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Aftercare services for discharged mental patients : an initial assessment of the services offered by… Rodgers, Patricia Fern 1966

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AFTERCARE SERVICES FOR DISCHARGED MENTAL PATIENTS  An I n i t i a l Assessment o f the S e r v i c e s O f f e r e d . by the A f t e r Care C l i n i c to P a t i e n t s D i s c h a r g e d from R i v e r v i e w H o s p i t a l  by PATRICIA' FERN RODGERS MARIANNE STEPHAN ROBERT WHITELAW  T h e s i s Submitted, i n P a r t i a l F u l f i l m e n t . o f the Requirements f o r the ..Degree o f MASTER OF SOCIAL WORK i n the. School of. S o c i a l . Work  Accepted, as conforming' t o the s t a n d a r d r e q u i r e d f o r the degree o f Master o f S o c i a l Work  School o f S o c i a l Work  1966 The U n i v e r s i t y o f B r i t i s h  Columbia  In  presenting  this thesis i n partial  f u l f i l m e n t of the  requirements f o r an advanced degree a t the U n i v e r s i t y of B r i t i s h Columbia,  I agree t h a t  f r e e l y a v a i l a b l e f o r reference  the L i b r a r y and study.  s h a l l make i t I further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s .  I t i s understood  that  copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l  gain  s h a l l not be allowed without my w r i t t e n  School o f S o c i a l Work The U n i v e r s i t y of B r i t i s h Columbia, Vancouver 8, Canada.  permission.  - i i-  TABLE OP CONTENTS Chapter 1.  The Development  of Aftercare  W r i t e r s concern and statement o f r e s e a r c h problem. General background o f a f t e r c a r e development. H i s t o r i c a l background. Development o f a f t e r c a r e i n B r i t i s h Columbia and G r e a t e r Vancouver Chapter 2.  Page  1  Review o f L i t e r a t u r e  F i v e State Study and Minnesota Follow-Up Study. Purpose and. c h a r a c t e r i s t i c o f the s t u d i e s . F i n d i n g s . Mental H e a l t h Survey o f Los Angeles County. Purpose o f the study. C l i n i c and o u t - p a t i e n t s e r v i c e s . Interpretation of rehabilitation services. Findings o f the survey. Conclusions and i m p l i c a t i o n s . . 25> Chapter 3.  Methodology o f the Study  Statement o f problem. Data. Research instruments. P a t i e n t q u e s t i o n n a i r e , the instrument, - the sample, and comments. The s t a f f q u e s t i o n n a i r e , the i n s t r u ment, the sample, and comments. The agency q u e s t i o n n a i r e , the instrument, the sample and comments i|6 Chapter Ij.  P r e s e n t a t i o n o f Data o f t h e P a t i e n t Questionnaire  D e s c r i p t i o n o f the sample. S o c i a l needs and h e l p given. Work needs and h e l p g i v e n . Home needs a n d help given Chapter 5. General needs.  5>9  S i g n i f i c a n c e o f t h e F i n d i n g s o f the P a t i e n t Questionnaire"  comment on sample. S e r v i c e s rendered. Work S o c i a l needs. Home needs. C o n c l u s i o n s . . . . 91  Chapter 6.  Questionnaire  to P r o f e s s i o n a l  Personnel  Findings o f s t a f f questionnaire. Analysis of s t a f f q u e s t i o n n a i r e . F i n d i n g s o f agency q u e s t i o n n a i r e . Analyses o f agency q u e s t i o n n a i r e . . . . . 109 Chapter 7»  Conclusions  Scope o f s e r v i c e . C o o r d i n a t i o n o f s e r v i c e s . D i v i s i o n of r e s p o n s i b i l i t y f o r a f t e r c a r e s e r v i c e . Future trends I2I4  - iii  -  Appendices: A. B. C. D.  E.  Patient Questionnaire Tables S t a f f Questionnaire Agency Q u e s t i o n n a i r e Bibliography  - iv-  TABLES IN THE TEXT Table 1. Table 2. Table 3. Table k. Table 5>. Table 6. Table 7. Table 8. Table 9. Table 10. Table Table Table Table  11. 12. 13. II4.  Table 15*. Table Table Table Table  16. 17. 18. 19.  Table 20. Table 21. Table Table Table Table Table  22. 23. 25. 26.  Table 27.  Page  M a r i t a l s t a t u s and sex 60 L i v i n g arrangements by m a r i t a l s t a t u s and sex....... ll[9 D i s t r i b u t i o n o f age by m a r i t a l s t a t u s and sex 6l Education 15"0 E d u c a t i o n by m a r i t a l s t a t u s and. sex, hospital files 150 Source o f income 15*1 Number o f h o s p i t a l i z a t i o n s by m a r i t a l s t a t u s and sex, h o s p i t a l f i l e s 15"2 Number o f h o s p i t a l i z a t i o n s 15"2 Diagnoses by sex and m a r i t a l s t a t u s , hospital files 63 Comparison o f i n t e r v i e w e r and c l i e n t assessments o f mental h e a l t h 61j C l i e n t estimate o f symptoms.. 153 C l i e n t estimate o f c l i n i c h e l p 67 C l i e n t estimate o f improvement. 15>3 C l i e n t estimate o f h e l p g i v e n f o r s p e c i f i c problem by other a g e n c i e s . . . 15lj C l i e n t estimate o f time spent i n recreation. 15li C l i e n t c o n t a c t w i t h r e l a t i v e s and f r i e n d s 15? C l i e n t o p i n i o n o f neighbours 15>£ S o c i a l c o n t a c t by sex and m a r i t a l s t a t u s 70 Source o f income by m a r i t a l s t a t u s and sex. 75> Comparison o f employment s t a t u s and type before and a f t e r h o s p i t a l i z a t i o n l£6 I n t e r v i e w e r estimate o f housing, n e i g h . borhood and housekeeping 15*7 Statement o f work problem and h e l p g i v e n 82 R e s p o n s i b i l i t y f o r household t a s k s . . . . . 15"8 C l i e n t s a t i s f a c t i o n with household t a s k s . 15"8 C l i e n t and home member understanding... 159 Statement o f home problems and h e l p given by C l i n i c 89 Interview A t t i t u d e 55  -  V  -  ABSTRACT There has been a growing t r e n d to d i s c h a r g e p a t i e n t s from mental h o s p i t a l s a f t e r short p e r i o d s of hospitalization. These discharged p a t i e n t s may have unr e s o l v e d problems and need c o n t i n u i n g s e r v i c e i n the community i f they are t o m a i n t a i n t h e i r l e v e l of s o c i a l functioning. The A f t e r Care C l i n i c i n Burnaby was formed to p r o v i d e c o n t i n u i n g s e r v i c e to the p a t i e n t . However there i s much concern about the h i g h readmisaion r a t e s t o the h o s p i t a l and the adequacy o f the a f t e r c a r e s e r v i c e s . The present study i s a p i l o t study t o examine the s e r v i c e s p r o v i d e d by the A f t e r Care C l i n i c . The researchers reviewed a f t e r c a r e l i t e r a t u r e and u t i l i z e d , h o s p i t a l r e c o r d s . Information was obtained from q u e s t i o n n a i r e s to p a t i e n t s , c l i n i c s t a f f and other agency s t a f f . Prom these sources the s o c i a l , work, and home needs of p a t i e n t s and. the t r e a t ment g i v e n were examined. Opinions about the a f t e r c a r e s e r v i c e s and p o s s i b l e improvements were a l s o examined i n an attempt to assess the adequacy o f the s e r v i c e s p r o v i d e d by the A f t e r Care C l i n i c . The f i n d i n g s showed, a l a r g e number o f p a t i e n t needs and nominal s e r v i c e g i v e n . Treatment was medically o r i e n t e d w i t h b r i e f supportive therapy. Only one person i n the sample o f saw a s o c i a l worker. The s t a f f o f the c l i n i c and other agencies were aware of the l a c k of s e r v i c e s f o r the discharged p a t i e n t but d i f f e r e d i n t h e i r p e r c e p t i o n of t h e i r r o l e s and t h e i r e x p e c t a t i o n s o f an adequate s e r v i c e . The c l i n i c s t a f f thought t h a t r e s p o n s i b i l i t y f o r a f t e r c a r e s e r v i c e s should be shared between h o s p i t a l and community a g e n c i e s . However community agencies f e l t that the h o s p i t a l should assume r e s p o n s i b i l i t y . These f i n d i n g s i n d i c a t e the present gaps i n the a f t e r c a r e s e r v i c e s and the need, f o r r e s p o n s i b i l i t y and l e a d e r s h i p . I t seemed, apparent that i t should be the r o l e of the mental.health branch to take r e s p o n s i b i l i t y f o r l e a d e r s h i p i n the development o f a c o o r d i n a t e d and comprehensive a f t e r c a r e s e r v i c e .  - vi -  Acknowledgements  We  w i s h to convey our a p p r e c i a t i o n t o the Adminis-  t r a t i o n of R i v e r v i e w H o s p i t a l f o r making a p p r o p r i a t e  back-  ground i n f o r m a t i o n  the  a v a i l a b l e and wish to acknowledge  c o n s u l t a t i v e a s s i s t a n c e g i v e n by the p e r s o n n e l of the and  of the A f t e r c a r e C l i n i c ,  Burnaby, B.  C.  We would l i k e to express our most s i n c e r e a t i o n to Mrs.  Helga H i c k s ,  Hospital  our t h e s i s a d v i s e r , who  apprecigave so  generously o f her time and knowledge and without whose invaluable help  t h i s study c o u l d not have been completed.  AFTERCARE SERVICES FOR DISCHARGED MENTAL PATIENTS'  CHAPTER 1 THE A.  DEVELOPMENT OP AFTERCARE..'  Introduction As  an i n t r o d u c t i o n to Chapter 1 o f t h i s t h e s i s ,  b a s i s f o r the w r i t e r s ' Care S e r v i c e s to the  the  s e l e c t i o n of t o p i c - namely A f t e r  to the m e n t a l l y i l l - should, be made known  reader.  1. Adequacy o f  Service  F i r s t l y , the w r i t e r s , two mental h e a l t h f i e l d ,  having worked i n the  f e l t a concern over the q u a n t i t y  and  q u a l i t y of follow-up care a v a i l a b l e to p a t i e n t s a f t e r d i s charge.  T h i s problem, which had  e x i s t e d f o r many y e a r s ,  became even more a c u t e l y accentuated as a r e s u l t of  current  improved treatment methods and  of  the c u r r e n t  practice  r e t u r n i n g the p a t i e n t s r a p i d l y t o the community f o l l o w i n g remission  o f t h e i r symptoms.  More than ever, follow-up  care extending from the h o s p i t a l i n t o the community became e s s e n t i a l i n the treatment continuum i f the  gains made by  the p a t i e n t d u r i n g h i s h o s p i t a l i z a t i o n were t o be Hence, the A f t e r Care C l i n i c was of s u s t a i n i n g discharged As  maintained:  e s t a b l i s h e d f o r the purpose  mental p a t i e n t s  i n the  community.  s t a t e d , the w r i t e r s f e l t the adequacy o f t h i s s e r v i c e  might p r o f i t a b l y be a s s e s s e d p a r t i c u l a r l y i n view o f some o f the more evident  problems, f o r example, h i g h  re-admission  - 2 -  r a t e s , procedure, p o l i c y and s t a f f i n g , and c o - o r d i n a t i o n w i t h community r e s o u r c e s , to name a few. 2. Research Problem Therefore, i n t h i s study, the i n t e n t o f the w r i t e r s w i l l be to o b t a i n the judgements o f those p a t i e n t s , members of s t a f f , and community a g e n c i e s a c q u a i n t e d w i t h the A f t e r Care C l i n i c on the ways i n which the program meets and/or f a i l s to meet the needs of mental p a t i e n t s d i s c h a r g e d from the R i v e r v i e w H o s p i t a l . To conclude t h i s i n t r o d u c t i o n , the w r i t e r s , i n e l e c t i n g t o u t i l i z e the A f t e r Care C l i n i c ,  Burnaby, B. C.  f o r t h i s study, were h o p e f u l t h e i r e x p l o r a t i o n s might r e f l e c t c e r t a i n problem a r e a s which would m e r i t  further  r e s e a r c h and lead, e v e n t u a l l y t o an improved s e r v i c e .  The  H o s p i t a l A d m i n i s t r a t i o n have shown c o n s i d e r a b l e awareness  of  the problem and t h i s awareness c e r t a i n l y i s r e f l e c t e d by t h e i r w i l l i n g n e s s to a l l o w the w r i t e r s f r e e scope t o examine the v a r i o u s a s p e c t s . o f the dilemma.  The w r i t e r s w i l l , a t  t h i s p o i n t , move i n t o the main body o f Chapter 1 which i s concerned w i t h the background and development  o f A f t e r Care  C l i n i c s i n N o r t h America w i t h s p e c i f i c r e f e r e n c e t o the A f t e r Care C l i n i c  i n Burnaby.  B. General Background o f A f t e r c a r e  Development  1. Changing Concepts o f Mental I l l n e s s As a beginning the w r i t e r s i n v i t e the r e a d e r t o take a b r i e f l o o k a t the changing concept o f mental i l l n e s s .  In  - 3 order to do so, one should know how  the medieval  sought to comprehend the m e n t a l l y i l l being "possessed by the d e v i l " .  person i n terms o f  The problem was  a r e l i g i o u s r a t h e r than medical one.  concept  viewed  aa  Prayers or exorcisms  to e x p e l the d e v i l were the u n i v e r s a l means of d e a l i n g w i t h the p e r s o n a l f e a r which mental i l l n e s s generated i n the sane populace. altered  At a somewhat l a t e r p o i n t the medieval  - mental derangement then was  of " s i n " .  The  " s i n n e r " was  concept  c o n s i d e r e d the r e s u l t  " l o c k e d up" u n t i l such time as  r e m i s s i o n of h i s symptoms might "punishment" being over he was  occur.  At t h i s p o i n t h i s  r e l e a s e d t o face the  oppro-  brium o f the community. While t r a c e s o f the medieval concepts s t i l l  exist  down t o the p r e s e n t i n s t a t e h o s p i t a l s and community a l i k e , certainly,  care of the m e n t a l l y i l l has g r a d u a l l y  improved  w i t h the growth i n understanding of mental i l l n e s s .  As l o n g  as " c u r e " was r e g a r d e d as a matter o f chance, however, a sense o f hopelessness i n the area of mental i l l n e s s p r e v a i l e d .  The  break through the v e i l of pessimism c l o a k i n g mental i l l n e s s o c c u r r e d w i t h the advent o f the "wonder" drugs. 2. Advent o f "Wonder" Drugs Chance d i s c o v e r y of the t r a n q u i l i z i n g  effect  of  these drugs, o r i g i n a l l y developed f o r the treatment o f t u b e r culosis,  c r e a t e d the b a s i s f o r a more o p t i m i s t i c  the mental h e a l t h f i e l d .  outlook i n  The t r a n q u i l l i z i n g drugs, along w i t h  other forms of treatment, f o r example, e l e c t r o - c o n v u l s i v e  - htherapy and coma i n s u l i n , were h i g h l y e f f e c t i v e i n c o n t r o l of the gross symptoms o f mental i l l n e s s .  A l s o , awareness  sharpened t o the f a c t t h a t , u n d e r l y i n g mental i l l n e s s were poor i n t e r p e r s o n a l r e l a t i o n s h i p s , that confinement i n a mental h o s p i t a l apart  from the i l l n e s s i t s e l f was s o c i a l l y  c r i p p l i n g , and, t h a t t h e e x p e c t a t i o n s ity,  o f persons i n t h e commun-  i . e . o f f a m i l y , and s o c i a l groups were c o n s e q u e n t i a l i n  the r e s t o r a t i v e 3•  process.  Changing Role o f Mental H o s p i t a l s In the past  i t had been the r o l e o f mental h o s p i t a l s  to p r o t e c t the community from the mentally emergence o f new and more o p t o m i s t i c  ill.  Now, w i t h the  concepts concerning the  nature o f mental i l l n e s s and i t s treatment, a s h i f t i n the a t t i t u d e s o f s t a t e h o s p i t a l a d m i n i s t r a t o r s  occurred  and prac-  t i t i o n e r s a l i k e , away from the t r a d i t i o n a l c u s t o d i a l o r i e n t a tion.  To c l a r i f y , t h e former "psyche" o r i e n t e d approach  y i e l d e d t o a " s o c i a l l y " o r i e n t e d approach: the t r a d i t i o n a l c u s t o d i a l f u n c t i o n o f the mental h o s p i t a l gave way to' short term treatment f u n c t i o n .  Patients received b r i e f  treatment u t i l i z i n g drug or e l e c t r o - c o n v u l s i v e Following remission to t h e community. discharged  therapy.  o f symptoms, they were q u i c k l y Unfortunately  intensive  returned  over h a l f o f the p a t i e n t s  t o t h e community j u s t as q u i c k l y succumbed t o the  s t r e s s o f adjustment, and, f a i l i n g t o m a i n t a i n the gains made during h o s p i t a l i z a t i o n soon r e l a p s e d and. were r e h o s p i t a l ized.  - 5 !+• Need f o r Follow-up The  need f o r follow-up  as an e x t e n s i o n  s e r v i c e to d i s c h a r g e d  patients  o f h o s p i t a l treatment i n t o the community  become g l a r i n g l y apparent.  I t was  had  on the b a s i s of t h i s need  that the concept o f a f t e r c a r e programs took shape. The r e a d e r here should not have to s t r e t c h h i s imagina t i o n to envisage some of the problems, both o l d and. new  which  were exacerbated and c r e a t e d r e s p e c t i v e l y by the e x t e n s i o n the h o s p i t a l treatment i n t o the community i n the Care G l i n i c a f o r the er has  follow-up  of discharged  form o f A f t e r  patients.  magnitude of the problem of p r o v i d i n g a c o - o r d i n a t e d , grated, and  continuing  t h i s community. prograraa  s e r v i c e t o the  read-  the inte-  diacharged p a t i e n t i n  Thus, w i t h the establishment  of a f t e r c a r e  many immediate problems loomed up n e c e s s i t a t i n g  d e c i s i o n s on the p a r t of a d m i n i s t r a t i o n concerning and  The  only to remember the t r a d i t i o n a l h i a t u s between the  Mental H o s p i t a l and the community to g a i n some i d e a o f  age  of  the  q u a l i t y o f s e r v i c e , the type o f p a t i e n t s f o r  cover-  referral,  the e l i g i b i l i t y f o r s e r v i c e , the maximum l e n g t h of s e r v i c e o f f e r e d , the d i s c i p l i n e s to be i n v o l v e d i n programs, and  the  s e r i o u s problem o f s t a f f i n g , i n view o f shortage of t r a i n e d professionals. expansion o f the  A l s o , many long range problems i n v o l v i n g the s e r v i c e , c o - o r d i n a t i o n , and  w i t h other community agencies,  consultation  development of v a r i o u s  to meet d i v e r s e p a t i e n t needs, and d e t e r m i n a t i o n r e s p o n s i b i l i t y - these problems, too, r e q u i r e d  resources  of areas o f  attention.  - 6 Many o f the problem areas which have been b r i e f l y mentioned here w i l l be examined l a t e r i n r e l a t i o n t o the w r i t e r s ' study o f the present A f t e r Care C l i n i c  i n Burnaby.  At t h i s  p o i n t , the w r i t e r s wish t o d i r e c t the r e a d e r ' s a t t e n t i o n to the g e n e r a l h i s t o r i c a l development o f a f t e r c a r e programs on t h i s c o n t i n e n t , and t o the s p e c i f i c development  o f the A f t e r  Care C l i n i c w i t h which t h i s study i s i n v o l v e d . c  » H i s t o r i c a l Background o f A f t e r c a r e 1. Beginning Development  i n U.S.A.  The h i s t o r i c a l background o f a f t e r c a r e i n North America began i n 1873 when under the C h a r i t i e s A c t A s s o c i a t i o n i n the State o f New York the f i r s t a f t e r c a r e program was o r g a n i z e d on a l a y basis.  In 1908,  the Committee  Insane became the Committee  on A f t e r c a r e o f the  on P r e v e n t i o n and A f t e r c a r e , and  t h e r e a f t e r was concerned w i t h the r e h a b i l i t a t i o n o f mental patients.  In 1910 the name was changed to the Committee o f  Mental Hygiene o f the S t a t e C h a r i t i e s A s s o c i a t i o n and s i n c e has c o n t i n u e d t o be, "a Committee  o f a C i t i z e n ' s O r g a n i z a t i o n con-  cerned w i t h the development o f r e s o u r c e s f o r t h e treatment of any p e r s o n i n the s t a t e who i s i n need o f care f o r a mental or emotional handicap ,  The s i g n i f i c a n c e o f t h i s  statement l i e s  i n the f a c t t h a t the value and d e s i r a b i l i t y o f c i t i z e n  partic-  i p a t i o n i s r e c o g n i z e d and an o r g a n i z a t i o n i s s e t up and  1. Gamble, J . E . "The A f t e r Department, O n t a r i o H o s p i t a l , London," E x c e r p t from The S o c i a l Worker. June, 1951.  - 7 -  a u t h o r i z e d by the s t a t e t o promote p u b l i c education, and  understanding,  i n t e r e s t i n the mental h o s p i t a l and  gramme, and. i n the mental h e a l t h o f the  i t s pro-  community.  In the o p i n i o n o f the w r i t e r s , the approach taken by the Committee of Mental Hygiene of the State C h a r i t i e s Associ a t i o n c l e a r l y g i v e s r e c o g n i t i o n t o the r o l e o f the  community  i n the r e h a b i l i t a t i o n of the d i s c h a r g e d mental p a t i e n t . corroborates  It  the f e e l i n g of these w r i t e r s and o t h e r s t h a t  A f t e r Care C l i n i c s cannot begin t o operate  effectively in  i s o l a t i o n but must be c o - o r d i n a t e d w i t h other s o c i a l w i t h i n the community.  C e r t a i n l y , the expressed  resources  goals of the  Committee of Mental Hygiene o f the State C h a r i t i e s A s s o c i a t i o n were v e r y commendable. education  The w r i t e r s b e l i e v e more promotion  i n the f i e l d o f mental h e a l t h i s e s s e n t i a l i f p u b l i c  understanding  and the development of s u i t a b l e r e h a b i l i t a t i v e  r e s o u r c e s w i t h i n the community are our u l t i m a t e 2. A f t e r Care and  goals.  Social Service  The development o f t h i s i n t e r e s t has Care" and  and  l e d to " A f t e r  S o c i a l S e r v i c e becoming an i n t e g r a l p a r t of the  treatment programs o f h o s p i t a l s i n the U n i t e d S t a t e s and, a l e s s e r extent,  i n Canada.  The  to  f a c t t h a t most of the e a r l y  follow-up work w i t h d i s c h a r g e d p a t i e n t s was  done by the mental  h o s p i t a l s o c i a l workers whose competence l a y i n the a r e a  of  the f a m i l y and community, would e x p l a i n the n a t u r a l a f f i n i t y between the S o c i a l S e r v i c e and A f t e r Care development.  In  s h o r t , we would n a t u r a l l y expect S o c i a l S e r v i c e to have a major r o l e i n the program o f a f t e r c a r e .  I t w i l l be of i n t e r -  - 8 est t o the reader to study the f i n d i n g s o f t h i s t h e s i s i n r e g a r d t o t h i s one aspect program.  o f S o c i a l S e r v i c e r o l e . i n the  C e r t a i n l y , i f nothing  e l s e , i t does v e r i f y  a f t e r c a r e programs d i f f e r w i d e l y as t o t h e i r and  that  organization  o b j e c t i v e s and. a r e dependent on such f a c t o r s as s t a f f -  i n g , funds, g e o g r a p h i c a l  l o c a t i o n , and the degree o f c u r r e n t  enlightenment on t h e p a r t o f both h o s p i t a l and. community. The  w r i t e r s wish a t t h i s p o i n t t o continue t h e i r review o f  the h i s t o r i c a l background. comments r e g a r d i n g  This review w i l l i n c l u d e some  t h e a f t e r c a r e s i t u a t i o n p r i o r t o 1950,  the p e r i o d o f i n c r e a s i n g a f t e r c a r e development from 1950 on w i t h emphasis on the Canadian scene, c o n c l u d i n g  the sec-  t i o n w i t h an account o f a f t e r c a r e development i n t h i s p a r t i c u l a r area o f Vancouver. 3. P r i o r t o 1950 P r i o r t o World War I I , i f the r e a d e r were t o peruse the l i t e r a t u r e , he would find, l i t t l e in psychiatric r e h a b i l i t a t i o n . ally, practitioners  evidence o f i n t e r e s t  I n Mental H o s p i t a l s  gener-  t h i s applied, not only t o t h e m e d i c a l  s t a f f but t o the s o c i a l workers as w e l l who, by t r a i n i n g , were S o c i a l l y " o r i e n t e d  were t o o i n v o l v e d w i t h the i n -  h o s p i t a l "team" approach t o be a c t i v e o u t s i d e .  Among t h e  e a r l i e s t e f f o r t s perhaps were the s o l i t a r y attempts made w i t h i n the i n d i v i d u a l State o r P r o v i n c i a l Mental H o s p i t a l i n the l a t e 1930's and d u r i n g t h e 19140's t o a c t i v a t e p a t i e n t s who were becoming withdrawn.  Rehabilitation  - 9 programs, p r i o r to h i s , were l a r g e l y designed  f o r the  physic-  a l l y handicapped. In p s y c h i a t r y , i t was p h r e n i c s , who  the problem o f the  schizo-  comprised h a l f o f the h o s p i t a l p o p u l a t i o n ,  that  had long p r o v i d e d a r e a l c h a l l e n g e e s p e c i a l l y i n terms of rehabilitation.  I t was  the d i f f i c u l t y i n normal communication  and the r e s u l t i n g impoverishment i n s o c i a l r e l a t i o n s h i p t h a t o f t e n , over the y e a r s , had taxed the mind and  imagination  the p r o f e s s i o n a l i n working w i t h the s c h i z o p h r e n i c .  Early  r e h a b i l i t a t i o n programs were d i r e c t e d to a s s i s t i n g the p a t i e n t s move out of h o s p i t a l and back i n t o the  of  chronic  community.  P r i m a r i l y , they were attempts to provide the q u i e t e r s c h i z o phrenic p a t i e n t who  no longer r e q u i r e d t o be h o s p i t a l i z e d with  a more p l e a s a n t environment and y  overcrowded wards. appropriate  to reduce the pressure  They i n v o l v e d a process  of  of r e - e d u c a t i o n  in  behavior which i n many i n s t a n c e s began w i t h i n the  Mental H o s p i t a l l | . Family  itself.  and F o s t e r Care Programs  Thus e v o l v e d the program known as "Family"  Care.  In  e f f e c t , t h i s program c o n s i s t e d of p l a c i n g s u i t a b l e mental p a t i e n t s i n s e l e c t e d p r i v a t e homes i n the community. home c a r e o f the m e n t a l l y  i l l r e c e i v e d i t s impetus i n the  e a r l y 1930's, mainly through the e f f o r t s o f Hester d i r e c t o r of P s y c h i a t r i c S o c i a l S e r v i c e s f o r the New State Department of Mental Hygiene. a c t i v i t y , New  Foster  B.  Crutcher,  York  Owing l a r g e l y t o her  York f i n a l l y r u l e d i n 193£  that s e l e c t e d mental  - 10 p a t i e n t s could be p l a c e d  -  i n p r i v a t e homes.  other s e c t i o n s of the U n i t e d  At a l a t e r date,  States and Canada f o l l o w e d  suit  i n the development of f o s t e r home care programs. 5>»' The  Nature o f A f t e r c a r e  Before the w r i t e r s proceed:; t o d e s c r i b e g e n e r a l l y care developments o f the 195>0's i n Canada, and  after-  specifically,  the developments o f the A f t e r Care C l i n i c i n Burnaby, B r i t i s h Columbia, they wish to formulate f o r the r e a d e r a  perspective  on the nature o f a f t e r c a r e gleaned from some of the a r t i c l e s on the  written  subject.  " A f t e r c a r e i s d e f i n e d as a program designed -to m a i n t a i n or strengthen the improvement a t t a i n e d by a p a t i e n t during h i s h o s p i t a l treatment and to i n c r e a s e h i s l i k e l i h o o d o f making a good, adjustment t o community living." 1  At t h i s p o i n t , the w r i t e r s would, l i k e t o s t a t e , t h a t , in surveying i n various  i n the l i t e r a t u r e  a number o f a f t e r c a r e programs  p a r t s o f the country, they b e l i e v e t h a t , by  l a r g e , a f t e r c a r e i s a s e r v i c e i n name o n l y . literature lag  emphasizes the  inadequacy o f the  i n a f t e r c a r e development i s evident  t h i s l a g are m a n i f o l d . adequate funds and. the  and  So much i n the service.  and reasons to  A marked explain  Prominent among them are the l a c k s t a f f shortages; the  h e a l t h and w e l f a r e agencies and  of  inadequacy o f  t h e i r anxiety  i n c o p i n g with  ex-mental p a t i e n t s ; the absence of an educated community;  the  stigma which i s imposed by mental i l l n e s s ; the c o m p l e x i t y  of  1. Stokes, A.B. "The P r o v i s i o n f o r A p p r o p r i a t e A f t e r c a r e : H o s p i t a l and. Community. C o l l a b o r a t i o n . " E x c e r p t from Mental H o s p i t a l s , February, 1961.  - l i the i l l n e s s e s t h e m s e l v e s ; the s i z e o f t h e problem i n terms o f the number o f p a t i e n t s a f f e c t e d ; the p a t i e n t s own ing discharge f e e t ' ; and  desire follow-  t o 'shake the d u s t of the h o s p i t a l o f f t h e i r  f i n a l l y , the p a t i e n t s own  anxiety regarding  the  a t t i t u d e o f the community. Schwartz and  Schwartz s p e a k i n g o f t h e development o f  a f t e r c a r e have d e s c r i b e d a f t e r c a r e as a "'nominal' s e r v i c e r e n d e r e d i n compliance w i t h the law or t h e p o l i c y a t t e n d i n g the r e l e a s e o f p a t i e n t s from S t a t e M e n t a l H o s p i t a l s observe t h a t f o r t h e m a j o r i t y o f p a t i e n t s t h e r e none o f i t . "  and  is l i t t l e  A l s o t h e y s t a t e , " t h a t o l d assumptions  p r a c t i c e s are now  widely questioned,  and programs a r e  or  and being  s p e c i f i c a l l y designed f o r p a r t i c u l a r types of e x - p a t i e n t s . The  o l d and new  e x i s t s i d e by s i d e so t h a t a f t e r c a r e i s a  patchwork q u i l t o f o l d i d e a s and new  theories, with  experi-  2  m e n t a l programs implementing b o t h . " The w r i t e r s w i l l have t o agree w i t h the above comment a r y on g e n e r a l a f t e r c a r e development as i t e x i s t s a t present time.  the  C e r t a i n l y a wide v a r i a t i o n i n a f t e r c a r e  pro-  grams does o c c u r but most o f the programs appear t o have i n common a v e r y p r i m i t i v e s t a g e o f development p a r t i c u l a r l y i n regard, t o any comprehensive and c o - o r d i n a t e d i n v o l v e d approach.  community-  W i t h o u t a doubt, a dilemma does e x i s t f o r  hospital administration.  Improved t r e a t m e n t methods have  1. Schwartz, M o r r i s S. and C h a r l o t t e Green. S o c i a l Approaches t o M e n t a l P a t i e n t Care, °olumbia U n i v e r s i t y P r e s s , New York and London, 196h. 2.  Ibid.  - 12 -  meant a g r e a t e r turnover g r e a t e r need f o r beds.  o f the patient population,  hence a  Prom t h e viewpoint o f beds t h e r e f o r ,  as w e l l as the matter o f much h i g h e r  costs f o r  in-hospital  care, a d m i n i s t r a t i o n undoubtedly has the g r e a t e s t r e t u r n i n g p a t i e n t s t o t h e community.  interest i n  Prom the p o i n t o f view  of t h e p a t i e n t s i n t e r e s t s however, t h e w r i t e r s question the c u r r e n t p o l i c y o f r e t u r n i n g the p a t i e n t t o the community on the grounds t h a t i n many cases i t i s n e i t h e r t o the p a t i e n t ' s , nor  t o the community's b e n e f i t .  i n moving a c h r o n i c  What i s gained f o r example,  type p a t i e n t from the secure,  and o f t e n  more s t i m u l a t i n g environment o f t h e Mental H o s p i t a l and p l a c i n g him i n the s t a t i c  ' v e g e t a t i v e ' atmosphere o f a commercial  boarding home i n the community. Well,  the reader w i l l have ample o p p o r t u n i t y  t i o n the remarks, l a t e r c o n c l u s i o n s ,  t o ques-  and recommendations made  i n t h i s study and h o p e f u l l y i t w i l l s t i m u l a t e h i m t o draw a few  conclusions  o f h i s own.  Meanwhile, t h e w r i t e r s w i l l move  on to the f i n a l s e c t i o n o f t h i s , the f i r s t  Chapter, i n which  we wish t o cover b r i e f l y t h e s i t u a t i o n o f Canadian and Vancouver a f t e r c a r e development. 6.  Post Discharge Programs Across Canada In Canada as elsewhere, the s i t u a t i o n p e r t a i n i n g t o  the development o f A f t e r c a r e  s e r v i c e s r e a l l y o n l y gathered  momentum i n the l a t e .1950's and. e a r l y 1960«s. f o r a l l o f the P r o v i n c e s .  This holds true  A r e p o r t published, by the Mental  H e a l t h D i v i s i o n , Ottawa, i n I 9 6 0 i n d i c a t e s t h a t a l l o f the  - 13 p o s t - d i s c h a r g e programs then e s t a b l i s h e d , operated as outp a t i e n t departments o f P r o v i n c i a l Mental H o s p i t a l s and/or General H o s p i t a l s and t h a t p o s t - c a r e programs were s t i l l much i n the experimental phase.  In c o n j u n c t i o n w i t h t h e out-  p a t i e n t departments a l l o f the p r o v i n c e s sponsored mental h e a l t h c l i n i c s .  very  travelling  Day h o s p i t a l s or day c a r e c e n t r e s had  been e s t a b l i s h e d i n a number o f the P r o v i n c e s a t t h i s  time,  n o t a b l y i n O n t a r i o w i t h three P r o v i n c i a l sponsored day care c e n t r e s and three n o n - p r o v i n c i a l sponsored  centres; Montreal,  w i t h f o u r day c a r e c e n t r e s , Newfoundland w i t h one day h o s p i t a l , and B r i t i s h Columbia w i t h one day h o s p i t a l .  Night h o s p i t a l s  were t o be found o n l y i n the Montreal area where two were o p e r a t i n g on a t i m e - l i m i t  basis.  As one might expect, i t i s i n the l a r g e r c e n t r e s where, because o f t h e numbers o f p a t i e n t s alone, more o r g a n i z a t i o n o f s e r v i c e i s t o be found, t o g e t h e r w i t h more d i v e r s i t y o f s e r v i c e and a l s o s p e c i a l s e r v i c e s , f o r example the f o r e n s i c c l i n i c , designed t o meet a d i v e r s i t y o f p a t i e n t needs.  As y e t ,  however, nowhere i n Canada can any r e a l c l a i m be made t o a t o t a l a f t e r c a r e program c o - o r d i n a t e d w i t h community. most p a r t , each P r o v i n c e i s o p e r a t i n g a fragmentary F o r i n s t a n c e , t h e r e a r e t h e developed  F o r the program.  f o s t e r care programs i n  Manitoba and i n Saskatchewan, or the programs t o make more e f f e c t i v e use o f p u b l i c h e a l t h f i e l d  s t a f f i n Nova S c o t i a , t o  name two. The a f t e r c a r e s i t u a t i o n i n Canada does indeed p r e sent the p i c t u r e o f a patchwork q u i l t w i t h many problems i n  - Ill way o f g e t t i n g the p i e c e s  seamed  together.  To conclude t h i s s e c t i o n , p r e p a r a t o r y  t o examining  the l o c a l scene i n a f t e r c a r e development, the w r i t e r s do wish to say t h a t , h i s t o r i c a l l y , e a r l y r e c o g n i t i o n o f the i n t e g r a l p a r t o f a f t e r c a r e i n the treatment program prompted Dr. George H. Stevenson, former M e d i c a l Superintendent o f the Ontario Hospital  i n Eorridn, O n t a r i o ,  to create  a department i n the e a r l y  195>0's known as the A f t e r c a r e Department, t o operate as a f u n c t i o n o f the h o s p i t a l and aimed a t o f f e r i n g p a t i e n t s facility basic  f o r treatment.  every  In the program, r e c o g n i t i o n o f t h e  c o n t r i b u t i o n o f S o c i a l Work, because o f i t s " s o c i a l "  o r i e n t a t i o n , t o the f i e l d , o f a f t e r c a r e and. r e h a b i l i t a t i o n , assured s o c i a l workers an a c t i v e r o l e i n the program. w r i t e r s have but one comment t o make, namely t h i s ,  The  i f social  workers don't have a b a s i c c o n t r i b u t i o n t o make i n the f i e l d o f a f t e r c a r e and. r e h a b i l i t a t i o n , who, then does? D. Development o f A f t e r c a r e  i n B r i t i s h Columbia  1» Problems o f Follow-up In d i s c u s s i n g the development o f a f t e r c a r e i n B r i t i s h Columbia and. i n the G r e a t e r Vancouver area, t h e w r i t e r s w i s h at the beginning t o state that B r i t i s h Columbia, l i k e  other  p l a c e s , had innumerable problems i n r e l a t i o n t o the p o s t d i s c h a r g e care o f mental p a t i e n t s .  