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Foster home care for the mentally ill : a study of the needs of recidivist patients at the provincial… Goodwin, Harold G. 1960

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FOSTER HOME CARE FOR THE MENTALLY ILL A Study of the Needs of R e c i d i v i s t P a t i e n t s at the P r o v i n c i a l Mental H o s p i t a l , Essondale, B.C., 1959-ty HAROLD GEORGE GOODWIN Thesis Submitted i n P a r t i a l F u l f i l m e n t of the Requirements f o r the Degree of MASTER OF SOCIAL WORK i n the School of S o c i a l Work Accepted as conforming to the standard r e q u i r e d f o r the degree of Master of S o c i a l Work School of S o c i a l Work I960 The U n i v e r s i t y of B r i t i s h Columbia In presenting t h i s thesis i n p a r t i a l fulfilment of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the Head of my Department or by his representative. It i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of . ^fr-Q The University of B r i t i s h Columbia Vancouver 8, Canada. - i v -ABSTRACT Today much emphasis i s p l a c e d on the r e h a b i l i -t a t i o n o f the m e n t a l l y i l l . T h i s study u n d e r t a k e s a survey o f t h e v a l u e s o f f o s t e r home c a r e as a t h e r a p e u t i c r e s o u r c e i n the r e h a b i l i t a t i o n o f such p a t i e n t s . The programs p r e s e n t l y i n o p e r a t i o n i n M a r y l a n d , U.S.A. and O n t a r i o have been examined t o dete r m i n e t h e i r e f f e c t i v e -ness i n me e t i n g needs e v i n c e d by r e c i d i v i s t p a t i e n t s a t the P r o v i n c i a l M e n t a l H o s p i t a l , E s s o n d a l e , B.C. A sample group o f twenty-one p a t i e n t s was ob-t a i n e d by t a k i n g a l l r e c i d i v i s t p a t i e n t s r e t u r n i n g t o the h o s p i t a l from p r o b a t i o n between J u l y 1, 1959 and December 31 , 1959 , who had been a c t i v e w i t h t h e s o c i a l s e r v i c e department d u r i n g t h e p r e v i o u s a d m i s s i o n . P a t i e n t s who met t h e s e c r i t e r i a were assessed" p r i m a r i l y t h r o u g h the use o f r a t i n g s c a l e s based on i n f o r m a t i o n c o n t a i n e d i n the f i l e s . An e x a m i n a t i o n o f t h e needs and r e s o u r c e s o f t h e s e p a t i e n t s i n d i c a t e d t h a t the average p a t i e n t was u n m a r r i e d , r e t u r n i n g f o r h i s f o u r t h a d m i s s i o n , w i t h o u t f a m i l y r e s o u r c e s , and l i m i t e d i n s o c i a l , v o c a t i o n a l and e d u c a t i o n a l s k i l l s . P r e v i o u s t o t h i s r e a d m i s s i o n one out o f eve r y two had • become the c l i e n t o f p u b l i c w e l f a r e a g e n c i e s , d r a w i n g s o c i a l a s s i s t a n c e . The study s u g g e s t s t h a t p a t i e n t s ' needs may be a d e q u a t e l y met t h r o u g h a f o s t e r c a r e program w h i c h p r o v i d e s e m o t i o n a l s u p p o r t , t h u s h e l p i n g t o s t a b i l i z e and a i d the p a t i e n t i n h i s adjustment t o t h e community. The use o f t h i s system i s a l s o i n d i c a t e d f o r the care o f c h r o n i c p a t i e n t s whose symptoms o f i l l n e s s a r e c o n t r o l l e d , y e t who are un a b l e to a c c e p t f u l l r e s p o n s i b i l i t y f o r t h e i r own c a r e . The p r o -gram c o u l d a l s o be adapted t o p r o v i d e c a r e f o r the g e r i a t r i c p a t i e n t s who today s w e l l the p o p u l a t i o n o f m e n t a l h o s p i t a l s . C o n s i d e r i n g the program under t h r e e h e a d i n g s : g e n e r a l p o l i c y , r e q u i r e d f a c i l i t i e s and type o f p a t i e n t s , methods o f i m p l e m e n t i n g f o s t e r home c a r e i n the community a r e i n d i c a t e d . R e s e a r c h would be o f v a l u e i n d e v e l o p i n g methods o f s e l e c t i n g p a t i e n t s who would d e r i v e optimum b e n e f i t from the program, and i n a s s e s s i n g the p r o g r e s s made i n . t h e new s e t t i n g . F o s t e r home c a r e , w h i c h has a s ' i t s g o a l the p l a c i n g , o f pa t i e n t ' s i n f a m i l y s e t t i n g s i n the community, i s i n l i n e w i t h the c u r r e n t emphasis on d e c e n t r a l i -z a t i o n o f l a r g e m e n t a l i n s t i t u t i o n s , and, as such, p r o v i d e s a s u i t a b l e t h e r a p e u t i c r e s o u r c e i n the r e h a b i l i t a t i o n o f the' m e n t a l l y i l l . TABLE OF CONTENTS Chapter 1. F o s t e r Home Care: A Means to R e h a b i l i t a t i o n Pag F o s t e r home c a r e . P a r a l l e l s i n f o s t e r c a r e . The s i t u a t i o n i n B r i t i s h Columbia. Focus o f study 1 Chapter 2 . The Needs o f D i s c h a r g e d H o s p i t a l P a t i e n t s S e l e c t i n g t h e sample group: r e c i d i v i s t p a t i e n t s . P a t i e n t s i n t h e study group. D i a g n o s i s . Needs o f p a t i e n t s . V o c a t i o n a l need. F i n a n c i a l and m a t e r i a l r e s o u r c e s . The importance o f f a m i l y and f r i e n d s . Com-munity r e s o u r c e s 10 Chapter 3 . A F o s t e r Home Care P l a n V/hat a f o s t e r home c a r e p l a n i n v o l v e s . G e n e r a l p o l i c y . F a c i l i t i e s . P a t i e n t s 35 Chapter 4 . R e h a b i l i t a t i o n i n t h e Community G o a l s i n t r e a t m e n t . The a v e r a g e ' p a t i e n t . P r e s e n t i n g f o s t e r home c a r e t o t h e community. Re s e a r c h c o n s i d e r a t i o n s 47 Appendix A. B i b l i o g r a p h y 54 TABLES IN THE TEXT Table 1. F i r s t a d m i s s i o n s compared w i t h r e a d m i s s i o n s to t he P r o v i n c i a l M e n t a l H o s p i t a l , E s s o n d a l e , B.C 10 Table 2 . The d i a g n o s i s o f a group o f 21 r e c i d i v i s t p a t i e n t s a t the P r o v i n c i a l M e n t a l H o s p i t a l , E s s o n d a l e , B.C., 1959 16 Table 3 . E m p l o y a b i l i t y o f 21 r e c i d i v i s t p a t i e n t s a t the P r o v i n c i a l M e n t a l H o s p i t a l , E s s o n d a l e , B.C., 1959 20 - i i i -T a ble 4. Table 5. T a b l e 6 . Table 7. F i n a n c i a l and m a t e r i a l r e s o u r c e s o f 21 r e c i d i v i s t p a t i e n t s at. the P r o v i n c i a l M e n t a l H o s p i t a l , E s s o n d a l e , B.C., 1959. Page I n t e r e s t shown by r e l a t i v e s and f r i e n d s i n a group o f 21 r e c i d i v i s t p a t i e n t s a t the P r o v i n c i a l M e n t a l H o s p i t a l , E s s o n d a l e , B.C. 1959 .22 ,25 Reasons f o r r e c i d i v i s t p a t i e n t s a t the P r o v i n c i a l M e n t a l H o s p i t a l , E s s o n d a l e , B.C., 1959, not r e t u r n i n g ' to l i v e w i t h r e l a t i v e s . . . . . 2 6 R e f e r r a l s made t o community r e s o u r c e s on b e h a l f o f r e c i d i v i s t p a t i e n t s a t the P r o v i n -c i a l M e n t a l H o s p i t a l , E s s o n d a l e , B.C., 1 9 5 9 . . . . 3 0 -V-ACKNOWLEDGEMENTS I wish to express my thanks and a p p r e c i a t i o n to a l l those whose i n t e r e s t and a c t i v e help have made t h i s study p o s s i b l e . P a r t i c u l a r l y I wish to acknowledge w i t h g r a t i t u d e the d i r e c t i o n , c r i t i c i s m s and counsel of the f o l l o w i n g persons: Dr. Leonard C. Marsh and Mr. Gerald Pepper, of the School of S o c i a l Work, U n i v e r s i t y of B r i t i s h Columbia; Dr. F.G. Tucker, C l i n i c a l D i r e c t o r , Miss A.K. C a r r o l l , P r o v i n c i a l Supervisor, P s y c h i a t r i c S o c i a l Work, Miss D.R. Begg and Mr. R.M. Ross of the S o c i a l Service Department, P r o v i n c i a l Mental H o s p i t a l , Essondale, B r i t i s h Columbia. FOSTER HOME CARE FOR THE MENTALLY ILL CHAPTER I FOSTER HOME CARE: A MEANS TO REHABILITATION R e h a b i l i t a t i o n of the mental p a t i e n t becomes the concern of the mental h o s p i t a l the day the p a t i e n t enters i t s doors. Subsequent examination, treatment, nursing care, psychotherapy and s o c i a l casework are aimed at promoting h i s r e t u r n and h i s s o c i a l adjustment to community l i f e . - 1 - More s p e c i f i c a l l y , r e h a b i l i t a t i o n may be deflned'as, "the attempt to provide the best p o s s i b l e community r o l e which, w i l l enable the p a t i e n t to achieve the maximum range of a c t i v i t i e s , compatible w i t h h i s p e r s o n a l i t y and i n t e r e s t s , and of which he i s capable". This sums up the s o c i a l worker's goals i n the r e h a b i l i -t a t i o n of the h o s p i t a l p a t i e n t and gives appropriate meaning to the term " r e h a b i l i t a t i o n " as i t Is used i n t h i s t h e s i s . . I n s t i t u t i o n a l treatment methods today make i t p o s s i b l e to o f f e r more to the mental p a t i e n t than mere c u s t o d i a l care and humane treatment. Through the exten-s i v e use of t r a n q u i l i z i n g drugs, the outward symptoms of ^•'British Columbia, P s y c h i a t r i c Services P h y s i c i a n s '  Manual, 1950, C h a p t e r - ! ^ p Jones, M., R e h a b i l i t a t i o n i n P s y c h i a t r y , World Health Or g a n i z a t i o n , Geneva, J u l y , 1952, p.4. -2-m e n t a l i l l n e s s may be c o n t r o l l e d , e n a b l i n g many p a t i e n t s to b e n e f i t from t h e r a p i e s t o whi c h p r e v i o u s l y t hey were i n a c c e s s i b l e . While t h i s t r e n d r e s u l t s i n i n c r e a s e d d i s c h a r g e r a t e s from m e n t a l h o s p i t a l s , u n f o r t u n a t e l y many o f the p a t i e n t s b e i n g d i s c h a r g e d cannot be c o n s i d e r e d c u r e d ; a l t h o u g h symptoms o f i l l n e s s a r e no l o n g e r m a n i f e s t , the r e s i d u a l o f i l l n e s s c a r r i e d by the p a t i e n t may remain h i g h . As a r e s u l t , t he p a t i e n t not f u l l y r e c o v e r e d f a c e s the p o s s i b i l i t y o f a r e c u r r e n c e o f h i s i l l n e s s ; hence many unable to a d j u s t t o t h e normal s t r e s s e s o f community l i f e f i n d t h emselves back i n h o s p i t a l w i t h i n a y e a r o f t h e i r d i s c h a r g e . ^ I n a d d i t i o n t o t h i s , t he p a t i e n t may be un a b l e t o r e t u r n t o h i s home due t o h i s f a m i l y b e i n g u n a b l e o r u n w i l l i n g t o t a k e him back; o r the h o s p i t a l a u t h o r i t i e s may deem i t unwise f o r him t o r e t u r n t o the charged e m o t i o n a l r e l a t i o n s h i p s o f the f a m i l y w h i c h p l a y e d a p a r t i n p r o d u c i n g the i n i t i a l breakdown. Si n c e many p a t i e n t s have d i f f i c u l t y i n t h e i r i n t e g r a t i o n i n t o community, i t i s p a r t o f the s o c i a l w orker's r o l e t o a i d i n t h i s a d j u s t m e n t . The p r o c e s s may be c o n c e i v e d o f as a means t o b r i d g e t h e gap between h o s p i t a l and community. I t i s t h e s o c i a l w o r ker's 1 F i s h e r , S.H., "The Recovered P a t i e n t R e t u r n s t o the Community", M e n t a l Hygiene, V o l . 