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The sustaining clinic; outpatient services for the long-term mentally ill : a case review of low potential… Beck, Allan Stewart 1961

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THE SUSTAINING CLINIC:  OUTPATIENT SERVICES FOR THE LONG-TERM MENTALLY ILL A Case Review of Low P o t e n t i a l R e h a b i l i t a t i o n Patients i n the Sustaining C l i n i c and the S o c i a l Club; Mental Health Centre, Burnaby, B.C., 1957 - I960 by ALLAN STEWART BECK Thesis Submitted i n of the Requirements MASTER OF i n the School P a r t i a l Fulfilment f o r the Degree of SOCIAL WORK of S o c i a l Work Accepted as conforming to the standard required f o r the degree of Master of S o c i a l Work School of S o c i a l Work 1961 The U n i v e r s i t y of B r i t i s h Columbia In p r e s e n t i n g t h i s t h e s i s 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 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 the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r ext 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 of 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 t h a t 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 g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department of S>^Vxo\ Vx> *S\W^ The U n i v e r s i t y o f B r i t i s h Columbia, Vancouver o", Canada. Date V ^ O O A ^ \°\Vo\ y ~ - ^ — — - i i i -ABSTRACT The Sustaining C l i n i c i s a recently-added service provided by the Mental Health Centre i n B r i t i s h Columbia f o r a selected group of patients who are unable, f o r a v a r i e t y of reasons, to benefit from more intensive therapy than a monthly interview. This study reviews the contribution of the therapeutic team at the Sustaining C l i n i c (of which the s o c i a l worker i s a p a r t ) , toward the r e h a b i l i t a t i o n of a d i f f i c u l t group of m e n t a l l y - i l l patients, most of whom require long-term follow-up care. To emphasize the focus on the appropriate type of patients, the method i s to review ( l ) the problems of a sample group of these patients, and ( 2 ) the treatment services given to them; thus, e s t a b l i s h i n g how f a r t h i s meets t h e i r needs. Treatment i s evaluated with the a i d of three r a t i n g scales assessing the patient's functioning at the time of r e f e r r a l and at the time of discharge. The evidence i s that ( l ) The enormous d i s a b i l i t y associated with these patients i s to a large extent imposed, preventable, and t r e a t a b l e . D i s a b i l i t y originates p a r t i c u l a r l y from parental r e j e c t i o n , and i s l a t e r magnified by the r e j e c t i o n mechanisms stemming from c u l t u r a l a t t i t u d e s . ( 2 ) The treatment provided by the Sustaining C l i n i c i s e f f e c t i v e because i t i s r e l a t e d to the needs of the patient and to the s p e c i f i c conditions surrounding his i l l n e s s . Therapeutic contributions include regulation of medication, support i n cases of s t r e s s , l i m i t - s e t t i n g , information-giving, manipulation of the environment, and providing a f i g u r e f o r i d e n t i f i c a t i o n . (3) More resources than the C l i n i c can provide w i l l be needed, because of the deep-seated personal and s o c i a l handicaps of these patients. This study i t s e l f can be h e l p f u l only i f coordinated with others which examine other "halfway house" programs, and the s o c i a l worker's p a r t i c i p a t i o n i n them. - i v -ACKNOWLEDGEMENTS I wish to express my thanks to Dr. F. McNair and Mr. E. M. Elmore f o r making the Sustaining C l i n i c records a v a i l a b l e and f o r t h e i r many suggestions. Appreciation i s also extended to Dr. L. C. Marsh fo r h i s u n f a i l i n g guidance i n the planning and presenting of t h i s t h e s i s . - XI -TABLE OF CONTENTS Page Chapter 1. The R e h a b i l i t a t i o n Spectrum of the K e n t a l l y H I The nature of mental i l l n e s s . Areas of r e h a b i l i t a t i o n . Phases of i l l n e s s and t h e i r implications. Problems faced by discharged mental patients. The community side of the picture. The Mental Health Centre. Establishment of the Sustaining C l i n i c . Method of the present study 1 Chapter 2. The Patients and Thej.r Problems; An I l l u s t r a t i v e  Review General c h a r a c t e r i s t i c s . A sample group of patients. The t r a n s i t i o n problems. Personal behaviour. The f e e l i n g of i n f e r i o r i t y . The dynamic h i s t o r y of these p a t i e n t s . Poverty i n r e l a t i o n s h i p s 21 Chapter 3« Treatment Services Offered by the Sustaining C l i n i c Two forms of casework treatment. A therapy of r e l a t i o n -ship. The process of treatment with a case i l l u s t r a t i o n . An evaluation of the treatment 51 Chapter 4. The Sustaining C l i n i c as a Bridge to the Community The appropriateness of Sustaining C l i n i c f o r i t s type of patients. The Sustaining C l i n i c i n the network of s o c i a l agencies. Need for i n t e r p r e t a t i o n of mental i l l n e s s to the community 70 Appendices: A. Schedule giving s t