Firstly,  virtually  follow-up care c o u l d be made a v a i l a b l e to p a t i e n t s  discharged  from the P r o v i n c i a l Mental H o s p i t a l and Crease C l i n i c . minimal f o l l o w - u p there  little  was, mainly f e l l t o the S o c i a l  What  -15  -  S e r v i c e Department w i t h i n the h o s p i t a l 1950,  where b e f o r e basis  s o c i a l w o r k e r s e m p l o y e d on a  i n the Mental  H e a l t h S e r v i c e s , had  what more e x t e n s i v e l y i n f o l l o w - u p were i n c l o s e r h e a l t h nurse, the years therapy  contact w i t h the and  the  families  t h a t f o l l o w e d 1950,  unit  of operation.  f r o m community f o l l o w - u p  was  available fare  on  the  the  community s o c i a l  agencies  assumed much o f a r o l e charged  t o do  A . K.  result  time  of t h i s ,  even l e s s  social  on  of  Thirdly,  the  course,  follow-up  care  the S o c i a l  never h a p p i l y nor  i n providing follow-up  Wel-  other  effectively  care t o  a matter of f a c t ,  situation took  in British  office  felt  disquite  efforts  ignite  the  spark  factor  i n the  i n the M e n t a l  I t was Health  t h a t w e i g h s more t h a n  later  development  Throughout the  C o l u m b i a when  as the P r o v i n c i a l  S o c i a l Work i n 195l.  continuing  1950's.  team,  the  Responsibility  the  Carroll first  of Psychiatric  the  "team" a p p r o a c h became  so.  Division of T h i s was  the p u b l i c  S e r v i c e Department, and  m e n t a l p a t i e n t s and. a s  inadequate 2.  The  had  and.  patients, i n  s e r v i c e t o work f u l l  Social  some-  H e a l t h f i e l d , were withdrawn  t h e r e was  City  full-time  community  family doctor,  t o discharged, p a t i e n t s .  Branch,  i n the  As members o f t h e  based program.  t h a t f r o m 1950  care  Secondly,  been u t i l i z e d  of discharged  workers a t t a c h e d t o the M e n t a l  in-hospital  to provide.  her  other  of the A f t e r  1950's  Supervisor  early  and  Service Division any  Miss  to  single  Care C l i n i c  h o w e v e r , l e t i t be  in  stated,  - 16 that a serious struggle was being waged i n the area of followup care.  Heavily banded together on one side were the S o c i a l  Welfare Branches, The City S o c i a l Service Department, and other community s o c i a l agencies, increasing the pressure of t h e i r demands for c l a r i f i c a t i o n i n the matter of r e s p o n s i b i l i t y for  follow-up  services to patients discharged  c i a l Mental Hospital and Crease l i n i e . G  the P r o v i n c i a l Mental H o s p i t a l . was  from the Provin-  On the other side was  In between i n the struggle  the Social Service Department of the h o s p i t a l trying to  cope with the f r u s t r a t i o n s of planning  for discharged  patients  i n the face of increasing d i f f i c u l t i e s i n dealing with the Social Welfare Branch and the Municipal Agencies. By 19^7, the s i t u a t i o n concerning follow-up  and the  r e h a b i l i t a t i v e needs of discharged patients had reached the point where i t could no longer be ignored.  In a memo to the  Superintendent, re: After care needs of patient's  discharged  from P r o v i n c i a l Mental Hospital and Crease C n i c , Miss C a r r o l l n  r e i t e r a t e d that "a top l e v e l administrative meeting was,needed for the purpose of c l a r i f y i n g r e s p o n s i b i l i t i e s , functions and services related to the aftercare and r e h a b i l i t a t i o n of patients discharged Services.  from the Institutions of the Mental Health  I t i s my opinion that such interdepartmental ex-  ploration of r e s p o n s i b i l i t i e s and the formation  of p o l i c y II  regarding  these r e s p o n s i b i l i t i e s can no longer be postponed.  Some of the situations r e f e r r e d to as being i n need of c l a r i f i c a t i o n at that time concerned, residence  require-  ments and the objections on the part of at least one Social 1. Hospital Memo, May 8,  19^7.  1  -  Assistance  Administrator  of  the  to  individuals  patient  ity  was  Another  unable  concerned patients  who  charged up  itself  cost  main  from  with  to  the  of  area  not  that the  social  assistance  of the  City  needs  home c a r e ,  such  of  who  service which  for d e l i n e a t i o n of  adequacy  to  the  Administrators  Proposal It  was  put  forth  the  Provincial  of  The  but  Director  expressed  hospital  support  community  manage t h e i r  the  the  local  for at  the  of aged  was  unable  to  the  municipal-  without  supervision  s t i l l  and  regarding  affairs  adequate  of  carrying  of Welfare  concern own  and  responsibility  and  Social patients  who  were  planning  or  dis-  follow-  this  Mental  Social  of highest  posed  plan  was  co-ordinate  time  to  that  that  Health  Welfare  patient  with  of  and  their  families,  pre-admission  but  to  mentally  Welfare  psychiatric Services  incidence.  both  not  Social  be  social  The  patients with  health and  only  retarded  workers to  offices  purpose  of  aftercare services to  well.  to  the  those  this  services  from  work  in  psychiatric  and. w e l f a r e  in relation as  Administrators  appointed  Branch d i s t r i c t  supervise  provision  the  Districting  suggestion  areas  and  boarding  residuals.  unable  was  percent  service. 3.  in  and  discharged  were  administering  fifty  subsidize.  other  psychiatric Service  to  handling  problem concerned  prohibitive  The  to  area  whose r e s i d e n c e  for nursing  the  -  i n an  patients discharged  Vancouver.  meet  17  pro-  residual in  the  patients  mentally  i l l ,  A g a i n i t was  18  -  through the e f f o r t s of Miss  Carroll,  who  met w i t h l o c a l Welfare A d m i n i s t r a t o r s , t h a t i n i t i a l e x p l o r a t i o n and f o r m u l a t i o n was  undertaken  f o r implementation  f o r e g o i n g p r o p o s a l r e : d i s t r i c t i n g of p s y c h i a t r i c workers from the Mental H e a l t h S e r v i c e i n S o c i a l O f f i c e s on a p a r t - t i m e b a s i s to supervise and more complicated and d i f f i c u l t c a s e s .  While  o f the  social Welfare  follow-up the the P r o v i n c i a l  Government p r o b a b l y did. see the need a t t h i s p o i n t f o r such a p l a n , there were no funds forthcoming t o f i n a n c e the f o u r a d d i t i o n a l s o c i a l workers r e q u i r e d to c a r r y i t out. If-. F i r s t Attempted A f t e r c a r e Program In the f o l l o w i n g year o f 1959, attempt  was  a not too. s u c c e s s f u l  made to put the i n - h o s p i t a l w a r d - o r i e n t e d  social  worker back i n t o the community w i t h the aim i n mind of p r o v i d i n g more and b e t t e r follow-up care to p a t i e n t s i n the community.  An o l d house was  purchased  f o r the experiment  in  a s e c t i o n of Vancouver where i t was hoped p a t i e n t s c o u l d come f o r more a c t i v e f o l l o w - u p s e r v i c e w i t h scheduled o f f i c e home v i s i t s , resources.  and  c o l l a t e r a l c o n s u l t a t i o n , and development of While  some good work was  done i n the area o f  boarding homes, and i n the area of communication w i t h the g e n e r a l p r a c t i t i o n e r s , p u b l i c h e a l t h nurses, and community agencies, a number of f a c t o r s m i t i g a t e d a g a i n s t the of t h i s f i r s t a f t e r c a r e v e n t u r e . t i o n of the premises the main hub  success  Among these were the  loca-  i t s e l f which tended t o l i e away from  o f p o p u l a t i o n i n Vancouver; the  ineffectiveness  - 19 of one  c e n t r a l i z e d spot f o r a l l of the Vancouver area  as  compared w i t h the more d e s i r a b l e arrangement of v a r i o u s l o c a t e d , f o r example, as are  the P u b l i c H e a l t h U n i t s , i n a  number o f d i f f e r e n t d i s t r i c t s ; volved  units  the  'team' approach which i n -  the h o s p i t a l s o c i a l worker i n ward a c t i v i t y r a t h e r than  community s e r v i c e ; and. l a s t l y ,  d e s p i t e the t r e n d towards  t e n s i o n of the h o s p i t a l i n t o the  community, the p r e v a i l i n g  f e e l i n g on the p a r t of the h o s p i t a l medical s t a f f t h a t r e s p o n s i b i l i t y was i n t o h o s p i t a l and  ex-  their  to t r e a t the p a t i e n t when he f i r s t came t h a t , once the p a t i e n t was  r e s p o n s i b i l i t y became p r o p e r l y that of the In essence, the  discharged,  community.  improved treatment methods which  g r e a t l y shortened, the i n - h o s p i t a l phase, made i t i n c r e a s i n g l y difficult  to draw a sharp l i n e o f d i s t i n c t i o n between what  a p s y c h i a t r i c problem and what, a s o c i a l problem.  was  More than  ever, the need f o r extending treatment as a continuum from h o s p i t a l to community became apparent. Health  Centre opened i n 1955,  i t was  When the f i r s t  hoped t h a t the  Mental  Adult  C l i n i c c o u l d be u t i l i z e d as an A f t e r Care Centre f o r p a t i e n t s from the P r o v i n c i a l Mental H o s p i t a l and as the y e a r s r o l l e d by up t o 1961, Mental H e a l t h different.  Crease C l i n i c ,  i t became evident t h a t  Centre viewed t h e i r r o l e as  T h e i r s was  to be a few  but the  something q u i t e  case-intensive  therapy  approach. 5.  E s t a b l i s h m e n t o f A f t e r Care C l i n i c So  i t was,  that on December lj,, 1961,  The A f t e r Care  - 20 C l i n i c o f the P r o v i n c i a l Mental H o s p i t a l and Crease  C l i n i c was  opened f o r the purpose o f g i v i n g a follow-up s e r v i c e t o exp a t i e n t s o f the h o s p i t a l who were l i v i n g i n the community. 6. General  Policy  The g e n e r a l g o a l o f the u n i t was simply, t o m a i n t a i n p a t i e n t s out o f h o s p i t a l and. i n the community f u n c t i o n i n g up to t h e i r c a p a b i l i t i e s .  T h i s would, suggest a f a i r l y e x t e n s i v e  s e r v i c e but l i k e many g e n e r a l statements out much i s l e f t  t h a t are not s p e l l e d  t o the i m a g i n a t i o n o f t h e r e a d e r .  The expecta-  t i o n s o f the a f t e r c a r e p r o j e c t , however, were s p e l l e d out as follows: (a) Admissions  t o the A f t e r Care U n i t w i l l  likely  be upwards o f f i v e hundred p a t i e n t s per y e a r . (b) Shortening o f i n - p a t i e n t h o s p i t a l i z a t i o n . (c) A decrease  i n i n - p a t i e n t re-admission r a t e s  f o r the Crease  c  iinic  and P r o v i n c i a l  Mental  Hospital. (d) A r e d u c t i o n o f s o c i a l t e n s i o n s of p a t i e n t s i n the community. (e) B e t t e r adjustment  o f p a t i e n t s i n t h e community 1  s o c i a l l y , e c o n o m i c a l l y and o c c u p a t i o n a l l y . R e s u l t s o f a f t e r c a r e i n other areas o f the c o u n t r y showed: (a) Reduction o f re-admission r a t e s by o n e - h a l f . (b) Reduction  of duration o f h o s p i t a l stay a f t e r  re-admission. 1. H o s p i t a l Memo, December, I960  - 21  (c) The  -  c o s t o f a f t e r c a r e i s approximately 1  t e n t h t h a t of i n - p a t i e n t The  services.  d e c i s i o n t o e s t a b l i s h an A f t e r Care C l i n i c  p r o v i s i o n o f follow-up care t o the m e n t a l l y i l l ,  as  t r a c e d to a change i n a t t i t u d e o f a  for  afore-  mentioned i n an e a r l i e r s e c t i o n on g e n e r a l a f t e r c a r e ment, can be  one  develop-  thera-  p e u t i c a l l y h o p e f u l s o r t on the p a r t of the p r o f e s s i o n a l within  the h o s p i t a l .  The  growth i n emphasis on  care f o r the m e n t a l l y i l l ,  staff  community  p l u s the awareness o f the  harmful  e f f e c t s o f prolonged i n s t i t u t i o n a l care, were strong  factors  as w e l l i n the  itself,  decision.  a more e n l i g h t e n e d  A l s o , w i t h i n the community  p u b l i c and  professional  opinion  towards  the e s t a b l i s h m e n t o f such a s e r v i c e added p r e s s u r e from outside o f the h o s p i t a l . f a c t o r s such as the p a r t l y by  A d d i t i o n a l l y , there were c o n c r e t e  demand f o r h o s p i t a l beds o c c a s s i o n e d  the l e s s e n i n g  owing to b e t t e r  o f stigma and  f e a r of h o s p i t a l i z a t i o n  community understanding o f mental i l l n e s s ,  p a r t l y , t o shortened h o s p i t a l i z a t i o n s , and. p a r t l y , to h i g h admission and  re-admission r a t e f o r p a t i e n t s  the  discharged.  i to the community, many o f whom were s t i l l c a r r y i n g able  psychiatric residual.  A c t i v a t i o n of long term  and. subsequent discharge o f these p a t i e n t s  Ibid.  Finally,  the knowledge t h a t between seventy  e i g h t y per cent of the d i s c h a r g e d p a t i e n t s 1.  patients  to community aug-  mented the need i n the area f o r community c a r e . remaining f a c t o r was  consider-  a  and  l i v e d i n areas  22 -  -  t h a t were a c c e s s i b l e t o the A f t e r Care C l i n i c , and that o f t h i s group o f p a t i e n t s , a t l e a s t one i n f o u r r e q u i r i n g follow-up care would not r e c e i v e The  s e r v i c e from other p r o f e s s i o n a l  facilities.  procedure o f the A f t e r Care C l i n i c e v o l v e d i n what  seemed a f u n c t i o n a l l y p r a c t i c a l s e r v i c e o p e r a t i o n .  The s t a f f  comprised one f u l l time s e n i o r p s y c h i a t r i s t w i t h d i r e c t bility  t o the H o s p i t a l C l i n i c a l D i r e c t o r , and one f u l l  s o c i a l worker.  responsitime  T h i s team together w i t h a nurse a t t a c h e d  C l i n i c , handled the main o p e r a t i o n  o f A f t e r Care.  t o the  Additional  v i s i t i n g teams o f r e s i d e n t d o c t o r s and s o c i a l workers from h o s p i t a l provided  a visiting  s e r v i c e on a h a l f day per week  b a s i s and had r e s p o n s i b i l i t y f o r e x - p a t i e n t s their particular hospital  the  discharged  from  area.  In the b a s i c p o l i c y statement, two s e r v i c e s a v a i l a b l e i n the a f t e r c a r e program were d e l i n e a t e d as f o l l o w s : (a) A s u s t a i n i n g minimal type s e r v i c e w i t h p r o v i s i o n o f drugs which would a l s o o f f e r l i m i t e d c o n s u l t a t i v e advice f e s s i o n a l groups c a r i n g f o r  t o other p r o discharged  patients. (b) A more i n t e n s i v e s e r v i c e p r o v i d i n g  "supportive"  i n d i v i d u a l , group psychotherapy, s o c i a l a c t i v ities,  e t c e t r a , would, be p r o v i d e d  by the  1  Mental H e a l t h Centre, Burnaby. It  i s not t h e purpose o f t h i s t h e s i s t o examine m i n u t e l y  the o r g a n i z a t i o n a l problems o f the A f t e r Care C l i n i c . 1.  H o s p i t a l Memo, December, I 9 6 0 .  Such  - 23 problems as s t a f f or l i n e a d m i n i s t r a t i o n , involvement s t a f f i n the a f t e r c a r e program, r e s i g n a t i o n s of s t a f f , r e l i e f , adequate f a c i l i t i e s , care program development.  a l l were present  summer  i n the  after--  S u f f i c e to say t h a t the A f t e r Care  C l i n i c which commenced o p e r a t i o n s o f a two  of  December 1961,  operated  out  s t o r e y house l o c a t e d i n p r o x i m i t y t o downtown Van-  couver, was  compelled w i t h i n two  years  to r e l o c a t e because  o f the r a p i d i n c r e a s e i n the a f t e r c a r e p a t i e n t group whose numbers from A p r i l 1962 hundred and  to ^ a r c h 1963,  had. jumped from f o u r  s i x to e i g h t hundred and f o u r t e e n .  As  a measure  of expediency t o o f f s e t the overcrowding, o f f i c e  space f o r  continued  r e n t e d from  o p e r a t i o n o f the A f t e r Care C l i n i c was  the Burnaby ^ e n t a l H e a l t h new  quarters  Centre and  i n A p r i l o f 196k.  operations  Despite  the  moved i n t o the  somewhat i n a c c e s s -  i b l e l o c a t i o n f o r many p a t i e n t s , a f t e r c a r e o p e r a t i o n s and  up  to  i n c l u d i n g the p e r i o d i n which t h i s t h e s i s study i s being  done, have remained, as d e s c r i b e d i n r e g a r d t o l o c a t i o n , f a c i l ities,  s t a f f i n g , p o l i c y , procedure, and g e n e r a l g o a l .  It  should be mentioned i n c o n c l u s i o n , t h a t a s i n c e r e e f f o r t  on  the p a r t o f the Deputy D i r e c t o r of Mental H e a l t h  Services  towards c o - o r d i n a t i n g the A f t e r Care C l i n i c w i t h  the Vancouver  General H o s p i t a l , the other main community p s y c h i a t r i c r e source, was  not f r u i t f u l — b u t  does r e f l e c t the impasse  insurmountable problems t h a t at the moment e x i s t extending  i n terms o f  and, c o - o r d i n a t i n g the a f t e r c a r e s e r v i c e w i t h  c i t y h e a l t h and w e l f a r e  services.  and  other  - 2k T h i s concludes Chapter I o f t h i s T h e s i s .  In t h i s  chapter, the w r i t e r s have attempted t o d e s c r i b e the main trends i n g e n e r a l a f t e r c a r e development, ence t o the development  with specific  refer-  o f the A f t e r Care C l i n i c , Burnaby.  Chapter I I o f the Thesis w i l l concern i t s e l f w i t h a review of the l i t e r a t u r e  on a f t e r c a r e .  2  CHAPTER REVIEW OP A.  LITERATURE  Introduction Whenever a p r o b l e m i s t a k e n u n d e r  able  t o examine e x p e r i e n c e  viding  adequate a f t e r c a r e  C o l u m b i a by  any  means.  each year, approximately mental h o s p i t a l s . ment o u t s i d e  the  services  The  Many a r e  patient  i s t o c o n t i n u e any he  The  trend  community has  the  scarce  usual  difficulties  there  are  categories,  from  if a  with a continuity  of the  in obtaining by  the the  Also,  patient  i n turn,  of  to  and are  Besides actual  the  mapy still the  data,  complexity  when t h e  makes c o m p a r a b l e  of  the  c o v e r s a w i d e e x t r e m e o f a g e s and  this,  his  community.  However, f o l l o w - u p s t u d i e s  created  and  g a i n s made d u r i n g  f o r some y e a r s now  mental s t a t e .  Canada  improve-  r e l a t i o n s h i p s , environmental changes,  involved  British In  shown t h a t  in psychiatric literature.  a s s o c i a t i o n of time and of p a t i e n t s  to  pro-  percentage relapse  quick return  involved  of  discharged  h o s p i t a l i n t o the  further d i f f i c u l t i e s  interpersonal  nostic  provided  been e s t a b l i s h e d  p r o b l e m s h a v e emerged. relatively  a large  therapeutic  from the  of  unique  to m a i n t a i n t h e i r  E x p e r i e n c e has  must be  services, extending  i s not  question  persons are  able  h o s p i t a l but  rehospitalized.  The  problem i s world wide.  3 7 , 0 0 0  must be  hospitalization,  elsewhere.  study i t i s d e s i r -  group diag-  statistics  - 26 -  from one group o f p a t i e n t s to another sub-group o f q u e s t i o n able  validity. However, there are t h r e e a v a i l a b l e  s t u d i e s t h a t are  a p p r o p r i a t e f o r our purposes:1. F i v e State S t u d y 2. Minnesota Follow-up Study 1  -  3. Mental H e a l t h Survey of Los Angeles CountyThe f i r s t  5  two s t u d i e s were c o n c e i v e d to attempt t o  e v a l u a t e the e f f e c t i v e n e s s o f v a r i o u s a f t e r c a r e programs,  and  the c o n c l u s i o n s of these s t u d i e s a r e o f s i g n i f i c a n c e t o us i n our-study.  The t h i r d , the Los Angeles C u n t y Study, w h i l e G  p r i m a r i l y an i n v e n t o r y o f the mental h e a l t h r e s o u r c e s o f that County and suggestions f o r f u t u r e p l a n n i n g , c o n t a i n s one  sec-  t i o n extremely v a l u a b l e f o r t h i s p r e s e n t study, namely, the a r e a of unmet needs of former p a t i e n t s of mental h o s p i t a l s . Due t o l i m i t a t i o n s o f time and i n f o r m a t i o n  available  f o r making an i n t e n s i v e review, the w r i t e r s r e s t r i c t e d thems e l v e s to o f f e r i n g a b r i e f a p p r a i s a l o f the s a l i e n t  findings  of the three above-noted  findings  s t u d i e s and any summarized  by a u t h o r i t i e s of a f t e r c a r e programs this  that are a p p r o p r i a t e t o  thesis.  1. F r e e , Spencer M. and Dodd'/ David F. A f t e r c a r e f o r D i s charged. Mental P a t i e n t s . P h i l a d e l p h i a , Smith K l i n e & French L a b o r a t o r i e s , 1961. ~~ . 2. Minnesota Department of P u b l i c W e l f a r e . Follow-Up Study: F i n a l Report. Nov. 19.61.  Minnesota  3. C a l i f o r n i a Department of Mental Hygiene. Mental H e a l t h Survey of Los Angeles County. Los Angeles, C a l i f o r n i a , I960.  -  27  -  B. F i v e S t a t e Study and M i n n e s o t a Follow-Up  Study  1. Purpose and C h a r a c t e r i s t i c s o f t h e S t u d i e s I n 1959,  f i v e s t a t e s decided to p a r t i c i p a t e i n a  co-operative study of i n t e n s i v e follow-up care, or " a f t e r c a r e " , o f discharged, mental p a t i e n t s , t o determine whether i t i s m e d i c a l l y and e c o n o m i c a l l y sound. than 600 p a t i e n t s , was conducted  The s t u d y , i n v o l v i n g more i n Colorado,  M i c h i g a n , P e n n s y l v a n i a and V i r g i n i a . p a n t s were a b l e t o d i s c u s s t h e i r  I n May  Kentucky,  i960  the p a r t i c i -  findings.  There were c o n s i d e r a b l e d i s s i m i l a r i t i e s b o t h o f a g e o g r a p h i c a l and o r g a n i z a t i o n a l n a t u r e i n the a f t e r c a r e p r o grams o f the f i v e s t a t e s .  I t i s i n t e r e s t i n g to look a t these  d i f f e r e n c e s t o see how d i f f e r e n t programs e v o l v e when d i f f e r ent c i r c u m s t a n c e s p r e v a i l and d i f f e r e n t f a c i l i t i e s  exist.  I n C o l o r a d o t h e s t u d y was conducted, i n a G e n e r a l H o s p i t a l w i t h p a t i e n t s coming from the s t a t e mental 110 m i l e s away.  hospital  The program, s e t up by the p s y c h i a t r i c s e r -  v i c e o f t h e C i t y and County o f Denver, operated, i n d e p e n d e n t l y o f the s t a t e h o s p i t a l .  I t i n c l u d e d , a s i z a b l e number o f a l c o -  h o l i c s , a group o f p a t i e n t s excluded, from s t u d i e s i n t h e o t h e r four states. I n P e n n s y l v a n i a , t h e s t u d y was conducted, i n the p s y c h i a t r i c u n i t o f a l a r g e urban g e n e r a l h o s p i t a l . p a t i e n t s of t h i s u n i t were g i v e n s h o r t term i n t e n s i v e and most a d m i s s i o n s were v o l u n t a r y .  The i n therapy  A f t e r c a r e i n c l u d e d home  v i s i t s and r e p r e s e n t e d c l o s e f o l l o w - u p o u t p a t i e n t t r e a t m e n t  - 28 o f p a t i e n t s who  had  been i n the  hospital.  Kentucky, whose program encompassed a r u r a l populat i o n , u t i l i z e d t r a v e l l i n g c l i n i c s and hfO-$0 m i l e s f o r treatment.  the p a t i e n t s t r a v e l l e d .  A community a f t e r c a r e program  been i n i t i a t e d a t a s t a t e h o s p i t a l i n 1957  whereby a t r a v e l l i n g  p s y c h i a t r i c team h e l d monthly c l i n i c s i n the r u r a l The  study program was  integrated  had  counties.  with t h i s program.  M i c h i g a n , w i t h i t s s t a t e h o s p i t a l l o c a t e d l|5 m i l e s from D e t r o i t , served the m e t r o p o l i t a n area of t h i s c i t y . a f t e r c a r e program had was  set up  the  out-patient  e x i s t e d p r i o r t o the  on the b a s i s  of a monthly v i s i t by  c l i n i c a t the  functioning  hospital.  The  the p a t i e n t  a f t e r c a r e program  the  to  was  i n community c l i n i c s operated by the  A s t a t e h o s p i t a l team p a i d weekly v i s i t s to  c l i n i c s and  program  state h o s p i t a l .  In V i r g i n i a , a w e l l - o r g a n i z e d already  study.  No  study program was  incorporated,  state  the  i n t o the  exist-  i n g program. The Up  second study being examined, The Minnesota F o l l o w -  Study, was  c a r r i e d out by p r o f e s s i o n a l p e r s o n n e l of a  s t a t e mental h o s p i t a l from November The  1958  through January  f i n d i n g s were p r e s e n t e d at conferences i n August  March 1961.  The  p a t i e n t s , was  study, concerning 205  were:  and  former p s y c h i a t r i c  c o n c e i v e d to determine whether c e r t a i n f a c t o r s  would s i g n i f i c a n t l y a f f e c t the patient's  i960  i960.  q u a l i t y and  p o s t - d i s c h a r g e adjustment.  duration  of a  Such f a c t o r s c o n s i d e r e d  -  29  -  1 . a p e r i o d o f s p e c i a l p l a n n i n g f o r the p a t i e n t ' s d i s c h a r g e begun a t the time o f h i s a d m i s s i o n .  The  2.  i n t e n s i v e e f f o r t d i r e c t e d at m o b i l i z i n g exi s t i n g community t r e a t m e n t , c o u n s e l l i n g , casework, r e c r e a t i o n a l , j o b placement and o t h e r r e h a b i l i t a t i o n f a c i l i t i e s f o r use by the r e l e a s e d mental p a t i e n t .  3.  pre-discharge planning i n combination w i t h the m o b i l i z a t i o n o f e x i s t i n g community rehabilitation services.  "extra" pre-discharge planning  and  a f t e r c a r e were t o  p r o v i d e d by i n t e r d i s c i p l i n a r y teams l o c a t e d i n the h o s p i t a l and  i n the community.  Follow-Up Study was t o r s t h a t could, be  state  A second purpose of  the  t o attempt t o determine some of the shown t o be r e l a t e d t o the  be  fac-  post-hospital  adjustment of the s t a t e h o s p i t a l p a t i e n t s . Approximately two-thirds  o f the sample o f  205>  patients  l i v e d , i n urban a r e a s , the r e s t i n r u r a l communities and  on  i s o l a t e d farms. Both the F i v e S t a t e volved  two  Study and. the M i n n e s o t a Study i n -  groups o f p a t i e n t s , a " c o n t r o l " group and an a f t e r -  c a r e group o f s i m i l a r p a t i e n t s who  actively participated in a  program s e t up t o more n e a r l y e x e m p l i f y each s t a t e ' s of i d e a l care f o r discharged p a t i e n t s .  The  version  former l a s t e d t e n  months and t h e l a t t e r , w i t h t h r e e community f o l l o w - u p  inter-  v i e w s , extended over a p e r i o d o f a p p r o x i m a t e l y s i x months. 2.  Findings (a) Use  of Drugs i n A f t e r c a r e  S i n c e t r a n q u i l i z i n g drugs f i r s t made t h e i r impact i n the t r e a t m e n t o f the m e n t a l l y i l l  i n the 1 9 5 0 ' 3 ,  there  has  -  3 0  -  been c o n t r o v e r s y as t o t h e i r importance i n h e l p i n g the p a t i e n t maintain  h i s adjustment o u t s i d e o f the h o s p i t a l .  B o t h the  F i v e State Study and Minnesota Follow-Up Study c o n t a i n expressions  o f opinions  pharmaceuticals  concerning  the importance o f psycho-  in aftercare services.  The F i v e S t a t e  Study  came t o the c o n c l u s i o n that, on the one hand p a t i e n t s who continue  to take drugs w h i l e  to maintain  out o f the h o s p i t a l a r e more apt  t h e i r improvement than those  who do not but t h a t ,  on the other hand, twice as many p a t i e n t s i n the study group, r e g a r d l e s s of t a k i n g drugs or not, were a b l e t o maintain adjustment outside o f the h o s p i t a l . f o r e , although the m e n t a l l y  drugs a r e important  ill,  In t h e i r o p i n i o n , t h e r e i n the r e h a b i l i t a t i o n o f  the s o c i a l , t h e r a p e u t i c support  provided  by p s y c h i a t r i s t s and s o c i a l s e r v i c e workers i s much more e f f e c t i v e than drugs a l o n e . c l u s i v e evidence  In the Minnesota Study, no con-  could, be found t h a t p a t i e n t s remaining  on a  t r a n q u i l i z i n g drug regime d i d any " b e t t e r " than p a t i e n t s who d i d not take drugs; there was no s i g n i f i c a n t d i f f e r e n c e i n the ^ h o s p i t a l i z a t i o n r a t e , nor was there any s i g n i f i c a n t ence i n t h e i r f u n c t i o n i n g i n the community.  differ-  The r e s e a r c h e r s  came t o the t e n t a t i v e c o n c l u s i o n that t r a n q u i l i z e r s might " h e l p " the p a t i e n t i n the h o s p i t a l ,  speed h i s d i s c h a r g e , but  that a f t e r d i s c h a r g e , p s y c h o l o g i c a l and s o c i e t a l  rehabilita-  t i o n a p p a r e n t l y p l a y a more s i g n i f i c a n t r o l e than p u r e l y medical r e h a b i l i t a t i o n  i n h i s recovery.  - 31  -  (b) R e l a t i v e Costs of H o s p i t a l Care and One t i c u l a r l y one  Aftercare  very important a s p e c t of any program, p a r -  under Government a u s p i c e s ,  and  even more so i n  the mental h e a l t h f i e l d which more o f t e n than not has p r i o r i t y regarding  s e r v i c e s and  f a c i l i t i e s , i s cost.  low The  low  c o s t o f a f t e r c a r e s e r v i c e s as compared to h o s p i t a l i z a t i o n i s one  o f the most s i g n i f i c a n t f e a t u r e s  about i t . A l t h o u g h  f i g u r e s were available from the Minnesota study, we assume t h a t the ones from the F i v e State  might  Study w i t h t h e i r  extremely wide v a r i e t y of s e r v i c e s and. f a c i l i t i e s are The  p a r t i c i p a t i n g s t a t e s o f the F i v e State  that c o s t o f a f t e r c a r e was  no  typical.  Study concluded  services f o r discharged  mental p a t i e n t s  about one-tenth o f the h o s p i t a l r a t e s . Such f i g u r e s do not take i n t o account the  the s t a t e by i n d i v i d u a l s remaining e c o n o m i c a l l y r a t h e r t h a n being h o s p i t a l i z e d . human d i g n i t y t o the  A l s o there  i n d i v i d u a l who  savings t o  self-sufficient  are the gains i n  i s able t o remain  self-  supporting. (c) Problems Encountered. V a r i o u s problems arose i n the d i f f e r e n t types of a f t e r c a r e programs. In Colorado, the p s y c h i a t r i c s e r v i c e of General H o s p i t a l where the a f t e r c a r e program was found t h a t the  the  conducted  l a c k of s u f f i c i e n t data sent from the  State  Mental H o s p i t a l hampered t h e i r a b i l i t y to p l a n  intelligently  for  some of  the p a t i e n t s .  I t was  difficult  to contact  the  - 32 p a t i e n t s who hospital.  had moved from the addresses given by  Further,  the  there were some problems i n working w i t h  the l o c a l agencies i n t h a t the l a t t e r d i d not have knowledge o f mental i l l n e s s .  sufficient  Although Kentucky had no problems  w i t h agencies as none e x i s t e d , they d i d have d i f f i c u l t y i n g e t t i n g the p a t i e n t s t o the c l i n i c s as the d i s t a n c e was  time  consuming and  dis-  tance was  c o s t l y t o the.m.  a big obstacle  M i c h i g a n a l s o found t h a t  f o r p a t i e n t s and f u r t h e r , p a t i e n t s  were o f t e n r e l u c t a n t t o take advantage of the  services offered,  such as drugs without charge, monthly o u t p a t i e n t s e l l i n g , f a m i l y and  job problems, due  ^he Minnesota r e s e a r c h e r s  visits,  coun-  to f e a r o f r e h o s p i t a l i z a t i o n .  found t h a t the d e s i g n  r e s e a r c h which d i c t a t e d t h a t pre-discharge  of  the  and a f t e r c a r e be  t r e a t e d as d i s t i n c t and  d i f f e r e n t operations  constituted a  continuous d i f f i c u l t y .  They came to the c o n c l u s i o n that  the  most e f f e c t i v e r e h a b i l i t a t i o n of the mental p a t i e n t c o u l d  be  brought about by  the  s t a f f which, even i f s m a l l , could bridge  gaps between the h o s p i t a l and. community, between p a t i e n t f a m i l y , and  between p a t i e n t and  and  agency.  (d) S i g n i f i c a n t F a c t o r s We  were impressed by the  comments made by the r e s e a r c h e r s f o r i n s t a n c e , the  s i g n i f i c a n c e of s e v e r a l  of the  studies.  They noted  i n a b i l i t y of community agencies t o  s e r v i c e s needed by the m e n t a l l y  ill,  the  f a c t that  p a t i e n t s have g i v e n up h e l p i n g themselves by a s k i n g I t was  noted that the g r e a t m a j o r i t y  of d i s c h a r g e d  provide  often for help. patients  - 33 do have needs although they may not be able t o express them or b r i n g them t o the a t t e n t i o n o f o t h e r s . One o f the almost u n i v e r s a l needs of d i s c h a r g e d p a t i e n t s was found t o be the need t o "do something."  mental  Pew of  the p a t i e n t s o f the Minnesota Study found employment, p a r t l y because of t h e employment s i t u a t i o n .  But q u i t e a few o f them  d i d not even have chores, or s m a l l r e s p o n s i b i l i t i e s i n the home.  The r e s e a r c h e r s  noted that when they were g i v e n some  r e s p o n s i b i l i t y , i t g e n e r a l l y had a v e r y good e f f e c t on t h e i r wellbeing.  Their f e e l i n g was t h a t undoubtedly something c o u l d  be done i n the community to help t h i s group o f people develop i n t e r e s t i n g and meaningful l e i s u r e time For  activities.  the purposes o f t h i s study, we b e l i e v e i t i s  extremely important t h a t so o f t e n i n the g e n e r a l by the r e s e a r c h e r s appears.  comments made  of the two s t u d i e s , the word "community"  The concept o f community involvement i s c a r r i e d a  step f u r t h e r by the suggestion  o f one of the conferees o f the  F i v e State Study t h a t the community should, r e a l l y assume r e s p o n s i b i l i t i e s f o r the c o n t i n u i t y o f treatment o f p s y c h i a t r i c p a t i e n t to a much g r e a t e r e x t e n t the community-based a f t e r c a r e  arid t h a t the r e a l s o l u t i o n i s  clinic.  I t i s q u i t e s u r p r i s i n g t o l e a r n that the f i n d i n g s of d i f f e r e n t s t a t e s w i t h q u i t e d i s s i m i l a r a f t e r c a r e programs tend to be so s i m i l a r . Dr. James H a r r i s of P e n n s y l v a n i a observed We f i n d t h a t our g e n e r a l r e s u l t s p r e t t y much conform to the r e s u l t s of a l l the  - 31* d i f f e r e n t s t a t e s i n the p r o j e c t . Regardl e s s of the f a c t that we give s h o r t - t e r m i n t e n s i v e treatment, l i v e i n an urban community, that we have e a s i l y a v a i l a b l e o u t p a t i e n t f a c i l i t i e s , and so f o r t h , our r e s u l t s are q u i t e s i m i l a r t o those o b t a i n e d i n other s t a t e s . Dr. Punkhouser, commenting on the V i r g i n i a  findings  stated. . . . our a f t e r - c a r e program was a p p a r e n t l y b e t t e r o r g a n i z e d than some, and y e t we come up w i t h the same s o r t o f f i g u r e as the r e s t of the s t a t e s . 2  (e) Major  Conclusions  The major c o n c l u s i o n s of the F i v e S t a t e Study were summarized: 1.  Organized follow-up c a r e of d i s c h a r g e d mental p a t i e n t s can cut readmission r a t e s by about h a l f . As a c o r o l l a r y , i t i s much l e s s c o s t l y to m a i n t a i n a p a t i e n t i n the community, through a f t e r c a r e , than i t i s to maintain him i n the h o s p i t a l .  2. No two s t a t e s , same s i t u a t i o n so there i s no be f o l l o w e d i n  or even h o s p i t a l s , have the r e l a t i v e t o follow-up c a r e , standard procedure that can s e t t i n g up such programs.  