42, I\To. 4, October, 1958. 1 knowledge o f human b e h a v i o r , s o c i a l r e l a t i o n s h i p s and a v a i l a b l e community r e s o u r c e s t h a t e n a b l e s him to make a d i r e c t c o n t r i b u t i o n t o the w e l f a r e o f t h e p a t i e n t . F o s t e r Home Care In. o r d e r t o reduce t h e degree o f s t r e s s i n r e t u r n i n g t o community l i f e , a more p r o t e c t e d environment such as f o s t e r home o r f a m i l y home c a r e has been used as a r e s o u r c e i n the r e h a b i l i t a t i o n o f the m e n t a l l y i l l i n many c o u n t r i e s o f the w o r l d . The terms " f o s t e r home c a r e " o r " f a m i l y home c a r e " a r e used i n c o n n e c t i o n w i t h the p l a c i n g and s u p e r v i s i n g i n s e l e c t e d homes, o f men t a l p a t i e n t s who a c c o r d i n g t o m e d i c a l a d v i c e no l o n g e r r e q u i r e h o s p i t a l c a r e , but s t i l l would b e n e f i t from s u p p o r t i v e h e l p I n t h e i r r e t u r n t o community."^" (These terms, w h i l e they may have d i f f e r e n t meanings i n c e r t a i n t e x t s , are used synonymously i n t h i s t h e s i s . ) P r o b a b l y the most famous example o f f o s t e r home c a r e , and almost c e r t a i n l y t he o l d e s t , i s t h a t whieh was e s t a b l i s h e d a t the Colony o f Gheel i n Belgium i n the f i f t e e n t h c e n t u r y . At the o u t s e t t r e a t m e n t was c h i e f l y a r e l i g i o u s r i t u a l ; i f a f t e r n i n e days i n the Church's n i n e - b e d annex the p a t i e n t showed no improvement i n h i s x C r u t c h e r , H.B., F o s t e r Home Care f o r M e n t a l P a t i e n t s , The Commonwealth Fund, New York, 1944. . Jones, op. c i t . , p. 16. _4-m e n t a l o u t l o o k , he was housed w i t h a nearby f a m i l y where he c o u l d thus c o n t i n u e t o a t t e n d c h u r c h , s e e k i n g a c u r e . I t was i n t h i s manner that' t h e f a m i l y c a r e system o f Gh e e l had i t s e a r l i e s t b e g i n n i n g . I n 1852, a f t e r the Colony became a s t a t e i n s t i t u t i o n , a two hundred-bed i n f i r m a r y was b u i l t f o r the purpose, o f h o u s i n g m e n t a l l y i l l p a t i e n t s . P a t i e n t s come from a l l o v e r Europe to t h i s c e n t r e . A f t e r e x a m i n a t i o n they may be p l a c e d w i t h a f o s t e r f a m i l y o r may remain i n the. i n f i r m a r y f o r an extended p e r i o d o f o b s e r v a t i o n and s t u d y . I n 1952, Gh e e l , w i t h a p o p u l a t i o n o f 20,000, had 2700 p a t i e n t s i n f o s t e r home o r family-c a r e . A l t h o u g h the payment f o r care i s . low, t h e r e a re always more t h a n enough f a m i l i e s who a r e w i l l i n g t o take p a t i e n t s . I t i s not uncommon t o p l a c e v e r y i l l p a t i e n t s w i t h t h e s e f a m i l i e s , a l t h o u g h t h e i n f i r m a r y i s r e s e r v e d f o r the more a c u t e c a s e s . There are some r i s k s : r e c o r d e d a r e two murders committed by p a t i e n t s i n c a r e d u r i n g the p a s t one hundred y e a r s . (Attempted h o m i c i d e i s not uncommon. There a r e p e r e n n i a l s u i c i d e s , but t h e s e do not cause any g r e a t c o n c e r n t o the p e o p l e o f Gheel.) The c o l o n y i s d i v i d e d i n t o f i v e s e c t i o n s , each w i t h i t s own d o c t o r as w e l l as two n u r s e s . S i n c e the war a p s y c h i a t r i c s o c i a l w orker has been added t o the g e n e r a l s t a f f . F a m i l i e s a r e chosen c a r e f u l l y t o f i t t h e p e r s o n a l i t y o f the p a t i e n t ; however, "both the p a t i e n t and the f a m i l y a r e made aware t h a t a change o r t r a n s f e r may be a r r a n g e d i f the p l a c e -ment i s n o t m u t u a l l y s a t i s f y i n g . Based on the l e n g t h y e x p e r i e n c e and p r o v e n v a l u e , t h e system o f f o s t e r home c a r e i n a u g u r a t e d a t Gheel has sprea d e l s e w h e r e . The mental h o s p i t a l s o f S c o t l a n d have p l a c e d p a t i e n t s i n f o s t e r c a r e i n i s o l a t e d communities f o r o v e r one hundred y e a r s . I n Fr a n c e , Sweden, S w i t z e r l a n d and Germany, f o s t e r home c a r e i s a common method used to c a r e f o r some o f t h e i r m e n t a l l y i l l . 1 I n the y e a r 1 8 8 5 , the l e g i s l a t u r e o f M a s s a c h u s e t t s p a s s e d an a c t p r o v i d i n g f o r the placement o f q u i e t m e n t a l p a t i e n t s i n p r i v a t e f a m i l i e s o t h e r t h a n t h e i r own. T h i s was t h e b e g i n n i n g o f f o s t e r home c a r e i n the U n i t e d S t a t e s . However, t h i s system was used r a t h e r s p a r i n g l y u n t i l 1935 when i n t e r e s t i n the t h e r a p e u t i c a s p e c t o f f a m i l y c a r e d e v e l o p e d . I n the s t a t e s o f New York and M a r y l a n d , f o s t e r home care f o r p a t i e n t s was d e v e l o p e d t o a much g r e a t e r e x t e n t t h a n i n any o f the o t h e r s . M a r y l a n d ' s program, w h i c h w i l l be d e s c r i b e d i n more d e t a i l i n a l a t e r c h a p t e r , p l a c e s much v a l u e on the t h e r a p e u t i c and r e h a b i l i t a t i v e p o s s i b i l i t i e s o f f o s t e r home c a r e . ^ G r u t c h e r , op. c i t . . p. 103. 2 I b i d . , p. 186. •^Dorgan, J . , " F o s t e r Home Care f o r t h e P s y c h i a t r i c P a t i e n t " R e p r i n t e d from the Canadian J o u r n a l o f P u b l i c H e a l t h , V o l . 49, No". 10, October, 1958, p. 413. -6-, In Canada, f a m i l y care has not been developed to the extent that i t i s used i n the United States or Europe. A l l provinces have used some form of hoarding home care f o r p a t i e n t s at one time o r another, but i t has never been developed on any s i g n i f i c a n t s c a l e , due to the f i n a n c i a l cost and shortage of s t a f f . Ontario and Saskatchewan are the only provinces t h a t have a planned f o s t e r home care program i n ope r a t i o n . P a r a l l e l s i n Foster Care In examination of c r i t e r i a f o r the operation of f o s t e r care plans f o r mental p a t i e n t s , an obvious p a r a l l e l to c h i l d f o s t e r care p r i n c i p l e s becomes evident. Both plans recognize the f a m i l y as the b a s i c u n i t of s o c i e t y which provides s e c u r i t y and a sense of belonging f o r the i n d i v i d u a l . Both are designed f o r the b e n e f i t and welfare of the i n d i v i d u a l . Both operations may come under the guidance of the p r o f e s s i o n a l s o c i a l worker whose t r a i n i n g and s k i l l s equip him to understand and to handle problems which may a r i s e . C r i t e r i a that apply to the placement of mental p a t i e n t s , types of homes used, pre-p a r a t i o n of the p a t i e n t f o r placement, work c a r r i e d out w i t h r e l a t i v e s to help them accept the the r a p e u t i c value of placement, enabling the operators of f o s t e r homes to understand and accept the demands the p a t i e n t s may make, -7-are a l l c l o s e l y r e l a t e d t o good c h i l d f o s t e r c a r e practices."*" One o f the b a s i c d i f f e r e n c e s between f o s t e r c a r e f o r me n t a l p a t i e n t s and c h i l d r e n i s i n the a r e a o f dependency. C h i l d r e n a r e g e n e r a l l y encouraged t o become dependent.on t h e f o s t e r p a r e n t , whereas the m e n t a l p a t i e n t w i l l be encouraged t o show h i s independence and/to do h i s own p l a n n i n g . B r i t i s h Columbia has d e v e l o p e d f o s t e r c a r e programs i n the a r e a o f c h i l d w e l f a r e , but as y e t no s i m i l a r development has t a k e n p l a c e i n t h e a r e a o f men t a l c a r e . The S i t u a t i o n i n B r i t i s h Columbia I n t h e p r o v i n c e o f B r i t i s h Columbia, a p e r s o n deemed m e n t a l l y i l l and i n need o f h o s p i t a l i z a t i o n may r e c e i v e t r e a t m e n t a t t h e Crease C l i n i c o f P s y c h o l o g i c a l p 3 M e d i c i n e o r the P r o v i n c i a l M e n t a l H o s p i t a l , b o t h l o c a t e d a t E s s o n d a l e , B.C. I f t h e i l l n e s s i s not i n an a c u t e phase, he may r e c e i v e t r e a t m e n t a t the Burnaby M e n t a l H e a l t h C e n t r e , Vancouver G e n e r a l P s y c h i a t r i c Ward o r O u t - P a t i e n t C l i n i c , o r t h r o u g h p r i v a t e p s y c h i a t r i c t r e a t m e n t . I n r e g a r d t o t h e a c u t e and c h r o n i c t r e a t m e n t c e n t r e s l o c a t e d a t E s s o n d a l e , the p a t i e n t ' s d o c t o r s t i p u l a t e s on the h o s p i t a l a d m i s s i o n forms whether h i s . Bowlby, J . , C h i l d Care and the Growth o f Love, P e l i c a n , W h i t e f r i a r s P r e s s L t d . , London, 1 9 5 3 . 2 M e n t a l H o s p i t a l s A c t , P r o v i n c e o f B r i t i s h Columbia, 194-0, S e c t i o n 9 - 2 . ^ C l i n i c s o f P s y c h o l o g i c a l M e d i c i n e A c t , P r o v i n c e o f B r i t i s h Columbia, 1 9 4 8 , S e c t i o n 6 . 