a t i s t i c a l data on the male sample group. B. Schedule giving s t a t i s t i c a l data on the female sample group. C. Bibliography TABLES AND SCHEDULES IN THE TEXT (a) Tables Table 1. Comparative r a t i n g of sample group at r e f e r r a l and at discharge 68 (b) Schedules Schedule A. C r i t e r i a used f o r ra t i n g degree of i l l n e s s or improvement 67 THE SUSTAINING CLINIC: OUTPATIENT SERVICES FOR THE LONG-TERM MENTALLY ILL A Case Review of Low P o t e n t i a l R e h a b i l i t a t i o n Patients i n the Sustaining C l i n i c and the S o c i a l Club; Mental Health Centre, Burnaby, B. C., 1957 - I960. CHAPTER I THE REHABILITATION SPECTRUM OF THE MENTALLY ILL The nature of disability produced by mental illness varies widely because of the complexities of personality development, marked individual differences in adaptation to stress, and great variations in ethnic and cul-tural milieu. However, it is currently assumed by many psychiatrists, psy-chologists and social workers, that mental illness derives from difficulties in interpersonal relations that result in the frustration of instinctive needs and strivings whose satisfaction is essential for normal growth and happiness. The blocking of thwarting of these drives leads to various un-pleasant tension states, but their specific expressions vary over a wide spectrum. In some patients the tension is manifested by anxiety or apprehen-sion; in others, it is transformed into obsessions or compulsions. Some pa-tients fix their attention upon actual or fancied somatic complaints and become "psychic invalids"; others have major disturbances in autonomic ba-lance that result in malfunctioning of visceral organs (psychosomatic illness). The behaviour of the Sustaining Clinic group is characterized by withdrawal, by preoccupation with primitive fantasies and attempts at the resolution of psychic tensions either by inappropriate aggressive action, or by specialized psychic trends such as delusions and hallucinations. From another point of view, the Sustaining Clinic persons may be understood as suffering from deep-seated feelings of unworthiness that freo^ently break - 2 -out in antagonism to authority or "rivalry figures" or potential objects of affection, and seriously impair their ability for work, play, or love. Behaviour pathology is to a considerable degree the product of serious defects in the techniques of sharing the perspectives common to one's society. The difficulty in a specific case may stem from a failure to acquire adequate social skill in "role-taking" during early personality de-velopment, or it may represent the loss or distortion of role-taking in a person who had once acquired sufficient skill. Sharing attitudes and taking roles are matters of the utmost significance both in forming a diagnosis of and in planning a therapy for the Sustaining Clinic patient. One of the most difficult tasks in the treatment of behaviour disorders is that of lear-ning to see a patient's problems from his own highly individual, personal perspective; yet at the same time leading the patient toward sharing some of the therapist's impersonal detached attitudes about symptoms and their ori-gins. This is the basis of "rapport", and one of the factors in "transference". The patients attending the Sustaining Clinic are maintained in the community on tranquilizing drugs, and are unable, for a variety of reasons, to benefit from intensive therapy. For many of these patients any contact beyond a brief monthly interview is so frightening they will terminate treat-ment. Though they crave a close relationship with someone who will understand and accept them, their fear of rejection and loss of power through lowering their defences is great. Thus, the therapist, because of the very nature of his patient's personality, is forced to deal with everyday reality problems. Areas of Rehabilitation The rehabilitation of the psychiatric patient presents a special - 3 -problem: How can the mentally i l l patient be helped to live in the community, both socially and vocationally, in spite of any residual symptoms or perso-nality disorder he may s t i l l have? Therefore, part of the rehabilitation process is not only to reduce or eliminate the psycho-pathology, but also to re-educate the individual in social and vocational skills to enable him to face situations that he will encounter in his community. The principal areas in which rehabilitative effort should be ap-plied in assisting the mentally-ill patient are: (l) psychological rehabili-tation, ( 2 ) vocational, ( 3 ) family, ( 4 ) social-recreational, ( 5 ) community and ( 6 ) educational rehabilitation. Such a concept of rehabilitation of the mentally i l l approaches that of total treatment. Psychological rehabilitation comes first in the hierarchy of con-cern. Here interest is primarily focused in reduction or removal of clinical symptoms, resolution of disruptive anxieties and tensions, neutralization of intrapsychic conflicts, and so on. This is primarily a psychodynamic thera-peutic problem and is best managed by intensive individual or group therapy, together with all other measures available in the hospital and out-patient setting. It is