3 . An a f t e r c a r e program cannot e x i s t by i t s e l f , but must be c l o s e l y i n t e g r a t e d w i t h the community and community r e s o u r c e s . ij,.'Such seemingly mundane problems as t r a n s p o r t a t i o n and communication can be of major importance t o an a f t e r c a r e program. 5". P a t i e n t s who continue to take psychop h a r m a c e u t i c a l s while out of the h o s p i t a l are more apt t o m a i n t a i n t h e i r improvement than those who r e f u s e them.  1.  Free and Dodd, op. c i t . . p. 5>.  2. Loc. c i t .  - 35 6.  Patient cooperation i s c r u c i a l f o r a followup program. One source o f r e l u c t a n c e to cooperate appears to be f e a r that the p r o gram w i l l r e t u r n them to h o s p i t a l . Adequate o r i e n t a t i o n and p l a n n i n g w i t h p a t i e n t s and f a m i l y are o f utmost importance.1  The Minnesota Study a r r i v e d a t the f o l l o w i n g major conclusions: 1.  The data c o l l e c t e d i n the Study suggest t h a t the i n t r o d u c t i o n o f e x t r a p r e - d i s c h a r g e p l a n n i n g and e x t r a follow-up care are e f f e c t i v e i n i n c r e a s i n g the percentage of p a t i e n t s who a r e able to m a i n t a i n themselves o u t s i d e o f the h o s p i t a l . I t seems impossible, as y e t , to say whether such e x t r a s e r v i c e s may be most e f f e c t i v e l y a p p l i e d b e f o r e or a f t e r discharge.  2.  Data from the Study a l s o suggest t h a t r e h o s p i t a l i z a t i o n i s a f f e c t e d g r e a t l y by the t o l e r a n c e of deviance o f persons i n the p a t i e n t ' s immediate environment while a number of other f a c t o r s seem to have an e f f e c t on the q u a l i t y o f the p a t i e n t ' s p o s t - h o s p i t a l adjustment.  3.  For a s i z e a b l e group of p a t i e n t s (almost 1/3 o f the sample) placement i n a . n u r s i n g or f o s t e r home was s u c c e s s f u l , i n terms o f t h e i r b e i n g a b l e t o m a i n t a i n themselves i n the community.^  G. Mental H e a l t h Survey o f Los Angeles County 1.  Purpose o f the Study In A p r i l  I960  the t e x t of the Mental H e a l t h Survey o f  the Los Angeles County was p u b l i s h e d .  T h i s was a d e t a i l e d  i n v e n t o r y of the e x i s t i n g mental h e a l t h treatment r e s o u r c e s and. a l s o a s p e c i f i c b l u e p r i n t i n d i c a t i n g the l i n e s a l o n g  1.  I b i d . . p p . 5 . - 6.  2. Minnesota, op. c i t . ,  S e c t i o n F, p .  17.  36  -  which development and  -  community o r g a n i z a t i o n  s h o u l d proceed  i n the e f f o r t to meet the mental h e a l t h needs of i t s population. The  report  i s an extremely comprehensive survey f e l t  to be unique a t the t i m e .  A 3 noted e a r l i e r , the s e c t i o n  i s o f s i g n i f i c a n c e f o r our purposes i s the  one  concerning  unmet needs of former p a t i e n t s o f mental h o s p i t a l s . however, a b r i e f comment w i l l be made about the  the  First,  resources  t h a t are a v a i l a b l e t o former mental h o s p i t a l p a t i e n t s , as c l i n i c s , o u t p a t i e n t  that  such  services, r e h a b i l i t a t i o n services  and  facilities. 2. C l i n i c and These two the g e n e r a l themselves.  Outpatient  terms tend t o be used i n t e r c h a n g e a b l y  p u b l i c and  pay  and  The  by  o c c a s i o n a l l y by m e d i c a l i n s t i t u t i o n s  In the Los Angeles County area there  main types of c l i n i c s , public.  Services  are  three  the community, the p r o p r i e t o r y and  s e r v i c e of the community c l i n i c s i s f r e e or  the part  i s o r i e n t e d t o psychotherapy, group or i n d i v i d u a l ,  and would be  s i m i l a r t o t h a t g i v e n a t the Burnaby Mental  Health Center.  A r e l a t i v e l y small proportion  f e r r a l s are from i n p a t i e n t h o s p i t a l s e r v i c e s . c l i n i c s , p r i v a t e l y owned and referrals i n number.  of t h e i r r e The  proprietory  operated, charge f e e s , and t h e i r  from h o s p i t a l i n p a t i e n t s e r v i c e s are extremely T h e i r purpose and  v i c e s of some are  function vary widely.  The  small ser-  s i m i l a r t o community p s y c h i a t r i c c l i n c s  others are s p e c i f i c a l l y l i m i t e d to a c e r t a i n f u n c t i o n  only  and  - 37 auch as marriage c o u n s e l l i n g .  The  p u b l i c or o u t p a t i e n t  v i c e s are b e g i n n i n g to t r e a t more p a t i e n t s  r e f e r r e d from  h o s p i t a l s and. i t i s expected the numbers w i l l continue r i s e i n the pay.  No  future.  to  Pees are c o l l e c t e d from those able  information  i s a v a i l a b l e as t o the s e r v i c e  i s s i m i l a r to t h a t o f the community c l i n i c s and  to  offered  i n the p u b l i c c l i n i c s a l t h o u g h i t i s s t a t e d t h a t the  personnel  some p r o p r i e t o r y  c l i n i c s - p s y c h i a t r i s t s , c l i n i c a l psychologists, s o c i a l workers and  ser-  psychiatric  nurses.  Approximately 10 p e r c e n t o f the t o t a l number of p a t i e n t s who  attend  hospital inpatient  the above c l i n i c s are r e f e r r a l s from services.  As we  can  see,  the  services  they  o f f e r do not appear t o be designed t o meet the broad needs o f p a t i e n t s who  are  d i s c h a r g e d from mental h o s p i t a l s .  f i r s t chapter o f t h i s study, the  Prom the  services required  and  offered  by a f t e r c a r e s e r v i c e s would appear t o be broader, i . e . more i n the d i r e c t i o n o f r e h a b i l i t a t i o n . What would r e h a b i l i t a t i o n services consist 3.  of?  Interpretation  -  of R e h a b i l i t a t i o n  •. The  Services  .,  1  C a l i f o r n i a State Department o f Mental Hygiene  state that p s y c h i a t r i c r e h a b i l i t a t i o n c o n s i s t s of  services  p r o v i d e d under p s y c h i a t r i c d i r e c t i o n w i t h the major  and  primary i n t e n t o f such s e r v i c e s b e i n g t o r e s t o r e , e s t a b l i s h and/or m a i n t a i n an optimum l e v e l of s o c i a l , emotional, vocat i o n a l , and/or p h y s i c a l f u n c t i o n i n g  1.  C a l i f o r n i a , op.  c i t . , p.  253*  consistent  with  the  - 38 l i m i t a t i o n s imposed  by the sequelae or r e s i d u a l s o f mental  ill-  ness, mental r e t a r d a t i o n or emotional d i s o r d e r . P s y c h i a t r i c r e h a b i l i t a t i o n , under p s y c h i a t r i c t i o n may  p r o v i d e the f o l l o w i n g approaches: 2.  testing.  direc-  1. P s y c h o l o g i c a l  Supportive psychotherapy, s o c i a l  casework,  p a s t o r a l c o u n s e l l i n g , p s y c h o l o g i c a l c o u n s e l l i n g - group and 3«  i n d i v i d u a l , w i t h p a t i e n t and. w i t h p a t i e n t ' s f a m i l y . i c a l therapies.  l\»  educational t r a i n i n g . environment  C o r r e c t i v e therapy. 6.  S  o c  V o c a t i o n a l or  i x group a c t i v i t y . a  (social, vocational).  8.  Phys-  7.  Sheltered  Community p l a n n i n g ,  i n t e r p r e t a t i o n and. c o - o r d i n a t i o n o f r e h a b i l i t a t i o n needs.^" The Committee o f the Los Angeles Survey r e c o g n i z e d that agencies d i f f e r i n g w i d e l y i n s t r u c t u r e and purposes were r e n d e r i n g one or more r e h a b i l i t a t i o n s e r v i c e s s u c h as the ones noted, above, t o persons w i t h mental or s e r i o u s emotional d i s turbances.  They found t h a t they c o u l d c l a s s i f y the agencies  i n Los Angeles County  i n t o two main groups as f o l l o w s :  a. Primary Agencies - those whose t o t a l caseload, cons i s t s o f persons r e c o v e r i n g from p s y c h i a t r i c d i s o r d e r s such as (1) the h o s p i t a l s care),  (2)  (sometimes  o f f e r i n g day and n i g h t  outpatient psychiatric c l i n i c s  e x c l u s i v e l y treatment focussed),  (3)  ( a c t u a l l y almost  the Bureau o f S o c i a l Work  o f the State Department o f Mental Hygiene  ( f o s t e r home care  and, supervised, work placements are among the major and  hospital  functions)  (k) halfway houses and day c e n t e r s designed e x c l u s i v e l y 1. Ibid... p.  - 39 f o r the m e n t a l l y  ill.  b. Secondary Agencies - those whose c a s e l o a d some persons r e c o v e r i n g  from p s y c h i a t r i c d i s o r d e r s .  included This  c a t e g o r y i n c l u d e s the agencies whose primary f u n c t i o n i s i n an a r e a other than r e h a b i l i t a t i o n and  a l s o the  rehabilita-  t i o n agencies s e r v i n g c h i e f l y persons with other p s y c h i a t r i c ) types o f d i s a b i l i t i e s . Bureau o f P u b l i c A s s i s t a n c e , t i o n Service  o f the  (2)  and  (6)  (1)  It included Vocational  The  Rehabilita-  State Department of E d u c a t i o n , (3)  t e r e d workshops, (1+) f a m i l i e s and the s c h o o l ,  The  (non-  shel-  c h i l d r e n ' s agencies, (5>)  group work and r e c r e a t i o n a g e n c i e s .  I t i s most s i g n i f i c a n t t o note t h a t , as i n the S t a t e Study and the Minnesota o l l o w - U p Study, two F  Five  types o f  r e s o u r c e s are f e l t t o be r e q u i r e d i n an a f t e r c a r e program: those devoted t o the  follow-up p s y c h i a t r i c treatment o f mental  or emotional d i s o r d e r s and nomic, and  those devoted to the  social,  eco-  v o c a t i o n a l r e h a b i l i t a t i o n of p a t i e n t s .  C e r t a i n l y the  s e r v i c e s o f f e r e d by  are many and v a r i e d and  the above agencies  t h e r e would, supposedly be a v a s t  number o f r e s o u r c e s a v a i l a b l e to the former p s y c h i a t r i c patient. I|.  How  were the r e s o u r c e s meeting the needs?  Opinions on Unmet Needs f o r R e h a b i l i t a t i o n The  researchers  of the  unmet need f o r almost any  Survey r e c o g n i z e d  that  the  type of community s e r v i c e i s , f o r  a l l p r a c t i c a l purposes, unmeasureable. might be  Services  They b e l i e v e d i t  p o s s i b l e t o come c l o s e to an a c c u r a t e measurement  - ko i n the f i e l d of r e h a b i l i t a t i o n of t h e post h o s p i t a l mental p a t i e n t , i f every h o s p i t a l had adequate d i s c h a r g e p l a n n i n g , and i f i t c o u l d be determined  a t the p o i n t of d i s c h a r g e  the  s p e c i f i c community r e h a b i l i t a t i o n s e r v i c e s and f a c i l i t i e s p a t i e n t might r e q u i r e .  He might remain a s t a b i l i z e d  t i c f o r a w h i l e i f i t turned out he was f a c i l i t y and s e r v i c e along a planned p r o v i d e d he d i d not s u f f e r a r e l a p s e . would have been expressed,  a b l e t o use  the  statiseach  continuum and of course, At l e a s t h i s needs  " i t i s the unexpressed need,  still  u n a r t i c u l a t e d as demand, t h a t i s the unknown q u a n t i t y ; f o r i t there i s no r e a l i s t i c yardstick.""'" With the above i n mind, the survey r e s e a r c h e r s c i d e d on an i n t e r e s t i n g approach.  They f e l t  de-  i t would be most  u s e f u l t o c o n s u l t the experience c l o s e s t t o the problem of s e c u r i n g adequate r e h a b i l i t a t i o n r e s o u r c e s f o r t h e i r p a t i e n t s . The  o p i n i o n s o f a v a r i e t y o f p r o f e s s i o n s and  agencies d e a l i n g  every day w i t h the s e r i o u s l y e m o t i o n a l l y disturbed, or the m e n t a l l y i l l were t h e r e f o r e sought. (a). The M e d i c a l P r o f e s s i o n and Other P r i v a t e P r a c t i t i o n e r s i n the C e n t a l H e a l t h D i s c i p l i n e s . " Over 1^00 ists, ers  p r o f e s s i o n a l s , doctors, medical  special-  the p s y c h i a t r i s t s , the p s y c h o l o g i s t s , t h e s o c i a l work-  i n p r i v a t e p r a c t i c e , were c o n t a c t e d .  N i n e t y - t h r e e out o f  a hundred r e p o r t e d a shortage o f a l l k i n d s o f r e h a b i l i t a t i o n facilities  i n Los Angeles.  1. I b i d . , p. 299.  In answer to r e l a t e d  questions  - kl  -  concerning community p l a n n i n g f o r mental h e a l t h f o r r e c r e a t i o n a l and h o s p i t a l s , night  camping f a c i l i t i e s ,  hospitals,  the  needs, the  shortage o f  need  day  of f o s t e r homes f o r mental  p a t i e n t s , were a l l noted. (b) Selected. O u t p a t i e n t P s y c h i a t r i c C l i n i c s S t a f f s of such c l i n i c s are treatment r e s p o n s i b i l i t i e s r e q u i r e facilities  available Ten  facility,  to t h e i r  knowledge of r e h a b i l i t a t i o n  patients.  c l i n i c s , representative  were asked, w i t h r e s p e c t  h a b i l i t a t i o n such as s h e l t e r e d  administrator  d i d not  available.  the  There  find, i n short  supply.  State Department of  l a r g e s t s i n g l e agency i n Los Angeles d i r e c t -  l y concerned w i t h the r e h a b i l i t a t i o n of the m e n t a l l y working e n t i r e l y w i t h p a t i e n t s Bureau of S c i a l Work was 0  i t s 37  from the  requested to  caseworkers r e g a r d i n g the  t i o n and  was  or s e r v i c e which some  (c) Bureau of S o c i a l Work of the Mental Hygiene" As  of  employment or the h a l f w a y house  type o f r e h a b i l i t a t i v e f a c i l i t y  clinic  o f t h i s type  t o a s p e c i f i c type of r e -  to i n d i c a t e the degree to which i t was no  another group whose  facilities.  The  ill,  state hospital,  the  secure the o p i n i o n  of  a v a i l a b i l i t y of r e h a b i l i t a -  f o l l o w i n g are  the  findings:  1. The caseworkers reported. 2,296 unmet i n d i v i d u a l needs f o r r e h a b i l i t a t i o n s e r v i c e s , w i t h some p a t i e n t s needing more than one s e r v i c e . 2.  The l a r g e s t number of p a t i e n t s , I477, were d e s c r i b e d as i n need of s o c i a l or r e c r e a t i o n a l s e r v i c e s which would, normally be the r e s p o n s i b i l i t y of s o c i a l group work a g e n c i e s .  3.  -  Outpatient p s y c h i a t r i c s e r v i c e s were needed by 396 o f t h e i r p a t i e n t s to enable them t o remain i n the community ( v a r i o u s kinds of medical c a r e , f o r s u p e r v i s i n g p a t i e n t s u s i n g t r a n q u i l i z i n g drugs and f o r p r e s c r i p t i o n o f the drugs t h e m s e l v e s ) .  1*. Almost 8I4 p e r c e n t o f the casework s t a f f s t r e s s e d the need f o r community jobs, v o c a t i o n a l t r a i n i n g , s h e l t e r e d employment and s i m i l a r work focused s e r v i c e s . 5.  Almost I4O percent of the caseworkers s a i d t h e i r c l i e n t s stood i n need o f more casework s e r v i c e s .  6.  Over h a l f of the casework s t a f f i d e n t i f i e d p a t i e n t s (55) who needed f a m i l y care homes and an a d d i t i o n a l I4I p a t i e n t s were b e l i e v e d to be i n need o f the halfway house type o f c a r e .  7. More than a t h i r d o f t h e caseworkers emphasized the c u r r e n t need f o r day h o s p i t a l s and n i g h t h o s p i t a l s f o r those p a t i e n t s on leave i n the community. 8.  About a h a l f dozen of the bureau caseworkers o f f e r e d spontaneous comments about the great need to c o - o r d i n a t e community s e r v i c e s on b e h a l f o f the mentally i l l .  (d) Bureau o f P u b l i c A s s i s t a n c e I t was not f e a s i b l e to survey the e n t i r e  roster  of p u b l i c a s s i s t a n c e r e c i p i e n t s t o determine the number of diagnosed mental p a t i e n t s on the r o l l s who were c u r r e n t l y i n need o f r e h a b i l i t a t i o n s e r v i c e s .  In l i e u o f such an  overall  survey, the Bureau s e l e c t e d 20 experienced caseworkers whose background and t r a i n i n g q u a l i f i e d them to i d e n t i f y those i n need of such s e r v i c e s .  The caseworkers i d e n t i f i e d 229  i d u a l s as needing p s y c h i a t r i c r e h a b i l i t a t i o n s e r v i c e s .  indiv Of  these, J4I.5 percent had been former p a t i e n t s i n mental hospitals.  Close to o n e - t h i r d had been t r e a t e d i n c l i n i c s  - U3 or o u t p a t i e n t  departments of h o s p i t a l s and  the remainder,  28.8  p e r c e n t , had r e c e i v e d p s y c h i a t r i c treatment from other sources such as p r i v a t e p r a c t i t i o n e r s .  This d i s t r i b u t i o n p o i n t s  up  that the need f o r r e h a b i l i t a t i o n s e r v i c e s cannot be measured i n terms of the p o s t - h o s p i t a l p a t i e n t a l o n e . be more diagnosed and s e r v i c e s who  There may,  in fact,  t r e a t e d i n d i v i d u a l s needing r e h a b i l i t a t i o n  have never been i n h o s p i t a l s than there  are  post-  h o s p i t a l p a t i e n t s w i t h s i m i l a r needs. (e) V o c a t i o n a l R e h a b i l i t a t i o n The  opinions  Service  of s i x s e l e c t e d c o u n s e l l o r s were  r e q u e s t e d c o n c e r n i n g the unmet s e r v i c e needs o f 99 c l i e n t s were i n the process o f v o c a t i o n a l r e h a b i l i t a t i o n . The cases were d i s t r i b u t e d as  who  99  follows:  Status A (former p a t i e n t s of mental h o s p i t a l s ) . . . 17 Status B ( c l i n i c a l l y diagnosed but not h o s p i t a l i z e d ) . l\J S t a t u s C (judged t o be s e r i o u s l y d i s t u r b e d ) . . . . 35> The  six r e h a b i l i t a t i o n counsellors  i d e n t i f i e d kk d i f f e r e n t  c l i e n t s needing a t o t a l o f l k 5 r e h a b i l i t a t i o n s e r v i c e s , a v a i l a b l e e i t h e r through the V o c a t i o n a l or o u t s i d e  sources a t the  were i n need of two were r e c e i v i n g .  The  time o f the  Rehabilitation  study.  Several  unService  clients  or more k i n d s of s e r v i c e beyond those they unmet needs of the  17 former p a t i e n t s  mental h o s p i t a l s were those such as psychotherapy, work, maintenance f o r the c l i e n t  during  of  sheltered  t r a i n i n g , job  place-  ment, maintenance o f f a m i l y member(s) during program, r e h a b i l i t a t i o n transportation, occupational l i c e n s e , s o c i a l casework, and  t o o l s , equipment,  vocational training.  - kk 5.  F i n d i n g s o f the Survey 'The Survey r e s e a r c h e r s found that the supply of r e h a b i l -  itation facilities  f o r the m e n t a l l y i l l i n Los Angeles  i s not adequate and t h a t there i s not the systematic o r d i n a t i o n of e f f o r t s e s s e n t i a l to the e f f e c t i v e and use.  County  co-  distribution  More s p e c i f i c a l l y , t h e i r o p i n i o n s concerning  the  inadequacies were:1. Only one Agency, the Bureau of S o c i a l Work reaches any s u b s t a n t i a l number of p a t i e n t s once they come out o f h o s p i t a l and i t i s s e r i o u s l y hampered by the acute shortage of community f a c i l i t i e s i n every area of s e r v i c e and program e s s e n t i a l t o the achievement of i t s g o a l s . 2 . Evidence suggests that many people are d i s c h a r g e d by the h o s p i t a l s and other types of p s y c h i a t r i c i n s t i t u t i o n s , whose r e h a b i l i t a t i o n i s nobody's special responsibility. For most of these p a t i e n t s there i s no p l a n of follow-up c a r e . 3. F r e q u e n t l y the i n s t i t u t i o n s the p a t i e n t s l e a v e operate i n i s o l a t i o n from the community r e sources and make no e f f o r t t o connect the p a t i e n t w i t h the s e r v i c e s he needs. l | . There i s a c o n f u s i n g a r r a y of e x i s t i n g f a c i l i t i e s , most o f which are designed p r i m a r i l y f o r a c l i e n t e l e other than the m e n t a l l y i l l . Many of these agencies endeavor to serve some mental p a t i e n t s along w i t h t h e i r other c l i e n t s . The m a j o r i t y o f f e r only a p a r t o f the s e r v i c e r e q u i r e d f o r t o t a l r e h a b i l i t a t i o n of the p a t i e n t and do not have the necessary l i a s o n w i t h other agencies i n order to ensure t h a t the r e h a b i l i t a t i o n t a s k i s completed.1 D. Conclusions and I m p l i c a t i o n s From the three s t u d i e s surveyed  there are c e r t a i n  ings t h a t are p a r t i c u l a r l y s i g n i f i c a n t i n our study of the  1. I b i d . .  pp>.30l4 -305. ?  find-  -1+5  -  a f t e r c a r e s e r v i c e s o f f e r e d a t the Burnaby Mental H e a l t h  Centre.  Summarized v e r y b r i e f l y they a r e : 1.  Organized follow-up care o f d i s c h a r g e d mental p a t i e n t s can cut readmissions r a t e s by about h a l f .  2.  I t c o s t s about 1 / 1 0 o f the h o s p i t a l p e r diem r a t e to t r e a t the p a t i e n t out o f h o s p i t a l .  3.  The c o n t i n u i t y o f s e r v i c e s f o r the p a t i e n t from the h o s p i t a l to the community i s o f g r e a t importance .  h. A f t e r c a r e programs must be i n t e g r a t e d w i t h the community and community r e s o u r c e s . 5. Community r e s o u r c e s must be able t o provide s e r v i c e s needed by the m e n t a l l y i l l . They must, i n other words, have some f a m i l i a r i t y w i t h p s y c h i a t r i c i l l n e s s o r have adequate p s y c h i a t r i c c o n s u l t a tion . 6.  P a t i e n t c o o p e r a t i o n i s the crux o f the success o f any program. They must be thoroughly assured o f the g o a l s and the c o o p e r a t i o n o f t h e i r f a m i l i e s must be o b t a i n e d .  7. The a c t u a l value o f psychopharmaceuticals cannot be gauged. Although believed, t o be h e l p f u l i n m a i n t a i n i n g adjustment o u t s i d e o f t h e p s y c h i a t r i c h o s p i t a l , the p s y c h o l o g i c a l and s o c i e t a l r e h a b i l i t a t i o n a p p a r e n t l y p l a y the moat s i g n i f i c a n t roles. 8.  Everyday problems o f communication and t r a n s p o r t a t i o n have great e f f e c t on the success o f the programs.  9.  R e h a b i l i t a t i o n touches on a l l the important areaa o f the former p s y c h i a t r i c p a t i e n t ' s l i f e - p h y s i c a l , mental, emotional, economic, v o c a t i o n a l and. s o c i a l and t h e r e f o r e , r e q u i r e s a wide range o f s e r v i c e s to meet h i s needs adequately.  These s t u d i e s have been h e l p f u l t o us i n p l a n n i n g our approach to our own study o f the Burnaby A f t e r Care C l i n i c and have had some b e a r i n g on the methodology used i n the i n q u i r y .  CHAPTER 3 METHODOLOGY OP THE STUDY In t h i s chapter we w i l l o u t l i n e the s o c i a l work and r e s e a r c h problem.  We w i l l then d i s c u s s i n some d e t a i l the  r e s e a r c h instruments  and t h e i r use i n t h i s  study.  S o c i a l Work Problem In recent years there has been a growing t r e n d t o discharge mental p a t i e n t s a f t e r s h o r t p e r i o d s o f h o s p i t a l i z a tion.  As e l a b o r a t e d i n Chapter 1 t h i s t r e n d i s p a r t l y the  r e s u l t o f new developments i n medication mental i l l n e s s .  and new ideas about  There has been a growing r e c o g n i t i o n o f the  dangers o f i n s t i t u t i o n a l i z a t i o n and the need f o r the p a t i e n t to have s o c i a l r e l a t i o n s h i p s i n the community.  Consequently  there has been l e s s emphasis by h o s p i t a l s t a f f on c u s t o d i a l care and more emphasis on s h o r t term treatment.  The shortage  o f h o s p i t a l beds and t h e h i g h c o s t s o f h o s p i t a l treatment  also  encouraged s h o r t term treatment.and e a r l y d i s c h a r g e . However, w i t h e a r l i e r d i s c h a r g e , p a t i e n t s leave the h o s p i t a l w i t h many u n r e s o l v e d problems.  In order to keep  them i n the community and m a i n t a i n or improve t h e i r  social  f u n c t i o n i n g , c o n t i n u i n g s e r v i c e i s needed. As noted  i n the f i r s t  chapter there was some un-  w i l l i n g n e s s on the p a r t o f t h e Greater Vancouver community to accept  the d i s c h a r g e d p a t i e n t .  Many c i t i z e n s f e a r e d and  - 1*7 s t i g m a t i z e d the e x - p a t i e n t and s o c i a l agencies d i d not wish to p r o v i d e c o n t i n u i n g s e r v i c e because of l a c k o f money and experienced s t a f f .  R e c o g n i t i o n o f these problems l e d t o the  formation o f the f i r s t a f t e r c a r e c l i n i c A f t e r Care C l i n i c  i n Burnaby.  and l a t e r to the  However, many problems  remain, as i n d i c a t e d by the h i g h r a t e o f r e a d m i s s i o n  still t o the  hospital. The h o s p i t a l i s concerned discharged p a t i e n t .  about t h e s e r v i c e s f o r the  In p a r t i c u l a r , h o s p i t a l s t a f f are con-  cerned about the A f t e r Care C l i n i c and q u e s t i o n s r e l a t i n g t o policy, f a c i l i t i e s ,  s t a f f i n g and c o - o r d i n a t i o n w i t h other  agencies. Research Problem A s e r i e s o f d i s c u s s i o n s were h e l d between r e s e a r c h e r s and. h o s p i t a l s t a f f i n which the a f t e r c a r e problem was explored.  As a r e s u l t o f these d i s c u s s i o n s , and d i s c u s s i o n s  w i t h u n i v e r s i t y s t a f f , the r e s e a r c h problem was s e l e c t e d .  The  r e s e a r c h e r s decided t o e v a l u a t e the s e r v i c e s o f the A f t e r Care C l i n i c as t h i s was the major s e r v i c e a v a i l a b l e t o d i s c h a r g e d p a t i e n t s and was manageable w i t h the l i m i t e d manpower and time. The problem chosen f o r r e s e a r c h then was:  Are t h e  needs o f t h e d i s c h a r g e d p a t i e n t being met by the A f t e r Care Clinic?  Throughout the study the r e s e a r c h e r s were guided by  the f o l l o w i n g q u e s t i o n s :  - Ii8 1. What are the s o c i a l , work, and home needs o f the discharged patient? 2 . What needs a r e met by the A f t e r Care C l i n i c ? 3.  What needs are not met by the A f t e r Care C l i n i c ?  I 4 . What r o l e do other agencies  play?  5 . What suggestions c o u l d be made t o improve the services to the discharged patient? The  d e s i g n o f the study was e x p l o r a t o r y , chosen t o  s t i m u l a t e i n q u i r y i n t o the a f t e r c a r e s e r v i c e s i n the G r e a t e r Vancouver a r e a . U n d e r l y i n g the r e s e a r c h study were f a c t u a l and v a l u e assumptions.  The r e s e a r c h e r s thought  t h a t e a r l y discharge and  r e h a b i l i t a t i o n i n the community was g e n e r a l l y d e s i r a b l e .  They  assumed t h a t an adequate a f t e r c a r e programme would r e q u i r e adequate p o l i c i e s , f a c i l i t i e s and s t a f f i n g i n a comprehensive community programme and that such a programme would be l e s s ;  expensive  i n economic and human terms than an inadequate  care programme.  after-  G e n e r a l l y the r e s e a r c h e r s f e l t t h a t the d i s -  charged p a t i e n t has a r i g h t t o adequate a f t e r c a r e s e r v i c e s . They b e l i e v e d t h a t the community has some r e s p o n s i b i l i t y t o accept the d i s c h a r g e d p a t i e n t and t h e h o s p i t a l ; i b i l i t y to f a c i l i t a t e  this  some respons-  acceptance.  These g u i d i n g q u e s t i o n s and u n d e r l y i n g assumptions were f o r m u l a t e d a f t e r some f a m i l i a r i t y w i t h the a f t e r c a r e problem through  c o n s u l t a t i o n w i t h experts and r e a d i n g o f  h o s p i t a l and g e n e r a l l i t e r a t u r e .  -  1+9  -  Research Instruments In essence the r e s e a r c h e r s wanted to o b t a i n d a t a which would a l l o w them t o evaluate answer t h e i r g u i d i n g q u e s t i o n s . q u e s t i o n the i n d i v i d u a l s who aftercare services:  the A f t e r Care C l i n i c  They chose t h e r e f o r e t o  were most i n v o l v e d w i t h  the p a t i e n t s , the c l i n i c  other community agency  and  s t a f f were asked  about p a t i e n t needs and treatment g i v e n .  agencies  staff,  the  staff.  G e n e r a l l y p a t i e n t s and c l i n i c  e r s some i d e a o f met  and  and unmet needs.  T h i s gave r e s e a r c h -  Clinic  s t a f f and  were a l s o asked f o r t h e i r comments and.  on a f t e r c a r e s e r v i c e s .  T h i s was  on the r o l e of other agencies  done to o b t a i n  and  suggestions  other  suggestions information  f o r improve-  ments which might be made i n the a f t e r c a r e s e r v i c e s . Sources o f  Information H o s p i t a l memos and communication p r o v i d e d  vital  i n f o r m a t i o n f o r a h i s t o r i c a l review o f the a f t e r c a r e s e r v i c e s i n Vancouver.  They a l s o c l a r i f i e d h o s p i t a l p o l i c i e s  and o b j e c t i v e s f o r the A f t e r Care l i n i c . c  was  T h i s background  e s s e n t i a l i n f o r m u l a t i n g a knowledgeable q u e s t i o n n a i r e  clinic  and agency Patient  staff. f i l e s c o n t a i n e d i n f o r m a t i o n on the p a t i e n t  and h i s treatment both i n the h o s p i t a l and a t the  clinic.  T h i s i n f o r m a t i o n gave a p r e l i m i n a r y view of p a t i e n t needs treatment and was to p a t i e n t s .  to  kept i n mind i n f o r m u l a t i n g a  Such background, i n f o r m a t i o n h e l p e d  and  questionnaire interviewers  - 50 t o handle the i n t e r v i e w more s e n s i t i v e l y and allowed  f o r per-  t i n e n t probe q u e s t i o n s .  files  Information  on the h o s p i t a l  such as age and e d u c a t i o n gave a rough check on t h e v a l i d i t y o f p a t i e n t responses,  while i n f o r m a t i o n such as  diagnoses  p r o v i d e d a d d i t i o n a l data r e l e v a n t t o p a t i e n t needs. A b r i e f review  o f the l i t e r a t u r e gave a g e n e r a l  o r i e n t a t i o n t o t h e s u b j e c t and was u s e f u l i n d e f i n i n g the r e s e a r c h problem and i n f o r m u l a t i n g q u e s t i o n n a i r e s .  A more  e x t e n s i v e r e a d i n g p r o v i d e d f u l l e r background on a f t e r c a r e s e r v i c e s i n g e n e r a l and i n other c l i n i c s .  In p a r t i c u l a r we  used:  The f i r s t  1.  F i v e State Study  2.  Minnesota Follow-up Study  3.  Mental H e a l t h Survey o f Los Angeles County  two s t u d i e s e v a l u a t e d v a r i o u s a f t e r c a r e programmes  and the t h i r d study Angeles C material.  o u n  ty.  surveyed  aftercare resources  i n the Los  These s t u d i e s p r o v i d e d v a l u a b l e comparative  They h e l p e d the r e s e a r c h e r s t o assess the s e r v i c e s  i n the G r e a t e r Vancouver area and t o make suggestions  f o r more  adequate a f t e r c a r e s e r v i c e s . Patient Questionnaire: The  The Instrument  p a t i e n t q u e s t i o n n a i r e grew out o f a p e r u s a l o f  a f t e r c a r e , hospital,,and r e s e a r c h l i t e r a t u r e .  The q u e s t i o n n a i r e  preceded t h e - e x p l i c i t f o r m u l a t i o n o f the r e s e a r c h d e s i g n . g e n e r a l format was as f o l l o w s : 1.  Social Life  2.  Treatment  (1-5 and  (6-25)  2 6 - 3 3 )  The  - 51 3.  Work L i f e  (3k-kk)  k.  Home L i f e  (k5-k6 and 55-63)  5.  General I n f o r m a t i o n  (I47-5I4)  1 6. 7.  P e r s o n a l i t y Inventory (6k-85) I n t e r v i e w e r Assessment  1  (85-95)  The P a t i e n t Q u e s t i o n n a i r e thus e l i c i t e d i n f o r m a t i o n which would p r o v i d e a g e n e r a l d e s c r i p t i o n o f the p a t i e n t s i n the sample, an assessment o f s o c i a l , work, and home needs o f the p a t i e n t s , and the h e l p g i v e n by the A f t e r Care C l i n i c and other  agencies. Questions were phrased  arranged  as i n f o r m a l l y as p o s s i b l e and  so t h a t the l e s s t h r e a t e n i n g and more o b j e c t i v e ques-  t i o n s were a t the beginning, the more i n t e n s e and s u b j e c t i v e ^ i n the middle, at the end. the c l i e n t  and an i n t e r e s t i n g but more impersonal  The r e s e a r c h e r s f e l t  question,  t h a t t h i s order would make  f a i r l y comfortable and f a c i l i t a t e honest  responses.  G e n e r a l l y each s e c t i o n i n the q u e s t i o n n a i r e was organized, w i t h closed, questions f i r s t tions.  followed, by open ques-  The c l o s e d questions obtained, more o b j e c t i v e and com-  p a r a t i v e i n f o r m a t i o n while the open questions allowed f o r g r e a t e r depth i n t o i n d i v i d u a l responses  and thus p r o v i d e d a  check on the p r e c e d i n g c l o s e d q u e s t i o n s . 1. The p e r s o n a l i t y i n v e n t o r y and i n t e r v i e w assessment were p a t t e r n e d a f t e r questions presented i n : Freeman, H.E.^ Simmons, 0 . Wiley, New York, 1963.  The Mental  P a t i e n t Comes Home,  - 52 The  Sample The r e s e a r c h e r s were i n t e r e s t e d  mental p a t i e n t .  i n the discharged  However .,in choosing a p o p u l a t i o n ^ ) they  d e c i d e d t o study only those i n d i v i d u a l s who had been d i s charged  from the Crease U n i t a f t e r A p r i l  '65.  T h i s was done  because the new Mental H e a l t h A c t became e f f e c t i v e a t that date.  The r e s e a r c h e r s f u r t h e r l i m i t e d the p o p u l a t i o n t o  those who were referred, t o the A f t e r Care C l i n i c .  T h i s was  done because past and present i n f o r m a t i o n , i n c l u d i n g  recent  phone numbers and addresses were r e a d i l y a v a i l a b l e a t the Clinic that  f o r those r e f e r r e d .  including  Moreover, the r e s e a r c h e r s f e l t  two d i f f e r e n t groups (those r e f e r r e d and those  not r e f e r r e d ) would make the study too complicated f o r the l i m i t e d time a v a i l a b l e .  I t was f u r t h e r agreed t o l i m i t the  p o p u l a t i o n t o those r e f e r r e d i n d i v i d u a l s who were r e c e i v i n g services  from the C l i n i c .  Thus the p o p u l a t i o n excluded  people who were not r e f e r r e d to the C l i n i c ,  those  those who were  referred, but d i d not a t t e n d , and those who were r e f e r r e d , attended b r i e f l y , The reasonable The  and dropped o u t .  sample s i z e was 1*5.  This number was c o n s i d e r e d  f o r the l i m i t e d time a v a i l a b l e t o the r e s e a r c h e r s .  sample was drawn by u s i n g a random number t a b l e .  1  The  r e s e a r c h e r s phoned the people drawn and made appointments. There was some d i f f i c u l t y i n c o n t a c t i n g the f i r s t  1 . Edwards, A l l a n L. S t a t i s t i c a l Methods f o r the B e h a v i o r a l Sciences.. Reinehart and. Co. Inc., New York,  1954•  - 53 i|5 s e l e c t e d and others were randomly added.  However i t was  only a f t e r lkO people were drawn t h a t a sample o f k£ was obtained.  Thus 30 people  were drawn who had no phone, 11 d i d  not answer t h e i r phones a f t e r r e p e a t e d attempts t o c o n t a c t them, 16 people  l i v e d too f a r away, 8 people had moved and  c o u l d not be reached, viewed.  and 13 people r e f u s e d t o be i n t e r -  In a d d i t i o n , the r e s e a r c h e r s excluded  10 people  were not p r e s e n t l y r e c e i v i n g s e r v i c e s and 7 people r e c e i v i n g medication  only.  who  who were  I n t o t a l then 95 people were drawn  and not i n c l u d e d i n the sample. I t would appear from these r e j e c t i o n s t h a t our sample i s b i a s e d i n favour o f those  i n d i v i d u a l s who a r e more  s e t t l e d , who had phones, who d i d not move, and who kept i n contact w i t h the C l i n i c .  