2 . - 8 -p a t i e n t i s i n need o f t r e a t m e n t a t Crease C l i n i c o r a t the P r o v i n c i a l M e n t a l H o s p i t a l . Crease C l i n i c i s the a c u t e t r e a t m e n t c e n t r e where t h e maximum p e r i o d o f time a p a t i e n t m a y . r e c e i v e t r e a t m e n t i s f o u r months. I n 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 , which- a c c e p t s b o t h a c u t e and c h r o n i c c a s e s , t h e r e i s no time f a c t o r , as t h e committed p a t i e n t e n t e r s f o r an i n d e f i n i t e p e r i o d w h i c h i s t e r m i n a t e d a t .the d i s c r e t i o n o f the m e d i c a l s u p e r i n t e n d e n t . There may a l s o be v o l u n t a r y a d m i s s i o n s t o b o t h i n s t i t u t i o n s . S o c i a l S e r v i c e departments a re a c t i v e i n b o t h i n s t i t u t i o n s . The P r o v i n c i a l M e n t a l H o s p i t a l i s made up : o f t h r e e u n i t s : C entre Lawn, w h i c h i s t h e a d m i t t i n g and s e m i - a c u t e , t r e a t m e n t u n i t f o r male and female p a t i e n t s ; E a s t Lawn, l o n g term c h r o n i c female t r e a t m e n t u n i t ; and West Lawn, t h e l o n g term c h r o n i c male t r e a t m e n t u n i t . Each o f t h e s e i n d i v i d u a l u n i t s has i t s own s o c i a l s e r v i c e department. A s o c i a l worker g e n e r a l l y becomes a c t i v e on a case a t the s p e c i f i c r e q u e s t o f the p a t i e n t ' s d o c t o r , a l t h o u g h t h i s i s not t h e o n l y c h a n n e l t h r o u g h w h i c h r e f e r r a l s a r e r e c e i v e d . A case may be opened, w i t h a p p r o v a l o f the a t t e n d i n g d o c t o r , due t o a r e q u e s t f o r s e r v i c e from any o f t h e f o l l o w i n g : p a t i e n t , r e l a t i v e s , n u r s i n g s t a f f , o r community r e s o u r c e s . A number o f r e f e r r a l s a r e d i r e c t r e q u e s t s t o a s s i s t the p a t i e n t i n r e h a b i l i t a t i o n p l a n s , - 9 -althoUgh, again, these are not the only s e r v i c e s that are requested. Other areas i n which, help may he o f f e r e d w i l l be i n d i c a t e d as the focus of t h i s study i s described. Focus of Study The f i l e s of r e c i d i v i s t p a t i e n t s at the Pro-v i n c i a l Mental H o s p i t a l , Essondale, B.C., w i l l be examined to determine the needs of p a t i e n t s at the p o i n t of discharge, to consider -why these p a t i e n t s returned from probation, and whether o r not a f o s t e r home care program would a i d i n the r e h a b i l i t a t i o n of p a t i e n t s . Based on in f o r m a t i o n e l i c i t e d i n t h i s study, and the examination of e x i s t i n g f o s t e r care programs p r e s e n t l y i n operation i n mental i n s t i t u t i o n s i n Maryland, U.S.A., and Ontario, Canada, a c r i t e r i o n t h a t could be operable at the P r o v i n c i a l Mental H o s p i t a l , Essondale, w i l l be o u t l i n e d . Mr. Robert M. Sutherland, has made an a n a l y s i s of the needs of 100 male p a t i e n t s discharged from Crease C l i n i c between A p r i l 1, 1952 and March 31, 1953, examining three areas of adjustment: housing, v o c a t i o n a l s k i l l s and t r a i n i n g , and problems of in n e r s t r e s s r e q u i r i n g casework s e r v i c e s . Sutherland, R.M., The R e h a b i l i t a t i o n of Dis- charged Mental P a t i e n t s , Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1954. CHAPTER I I NEEDS OF DISCHARGED HOSPITAL PATIENTS With the use of the new psychopharmacological treatments there has been a decided upswing i n discharge r a t e s from mental h o s p i t a l s . U n f o r t u n a t e l y, the value of t h i s trend i s somewhat o f f s e t by the increase i n re-admissions to. h o s p i t a l . At the P r o v i n c i a l Mental H o s p i t a l , Essondale, B.C., there has been a 65 per cent increase In re-admissions over the past f i v e years. TABLE 1 F i r s t Admissions Compared w i t h Re-admissions to the  P r o v i n c i a l Mental H o s p i t a l , Essondale. B.C. Year F i r s t Admission Re-admission 1954 653 388 1955 678 461 1956 617 636 1957 628 631 1958 695 671 Source: Mental Health S e r v i c e s , Annual Report, Province of B r i t i s h Columbia, 1 9 5 8 , p.L 5 9 . The r i s i n g r a t e i n r e - a d m i s s i o n s t o - h o s p i t a l i s p a r t l y a r e s u l t o f l a c k o f f o l l o w - u p f a c i l i t i e s . A t the p r e s e n t time the community i s u n a b l e to assume r e s p o n s i b i l i t y f o r ongoing h e l p to a l a r g e p r o p o r t i o n o f d i s c h a r g e d p a t i e n t s . There i s an o b v i o u s need t o e x t e n d s u p p o r t i v e s e r v i c e s i n t o the community where the p a t i e n t needs h e l p ; o t h e r w i s e the b e n e f i t g a i n e d from t r e a t m e n t and h o s p i t a l i z a t i o n i s l o s t . A F o s t e r Home Care Program, one method t h r o u g h w h i c h such s u p p o r t i v e h e l p may be o f f e r e d , might be a means o f me e t i n g some o f t h e needs of" p a t i e n t s w h i c h a t the p r e s e n t time cannot be met t h r o u g h t h e i r own i n i t i a t i v e . . I t s h o u l d not need t o be r e a f f i r m e d t h a t m e n t a l p a t i e n t s a re human b e i n g s and as such have b a s i c needs f o r f o o d , c l o t h i n g and s h e l t e r . However, because o f i l l n e s s , t hey have been removed from the n a t u r a l community and p l a c e d i n an i n s t i t u t i o n a l s e t t i n g (which i n i t s e l f i s a community w i t h i n a community, but one i n wh i c h the d a i l y needs o f the i n d i v i d u a l a re met i n a h i g h l y s t r u c t u r e d and o r d e r e d manner). What, t h e n , a r e t h e needs o f p a t i e n t s a t the p o i n t o f d i s -charge? Why i s i t t h a t many o f t h e s e p a t i e n t s r e t u r n from t h e i r p r o b a t i o n a r y p e r i o d r e q u i r i n g f u r t h e r t r e a t m e n t and h o s p i t a l i z a t i o n ? Would a f o s t e r home care program meet some o f t h e needs o f r e c i d i v i s t p a t i e n t s who a r e u n a b l e t o rema i n i n t h e community f o r any extended t i m e p e r i o d ? W i t h q u e s t i o n s such as th e s e i n mind, a group o f r e c i d i v i s t p a t i e n t s o f the P r o v i n c i a l M e n t a l H o s p i t a l , E s s o n d a l e , B.C. was examined. - 1 2 -S e l e c t i n g the Sample Group; R e c i d i v i s t P a t i e n t s A s i x month time p e r i o d , J u l y 1, 1959 to December 31 , 1959 , was used i n o b t a i n i n g a sample of r e c i d i v i s t p a t i e n t s . This p a r t i c u l a r time sequence was chosen as i t meant that a l l p a t i e n t s r e t u r n i n g from pro b a t i o n during t h i s p e r i o d would have been discharged from h o s p i t a l at some.date i n the year 1959 . The f o l l o w i n g c r i t e r i a were used to o b t a i n the sample of r e c i d i v i s t s f o r t h i s p a r t i c u l a r study: (1) P a t i e n t was a c t i v e w i t h the S o c i a l Service Depart-ment during t h i s l a s t admission. (2) P a t i e n t was discharged on probation from Centre Lawn and returned p r i o r to t e r m i n a t i o n of h i s p r o b a t i o n during the s t a t e d time sequence. By i n c l u d i n g i n t h i s study a l l p a t i e n t s who met these c r i t e r i a , a t o t a l of twenty-one r e c i d i v i s t p a t i e n t s was obtained. In order to c a r r y out an a n a l y t i c a l study of the f i l e s of these p a t i e n t s i t i s e s s e n t i a l that c e r t a i n i n f o r m a t i o n be a v a i l a b l e . The c l i n i c a l f i l e s , s o c i a l s e r v i c e notes, l e t t e r f i l e and v i s i t o r s sheet, on each p a t i e n t , were examined. Where p o s s i b l e , b r i e f d i s c u s s i o n s were h e l d w i t h the p a t i e n t ' s doctor regarding the p a t i e n t ' s progress i n h o s p i t a l and the reasons f o r r e t u r n . (This was of n e c e s s i t y l i m i t e d , as s e v e r a l doctors were no longer i n the Essondale s e r v i c e . ) The p o i n t at which the s o c i a l s e r v i c e -13-department became a c t i v e v a r i e d from case to case, and the p e r i o d of a c t i v i t y depended on the type of s e r v i c e requested. Generally the s o c i a l s e r v i c e a c t i v i t y could be grouped i n t o three c a t e g o r i e s : (1) S i t u a t i o n s i n which s o c i a l casework s e r v i c e s were extended over a p e r i o d of time and where, w i t h medical c o n s u l t a t i o n , r e h a b i l i t a t i o n plans were worked out w i t h the p a t i e n t . Ten p a t i e n t s of the sample group examined came under t h i s category. (2) S i t u a t i o n s i n which the S o c i a l Service Department was a c t i v e i n o b t a i n i n g a d d i t i o n a l background in f o r m a t i o n on the p a t i e n t or where, at the p o i n t of discharge, help was requested i n completing discharge plans. Eight p a t i e n t s f e l l w i t h i n t h i s group. (3) . S i t u a t i o n s where s o c i a l s e r v i c e contact was l i m i t e d to one i n t e r v i e w concerning a r e f e r r a l to a community resource f o r f i n a n c i a l or employment a s s i s t a n c e . There were only three p a t i e n t s who came under t h i s category. Adequate i n f o r m a t i o n on the p a t i e n t ' s progress and response to treatment was contained i n the f i l e s ; however, i n f o r m a t i o n on the factors' p r e c i p i t a t i n g the r e t u r n of the p a t i e n t from p r o b a t i o n was l i m i t e d . In t h i s area i t was necessary to i n f e r the reasons from m a t e r i a l d i s c l o s e d i n recorded i n t e r v i e w s with p a t i e n t s . F o r t u n a t e l y , there was enough m a t e r i a l of s u f f i c i e n t l y high c a l i b r e i n -14-the f i l e s from which a study of the needs of mental p a t i e n t s i n r e l a t i o n to the f o s t e r home care program could be c a r r i e d out. P a t i e n t s i n the Study Group Of the twenty-one r e c i d i v i s t p a t i e n t s comprising the group, eleven were women and ten, men. This group was predominantly Canadian, fourteen having been born i n Canada. Another three (of Russian, F i n n i s h and E n g l i s h o r i g i n ) had l i v e d i n Canada f o r many years. Only four were recent immigrants: two. from Hungary and one each from Germany and Poland. Examination of the m a r i t a l status of the group revealed t h a t f i f t e e n of the twenty-one had never married, four were separated (of whom two had entered i n t o common-law r e l a t i o n s h i p s ) , one was divorc e d and one was married. S i m i l a r i n f o r m a t i o n about the t o t a l p o p u l a t i o n of the i n s t i t u t i o n i s not r e a d i l y a v a i l a b l e . Diagnosis "Schizophrenia i s one of the most frequent forms of the major psychoses, c o n s t i t u t i n g from f i f t e e n to twenty per cent of the f i r s t admissions to p u b l i c h o s p i t a l s f o r mental diseases. Because the d i s o r d e r tends to c h r o n i c i t y and i n many instances does not shorten l i f e i t w i l l u s u a l l y be found that s i x t y per cent of the po p u l a t i o n of st a t e -15-h o s p i t a l s i s made up of schizophrenic p a t i e n t s . " Of f i r s t admissions to the P r o v i n c i a l Mental H o s p i t a l , Essondale, B.C. between A p r i l 1, 1957 to March 31, 1958, 30.2 per cent bore a diagnosis of some form of schizophrenic d i s o r d e r . Of the readmissions during the. same time p e r i o d , 70.2 per cent c a r r i e d a diagnosis of some schizophrenic d i s o r d e r . In t h i s study i t i s seen that seventeen or 80.19 per cent of the r e c i d i -v i s t p a t i e n t s reviewed here had a diagnosis of a schiz o -phrenic d i s o r d e r . Schizophrenia may occur at any time 2 from l a t e childhood to l a t e middle age. Twelve of the p a t i e n t s i n t h i s study were i n the twenty to f o r t y year age group, which f o l l o w s the general age p a t t e r n of schizophrenia. 1Noyes, A.P. and Kolb, L.C., Modern C l i n i c a l P s y c h i a t r y . W.B. Saunders Company, P h i l a d e l p h i a , 1958, p. 391. 2 I b i d . . p. 390. -16-TABLE 2 The Diagnosis of a Group of 21 R e c i d i v i s t P a t i e n t s at  the P r o v i n c i a l Mental H o s p i t a l , Essondale, B.C., 1959. I l l n e s s No. Average Age 1. Schizophrenic Reaction 16 36 .1 2. Passive Aggressive P e r s o n a l i t y 2 27 3.. Catatonic Schizophrenia 1 56 4. Sociopathlc P e r s o n a l i t y Disturbance A n t i - S o c i a l Reaction 1 21 5. Chronic B r a i n Syndrome Gross Trauma 1 48 - 1 7 -Doctors s t a t e i t i s d i f f i c u l t to f o r e c a s t the fu t u r e adjustment of p a t i e n t s who have had a schizophrenic reaction." 