worth stressing that, for many patients, there exists a "psycho-pathological ceiling", which limits adaptational growth very sharply. For these patients, the critical psychological problems must be dealt with and resolved first before further rehabilitation effort can pay off. How-ever, for other patients, although psychological problems may be sharply limiting, marked rehabilitative gains can be made through the employment of methods which are further discussed. Second, vocational rehabilitation involves careful assessment or - 4 -survey of patients1 occupational or vocational interests and capacities, testing of his fitness through occupational assignment, developing old or new skills via occupational therapy or work therapy, increasing work tole-rance, training outside the hospital setting where indicated, assistance in job placement, and follow-up of vocational adjustment through contacts with the patient and, where possible and helpful, with the employer. Third, family reh ab ili t a t i on: The family and its assets and lia-bilities, it seems clear, will be of increasing concern to social work of the future. Child guidance clinics point the way by extending treatment to both child and parent. The patient's breakdown is often part of a major struggle going on in the family, the patient being the victim of character disturbances of other family members, long-standing feuds, or basic incom-patibilities. The beneficial effects of hospitalization and the total plan of treatment may be vitiated by the family, unless considerable support and understanding is given them. Major changes within the family may occur as the result of a patient's hospitalization, and in turn may affect him: mental or physical stress in one or more family members, stigmatization by friends or community, movement of residence to another vicinity, or closing of ranks against him, especially if his illness assumes a chronic course. Thus, the family must be brought within the therapeutic orbit if the pati-ent's rehabilitation potential is to be realized fully. Fourth and fifth are social-recreational and community rehabilita-tion. Experience indicates that this is one of the weakest areas of patient adaptation and one toward which relatively little treatment effort is direc-ted. Yet it is generally felt that those patients who develop deep roots - 5 -in the community have the fewest relapses. The ex-patient may go through the motions of holding a job, indeed be quite productive, yet be unable to tolerate social contacts, dependent as they are upon ease and naturalness of association and confidence in oneself. Part of the d i f f i c u l t y i s the un-availability of suitable socio-recreational groups - "halfway" groups, so to speak - that have tolerance for the ex-patient appropriate to each stage i n his reintegration. Sixth i s educational rehabilitation. The experience of being i l l and of recovering, plus a l l the self-understanding that i t can imply, espe-c i a l l y in the successful case, may make a profound contribution to one's psychological education. Additional efforts are often worthwhile to attempt to develop more f u l l y the person's s k i l l s , talents, curiosities, and special interests. Thus, mental hospitals should include programs of art, music appreciation, language instruction, photography, carpentry and cabinet-making, the dance, and lectures by teachers of local institutions as part of the rehabilitative procedure. Many patients have discovered that t o t a l l y new areas of curiosity, competence, or striving, could be developed through the stimulation and support provided by a rich rehabilitative program. Phases of Illness and their Implications There are three phases of the patient's il l n e s s during which reha-b i l i t a t i o n efforts must be applied: ( l ) during his hospitalization, (2) during transition to the community, and (3) during his community l i f e . During hospitalization, rehabilitation emphasis i s on achieving a "therapeutic climate," that i s , an interpersonal atmosphere calculated to undo the pathogenic relations of the patient's earlier l i f e . Hospital staff, - 6 -therefore, i n the aggregate should be accepting, sympathetic, u n c r i t i c a l , i n t e r e s t e d , and understanding. Within such a climate, three general patterns of treatment may be stressed. F i r s t , i s intensive, i n d i v i d u a l psychothera-peutic work with a trained, professional t h e r a p i s t . A steadfast, r e l i a b l e r e l a t i o n s h i p that explores thoroughly a patient's thinking and f e e l i n g can be a remarkable c a t a l y s t f o r growth. The second aspect i s "milieu" therapy; here i s implied not only the "therapeutic climate" mentioned above, but also a program that makes a v a i l a b l e to the patient many a c t i v i t i e s , d i v e r s i o n s , and s o c i a l i z i n g p o s s i b i l i t i e s . An act i v e occupational therapy, recreation, work, and sports program i s e s s e n t i a l . Also c r u c i a l are the r e l a t i o n s h i p s developed with other persons - with s t a f f or patients - i n these a c t i v i t i e s . Often the m i l i e u program can be s u c c e s s f u l