In a d d i t i o n t h e r e s e a r c h e r s  the sample by e x c l u d i n g , i n some cases, i n d i v i d u a l s attended  biased  who  s p o r a d i c a l l y o r who r e c e i v e d only m e d i c a t i o n .  In  g e n e r a l then i t appears t h a t our sample favours the more  for-  tunate d i s c h a r g e d p a t i e n t , the one who i s r e c e i v i n g most s e r v i c e from the C l i n i c and who may be more s t a b l e . reader  The  should take t h i s b i a s i n t o account when r e a d i n g the  study. Comments The p a t i e n t q u e s t i o n n a i r e was p r e t e s t e d a t the A f t e r Care C l i n i c .  Each r e s e a r c h e r i n t e r v i e w e d two p a t i e n t s  and. t h e r e s u l t s of the i n t e r v i e w s were d i s c u s s e d . questions  seemed too long or complicated  Some  f o r the p a t i e n t s ;  - 51+ these q u e s t i o n s were shortened or s u b d i v i d e d . p a t i e n t s found h a r d to understand; make t h e i r meaning more c l e a r .  Other  questions  these were re-worded to  The  order o f p r e s e n t a t i o n was  a l s o changed t o g i v e a smoother flow to the i n t e r v i e w .  How-  ever; i n s p i t e o f the p r e - t e s t i n g some flaws i n the q u e s t i o n n a i r e and i n the i n t e r v i e w procedure ; 1  was  remained.  One  question  too c o m p l i c a t e d and l e d to i n c o n s i s t e n c i e s i n response.  Thus the number o f people who  s a i d they had a problem some-  times d i d not correspond t o the number of people who what k i n d o f h e l p they r e c e i v e d f o r t h a t problem. no c a t e g o r i e s f o r undecided  There were  or i n a p p l i c a b l e ^ w h i c h would have  been u s e f u l i n t a b u l a t i o n s . again l e d to d i f f i c u l t i e s  indicated  Other c a t e g o r i e s overlapped which  in tabulation.  Some s u b j e c t i v e q u e s t i o n s might have been supplemented with objective questions. you  For example i n q u e s t i o n 55  "Would  say your l i v i n g accommodation i s s a t i s f a c t o r y ? " a q u e s t i o n  on the number of people and rooms might have been added. Similarlj  w i t h question./ 53 n d 51+ on f i n a n c i a l w o r r i e s an a  y  a d d i t i o n a l q u e s t i o n on the l e v e l of income would have g i v e n the answers more meaning. In g e n e r a l the time allowed f o r the d i s c u s s i o n o f the p r e t e s t r e s u l t s was q u e s t i o n n a i r e was  insufficient.  not gone over and  The meaning o f terms i n the i n t e r v i e w e r s independently  omitted and added c a t e g o r i e s which l e d t o some i n c o n s i s t e n c y i n the r e s u l t s . The  i n t e r v i e w e r s d i d not d i s c u s s beforehand  their  manner o f approachg and i n t e r v i e w i n g p a t i e n t s and i t was  - 55 l a t e r seen t h a t t h e r e were d i f f e r e n c e s . searchers  favored a f a i r l y aggressive  f a v o r e d a more permissive  Two o f the r e -  approach while a t h i r d ,  approach g i v i n g the p a t i e n t more  chance t o r e f u s e t o be i n t e r v i e w e d .  The i n t e r v i e w e r s a l s o  d i f f e r e d i n t h e i r method of i n t e r v i e w i n g . asked questions  interviewer  i n a s t r a i g h t f o r w a r d manner while the other  two cushioned questions w i t h c o n s i d e r a b l e searchers  One  support.  The r e -  agreed t h a t t h e i n t e r v i e w should, be made as com-  f o r t a b l e as p o s s i b l e f o r the p a t i e n t , b u t had d i f f e r e n t i n t e r p r e t a t i o n s o f how t h i s might be done. One o f t h e r e s e a r c h e r s knew some o f h i s i n t e r v i e w e e s from work w i t h them a t the h o s p i t a l .  I t would, seem t h a t  this  former r e l a t i o n s h i p might i n f l u e n c e t h e answers given, but i t is d i f f i c u l t  t o know the extent  or d i r e c t i o n o f t h i s i n f l u e n c e .  Despite t h e d i f f e r e n c e s i n i n t e r v i e w i n g , i n g e n e r a l it  seemed that p a t i e n t s were more r e l a x e d towards the end of  the i n t e r v i e w .  The f o l l o w i n g c h a r t taken from the r a t i n g made  by the i n t e r v i e w e r s  shows the d i s t r i b u t i o n o f a t t i t u d e s a t the  s t a r t and a t the c l o s e o f the i n t e r v i e w . Table 27 Interview A t t i t u d e Attitude At S t a r t  At  Ulose  5  0  Suspicious Guarded  18  13  Friendly  17  21  Solicitous  2  8  Other (Accepting)  3  3  1+5  U5  Hostile  Total.  - 56 From the g e n e r a l correspondence o f the answers g i v e n w i t h i n f o r m a t i o n received, from the h o s p i t a l ^ c o n c e r n i n g number o f h o s p i t a l i z a t i o n s a n d e d u c a t i o n 7  age,  i t would, seem t h a t  the questions were answered w i t h c o n s i d e r a b l e honesty. f o r t u n a t e l y , time d i d not a l l o w f o r a more accurate check on Staff  Un-  individual  validity.  Questionnaire The  s t a f f q u e s t i o n n a i r e was  the r e s e a r c h team who  designed by a member of  i s working at the h o s p i t a l .  His  famili-  a r i t y w i t h the h o s p i t a l and A f t e r Care C l i n i c added t o the s o p h i s t i c a t i o n o f the r e s e a r c h The  instrument.  Instrument The  questions.  q u e s t i o n n a i r e was  3 pages long and c o n t a i n e d  I t i n q u i r e d i n t o the c h a r a c t e r o f the s e r v i c e ,  b a s i c t h e r a p i e s , type of p a t i e n t r e f e r r e d , p a r t i c i p a t i o n s t a f f , and amount o f contact w i t h p a t i e n t s . t i o n s were c l o s e d . to  12  In a d d i t i o n o p e n  A n  the improvement o f s e r v i c e .  The  Sample The  suggestions  p o p u l a t i o n from which the sample was  determined to be a l l those A f t e r Care C l i n i c .  The  s t a f f who  ques-  q u e s t i o n s were i n c l u d e d  o b t a i n o p i n i o n s about the c l i n i c purpose and  for  these  of  taken  was  had work experience a t  sample s i z e was  set at 10.  The  the  re-  researcher,:! decided t o choose 5 s o c i a l workers and 5 p s y c h i a t r i s t s as t h i s would give two  important  and perhaps d i f f e r e n t  -  outlooks.  57  -  The r e s e a r c h e r then s e l e c t e d those  i n d i v i d u a l s he  c o n s i d e r e d t o be most experienced w i t h the C l i n i c .  The  sample so chosen c o n t a i n e d almost the t o t a l p o p u l a t i o n . Comments The  q u e s t i o n n a i r e was  not pretested., but i t was  g i v e n to two e x p e r t s a t the C l i n i c r e v i s e d q u e s t i o n n a i r e was  convenience.  q u e s t i o n was  g e n e r a l the q u e s t i o n n a i r e was I t was  felt  The  then g i v e n to each s t a f f member t o  be completed a t h i s e a r l i e s t Only one  f o r suggestions.  somewhat ambiguous and i n  well  understood.  t h a t the working r e l a t i o n s h i p which  e x i s t e d between the r e s e a r c h e r and the s t a f f f a c i l i t a t e d open e x p r e s s i o n o f o p i n i o n t h a t might otherwise difficult  to o b t a i n .  The response served the  an  have been  questionnaire's  purpose; i t helped r e s e a r c h e r s evaluate the C l i n i c s e r v i c e and g a i n a b e t t e r a p p r e c i a t i o n of a f t e r c a r e problems  and  possibilities. Agency Q u e s t i o n n a i r e : The The had  Instrument  agency q u e s t i o n n a i r e was  8 questions.  care s e r v i c e s and  o n l y one  page l o n g  and  I t asked f o r o p i n i o n s on the present  after-  the l i a s o n between that agency, other  agencies, and the A f t e r Care C l i n i c . o b t a i n an understanding  o f the way  G e n e r a l l y i t sought to  i n which agencies  per-  c e i v e d the d i v i s i o n of r e s p o n s i b i l i t y between community agencies and the A f t e r Care C l i n i c . open p a r t to a l l o w agencies  A l l questions had  to express  an  t h e i r views more f u l l y .  - 58 The  Sample The  agencies  r e s e a r c h e r s d e c i d e d t o m a i l q u e s t i o n n a i r e s to a l l  i n the Greater  Vancouver area who might have c o n t a c t  w i t h the d i s c h a r g e d p a t i e n t . mailed  A c c o r d i n g l y q u e s t i o n n a i r e s were  t o p r o v i n c i a l and. m u n i c i p a l  Metropolitan Health C l i n i c s ,  s o c i a l welfare  C h i l d r e n s ' A i d S o c i e t i e s , Can-  a d i a n Mental H e a l t h A s s o c i a t i o n s , and t h e Family Agency.  offices,  In a l l 12 q u e s t i o n n a i r e s were  Service  mailed.  Comments Responses were r e c e i v e d from a l l 12 a g e n c i e s . G e n e r a l l y t h e responses were d e t a i l e d and gave a good p i c t u r e o f agency o r i e n t a t i o n t o a f t e r c a r e s e r v i c e s . u s e f u l i n understanding  This response was  the gaps and. o b s t a c l e s t o an adequate  community a f t e r c a r e s e r v i c e and i n v i s u a l i z i n g  some b r i d g e s t o  a more adequate s e r v i c e . In c o n c l u s i o n s we have b r i e f l y o u t l i n e d the s o c i a l work and r e s e a r c h problem and i n d i c a t e d some o f the steps  that  were taken i n t h i s study  We  s h a l l now present questionnaire.  to o b t a i n r e l e v a n t I n f o r m a t i o n .  i n d e t a i l the f i n d i n g s o f the p a t i e n t  CHAPTER k PRESENTATION OP DATA OP THE , . PATIENT ..QUESTIONNAIRE In t h i s chapter we w i l l present data from the p a t i e n t q u e s t i o n n a i r e supplemented t o a l i m i t e d extent by data from h o s p i t a l f i l e s .  A l l t a b l e s are taken from the p a t i e n t  q u e s t i o n n a i r e except where i n d i c a t e d otherwise.  Tables not  included, i n the t e x t a r e found i n Appendix B. We w i l l f i r s t  give a g e n e r a l d e s c r i p t i o n o f t h e  sample and the h e l p g i v e n .  Then we w i l l d e s c r i b e the s o c i a l ,  work, and home needs and. t h e h e l p g i v e n i n each o f these a r e a s . A. General D e s c r i p t i o n of t h e Sample and the Help  Given  In- t h i s "section we w i l l d e s c r i b e the m a r i t a l s t a t u s , l i v i n g arrangements, age, e d u c a t i o n , source o f income, mental h e a l t h , and s t a t e d problems o f the sample.  We w i l l f o l l o w  t h i s d e s c r i p t i o n o f the sample w i t h a statement given by the A f t e r Care C l i n i c  o f the h e l p  and other a g e n c i e s .  M a r i t a l Status Our  sample c o n t a i n e d 26 women and 19 men.  Twenty-  f i v e i n d i v i d u a l s were married and most o f these were women. Most o f the 11 s i n g l e persons were men and the 8 separated, d i v o r c e d , and widowed people were a l l women w i t h one exception.  - 60 TABLE 1.  M a r i t a l Status and  Sex  Marital Status  Men  Married  8  17  25  Separated  1  3  k  Widowed  0  3  3  Divorced  0  1  1  Single  10  2  12  Total  19  26  Sex  Women  Total  L i v i n g Arrangements In the f o l l o w i n g p r e s e n t a t i o n o n l y s i n g l e and m a r r i e d c a t e g o r i e s . widowed and d i v o r c e d  We  of data we have used grouped the  separated,  individuals with single i n d i v i d u a l s .  chose to do t h i s because i t seemed that  We  t h e i r s o c i a l , work, and  home needs would tend, t o be more s i m i l a r t o those of the  single  person than to the married, person.  notice  i n Table 2,  However, as you w i l l  there i s a wide range of l i v i n g  arrangements.  Thus some separated i n d i v i d u a l s w i t h c h i l d r e n may resemble married, people w i t h c h i l d r e n . range o f s i t u a t i o n s any  more c l o s e l y  Because there i s a wide  simple grouping w i l l be  unsatisfactory.  The reader should take the b i a s of our p a r t i c u l a r i n t o account  as he reads the f o l l o w i n g  As can be seen from Table 2,  grouping  tables. 8 s i n g l e people were  l i v i n g alone, 3 i n b o a r d i n g homes and k w i t h t h e i r f r i e n d s or  - 61 relatives.  Two s i n g l e men l i v e d w i t h t h e i r mother, 2 m a r r i e d  people l i v e d w i t h t h e i r parents, and 2 separated women w i t h children also l i v e d with parents. her c h i l d r e n .  One woman l i v e d alone w i t h  The m a j o r i t y o f the m a r r i e d people  t h e i r spouse and c h i l d r e n .  (Appendix  l i v e d with  B, Table 2)  Age There was q u i t e a l a r g e age range:  from  i n t h e i r twenties t o those i n t h e i r s e v e n t i e s . (25) f e l l w i t h i n the t h i r t i e s and f o r t i e s . people  i n t h a t range, TABLE 3 .  Age  Single  Men  individuals  More than h a l f  There were 25  7 were younger and. 13 o l d e r . D i s t r i b u t i o n o f Age by M a r i t a l Status and Sex  Married  Women Single Married  Total  20-29  2  0  1  k  7  30-39  5  2  1  3  11  U0-U9  3  2  2  7  H*  50-59  1  1  k  1  7  60 &  0  3  1  2  6  11  8  9  17  i|5  Over Total  I t i s i n t e r e s t i n g t o note t h a t the  l a r g e s t group o f  s i n g l e women were i|0 and over, while the l a r g e s t group o f s i n g l e men were under hO. people.  The r e v e r s e i s true f o r the m a r r i e d  Here very few o f the married women were over 50  - 62 while h a l f o f the m a r r i e d men were.  Thus the s i n g l e women and  the m a r r i e d men were g e n e r a l l y older.' Education Pour i n d i v i d u a l s had l e s s than grade 6 while 13 had over grade 12. The bulk o b v i o u s l y f a l l s i n between w i t h the most f r e q u e n t category b e i n g those i n d i v i d u a l s w i t h grade 7 t o grade 9 .  The s i n g l e men a r e the most p o o r l y educated,  by the m a r r i e d men. (Appendix Source  M a r r i e d women were the best  followed  educated.  B, Tabes k and 5")  o f Income Out o f our sample there were 13 people w i t h jobs and l£  who l i v e d from t h e i r husband's income.  Government  supported. 8 and 10 were on S o c i a l A s s i s t a n c e .  pensions  Thus we have  28 i n d i v i d u a l s who were l i v i n g on t h e i r own o r immediate f a m i l y r e s o u r c e s and 18 i n d i v i d u a l s who were being supported by the government.  Other  sources o f income were a l s o noted, and some  i n d i v i d u a l s had. more than one source.  (Appendix  B, Table 6)  In summary then, i f we looked f o r the most c h a r a c t e r i s t i c person i n our sample, we would f i n d a m a r r i e d woman l i v i n g w i t h her  spouse and c h i l d r e n .  She would be i n h e r  f o r t i e s and have a grade 7 - 9 e d u c a t i o n .  She would be supported  by h e r husband. Mental  Health We e x p l o r e d the mental h e a l t h o f our sample by n o t i n g  the number o f admissions  t o the h o s p i t a l  (Riverview o n l y ) , the  h o s p i t a l diagnoses, c l i e n t and i n t e r v i e w e r r a t i n g s o f mental h e a l t h and symptoms, and a p e r s o n a l i t y i n v e n t o r y .  - 63 A c c o r d i n g t o t h e q u e s t i o n n a i r e , 9 people were h o s p i t a l i z e d f o r the f i r s t time.  Nineteen had been h o s p i t a l i z e d 2 or  3 times, and the r e s t more than 3 times i n f o r m a t i o n corresponded (Appendix  hospital Diagnoses  f a i r l y w e l l with h o s p i t a l data.  Diagnoses by Sex and M a r i t a l S t a t u s  Men Single Married  Schizophrenic Jndifferentiated Schizophrenic Paranoid Ylanic Depressive Neurotic Depressive Psychotic Depressive Other Depressive Chronic Anxiety Personality T r a i t Disturbance  Women Single Married  1  Total  k  1  3  7  15  k  2  k  1  11  1  k  1  k  5  1  1  3  2  5  3 1 2  1  1  l 1  11  8  9  Prom Table 9 i t i s apparent diagnosed  This  B, Tables 7 and 8)  Table 9.  Total  (7 were unknown).  as s c h i z o p h r e n i c .  17  l  45  that most people were  The remainder  were a l l d e p r e s s i v e  r e a c t i o n s except f o r 2 who were diagnosed as p e r s o n a l i t y d i s t u r b a n c e and. c h r o n i c a n x i e t y .  trait  Most s i n g l e people were  s c h i z o p h r e n i c w h i l e most of t h e m a r r i e d people were d e p r e s s i v e reactions. 1 . These diagnoses are from h o s p i t a l f i l e s and p e r t a i n to the l a s t h o s p i t a l i z a t i o n o n l y .  - 6k The i n t e r v i e w e r s a s s e s s e d  the p a t i e n t s ' mental  h e a l t h a c c o r d i n g t o these c a t e g o r i e s : Grossly Disturbed  - Needing h o s p i t a l i z a t i o n  Disturbed  - Symptoms severe, may need h o s p i t a l i z a t i o n  Somewhat D i s t u r b e d  - Symptoms c o n t r o l l e d , f u n c t i o n i n g m i n i m a l l y i n community  S l i g h t l y Disturbed  - Some d i s c e r n a b l e i n community  Not  - No d i s c e r n a b l e  Disturbed  functioning  symptoms,  functioning  symptoms, appears t o be  normally  I f we c o n s i d e r t h i s assessment as p a r a l l e l t o r a t i n g s o f Very Poor, Poor, P a i r , Good and Very Good we can compare i n t e r v i e w e r and c l i e n t r a t i n g s as f o l l o w s : Table  10.  Comparison o f Interviewer and C l i e n t Assessments o f Mental H e a l t h  Assessment  Interviewer  Client  Very Poor  2  0  Poor  8  3  Pair  17  12  Good  13  26  Very good Undecided  3 0  1  Total  Thus we see t h a t c l i e n t s tend t o r a t e t h e i r mental h e a l t h b e t t e r than i n t e r v i e w e r s .  T h i s i s s u b s t a n t i a t e d by  the i n t e r v i e w e r s ' comments on the question (Appendix A, Question 13)  about  symptoms.  -  65 -  There were a number o f people who denied t h a t they had  symptoms.  The i n t e r v i e w e r s noted t h a t these people were  often schizophrenic considerable  paranoid  anxiety.  p a t i e n t s or p a t i e n t s w i t h con-  F o r each symptom l i s t e d i n Table 11,  there were about o n e - t h i r d a f f i r m a t i v e responses.  Peeling  depressed, anxious, and t i r e d were the most frequent  responses  f o l l o w e d by d i f f i c u l t y i n s l e e p i n g and. f o r g e t f u l n e s s . answer t o the q u e s t i o n mental h e a l t h ? "  l k , "What w o r r i e s  fused i d e a s .  low energy, and con-  o f the sample were s u f f e r i n g from  r e s i d u a l symptoms o f t h e i r  inventory,  to f u n c t i o n i n the  Many f e a r e d r e h o s p i t a l i z a t i o n . Thus i t appeared  that at l e a s t one-third  It  you most about your  some s t a t e d t h e i r i n a b i l i t y  community, t h e i r l a c k o f c o n c e n t r a t i o n ,  In  illness.  i s i n t e r e s t i n g to note that i n the p e r s o n a l i t y  optimism was the most frequent  ism the l e a s t f r e q u e n t .  response and f a t a l -  E i t h e r t h i s i n v e n t o r y was an i n -  adequate measurement o f p e r s o n a l i t y or p a t i e n t s r e t a i n e d considerable  hope d e s p i t e  t h e i r mental d i f f i c u l t i e s .  In summary, when we looked, a t the mental h e a l t h o f our  sample we found that most i n d i v i d u a l s have been h o s p i t a l -  i z e d at l e a s t 3 times and are u s u a l l y diagnosed, as s c h i z o phrenic.  Most c l i e n t s r a t e d t h e i r h e a l t h as good, but the  interviewers  r a t e most as only f a i r o r good.  Many people d i d  not admit to symptoms and a p e r s o n a l i t y i n v e n t o r y optimism to be the most frequent  found  response.  C l i e n t s were asked about f i n a n c i a l , work, p h y s i c a l , m a r i t a l and other  f a m i l y problems.  personal,  Many people  - 66 d i d not admit t o any problems.  Those who d i d , noted f i n a n -  c i a l , p h y s i c a l and other f a m i l y problems most f r e q u e n t l y . (Appendix B, Table 12) In the probe q u e s t i o n c l i e n t s e l a b o r a t e d on t h e i r problems.  Some w o r r i e d about t h e i r marginal income, o t h e r s  about t h e i r spouse or themselves l o s i n g t h e i r j o b .  Some  w o r r i e d about t h e i r work performance, t h e i r l a c k o f d r i v e , c o o r d i n a t i o n and the p r e s s u r e on the j o b .  Some people had  p h y s i c a l problems, u l c e r s , p o l i o , back t r o u b l e and the p h y s i c a l problems  accompanying o l d age.  with t h e i r  Many people were i n c o n f l i c t  spouse. ^  Help Given by the C l i n i c We s h a l l estimate the h e l p g i v e n by the C l i n i c by l o o k i n g a t t h e k i n d o f h e l p the c l i e n t s i n d i c a t e d they r e c e i v e d , t h e c l i e n t s ' e s t i m a t e o f t h i s h e l p and t h e i r ;  estimate o f t h e i r improvement s i n c e coming t o t h e C l i n i c . Only one person was seeing a s o c i a l worker. overwhelming  m a j o r i t y o f people saw a p s y c h i a t r i s t , b u t  l e s s than once a month and f o r o n l y 1-15> minutes.  The usually  A few people  saw t h e i r p s y c h i a t r i s t more than once a month f o r i n t e r v i e w s l a s t i n g a t l e a s t 30 minutes.  A few people were s e e i n g a  p s y c h o l o g i s t f o r i n t e n s i v e group  treatment.  None o f t h e people were i n v o l v e d i n any s o c i a l a c t i v i t i e s offered, by t h e C l i n i c , but most (38) were r e c e i v ing medication.  Some s a i d t h a t the m e d i c a t i o n was keeping  them away from the h o s p i t a l .  - 67 Asked i f they thought the C l i n i c was g i v i n g them any h e l p w i t h t h e i r problems, Table 12.  Problem  Yes  c l i e n t s r e p l i e d as f o l l o w s :  C l i e n t Estimate o f C l i n i c  No Help  Help Given Some Help  Help  L o t s of Help  Financial  13  10  1+  1  Work  18  11  3  0  Personal  9  6  3  1  Physical  13  7  3  0  8  7  0  1  Family  12  6  3  1  Total  72  1+7  16  Marital  '-i  1+  Most people who f e l t t h a t they were r e c e i v i n g  finan-  c i a l or p h y s i c a l h e l p were r e f e r r i n g t o the m e d i c a t i o n they received, f r e e from the In  Clinic.  the probe q u e s t i o n i t appeared t o t h e i n t e r -  viewers that many people were r e c e i v i n g m e d i c a t i o n and some supportive h e l p .  Some people s a i d t h a t the doctor  "encouraged"  them and that " t a l k w i t h the d o c t o r h e l p e d " , "someone l i s t e n e d . " A few people thought t h a t t h e d o c t o r s d i d n ' t have enough time for  them.  Quite a few people d i d n ' t want h e l p . A few ex-  p r e s s e d a d e s i r e t o t r y t o get a l o n g by themselves, and. a number d i d n ' t t h i n k they needed anything from the C l i n i c but medication.  When asked whether they thought t h e i r  difficulties  - 68  had improved to  -  s i n c e coming to the C l i n i c 9 people were unable  answer and 12  f e l t t h a t they had not improved  S i x t e e n people, however, f e l t t h e y had improved and 8 thought they had improved  a great d e a l .  at a l l . somewhat  (Appendix  B,  13)  Table  To summarize, the h e l p g i v e n by the C l i n i c , i t appears t h a t o n l y a few i n d i v i d u a l s get more than m e d i c a t i o n and a b r i e f v i s i t w i t h t h e i r p s y c h i a t r i s t . admit t o problems, from the C l i n i c .  Of those  who  most estimate t h a t they r e c e i v e no h e l p However, most people do f e e l t h a t  d i f f i c u l t i e s have improved  i n some degree  their  s i n c e coming t o the  Clinic. Help Given by Other  Agencies  T h i r t e e n people s a i d that t h e y were g e t t i n g h e l p from other a g e n c i e s .  Ten out of the 13  f i e d with t h i s help.  Most of the people thought  s a i d they were s a t i s that  they  were g e t t i n g some h e l p from these agencies and others  felt  that they were r e c e i v i n g a l o t o f h e l p . II4)  Most people who  thought  i n d i c a t e d t h a t t h i s h e l p was However, those who  B, Table  t h a t they were g e t t i n g some h e l p f o r f i n a n c i a l or p h y s i c a l  problems.  i n d i c a t e d that they were r e c e i v i n g a l o t o f  h e l p indicated, that t h i s h e l p was problems.  (Appendix  f o r p e r s o n a l and m a r i t a l  Thus i t would appear from c l i e n t e s t i m a t e s t h a t  other agencies do g i v e some or a l o t o f h e l p w i t h p h y s i c a l , p e r s o n a l , and m a r i t a l  problems.  financial,  - 69 B  »  S o c i a l Meeds and Help Given We t u r n now from the g e n e r a l d e s c r i p t i o n o f the  sample and the h e l p g i v e n t o an assessment  o f the s o c i a l , work,  and home needs and h e l p g i v e n i n each o f these a r e a s . I n t h i s s e c t i o n on s o c i a l needs we w i l l o u t l i n e the s o c i a l problems  by d e s c r i b i n g the c l i e n t  r e c r e a t i o n , contact  w i t h neighbours, r e l a t i v e s , and f r i e n d s , i n t e r v i e w e r estimate o f s o c i a l c o n t a c t , and c l i e n t d e s i r e f o r s o c i a l c o n t a c t .  We  w i l l c o n s i d e r the s o c i a l needs o f the s i n g l e men and women i n more d e t a i l and l o o k a t t h e i r statement o f problems and h e l p given. Recreation The most common r e c r e a t i o n was watching TV and l i s t e n i n g t o the r a d i o .  Movies and d r i v e s were the next most p o p u l a r .  Most people i n d i c a t e t h e i r involvement w i t h s p o r t s i s mainly through TV.  It is difficult  t o say how t h i s would compare w i t h  the average V a n c o u v e r i t e , b u t c e r t a i n l y i t does p o i n t out t h e frequency o f r e c r e a t i o n t h a t i s p a s s i v e r a t h e r than a c t i v e . (Appendix B, Table l£) I t i s i n t e r e s t i n g t o note that most people (26) f e l t t h a t they would l i k e t o be more a c t i v e . Contact w i t h Neighbours. F r i e n d s , and R e l a t i v e s Only one person thought t h a t the people i n h i s n e i g h borhood, were u n f r i e n d l y , w h i l e t w o - t h i r d s thought t h a t neighbours were f r i e n d l y or f a i r l y f r i e n d l y .  their  F o u r t e e n people  were undecided about t h e i r neighbours or thought they were indifferent.  Nine people had no c l o s e r e l a t i v e s , 12 s a i d they  - 70 had no f r i e n d s . at  l e a s t once a week, while o n l y 12  month.  Of those who  week, w h i l e 10 Tables 16 to  d i d have r e l a t i v e s , 15> saw  Of those who  had  saw  f r i e n d s , 17  saw  them l e s s than once a them at l e a s t once a  saw them l e s s than once a month.  and 17)  We  (Appendix  can see from t h i s that some people  have q u i t e a l o t of c o n t a c t w i t h f r i e n d s and  Others, however, may  them  B,  appear  relatives.  have no f r i e n d s or r e l a t i v e s or v i s i t  them  l e s s than once a month. I n t e r v i e w e r Estimate of S o c i a l  Contact  The w r i t e r s looked a t the s o c i a l c o n t a c t f o r each person and a r b i t r a r i l y a s s i g n e d a r a t i n g of poor, good c o n t a c t .  G e n e r a l l y , t h i s was  and q u a l i t y of c o n t a c t . istically,  fair,  a combination  However, because i t was  and  o f the number done i m p r e s s i o n -  i t i s s u b j e c t t o e r r o r , and the reader should keep  t h i s i n mind i n r e a d i n g the f o l l o w i n g m a t e r i a l . Table 18.  Social Contacts  S o c i a l Contact by Sex M a r i t a l Status Men Single Married  and  Women Single Married  Total  Poor  *  1  3  5  Ik  Pair  5  6  6  11  28  Good  1  1  0  1  3  11  8  9  17  kS  Total  Prom t h i s t a b l e we social contacts. have good.  see t h a t most people do have  fair  Some people have o n l y poor c o n t a c t s and 3  There does not seem t o be any s i g n i f i c a n t  differ-  - 71 ences between men due  and women, m a r r i e d and s i n g l e . T h i s may  be  to the wide range o f l i v i n g arrangements f o r p a t i e n t s i n  each of these c a t e g o r i e s . About h a l f of the c l i e n t s s a i d t h a t they wanted more c o n t a c t ; another h a l f d i d n o t . t h e i r s o c i a l l i f e was unsatisfactory.  Again,about  half  s a t i s f a c t o r y and h a l f thought  thought  i t was  A few people were undecided.  When we examined the probe q u e s t i o n s on s o c i a l t a c t we  f i n d that some people were doing q u i t e w e l l .  con-  They  seemed to have q u i t e a number o f a c t i v i t i e s and. f r i e n d s and got along w i t h these f r i e n d s . t h e i r s o c i a l l i f e was  Of those who  thought  that  not s a t i s f a c t o r y some were f u l l y i n -  v o l v e d w i t h t h e i r f a m i l i e s and c o u l d not manager more c o n t a c t w i t h ease.  Others wished  i t was  more l i k e  "the good, o l d days"  when they had more f r i e n d s and "used t o know everybody."  Some  wanted to be a "part o f something."  few  people they "could t a l k t o . seeking more c o n t a c t .  Others j u s t wanted a  However there were drawbacks t o  Some complained  of l a c k o f money or  t r a n s p o r t a t i o n ; others f e l t t h a t they j u s t d i d n ' t know what t o do.  Some f e l t t h a t t h e i r age and p h y s i c a l problems h e l d them  back while o t h e r s f e l t t i e d down a t home.  A good many people  were too tired, to do a n y t h i n g and others found i t d i f f i c u l t to  t a l k to f r i e n d s , who  d i f f e r e n t from normal  d i d n ' t understand them.  They  felt  people.  Other people who  were s a t i s f i e d w i t h t h e i r  l i f e had minimal c o n t a c t w i t h o t h e r s . "weren't bored"..."don't  social  They thought that they  want t o be bothered w i t h people" or  - 7 2 were i n d i f f e r e n t .  Many of those who  had minimal communication.  d i d have some c o n t a c t ,  They d i d n ' t l i k e t o express t h e i r  opinions, "never argue w i t h f r i e n d s . "  The  interviewers  commented that some people were too p r e o c c u p i e d w i t h n e u r o t i c symptoms to t o l e r a t e p e o p l e . In summary then, we f i n d t h a t most people have f a i r l y passive recreation.  About o n e - t h i r d c o n s i d e r e d t h e i r  neighbours u n f r i e n d l y , i n d i f f e r e n t , or were undecided. About 20 people had no f r i e n d s or saw them l e s s than once a month:  20 had no r e l a t i v e s or saw them l e s s than once a  month.  The i n t e r v i e w e r s r a t e d about o n e - t h i r d as having poor  contact and most as only f a i r c o n t a c t .  Most people  indicated  that they wanted t o be more a c t i v e and almost h a l f d e s i r e d c l o s e r c o n t a c t w i t h people and thought t h e i r s o c i a l l i f e  was  unsatisfactory. S o c i a l Needs o f the S i n g l e  Man  Of the 11 s i n g l e men  i n our sample,  7 had been i n  the h o s p i t a l 3 times, 2 more o f t e n and 2 l e s s o f t e n .  F i v e were  assessed by the i n t e r v i e w e r s t o have poor s o c i a l c o n t a c t , $ to have f a i r , and 1 t o have good s o c i a l c o n t a c t . All  5> of those w i t h poor c o n t a c t were s c h i z o p h r e n i c .  Three were i n t h e i r t h i r t i e s ,  and 2 i n t h e i r f o r t i e s .  Two  l i v e d by themselves, 2 i n boarding homes, and 1 with a b r o t h e r . Four were on S o c i a l A s s i s t a n c e , and 1 was  on D i s a b l e d Person's  Allowance. One person s t a t e d t h a t he had a p h y s i c a l problem  and  -  73  -  was r e c e i v i n g some h e l p from another agency f o r t h i s . e l s e was r e c e i v i n g any h e l p from the C l i n i c  No one  or other agencies  f o r any p h y s i c a l , p e r s o n a l , or f a m i l y problems.  One person,  who l i v e d w i t h h i s b r o t h e r , s t a t e d p e r s o n a l and f a m i l y problems.  Another person who s t a t e d t h a t he had no problems,  was not r e c e i v i n g m e d i c a t i o n . Of those 5? who had. f a i r c o n t a c t , 3 were s c h i z o p h r e n i c , 1 s u f f e r e d from a c h r o n i c a n x i e t y s t a t e and another from a r e a c t i v e d e p r e s s i o n .  Pour were i n t h e i r t w e n t i e s , and  t h i r t i e s , and one was i n h i s f i f t i e s .  Three were l i v i n g by  and t h e other 2 were w i t h t h e i r mothers.  themselves  Two had  jobs, one was on S o c i a l A s s i s t a n c e , and the other two were supported by r e l a t i v e s or t h e i r own s a v i n g s . One o f the above people  s t a t e d he had a p e r s o n a l  problem, but he was not on m e d i c a t i o n .  Two, who l i v e d w i t h  t h e i r mothers, s t a t e d p e r s o n a l and f a m i l y problems. these was not t a k i n g m e d i c a t i o n .  One o f  Other men d i d not s t a t e any  p e r s o n a l , p h y s i c a l , or f a m i l y problems.  None o f these men  w i t h f a i r c o n t a c t was r e c e i v i n g any h e l p from the C l i n i c f o r p e r s o n a l , f a m i l y or p h y s i c a l problems. The  i n d i v i d u a l w i t h good c o n t a c t was a separated  man i n h i s f o r t i e s who  s u f f e r e d from a d e p r e s s i v e r e a c t i o n  a f t e r h i s wife l e f t him. had a j o b .  He was now l i v i n g with f r i e n d s and  He d i d not s t a t e any problems o r h e l p and was  not on m e d i c a t i o n .  - 74 S o c i a l Meeds o f the S i n g l e Woman There a r e 2 s i n g l e , 3 separated, 3 widowed, and 1 d i v o r c e d woman i n t h e sample c l a s s i f i e d as s i n g l e women. The  i n t e r v i e w e r s a s s e s s e d 3 t o have poor c o n t a c t and 6 t o  have f a i r c o n t a c t . The 3 women w i t h poor contact had 2, 3, and 6 These 3 women are a l l over l\Q.  hospitalizations.  One l i v e s  by h e r s e l f , another w i t h h e r s i s t e r , and the t h i r d w i t h h e r mother and daughter.  None had j o b s .  None o f the above mentioned women s t a t e d any personal problems.  The woman w i t h the o l d e r daughter  f a m i l y problem.  Not one was r e c e i v i n g any h e l p f o r s o c i a l  problems.  stated a  The woman who l i v e d alone was r e h o s p i t a l i z e d  s h o r t l y a f t e r the i n t e r v i e w .  She was not t a k i n g m e d i c a t i o n .  Those 6 women who have f a i r c o n t a c t range i n age from 20 t o over £0. others 3, k  a  n  Three had been h o s p i t a l i z e d once: the  d 6 times.  Two l i v e d w i t h c h i l d r e n , one w i t h  a s i b l i n g , one i n a boarding home, and 2 l i v e d by themselves. Three have jobs, 2 a r e on S o c i a l A s s i s t a n c e and one has a pension. Three o f the women w i t h f a i r c o n t a c t admitted no problems and were not g e t t i n g any h e l p from the C l i n i c .  Of  the o t h e r s , 3 s t a t e d t h a t they had p e r s o n a l , p h y s i c a l o r f a m i l y problems and were r e c e i v i n g  some h e l p from the  Clinic.  In summary then, we sea that none o f the s i n g l e men  were r e c e i v i n g any h e l p f o r t h e i r s o c i a l problems.  o f the women w i t h poor s o c i a l c o n t a c t were r e c e i v i n g any  None  - 75 help.  Some o f these people were not t a k i n g m e d i c a t i o n . Those three who were helped, were women who s t a t e d  problems and. who had f a i r s o c i a l c o n t a c t s .  Two were young  women w i t h c h i l d r e n , and one was an o l d e r u n i v e r s i t y woman who was l i v i n g by h e r s e l f and working. 0. Work Heeds and Help  Given  In t h i s s e c t i o n on work needs we w i l l c o n s i d e r the work problems and help g i v e n by the C l i n i c and other We w i l l d i s c u s s the sources o f income and f e l t problems.  