1' In some cases the course i s continuously pro-g r e s s i v e ; i n others i t i s i n t e r m i t t e n t . More f r e q u e n t l y i t i s a question of remissions and re l a p s e s . In t h i s group of p a t i e n t s the relapse r a t e or readmission r a t e f o r both p a t i e n t s bearing a schizophrenic diagnosis or some other diagnosis i s notably high. These twenty-one p a t i e n t s account f o r 89 admissions to h o s p i t a l — an average of 4 . 2 admissions per p a t i e n t . Needs of P a t i e n t s There are many needs which must be considered when a p a t i e n t i s being discharged from an i n s t i t u t i o n a l s e t t i n g such as a mental h o s p i t a l and i s r e t u r n i n g to the community. H o s p i t a l , community and the p a t i e n t h i m s e l f a l l have a r e s p o n s i b i l i t y i n meeting these needs. Not only must the p h y s i c a l needs of food, c l o t h i n g , s h e l t e r , be met, but there should a l s o be "an opportunity to grow up f r e e to make choices which w i l l make i t p o s s i b l e f o r him to secure a l i v i n g , e s t a b l i s h a home, r a i s e c h i l d r e n , enjoy l e i s u r e , and f e e l at home i n the u n i v e r s e . " 2 I t i s 1 I b i d . , p. 4 1 7 . 2 Wilson, G., and Ryland, G., S o c i a l Group Work P r a c t i c e , Houghton M i f f l i n Co., Boston, 1949, p. 17 . -18-e s s e n t i a l that some degree of harmony be maintained i n the way he meets these needs; otherwise he f i n d s h i m s e l f i n c o n f l i c t w i t h h i s environment. V o c a t i o n a l Need Recognition i s given the f a c t that a s a t i s f y i n g work experience i s e s s e n t i a l to good mental h e a l t h . North American c u l t u r e places much emphasis on work and the a b i l i t y to o b t a i n and h o l d a job, consequently there i s a tendency to look down on those who are unable to main-t a i n themselves i n g a i n f u l employment. Work, which pro-vides not only an o u t l e t f o r aggressive and competitive d r i v e s , but a l s o a means f o r making s o c i a l contacts, enhances the p a t i e n t ' s f e e l i n g s of personal worth. For the mental dischargee, work i s of primary importance i n h i s r e h a b i l i t a t i o n . " ' " Yet, f o r many, i t proves to be a stumbling block, c r e a t i n g s t r e s s and anxiety which may l e a d to a r e l a p s e . The r e s i d u a l of i l l n e s s c a r r i e d by the p a t i e n t at the time of discharge may account f o r one reason why' s t r e s s b u i l d s up so r a p i d l y i n the work s i t u a t i o n . I t a l s o p l a y s i t s p a r t i n the p a t i e n t ' s a b i l i t y to f i n d and hold a s a t i s f y i n g employment s i t u a t i o n . Again, the degree of education and t r a i n i n g w i l l be a s i g n i f i c a n t ± M o d l i n , C , and H a l l , H., "The P s y c h i a t r i c P a t i e n t Bridges the Gap Between The H o s p i t a l and The Community", B e t t e r S o c i a l Services For Mentally 111 P a t i e n t s , Knee, Ruth I . , Ed.., American A s s o c i a t i o n of P s y c h i a t r i c S o c i a l Workers, Inc., New York, 1955. - 1 9 -f a c t o r here. The group of p a t i e n t s examined In t h i s study w i t h l i t t l e . t o o f f e r to the prospective employer, would have l i t t l e chance of becoming g a i n f u l l y employed. The q u a l i f i c a t i o n s of three out of four r e c i d i v i s t p a t i e n t s s t u d i e d here f a l l i n t o a category of f a i r to poor when ra t e d on t h e i r p o t e n t i a l e m p l o y a b i l i t y . -20-• TABLE 3 E m p l o y a b i l i t y of 21 R e c i d i v i s t P a t i e n t s at the P r o v i n c i a l  Mental H o s p i t a l , Essondale, B.C., 1959. Degree D e s c r i p t i o n No. Good P a t i e n t has h i g h school or equiva-l e n t t r a i n i n g ; a trade c u r r e n t l y i n demand on labour market; i s r e t u r n -to h i s former job; or owns own business; or has money to i n v e s t i n a business and a b i l i t y to make a good choice. Presents h i m s e l f w e l l i n i n t e r v i e w , would present favourable p e r s o n a l i t y p r o f i l e to prospective employer. 2 Average Obtained h i g h school or equivalent t r a i n i n g ; possesses some s k i l l s but not s p e c i f i c trade. Has steady work h i s t o r y though o c c a s i o n a l seasonal l a y o f f s . Could take trade t r a i n i n g . Can present adequate p i c t u r e of him-s e l f and h i s c a p a b i l i t i e s . 3 F a i r P a t i e n t l e f t school a f t e r f i n i s h i n g Grade 8; no s p e c i f i c s k i l l s , has worked at a v a r i e t y of jobs. Cannot express h i m s e l f w e l l , appears to disadvantage i n i n t e r v i e w . 3 Poor P a t i e n t has l e s s than Grade 8 or equ i v a l e n t ; l i m i t e d to manual work or has experience only i n u n s k i l l e d work. Poor p e r s o n a l i t y p r o f i l e , unstable h i s t o r y . Language b a r r i e r . Residual of i l l n e s s p a t i e n t i s c a r r y i n g prevents him from making use of previous t r a i n i n g or s k i l l . 12 One -female p a t i e n t returned to husband and w i l l not be competing i n labour market. - 2 1 -F l n a n c i a l and M a t e r i a l Resources • When.discharge plans are being made, c a r e f u l c o n s i d e r a t i o n should be given to the a c t u a l f i n a n c i a l and m a t e r i a l resources of the p a t i e n t . I t i s of primary importance that some f i n a n c i a l means be a v a i l a b l e to cover the time i n t e r v a l between the discharge date and the date when the p a t i e n t becomes f i n a n c i a l l y s e l f - • supporting again, or i s e l i g i b l e f o r f i n a n c i a l a s s i s t a n c e through a welfare agency. This e n t i r e area may produce considerable s t r e s s i f the p a t i e n t ' s f i n a n c i a l p o s i t i o n i s somewhat p r e c a r i o u s . C e r t a i n m a t e r i a l goods w i l l be re q u i r e d , e i t h e r as equipment f o r a p a r t i c u l a r job or as simply p r o t e c t i o n from the elements. Only one person In t h i s study could be described as f a l l i n g i n t o the category of being completely s e l f - s u s t a i n i n g : a woman r e t u r n i n g to her husband who would be att e n d i n g to her f i n a n c i a l and m a t e r i a l needs. The others were eq u a l l y d i v i d e d between the p a r t l y s e l f - s u s t a i n i n g and the dependent c a t e g o r i e s . -22-TABLE 4 F i n a n c i a l and M a t e r i a l Resources of 21 R e c i d i v i s t P a t i e n t s  at the P r o v i n c i a l Mental H o s p i t a l , Essondale, B.C., 1959. Degree D e s c r i p t i o n No. Completely s e l f - P a t i e n t has p r i v a t e income; owns property; capable of buying or r e n t i n g a home. Has m a t e r i a l goods or can purchase same. ' No apparent s t r e s s i n t h i s area. Good fam i l y resources. 1 s u s t a i n i n g P a r t l y s e l f -' s u s t a i n i n g Has l i m i t e d income or per-sonal savings. W i l l need employment to maintain f i n a n c i a l solvency and acquire necessary m a t e r i a l goods. Supportive help i n d i c a t e d u n t i l working and e s t a b l i s h e d again. 10 Dependent Has no income, savings or r e a l e s t a t e . M a t e r i a l possessions very l i m i t e d or non-existent. W i l l r e q u i r e f i n a n c i a l a s s i s -tance u n t i l s e l f - s u p p o r t i n g . D e f i n i t e l i m i t a t i o n s i n type of work p a t i e n t can undertake. 10 - 2 3 -The Importance of Family and Friends I t i s important to belong and to f e e l needed and wanted. The need to love and be loved Is part of the ba s i c human p s y c h o l o g i c a l s t r u c t u r e . ^ Today, due to i n c r e a s i n g u r b a n i z a t i o n and i n d u s t r i a l i z a t i o n , family t i e s have become weaker and these are f u r t h e r a f f e c t e d by the demands i n d u s t r y makes tha t m o b i l i t y be an e s s e n t i a l requirement f o r a job, expecting i t s workers to move from place to pla c e . The e f f e c t s of l o n e l i n e s s upon people can be seen today as a deterrent to good mental h e a l t h . I t has been t h e o r i z e d that a close l i n k a g e e x i s t s between the p a t i e n t ' s response to treatment and the degree of i n t e r e s t shown i n him by h i s fami l y and 2 f r i e n d s . Unfortunately f o r the mental p a t i e n t , as h i s readmisslons occur c l o s e r together, n e c e s s i t a t i n g longer periods i n h o s p i t a l , the fa m i l y and f r i e n d s l o s e f a i t h i n the p o s s i b i l i t y of recovery and g r a d u a l l y cease to v i s i t the p a t i e n t . This may have a very damaging e f f e c t on the p a t i e n t and h i s d e s i r e f o r recovery. S t i l l , there are fam i l y s i t u a t i o n s which are so damaging to a p a t i e n t ' s mental h e a l t h that the doctor advises the p a t i e n t against r e t u r n i n g home. This can create problems f o r the p a t i e n t as to where he can go. For others, the fa m i l y has already R i b b l e , Margaret A., The Rights of I n f a n t s , Columbia U n i v e r s i t y Press, New York, 1 9 5 3 . 2 B l a n t o n , Smiley, Love or P e r i s h , Simon and Schuster, New York, 1956. -24-severed contact. Yet a l l these p a t i e n t s d e s i r e and need personal.contacts and people.to take an i n t e r e s t i n them while they are t r y i n g to make an adjustment to community. I t i s i n t h i s area that f o s t e r care has i t s g r e a t e s t p o t e n t i a l : l a c k i n g the h i g h l y charged emotional r e l a t i o n -ships that may, develop w i t h i n the f a m i l y , i t can o f f e r the p a t i e n t many of the b e n e f i t s of a fa m i l y s e t t i n g . . - 2 5 -TABLE 5 I n t e r e s t Shown by R e l a t i v e s and Friends i n a Group of 21  R e c i d i v i s t P a t i e n t s at the P r o v i n c i a l ' M e n t a l H o s p i t a l , Essondale, B.C., 1 9 5 9 . Degree of I n t e r e s t D e s c r i p t i o n No. High P a t i e n t has r e g u l a r v i s i t s or corr e s -pondence from f a m i l y or f r i e n d s . Con-t a c t i s maintained w i t h h o s p i t a l i n order to f o l l o w progress and plans f o r discharge. P a t i e n t goes on r e g u l a r leaves to v i s i t r e l a t i v e s or f r i e n d s when f e a s i b l e . C l e a r i n d i c a t i o n ex-pressed on p a r t of r e l a t i v e or f r i e n d of w i l l i n g n e s s to o f f e r d i r e c t a s s i s -tance i n the establishment of p a t i e n t i n the•community. P a t i e n t i s al s o desirous' of t h i s . 