l y supplemented by a d d i t i o n a l group experience such as formal group therapy or patient government. The t h i r d area of emphasis i s somatic therapy. Here are included a l l e f f o r t s directed toward removal of phys i c a l or p h y s i o l o g i c a l handicaps, and i n addi-t i o n , s p e c i f i c somatic treatments inc l u d i n g e l e c t r i c shock, i n s u l i n , surgery, and pharmacotherapeutic agents. A l l these e f f o r t s to help the patient, i t must be noted, put major stress upon communication and coordination functions of the h o s p i t a l ; these are primary concerns of management or administration and are delegated e s s e n t i a l l y to the c l i n i c a l team headed by the p s y c h i a t r i s t . I n s u f f i c i e n t a t t e n t i o n has been paid to the t r a n s i t i o n a l phases of the patient's experience. A severe c u l t u r a l d i s c o n t i n u i t y e x i s t s between the h o s p i t a l and the outer community that most patients, upon discharge, ex-perience as more or l e s s threatening. Much e f f o r t w i l l be needed i n the future t o develop c a r e f u l l y graded steps f o r the movement of the patient - 7 -from the hospital to the outside world. In the case of deep-seated, chronic illness (e.g., the Sustaining Clinic patients), weeks or months of arrest in various transitional phases may be expected before the patient is secure enough to resettle himself independently in the community. It is not neces-sary to give more than a few illustrations of the types of facilities that may be offered. 1. The day or night hospital. The day hospital has been developed to allow early discharge of patients from hospital residency; however, they may continue their association with the hospital in whatever capacity is needed by returning during the day. This is especially suitable where the home environment is too difficult to endure for the full day, when patients are as yet unable to work on their own, and where long-terra contact with the therapeutic climate is necessary. Night hospital patients work during the day but return to the hospital overnight. 2. The "sheltered workshop". This has been found helpful in the rehabilitation of many patients. It best follows a well-developed work prog-ram within the hospital. Additional work training and work "hardening" can occur within a sheltered workshop situation where progressively conditions of industry can be approached. 3. The "halfway house". This refers to a residency situation, usually under the guidance of a supervising person, for patients who might profit by group or dormitory living and can earn and help pay for their main-tenance. Patients who have no home to go to, or cannot anticipate comfortable acceptance in a home, may do very well in a halfway house as a transitional measure. - 8 _ 4. "Family care". Especially for chronic patients, family care programs may be very successful. The patient is placed within a selected family where he becomes a member who may work or contribute up to his capa-city. Either the provincial government or a philanthropic agency foots the b i l l , and the hospital usually maintains a iratchful, supervising function through a social worker. 5 . The ex-patient club. Patients and ex-patients are able to band together successfully in their own interests. Inpatient self-government is a gratifying actuality in some hospitals, and ex-patient clubs are increa-sing in number and variety throughout this country. In ex-patient clubs, former patients have an opportunity to participate in many group activities and thus gain assurance and confidence in social situations. Club membership may be a stepping stone to developing more secure community roots, and thus may play an important role in prevention of relapse. 6. Outpatient therapy. This is a growing service that proves in-valuable to many ex-patients who need long-term supportive or analytic therapy, group work, or who require a course of pharmacotherapy or electric shock treatments. Outpatient clinics such as the Sustaining Service constitute a major bulwark of support and a line of defense against re-hospitalization. Community adjustment under the conditions indicated above becomes a natural and easy consequence of graded transitional steps back to society. The patient will need considerable support against the stresses and slights felt in interaction with other citizens. Job finding often presents a prob-lem because of the stigma of mental illness, and acceptance within the family or social group may be achieved at times only through an up-hill fight. Here - 9 -the continued i n t e r e s t and support of a s o c i a l agency i s e s s e n t i a l , and i n some instances counselling and home v i s i t s by a trained s o c i a l worker can be h e l p f u l . Often family members may be encouraged to seek p s y c h i a t r i c or s o c i a l work help themselves, f o r a patient's breakdown i n many instances can be assumed to be part of a psycho-pathological family atmosphere. F i n a l -l y , the h o s p i t a l and s o c i a l agencies working with discharged mental patients have a r e s p o n s i b i l i t y to educate c i t i z e n s , i n