agencies.  financial  We w i l l b r i e f l y c o n s i d e r t h e work problems f o r  those working, l o o k i n g f o r work and not l o o k i n g f o r work.  We  w i l l then examine i n some d e t a i l the work problems o f the s i n g l e and married, man and woman and the h e l p given each o f these groups. Source o f Income Table 19.  Source o f Income  Source o f Income by M a r i t a l Status and Sex  Men Single  Married  Women Single H a r r i e d  Total  Job  3  k  k  2  13  Social Assistance  5  1  2  1  9  Pension  l  2  0  1  k  Spouse  0  13  13  Other  2  1  3  0  6  Total  11  8  9  17  U5  - 76 We  n o t i c e from Table 19 that many o f our sample  l i v e on marginal incomes. k on p e n s i o n s . savings.  We  Nine l i v e on S o c i a l A s s i s t a n c e and  Other sources o f income i n c l u d e  minimal  do not know the occupations of husbands of  p a t i e n t s but many o f these f a m i l i e s appeared t o the viewers to be l i v i n g on m a r g i n a l  inter-  incomes.  F i n a n c i a l Problems In  r e p l y t o the q u e s t i o n on f i n a n c i a l w o r r i e s , 26  i n d i c a t e d that they were not w o r r i e d at a l l .  Only one  person  considered, h i m s e l f very w o r r i e d , and. the remaining 18  felt  that they were w o r r i e d or somewhat w o r r i e d .  fre-  quent  f i n a n c i a l worry was  The most  f o r the l a c k of money i n the  However, o n l y 10 people expressed that f e a r .  Still  future.  fewer  expressed the worry o f l a c k of money p r e s e n t l y or worry old. d e b t s . ent  of  A scanty 3 people were w o r r i e d about being depend-  on other people.  Work Problems The trend, i s g e n e r a l l y f o r l e s s people to be p l o y e d a f t e r h o s p i t a l i z a t i o n and f o r more work t o be s k i l l e d , p a r t time and i r r e g u l a r . Of the 13 i n d i v i d u a l s who 10 f e l t  of  un-  (Appendix B, Table 2 0 ) were p r e s e n t l y working,  that t h e i r f e l l o w workers and boss were easy t o get  along w i t h . Asked  em-  Six f e l t  that they d i d have work problems.  i f anything bothered them a t work, 2 complained  of lack  c o o r d i n a t i o n and energy, 2 of slowness and. f e a r o f making  - 77 -  mistakes.  One person thought the j o b d i d n o t pay enough and  2 complained o f t h e p r e s s u r e on t h e j o b . F i v e people were l o o k i n g f o r work.  Three went  f a i r l y r e g u l a r l y t o the employment o f f i c e and. 2 made some attempt t o f i n d work.  These people thought t h a t more j o b s  a v a i l a b l e , more e d u c a t i o n , and more c o n f i d e n c e would be u s e f u l i n g e t t i n g work.  "More e x p e r i e n c e would be u s e f u l .  Once  employers knew t h a t you had been i n h o s p i t a l i t made t h i n g s more d i f f i c u l t . " Others who were n o t l o o k i n g f o r work were women w i t h c h i l d r e n , those who were t o o o l d , and those who thought t h a t t h e i r e m o t i o n a l problems were t o o s e v e r e .  Some explained, t h a t  they were a f r a i d t h e y would "not measure up", " l a c k e d t h e conf i d e n c e " and. " d i d n ' t have t h e spunk." In  summary, we see a number o f people on m a r g i n a l  incomes, and n o t i c e t h e tendency f o r those who work t o g e t worse j o b s a f t e r h o s p i t a l i z a t i o n .  N i n e t e e n people worry  f i n a n c e s and. most o f t h e s e worry about f u t u r e f i n a n c i a l culties.  about diffi-  Most people s t a t e d t h a t t h e y got a l o n g w i t h t h e  people t h e y worked w i t h , b u t almost h a l f thought t h a t t h e y had. some work problems. of  these h e s i t a n t l y .  Only 5" people were l o o k i n g f o r work, most Some o t h e r s who were n o t l o o k i n g f o r  work, were f e a r f u l . We s h a l l now l o o k i n d e t a i l a t t h e work needs o f t h e s i n g l e man, s i n g l e woman, m a r r i e d man and m a r r i e d woman.  We  s h a l l c o n s i d e r t h e needs and. h e l p g i v e n f o r t h o s e who a r e working,  those who a r e l o o k i n g f o r work, and those who a r e n o t  - 78 -  l o o k i n g f o r work. We w i l l d e s c r i b e each group so t h a t the reader have some understanding  of the c a p a c i t y f o r work.  We  may  will  u s u a l l y enumerate age, e d u c a t i o n , diagnoses, number of h o s p i t a l i z a t i o n , and work e x p e r i e n c e . Work Needs of the S i n g l e The  11  Man  s i n g l e men  i n our sample are f a i r l y young.  Seven are i n t h e i r twenties or t h i r t i e s . h o s p i t a l i z e d 3 times. from 7-9  F i v e have grade 10-12  e d u c a t i o n , [j. have  Only 3 are s k i l l e d workers.  and the others have l e s s .  Three were working,  Most have been  2 l o o k i n g f o r work, and 6 not l o o k i n g f o r  work. Those 3 who t i o n a l range.  d i d have jobs had l a r g e age and educa-  A l l were u n s k i l l e d .  d e p r e s s i v e r e a c t i o n s , and one was  Two  were diagnosed  schizophrenic.  Two  asindicated  that t h e y were having work problems, but were not g e t t i n g help.  One  d i d not s t a t e any problems or any h e l p .  Two  any  men  were not on m e d i c a t i o n . Both men  who  were l o o k i n g f o r work were young  l i v e d w i t h t h e i r mothers. were u n s k i l l e d .  They were diagnosed  3 and 5 h o s p i t a l i z a t i o n s . s t a t e d t h a t he had work and was  They had grade 12  education  and and  as s c h i z o p h r e n i c and  Both had. work e x p e r i e n c e .  Each  f i n a n c i a l problems, but thought  g e t t i n g no h e l p from the C l i n i c or any other agency.  o f these men  was  not r e c e i v i n g  Of the 6 men  had  he One  medication.  not l o o k i n g f o r work £ were on S o c i a l  - 79 A s s i s t a n c e and 1 on D i s a b l e d Person's Allowance. l a r g e age and e d u c a t i o n a l range.  They had a  A l l were s c h i z o p h r e n i c  except f o r one, and most had been h o s p i t a l i z e d at l e a s t 3 times.  Only one had worked b e f o r e .  F i v e i n d i c a t e d that they  had a f i n a n c i a l problem, and most s a i d t h e y were g e t t i n g h e l p from o t h e r a g e n c i e s .  Three s t a t e d that they had a work  problem, but were r e c e i v i n g no h e l p from the C l i n i c other agency.  or any  A l l were on m e d i c a t i o n .  Work Needs o f the S i n g l e Woman The 9 s i n g l e women i n our sample comprised 3 who had grade 7-9 e d u c a t i o n , 3 who had grade 10-12 and another 3 who had some u n i v e r s i t y .  Two s t a t e d that they had jobs, 3  that t h e y were l o o k i n g f o r work, and I4 t h a t they were n o t l o o k i n g f o r work. The two working women had a l a r g e age and e d u c a t i o n a l range.  One f e l t  that she had no work problems.  mentioned work problems, but f e l t for  t h i s problem from the C l i n i c .  The other  she was r e c e i v i n g some h e l p Both were r e c e i v i n g  medica-  tion. Three women were l o o k i n g f o r work. ent  c h i l d r e n and both were young.  Two had depend-  One had a grade 9 e d u c a t i o n  and the other had a grade 12 e d u c a t i o n .  One was diagnosed as  s c h i z o p h r e n i c and was h o s p i t a l i z e d 7 times; t h e other was diagnosed as a d e p r e s s i v e r e a c t i o n and had been h o s p i t a l i z e d once.  The former woman s t a t e d both f i n a n c i a l and work problems  and f e l t  she had r e c e i v e d no h e l p from the C l i n i c or any other  -  agency.  8 0 -  She was on m e d i c a t i o n .  The l a t t e r woman s t a t e d  f i n a n c i a l and work problems, hut thought she was g e t t i n g some help  from the C l i n i c f o r her work problem.  The t h i r d woman  was i n h e r f o r t i e s and had a grade 8 e d u c a t i o n . on S  o c  i a l Assistance.  she was g e t t i n g no help  She was l i v i n g  She had been h o s p i t a l i z e d once and f e l t f o r h e r work problem.  There were two o l d e r women who were not l o o k i n g f o r work.  v.Qne was on a pension and the other r e c e i v e d money from  her husband's e s t a t e . lems.  N e i t h e r had any f i n a n c i a l  o r work prob-  A t h i r d younger women on D i s a b l e d Person's Allowance  stated, she d i d r e c e i v e f i n a n c i a l h e l p , but thought she had a work problem f o r which she was n o t r e c e i v i n g h e l p .  Our f o u r t h  woman was i n a very confused s t a t e and. was r e h o s p i t a l i z e d as mentioned  earlier.  Work Needs o f the M a r r i e d Man Of the 8 married men four men were working, and the remaining k were not l o o k i n g f o r work. One o f t h e working men was i n h i s t h i r t i e s , 2 were i n t h e i r f o r t i e s , and. the other nosed as s c h i z o p h r e n i c s  inhis fifties.  and 2 as depressive  Two were d i a g reactions.  One  was a u n i v e r s i t y graduate and t h e others had grade 9 or l e s s . Two were u n s k i l l e d , one s k i l l e d , and one p r o f e s s i o n a l . One person s t a t e d that he had f i n a n c i a l problems and was g e t t i n g no h e l p . and no h e l p g i v e n .  and work  Another stated, work problems  One f e l t he had no f i n a n c i a l  or work  problems and a f o u r t h s t a t e d work problems, but thought he  - 81 was r e c e i v i n g a l o t o f h e l p from the C l i n i c and therapy group f o r t h i s  difficulty.  Three people n o t l o o k i n g f o r work were a l l over 60 and were r e t i r e d . problems.  They s t a t e d no f i n a n c i a l or work  The remaining  person  young man with 3 c h i l d r e n . tance, was diagnosed ized twice.  not l o o k i n g f o r work was a  He was l i v i n g on S o c i a l A s s i s -  as s c h i z o p h r e n i c , and had been h o s p i t a l -  He h a d a u n i v e r s i t y degree.  He thought he had  f i n a n c i a l and work problems, but was not r e c e i v i n g any h e l p . A l l were t a k i n g  medication.  Work Needs o f the M a r r i e d Woman There were 2 married women w i t h j o b s . were not l o o k i n g f o r work.  A l l the r e s t  One woman had o b t a i n e d h e r j o b  with t h e h e l p o f t h e C l i n i c .  Both working women s t a t e d  f i n a n c i a l problems and no h e l p g i v e n . There were l£ women not l o o k i n g f o r work. S i x thought t h a t they had no f i n a n c i a l o r work problems.  One  s t a t e d a f i n a n c i a l worry and a l o t o f h e l p g i v e n by another agency.  Two s t a t e d f i n a n c i a l problems and no h e l p g i v e n , and  3 s t a t e d work problems and no help g i v e n .  Other women i n d i -  c a t e d t h a t t h e i r husbands were r e c e i v i n g S o c i a l A s s i s t a n c e , Workmen's Compensation, Veteran's sion.  Allowance, or O l d Age Pen-  Of these women a few s t a t e d f i n a n c i a l problems and  work problems and no h e l p given from other  agencies.  In summary then we f i n d the f o l l o w i n g problems and h e l p g i v e n .  - 82 Table 22.  Statement of Work Problem and Help Given  Work Problem Stated By  Help Given by Clinic  1 Single Woman Working  YES  1 Single Woman Looking f o r Work  YES  1 Married Man Working  YES  3 Married Women with Husbands on Some Assistance  YES Total  6  1 Single Man Working  NO.  1 Single Man Looking f o r Work  NO  2 Single Women Looking for Work  NO  1 Single Woman Not Looking for Work  NO  2 Married Men Working  NO  1 Married Man Not Looking f o r Work  NO  3 Married Women Not Looking for Work  NO Total  11  C. Home Needs and Help Given In this section on home needs we w i l l consider the interviewer and c l i e n t problems.  estimates of housing and housekeeping  We w i l l then look at the c l i e n t and interviewer  assessment of family relationships.  Finally,  we w i l l examine  the home needs of married and single men and women with part i c u l a r attention to those with children and those who were,  - 83 according t o interviewer estimates, coping, not coping^or p a r t i a l l y coping. C l i e n t and I n t e r v i e w e r E s t i m a t e o f Housing Problem The overwhelming m a j o r i t y o f t h e c l i e n t s r a t e d t h e i r accommodations as s a t i s f a c t o r y .  The i n t e r v i e w e r s e s t i m a t e d  h o u s i n g and neighbourhood as v e r y p o o r , p o o r , f a i r , good, v e r y good, and e x c e l l e n t .  They found 30 i n d i v i d u a l s t o have  fair  or good h o u s i n g , 9 f e l l below t h a t and 3> were above.  Similar-  l y w i t h neighbourhood, 32 p e o p l e were r a t e d as l i v i n g  ina  f a i r o r good neighbourhood. f? were i n b e t t e r a r e a s .  Seven were i n p o o r e r a r e a s , w h i l e  (Appendix B , Table 21)  Asked about t h e i r accommodations some p e o p l e comp l a i n e d t h a t t h e r e was n o t enough room.  S e v e r a l people had  more than 2 p e o p l e s h a r i n g one bedroom.  A t l e a s t £ accommo-  d a t i o n s were i n t h e s k i d row o f downtown Vancouver:  dingy  s i n g l e rooms g e n e r a l l y u n a t t r a c t i v e and d i r t y . U s u a l l y p e o p l e l i v e d i n t h e i r r e s i d e n c e s f o r some time.  T h i r t y had been i n t h e i r home over a y e a r .  The o v e r -  whelming m a j o r i t y o f people had. been out o f h o s p i t a l under 6 months. C l i e n t and I n t e r v i e w e r E s t i m a t e v o f Housekeeping  Problems  The i n t e r v i e w e r s a l s o r a t e d t h e housekeeping s t a n d ards.  They c o n s i d e r e d 30 t o have f a i r t o good housekeeping,  7 t o have poor o r v e r y p o o r , and t h e r e m a i n i n g 7 t o have v e r y good.  (Appendix B , Table 21)  - 81+ About h a l f o f the p e o p l e p r e p a r e d meals handled third  t h e g r o c e r y money, a n d d i d t h e c l e a n i n g .  d i d t h e shopping  tasks,  themselves,  and l a u n d r y .  notably the cleaning.  took household  Some p e o p l e  shared  In other situations,  responsibility,  especially  and t h e h a n d l i n g o f g r o c e r y money.  or f a i r l y  these  others  f o r the shopping  O n l y f> p e o p l e  were u n s a t i s f i e d w i t h t h e housework s i t u a t i o n . t h a t t h e y were s a t i s f i e d  About one-  satisfied.  said  they  Thirty  thought  (Appendix  B,  T a b l e s 2 3 a n d 2i\) In plained it, to  t h e probe q u e s t i o n s about  o f t h e housework.  Some s a i d t h e y h a d no i n t e r e s t i n  o t h e r s s a i d t h e y h a d no e n e r g y keep i t up.  conditions  About  satisfactory  I n t e r v i e w e r and C l i e n t Most p e o p l e  of  in filthy  b u t some h a d f a m i l i e s .  living  felt  that  them.  others understood  felt  that  them.  Those  of Family  Problems  they understood  When we compared  they understood  o t h e r s and understanding  found  that  o t h e r s more  understanding o f the people  B, T a b l e 2 k )  than  I n t h e p r o b e q u e s t i o n s i t seemed, t o  i n t e r v i e w e r s t h a t many o f t h e s e p e o p l e h a d a r a t h e r  ficial  who  or r e l a t i v e s had  o t h e r s w i t h o t h e r s u n d e r s t a n d i n g them, we generally  Many o f  conditions.  Assessment  others understood  people  the  lived  a n d were s a t i s f i e d w i t h t h e h o u s e k e e p i n g .  i n b o a r d i n g homes o r w i t h f r i e n d s  relatively  that  t o do i t a n d no a m b i t i o n  a h a l f dozen people  t h e s e were s i n g l e p e o p l e , lived  a d o z e n women com-  they l i v e d w i t h .  super-  (Appendix  - 85 -  Only 7 people thought t h a t t h e i r r e l a t i o n s h i p w i t h t h e i r f a m i l y was poor or v e r y poor.  The remaining 27  that t h e y got a l o n g w e l l or v e r y w e l l . s t a t e d t h a t he o f t e n thought  thought  Only one person  o f l e a v i n g , although about one-  t h i r d c o n s i d e r e d i t sometimes. A c c o r d i n g t o the i n t e r v i e w e r s , i t seemed that about h a l f a dozen people had good r e l a t i o n s w i t h t h e i r The  spouses were r e a l i s t i c and s u p p o r t i v e .  had adjustment little  contact:  problems, but were managing.  spouses.  S e v e r a l people A number had.  they were " l e a v i n g each other a l o n e . "  Another h a l f a dozen were c o n t i n u a l l y q u a r r e l l i n g ,  fighting  over money problems, and d r i n k i n g h e a v i l y . C h i l d r e n presented some problems. about o l d e r c h i l d r e n : behavior.  Some w o r r i e d  t h e i r r e b e l l i o n and "boy c r a z y "  Smaller c h i l d r e n were d i s c i p l i n e problems and a  source o f f r u s t r a t i o n t o some of the m a r r i e d women. Other i n d i v i d u a l s were l i v i n g w i t h t h e i r f a m i l y of o r i e n t a t i o n .  There were f r i c t i o n s i n these homes.  Home Needs o f the S i n g l e Man For home needs we w i l l c o n s i d e r any statement p e r s o n a l , m a r i t a l , or other f a m i l y problems.  of  The i n t e r -  viewers assessed l\ i n d i v i d u a l s as not coping, 5> as p a r t i a l l y coping and 2 as c o p i n g .  Again background i n f o r m a t i o n i s p r o -  v i d e d on each group to h e l p the reader make a f u l l e r a s s e s s ment . The 1* i n d i v i d u a l s who were not coping ranged  i n age  -. 86 - . from  30-50  years.  .  Three were s c h i z o p h r e n i c and o n l y one had.  been h o s p i t a l i z e d l e s s than three times. s e l v e s and none was working.  Three lived, by them-  None o f these men s t a t e d any  p e r s o n a l or f a m i l y problems and no h e l p was i n d i c a t e d . One man was not t a k i n g m e d i c a t i o n . Those p a r t i a l l y c o p i n g ranged i n age from 20-lj.O A l l had been h o s p i t a l i z e d 3 times or more.  years.  schizophrenics.  One l i v e d by h i m s e l f , one boarded, one l i v e d  w i t h a b r o t h e r and 2 l i v e d w i t h mothers. their  present addresses  not moved from t h e i r persons  help.  Two had r e s i d e d a t  l e s s than 6 months and the other 3 had  families.  Only one had a j o b . Three  s t a t e d a p e r s o n a l problem.  problems.  Most were  Three l i s t e d other f a m i l y  None of these men said, t h a t they had. r e c e i v e d any  Three were t a k i n g medication and 2 were n o t . The  two men who c o u l d cope both had j o b s .  w i t h f r i e n d s and. the other by h i m s e l f .  One l i v e d  No problems were s t a t e d  by these 2 men and no h e l p g i v e n . Home Needs o f the S i n g l e Woman There were 3 women who the i n t e r v i e w e r s e s t i m a t e d were n o t coping, 5 who were p a r t i a l l y coping and one who was coping. The 3 women who were n o t coping were o l d e r . A l l were s c h i z o p h r e n i c and had been h o s p i t a l i z e d 2, h, and 6 t i m e s . Two l i v e d by themselves and one w i t h a s i s t e r .  One had  r e c e n t l y moved and the o t h e r 2 had. l i v e d i n t h e i r f o r over one y e a r .  residence  One had a j o b . Two o f these women s a i d  -  8 7  -  t h a t t h e y had no problems and were r e c e i v i n g no h e l p . third  The  s t a t e d a p e r s o n a l and other f a m i l y problem and thought  she was g e t t i n g some h e l p from the C l i n i c f o r these problems. For those p a r t i a l l y coping there was an age range from  20-70  years.  Three were diagnosed  2 as d e p r e s s i v e r e a c t i o n . 7 times.  They were h o s p i t a l i z e d from one t o  One l i v e d i n a boarding house, one with h e r s i s t e r ,  one w i t h her mother and daughter son.  as s c h i z o p h r e n i c and  and one w i t h h e r p a r e n t s and  The f i f t h l i v e d alone w i t h h e r c h i l d r e n .  Three o f these  women s a i d they had no problems and were n o t g e t t i n g any h e l p . The other two women both had. c h i l d r e n and s t a t e d p e r s o n a l and other f a m i l y problems.  Both f e l t t h a t they were g e t t i n g some  h e l p from the C l i n i c . One person was c o p i n g . h o s p i t a l i z e d o n l y once. hotel.  She was £ 0 years o l d , had been  T h i s person had. a j o b and l i v e d i n a  She s t a t e d no problems and no help g i v e n .  Home Needs o f t h e M a r r i e d Woman Twelve o f t h e m a r r i e d women had young c h i l d r e n , 2 had o l d e r c h i l d r e n and 3 bad no c h i l d r e n i n t h e home.  The  i n t e r v i e w e r s found t h a t 6 were coping, 8 p a r t i a l l y c o p i n g and 3 were not c o p i n g . A l l 3 o f those women not coping had c h i l d r e n . woman s a i d she had no problems and r e c e i v e d no h e l p .  One  Another  mentioned, a p h y s i c a l problem and, was g e t t i n g no h e l p .  The t h i r d  s t a t e d m a r i t a l and other f a m i l y problems.  that she  She thought  was g e t t i n g some h e l p f o r these problems from other a g e n c i e s .  -  8 8  -  One woman was n o t t a k i n g m e d i c a t i o n . Two o f the 8 women who were p a r t i a l l y coping had no children.  Both expressed p h y s i c a l problems and one a p e r -  s o n a l problem. women i n t h e i r  No h e l p was r e c e i v e d .  There were 2 young  twenties and k o l d e r women i n t h e i r  Two o f the o l d e r women s a i d t h e y had no problems. o l d e r women s a i d they had m a r i t a l problems. Both young women thought problems.  forties. Two other  No h e l p was g i v e n .  they had m a r i t a l and other f a m i l y  One s a i d t h a t she was o b t a i n i n g some h e l p f o r  these problems and. the other s a i d she was r e c e i v i n g a l o t o f h e l p from the C l i n i c and from other a g e n c i e s . One woman without c h i l d r e n was c o p i n g .  She ex-  pressed p h y s i c a l , m a r i t a l and other f a m i l y problems. thought  She  she r e c e i v e d some h e l p f o r h e r other f a m i l y problems. There were 5> women w i t h c h i l d r e n who were c o p i n g .  Three people expressed p h y s i c a l problems: r e c e i v i n g some h e l p . 3 thought  2 f e l t they were  Four women s t a t e d p e r s o n a l problems and  they had h e l p g i v e n .  Three l i s t e d m a r i t a l problems  but none were g e t t i n g any h e l p f o r t h i s problem.  Three  s t a t e d other f a m i l y problems and. a g a i n no help was g i v e n . A l l these women were on m e d i c a t i o n . Home Needs o f the M a r r i e d Man Four o f these 8 men l i v e d w i t h t h e i r  spouses only,  3 w i t h t h e i r spouse and. c h i l d r e n and one w i t h h i s spouse and parents.  There were only 2 men who had dependent c h i l d r e n .  One o f these w i t h c h i l d r e n had a j o b and. the other was on  8 9 -  -  Social Assistance. and were i n t h e i r  Both o f these men had u n i v e r s i t y  degrees  t h i r t i e s and f o r t i e s .  Pour people s t a t e d no problems and no h e l p g i v e n . One man s t a t e d a m a r i t a l and other f a m i l y problem.  Another  s t a t e d a p e r s o n a l problem and a t h i r d s t a t e d p h y s i c a l and other f a m i l y problems. help.  None o f these people r e c e i v e d any  One man c o n s i d e r e d that he had a m a r i t a l problem and  s a i d he g o t a l o t o f h e l p through group In  therapy.  summary we f i n d :  Table 2 6 .  Statement o f Home Problem and Help Given By C l i n i c " "  Home Problem S t a t e d by  Help Given by C l i n i c  1 S i n g l e Woman Not Coping 2 S i n g l e Women P a r t i a l l y  YES Coping  YES  1 M a r r i e d Woman Not Coping 2 M a r r i e d Women P a r t i a l l y  YES  Coping  YES  6 M a r r i e d Women Coping  YES  1 M a r r i e d Man  YES Total  13 3 S i n g l e Men P a r t i a l l y  Coping  2 M a r r i e d Women Not Coping l\ M a r r i e d Women P a r t i a l l y 2 M a r r i e d Women Coping 3 M a r r i e d Men  14  NO NO  Coping ^  NO NO NO Total  - 90 -  In t h i s chapter we have examined the c h a r a c t e r i s t i c s o f the sample and explored, t h e i r  s o c i a l , work, and home needs.  We have d i v i d e d the sample i n t o married and. s i n g l e , men and women and d i s c u s s e d each group s e p a r a t e l y .  We have t r i e d t o  give the r e a d e r some background i n f o r m a t i o n on each group that would prove u s e f u l i n a s s e s s i n g the potential;, o f these people  for  treatment. In t h e next  chapter we w i l l d i s c u s s the s i g n i f i c a n c e  o f our f i n d i n g s i n r e g a r d t o an assessment o f the s e r v i c e s p r e s e n t l y p r o v i d e d f o r the d i s c h a r g e d p a t i e n t .  GHAPTER 5 SIGNIFICANCE OF THE FINDINGS OF THE PATIENT QUESTIONNAIRE A.  Introduction In examining the  f i n d i n g s of our p a t i e n t q u e s t i o n -  n a i r e , one must be cautioned, to a v o i d making g e n e r a l i z a t i o n s about the sample.  In the  f i r s t p l a c e , some problems arose  in  the s e l e c t i o n o f the sample so the l\$ s u b j e c t s do not  con-  s t i t u t e a t r u l y random sample.  course,  Secondly, t h i s i s , o f  an e x p l o r a t o r y study and there i s no c o n t r o l group w i t h which t o compare the r e s e a r c h sample.  Some o f the needs t h a t  we  b e l i e v e are c h a r a c t e r i s t i c of our sample, c o u l d w e l l be c h a r a c t e r i s t i c of persons i n the g e n e r a l  population.  Because o f the i n c o n c l u s i v e n e s s o f data, the w r i t e r s are o f t e n only a b l e to speculate on problems and unmet needs that appear t o be p r e s e n t . questions  We  do b e l i e v e , however, t h a t the  posed i n t h i s chapter  i t y f o r f u r t h e r study concerning mental p a t i e n t s and to meet these  are i n d i c a t i v e of the necessunmet needs o f  discharged  the o r g a n i z a t i o n of community s e r v i c e s  needs.  To l o o k at our sample more s p e c i f i c a l l y , we that one  believe i  o f the most s i g n i f i c a n t f e a t u r e s i s the f a c t t h a t  $Q percent were diagnosed as s c h i z o p h r e n i c . i s i n l i n e w i t h the g e n e r a l l y accorded  T h i s percentage  i n c i d e n c e of the  - 92  diagnoses Clinic  -  o f a l l those p a t i e n t s a t t e n d i n g the A f t e r Care  i n Burnaby, B. C.  The d e b i l i t a t i n g e f f e c t s o f the  disease must c o n s t a n t l y be kept  i n mind.  I t i s o f t e n i n s i d i o u s i n onset, preceded, by gradual f a i l u r e i n a number o f areas of l i f e . Although treatment b r i n g s about a r e m i s s i o n o f acute symptoms, i t might be thought o f an e s s e n t i a l l y a c h r o n i c . p h a s i c d i s o r d e r r a t h e r than as a r e l a p s i n g d i s o r d e r because I t o f t e n l e a v e s a d e f e c t t h a t continues to h a n d i cap the a f f l i c t e d , i n d i v i d u a l between acute e p i s o d e s . Throughout the a n a l y s i s o f our p a t i e n t q u e s t i o n n a i r e , the f a c t that t h e r e i s such a h i g h percentage of our s u b j e c t s w i t h the diagnosis of schizophrenia, i s r e f l e c t e d t i o n s r a i s e d and  i n many o f the ques-  suggestions made.  I n i t i a l l y , we are i n t e r e s t e d i n the g e n e r a l p i c t u r e presented  of the s e r v i c e s g i v e n a t the A f t e r Care  Clinic.  B. S e r v i c e s Rendered To go back t o the time o f d i s c h a r g e o f the the mental h o s p i t a l , we percent  f i n d i t q u i t e s u r p r i s i n g t h a t i n 3k  o f the cases the s u b j e c t s s t a t e t h a t the h o s p i t a l  made no leave p l a n f o r them. reasons  sample from  We might speculate on s e v e r a l  f o r the apparent omission  rehabilitation.  First  of a l l ,  had  o f t h i s e s s e n t i a l phase o f  i t might be as the p a t i e n t s  s t a t e , t h a t no leave plans were made.  Secondly,  i t might be  that i f made, they weren't communicated adequately  1. Cumming, E l a i n e and John. "Some Questions Care." Canada's Mental H e a l t h , 1 3 ( 6 ) , p. 9<>  t o the  on Community  - 93  -  p a t i e n t or t h i r d l y , perhaps the  s u b j e c t s we  r a t h e r hazy on what had been done. contact  interviewed  I t i s considered  were  that  by the h o s p i t a l p s y c h i a t r i s t or s o c i a l worker w i t h  r e l a t i v e s i s a l s o an e s s e n t i a l f a c t o r i n d i s c h a r g e but a c c o r d i n g  t o some o f the p a t i e n t s t h i s contact  planning was  not  always made. The  subjects  of our  they are concerned about. the A f t e r Care C l i n i c  sample express 72  problems that  I t i s i n t e r e s t i n g t o observe that  i s giving assistance  on 20 o f these  problems whereas the community agencies are g i v i n g help 35  o f the problems.  Such community agencies and  on  individuals  are the P u b l i c H e a l t h Nurse, school c o u n s e l l o r s , P r o v i n c i a l Department o f R e h a b i l i t a t i o n , C i t y S o c i a l S e r v i c e , Department o f Veterans A f f a i r s , Outpatient Vancouver General H o s p i t a l .  We  Department of the  might wonder i n what  way  these agencies became i n v o l v e d w i t h the p a t i e n t s , i . e . r e f e r r a l s were made by h o s p i t a l or A f t e r Care C l i n i c sonnel.  Initially,  per-  of course, the making of r e f e r r a l s i s the  r e s p o n s i b i l i t y of the h o s p i t a l a t the time of d i s c h a r g e the p a t i e n t .  One  noted a g a i n and  of  of the most s i g n i f i c a n t concepts t h a t i s  again i n the l i t e r a t u r e  necessity of continuity of care. u i t y of care r e q u i r e s  "The  i s that o f p r i n c i p l e of  the contin-  the c l o s e s t p o s s i b l e c o - o p e r a t i o n  i n t e g r a t i o n between the v a r i o u s staff."  if  s e r v i c e s and  and  professional  1  1. Canadian Mental H e a l t h A s s o c i a t i o n . More f o r the Mind. 52 S t . C l a i r Ave., Toronto, Ont., 1963, p. 1+1+.  -  91+ -  When asked the q u e s t i o n  as t o whether t h e i r  difficul-  t i e s had improved since coming t o A f t e r Care, 12 persons o f the t o t a l k5 r e p l y "not a t a l l " and 16 say "somewhat." Although i t i s d i f f i c u l t  t o assess the v a l i d i t y o f t h e i r  r e p l i e s , we might look a t the f a c t s o f the s e r v i c e s a v a i l a b l e , i.e.  3U o f the kf> p a t i e n t s see the p s y c h i a t r i s t s f o r  1-15  minutes and f o r a l l p r a c t i c a l purposes no s o c i a l s e r v i c e h e l p i s giveni t o them. The  w r i t e r s cannot h e l p but f e e l t h a t i t i s somewhat  i n c r e d i b l e that l+lf. s u b j e c t s o f the k£ t o t a l sample s t a t e t h a t they have no c o n t a c t w i t h a s o c i a l worker.  Many o f the  problems the s u b j e c t s note - f i n a n c i a l , employment, m a r i t a l , f a m i l y - f o r which they r e c e i v e no h e l p would r e q u i r e the p a r t i c u l a r corapentence o f t h e f u l l y - t r a i n e d s o c i a l worker to deal w i t h - the c a p a c i t y t o understand the p a t i e n t arid his  f a m i l y , the knowledge o f the community and i t s r e s o u r c e s ,  and the s k i l l r e q u i r e d t o b r i n g p a t i e n t and r e h a b i l i t a t i o n services together.  Once a g a i n ,  t h a t w i t h the r a p i d discharge  we f e e l t h a t we must  repeat  p o l i c i e s now i n e f f e c t , the  p a t i e n t cannot be expected t o m a i n t a i n any t h e r a p e u t i c gains made i n h o s p i t a l u n l e s s he r e c e i v e s adequate a f t e r c a r e service. I f the community as a whole i s t o be served,  treat-  ment i n most cases must be based mainly on s u p p o r t i v e , r e a l i t y - o r i e n t e d therapy p l u s p h a r m a c o l o g i c a l and e n v i r o n mental l i n e s .  As s t a t e d above, 71+ percent  sample see the p s y c h i a t r i s t 1 - 15 minutes.  (31+) o f the His  - 95 treatment then i s going to be l i m i t e d to d i s p e n s i n g and very b r i e f , be the coming  supportive  "therapy."  ^ h i s may,  medication  of course,  trend.  Should the p h y s i c i a n perhaps, be r e s p o n s i b l e f o r d i a g n o s i s , m e d i c a l treatment and f o l l o w up and leave to others who may be more s k i l l e d and more a p p r o p r i a t e l y t r a i n e d the problems of d e a l i n g w i t h the s o c i a l , v o c a t i o n a l and other aspects o f the p a t i e n t ' s t o t a l needs? 1  We  are  suggesting,  then, that one  of the most obvious l a c k s  i n meeting the needs o f the p a t i e n t s o f the A f t e r Care C l i n i c i s the almost t o t a l absence, at l e a s t i n our tial  sample, o f essen-  s o c i a l work, c o u n s e l l i n g or r e h a b i l i t a t i v e We  s t a t e d t h a t 58 percent  as s c h i z o p h r e n i c .  services.  o f our sample were diagnosed  T h i s mental d i s o r d e r i s the  outstanding  problem f o r comprehensive community p s y c h i a t r i c s e r v i c e s . H o s p i t a l s can r e a d i l y o b t a i n a r e m i s s i o n  which j u s t i f i e s  dis-  charge, yet a l l too o f t e n t h i s i s f o l l o w e d by e a r l y r e l a p s e i n the community. extent  I t i s true t h a t we r e a l l y don't know t o what  a comprehensive community s e r v i c e can r e l i e v e  c h r o n i c handicaps o f s c h i z o p h r e n i a .  the  However, i t i s g e n e r a l l y  agreed t h a t an a f t e r c a r e s e r v i c e i n c r e a s e s  the chances o f 2  p a t i e n t s being a b l e to remain i n the community.  Some s t u d i e s  show t h a t organized  mental  follow-up  care o f discharged  p a t i e n t s can cut readmission r a t e s by about h a l f .  Therefore,  although there are g r e a t gaps i n knowledge concerning  a mental  1. Roberts, C. A. "Community P s y c h i a t r y - I n t e g r a t i o n or More S p e c i a l i z a t i o n ? " Canada's Mental H e a l t h . 13(6), 1965. 2.  Free and Dodd, op. c i t .  - 9 6 d i s o r d e r such as s c h i z o p h r e n i a , the problem remains o f p r o v i d i n g as e f f e c t i v e an a f t e r c a r e s e r v i c e as i s p o s s i b l e a t the present  time.  E i g h t y - f o u r percent of our sample are t a k i n g medication.  As noted i n Chapter  2, although the c o n t i n u e d use  of  medication i s f e l t t o be h e l p f u l , the p s y c h o l o g i c a l and s o c i e t a l r e h a b i l i t a t i o n a p p a r e n t l y p l a y the most roles.  significant  Once again, as w i l l be r e p e t i t i o u s l y noted  through  t h i s study, we must p o i n t a t the l a c k of s o c i a l s e r v i c e tact.  con-  We might query what b e n e f i c i a l e f f e c t the drugs are  r e a l l y having on these 38 p a t i e n t s when f o r most of them there i s an absence o f the r e h a b i l i t a t i o n s e r v i c e s b e l i e v e d t o be the most  important. S i x t y percent  (27)  of the sample a r e b e l i e v e d by  the  i n t e r v i e w e r s to be f u n c t i o n i n g m i n i m a l l y or l e s s than m i n i mally i n the community.  A l t h o u g h the accuracy of t h i s  figure  can be questioned, i t does seem t o be o f s i g n i f i c a n c e i n bearing  out the o p i n i o n s o f former p a t i e n t s of the mental h o s p i t a l  that t h e i r needs are not being met  adequately.  C. Needs o f the Sample 1 . Work Needs "Fundamental to adequate s o c i a l adjustment a b i l i t y t o c a r r y on a l i f e means engaging  task.  i s the  F o r most a d u l t men  this  i n a g a i n f u l occupation; f o r women i t may  be  e i t h e r homemaking or employment o u t s i d e the home."