3 Moderate P a t i e n t has o c c a s i o n a l v i s i t s and correspondence from r e l a t i v e s or f r i e n d s . There i s l i t t l e e f f o r t on t h e i r p a r t to contact h o s p i t a l a u t h o r i t i e s f o r progress r e p o r t s on p a t i e n t s . They w i l l take p a t i e n t home f o r v i s i t s , provided they have rec e i v e d adequate n o t i c e and re-assurance as to p a t i e n t s h e a l t h . W i l l i n g to help patient-upon d i s -charge, as they f e e l morally o b l i g a t e d . 13 None No v i s i t s or correspondence to p a t i e n t by r e l a t i v e s or f r i e n d s . R e l a t i v e s have contacted h o s p i t a l to advise they w i l l not accept p a t i e n t ' s r e t u r n to t h e i r home upon discharge.. No f r i e n d s w i l l i n g to help p a t i e n t nor r e l a t i v e s l i v i n g i n t h i s country. 5 -26-TABLE 6 Reasons f o r R e c i d i v i s t P a t i e n t s at the P r o v i n c i a l Mental  H o s p i t a l , Essondale, B.C.. 1959. Not Returning To Liv e With R e l a t i v e s . D e s c r i p t i o n No. 1. Emotionally damaging r e l a t i o n s h i p between r e l a t i v e s and p a t i e n t . P a t i e n t ' s doctor advises against c o n t i n u i n g t h i s l i v i n g arrangement. . P a t i e n t h i m s e l f s t a t e s he w i l l not r e t u r n to past l i v i n g arrangements. 4 2. R e l a t i v e s are unable or u n w i l l i n g , and have contacted h o s p i t a l or p a t i e n t a d v i s i n g they cannot or w i l l not assume any r e s p o n s i b i l i t y f o r p a t i e n t upon discharge. P r i o r to t h i s h o s p i t a l i z a t i o n p a t i e n t had severed f a m i l y t i e s and was l i v i n g independently. 2 3. No r e l a t i v e s a v a i l a b l e or capable, e i t h e r as r e s u l t of death, or of p a t i e n t being an immigrant i n t h i s country. P a t i e n t p r e f e r s to e s t a b l i s h h i m s e l f and l i v e independently. 9 -27-Community Resources In the Greater Vancouver area there are three hundred and twenty-nine f o r m a l l y c o n s t i t u t e d agencies, o r g a n i z a t i o n s and departments of government which e x i s t as h e a l t h , welfare and.recreation resources f o r Vancouver. The discharged h o s p i t a l p a t i e n t supposedly should have l i t t l e problem i n f i n d i n g a s u i t a b l e o u t l e t f o r h i s i n t e r e s t or needs. This, however, i s not the case. Often the p a t i e n t , f e e l i n g the stigma of having been mentally i l l , does not wish to become i n v o l v e d w i t h clubs or groups, since he f e e l s he Is d i f f e r e n t and that others are aware of these d i f f e r e n c e s . Many others s t i l l have d i f f i c u l t y forming s o c i a l r e l a t i o n s h i p s and are i n c l i n e d to withdraw from s i t u a t i o n s where they are expected to c o n t r i b u t e of themselves. For reasons such as these, s p e c i a l resources are needed to meet the needs of p a t i e n t s . There i s a Mental Health Centre i n Burnaby, B.C., to whieh a l i m i t e d number of p a t i e n t s discharged from h o s p i t a l who are remaining i n t h i s area may be r e f e r r e d . This centre i s an a c t i v e treatment centre f o r prevention of i l l n e s s , and as such, treatment and p o l i c y are geared to working w i t h people who have not had p r i o r 1 a d m i s s i o n s to a mental D i r e c t o r y of Health, Welfare and Recreation Services i n M e t r o p o l i t a n Vancouver, Community Chest and Councils of Greater Vancouver, 1958. -28-h o s p i t a l . There i s , however, an evening c l i n i c one evening a week when discharged 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 are seen and supportive help or renewal of medication may be obtained. There are a l s o two "half-way houses" operated i n Vancouver: the "Venture" f o r male p a t i e n t s , the " V i s t a " f o r female p a t i e n t s . 1 - These o r i g i n a t e d to meet the needs of p a t i e n t s ready to leave h o s p i t a l whom i t i s f e l t e i t h e r should not r e t u r n to t h e i r own f a m i l y due to an emotionally damaging r e l a t i o n s h i p or who l a c k finances and r e q u i r e supportive l i v i n g arrangement while seeking employment. They a l s o serve as a resource f o r h o s p i t a l i n t e s t i n g out a p a t i e n t ' s a b i l i t y to r e t u r n to community and i n observing whether h i s symptoms of i l l n e s s w i l l remain c o n t r o l l e d . Both of these resources provide a needed resource, however they are l i m i t e d to a small number of p a t i e n t s . Generally not more than seven can be accommodated i n e i t h e r home at any one time. The l e n g t h of stay i n these half-way houses i s l i m i t e d to one month, although f o r c e r t a i n s p e c i a l cases the p e r i o d of time may be extended. The p a t i e n t i s expected to com-p l e t e plans to move to p r i v a t e accommodation p r i o r to the t e r m i n a t i o n of the month's stay, i n order to r e l e a s e beds f o r other p a t i e n t s . B r i t i s h Columbia, Annual Report of Mental Health  S e r v i c e s , Queen's P r i n t e r , 1958, p.L 46. -29-A s o c i a l centre f o r discharged mental p a t i e n t s , designed to provide a program of a c t i v i t i e s and c o u n s e l l i n g which w i l l a i d i n the s o c i a l r e i n t e g r a t i o n of persons who have been mentally i l l , has r e c e n t l y been e s t a b l i s h e d In Vancouver by the Canadian Mental Health A s s o c i a t i o n . The f o l l o w i n g t a b l e i s designed to show the va r i o u s resources i n the community to which the p a t i e n t s In t h i s study group were r e f e r r e d . Five p a t i e n t s were n o t . r e f e r r e d to any resource, w h i l e , i n some instances, p a t i e n t s were r e f e r r e d to two or more resources. As a f u r t h e r i n d i c a t i o n of f i n a n c i a l dependency, eleven or 52.3 per cent of the p a t i e n t s s t u d i e d were r e f e r r e d to a p u b l i c welfare agency w i t h a request that they be granted f i n a n c i a l a s s i s t a n c e . -30-TABLE 7 R e f e r r a l s Made to Community Resources on Behalf of  R e c i d i v i s t P a t i e n t s at the P r o v i n c i a l Mental H o s p i t a l , Essondale. B.C.. 1959. Name of Agency No. 1. P u b l i c Welfare Agency 11 2. Na t i o n a l Employment Service ( S p e c i a l Place-ment D i v i s i o n ) 3 3. Mental Health Centre 1 4. V i s t a •" 2 5. P r i v a t e P s y c h i a t r i s t 1 6. P r i v a t e Employer 1 7. Immigration Department 1 8. Unemployment Insurance Commission 1 . Some p a t i e n t s were r e f e r r e d to more than one source. Five p a t i e n t s were not r e f e r r e d to any agency .at the p o i n t of discharge. -31-In a n a l y z i n g the f i l e s of t h i s group of r e c i d i v i s t p a t i e n t s i t has not been easy to obta i n c l e a r - c u t reasons f o r the p a t i e n t ' s r e t u r n . Symptoms prevale n t at the time of readmission are well-documented, but the problem of what happened to the p a t i e n t i n the i n t e r v a l between h i s l a s t admission and t h i s one, leaves many questions unanswered. One p o i n t noted about r e t u r n from pr o b a t i o n i s that i n few cases i s the p a t i e n t accompanied by a r e l a t i v e . Normally, on any admission or readmission, i f r e l a t i v e s are accompanying the p a t i e n t they are interviewed by the S o c i a l Service Department f o r appropriate i n f o r m a t i o n . At Crease C l i n i c t h i s system works very w e l l , as a high percentage of admissions are accompanied to h o s p i t a l by close r e l a t i v e s . Many P r o v i n c i a l Mental H o s p i t a l admiss-i o n s , however, occur a f t e r 4:30 p.m., the end of the normal working day when s o c i a l s e r v i c e s t a f f i s not on duty. Again, when p a t i e n t s are brought to h o s p i t a l under the e s c o r t of the p o l i c e , R.C.M.P., or p r i v a t e ambulance s e r v i c e , the background i n f o r m a t i o n regarding reasons f o r r e t u r n i s u s u a l l y not a v a i l a b l e . Recognized by the medical s t a f f as a d e f i n i t e l a c k , i t i s hoped that something may be done to b r i n g about improvement i n t h i s area. A l s o , w i t h the present shortage of s o c i a l workers i n the P r o v i n c i a l -32-S o c i a l Welfare Department, i t takes many weeks to get a re p o r t from them on the f a c t o r s p r e c i p i t a t i n g the p a t i e n t ' s r e l a p s e . While causes f o r r e t u r n from probation were not e x p l i c i t l y s t a t e d , i t was p o s s i b l e to deduce c e r t a i n reasons from i n f o r m a t i o n contained i n the f i l e s . -33-TABLE 8 Reasons f o r the Return of 21 R e c i d i v i s t P a t i e n t s from  Pr o b a t i o n to the P r o v i n c i a l Mental H o s p i t a l , Essondale, B . C i D e s c r i p t i o n •No. 1. P a t i e n t s returned to have probationary s t a t u s r e v i s e d by h o s p i t a l a u t h o r i t i e s . 2 2. P a t i e n t was returned by the p o l i c e . No repo r t was submitted as to c o n d i t i o n s p r e c i p i t a t i n g t h i s r e t u r n to h o s p i t a l . 4 3. P a t i e n t found the s t r e s s of h i s s o c i a l s i t u -a t i o n (community, f a m i l y , job) more than he could endure w i t h r e s u l t a n t recurrence of i l l n e s s . 10 4. P a t i e n t returned as he looked to h o s p i t a l as resource, having spent most of h i s formative years there. 2 5. P a t i e n t returned due to an acute recurrence of i l l n e s s symptoms. 