the Mentally 111. Washington: The Joint Information Service, 1969. Hyman, Herbert. Survey Design and Analysis. Glencoe: The Free Press, 1960. Jourard, Sidney M. The Transparent Self. Reinhold Co., 1971.  Toronto:  Van Nostrand  Meltzoff, J . and R.L. Blumental. The Day Treatment Centre. S p r i n g f i e l d : Charles C. Thomas, 1966. M i l l o n , Theodore and H.I. Diesnhaus. Research Methods in PsychoPathology. Toronto: John Wiley and Sons, 1972. Rehin, G.F. and F.M. Martin. Patterns of Performance i n Community Care. Toronto: Oxford U n i v e r s i t y Press, 1968. Robert, Leigh M., S.L. Halleck and M.B. Loeb (eds.). Community Psychiatry. London: The U n i v e r s i t y of Wisconsin Press, 1966. Scheff, Thomas J . Being Mentally 111: A Sociological Theory. New York: Aldine Publ. Co., 1966. Suchman, E.A. Sociology and the F i e l d of Public Health. New York: Russell Sage Foundation, 1963. Susser, Mervyn. Community Psychiatry. New York:  Random House, 1968.  80 B.  PERIODICALS  Astrachan, B.M. and others. "Systems Approach to Day Hospitalization," Archives of General Psychiatry, Vol. 22, June, 1970. Batey, M.V. "Conceptualizing the Research Process," Vol. 20, No. 4, 1971.  Nursing Research,  Bierer, J. "Theory and Practice of Psychiatric Day Hospitals," Lancet II, 1959. Cameron, D.E.  "The Day Hospital," Modern Hospitals, 69:40, 1947.  Congdon, R.G. "Partial H o s p i t a l i z a t i o n , " Canadian P s y c h i a t r i c Association Journal, Vol. 16, 1971. C r a f t , M. "Psychiatric Day Hospitals," American Journal of Psychiatry, 116, 1959. Cravens, R.B. "Evaluation of Community Mental Health Center Programs," Journal of Operational Psychiatry, Vol. 3, No. 2, 1967. Cumming, J. and J. Bass. "A Review of the L i t e r a t u r e on P s y c h i a t r i c Day Hospitals With Special Reference to Evaluation," Department of Health Services and Hospital Insurance, V i c t o r i a , B r i t i s h Columbia, May, 1972. Gove, W. and J.E. Lubach. "An Intensive Treatment Program f o r Psychiatric Inpatients: A Description and Evaluation," Journal of Health and Social Behavior, Vol. 10, 1969. Guy, W. and G.M. Gross. "Problems in the Evaluation of Day Hospitals," Community Mental Health Journal, Vol. 3, No. 2, 1967. Herz, M.I. and others. "Day Versus Inpatient H o s p i t a l i z a t i o n : A Controlled Study," American Journal of Psychiatry, 127: 10, A p r i l , 1971. Lamb, H. Richard. "Release of Chronic P s y c h i a t r i c Patients Into The Community," Archives of General Psychiatry, Vol. 19, July, 1968. Morgenstern, J.A. and J.T. Ungerleider. "Integration of a Day-Care Program Into a General P s y c h i a t r i c Hospital," American Journal of Psychiatry, 122: 1966.  81 Odenheimer, J.F. "Day Hospital as an A l t e r n a t i v e to the P s y c h i a t r i c Ward," Archives of General Psychiatry, Vol. 13, J u l y , 1963. P e a r s a l l , Marion. "Participant Observation As Role And Method In Behavioral Research," Nursing Research, Vol. 14, No. 1, 1965. U.S. Department of Health, Education and Welfare. "Community Mental Health Centers Act of 1963," T i t l e 2, Public Law 88-164, Regulations (Federal Register) 1964. Wiener, D.N. "Problems and Directions f o r the Day Treatment Center," Mental Hygiene, 47: 1963. Wilder, J.F. and others. "A Two-Year Follow-Up Evaluation of Acute Psychotic Patients Treated in a Day Hospital," American Journal of Psychiatry, 122: 1966.  

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