^" With t h i s  1 . Rose, A. Mental H e a l t h and. Mental D i s o r d e r . W. Norton Inc., New York, 1 9 5 5 , p. 5 0 b " .  W.  - 97  -  i n mind we  wish to look at the employment p a t t e r n of  subjects.  While we  recognize  t e n t a t i v e because of the  t h a t any  conclusions  must be  s i z e and s e l e c t i o n of the  sample,  f e e l j u s t i f i e d i n making c e r t a i n comments about f a c t o r s that appear to stand out r a t h e r To l o o k at the g e n e r a l s e v e r a l a s p e c t s that c o u l d be instance  our  we  employability  sharply.  employment p i c t u r e , we significant.  We  find  note f o r  that s i x o f the 13 persons working complain o f slow-  ness, l a c k o f energy and  co-ordination.  people express c o n s i d e r a b l e and others  hesitancy  about l o o k i n g f o r work  are a f r a i d t o l o o k a t a l l .  i f these problems could be due  F i v e unemployed  I t might be wondered  to temporary or long-term  r e s i d u a l e f f e c t s of the mental i l l n e s s ,  e f f e c t s of any  medi-  c a t i o n they are t a k i n g or t o l o s s of t h e i r former a b i l i t y  to  f u n c t i o n more adequately. We  have a p i c t u r e here then o f approximately  t h i r d of our speculate  sample e x p r e s s i n g  unmet needs.  We  can  what would be necessary t o meet these.  oneonly  I t might  be that the o v e r a l l e f f e c t of the medication should be examined, that work assessments should be made, that r e - t r a i n i n g or s h e l t e r e d work placements should be  explored.  Of the 11 s i n g l e male s u b j e c t s , seven are unemployed whom we  might normally expect t o be employed i n our  To look at t h i s more c l o s e l y , we  are able t o a s c e r t a i n some  o f the p o s s i b l e reasons f o r unemployment. o f frequent  relapses  society.  We  have a p i c t u r e  i n mental i l l n e s s and. s e v e r a l of these  9 8  -  s u b j e c t s have l i m i t e d e d u c a t i o n . diagnosed as s c h i z o p h r e n i c .  -  Of the seven, s i x have been  As noted, e a r l i e r ,  schizophrenia  o f t e n l e a v e s a defect t h a t continues t o handicap the a f f e c t e d i n d i v i d u a l s between acute  episodes.  We have t o c o n s i d e r t h a t  many o f these persons may not have a c q u i r e d work s k i l l s  or an  employment h i s t o r y h e l p f u l i n p l a n n i n g any r e h a b i l i t a t i o n . Although we might assume t h a t p o s s i b l y s e v e r a l might not be able t o meet the demands and. p r e s s u r e s  of private industry,  they might be a b l e t o do a l i m i t e d amount o f work under sheltered conditions.  We have t o remember, o f course,  that  f r e q u e n t l y the problem i s c h a r a c t e r i z e d l e s s by the n e c e s s i t y o f f i n d i n g work f o r the p a t i e n t than the need t o s u s t a i n him p s y c h o l o g i c a l l y so t h a t he w i l l not have t o r e t u r n t o t h e hospital. A.s f a r as the married men a r e concerned, one man only i s on S o c i a l A s s i s t a n c e . U n i v e r s i t y education. action, paranoid  T h i s man aged 3h has a s p e c i a l i z e d  H i s d i a g n o s i s was s c h i z o p h r e n i c r e -  type.  case, b u t the complexity  He i s , o f course, a very  isolated  o f problems i n r e h a b i l i t a t i o n and  treatment are p o i n t e d out here - the n e c e s s i t y t o look at the s e v e r i t y o f i l l n e s s , the home s i t u a t i o n , c u l t u r a l background, pressures  of responsibility.  A  l l  o f these f a c t o r s would be  o f importance i n h i s c a p a c i t y t o be employed and would, have to be taken i n t o c o n s i d e r a t i o n i n order t o be able to p l a n adequately  t o meet h i s needs.  The s u b j e c t i n question  stated  he was not r e c e i v i n g any help f o r h i s employment problems from e i t h e r the A f t e r Care C l i n i c o r any other  agencies.  9 9  -  Two  -  o f the nine s i n g l e women a r e on S o c i a l A s s i s t a n c e  and both r e q u i r e c o n s i d e r a b l e h e l p .  Both were diagnosed a s  One, a young woman o f 2 6 has a h i s t o r y o f  schizophrenic.  seven or more h o s p i t a l i z a t i o n s .  She has l e s s than a Grade  nine education and no s p e c i a l work t r a i n i n g . her p a r e n t s .  She l i v e s w i t h  From the f i l e s we know t h a t i t i s b e l i e v e d h e r  environment i s not conducive accommodation i n a halfway  t o her improvement„  Alternative  house had been a r r a n g e d f o r h e r a t  one p o i n t but she had d e c l i n e d t o t r y i t and r e t u r n e d t o h e r f a m i l y ' s home. suggest  Now that the p a t i e n t has r e t u r n e d , t h e w r i t e r s  that h e r needs might be best met by g i v i n g casework  s e r v i c e s t o t h e f a m i l y and by endeavoring s u s t a i n h e r i n the community.  to psychologically  The other woman on S o c i a l  A s s i s t a n c e , aged I4I, has Grade e i g h t e d u c a t i o n only, has done housework a t one time, and was a t the time o f our c o n t a c t from the i n t e r v i e w e r ' s impression, incapable of h o l d i n g a job. Both o f these two s i n g l e unemployed women s t a t e t h a t they a r e not r e c e i v i n g any s o c i a l s e r v i c e h e l p through t h e A f t e r Care C l i n i c o r from any other community agency. however, f e e l s she r e c e i v e s some h e l p from her  One,  psychiatrist  at the A f t e r Care C l i n i c f o r h e r p e r s o n a l problems. Concerning  the m a r r i e d women, a s i g n i f i c a n t f a c t f o r  the purposes o f our study i s brought out.  Some of the women  s u b j e c t s who s t a t e t h e i r husbands a r e on S o c i a l A s s i s t a n c e or a r e r e c e i v i n g pensions  o f some type, i n d i c a t e there a r e  f i n a n c i a l and work problems i n the home.  We might wonder t o  - 100  what extent  -  the women's mental i l l n e s s i s a f f e c t e d by  economic s i t u a t i o n or c o n v e r s e l y , t o what extent s t a t u s i s a f f e c t e d by the i l l n e s s . r e s p o n s i b l e f o r g i v i n g these  We  their  the work  might ask who  is  f a m i l i e s some type of s e r v i c e ?  Would i t be community agencies  or the A f t e r Care C l i n i c ?  Because o f u n c e r t a i n t y , would no one  feel  responsible?  2. S o c i a l Needs There are two  aspects t h a t should be  when a s s e s s i n g the s o c i a l adjustment of our  borne i n mind sample.  In  the  f i r s t p l a c e our middle c l a s s Canadian c u l t u r e i s s t r o n g l y o r i e n t e d toward s o c i a l a c t i v i t y . who  However, not a l l persons  are d i s c h a r g e d mental p a t i e n t s come from such backgrounds  and t h e i r v a l u e s and those the middle c l a s s norm.  of t h e i r f a m i l i e s may  Secondly, although  d i f f e r from  a pattern of  s o c i a l a c t i v i t y might seem q u i t e r e s t r i c t e d to the viewers,  i t has been found t h a t former p a t i e n t s Who  t h e i r e x i s t e n c e , although  interf e e l that  i t might be l o n e l y and i n a c t i v e , i s  consonant w i t h t h e i r p r e f e r e n c e s , a d j u s t s i g n i f i c a n t l y b e t t e r than do those who l e v e l . ^ We  seem t o p r e f e r a g r e a t e r or l e s s e r a c t i v i t y  have to keep i n mind, a l s o , that those who  numerous a c t i v i t i e s and  have  i n t e r e s t s d i s p l a y a more s u c c e s s f u l  l e v e l o f adjustment i n g e n e r a l . F i v e o f the s i n g l e men poor s o c i a l c o n t a c t s had  i n our sample who  have v e r y  the d i a g n o s i s of s c h i z o p h r e n i a  none are r e c e i v i n g any h e l p i n the  s o c i a l i z a t i o n area.  1. Minnesota, op. c i t . . S e c t i o n D, p.  9.  and Per-  - 101 sons s u f f e r i n g from t h i s d i s o r d e r u s u a l l y f i n d i t hard t o relate to others.  Part o f t h e treatment  i n hospital i s directed  to t h e i r r e s o c i a l i z a t i o n , but u n f o r t u n a t e l y , any t h e r a p e u t i c advances made d u r i n g h o s p i t a l i z a t i o n may w e l l disappear i f f o l l o w i n g d i s c h a r g e the p a t i e n t has no f u r t h e r o p p o r t u n i t y for s o c i a l contact.  I n a l l o f Vancouver, there i s o n l y one  s o c i a l i z a t i o n resource with services s p e c i f i c a l l y f o r p a t i e n t s d i s c h a r g e d from R i v e r v i e w H o s p i t a l .  This i s the White  Cross  S o c i a l Center o f the Canadian Mental H e a l t h A s s o c i a t i o n . An i n t e r e s t i n g p o i n t t o the i n t e r v i e w e r s i s t h a t none o f the s i n g l e men and women who a r e f e l t  t o have v e r y poor  s o c i a l i z a t i o n a c t i v i t i e s are being g i v e n any h e l p by the C l i n i c or any other agency.  Y e t the three s i n g l e women who  have been helped, have f a i r s o c i a l c o n t a c t s , and are a b l e to s t a t e t h a t they have problems.  We might ask i f any help t h a t  i s g i v e n i s d i r e c t e d t o t h e i n d i v i d u a l s who have more h o p e f u l prognoses and who a r e able t o v e r b a l i z e t h e i r  difficulties,  and the persons w i t h the l e a s t h o p e f u l prognoses and p o o r e s t communication a b i l i t i e s ,  are n e g l e c t e d .  We might  suggest  that the l a c k o f h e l p g i v e n seems bound t o be r e f l e c t e d i n the h i g h r e - h o s p i t a l i z a t i o n r a t e and. c o u l d assume the form of a vicious  circle. We observe t h a t most people  are not s a t i s f i e d w i t h  t h e i r s o c i a l l i f e and we r e c e i v e a r a t h e r g e n e r a l f e e l i n g o f hopelessness situation.  i n the comments made concerning t h e i r e n t i r e We might remember t h a t i t i s i n the v e r y  nature  - 102  -  of mental i l l n e s s that p a t i e n t s g i v e up h e l p i n g themselves or or o f t e n even seeking  necessary a s s i s t a n c e .  require a reaching-out s e r v i c e . these people are e x p r e s s i n g  We  They t h e r e f o r e  are suggesting  then, t h a t  unmet needs, t h a t some s e r v i c e  must r e a c h them i f they are to be more " i n " the community, j u s t on the  periphery.  A very t h a t not one  s i g n i f i c a n t p o i n t i n l i n e w i t h the  o f the p a t i e n t s i s involved, i n any  i t i e s that the A f t e r Care C l i n i c Mental H e a l t h  Center.  F o r one  above i s  social  sponsors a t the  t h i n g , the C l i n i c  activ-  Burnaby i s located  i n a p l a c e very awkward t o reach except by automobile.  It is  a l s o of note t h a t the C l i n i c i a located, i n Burnaby, w h i l e g r e a t e r p o r t i o n of the p a t i e n t a l i v e i n Vancouver.  hood, o f u t i l i z i n g a community p s y c h i a t r i c clinic  likeli-  productively  decreases i n p r o p o r t i o n  to the d i s t a n c e  t r a v e l to r e a c h i t . We  know t h a t the inconvenient  and  the  The  C a l i f o r n i a Survey"'' observed t h a t i t appears t h a t the  the d i s t a n c e  not  the p a t i e n t must location,  cost of the t r a n s p o r t a t i o n make i t d i f f i c u l t  f o r many p a t i e n t s t o come t o the  C l i n i c f o r treatment.  There-  f o r e , u n l e s s he has ready t r a n s p o r t a t i o n and happena to l i v e near the C l i n i c , he  i s u n l i k e l y to u t i l i z e any s o c i a l  activ-  ities. 3.  Home Needs There are s e v e r a l f a c t o r s i t i s h e l p f u l to keep i n  mind w h i l e l o o k i n g at the home needs of the s u b j e c t s .  1.  C a l i f o r n i a , op.  c i t . , p.  7.  One  is  - 103 t h a t s t u d i e s have shown t h a t i n f a m i l i e s where t h e r e i s a h i g h emotional involvement between t h e p s y c h o t i c p a t i e n t and one or more f a m i l y members and where c o n t a c t w i t h them i s as l o n g as 35 hours a week, the h o s p i t a l r e a d m i s s i o n r a t e i s s i g n i f i c a n t l y h i g h e r than f o r low-involvement, patients.  1  The Minnesota  Study r e s e a r c h e r s  2  low-contact  s t a t e d t h a t one  o f t h e important f a c t o r s a f f e c t i n g h o s p i t a l i z a t i o n o f the p a t i e n t i s t h e t o l e r a n c e f e l t by r e l a t i v e s i n h i s immediate environment  f o r h i s behavior.  I t was found f o r i n s t a n c e ,  that the p a t i e n t s p l a c e d i n n u r s i n g and f o s t e r homes, a l t h o u g h they might have had a l o n g e r p e r i o d o f h o s p i t a l i z a t i o n and were c o n s i d e r e d a "poor r i s k " had a s i g n i f i c a n t l y lower r e hospitalization rate.  The o p e r a t o r s of the homes had a  greater tolerance o f deviance.  A t the same time, the study  concluded t h a t an o p t i m a l balance o f t o l e r a n c e and a n t i c i p a t i o n o f normal behavior i s important i n t h e e x - p a t i e n t ' s adjustment. Looking a t the p i c t u r e I n g e n e r a l c o n c e r n i n g home needs, we see that 2lj, o f the 1*5 s u b j e c t s have had t h r e e h o s p i t a l i z a t i o n s or more. eight h o s p i t a l i z a t i o n s . schizophrenic.  Of t h e 2 I 4 , seven have had seven o r  F i f t e e n o f the 2 i | were diagnosed as  Only one o f these 15 i s l i v i n g by h i m s e l f , i n  1. Titmuss, R i c h a r d M, "Community Care o f the Mental 111: Some B r i t i s h O b s e r v a t i o n s . " Canada's Mental H e a l t h . Supplement No. 1+9, Nov.-Dec. 1965, Department o f N a t i o n a l H e a l t h and Welfare, Ottawa, Can. p. 5. 2. Minnesota,  op. c i t . .  S e c t i o n D, p. IJ4.  - 10k a boarding home. parents,  The remainder are l i v i n g w i t h t h e i r  mothers, r e l a t i v e s and f r i e n d s .  spouses,  They a r e g o i n g t o be  i n e v i t a b l y i n v o l v e d i n the i n t e r p e r s o n a l r e l a t i o n s h i p s i n t h e home.  Me are j u s t i f i e d i n asking whether i t i a p o s s i b l e  that  the environment i a a f a c t o r i n the number o f h o a p i t a l i z a t i o n a o f these persons, and whether an a l t e r n a t i v e environment i s l e s s l i k e l y t o produce  exacerbations.  We f u r t h e r note i n t h i s c o n n e c t i o n  t h a t two young  a i n g l e men a r e l i v i n g with t h e i r mothera and. one young woman w i t h her p a r e n t a . the three phrenia  i s 15>.  The t o t a l number o f h o s p i t a l i z a t i o n s f o r Current  t h e o r i e a o f the e t i o l o g y o f s c h i z o -  i n regarda t o the e f f e c t o f f a m i l i a l environment  emphaaize even f u r t h e r the reason f o r e x p l o r i n g t h e e n v i r o n ment o f theae peraona.  None o f the three  i n g aaaiatance concerning  are c u r r e n t l y r e c e i v -  f a m i l y r e l a t i o n a h i p a , although we  know attempts had been made t o h e l p the young women i n the past. Freeman"*" s t a t e s t h a t the t r e n d o f d i s c h a r g i n g  patients  to the community who would be formerly kept h o s p i t a l i z e d due to chronic mental i l l n e a a can mean t h a t the burden ahed by the h o s p i t a l w i l l be passed on t o the f a m i l y and w i l l be  aeen i n v a r i o u s kinds  members.  eventually  o f secondary breakdowna i n f a m i l y  Repeated r e l a p a e a  o f p a t i e n t s with a l l t h e i r aasoc-  1.Freeman, Hugh. "Community Mental H e a l t h S e r v i c e s and the Mental H o s p i t a l . " Presented May 3 , 1 9 6 3 a t a Conference h e l d by the Pueblo A s s o c i a t i o n f o r Mental H e a l t h i n Pueblo, Colorado, p. l 6 k „  - 105 i a t e d s o c i a l d i s r u p t i o n s w i l l exhaust the t o l e r a n c e of r e l a t i v e s and  of the community i n g e n e r a l .  What about the s u b j e c t s w i t h c h i l d r e n ? with three or more h o s p i t a l i z a t i o n s , dren of school age  or under.  We  Of  those  (2lj), e i g h t have c h i l -  might ask o u r s e l v e s what  the repeated h o s p i t a l i z a t i o n s are doing to t h e c h i l d r e n .  Who  looks a f t e r them when the mother of a f a m i l y i s h o s p i t a l i z e d ? Homemaker s e r v i c e i s almost n o n - e x i s t e n t  i n comparison t o the  needs of the area served by t h e A f t e r Care C l i n i c .  There are  o f t e n only two a d u l t s i n the f a m i l y u n i t and i t i s very c u l t f o r the d u t i e s o f e i t h e r one other.  the  F r e q u e n t l y i t i s the c h i l d r e n i n t h e f a m i l y who  most when a parent Not  to be t a k e n over by  diffi-  suffer  i s h o s p i t a l i z e d because of mental i l l n e s s .  only are t h e r e the immediate problems i n r e l a t i o n t o the  care of the c h i l d r e n , but there are the l o n g range e f f e c t s  1 to be c o n s i d e r e d .  One  study  i n d i c a t e s t h a t c h i l d r e n coming i n -  t o the care of a c h i l d w e l f a r e o r g a n i z a t i o n are t h r e e more l i k e l y t o have a m e n t a l l y  ill  times  parent than those w i t h  o r d i n a r y background.  Of the 12 m a r r i e d women w i t h p r e -  s c h o o l or s c h o o l age  c h i l d r e n , none seem t o be o b t a i n i n g  s p e c i f i c h e l p from the A f t e r Care C l i n i c r e g a r d i n g the of t h e i r c h i l d r e n .  care  adequate a f t e r -  care program. In connection w i t h c a r r y i n g the r e s p o n s i b i l i t y  Titmuss,  any  A s s i s t a n c e t o d i s c h a r g e d mothers w i t h  c h i l d r e n would seem t o be an e s s e n t i a l of any  1.  an  loc. c i t .  of  - 106  horaemaking t a s k s , we  -  note t h a t o n l y s i x o f the 17  women seem to be coping adequately. persons  married  What happens to the  i n the r o l e s of mothers and wives?  We might ask  11 our-  s e l v e s i f the t o l e r a n c e o f the f a m i l i e s i s not b e i n g s t r a i n e d . D.  Conclusions Prom the data of our p a t i e n t q u e s t i o n n a i r e and  the  o p i n i o n s o f the s u b j e c t s as t o the ways the program meets o r f a i l s t o meet t h e i r needs, the f o l l o w i n g s a l i e n t p o i n t s have emerged: 1.  The s u b j e c t s express 72 needs, f i n a n c i a l , work, p e r s o n a l , p h y s i c a l , m a r i t a l , and others, such as f a m i l y problems. They s t a t e they are r e c e i v i n g no h e l p from the A f t e r Care C l i n i c f o r h7 of the needs but some h e l p f o r 16. On the other hand, they say they r e c e i v e some h e l p f o r 17 o f these needs and c o n s i d e r a b l e f o r 18 from community a g e n c i e s .  2 . F i f t y - e i g h t percent of the sample were diagnosed as s c h i z o p h r e n i c . T h i s f a c t must be kept i n mind when c o n s i d e r i n g how t h e i r needs must be met and t h a t a wide range o f s e r v i c e s w i l l be n e c e s s a r y . 3. In 31+ percent o f the c a s e s , the h o s p i t a l made no l e a v e p l a n f o r the p a t i e n t s and t h e r e was a l a c k of c o n t a c t w i t h " s i g n i f i c a n t o t h e r s . " k. S e v e n t y - f i v e percent of the p a t i e n t s s t a t e they see t h e i r p s y c h i a t r i s t f o r 1 - 15> minutes, u s u a l l y once a month. 5.  N i n e t y - e i g h t percent of the p a t i e n t s do not r e c e i v e social services.  6.  S i x t y percent of the s u b j e c t s , a c c o r d i n g t o t h e i n t e r v i e w e r ' s impressions, are f u n c t i o n i n g m i n i m a l l y or l e s s than m i n i m a l l y i n the community.  7.  F i f t y - t h r e e percent o f the sample have had three h o s p i t a l i z a t i o n s or more. Fourteen percent have had seven or more h o s p i t a l i z a t i o n s .  107  -  -  8. Of the 11 s i n g l e men, seven are unemployed and we have a p i c t u r e o f frequent h o s p i t a l i z a t i o n s and l i m i t e d employment o p p o r t u n i t i e s due to l a c k of e d u c a t i o n and t r a i n i n g . I t seems u n l i k e l y t h a t s e v e r a l would be able t o f u n c t i o n i n the u s u a l work s e t t i n g . Only one of these persons r e c e i v e s any h e l p from the A f t e r Care C l i n i c or community agencies i n t h i s r e g a r d . Two s i n g l e women a r e on Social Assistance. One s t a t e s she r e c e i v e s some h e l p through her p s y c h i a t r i s t at the C l i n i c conc e r n i n g work problems. 9.  F i v e of the s i n g l e men i n the sample have v e r y poor s o c i a l c o n t a c t s but s t a t e they are r e c e i v i n g no help i n t h i s area.  10. h e A f t e r Care C l i n i c s o c i a l program held, a t Burnaby, B. C. i not u t i l i z e d by any o f our sample. The w r i t e r s suggest that d i s t a n c e from Vancouver might be a reason. T  s  11. The s u b j e c t s , i n the w r i t e r s ' o p i n i o n s , are d i r e c t l y and i n d i r e c t l y e x p r e s s i n g a wide range o f needs that are not being met, such as employment, p o s s i b l e s h e l t e r e d work placements. There are needs f o r m a r i t a l and f a m i l y c o u n s e l l i n g , s o c i a l i z a t i o n and r e c r e a t i o n a l a c t i v i t y , halfway houses. I t i s the unexpressed need, s t i l l u n a r t i c u l a t e d as demand that i s the unknown We t h a t we  have posed a number of q u e s t i o n s i n t h i s chapter  judge as l e g i t i m a t e .  we have not  quantity.  We  are aware, of c o u r s e ,  been able t o o b t a i n a l l the f a c t s that are  importance i n the q u e s t i o n s r a i s e d . j u s t i f i e d i n t a k i n g note of v a r i o u s  However, we  do  p a t i e n t s through an a f t e r c a r e program. opinions  of  feel  f a c t o r s that appear t o  be o f s i g n i f i c a n c e i n meeting the needs of d i s c h a r g e d  we w i l l l o o k a t the  that  In our  mental  next chapter,  o f p r o f e s s i o n a l personnel from  Riverview H o s p i t a l w i t h r e g a r d to the present a f t e r c a r e program at Burnaby Mental H e a l t h Center and a l s o the o p i n i o n s  - 108 of v a r i o u s community agencies t h a t have contact with the d i s c h a r g e d p s y c h i a t r i c p a t i e n t s .  some o f  GHAPTER 6 QUESTIONNAIRE TO STAFF I n o r d e r t o a s c e r t a i n s t a f f a t t i t u d e towards  present  A f t e r Care program and pha purpose o f A f t e r C a r e , a q u e s t i o n n a i r e was s u b m i t t e d t o f i v e s t a f f  d o c t o r s and f i v e  social  workers who a r e e i t h e r p r e s e n t l y o r were f o r m e r l y a t t e n d i n g the A f t e r Care C l i n i c .  R e s u l t s of the enquiry i n d i c a t e very  d e c i d e d l y t h a t the s e r v i c e  i s inadequate.  (Question 1 -  Appendix C ) . A. Findings 1 . Purpose o f the A f t e r Care  Clinic.  I n the o p i n i o n o f the t e n p r o f e s s i o n a l s  questioned  the main purpose o f the A f t e r Care C l i n i c was t o p r o v i d e the d i s c h a r g e d p a t i e n t r e f e r r e d to the s e r v i c e w i t h an immediate post-hospital contact,  t h e r e b y f i l l i n g h i s dependency  and, h e l p i n g c o n t r o l a c u t e symptoms. l e a s t h a l f o f those q u e s t i o n e d ,  needs,  I n the o p i n i o n o f  symptom r e l i e f ,  at  and the  p r e v e n t i o n o f r e h o s p i t a l i z a t i o n were the main aims of the A f t e r Care C l i n i c  ( Q u e s t i o n 2 - Appendix C ) .  Pharmacotherapy  was h e a v i l y emphasized i n the A f t e r Care program ( Q u e s t i o n I4 - A p p e n d i x C ) .  The main t h e r a p i e s employed were l i s t e d as  (a) m e d i c a t i o n , (b) i n d i v i d u a l s u p p o r t i v e t h e r a p y , b r i e f r e a l i t y t h e r a p y ( Q u e s t i o n 3 - Appendix C ) .  and (c)  - 110 2.  Character of Service Both the q u a n t i t y and q u a l i t y o f the present s e r v i c e  was f e l t  t o be u n s a t i s f a c t o r y by a m a j o r i t y o f the p r o f e s s i o n a l s .  (Question 9a and 10 - Appendix C ) . 3.  Types o f P a t i e n t s R e f e r r e d Main c a t e g o r i e s o f p a t i e n t s referred, t o , or seen a t  A f t e r Care were s c h i z o p h r e n i c , s c h i z o i d , and depressed. of  the other problem types, f o r example, a l c o h o l i c s ,  Many  inade-  quate p e r s o n a l i t i e s , m a r g i n a l l y adjusted, s k i d road p a t i e n t s , and s o c i o p a t h s , i n p a r t i c u l a r , were not u s u a l l y seen a t A f t e r Care.  (Question £b and A p p d i x C ) . Q n  Obviously there a r e many  p a t i e n t s who do not r e c e i v e support from A f t e r Care nor from any other agency i n the community. h. P a r t i c i p a t i o n o f S t a f f Attendance at the A f t e r Care by the p r o f e s s i o n a l s i n t e r v i e w e d was l e s s frequent than might be expected.  As a  p o i n t f o r s e r i o u s s p e c u l a t i o n three o f the f i v e s o c i a l workers were a t t e n d i n g not a t a l l .  (Question 3>a - Appendix C ) .  Among the reasons g i v e n by the s o c i a l workers f o r not a t t e n d ing  were:  "too i n v o l v e d w i t h i n - h o s p i t a l c a s e l o a d " , "not  convinced, o f the value o f the present A f t e r Care set-up." 5>. E x t e n t o f Contact The ing  average time spent w i t h a p a t i e n t by the v i s i t -  doctor, who saw an average o f 8 p a t i e n t s i n t h r e e  was 1$ minutes.  A c t u a l time  p a t i e n t would be reduced  hours,  spent by the d o c t o r w i t h the  by time u t i l i z e d t o w r i t e up d a i l y  - Ill  -  p r e s c r i p t i o n s and b r i e f d i c t a t i o n on each p a t i e n t Visiting  s o c i a l workers spent an average  seen.  of 30 minutes  with  each p a t i e n t and saw an average o f f o u r p a t i e n t s i n three hours.  The permanent s t a f f p s y c h i a t r i s t o f the A f t e r  program averaged 20-30 minutes p a t i e n t s each week. an average  Care  per p a t i e n t and saw 20-30  The permanent s t a f f s o c i a l worker spent  o f 30 minutes per p a t i e n t with the 3O-I4O p a t i e n t s  seen on the average weekly. 6. Other  (Question 6 - Appendix C ) .  Resources  Community r e s o u r c e s regarded t o be c h i e f l y  involved  i n shared r e s p o n s i b i l i t y f o r any adequate program o f a f t e r care i n the community o f G r e a t e r Vancouver included, the two main p s y c h i a t r i c u n i t s , namely, the Burnaby Mental H e a l t h Centre and the Vancouver General H o s p i t a l .  Other h e a l t h and  w e l f a r e a g e n c i e s such as M e t r o p o l i t a n H e a l t h , the F a m i l y S e r v i c e Agencies, and t h e Department o f S o c i a l Welfare were viewed as r e l a t e d p a r t s i n the t o t a l a f t e r c a r e p i c t u r e .  The  p r i v a t e p s y c h i a t r i s t , and the g e n e r a l p r a c t i t i o n e r were a l s o seen as fundamental r e s o u r c e persons t o the program.  These  f i n d i n g s r e l a t e t o Questions 7 and 8 - Appendix C o f the Questionnaire.  As designed, these q u e s t i o n s , u n f o r t u n a t e l y ,  proved too complicated and as a consequence, t a b u l a t i o n s have been omitted, 7. B a s i c Therapies Questioned as to the type o f therapy regarded t o be e s s e n t i a l i n an adequate a f t e r c a r e treatment program, the  -  112  -  d o c t o r s l i s t e d i n d i v i d u a l s u p p o r t i v e therapy as  foremost  therapy; the s o c i a l workers l i s t e d c o - o r d i n a t e d r e h a b i l i t a t i o n planning.  T h i s probably r e f l e c t s the p a r t i c u l a r  o f each d i s c i p l i n e .  orientation  M e d i c a t i o n and b r i e f r e a l i t y  oriented  therapy were d e f i n i t e l y r e g a r d e d t o be important i n the a f t e r care program and r e f l e c t e d the most commonly employed forms of therapy i n the present nominal A f t e r Care s e r v i c e .  Family  therapy and group therapy as f a r as both d o c t o r s and  social  workers were concerned, were seldom embarked upon but were viewed as important forms of therapy i n any adequate a f t e r care s e r v i c e .  Long term e x t e n s i v e psychotherapy  by both d i s c i p l i n e s as the one for aftercare.  was  regarded  " u n e s s e n t i a l " therapy form  (Question 2a and. 2b - Appendix C).  8. S t a f f A t t i t u d e I t goes without  saying t h a t the b a s i c p h i l o s o p h y o f  the t h e r a p i s t c o n s i d e r a b l y a f f e c t s the treatment  approach.  As evidenced, from the f i n d i n g s of the q u e s t i o n n a i r e , the marked t r e n d towards a m e d i c a l - p h a r m a c e u t i c a l therapy  orientation  would narrow the base o f s e r v i c e mainly t o an e x t e n s i o n of i n - h o s p i t a l treatment w i t h heavy emphasis on m e d i c a t i o n .  As  a consequence, p r o f e s s i o n a l s i g h t s on the o v e r a l l s o c i a l  and  r e h a b i l i t a t i o n goals are d e s u l t o r y and l a c k i n g i n any s i s t e n t sharp f o c u s .  con-  T h i s s i t u a t i o n i s b e s t r e f l e c t e d i n the  l i m i t e d r o l e o f the s o c i a l worker i n the present a f t e r c a r e program.  - 113 9.  -  Suggested Improvement of  Service  Ways i n which the a f t e r c a r e s e r v i c e s can be were suggested.  The  open q u e s t i o n (Question 12  C) evoked some i n t e r e s t i n g and  constructive  improved  - Appendix  ideas o f a more  comprehensive s o r t together w i t h other, b r i e f e r , unelaborated responses.  In t h e i r comments, doctors and  s o c i a l workers  a l i k e expressed ideas cogent to the concept of an adequate aftercare  service.  These ideas i n v o l v e d  the area of  organiz-  a t i o n of a f t e r c a r e s e r v i c e s w i t h i t s r e l a t e d problems of s t a f f i n g , l o c a t i n g and p r e s s e d which are  s e r v i c e coverage.  Ideas were a l s o  ex-  c e n t r a l t o comprehensive a f t e r c a r e program-  ming - t o t a l c o - o r d i n a t i o n  of a f t e r c a r e r e s o u r c e s , development  of r e s o u r c e s t a i l o r e d to the needs of the p a t i e n t s ,  decentral-  i z a t i o n o f A f t e r Care C l i n i c s , and broad community involvement. A l s o mentioned were the e s t a b l i s h m e n t and  utilization  community-centered treatment r e s o u r c e s such as S e r v i c e , Day B. A n a l y s i s  Care U n i t s , of  a b r i e f 2 - 3 day  Pre-Admission  In-Patient  Clinic.  Findings  1. An A n a l y s i s An  and  of  o f the S t a f f Q u e s t i o n n a i r e  a n a l y s i s o f the  concensus o f p r o f e s s i o n a l  S t a f f Q u e s t i o n n a i r e r e f l e c t s the opinion that-the  present  aftercare  i s g i v i n g only nominal s e r v i c e i n both coverage and d i v e r s i t y . The  f i n d i n g s have i n d i c a t e d t h a t many p a t i e n t s who  contact  w i t h the A f t e r Care C l i n i c are  the p a t i e n t s who  e x i s t i n the  require  d i s c h a r g e d from R i v e r -  view H o s p i t a l without r e f e r r a l f o r a f t e r c a r e are  may  services.  These  community l a r g e l y as s o c i a l  -  I l k  r e j e c t s , appearing as frequent  -  c l i e n t s a t t h e Vancouver General  H o s p i t a l O u t - p a t i e n t ' s Department o r as re-admissions t o R i v e r view H o s p i t a l .  A d d i t i o n a l l y , many p a t i e n t s who could, d e r i v e  b e n e f i t from group d i s c u s s i o n or m a r i t a l c o u n s e l l i n g a r e d e n i e d t h i s help  owing to the l i m i t e d nature and aims o f the p r e s e n t  a f t e r c a r e program.  I n essence, i f as the l i t e r a t u r e  suggests,  an adequate a f t e r c a r e s e r v i c e i s based on the 'spectrum' i d e a of o f f e r i n g a d i v e r s i f i e d service to a v a r i e t y of d i f f e r e n t c l i e n t s , then the doctors and s o c i a l workers a r e j u s t i f i e d i n concluding  t h a t i n i t s present s t a t e , the A f t e r Care C l i n i c  cannot, by any means, be r e g a r d e d as adequate. aftercare service i s e s s e n t i a l l y a medically and  A t present t h e  focused  service  as such o f f e r s t h e s o c i a l worker a very l i m i t e d r o l e i n the  t o t a l program.  This l a r g e l y would e x p l a i n why not a l l s o c i a l  workers attend, t h e C l i n i c and why the S o c i a l S e r v i c e  department  as a whole i s not more a c t i v e i n the a f t e r c a r e program. 2.  The Idea o f The  Co-ordination  idea o f co-ordination  t a l and the community - r e c u r r e d  - a c l o s e l i n k between h o s p i throughout the q u e s t i o n n a i r e .  I t seemed obvious from the comments o f both d o c t o r s and s o c i a l workers than an a f t e r c a r e program cannot operate i n i s o l a t i o n but  should, be i n t e g r a t e d w i t h the community and. the r e s o u r c e s  therein.  In the l o c a l a r e a at the moment, i t i s evident  have not y e t c o n s o l i d a t e d  the f i r s t  we  step towards b e t t e r c o -  o r d i n a t i o n and t h a t i n t e g r a t i o n o f A f t e r Care C l i n i c w i t h other community r e s o u r c e s i n Vancouver i s as y e t a f a r c r y from reality.  -115  -  3. Leadership The  c o n v i c t i o n comes through i n t h e q u e s t i o n n a i r e t h a t  the Mental H e a l t h S e r v i c e s must p r o v i d e l e a d e r s h i p i n the development and c o - o r d i n a t i o n o f a f t e r c a r e s e r v i c e s w i t h community r e s o u r c e s .  It is illogical,  r e s i s t e n t and p o o r l y informed ship r o l e . support  after a l l ,  other  t o expect a  community t o assume the l e a d e r -  The i m p l i c a t i o n i s t h a t without  t o develop s e r v i c e s f o r t h e m e n t a l l y  considerable ill,  the commun-  i t y w i l l not only r e s i s t involvement but may w e l l m o b i l i z e i t s h o s t i l i t y , and end up by c l o s i n g i t s door more t i g h t l y on the problem.  - 116  -  QUESTIONAIRE TO AGENCIES A.  Introduction In an attempt to e l i c i t  an o p i n i o n  concerning  d i v i s i o n of r e s p o n s i b i l i t y between a f t e r c a r e and agencies, the adequacy or otherwise of the  the  community  aftercare  service  from the viewpoint o f the community a g e n c i e s , the major problems i n p l a n n i n g  as  seen through the eyes of the  commun-  i t y agencies, l e t t e r s were submitted t o twelve community agencies.  In sending q u e s t i o n n a i r e s  t o these community  agencies, the w r i t e r s hoped to o b t a i n a feedback which would shed f u r t h e r l i g h t on the adequacy o f a f t e r c a r e s e r v i c e s which a l s o would a s s i s t i n v a l i d a t i n g the  findings of  and  our  study. B. Agencies The  Selected agencies s e l e c t e d f e l l w i t h i n the catchment area  i n which the group o f p a t i e n t s i n the were namely drawn.  Our  sample f o r t h i s study  i n q u i r i e s were d i r e c t e d t o the  i n g agencies, most o f whom had  a r e s p o n s i b i l i t y i n accordance  w i t h the agency f u n c t i o n t o meet the needs of patients l i v i n g i n t h e i r area.  follox*-  discharged  I n q u i r i e s were d i r e c t e d as  follows: Metropolitan Health Services S o c i a l Welfare Departments Children's Aid Societies C i t y S o c i a l S e r v i c e Department Canadian Mental H e a l t h A s s o c i a t i o n F a m i l y S e r v i c e Agency  . . . .  