3 -34-Foster home care as a r e h a b i l i t a t i o n resource may provide through the fami l y s e t t i n g the s i g n i f i c a n t a d d i t i o n a l a i d s which w i l l enable the p a t i e n t to res o l v e h i s i n n e r and outer c o n f l i c t s . I t provides an environ-ment where emotional needs can be met, and f r i e n d s h i p s develop i n a normal f a s h i o n . From t h i s secure and i n t e r e s t e d f a m i l y s e t t i n g , the p a t i e n t can move out i n t o the competitive v o c a t i o n a l f i e l d knowing he has a haven to which he may r e t u r n at the end of the working day. Some c o n s i d e r a t i o n w i l l now be given to the e x i s t i n g plans i n operation i n Maryland and Ontario to determine whether programs of the type i n operation there would be s u i t a b l e i n t h i s p r o v i n ce. P o s s i b l e c r i t e r i a f o r use i n s e t t i n g up a s i m i l a r p l a n i n t h i s province w i l l be suggested i n the f o l l o w i n g chapter. CHAPTER I I I A FOSTER HOME CARE.PLAN As shown from the a n a l y s i s of f i l e s of r e c i d i -v i s t p a t i e n t s at the P r o v i n c i a l Mental H o s p i t a l , Essondale, c e r t a i n f a c t o r s common to the group were observed. A h i g h percentage (70.2) of these p a t i e n t s bore a diagnosis of 1 a schizophrenic d i s o r d e r , which has a poor prognosis, since i t "tends to be p r o g r e s s i v e and chronic i n nature. Needs of these p a t i e n t s , while great i n the areas of food, c l o t h i n g and s h e l t e r , were a l s o very n o t i c e a b l e i n the areas of v o c a t i o n , f i n a n c i a l and m a t e r i a l resources, fa m i l y and f r i e n d s ; and needs of t h i s nature could only be met through s p e c i a l resources. There are f a c i l i t i e s i n the community to a i d the p a t i e n t i n h i s adjustment, but no p r e t e x t i s made of being able to meet a l l h i s needs. For those w i t h s u i t a b l e e d u c a t i o n a l q u a l i f i c a t i o n s there i s the p o s s i b i l i t y of t r a i n i n g or r e t r a i n i n g through v o c a t i o n a l courses; f i n a n c i a l need can be met to some degree through s o c i a l a s s i s t a n c e , although t h i s i n i t s e l f i s only a subsistence l i v i n g r a t e . At the present time, there i s no resource o f f e r i n g a f a m i l y s e t t i n g where a p a t i e n t i n a p r o t e c t e d and understanding environment can Table 2, p. 16. -36-make another attempt at l i f e . I t was noted that of the group.of r e c i d i v i s t p a t i e n t s examined i n .this study a s i g n i f i c a n t number were not r e t u r n i n g to l i v e w i t h relatives," 1" but planned to make t h e i r way independently. Frequently, as time passes and attempts by the p a t i e n t to meet h i s b a s i c needs are f r u s t r a t e d , he begins once more to withdraw from the s o c i a l world that i n f l i c t s t h i s uneasiness and i n s e c u r i t y upon him. I t i s not too long before the anxiety and t e n s i o n have b u i l t up to a degree s u f f i c i e n t to b r i n g on a recurrence of symptoms, n e c e s s i -2 t a t i n g a f u r t h e r p e r i o d i n h o s p i t a l . From examination of the f o s t e r care plans p r e s e n t l y i n o p e r a t i o n at the s t a t e h o s p i t a l s i n Maryland, 3 U.S.A. and the p r o v i n c i a l mental h o s p i t a l s i n Ontario, Canada,^ i t Is evident that these h o s p i t a l s have found the f o s t e r home care p l a n a d e f i n i t e asset i n the meeting of p a t i e n t s ' needs; needs which, i f not e x a c t l y the same as those of p a t i e n t s here, are s i m i l a r enough that plans of t h e i r s might conceivably be adapted f o r use i n B r i t i s h Columbia. x T a b l e 6, p. 26 2 T a b l e 8, p. 33 ^Padula, H., "The Mental H o s p i t a l : A S p e c i a l i z e d Treat-ment Service or Way of L i f e ? " Presented at the I n s t i t u t e of the U n i v e r s i t y of Pennsylvania, School of S o c i a l Work, June 24, 1954. (Mimeographed.) ^Ontario Department of Health, "A Handbook on Approved Homes i n Ontario H o s p i t a l s " , 1 9 5 7 . (Mimeographed.) -37-"The Maryland P l a n " , i n operation since 1 9 3 5 , has a h i g h l y s u c c e s s f u l record of placement. At the outset i t was designed mainly f o r the placement of long-term chronic p a t i e n t s whom i t was f e l t could l i v e out t h e i r days i n a f o s t e r home s e t t i n g . This released beds f o r more acute cases, simultaneously h e l p i n g to r e l i e v e the overcrowded c o n d i t i o n s of the h o s p i t a l s . To the amazement of h o s p i t a l a u t h o r i t i e s , some p a t i e n t s began improving i n t h i s s o c i a l • s e t t i n g u n t i l they were able to appear before t h e i r parole board to request discharge. I t was at t h i s time that f o s t e r care was recognized as a val u a b l e t o o l i n the r e h a b i l i t a t i o n of the p a t i e n t as w e l l as i n the p r o v i s i o n of.care f o r the c h r o n i c a l l y i l l . While Ontario p r o v i n c i a l mental h o s p i t a l s have not used f o s t e r home care as e x t e n s i v e l y , a c a r e f u l study has a l s o been made of t h e i r system. One decided d i f f e r e n c e i n the op e r a t i o n of a . f o s t e r care program between Ontario and Maryland i s that the p l a n i n Maryland h o s p i t a l s i s set up and supervised by the h o s p i t a l s o c i a l s e r v i c e departments, whereas i n Ontario both s o c i a l workers.and nurses are used to supervise t h e i r f o s t e r care program. ' xDeWitt, H.B., "The Foster Care Placement of State Mental P a t i e n t s : Maryland P l a n , 1 9 5 4 . " Presented at the Second Annual I n s t i t u t e of the New Jersey Neuro-Psychiatric I n s t i t u t e , P r i n c e t o n , New Jersey, September 1 5 , 1954. (Mimeographed.) -38-The l a t t e r p l a n could lead to a d m i n i s t r a t i v e problems as to the a u t h o r i t y and areas of competence assigned to the re s p e c t i v e professions:! The p r o f e s s i o n a l s o c i a l worker's s k i l l and knowledge acquired through h i s t r a i n i n g p a r t i c u -l a r l y equips him f o r s u p e r v i s i n g such programs, as he has knowledge not only i n the handling of problems a r i s i n g i n areas of r e l a t i o n s h i p and human behavior, but a l s o i n developing e x t e n s i v e l y the use of community resources f o r the b e n e f i t of the p a t i e n t i n h i s adjustment. Consideration should a l s o be given to the f a c t that p a t i e n t s and f o s t e r home operators might f i n d i t confusing to have two i n d i v i d u a l s overseeing the operation of t h e i r home. The Ontario p l a n does not s t r e s s the importance ,of l i m i t i n g the number of p a t i e n t s placed i n a home, nor does i t attempt to s t r u c t u r e p a t i e n t s ' p e r s o n a l i t i e s and ages to create a fa m i l y s e t t i n g , as f o r example, s e l e c t i n g an o l d e r p a t i e n t who might be the grandmother or grand-f a t h e r f i g u r e , or a younger p a t i e n t who might be i n the • age range of a son or daughter. The Maryland f o s t e r care p l a n uses t h i s idea e x t e n s i v e l y and has had considerable success w i t h i t . 1 There i t i s b e l i e v e d t h a t a fam i l y cannot absorb more than two people i n t o I t s p a t t e r n of l i v i n g without c r e a t i n g d r a s t i c changes i n the design of fa m i l y r e l a t i o n s h i p s . The r o l e of the p a t i e n t i n the I b i d . . p. 7. -39-f o s t e r home i s c a r e f u l l y , considered i n order that he w i l l not be placed i n a p o s i t i o n of unfavourable competition w i t h other members of the f o s t e r f a m i l y or perhaps excluded from the fa m i l y group. The placement of two p a t i e n t s of the same sex and age could set them apart, w i t h the consequence of t h e i r being looked upon or thought of as "the p a t i e n t s " , which might w e l l mean they would not be recognized and accepted as i n d i v i d u a l s . The l i t e r a t u r e w r i t t e n about the use of f o s t e r care i n Maryland s t a t e h o s p i t a l s goes i n t o considerable d e t a i l regarding the value of preparing the c l i e n t f o r t h i s program, and the importance of having r e l a t i v e s , i f any, r e a l i z e the value and t h i n k i n g behind the placement of the p a t i e n t In t h i s type of s e t t i n g . Use of "planned i n t e r v e n t i o n " 1 i n c e r t a i n s i t u a t i o n s where long-term chronic p a t i e n t s have no wish to leave the h o s p i t a l a l s o r e q u i r e s s k i l l i n dia g n o s i s of the p e r s o n a l i t y of the p a t i e n t as w e l l as the a b i l i t y to recognize when to use i t . What a Foster Home Care P l a n Involves From examination of e x i s t i n g f o s t e r care programs and r e c o g n i t i o n of the degree to which the h o s p i t a l s o c i a l worker i s p r e s e n t l y i n v o l v e d i n r e h a b i l i t a t i o n , the h o s p i t a l must have a d d i t i o n a l s o c i a l workers a v a i l a b l e whom I t can f r e e from other d u t i e s In order to e s t a b l i s h 1 I b l d . , p. 13. -40-a f o s t e r eare program. Since a program of t h i s type must begin i n a small way, g r a d u a l l y growing i n s i z e , s i g n i f i -cant r e s u l t s should not be expected w i t h i n a few months of i t s i n c e p t i o n . Based on programs p r e s e n t l y i n operation and a v a i l a b l e l i t e r a t u r e on t h i s subject, the f o l l o w i n g c r i t e r i a , grouped under three general headings: General P o l i c y , F a c i l i t i e s , and P a t i e n t s , i s o f f e r e d , to i n d i c a t e areas which must be considered i n f o s t e r care. General P o l i c y . A l l p a t i e n t s placed i n f o s t e r care would be under the r e g u l a t i o n s , management and d i s c i p l i n e of the h o s p i t a l as the program would be operated by the h o s p i t a l ' s s o c i a l s e r v i c e s t a f f . This, too, would s i m p l i f y the r e t u r n of a p a t i e n t to i n s t i t u t i o n a l care i f the need should a r i s e , since i t would e l i m i n a t e the us u a l admission procedure. I t would be the r e s p o n s i b i l i t y of the s o c i a l worker to keep recording up to date on the progress of p a t i e n t s i n f o s t e r care. He should also be expected to advise the business a d m i n i s t r a t o r on a monthly b a s i s of the number of p a t i e n t s i n f o s t e r care, and the number of days each p a t i e n t remains i n an approved home. Any change i n the p a t i e n t p o p u l a t i o n i n a home would be s i m i l a r to that f o l l o w e d i n c h i l d welfare a d m i n i s t r a t i o n . Medical and d e n t a l s e r v i c e s would have to be provided by the h o s p i t a l as t h i s program would be an -41-extension of h o s p i t a l care i n t o the community. Other matters which would have to be considered are allowances f o r p a t i e n t s who have no f i n a n c i a l resources. As i n d i c a t e d by Table 4, page 22, t h i s area would be one a f f e c t i n g a la r g e percentage of p a t i e n t s . S i m i l a r l y , the need f o r s u i t a b l e c l o t h i n g would have to be met by the h o s p i t a l as the r e c i d i v i s t p a t i e n t s g e n e r a l l y are l a c k i n g i n m a t e r i a l resources. In some instances r e l a t i v e s might be w i l l i n g to supply t h i s need, but as Table 5, page 25, i n d i c a t e s , there was a l i m i t e d degree of i n t e r e s t shown by r e l a t i v e s of the twenty-one r e c i d i v i s t p a t i e n t s studied. C a r e f u l t i m i n g as to the p l a c i n g of p a t i e n t s i n f o s t e r care i s e s s e n t i a l f o r the success of the pl a n . The p a t i e n t should understand the reasons f o r h i s being placed i n a f o s t e r home and any p o s s i b l e disadvantages should be discussed w i t h him. V i s i t s to the proposed home are a u s e f u l and h e l p f u l method of i n t r o d u c i n g a p a t i e n t to the pl a n . Since f o s t e r home care can r e a d i l y be adopted not only f o r r e h a b i l i t a t i o n , but e q u a l l y w e l l f o r long-term