problems of mental health and to c u l t i v a t e good w i l l toward both in p a t i e n t s and ex-patients. Problems Faced by Discharged Mental Patients For the person torho has been h o s p i t a l i z e d f o r mental i l l n e s s , the period of readjustment t o community l i f e can be an extremely d i f f i c u l t and traumatic one. Long-term h o s p i t a l i z a t i o n i n any s e t t i n g often r e a c t i v a t e s a person's dormant dependency needs. When he i s mentally i l l t h i s problem can be p a r t i c u l a r l y severe. Frequently, the mental-hospital patient who r e -turns to the community s u f f e r s from i n t e n s i f i e d f e e l i n g s of i n s e c u r i t y and extreme lack of confidence. Once again he must face problems and c o n f l i c t s , perhaps the very ones from which his mental i l l n e s s afforded an escape. The r e h a b i l i t a t i o n of the Sustaining C l i n i c person i s further comp-l i c a t e d because, i n a l l instances, there i s s t i l l a residue of the mental i l l n e s s . Unlike other people who have experienced emotional problems but whose defences have remained i n t a c t , t h i s type of patient, returning to the community from the mental h o s p i t a l , i s l i k e l y to be disabled i n most areas of s o c i a l functioning. Often, h i s d i s i n t e g r a t i o n i s so complete that he needs help i n a l l the v i t a l areas of day-to-day l i v i n g - job placement, l i v i n g arrangements, s o c i a l contacts, and so on. - 10 -Since rehabilitation of the mentally i l l is a social problem, in the most encompassing sense, it is the social worker who is best fitted to assume the role of the helping person. The social worker works with a men-tally i l l individual within the context of that person's social environment and, therefore, has the most appropriate skills to aid him in his environ-ment. what seems to happen in the vast majority of cases is that the pa-tient returns to- an environment which, far from being favorable, is not even neutral; it is more likely to be hostile or in some other way destructive. Frequently, the patient who returns home has little or no money, no job, and poor prospects either of obtaining a job in the near future or of being able to hold a job i f one is offered to him. If his family is living on a minimal income, his release will mean that there is one more mouth to feed. It is obvious that these and similar factors can create or exacerbate cer-tain psychological as well as financial problems. Many families or spouses get used to having the patient in the hos-pital; in many instances they are actually better off without the patient. Is it any wonder that their behaviour toward him may range from passive re-jection to overt control, humiliation, or even threats to send him back to the hospital? One should not forget that the family is a constellation of inter-acting personalities. In the absence of one member of the family for a long period of time, the constellation re-forms, and the place formerly occupied by the absent one is eliminated. It follows, therefore, that the social wor-ker may be faced with the added task of helping to realign the family con-- 11 -s t e l l a t i o n i n such a tray that the returned patient i s again a part of i t . There are many basic s o c i a l and psychological dependency needs which must be met before these patients are re-established i n the community; income, c l o t h i n g , s h e l t e r , employment, and a meaningful r e l a t i o n s h i p with one or more people who w i l l understand t h e i r deep basic needs. The return to the community f o r a person who has been h o s p i t a l i z e d f o r a mental disorder i s often a threatening experience. To lack adequate resources i n finances, home, r e l a t i v e s or interested friends increases the patient's i n s e c u r i t y and, therefore, f e e l i n g s of anxiety. The p o s s i b i l i t y of a relapse and return to h o s p i t a l becomes very r e a l . There are p a t i e n t s , as already mentioned, who leave the mental h o s p i t a l with a residuum of the mental disorder which l e d to t h e i r h o s p i t a l i z a t i o n . The inner psychological problems of these patients may be of such s e v e r i t y that they cannot be resolved by known methods of psy-c h i a t r i c therapy. The stresses of these patients can be eased, although not resolved, i n making an adjustment to l i f e , by manipulation of environment to help them f e e l more comfortable i n t h e i r adaptation, and by the warm support, encouragement, and a c t i v e i n t e r e s t of a s o c i a l worker. The discharged mental patient who i s imrardly weakened or handicapped i n h i s a b i l i t y to meet the exigencies of his s i t u a t i o n , needs - and u s u a l l y looks f o r - help i n meeting the inner and outer stresses involved i n maintaining himself, such as i n se-curing accommodation, or obtaining f i n a n c i a l assistance, u n t i l he can become self-supporting and able to l i v e independently i n the present complex society. The Community Side of the Picture The return of these patients to the community i s s e t t i