k 3 2 1 1 1  - 117 -  C. Responses Obtained In response t o our i n q u i r y , a l l o f the agencies contacted r e p l i e d . hensive, varying  Two o f the agencies r e t u r n e d most compre-  w e l l considered  reports.  The remainder showed  degrees o f awareness o f the f u n c t i o n and r e s p o n s i -  b i l i t y o f the A f t e r Care C l i n i c . ment a d m i n i s t r a t o r aftercare.  One s o c i a l w e l f a r e  s t a t e d that he had l i t t l e knowledge o f  P a r t l y t h i s l a c k o f knowledge can be a t t r i b u t e d  to the f a c t t h a t h i s p a r t i c u l a r agency had been minimally  depart-  i n planning  f o r discharged  to the f a c t t h a t very l i t t l e administration  involved  p a t i e n t s , and p a r t l y  e f f o r t has been made by h o s p i t a l  t o p u b l i c i z e or i n t e r p r e t t h e s e r v i c e t o the  community. D. F i n d i n g s  o f Questionnaire  1. Adequacy Tables o f the Agency Questionnaire viewed.  w i l l next be r e -  The ideas and a t t i t u d e s o f community agency adminis-  t r a t o r s and p e r s o n n e l a r e r e f l e c t e d i n t h i s s e c t i o n v i a the questions.  With one exception,  to t h e q u e s t i o n n a i r e  a l l o f the agencies r e p l y i n g  termed t h e s e r v i c e p r o v i d e d  Care C l i n i e inadequate i n t h e i r o p i n i o n . most commonly put f o r t h were:  Among the reasons  the d i s t a n c e  g e t t i n g t o and from the A f t e r Care C l i n i c :  by the A f t e r  involved i n the l a c k o f  s u f f i c i e n t coverage i n numbers o f p a t i e n t s d i s c h a r g e d community and s t i l l r e q u i r i n g follow-up:  t o the  the b r e v i t y and  - 118 i n f r e q u e n c y of contact between the p a t i e n t and a f t e r c a r e f o l l o w i n g d i s c h a r g e from the h o s p i t a l : patient motivation:  the problem o f  the emergencies which a r i s e a f t e r hours  and on weekends when no a f t e r c a r e h e l p i s a v a i l a b l e : finally,  and  the l a c k o f adequate community r e s o u r c e s t o d e a l w i t h  the v a r i e t y o f problems presented by the d i f f e r e n t types o f discharged p a t i e n t s .  (Question 1 - Appendix D).  2. L i a s o n I n s u f f i c i e n t l i a s o n was  f e l t t o be a problem by more  than h a l f o f the a g e n c i e s both i n r e g a r d t o other and to the A f t e r Care C l i n i c .  agencies  Lack o f r e f e r r a l by the agen-  c i e s and h o s p i t a l a l i k e o c c u r r e d a l l too f r e q u e n t l y . by the h o s p i t a l to n o t i f y a p p r o p r i a t e agencies o f i n - h o s p i t a l treatment  Failure  of t e r m i n a t i o n  and discharge o f p a t i e n t s to commun-  i t y was l i k e w i s e , a f r e q u e n t omission.  Communication  difficul-  t y was l i s t e d as the third, main problem a r e a f o r community agencies, w i t h s t a f f shortages and d i v e r s e d i s c i p l i n e t i o n s at the base of the d i f f i c u l t y .  orienta-  (Questions 2 and 3 -  Appendix D). 3. D i v i s i o n o f R e s p o n s i b i l i t y D i v i s i o n of r e s p o n s i b i l i t y f o r p r o v i s i o n of s e r v i c e s to d i s c h a r g e d p a t i e n t s i s covered under (a) own agency responsibility,  (b) other agency r e s p o n s i b i l i t y , and (c)  A f t e r Care C l i n i c (a)  responsibility.  Own Agency R e s p o n s i b i l i t y Own agency r e s p o n s i b i l i t y i n c l u d e d mainly  -  119  -  f i n a n c i a l h e l p to p a t i e n t s - s o c i a l a s s i s t a n c e , boarding placement, c l o t h i n g .  The  number o f the agencies i l i e s was One  second major s e r v i c e g i v e n by a  to d i s c h a r g e d p a t i e n t s and t h e i r fam-  concerned, w i t h the care and p r o t e c t i o n o f c h i l d r e n .  Vancouver agency f u n c t i o n e d to meet the s o c i a l and. r e -  c r e a t i o n a l needs o f e x - p a t i e n t s . work was  L i m i t e d s u p p o r t i v e case-  only once mentioned as a g i v e n s e r v i c e and  reflects  one o f the g r e a t e s t gaps i n on-going community h e l p t o the discharged p a t i e n t .  Family c o u n s e l l i n g s e r v i c e ( i f appro-  p r i a t e f o l l o w i n g assessment) was f u n c t i o n by one agency.  mentioned as being a  (Question J4 - Appendix  D)  (b) Other Agency R e s p o n s i b i l i t y Other agency r e s p o n s i b i l i t y i t was be determined  by the needs o f the p a t i e n t .  felt  should  Mentioned as  agencies which should assume r e s p o n s i b i l i t y f o r meeting the needs o f e x - p a t i e n t s were: casework s e r v i c e s , The  The Family S e r v i c e Agency f o r  Community Neighbourhood Houses f o r  group work s e r v i c e s and group a c t i v i t i e s , The M e t r o p o l i t a n H e a l t h C l i n i c s i n the case o f p r e - s c h o o l and  school c h i l d r e n ,  and. The Canadian Mental H e a l t h A s s o c i a t i o n i n the area of s o c i a l i z a t i o n and r e c r e a t i o n . (c) A f t e r Care C l i n i c  (Question £ - Appendix Responsibility  A f t e r Care C l i n i c r e s p o n s i b i l i t y was critically  by the v a r i o u s agencies c o n t a c t e d .  A f t e r Care C l i n i c  D)  viewed  Most f e l t  should, p r o v i d e a c t i v e c o n s u l t a t i o n to  other community agencies as w e l l as g i v i n g an on-going  the  - 120 -  q u a n t i t a t i v e and q u a l i t a t i v e patients.  supportive therapy t o d i s c h a r g e d  The need f o r a more frequent contact w i t h the  f a m i l y doctor was emphasized as w e l l as a more a g g r e s s i v e and s u s t a i n i n g follow-up s e r v i c e by the A f t e r Care doctors and s o c i a l workers.  One agency f e l t b e t t e r c o n t r o l ought t o be  e x e r c i s e d by A f t e r Care over the unmanageable or dangerous patient.  (Question 6 - Appendix D)  k» Major Planning Problems Major problems i n p l a n n i n g f o r d i s c h a r g e d p a t i e n t s were c i t e d by the community agencies as f o l l o w s : charge w i t h inadequate  rapid  dis-  discharge p l a n n i n g ; l a c k o f s u s t a i n e d  contact f o l l o w i n g d i s c h a r g e and l a c k o f adequate follow-up by both doctors and s o c i a l workers; unproductive r e f e r r a l s t o the f a m i l y doctor; and l a c k o f adequate r e f e r r a l t o the community agencies  involved.  I n s u f f i c i e n t p l a n n i n g f o r need-  ed, s e r v i c e was coupled w i t h the l a c k of s u i t a b l e community resources  ( i . e . a p p r o p r i a t e j o b s , s u i t a b l e l i v i n g arrangements)  and an i n s u f f i c i e n c y o f t r a i n e d p r o f e s s i o n a l s . p o i n t was expressed o f i n s u f f i c i e n t concern  A l s o , the  f o r the pro-  t e c t i o n o f the community and. the i n a b i l i t y o f community agency p e r s o n n e l t o p r o v i d e adequate s u p e r v i s i o n .  (Question 7 -  Appendix D) 5. Other Comments Other c o n s t r u c t i v e suggestions i n c l u d e d :  emphasis on  p r e v e n t i o n u s i n g the Mental H e a l t h Centre f o r r e f e r r a l s and s c r e e n i n g t o a v o i d unnecessary  h o s p i t a l i z a t i o n ; an estimate  - 121 of present  -  and p r o j e c t e d needs f o r s e r v i c e so t h a t  on an on-going b a s i s might be provided;  services  r e s p o n s i b i l i t y for  the development and. p r o v i s i o n o f these s e r v i c e s to the mentally i l l ;  adequate medical s u p e r v i s i o n on a twenty-four  hour b a s i s , w i t h home v i s i t s when necessary; resources  tailored  such as small l i v i n g u n i t s operated, by  qualified  people, s h e l t e r e d workshops, s u i t a b l e job placements, and opportunity  for socialization.  E. A n a l y s i s o f  (Question  8 - Appendix  indicates in  sharp awareness on the p a r t of community  agency a d m i n i s t r a t o r s  where the problem of the m e n t a l l y i l l  person i n the community i s concerned. one  D)  Findings  'Analysis of the Agency Q u e s t i o n n a i r e many i n s t a n c e s ,  the  As a matter of  fact,  f e e l s the views expressed r e f l e c t a r e a l i s t i c i n t e r e s t  i n the c u r r e n t t r e n d towards comprehensive community psychiatry. 1. R e s p o n s i b i l i t y i n Development and P r o v i s i o n o f Service' In g e n e r a l ,  administrators  of s o c i a l agencies are  k e e n l y aware no a r r a y o f t h e r a p e u t i c and  supportive  e x i s t to meet the needs of p a t i e n t s d i s c h a r g e d community. not,  E x i s t i n g resources  lacking altogether.  i t s primary s e r v i c e — n o t  are  local  Each agency sees i t s e l f g i v i n g only i n c l u d i n g p s y c h i a t r i c follow-up. i n v o l v e d as  p a r t i c u l a r sphere of f u n c t i o n , are not  to take the i n i t i a t i v e f o r developing to the m e n t a l l y  t o the  s l i m , and more o f t e n than  seems apparent t h a t the community agencies, are i n t h e i r own  programs  ill.  and. p r o v i d i n g  It  they going  services  T h i s means o f course, i n i t i a l l y ,  the  -  122  -  major r e s p o n s i b i l i t y f o r t h e development and p r o v i s i o n o f a f t e r c a r e s e r v i c e s must i n e v i t a b l y l i e w i t h the Mental Service D i v i s i o n .  Health  The i m p l i c a t i o n here i s t h a t i f the commun-  i t y agencies a r e expected e v e n t u a l l y t o c a r r y t h e i r own p r o grams f o r a f t e r c a r e , then c o n s i d e r a b l y more e f f o r t by t h e Mental H e a l t h Branch must be made t o educate,  i n v o l v e , and  support the community agencies t o equip them to handle the problems of the m e n t a l l y 2.  ill.  C o o r d i n a t i o n and C o n t r o l F u r t h e r , from the comments made, agency  t r a t o r s f e e l k e e n l y about the inadequacy  adminis-  of t h e i r s t a f f to  cope w i t h the problems o f the m e n t a l l y i l l  i n the community.  They s t a t e , a l l too o f t e n when p a t i e n t s a r e d i s c h a r g e d , t h e " f e l t " a n x i e t y on the p a r t o f the community and o f the communi t y agencies themselves, administration.  i s e n t i r e l y d i s r e g a r d e d by h o s p i t a l  To expect the community, without  adequate  support, t o assume r e s p o n s i b i l i t y where " t h r e a t " e x i s t s i s wrong, p a r t i c u l a r l y , when one stops t o t h i n k how b a d l y needed i s a " t h e r a p e u t i c " community i f p a t i e n t s are t o be r e h a b i l i t a t e d t o t h a t community.  I n t h i s l i g h t , i t would seem that  c o o r d i n a t i o n o f s e r v i c e s between the Mental H o s p i t a l and the community agencies i s a must i f c o n t r o l i s t o be brought  into  the present u n s t a b l e s i t u a t i o n between t h e community w i t h i t s s o c i a l agencies and t h e Mental 3.  Hospital.  Current Dilemma I n terms o f p o s t - d i s c h a r g e p l a n n i n g , a d e f i n i t e  - 123 schism appears t o e x i s t between what the h o s p i t a l s t a f f f e e l t o be adequate treatment the community agencies  medical  and p l a n n i n g and. what  see as adequate.  While,  undoubtedly,  community e x p e c t a t i o n s a r e perhaps t o o h i g h , the same may be s a i d o f h o s p i t a l e x p e c t a t i o n s i n terms of what behavior i s a c c e p t a b l e t o the community o r what community agencies can accomplish w i t h l i m i t e d s t a f f and r e s o u r c e s i n terms of a s s i s t i n g p a t i e n t s i n t h e i r s o c i a l and v o c a t i o n a l a d j u s t ment.  C e r t a i n l y the f a m i l y d o c t o r t o whom many p a t i e n t s a r e  r e f e r r e d f o r follow-up s e r v i c e , i s i n no b e t t e r p o s i t i o n than the community agency as f a r as time and t r a i n i n g , but i s able to p r o v i d e m e d i c a t i o n .  The crux o f the matter would  seem t o be t h a t the c u r r e n t t r e n d o f b r i e f i n t e n s i v e t r e a t ment and rapid, r e t u r n of p a t i e n t s to the community has p r o duced a dilemma i n the p r o v i s i o n o f adequate a f t e r c a r e services.  T h i s dilemma i s r e f l e c t e d i n the comments of  community agency a d m i n i s t r a t o r s on problems i n p l a n n i n g .  CHAPTER 7 CONCLUSIONS A. I n t r o d u c t i o n Prom the beginning o f t h i s century there has been a p e r s i s t e n t s h i f t o f the l o c u s o f p s y c h i a t r i c care toward the community and i t i s now g e n e r a l l y b e l i e v e d t h a t p s y c h i a t r i c p a t i e n t s should be t r e a t e d e a r l y ,  s p e e d i l y and c l o s e t o home -  95 percent o f g e n e r a l a d u l t p s y c h i a t r i c cases, i t appears, can be t r e a t e d with, o r without, h o s p i t a l i z a t i o n and can be maintained  i n the community w i t h adequate treatment and 1  supportive s e r v i c e s .  Two p a t t e r n s of community p s y c h i a t r y  are p r e s e n t l y apparent.  The f i r s t  i s the p l a n based on a  community mental h e a l t h c e n t e r and the second, the i n t e g r a t i o n o f the mental h e a l t h s e r v i c e s w i t h other community h e a l t h and welfare  services. At t h e moment, the Burnaby A f t e r Care C l i n i c o f the  P r o v i n c i a l Mental H e a l t h S e r v i c e s i s i n the unique p o s i t i o n o f being somewhat i n the c e n t e r o f two such p a t t e r n s w i t h no b l u e p r i n t f o r the f u t u r e v i s i b l e .  There seems t o be no p l a n a t  the present o f d e v e l o p i n g a community-based mental h e a l t h c e n t e r i n Vancouver.  The i n t e g r a t e d approach o f p s y c h i a t r i c  s e r v i c e s , based on g e n e r a l h o s p i t a l s , although i t has been i n the d i s c u s s i o n stage, has so f a r not m a t e r i a l i z e d . 1.  Roberts,  op. c i t . .  p. 3 .  - 125 Along with t h e c o n f l i c t i n g o p i n i o n s  concerning the  above two approaches, an extremely important f a c t o r t o take i n t o c o n s i d e r a t i o n i s t h a t of t h e recommendations o f t h e „ 1 Royal C o m m i s s i o n on H e a l t h S e r v i c e s . The Commission has made a number o f important recommendations t h a t a r e i n e v i t a b l y going t o have c o n s i d e r a b l e for  the m e n t a l l y i l l .  i n f l u e n c e on our present  services  Some o f t h e recommendations concern  t r a i n i n g g r a n t s f o r p r o f e s s i o n a l personnel, or u n i t s i n or a t t a c h e d  p s y c h i a t r i c wards  t o general h o s p i t a l s , that  p s y c h i a t r i c u n i t s have o u t - p a t i e n t  such  departments, i n - p a t i e n t  treatment and c o n s u l t a t i v e s e r v i c e , 21+ hour emergency s e r v i c e and  "day" and " n i g h t " care programs.  tor  i s t h a t a n a t i o n a l h e a l t h scheme w i l l g i v e  s e r v i c e t o everyone.  Another important f a c free p s y c h i a t r i c  I t i s expected t h a t p s y c h i a t r i c coverage  w i l l be a v a i l a b l e under such a p l a n t o i\0 percent o f t h e population by p r e - p a i d  f o r the f i r s t  time, t h a t percentage not c o v e r e d now  plans.  We hope and i n f a c t expect that i n time most o f t h e s e recommendations w i l l be implemented.  However, we know t h a t  none o f t h e recommendations w i l l come i n t o e f f e c t u n t i l 1967  and t h a t a g r e a t  July  percentage o f them w i l l i n a l l proba-  b i l i t y take a t l e a s t s e v e r a l  years.  In the meantime, we a r e f a c e d w i t h problems t h a t must at  t h i s time be coped w i t h .  Ways must be found t o meet the  1 . Canada, Royal Commission on H e a l t h S e r v i c e s , Ottawa, Queen's P r i n t e r , 196)4.  Report,  - 126 -  problems i n c a r i n g f o r mental i l l n e s s i n the community and developing r e h a b i l i t a t i o n r e s o u r c e s and a l s o , t h e trends t h a t are v i s i b l e i n mental h e a l t h programming must be kept i n mind. In t h i s t h e s i s we have looked a t , amongst other the needs o f t h e p a t i e n t s the o p i n i o n s and  things,  served by the A f t e r Care C l i n i c ,  o f the p r o f e s s i o n a l personnel regarding  services  a l s o those o f the community a g e n c i e s who see a p o r t i o n o f  former mental h o s p i t a l p a t i e n t s .  C e r t a i n important  have emerged concerning t h e scope, c o - o r d i n a t i o n and t h e d i v i s i o n o f r e s p o n s i b i l i t y f o r those  ideas  of services  services,  B. Scope o f S e r v i c e Aftercare  i s d e f i n e d as any s e r v i c e which promotes  the adjustment o f t h e discharged anew i n the community. questionnaire  We have i l l u s t r a t e d from our p a t i e n t  t h a t the needs o f the former p s y c h i a t r i c p a t i e n t s  are many and v a r i e d . them.  p a t i e n t as he s t a r t s l i f e  Numerous r e s o u r c e s a r e r e q u i r e d t o meet  Treatment must be based mainly on s u p p o r t i v e ,  reality-  o r i e n t e d therapy p l u s p h a r m a c o l o g i c a l and environmental l i n e s i f the community as a whole i s t o be served although  intensive  psychotherapy both i n d i v i d u a l and. group, should be one o f the treatment f a c i l i t i e s a v a i l a b l e . f a c i l i t i e s that are considered  Some o f t h e newer a f t e r c a r e t o be e s s e n t i a l a r e s p e c i a l -  i z e d day and n i g h t h o s p i t a l s , half-way houses, day c e n t e r s , vocational r e h a b i l i t a t i o n resources,  f o s t e r f a m i l y homes,  s h e l t e r e d workshops, group and r e c r e a t i o n a l o u t l e t s .  - 127  The  -  p r o f e s s i o n a l s who a r e engaged i n p r o v i d i n g  v i c e s a t the A f t e r Care l i n i c c  ser-  agree t h a t m e d i c a t i o n and  b r i e f r e a l i t y o r i e n t e d therapy a r e the most commonly employed forms o f t h e r a p y .  However, they i n d i c a t e t h a t they b e l i e v e a  more d i v e r s i f i e d s e r v i c e t h a t would i n c l u d e such as noted above must be p r o v i d e d  facilities  t o meet t h e v a r i o u s t r e a t -  ment needs o f the p a t i e n t s and f u r t h e r t h a t t h e base of the s e r v i c e should be broadened t o cover a wider range o f patients. It  i s recognized  that t h e r e  i s almost a complete l a c k  o f t h e s e r v i c e s that a r e considered, a sine qua non o f any comprehensive a f t e r c a r e program.  However, there a r e c e r t a i n  s p e c i f i c d e f i c i e n c i e s we f e e l j u s t i f i e d i n n o t i n g . 1.  Location One  o f the g r e a t e s t drawbacks o f the A f t e r Care C l i n i c  i s t h e f a c t t h a t i t i s not l o c a t e d i n the center and undue h a r d s h i p The  Clinic  distance  of p o p u l a t i o n  i s imposed on many p a t i e n t s because o f t h i s .  does o f f e r s e r v i c e s one evening a month but the  t h a t most p a t i e n t s have t o t r a v e l i s a d i s c o u r a g i n g  factor that adversely  a f f e c t s the f u l l u t i l i z a t i o n o f these  services. 2.  Emergency Night Time a n d Weekend S e r v i c e T h i s type o f s e r v i c e i s not a v a i l a b l e t o the p a t i e n t s  of the A f t e r Care l i n i c .  The Amsterdam M u n i c i p a l  c  Psychiatric  Service" "which o f f e r s a 2I4 hour s e r v i c e found that w e l l over 1  70 percent  o f emergency c a l l s do not r e s u l t i n h o s p i t a l i z a t i o n .  1. Lemkau, P.V. and C c e t t i , G-.M. The Amsterdam M u n i c i p a l P s y c h i a t r i c S e r v i c e . A P s y c h i a t r i c S o c i o l o g i c a l Review, American J o u r n a l o f P s y c h i a t r y . V o l . 117, pp.779-783, 1961. r o  -  128  -  The M o n t r e a l General H o s p i t a l o f f e r s t h e same range of s e r v i c e s and have found t h a t the g r e a t m a j o r i t y  of p s y c h i a t r i c emer-  gencies take p l a c e d u r i n g the n i g h t hours. ience c l o s e t o 5>0 percent  In t h e i r exper-  of a l l p s y c h i a t r i c emergencies do  not r e q u i r e treatment i n h o s p i t a l .  We  f e e l that i t i s  l e g i t i m a t e to suggest t h a t the r e h o s p i t a l i z a t i o n s o f a number of A f t e r Care p a t i e n t s might be prevented i f emergency s e r v i c e were a v a i l a b l e . We month.  mentioned that the  c  linic  i s open one  evening a  Formal daytime hours o f c l i n i c s are b e l i e v e d t o have  an adverse e f f e c t on the employment s t a t u s o f p a t i e n t s .  If  more p a t i e n t s had r e a d i l y a v a i l a b l e and a c c e s s i b l e evening s e r v i c e s , they might be more able t o f u l f i l l  t h e i r working  responsibilities. 3• E x c l u s i o n of C e r t a i n D i a g n o s t i c Certain categories  Categories  of p a t i e n t s from R i v e r v i e w H o s p i t a l  are more or l e s s r o u t i n e l y excluded from r e f e r r a l to the A f t e r Care C l i n i c . character should  These i n c l u d e , f o r i n s t a n c e , a l c o h o l i c s and  disorders.  We  are not suggesting  be the r e s p o n s i b i l i t y of the C l i n i c .  t h a t these groups We  a r e , however,  saying t h a t they most f r e q u e n t l y do not r e c e i v e any a s s i s tance whatsoever from the C l i n i c or the community, and some form o f s e r v i c e should be  that  developed f o r them.  Another group o f p a t i e n t s t h a t the h o s p i t a l seldom r e f e r s t o the A f t e r Care C l i n i c e l i g i b l e f o r M.  S. A. i n s u r a n c e .  i s the one  composed of those  R e f e r r a l t o the  Clinic  - 129 i s at the and  d i s c r e t i o n of the  i s highly  are not  subject  always the  -  individual hospital psychiatrist  to b i a s .  Private psychiatric  answer t o the r e h a b i l i t a t i o n problems of  the d i s c h a r g e d mental p a t i e n t s and s i d e r a t i o n o f the  services  there i s a l s o the  coat of m e d i c a t i o n .  The  Clinic  con-  dispenses  m e d i c a t i o n f r e e o f charge. k. A v a i l a b i l i t y o f Psychotherapy I t i s not p r a c t i c a l to expect the A f t e r Care C l i n i c to o f f e r psychotherapy to d i a c h a r g e d mental p a t i e n t s .  How-  ever, as noted e a r l i e r i n t h i s s e c t i o n , such a s e r v i c e at l e a s t be  a v a i l a b l e i n a comprehensive a f t e r c a r e  The  Burnaby Mental H e a l t h Center does o f f e r such a  but  i t i a h i g h l y s e l e c t i v e and  to former p a t i e n t s who  not  should  program. service  always r e a d i l y a v a i l a b l e  might be r e f e r r e d from R i v e r v i e w .  5>. Croup Therapy J  This  Clinic. who  i s a s a d l y n e g l e c t e d f a c e t o f the A f t e r  In our p a t i e n t  questionnaire,  two  s a i d they were r e c e i v i n g c o n s i d e r a b l e  of the  patients  s e r v i c e from  C l i n i c , were i n group therapy w i t h a p s y c h o l o g i s t view H o s p i t a l who  Care  the  from R i v e r -  assumes a f t e r c a r e r e s p o n s i b i l i t i e s .  Group  therapy i s w e l l r e c o g n i z e d as a s i g n i f i c a n t t r e n d i n t r e a t i n g mental p a t i e n t s . to the  I f we  are t o p r o v i d e b e t t e r  i n c r e a s i n g l y l a r g e numbers r e q u i r i n g i t , t h i s type  o f treatment seems t o be a n a t u r a l l i n e t o 6.  service  follow.  S o c i a l Work S e r v i c e One  of the most s i g n i f i c a n t f i n d i n g s o f  our  - 130 questionnaires  i s t h a t J4I4 o f 1+5 o f our sample are not r e c e i v -  i n g s o c i a l work s e r v i c e s and t h a t t h r e e workers q u e r i e d  o f the f i v e  social  about a f t e r c a r e s e r v i c e s do not a t t e n d the  A f t e r Care C l i n i c .  Since the needs o f the p a t i e n t are o f  such a v a r i e d nature, i t would seem d e s i r a b l e t o expand the involvement o f s o c i a l workers i n an a f t e r c a r e  program.  These are o n l y a few f a c e t s t h a t we b e l i e v e t o be o f s i g n i f i c a n c e i n the scope o f s e r v i c e s o f f e r e d .  We  believe  t h a t readily a c c e s s i b l e emergency s e r v i c e i s e s s e n t i a l .  We  f u r t h e r f e e l j u s t i f i e d i n s t a t i n g that c e r t a i n forms o f s e r v i c e c o u l d be implemented without too much d i f f i c u l t y and a l s o t h a t a c r i t i c a l eye should be c a s t a t c e r t a i n procedures o f the Burnaby Mental H e a l t h Center and R i v e r v i e w H o s p i t a l . C. C o - o r d i n a t i o n  of Services  1. W i t h i n the H o s p i t a l As i n a l l l a r g e mental h o s p i t a l s , R i v e r v i e w H o s p i t a l has w i t h i n i t s s t r u c t u r e many problems o f c o - o r d i n a t i o n the present a d m i n i s t r a t i o n  i s t r y i n g t o work o u t .  s p e c i f i c a l l y m e d i c a l s e t t i n g , the S o c i a l S e r v i c e functions  as an a n c i l l a r y s e r v i c e .  Problems of  which  In a Department  co-ordinating  the treatment aims o f the m e d i c a l s t a f f and t h e r e h a b i l i t a t i o n g o a l s o f t h e s o c i a l workers have always e x i s t e d and i n some measure w i l l continue t o e x i s t . o f the problems In c o - o r d i n a t i o n among the v a r i o u s p r o f e s s i o n a l  I t would appear many  stem from the l a c k o f u n i t y  disciplines.  - 131 2.  Between the Mental H e a l t h  Services  C o - o r d i n a t i o n between the R i v e r v i e w Mental H e a l t h  Center has r e l e v a n c e  H o s p i t a l and the  f o r t h i s study, i f f o r no  other reason than t o r e f l e c t the d i f f i c u l t y o f c o - o r d i n a t i n g r e l a t e d s e r v i c e s w i t h i n the Mental H e a l t h  Services D i v i s i o n .  A c u r r e n t problem o f c o - o r d i n a t i o n p r e v a i l s between the Burnaby Mental H e a l t h C l i n i c which g e n e r a l l y p r o v i d e s  therapy  f o r a s m a l l number o f s e l e c t e d p a t i e n t s and t h e A f t e r Care C l i n i c which must p r o v i d e therapy f o r a maximum number o f p a t i e n t s i n r e l a t i o n t o a s m a l l p a r t time 3• Between R i v e r v i e w  staff.  H o s p i t a l and Community Agencies  Some o f the s i g n i f i c a n t f i n d i n g s o f the Agency Questionnaire  i n v o l v e d v i t a l f a c t o r s i n the whole  of co-ordination of services. were l i a s o n between agencies,  process  Among the f a c t o r s mentioned, adequate r e f e r r a l s e r v i c e ,  r e l a x e d communication, c o - o p e r a t i o n ,  and c o n s u l t a t i o n .  We  must f a c e the f a c t t h a t f o r a number of reasons t h e communic a t i o n between the Riverview  H o s p i t a l and the community  agencies g e n e r a l l y has been s c a n t .  We a r e o f t h e o p i n i o n  t h a t ease i n communication between s e r v i c e s c o i n c i d e s w i t h good c o - o r d i n a t i o n o f the s e r v i c e s each has t o o f f e r . I4. Between the A f t e r Care C l i n i c and Community Agencies At the moment any semblance o f c o - o r d i n a t i o n between the A f t e r Care C l i n i c and. other community h e a l t h and welfare agencies i s p r a c t i c a l l y n o n - e x i s t e n t .  An attempt on the  p a r t o f t o p h o s p i t a l a d m i n i s t r a t i o n to c o - o r d i n a t e  the A f t e r  - 132 Care  Clinic  resource,  w i t h t h e one o t h e r m a i n  community  psychiatric  the Vancouver G e n e r a l H o s p i t a l has n o t been t o o  successful. tiations  I t d i d open t h e d o o r however  so t h a t  an a c c e s s i b l e  now a t l e a s t t h e r e  aftercare  f o r future  i s the p o s s i b i l i t y  service could  conceivably  i n t h e community  conjunction  w i t h t h i s one o t h e r m a j o r p s y c h i a t r i c  the  o f Vancouver proper working i n  i n t h i s sort of aftercare  resource.  p r o g r a m many o f  s e r v i c e s recommended b y b o t h t h e s t a f f a n d a g e n c y  sonnel i n t h e i r r e s p e c t i v e admission  that  be  established  We w o u l d e n v i s a g e  nego-  questionnaires,  service, walk-in c l i n i c ,  night  namely,  hospital,  per-  preemergency  s e r v i c e , and the l i k e . 5« R e f e r r a l s  f o r Service.  I n no o t h e r a r e a d o e s t h e i n t e r - d i s c i p l i n a r y b i a s show so c l e a r l y a s i n t h e a r e a o f r e f e r r a l s .  As  previously  mentioned i n t h i s s e c t i o n r e f e r r a l s have a s i g n i f i c a n t relationship  to c o - o r d i n a t i o n  Under body the case  of service.  the p r e s e n t a f t e r c a r e arrangement t h e main  of r e f e r r a l s from the h o s p i t a l t o a f t e r c a r e doctors themselves. since  aftercare requires  We w o u l d e x p e c t  come f r o m  t h i s t o be t h e  each doctor has the r e s p o n s i b i l i t y f o r p r o v i d i n g services t o those  them.  of h i s patients  One w o u l d q u e s t i o n  whom he f e e l s  what h a p p e n s  i fa p a r t i c -  u l a r d o c t o r has a p a r t i c u l a r b i a s towards a p a t i e n t ; It Care  i s s i g n i f i c a n t that  few r e f e r r a l s t o t h e A f t e r  C l i n i c a r e made b y t h e h o s p i t a l s t a f f  One w o u l d wonder w h e t h e r  s o c i a l workers.  t h e h o s p i t a l s o c i a l w o r k e r s do n o t  - 133 f e e l t h e y have a c o n t r i b u t i o n t o make i n t h e a r e a o f f o l l o w up and r e h a b i l i t a t i o n . As t h e r e f e r r a l system i s s t r u c t u r e d a t p r e s e n t p r i v a t e p s y c h i a t r i s t s and g e n e r a l  p r a c t i t i o n e r s i n the  community c a n and do make a number o f r e f e r r a l s o f p a t i e n t s to a f t e r c a r e .  I n the case o f community s o c i a l a g e n c i e s how-  ever the p r e s e n t g e n e r a l p o l i c y governed by f a c t o r s such a s the s i z e o f a f t e r c a r e s t a f f , does n o t encourage e x p a n s i o n o f the s e r v i c e through community r e f e r r a l s . D. D i v i s i o n o f R e s p o n s i b i l i t y f o r A f t e r c a r e  Service  I f we a r e t o c o n s i d e r where t h e d i v i s i o n o f r e s p o n s i b i l i t y f o r t h e p r o v i s i o n o f a f t e r c a r e s e r v i c e s l i e s , we must f i r s t determine t o what e x t e n t t h e community a g e n c i e s a r e w i l l i n g t o p a r t i c i p a t e i n a comprehensive a f t e r c a r e program. A t t h e moment community a g e n c i e s p r e f e r t o r e m a i n o u t s i d e \ o f t h e program g i v i n g o n l y t h e i r p r i m a r y s e r v i c e t o d i s charged p a t i e n t s b u t n o t t h e p s y c h i a t r i c f o l l o w - u p patients usually require.  R a t h e r , from t h e i r  questionnaire  comments about r e s p o n s i b i l i t y , community agency tended t o e x p e c t t h e P r o v i n c i a l M e n t a l H e a l t h  which  administrators  Services to  take the r e s p o n s i b i l i t y o f p r o v i d i n g a f t e r c a r e s e r v i c e s t o discharged p a t i e n t s . The  R i v e r v i e w H o s p i t a l , on the o t h e r hand, w h i l e i t  has e x t e n d e d s e r v i c e i n t o t h e community t h r o u g h t h e A f t e r Care C l i n i c w o u l d p r e f e r t h a t community h e a l t h and w e l f a r e  - 13k -  a g e n c i e s share r e s p o n s i b i l i t y w i t h t h e h o s p i t a l i n the p r o v i s i o n o f a f t e r c a r e s e r v i c e s t o t h e many p a t i e n t s t o the community.  discharged  I n p a r t i c u l a r , the p r o f e s s i o n a l personnel  o f R i v e r v i e w H o s p i t a l saw t h e Burnaby M e n t a l H e a l t h the Vancouver G e n e r a l H o s p i t a l ' a s Here then i s t h e p i c t u r e :  Centre and  sharing the r e s p o n s i b i l i t y . On t h e one hand o f commun-  i t y agency p e r s o n n e l f e e l i n g t h a t r e s p o n s i b i l i t y f o r t h e p r o v i s i o n o f a f t e r c a r e s e r v i c e should, be t h a t o f t h e P r o v i n c i a l M e n t a l H o s p i t a l w h i l e , on t h e o t h e r hand h o s p i t a l p e r s o n n e l f e e l t h e a f t e r c a r e s e r v i c e s h o u l d be a shared r e s p o n s i b i l i t y . Because t h e d i v i s i o n o f r e s p o n s i b i l i t y f o r p r o v i s i o n o f a f t e r c a r e s e r v i c e s was n o t c l e a r l y a g r e e d upon by t h e r e s p e c t i v e a g e n c i e s concerned, i t seemed t o us t h a t many p a t i e n t s  dis-  charged from h o s p i t a l t o community were n o t r e c e i v i n g s e r v i c e from e i t h e r  resource.  A n o t h e r a s p e c t w h i c h must be c o n s i d e r e d nature of the service i t s e l f .  Many s o c i a l a g e n c i e s i n the  community employ a l a r g e number o f u n t r a i n e d are i l l - e q u i p p e d t o p r o v i d e  i s the s p e c i a l  p e r s o n n e l who  t h e s p e c i a l i z e d casework s e r v i c e s  w h i c h the d i s c h a r g e d p a t i e n t s would r e q u i r e .  As a m a t t e r o f  f a c t , even t h e e x p e r i e n c e d s o c i a l w o r k e r , g e n e r i c a l l y t r a i n e d , could, q u i t e c o n c e i v a b l y  f e e l out o f h i s depth i n c o p i n g w i t h  the p r o b l e m o f g i v i n g a f t e r c a r e s e r v i c e s t o t h e m e n t a l l y  ill.  M i g h t t h i s i l l u s t r a t i o n n o t p o i n t up t h e need f o r s p e c i a l i z e d casework t r a i n i n g f o r s o c i a l w o r k e r s g o i n g i n t o s p e c i a l f i e l d s , t h e f i e l d o f m e n t a l h e a l t h b e i n g one o f them?  - 135  -  Disadvantaged as most of the community agencies would appear to be  through l a c k o f t r a i n e d s t a f f and  limited re-  sources i t i s not p a r t i c u l a r l y unusual t h a t they should l o o k to the Mental H e a l t h S e r v i c e s D i v i s i o n to p r o v i d e the  leader-  ship r e q u i r e d to educate the community and t o p r o v i d e  the  g u i d e l i n e s f o r p a r t i c i p a t i o n i n the development o f r e s o u r c e s t a i l o r e d to meet the needs o f the d i s c h a r g e d T h i s r e s p o n s i b i l i t y , we  mental p a t i e n t ;  b e l i e v e , the Mental H e a l t h  D i v i s i o n should assume.  Might not  Services  trained, s o c i a l work s t a f f  from the Mental H e a l t h S e r v i c e s D i v i s i o n be d i s t r i c t e d i n community h e a l t h or welfare o f f i c e s to a s s i s t as psychosocial  d i a g n o s t i c i a n s , and  educators,  therapists?  Future developments i n the p r o v i s i o n of a f t e r c a r e s e r v i c e s may m e d i c a l and  a l s o a f f e c t the  d i v i s i o n of r e s p o n s i b i l i t y between  s o c i a l work s t a f f .  doctors i n f u t u r e may  There i s the s u g g e s t i o n that  f u n c t i o n p r i m a r i l y w i t h i n the h o s p i t a l  s e t t i n g s t o diagnose and and r e h a b i l i t a t i o n t o the  1  t r e a t l e a v i n g the a r e a of s o c i a l workers and  aftercare  other s p e c i a l -  ists. T h i s t r e n d o f development c o u l d w e l l pose a problem to a c o n t i n u i t y o f care i n the  serious  service of a f t e r c a r e .  Although f e l t t o be h i g h l y d e s i r a b l e , a c t u a l c o n t i n u i t y care i s seldom p o s s i b l e f o r a number of reasons. seem imperative 1.  I t would  i f the r e s p o n s i b i l i t y between d o c t o r s  Gumming, op. c i t .  