chronic care of p a t i e n t s , i t would be u s e f u l to c l a s s i f y the homes according to the purpose they serve. Homes f o r chronic p a t i e n t s would be set up on the basis that the p a t i e n t would be l i v i n g out h i s days there, -42-unless f o r medical reasons he had to be removed. On the other hand, i f a home were being used f o r r e h a b i l i t a t i o n purposes, i t would be expected that the patient.would e v e n t u a l l y be moving out on h i s own. In these homes one might expect to place p a t i e n t s p r i o r to probationary discharge or those c u r r e n t l y on probation from h o s p i t a l . The l e n g t h of time the p a t i e n t could remain i n t h i s s e t t i n g would depend on the d i s c r e t i o n of the p a t i e n t ' s doctor and the s u p e r v i s i n g s o c i a l worker. Once the p a t i e n t became employed he would be expected to pay a p o r t i o n or the f u l l cost of the f o s t e r care r a t e , but the f a c t o r of employment could not be the only c r i t e r i o n upon which a p a t i e n t ' s readiness f o r discharge to community would be evaluated. F a c i l i t i e s . In s e l e c t i n g the homes to be used i n a f o s t e r care program, c e r t a i n p h y s i c a l f a c t o r s must be given c a r e f u l c o n s i d e r a t i o n . The a c t u a l l o c a t i o n of the home i s important, both i n i t s r e l a t i o n to other homes i n the area and i n regard to i t s distance from the h o s p i t a l and other f o s t e r care homes. Good t r a v e l con-nections would be e s s e n t i a l i n p i c k i n g homes f o r r e h a b i l i -t a t i o n purposes i n order t h a t p a t i e n t s could commute f o r work. There are c e r t a i n p h y s i c a l standards upon which an assessment could be made. The home should show evidence of c l e a n l i n e s s , have p r o v i s i o n f o r adequate p h y s i c a l care, and some f a c i l i t i e s f o r r e c r e a t i o n . A li v i n g - r o o m which may be used by both p a t i e n t s and fam i l y would play an important p a r t i n the s o c i a l i z a t i o n of the p a t i e n t . I t Is g e n e r a l l y considered advisable to have a male member i n a family where male p a t i e n t s are to be placed, and while c h i l d r e n are no c o n t r a i n d i c a t i o n to the use of a home f o r f o s t e r care, c a r e f u l screening i s i n d i c a t e d . 1 While c e r t a i n p h y s i c a l standards must .be r e q u i r e d i n a home, of primary importance i s the p e r s o n a l i t y of the operator who w i l l manage the home. Any other persons who occupy the home should a l s o be considered as they, too, w i l l be i n continuous contact w i t h the p a t i e n t s . Such c o n s i d e r a t i o n s are necessary as i t i s i n the area of r e l a t i o n -ship t h a t a high percentage of mental p a t i e n t s have d i f f i c u l t y . The operator of the home should be a woman, and because of the v a r i o u s r o l e s she may be expected to- play she w i l l need to be an understanding person, k i n d l y and sympathetic, yet knowing when and how to be f i r m . I t would be necessary that she.-be respected and l i k e d i n the community, and tha t her motive f o r t a k i n g p a t i e n t s i n f o s t e r care be mainly humanitarian. In t h i s regard there should be a source of income apart from that d e r i v e d through f o s t e r care. I t •^Ontario Department of Health, "A Handbook on Approved Homes i n Ontario H o s p i t a l s " , 1 9 5 7 , p. 6. (Mimeographed.) -44-would be h e l p f u l i f the home operator were to possess ing e n u i t y and be able to help p a t i e n t s f i n d occupations and i n t e r e s t s s u i t e d to them. Her t r a i n i n g could come through a s e r i e s of l e c t u r e s whieh would f a m i l i a r i z e her wit h h o s p i t a l p o l i c y and treatment programs. She would be r e q u i r e d to assume r e s p o n s i b i l i t y f o r the welfare of the p a t i e n t on a twenty-four hour b a s i s and during minor p h y s i c a l i l l n e s s , although having assurance from the hos-p i t a l that the p a t i e n t could be returned to h o s p i t a l on d e c i s i o n of the s o c i a l worker or other h o s p i t a l a u t h o r i t y , should he r e q u i r e a more c o n t r o l l e d s e t t i n g e i t h e r because of p h y s i c a l or mental symptoms. . Another important area would concern her a b i l i t y to work wit h a u t h o r i t y f i g u r e s , such as the s o c i a l worker, who would have the r e s p o n s i b i l i t y of s u p e r v i s i n g both the home and the degree of care a f f o r d e d the p a t i e n t . 1 P a t i e n t s . P a t i e n t s f o r placement i n f o s t e r home care w i l l be chosen by the s o c i a l worker i n c o n s u l t a t i o n w i t h the medical superintendent of the h o s p i t a l or h i s r e p r e s e n t a t i v e and the charge nurse from the p a t i e n t ' s ward. P a t i e n t s w i t h needs s i m i l a r to those o u t l i n e d i n the study of the sample group of r e c i d i v i s t p a t i e n t s , i n c l u d i n g both c e r t i f i e d and volun t a r y p a t i e n t s , would be e l i g i b l e f o r 1IbId., p. 7. r e h a b i l i t a t i o n i n approved f o s t e r homes. C e r t a i n c a t e g o r i e s of p a t i e n t s who g e n e r a l l y would not be placed, except under s p e c i a l circumstances, are a l c o h o l i c s , drug a d d i c t s , s y p h i l i t i c a under treatment, i n v a l i d s or semi-i n v a l i d s , or u n c o n t r o l l e d e p i l e p t i c s , as i t i s e s s e n t i a l to place p a t i e n t s who w i l l be r e a d i l y accepted by the community. Such p a t i e n t s can be very demanding of the operator's time, to the detriment of other p a t i e n t s i n the home, as w e l l as c r e a t i n g problems i n the community. Neither should the operator of a home be expected to care f o r inc o n t i n e n t p a t i e n t s or those w i t h unclean h a b i t s . P a t i e n t s s u i t a b l e f o r chronic care i n f o s t e r homes would be o l d e r , r e s p o n s i b l e chronic p a t i e n t s who do not r e q u i r e nursing home care and who do not have f i n a n c i a l means of t h e i r own, nor fami l y or r e l a t i v e s w i l l i n g to take them. S u i t a b l e a l s o f o r t h i s type of program are p a t i e n t s who do not r e q u i r e h o s p i t a l care, but need s u p e r v i s i o n . This would Include p a t i e n t s who, though they have a f i x e d d e l u s i o n a l system, are not a problem i n management. Here, too, would f i t p a t i e n t s who need to remain on medication of an o r a l nature t h a t could be supervised by the home operator. From the foregoing requirements, i t i s obvious th a t a f o s t e r care p l a n r e q u i r e s considerable planning, s u f f i c i e n t p r o f e s s i o n a l l y t r a i n e d s o c i a l work s t a f f -46-capable of s u p e r v i s i n g i t s operation, and a community w i l l i n g to p a r t i c i p a t e i n i t s development. F o s t e r home care can be the means of opening another door to the community, h o p e f u l l y p r o v i d i n g the impetus f o r p a t i e n t s who have i n the past been unable to r e h a b i l i t a t e themselves. Examining such a program from the economic standpoint i t can r e a d i l y be shown tha t i t i s l e s s c o s t l y to maintain a p a t i e n t i n i 2 f o s t e r home c a r e x than i n the i n s t i t u t i o n . However, i t s g r e a t e s t value i s as a th e r a p e u t i c t o o l to a i d i n the r e h a b i l i t a t i o n of the mentally i l l . D a i l y per c a p i t a cost of boarding home care f o r S o c i a l A s s i s t a n c e c l i e n t s i s § 2 . 8 5 . This r a t e has been e s t a b l i s h e d by the B r i t i s h Columbia Department of Welfare. 2 D a i l y per c a p i t a cost at the P r o v i n c i a l Mental H o s p i t a l , Essondale, B.C.,- i s | 4 . 5 9 . Annual Report of the Mental  Health S e r v i c e s , Province of B r i t i s h Columbia, 1958, p. L 2 5 . CHAPTER IV REHABILITATION IN THE COMMUNITY S o c i a l workers began working i n p s y c h i a t r i c h o s p i t a l s some f i f t y - f i v e years ago. Over these years there has been considerable advancement i n treatment methods u n t i l today the r o l e of the s o c i a l worker as a member of the treatment team i s a valued one. A c t i v e l y c o l l a b o r a t i n g i n a l l phases of the p a t i e n t ' s treatment, from the p e r i o d preceding admission, through h o s p i t a l i -z a t i o n and a f t e r care, t h e i r knowledge of s o c i a l adjust-ment, p s y c h o l o g i c a l aspects of mental I l l n e s s and of community resources, has enabled them to spearhead move-ments, to b r i n g community and h o s p i t a l c l o s e r t o g e t h e r . 1 Goals i n Treatment The primary goal i n p s y c h i a t r i c treatment of . •.the h o s p i t a l p a t i e n t i s to b r i n g h i s i l l n e s s i n t o remission, enabling the p a t i e n t to r e t u r n to h i s f a m i l y and community, to f u n c t i o n i n that environment i n a reasonably adequate and s a t i s f y i n g way. The p r o f e s s i o n a l t r a i n i n g of the s o c i a l worker e s p e c i a l l y equips him to work w i t h the p a t i e n t f o r the r e s o l u t i o n of c o n f l i c t s a r i s i n g i n the area of s o c i a l f u n c t i o n i n g . Knee, R.J., Ed., B e t t e r S o c i a l Services f o r Mentally  111 P a t i e n t s , American A s s o c i a t i o n of P s y c h i a t r i c S o c i a l Workers, Inc., 1955, p. v i i . -48-Various resources such as "half-way houses," o u t - p a t i e n t c l i n i c s , day h o s p i t a l s , f o s t e r care programs and s o c i a l clubs f o r p a t i e n t s have been provided to extend supportive s e r v i c e s i n t o the community. B r i t i s h Columbia has used a l l these, w i t h the exception of a f o s t e r home care program, but no research has been c a r r i e d out here to determine the value of f o s t e r home care f o r mental p a t i e n t s . This study examined f o s t e r care programs used elsewhere i n order to r e l a t e the meri t s of these plans i n meeting the needs of p a t i e n t s . I t was also a r e q u i s i t e that needs of p a t i e n t s at the po i n t of discharge.be determined, as w e l l as f a c t o r s which appear to p r e c i p i t a t e a r e l a p s e . As p r e v i o u s l y described, twenty-one p a t i e n t s who returned to h o s p i t a l p r i o r to t e r m i n a t i o n of t h e i r probationary p e r i o d were assessed. Chosen by a r o u t i n e sampling method, a l l had some degree of a c t i v i t y w i t h the s o c i a l s e r v i c e department p r i o r to discharge. The Average P a t i e n t The t y p i c a l p a t i e n t examined by t h i s study was found to be t h i r t y - s i x years of age, diagnosed as having some form of schizophrenic d i s o r d e r , and i n h i s (or her) f o u r t h admission to h o s p i t a l . Unmarried, wi t h few f r i e n d s , no f a m i l y environment to which he could r e t u r n , no f i n a n c i a l -49-resources, an inadequate education, and a l a c k of work s k i l l s , h i s prospects f o r s u c c e s s f u l r e h a b i l i t a t i o n are d i s c o u r a g i n g . L i m i t e d to c e r t a i n f i e l d s of work as a r e s u l t of h i s inadequacies and l a c k i n g f i n a n c i a l resources, one out of every two i n the sample group became the c l i e n t of p u b l i c welfare agencies, drawing s o c i a l a s s i s t a n c e . This subsistence l e v e l of f i n a n c i a l assistance" 1 - does l i t t l e to help i n the r e h a b i l i t a t i o n of the mentally i l l . Forced under such circumstances to o b t a i n a s m a l l , dingy room where he does h i s own cooking and laundry, he begins i n t h i s atmosphere once again to withdraw from the harsh r e a l i t y of l i f e . C o n t r i b u t i n g to h i s withdrawal' i s the l a c k of i n t e r e s t shown i n him by r e l a t i v e s , and h i s very l i m i t e d c i r c l e ' of f r i e n d s . Many p a t i e n t s , since they f e e l d e f i c i e n t i n the s o c i a l graces, avoid j o i n i n g clubs or s o c i a l groups f o r f e a r of being considered odd. This, too, c o n t r i b u t e s to the general p a t t e r n of withdrawal from l i f e , so common to the mental p a t i e n t . For some p a t i e n t s , who r e t u r n to l i v e w i t h t h e i r n a t u r a l f a m i l y , the intense emotional r e l a t i o n s h i p s w i t h i n the f a m i l y appear to p r e c i p i -2 t a t e a r e l a p s e . Examination of the sample group d i s c l o s e d the c h i e f reason f o r the p a t i e n t ' s r e t u r n was s t r e s s of the s o c i a l s i t u a t i o n . ^The present s o c i a l a s s i s t a n c e r a t e i n B r i t i s h Columbia i s |66.00 per month f o r a s i n g l e person. 2 T a b l e 8, p. 33. -50-From examination of the f o s t e r care plans i n Maryland and Ontario, i t can be i n f e r r e d that t h e i r p a t i e n t s have had needs s i m i l a r to Essondale p a t i e n t s , and that these have been met s a t i s f a c t o r i l y by f o s t e r home care. The progress of even q u i t e d e t e r i o r a t e d p a t i e n t s , who were able to g a i n a sense of s e c u r i t y and a f e e l i n g of belonging from the personal i n t e r e s t taken i n them by the operator of the home, i n d i c a t e s the value and p o t e n t i a l of t h i s resource. Having a wide range of a p p l i c a t i o n , f o s t e r home care, i n a d d i t i o n to i t s use f o r r e h a b i l i t a t i o n , i s q u i t e adaptable to the care of quie t chronic p a t i e n t s f o r whom l i t t l e progress i s expected. There i s every reason to b e l i e v e i t could be r e a d i l y adapted to a i d i n the a f t e r - c a r e of s e n i l e p a t i e n t s who no longer r e q u i r e i n s t i t u t i o n a l care, but f o r whom the community or r e l a t i v e s are unable to provide a resource. O r i g i n a l l y f o s t e r home care was developed f o r the placement of quiet chronic p a t i e n t s , however many p a t i e n t s improved even, to the p o i n t where a complete discharge was p o s s i b l e ; hence the program's use as a r e h a b i l i t a t i o n resource 2 came i n t o being. xAn a n a l y t i c a l survey of a group of p a t i e n t s h o s p i t a l i z e d f o r mental i l l n e s s i n the Home f o r the Aged, Port Coquitlam, B.C., i n d i c a t e s the f e a s i b i l i t y of discharge f o r a number of e l d e r l y p a t i e n t s , provided there i s some resource a v a i l a b l e f o r t h e i r care. E. Elmore, Discharge Planning i n the Homes  f o r the Aged, Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1959. 2 C r u t c h e r , Hester B., Fost e r Home Care For Mental P a t i e n t s . The Commonwealth Fund, New York, 1944. -51-In t h i s study the examination of the program developed under three general areas: general p o l i c y , needed f a c i l i t i e s , and types of p a t i e n t s , i n each area g i v i n g i n d i c a t i o n s of f a c t o r s worthy of c a r e f u l a t t e n t i o n . From an economic standpoint t h i s program could be expected to reduce the d a i l y per c a p i t a cost (I4.59)"1" of keeping such p a t i e n t s i n the mental i n s t i t u t i o n s . This, however, i s not the c h i e f merit of such a program, although i t could w e l l be a f a c t o r i n pre s e n t i n g the value of the program f o r t h i s province. P r e s e n t i n g Foster Home Care to the Community An important o r g a n i z a t i o n job would be the pre-s e n t a t i o n of the p l a n to the community. Support by the l o c a l branch of Canadian Mental Health A s s o c i a t i o n would be v a l u a b l e . Among t h e i r group of volunteers who come weekly to the h o s p i t a l might be found a good source of p o t e n t i a l f o s t e r home operators, as w e l l as strong advocates f o r the program i n the community. I t would be necessary f o r s o c i a l workers and medical personnel from the h o s p i t a l to address v a r i o u s groups i n the area, such as women's o r g a n i z a t i o n s , men's s e r v i c e c l u b s , r e l i g i o u s groups and -'•Daily per c a p i t a cost. The P r o v i n c i a l C e n t a l H o s p i t a l , Essondale, B.C. Annual Report Mental Health Services, Province of B r i t i s h Columbia, 1958, p. L 25. - 5 2 -others known to be i n t e r e s t e d and i n f l u e n t i a l i n support-i n g worthy community p r o j e c t s . Through an e f f e c t i v e p r e s e n t a t i o n of the p l a n , i t would be hoped to arouse acceptance and support. An important c o n s i d e r a t i o n i n i n i t i a t i n g the program i s t i m i n g . I f the community has not been prepared to accept the idea of a f o s t e r care program, then premature attempts may be d i s a s t r o u s . Many people may approve of the program, yet object very s t r o n g l y i f p a t i e n t s are to be placed i n the house next door. Here an e s s e n t i a l f a c t o r i n community o r g a n i z a t i o n processes must be recognized, that of p e r c e i v i n g , e l i c i t i n g and handling the f e a r s , concerns and o b j e c t i o n s of the community. I f the community i s judged to be ready, then a campaign might be launched i n conjunction w i t h the annual "Open House" h e l d by the h o s p i t a l . Research Considerations The sample group s t u d i e d here i n d i c a t e d the needs of p a t i e n t s and showed that these needs could be met, i n p a r t , through a f o s t e r care program; however, at the present time there i s no accurate estimate of the number of p a t i e n t s In the P r o v i n c i a l Mental H o s p i t a l , Essondale, B.C., who could b e n e f i t from a f o s t e r care program. P o s s i b l y the answer to t h i s w i l l be obtained through a questionnaire f o r use i n r a t i n g p a t i e n t s on the ward. -53-A v i t a l question, "Why do p a t i e n t s improve and recover i n the f o s t e r home s e t t i n g ? " r e q u i r e s s c i e n t i f i c research. I t i s recognized that some progress may be due to the i n t e r e s t and concern p a t i e n t s r e c e i v e from t h e i r f o s t e r f a m i l i e s , but hypotheses are not enough. I s o l a t i n g the v a r i a b l e s that b r i n g about recovery or improvement w i l l r e q u i r e c a r e f u l study. I t w i l l a l so be h e l p f u l to o b t a i n or devise some techniquerby whieh the degree of movement or, change i n a p a t i e n t through f o s t e r home placement can be measured. Such a rating, scale would be a valuable t o o l In s o c i a l work research. The emphasis today i n d e c e n t r a l i z a t i o n of la r g e mental I n s t i t u t i o n s , w i t h a community ' o r i e n t a t i o n toward mental h e a l t h s e r v i c e s , i s on keeping the p a t i e n t i n h i s n a t u r a l environment r a t h e r than i n i s o l a t i n g him from the community. Since f o s t e r home care i s a program which aims at a s i m i l a r g o a l , the p l a c i n g of the p a t i e n t . i n a n a t u r a l f a m i l y s e t t i n g i n the community, the time may be here f o r i t s development i n t h i s province. APPENDIX A BIBLIOGRAPHY Blanton, Smiley, Love or P e r i s h , S i m 0 n and Schuster, New York, 1 9 5 6 . Bowl by, John., C h i l d Care, and the Growth of Love, A P e l i c a n Book,' W h i t e f r i e r s Press L t d . , London, 1 9 5 3 . B r i t i s h Columbia, Annual Report of the Mental Health  S e r v i c e s , Queen's P r i n t e r s , V i c t o r i a , 1 9 5 8 . Crutcher, Hester B., Foster Home Care f o r Mental P a t i e n t s , The Commonwealth Fund, New.York, 1944. DeWitt, H e n r i e t t a , "The Foste r Care Placement of State Men-t a l P a t i e n t s : Maryland Pla n , 1 9 5 4 . " Presented at the Second Annual I n s t i t u t e of the New Jersey Neuro-p s y c h i a t r y I n s t i t u t e , P r i n c e t o n , New Jersey, September 1 5 , 1954. (Mimeographed.) Dorgan, Jean, "Foster Home Care f o r the P s y c h i a t r i c P a t i e n t , " Reprinted from the Canadian Journa l of P u b l i c Health, Vol.. 4 9 , No. 1 0 , October, 1 9 5 8 . Elmqre, Eugene, Discharge Planning i n the Homes .for the Aged, Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1 9 5 9 . F i s h e r , Saul H.. "The Recovered P a t i e n t Returns to the • Community", Mental Hygiene, V o l . 42, No. 4, October, 1958 Jones, M a x w e l l R e h a b i l i t a t i o n i n P s y c h i a t r y , World Health Organization, Geneva, J u l y , 1 9 5 2 . Modlin, Herbert C , and. H a l l , Bernard H., "The P s y c h i a t r i c P a t i e n t Bridges the Gap Between the H o s p i t a l and the Community," B e t t e r S o c i a l Services f o r Mentally 111  Patient's, Knee, Ruth I . , Ed., American A s s o c i a t i o n of P s y c h i a t r i c S o c i a l Workers, Inc., New York, 1 9 5 5 . Noyes, Arthur P., and Kolb, Lawrence C., Modern C l i n i c a l P s y c h i a t r y , W.B.. Saunders Company, P h i l a d e l p h i a , 1 9 5 8 . Ontario Department of Health, "A Handbook on Approved Homes i n Ontario H o s p i t a l s , " 1 9 5 7 . (Mimeographed.) -55-Padula, Helen, "The Mental H o s p i t a l : A S p e c i a l i z e d Treatment Service or Way of L i f e ? " Presented at the I n s t i t u t e of the U n i v e r s i t y of Pennsylvania, School of S o c i a l Work, June 24, 1954. (Mimeographed.) R i p p l e , Margaret A., The Rights of I n f a n t s , Columbia U n i v e r s i t y Press, New York, 1943. Sutherland, Robert M., The R e h a b i l i t a t i o n of Discharged  Mental P a t i e n t s , Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1954. Wilson, Gertrude, and Ryland, Gladys, S o c i a l Group Work  P r a c t i c e , Houghton M i f f l i n , Boston, 1949. 

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