of  and  - 136  -  s o c i a l workers were d i v i d e d i n t h i s manner, however, to establish within  the community a complement o f h i g h l y  s k i l l e d p s y c h i a t r i c s o c i a l workers i n order t h a t of care f o r d i s c h a r g e d  mental p a t i e n t s w i l l be  To conclude, some of the  continuity  provided.  suggestions made here  may  be p a r t i c u l a r l y r e l e v a n t where engaging community agencies the  and  community at l a r g e i n a comprehensive a f t e r c a r e program  i s concerned. E . Future Trends As we have noted, there  i s an uneasy s t a t e of f l u x  at the present time i n mental h e a l t h programming between the P r o v i n c i a l M e n t a l H e a l t h S e r v i c e s and the Vancouver General Hospital.  Although the  i n t e g r a t e d approach to community  p s y c h i a t r y has not m a t e r i a l i z e d so f a r , we that w i t h the  might  speculate  i n f l u e n c e o f the recommendations of the  Commission on H e a l t h S e r v i c e s ,  such an approach c o u l d  Royal be  instituted. Aftercare  s e r v i c e s would no doubt be a f a c e t o f  an i n t e g r a t e d p a t t e r n . concerning o u t - p a t i e n t gency s e r v i c e and  "day"  We  have noted the  recommendations  departments, twenty-four hour emerand  " n i g h t " care programs.  Another  recommendation i s t h a t the proposed p s y c h i a t r i c u n i t s general  h o s p i t a l s develop a r e h a b i l i t a t i o n s e r v i c e  of  properly  s t a f f e d w i t h p s y c h i a t r i c s o c i a l workers and p s y c h i a t r i c nurses and  such  t h a t t h i s s e r v i c e be  f u l l y co-ordinated  o t h e r community h e a l t h and welfare  services.  with  -  We cerning  137  -  have made mention o f the  current problems con-  scope, c o - o r d i n a t i o n and r e s p o n s i b i l i t y f o r a f t e r -  care programs.  We  b e l i e v e that i n t e r n a l and  external  stress  w i l l be c h a r a c t e r i s t i c o f our mental h e a l t h s e r v i c e s f o r some time to come. Along w i t h the p o s s i b l e f u t u r e developments i n p r o v i d i n g s e r v i c e s there are other  trends  to c o n s i d e r ,  such as  those o f p o p u l a t i o n .  Since we have the a b i l i t y t o p r o j e c t  population  demographic t r e n d s ,  growth and  i t i s essential  that such p r o j e c t i o n s be used f o r r a t i o n a l p l a n n i n g mental h e a l t h needs of the  future.  We  are In a time of  extremely r a p i d s o c i a l change i n Canada and  i t i s safe t o  assume t h a t much o f t h i s change w i l l have a b e a r i n g mental h e a l t h of our p o p u l a t i o n required.  and  on  economic d i s t r e s s . t h a t d i v o r c e and  that  s u f f e r mental as w e l l as  Dr. Hugh K e e n l e y s i d e ^  recently predicted  a l c o h o l i s m r a t e s w i l l double and  r a t e w i l l t r i p l e w i t h i n the next ten y e a r s . questionnaire  the  mental h e a l t h s e r v i c e s  There i s reason t o b e l i e v e , f o r i n s t a n c e ,  workers d i s p l a c e d by automation may  i t seems t h a t many of our  the s u i c i d e  From our  patient  former mental h o s p i t a l  p a t i e n t s have unmet needs and we have f e l t j u s t i f i e d ing  to meet  i n mak-  assumptions as to what e f f e c t s the l a c k of a comprehensive  a f t e r c a r e i s h a v i n g on the r e h a b i l i t a t i o n of the  patients.  Even though p r i v a t e p s y c h i a t r i c care w i l l be a v a i l a b l e to many more c i t i z e n s i n the  f u t u r e under the proposed n a t i o n a l  1 . "Keenleyside P a i n t s a Gloomy Future," Vancouver Vancouver, 5 March 1 9 6 6 , p. 2 , ~ -  Sun.  - 138 medicare ing  p l a n , t h e r e w i l l s t i l l remain many persons  s e r v i c e s o f an a f t e r c a r e program.  requir-  With our experience i n  mind then, and such gloomy p r e d i c t i o n s as those o f Dr. Keenl e y s i d e , we see i t as e s s e n t i a l t h a t as adequate an a f t e r c a r e program as i s p o s s i b l e under the present confused s t a t e o f s e r v i c e s , be developed. I t i s v i t a l f u r t h e r , that i n c r e a s e d funds be made available  f o r t h e expansion o f c o - o r d i n a t e d programs o f r e -  s e a r c h i n t o t h e causes o f mental programs and p r e s e n t treatment  i l l n e s s and that  community  o f s e r v i c e s i n the mental  i l l n e s s f i e l d be c o n t i n u o u s l y e v a l u a t e d .  A better  understand-  ing must be gained o f the consequences o f v a r i o u s a c t i v i t i e s d i r e c t e d towards the improvement o f mental h e a l t h and the p r e v e n t i o n and c o n t r o l o f mental  disorders.  No ambitious p l a n s , o f course, can come t o f u l l f r u i t i o n without  the proper number o f people t o do the j o b .  I f mental h e a l t h f a c i l i t i e s and programs are t o accomplish the purpose f o r which they a r e designed, they must be c e n t e r e d i n people.  Along w i t h the present p o p u l a t i o n trends there  must be a commensurate i n c r e a s e i n the r e c r u i t m e n t and t r a i n ing  o f mental h e a l t h manpower.  - 139 -  APPENDIX A A QUESTIONNAIRE UNIVERSITY OF BRITISH COLUMBIA SCHOOL OF SOCIAL WORK We are doing a study on the A f t e r Care programme and need t o know something about the people who go t h e r e . FIRST WE WOULD LIKE TO KNOW SOMETHING ABOUT HOW YOU SPEND YOUR SPARE TIME. IT IS HARD TO ANSWER THESE QUESTIONS EXACTLY SO A GENERAL REPLY WILL BE FINE. 1. Could you t e l l me i f youspend no time Some time A l o t of time on the f o l l o w i n g : SOME LOT OF WITH WITH NO TIME TIME SELF OTHERS TIME LISTENING TO THE RADIO 21 11 7 GARDENING . 10 2 7 5 HOBBIES 2 6 sS 9 SPORTS 2 5 10 fj MOVIES 19 h 17 DRIVES 2 k 17 19 CLUBS 11 3 1 WATCHING T.V. 20 25 lk 7  -  -  y o u r s e l f or mostly w i t h o t h e r s . 3. G e n e r a l l y would you l i k e t o be more a c t i v e less active  YES YES  26  NO NO  17  UNDECIDED _2_  / k. What a c t i v i t i e s would you l i k e t o do more o f less~~of* 5. Would you say you have any problems i n occupying your spare time as you would l i k e ? EXPLAIN  I WOULD LIKE TO ASK FOR: YOUR OPINIONS ABOUT THE AFTER CARE PROGRAMME. AGAIN, I F YOU CANNOT.BE SPECIFIC A GENERAL IDEA WILL BE MOST APPRECIATED. . . .. 6. Do you know i f the h o s p i t a l had a leave p l a n o r l i s t o f recommendations made f o r you when you were d i s c h a r g e d from the h o s p i t a l ? YES 29 NO 15" UNDECIDED 1 7. I f y e s , Who were these plans d i s c u s s e d with? RELATIVES 10 FAMILY DOCTOR 5" OTHERS UNDECIDED l k  YOURSELF 8  21  - IkO 8.  Was t h i s your f i r s t h o s p i t a l i z a t i o n ?  9.  I f not, how may p r e v i o u s h o s p i t a l i z a t i o n s have there been? Number of hospitalizations  ( 1 - 9 ( 2 - 8 (  3  YES J §  - 1 1  1 1  "  h  10.  How long i s i t now t h a t you have been 1 month - 3 months - 1 4 months- 6 months - 1 Over 6 months - 1  11.  How long i s i t t h a t you have been clinic? 1 month - 3 months k months- 6 months Over 6 months  12.  out o f h o s p i t a l ? 7 patients 8 " 0 "  coming t o the a f t e r c a r e - 2 0 patients - 1 7 " - 1 8 "  Would, you r a t e your mental h e a l t h now as: VERY POOR POOR 3 PAIR 1 2 GOOD 2 6 UNDECIDED ~T .  VERY GOOD  YES 1 3 . o you have problems about SLEEPING PEELING TIRED BEING FORGETFUL FEELING DEPRESSED FEELING ANXIOUS D  INTERVIEWER'S  EATING COMMENTS  36  patients "  ( k - $  < 5 -  NO  3  Undecided  l£ 1 8 1 3 2 0 1 9  1 1  8  l k . What w o r r i e s you most about your mental h e a l t h ?  Do you f e e l that your d i f f i c u l t i e s have improved s i n c e coming to a f t e r care? NOT AT ALL 1 2 SOMEWHAT 1 6 QUITE A BIT J j A GREAT DEAL J j . UNDECIDED _ 9 16.  Abowt how o f t e n do you see a s o c i a l worker How long would you spend w i t h him each i n t e r v i e w ?  How Often Less than once a m o n t h - 1  Not a t a l l -kk  How Long 1 - 1 5 minutes-1  - l k l-  What about a p s y c h i a t r i s t  A NURSE PSYCHOLOGIST  Once a month  -  More frequent  -  -  HOW OFTEN Less than 12 once a month Not a t 5" a l l  HOW LONG 1-15 minutes - 3U  - 25" 16-30  Over 30  -  3 3  - 3  2  1-3 hours Group Therapy  17. A r e t h e i r any s o c i a l a c t i v i t i e s a t the a f t e r you attend? Yes _2 NO U5" 18. I f so, what a r e they?  -  "  5  care c l i n i c  that  N/A  19. How o f t e n do you attend? Do you have any FINANCIAL PROBLEMS WORK PROBLEMS . PERSONAL. PROBLEMS PHYSICAL PROBLEMS MARITAL- PROBLEMS OTHER FAMILY. PROBLEMS INTERVIEWER'S COMMENTS -  21. Do you f e e l that you a r e g e t t i n g f o r these problems at the c l i n i c FINANCIAL WORK PERSONAL PROBLEMS PHYSICAL PROBLEMS MARITAL PROBLEMS FAMILY PROBLEMS  YES  "TJ  NO 31  UNDECIDED . 1. . .  30  2  27 21  18 9 13 8 12  21 31  1  SOME HELP  10 11 6 7  h  1  3 3 3  1  -  3  1 1  ADDITIONAL COMMENTS  22. Are you t a k i n g medication?  YES 38  15 16 1  CONSIDERABLE HELP UNDECIDED  NO HELP  76  N/A  NO J7_  1 2  - Ik2 -  23* Are you getting help for your problems from any other agency (give examples of agencies) YES 13 NO _32 Which agencies? Dept. of Veteran A f f a i r s . Social Service Departments. Public Health Nurse. School Counsellors. Workmen's Compensation Board. P r o v i n c i a l Dept. of R e h a b i l i tation, Outpatient Dept. - Vancouver General Hospital, Disabled Person's Allowance Dept. 2k. What kind of problems do they help you with and to what extent: FINANCIAL WORK PERSONAL PROBLEMS PHYSICAL PROBLEMS MARITAL PROBLEMS FAMILY. PROBLEMS  No Help 1 1  Some Help  8.  2 1  h  2  Lot  of Help 1 2 3 1 3 1  Are you s a t i s f i e d with the help these other agencies are giving you? YES 10 N0 2 UNDECIDED 1 Explain: NOW  COULD I ASK YOU A LITTLE MORE ABOUT YOUR SOCIAL LIFE?  26. Would you t e l l me i f the people i n your neighbourhood are generally: Friendly 25> F a i r l y Friendly 5> Indifferent _8 Unfriendly _1 "Undecided j S 27. About how many close r e l a t i v e s do you have i n t h i s area? None _9 1-3 15 k-6 11 6-12 k Over 12 6_ 28. Do you get to see these r e l a t i v e s at least: °nce a week Once a month 12 Less often 12  15>  29. What about friends; how many do you have approximately: None 12 1-3 16 k-6 _8 7-12 _9 30. How often do you see them: Once a week Less frequently than once a month 10  17  Once a month _9  31. Would you l i k e to have closer contact with people? Yes _20 No 21 Undecided J± Explain 32. Concerning your s o c i a l l i f e , generally speaking, are you: S a t i s f i e d 2k Unsatisfied 20 Undecided 1_ Explain  - 143 -  3 3 . °o you f e e l you have d i f f e r e n c e s with your f r i e n d s concerning r e l i g i o n , sex, money, h e a l t h , others  I WOULD LIKE TO ASK YOU SOME QUESTIONS ABOUT WORK. AGAIN I DO NOT EXPECT THAT YOU WILL BE ABLE TO SAY EXACTLY, SO GENERAL ANSWERS WILL. DO. \ 34* Would you t e l l me i f you were working before h o s p i t a l i z a t i o n ? Yes 15 No J 3 35". I f yes: P u l l time  13  P a r t Time _1  I r r e g u l a r l y _1  36. What k i n d o f work d i d you do? U n s k i l l e d P r o f e s s i o n a l _Z  10  Skilled _ J  3 7 . Have you worked s i n c e being d i s c h a r g e d from h o s p i t a l ? Yes 18 No 20 38. I f yes: P u l l time  10  Irregularly _ J  Part time  39. What k i n d o f work do you do now? Professional 1  Unskilled  13  Skilled  hO:  IP WORKING; How about your f e l l o w workers? Are they easy t o get along w i t h 10 f a i r t o get along with __3 h a r d t o get a l o n g with 0  41.  O r d i n a r i l y , i s your boss easy t o get along w i t h 10 f a i r t o get along w i t h 3 h a r d t o get a l o n g w i t h  1*2. I n g e n e r a l , does anything bother you a t work? No 7 Explain:(probe)  43* I F NOT WORKING; Are you p r e s e n t l y l o o k i n g f o r work? Explain:(probe) ;  Yes 5>  0  Yes 6  No _ _ 2 7 .  14.14.. What would be most u s e f u l i n your g e t t i n g employment? More education or t r a i n i n g h More c o n f i d e n c e k ^ o r e skill 1 More l u c k 1 More jobs a v a i l a b l e U Explain:  2  - lkk1+5.  Would you t e l l y o u r home?  me  who  d o e s t h e f o l l o w i n g h o u s e h o l d work i n SELF 25 •  •  PREPARING THE MEALS DOES THE GROCERY SHOPPING HANDLES THE GROCERY MONEY DUSTS, SWEEPS AND DOES OTHER USUAL CLEANING TAKES CARE OP LAUNDRY AND MENDING  TOGETHER  UNDECIDED  OTHER  9-  11  14  9  18  21  17  17  2k  2  9  10  18  6  11  10  u  1+6.  C o n c e r n i n g t h e h o u s e w o r k s i t u a t i o n , A r e you SATISFIED 30 FAIRLY SATISFIED 10 UNSATISFIED Explain: . . . - . . . .-. .  NOW  I WOULD L I K E TO ASK  1+7.  Would you mind, i f I a s k e d y o u y o u r age? A r e you 20-29 _8 30-39 l k 1+0-1+9 11 Over £0 12  1+8.  A r e you m a r r i e d 25 Separated D i v o r c e d _1 Single 12  1+9.  I f m a r r i e d , how many p r e - s c h o o l c h i l d r e n 8 School c h i l d r e n _11 W o r k i n g c h i l d r e n home 2 C h i l d r e n not a t home 10  50.  What g r a d e d i d you c o m p l e t e ? 1-6 Over 12  51.  52.  YOU  SOME GENERAL PERSONAL QUESTIONS;  k  Widowed  J±  special  3  20  6-10  training?  10-12  Yes  19  Would, you m i n d t e l l i n g  me  what  _8  26  Estate  2  .  s o u r c e s o f income  No  (specify):  No  •  Job Spouse O l d Age P e n s i o n Veterans Allowance  53•  between  13  Have y o u h a d a n y I f so, what  Other  5  you h a v e :  Ye s Relatives Social Assistance O l d Age A s s t . Disability Allowance  2  C.P.R.Pension  1  °o you w o r r y about y o u r f i n a n c i a l Somewhat w o r r i e d U Worried k  No  p o s i t i o n : Not w o r r i e d Very worried _.l  _26  - 11*5 51*. I f worried, what bothers you about your f i n a n c i a l c o n d i t i o n : Debts 6 Lack o f money now 5 Lack o f money f o r f u t u r e .10 Being dependent on others 3 NOW COULD I ASK YOU SOME PERSONAL QUESTIONS ABOUT YOUR HOME LIFE 55. Would, you say your l i v i n g accommodation i s s a t i s f a c t o r y ? Yes 35 No 10 S iain x p  56. How l o n g have you l i v e d a t Under 6 months 7 months to 1 year 1-3 years Over 3 y e a r s  ;  t h i s place? - 9 patients 6 " - 12 " - 18 "  57. Do you l i v e by y o u r s e l f 10 Parents ( i f one, s p e c i f y ) _k__ Brother(s) 1 Sister(sl 1 Spouse 11 Children 2 Friends 1 Others ( s p e c i f y ) 1 Spouse and young c h i l d r e n _lu 58. How would you say you get along w i t h these people? Very w e l l 11 W e l l _l6 P o o r l y 6 Not a p p l i c a b l e 1* Alright 7 Very p o o r l y 1 59. o you f e e l that you have d i f f e r e n c e s w i t h the people you l i v e w i t h concerning r e l i g i o n , sex, money, h e a l t h , other? Yes _17 No 2k Not a p p l i c a b l e J± E x p l a i n : (probe) D  60. G e n e r a l l y , do you f e e l t h a t you understand t h e people w i t h Whom you l i v e ? Yes 28 No 6 Undecided k Not applicable 7Why? 61. ^o you f e e l that they understand you? Undecided 9 Not a p p l i c a b l e 9 Why  Yes 18  62. Have you ever thought o f l e a v i n g these people? Sometimes 13 Often _1 Not a p p l i c a b l e 10  3  No  9_  Never 18 Undecided  63. What a r e some o f your most important problems i n l i v i n g with these people?  - Lk6 WE ARE NEARING THE END OP THE QUESTIONNAIRE NOW. I HAVE A NUMBER OP SAYINGS TO READ TO YOU AND I WOULD LIKE YOU TO ANSWER AS BEST YOU CAN WHETHER YOU.THINK THE SAYING IS MOSTLY RIGHT OR MOSTLY . WRONG. Mostly Mostly  6k.  21  20  h  65.  27  h  66.  33  5  7  67.  12  8  25  68.  18  3  21+  69.  21  k  20  70.  23  k  18  71.  38  2  72.  23  6  16  73. 7k.  32 19  5 5  8 21  75.  15  h  26  76.  36  h  5  77.  13  5  27  5"  What young people need most o f a l l is strict discipline. Sometimes i t s h a r d t o t e l l whether one l i k e s something o r n o t . There's no reason t o a n t i c i p a t e t r o u b l e o r worry about what may never happen. Man's l i f e i s completely under the control of fate. There's l i t t l e use i n w r i t i n g t o p u b l i c o f f i c i a l s because they a r e n ' t r e a l l y i n t e r e s t e d i n the problems o f the average man. I t i s easy t o c l a s s i f y most things as e i t h e r good or bad. Any good, l e a d e r should, be s t r i c t w i t h people under him i n order t o gain t h e i r respect. I t i s worth a t l e a s t a thousand d o l l a r s a year to have the h a b i t o f l o o k i n g on the b r i g h t side o f t h i n g s . In s p i t e o f what some people say, the problems o f the average man a r e g e t t i n g worse. Nothing I s so f o o l i s h a s t o a n t i c i p a t e misfortune. Whatever you do must be done p e r f e c t l y . Whatever may happen t o a person, i t was prepared f o r him from a l l e t e r n i t y . To f e a r the worst i s t o go through l i f e w i t h an unnecessary burden. Once your mind, i s made up, don't l e t anything change i t .  QUESTIONS 6k-77 Authoritarianism Goal Dichotomy Pessimism Fatalism Ariomie Optimism Rigidity  Yes  hk  35 30 27 51  71+  32  No  38  V  50 51 30 10 k8  Undecided  8 8 10 12 9 6  10  - Ik7  -  WOULD YOU INDICATE IP YOU THINK THESE SAYINGS COULD GENERALLY APPLY TO, YOU OR NOT? . 78. I daydream i n s t e a d o f doing work  Yes  13  No  30  Undecided  79. I am o f t e n j u s t m i s e r a b l e f o r no s u f f i c i e n t reason No 26 Undecided 2 80. In g e n e r a l , I'm s e l f - c o n f i d e n t about my a b i l i t i e s No 12 Undecided Jj,  Yes Yes  17 29  81. To avoid arguments, do you u s u a l l y keep your o p i n i o n s t o y o u r s e l f ? Yes 26 No 17 Undecided _2 82. o you f e e l somewhat apart even among f r i e n d s No 26 Undecided. 2  Yes  D  83. Ideas r u n through my head so as t o prevent s l e e p No 23 Undecided 62  17 Yes  20  81|. My f e e l i n g s a l t e r n a t e between happiness and. sadness without reason Yes 11 No 32 Undecided. 2 85. I worry about b e i n g s u c c e s s f u l i n l i f e Undecided 3 QUESTIONS  Yes  20  No  22  78-85:  Autism C y c l o i d Thinking S e l f Confidence Withdrawal  Yes  33 28  kk k3  No  53 58 39  Undecided  k k  7  k3  k  RATINGS TO BE MADE BY INTERVIEWED IMMEDIATELY AFTER INTERVIEW Informant i n t e r e s t i n i n t e r v i e w :  At  12  Lack Mild High A t t i t u d e towards  interview: Hostile S u s p i c i o u s , guarded Friendly Solicitous Other (Accepting)  Start 26  7  At  Start 5  18 17 2 3  At Close  2 31 12 At Close 0  13 21 8 3  - Ik 8 88,  Informant's  tension level: At Nervous Sporadic nervousness Mostly relaxed  89.  Informant's  impression of emotional Grossly disturbed Disturbed Somewhat d i s t u r b e d Slightly disturbed Not d i s t u r b e d  90.  Distraction  during  interview: Outside  Much d i s t r a c t i o n Some d i s t r a c t i o n No d i s t r a c t i o n 91•  92.  estimate o f  Very poor Poor Pair Good Very good Excellent Not seen  Housing Housekeeping ' 2" \\ 7 3 15 16 15 lk k 7 1 0 1 1  Comments:  At Close 11 19 \$  condition: 2 8 17 13 $  sources  5 21 19  Intervierers  General  Start 19 IJ4 12  Interview 2 lf> 28  Standard """  Sources  Estimate of Neighbourhood 3 k 18 lk 1+ 1 1  - 11*9 -  APPENDIX B Table 2,  Living Arrangements  L i v i n g Arrangements by M a r i t a l S t a t u s and Sex  Men Single Married  Women Single Married  Total  Self  5"  3  8  Boarding Home  2  1  3  Relatives  1  2  3  Friends  1  1  Parents  2  2  Spouse  k  3  7  Spouse and Children  3  13  16  1  1  Children Spouse and Parents  1  1  Spouse,Children, and Parents  1  C h i l d r e n and Parents Total  2  2 11  8  9  17  US  - 150 -  Table Ij..  Education  Education  C l i e n t Response  Grade  1-6  k  Grade  7-9  20  Grade  10-12  8  Over Grade 12  13  Total  H5  Special  19  Training  Table  Sex Education  E d u c a t i o n by M a r i t a l Status and Sex'  Men Single Married  1-6  2  1  7-9  I*  k  Trade Total  1.  Prom h o s p i t a l  11  files.  Total  3 3  8  19  3  6  1U  2  1  2  (2)  (3)  10 - 12 University  Women Single Married  9  10  (5)  16  k6  - 151 -  Table 6.  Source o f Income  Source o f Income  C l i e n t Response  Job Spouse  15  Old Age Pension  13  Veterans Allowance  2  D i s a b i l i t y Allowance  2  Old Age A s s i s t a n c e  1  Social Assistance  10  Relatives  1  Estate  2  C.P.R. Pension  1  - 1^2 -  Table 7.  Sex Number o f Hospitalizations  Number o f H o s p i t a l i z a t i o n ; by M a r i t a l Status and Sex  Men Single  Women Married  Single  Married.  Total  1  1  1  3  k  9  2  1  k  1  3  9  3  7  1  3  11  k  1  2  5  1  6 * over Total  11  Table 8.  3  2  3  1  2  3  6  8  9  13  ill  Number of Hos p i t a l i z a t i o n s  Number o f Hospitalizations  C l i e n t Response  1  9  2  8  3  11  U  5  5  k  Over 5  i  Unknown  7  Total 1. Prom h o s p i t a l  1+5 files.  - 153 Table 1 1 .  C l i e n t Estimate o f Symptoms  Symptoms  C l i e n t Response  Sleeping  15  Tired  18  Forgetful  13  Depressed  20  Anxious  19  Eating  8  Table 1 3 .  Improvement  C l i e n t Estimate o f Improvement  C l i e n t Response  Not A t A l l  12  Somewhat  16  Quite a B i t  k  A Great  9  Unknown Total  -  Deal  4 45  -154  -  Table l k . C l i e n t Estimate o f Help Given F o r S p e c i f i c Problems by Other Agencies  Problems  YES  Other Agency Help Some Help L o t of Help No Help  Financial  13  1  8  1  Work  18  1  2  2  Personal  9  1  3  Physical  13  4  1  8  0  3  Other Family  12  2  1  Total  72  17  11  Marital  Table 15.  Recreation  2  C l i e n t Estimate o f Time Spent i n R e c r e a t i o n .  Time Spent Some time Lot o f time  Total  Radio  21  7  27  T.V.  20  14  34  Movies  19  4  23  Drives  17  4  21  Hobbies  15  2  17  Sports  lk  2  16  Clubs  7  3  10  Gardening  7  5  12  14  7  21  Other  -155  Table 16.  Number  -  C l i e n t Contact w i t h R e l a t i v e s and F r i e n d s  Friends  Relatives  0  12  9  1-3  16  15  k-6  8  11  7-12  9  k  Over 12  6 Friends  Time  17  15  9  12  10  12  Once a Week Once a Month Less Often  Table 17.  Relatives  C l i e n t Opinion o f Neighbours  Opinion Friendly  C l i e n t Response  25  Fairly Friendly  5  Indifferent  8  Unfriendly  1  Undecided  6  Total  1*5  - 156 -  Table 20.  Work  Comparison o f Employment Status and Type Before and A f t e r Hospitalization"^  Before Hospitalization  After Hospitalization  15  18  8  20  10  13  Skilled  3  2  Professional  2  1  F u l l Time  13  10  Part Time  1  5  Irregular  1  3  Yes No  Unskilled  1. I t was not always easy to c l a s s i f y s k i l l e d and uns k i l l e d . However, g e n e r a l l y , we used t r a d e s and white c o l l a r work as s k i l l e d ; o t h e r s as u n s k i l l e d .  - 157  Table  Interviewer Estimate  21.  -  I n t e r v i e w e r Estimate o f Housing Neighbourhood and Housekeeping l  Neighbourhood  Housing  Very Poor  3  2  l*  Poor  k  7  3  Pair  18  15  16  15  11*  Good  Housekeeping  Very Good  k  1*  7  Excellent  1  l  0  Total  1*1*  41+  1*4  1. G e n e r a l l y the r a t i n g was f a i r l y i m p r e s s i o n i s t i c but there was agreement between the i n t e r v i e w e r s to r a t e very poor and poor as s k i d row and poor i n d u s t r i a l neighbourhood, d e l a p i d a t e d housing and f i l t h y and g r o s s l y d i s o r d e r e d housekeeping. P a i r was r e s e r v e d f o r lox^r income neighbourhood j u s t adequate housing and. g e n e r a l l y c l e a n but disordered, housekeeping. Good, was considered, normal working c l a s s area, housing i n good, shape and c l e a n and. w e l l kept housekeeping. Very good, was c o n s i d e r e d to be good r e s i d e n t i a l area, modern, spacious home and c a r e f u l p e r s o n a l housekeeping. E x c e l l e n t was r e s e r v e d f o r upper income homes and neighbourhood.  - 158 -  Table 23.  Tasks  Responsibility  Self  f o r Household Tasks  Persons Respon s i b l e Undecided Share Other  9  11  • lk  9  18  Handles GroceryMoney  21  7  17  Gleaning  2k  2  9  10  Laundry & Mending  18  6  11  10  Meals Shopping  Table 2k.  Satisfaction  k  Client Satisfaction With Household Tasks  Response  Satisfied  30  Fairly Satisfied  10  Unsatisfied Total  $  45  - 159 -  Table 25.  Client Response  C l i e n t and Home Member Understanding  Understand Others  Understand You  28  .18  No  6  9  Undecided  a  9  38  36  Yes  Total  - 160 APPENDIX C QUESTIONNAIRE TO STAFF 1. D  0  you see the present A f t e r Care C l i n i c Adequate Inadequate  Dr. 1 k  services as:  S.W. 0 5>  2. (a) Which o f the f o l l o w i n g do you t h i n k would be e s s e n t i a l to an adequate A f t e r Care treatment program? I n d i c a t e order of importance - 1, 2, 3, e t c . Doctors Social Workers 2nd 3rd 1. m e d i c a t i o n 1st 2nd 2. i n d i v i d u a l supportive therapy 5th 5th 3» group therapy Ij,th 6th \\. f a m i l y therapy 3rd lj,th 5. b r i e f r e a l i t y o r i e n t e d therapy 6 . long term e x t e n s i v e psychotherapy 6th 1st 7 . coordinated r e h a b i l i t a t i v e planning 8 . others - s t a t e (b) Which o f the f o l l o w i n g do you t h i n k would be u n e s s e n t i a l f o r an adequate A f t e r Care treatment program? Mark 'U'. 1. m e d i c a t i o n -. 2. i n d i v i d u a l supportive therapy 3« group therapy i+. f a m i l y therapy Doctors S o c i a l 5 . b r i e f r e a l i t y o r i e n t e d therapy . Workers 6 . l o n g term e x t e n s i v e psychotherapy x Unessential 7 . coordinated r e h a b i l i t a t i v e planning 8 . others - s t a t e 3 . I n your o p i n i o n , which form o f therapy does the present A f t e r Care l i n i c seek t o p r o v i d e ? Please l i s t i n order o f emphasis. Doctors Social Workers 2nd 1st 1. medication 1st 3rd 2. i n d i v i d u a l supportive therapy 5th 6th 3« group therapy kth 5th \\, f a m i l y therapy 3rd 2nd 5 . b r i e f r e a l i t y o r i e n t e d therapy • 6. l o n g term e x t e n s i v e psychotherapy 6th kth 7 . coordinated r e h a b i l i t a t i v e planning 8 . others G  -  161 -  k» I n your o p i n i o n , what main purpose i s being served by the p r e s e n t A f t e r Care C l i n i c ? Doctors Immediate b r i e f p o s t h o s p i t a l contact. 2 . P i l l s the dependency needs o f p a t i e n t s . 3. Prevent r e h o s p i t a l i z a t i o n . C o n t r o l o f acute symptoms• k. D o l i n g out o f m e d i c a t i o n . 1.  5. Help p a t i e n t s r e a d j u s t t o home, job, problems.  $.a D  0  1. 2. 3. k. 5.  S o c i a l Workers B r i e f f o l l o w - u p . Emphasis on m e d i c a t i o n . Medication. Meeting crises. Dispensing medication. Maintaining contact to spot r e l a p s e . M e d i c a t i o n . Check p a t i e n t ' s p r o g r e s s i n community. Medication. Observation. Minimal support. Occasi o n a l r e f e r r a l t o community resources.  you a t t e n d the A f t e r Care C l i n i c ? Doctors S o c i a l Workers Daily 1 1 Weekly T* Bi-Monthly Monthly 1 Not a t a l l  "o~  5>.b What types o f p a t i e n t s do you mainly r e f e r t o A f t e r Care? Doctors Social Workers " 1 . patients with a chronic schizophrenic h i s t o r y or s c h i z o p h r e n i c r e s i d u a l . 2 . s i n g l e , s c h i z o i d p a t i e n t s w i t h few social contacts. 3. ( c h a r a c t e r d i s o r d e r ) p a t i e n t s , f o r example, problem p a s s i v e a g g r e s s i v e patients. ~ i+. p a r a n o i d a l p a t i e n t s . " 5". n e u r o t i c s . 6 . p a t i e n t s w i t h m a r i t a l adjustment problems. ~ 7. m a r g i n a l l y a d j u s t e d s k i d r o a d p a t i e n t s , " 8. a l c o h o l i c s . ~ 9 . a d o l e s c e n t adjustment problems. " 1 0 . depressed p a t i e n t s . ~ 1 1 . sociopathic personalities. " 1 2 . others.  - 162 6. I f you a t t e n d the C l i n i c , how much time do you spend, on t h e average, w i t h e a c h . p a t i e n t ? Average Time Spent  20-30 minutes  15  15  Doctors  Social  "  10 3 0 minutes 20 " 30 " it 30 it 30 it 20  Workers  How many p a t i e n t s , on the average, would you see? Average No.of P a t i e n t s Seen 2-30 p a t x e n t s per week 8 p a t i e n t s - 3 hours 8 patients - 3 " Doctors 8 patients - 3 " 7-10 p a t i e n t s - 3 " 3 0 - h 0 p a t i e n t s p e r week 5 p a t i e n t s - 3 hours 2-3 p a t i e n t s - 3 hours S o c i a l Workers 6-7 p a t i e n t s - 3 hours k p a t i e n t s - 3 hours 7. What community r e s o u r c e s would you see being i n v o l v e d i n an adequate h o s p i t a l a f t e r care program? For Example - V.G.H. - Metropolitan health - Burnaby Mental H e a l t h ^ l i n i c _ - Other community a g e n c i e s 1. M e d i c a t i o n  TABULATIONS WERE  2. S u p p o r t i v e Therapy  OMITTED OWING TO  3. I n d i v i d u a l Therapy  PROBLEM IN INTER*  h. Group  PRETATION OF QUESTION  Therapy  5. F a m i l y Therapy 6. B r i e f R e a l i t y O r i e n t e d Therapy 7. Dong Term E x t e n s i v e Psychotherapy 8. C o o r d i n a t e d R e h a b i l i t a t i v e  Planning  - 163 8.  Which d i s c i p l i n e s do you sea as h a v i n g a key r o l e t o p l a y i n post d i s c h a r g e adjustment o f p a t i e n t s ? F o r example, p s y c h i a t r i s t , G e n e r a l P r a c t i t i o n e r , P u b l i c H e a l t h Nurse, p s y c h i a t r i c s o c i a l workers, other agency s o c i a l workers, p s y c h o l o g i s t Please l i s t i n order o f importance. Concerning:1. M e d i c a t i o n  TABULATIONS WERE  2.  S u p p o r t i v e Therapy  OMITTED OWING TO  3.  I n d i v i d u a l Therapy  PROBLEM IN INTER-  k. Group Therapy  PRETATION OF QUESTION  5>. a m i l y Therapy F  9.  6.  B r i e f R e a l i t y O r i e n t e d Therapy  7.  Long Term E x t e n s i v e Psychotherapy  8.  Coordinated R e h a b i l i t a t i v e Planning  9.  Other  ,  Do you t h i n k the q u a n t i t y o f s e r v i c e a t the A f t e r Care i s on the whole: S o c i a l Workers Doctors Satisfactory 2 2 Unsatisfactory 3 3  Cii i n  c  you t h i n k the q u a l i t y o f s e r v i c e at the A f t e r Care on the whole: S o c i a l Workers Doctors Satisfactory . 2 1 Unsatisfactory 3 4 11.  Some people b e l i e v e t h a t the main s e r v i c e s r e n d e r e d by the A f t e r Care i i i c a r e : (a) r e l i e f o f symptoms. Doctors S o c i a l Workers Would you agree? YES 3 1 - NO c  n  (b) p r e v e n t i o n o f r e h o s p i t a l i z a t i o n . YES NO  2  k  12. I n what way do you t h i n k the A f t e r Care s e r v i c e s can be improved? (For analysis)  .  - 16k -  APPENDIX D QUESTIONNAIRE Generally  do you f e e l that a f t e r c a r e s e r v i c e s i n t h i s  community a r e adequate Unknown  1  No answer  1  Inadequate k  7  (Metropolitan  Health  Agencies)• In what way? Would you say that you have s u f f i c i e n t l i a s o n w i t h agencies i n v o l v e d w i t h the d i s c h a r g e d N  o  5"  Unstated  1  No answer  p a t i e n t ? Yes  other 3  k  Explain What about the A f t e r c a r e C l i n i c i n Burnaby.  Do you f e e l  that you have s u f f i c i e n t l i a s o n w i t h them? Yes  k  No  5  No answer  k  Explain What r e s p o n s i b i l i t y  do you f e e l your agency has f o r the  discharged  patient?  What other  agencies do you f e e l ought t o be i n v o l v e d w i t h  the p a t i e n t ?  How about the A f t e r c a r e C l i n i c ? do you f e e l they should  What r e s p o n s i b i l i t i e s  assume f o r the treatment o f the  - 165 -  patient?  7.  What do you see as the major problem i n p l a n n i n g f o r the discharged patient?  8.  Other remarks, suggestions, comments.  - 166 -  THE UNIVERSITY OP BRITISH COLUMBIA SCHOOL OP SOCIAL WORK Vancouver 8 , B. C.  Dear We a r e M a s t e r o f S o c i a l Work s t u d e n t s a t U n i v e r s i t y of B r i t i s h Columbia. evaluation of after  the  Our MSW T h e s i s i s an  care s e r v i c e s g i v e n by the  Aftercare  C l i n i c i n Burnaby. As y o u r agency has c o n t a c t w i t h many p a t i e n t s  dis-  charged from R i v e r v i e w H o s p i t a l , E s s o n d a l e , we would, f i n d i t most h e l p f u l t o have y o u r o p i n i o n about a f t e r services.  Could you complete the e n c l o s e d  and. r e t u r n i t t o us a t your e a r l i e s t  care  questionnaire  convenience.  Thank you so much f o r y o u r h e l p . Yours t r u l y ,  - 167 -  APPENDIX D AGENCY QUESTIONNAIRE 1.  2.  In what way? I n a c c e s s i b i l i t y and d i s t a n c e t o A f t e r care C l i n i c Lack o f coverage i n s e r v i c e Lack o f adequate s t a f f i n g . . Lack o f emergency s e r v i c e . . Lack o f s u s t a i n i n g contact and f o l l o w - u p . Lack o f adequate f a c i l i t i e s and r e s o u r c e s Explain. R e f e r r a l s slow, minimal, or l a c k i n g Inadequate discharge p l a n n i n g D i f f i c u l t i e s i n inter-professional . communication  AGENCIES  . . .  3.  Explain. Lack o f r e f e r r a l s Lack o f s t a f f i n g Lack o f communications. . . . . . . . . .  i|.  What r e s p o n s i b i l i t y do you f e e l your agency has f o r the d i s c h a r g e d p a t i e n t ? P r o v i s i o n o f s o c i a l a s s i s t a n c e , boarding homes, e t c P r o v i s i o n o f s o c i a l and r e c r e a t i o n a l needs P r o v i s i o n o f p r o t e c t i o n s e r v i c e s to c h i l d r e n Provision of family counselling service • P r o v i s i o n o f l i m i t e d supportive casework service P r o v i s i o n t o parents o f casework i n n e g l e c t cases  5>.  What other agencies do you f e e l ought to be i n v o l v e d w i t h the p a t i e n t ? Dependent on the needs o f t h e p a t i e n t . . Gap between the needs o f p a t i e n t s and resources None Metropolitan Health Service, public health nurses F a m i l y S e r v i c e Agency Canadian Mental H e a l t h A s s o c i a t i o n . . . . Neighbourhood Houses and Community Centres  3 3 3 1 k 1 k. 1 1 2 1 2  5> 1 2 1 1 2  2 1 1 2 2 1 3  - 168 AGENCIES 6.  7.  8.  How about the A f t e r c a r e C l i n i c ? What respons i b i l i t i e s do you f e e l they should assume f o r the treatment of the p a t i e n t ? C o u n s e l l i n g and casework s e r v i c e to p a t i e n t s C o n s u l t a t i o n s e r v i c e s to other agencies • • Adequate follow-up and s u p e r v i s i o n Total responsibility Continuum i n treatment Appropriate r e f e r r a l s . . . What do you see as the major problem i n p l a n n i n g f o r the d i s c h a r g e d p a t i e n t ? Lack o f adequate community r e s o u r c e s . . . . Lack i n d i v e r s i t y o f therapy Lack o f adequate s t a f f i n g Lag i n the development of s e r v i c e s Lack of adequate d i s c h a r g e p l a n n i n g . . . . Lack o f adequate follow-up s e r v i c e . . . . . Lack of adequate i n t e r - p r o f e s s i o n a l communication Inadequacy o f community agency p e r s o n n e l . to cope • Rapid discharge and need f o r adequate t r e a t ment Adequate s u p e r v i s i o n and community p r o t e c t i o n Lack of s u s t a i n i n g c o n t a c t f o r p a t i e n t s • • Other remarks, s u g g e s t i o n s , comments. Emphasis on p r e v e n t i o n , s c r e e n i n g and p r e admission s e r v i c e E s t i m a t e o f present and p r o j e c t e d needs, on-going s e r v i c e M e d i c a l l y s u p e r v i s e d emergency s e r v i c e 2h h r . basis • D i v e r s i t y and i n d i v i d u a l i z a t i o n of r e s o u r c e s R e s p o n s i b i l i t y f o r development and p r o v i s i o n of service T o t a l treatment p l a n n i n g  2 2 £ 1 2 2  7 1 2 1 3 l\ 1 1 3 2 1  1 1 1 2 1 1  - 169 -  APPENDIX E BIBLIOGRAPHY Books Edwards, A l l a n L. S t a t i s t i c a l Methods f o r the B e h a v i o r a l S c i e n c e s . 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McDermot, Anne. "Foster F a m i l i e s Teach S a n i t y t o the M e n t a l l y 111." McLeans Magazine. 17 u n e 1961. J  H o s p i t a l Memorandums, October 19i?9, December I 9 6 0 and December 1961.  

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