n g up a new stress s i t u a t i o n both f o r society and s o c i a l agencies: One which w i l l - 12 -require a significant change on the part of the staffs of social agencies and, equally, on the part of citizens. What does the return of the person with a chronic defect of per-sonality functioning mean to his family? What will he mean to his fellow workers.on the job, to rail-warmers in the neighbourhood bar, to members of the bowling team, to the general practitioner who prescribes for his belly-ache, to the surgeon who removes his appendix, to the nurse who looks after him in the general hospital? What does he represent to the policeman on the corner, to the traffic engineer? How will he appear to the booking sergeant, the police reporter, the judge and the jury? Because of his defects, the discharged patient will be a recurring burden to his family, his friends, his work mates, the social agencies and their professional staff. If these and other units of his society refuse to accept him, and adapt themselves to his peculiarities and weaknesses, then he will not be able to get well. He will probably be forced to return to the hospital. Hence any mental health rehabilitation program must complement efforts which deal with the patient's own response patterns with those de-signed to change the patient's environment in such a way as to meet him halfway. This two-way process of rehabilitation, that of modifying the patient and modifying the environment, has been adopted by the Sustaining Clinic at the Mental Health Centre. The Mental Health Centre Admissions rates to Crease Clinic and the Provincial Mental Hospital climbed steadily during the 1950's. Voluntary admissions now total one-third of all admissions. Treatment services have been strained to keep pace with - 1 3 -public demand, yet more and more patients are being returned to the commu-nity. The mentally-ill person is expected back in his place in the family and community in a relatively short period. At the same time the lot of the person who is sick a long time has changed. He enjoys more freedom on open wards, provision is made for a more rounded life with work assignments balanced with social activities, and community interest is shown by volun-teer workers of the Canadian Mental Health Association. Thus, by 1956» the time was ripe to develop a service totally at the voluntary level which could offer treatment without interruption of family life, sometimes without interruption of work. 1 The Mental Health Centre opened January 2 , 1 9 5 7 . It consists of an Adult Clinic and a Children's Clinic (formerly the Child Guidance Clinic). The service offered by the Adult Clinic is a new one, aimed at treating emotionally disturbed adults in the early stage of their illness, and thereby preventing their admission to a mental hospital for complete twenty-four hour care. Another function is the after-care of certain patients under treatment in other Mental Health Service settings. The Mental Health Centre serves two main functions - namely, consultation, and treatment. Two treatment services are offered - a day hos-pital service with a capacity of thirty patients with current staff, and an outpatient treatment service for a capacity of 140 - 1 6 0 patients. The con-sultative service is valuable both as a method of assessing patients for treatment and as a general service to the community, where many agencies The Mental Health Centre is located at the corner of Willingdon Avenue and the Grandview-Douglas Highway in Burnaby. - 14 -look for consultation and c o l l a b o r a t i o n with respect to the management of s i c k people who do not come within the scope of the Centre. The o v e r a l l aim of treatment offered to the patients at the Mental Health Centre i s the r e l i e f of anxiety and increase i n self-understanding. Since patients come v o l u n t a r i l y to the Centre by r e f e r r a l of a physician, they are u s u a l l y mo-t i v a t e d to want and accept help. During t h e i r care they are encouraged to p a r t i c i p a t e i n planning f o r t h e i r own treatment and to take increasing r e s -p o n s i b i l i t y f o r carrying i t out. The foremost categories of patient service may be defined as follows: 1. Intensive service - two hours or more of s t a f f time each week. 2. B r i e f regular service - one hour a week f o r a period not longer than two months. 3 . Prolonged regular service - one to three hours a month f o r a period i n excess of two months. 4. Minimal service - b r i e f contact of once monthly with addition of f i r s t a i d i n times of c r i s i s . The therapies o f f e r e d to the patient are f o u r f o l d . 1. Psychotherapy - This includes i n d i v i d u a l and group psychotherapy and s o c i a l casework. 2. M i l i e u therapy - This i s the most important feature of the day h o s p i t a l . 3 . Physical therapies - These include o r a l medication, intravenous l a r g a c t i l d r i p therapy, somnolent i n s u l i n , and electro-convulsive therapy. 4. The acceptance and f r i e n d l y contacts of other patients, volunteers and s t a f f are an invaluable contribution to the patient's r e h a b i l i t a t i o n . The Adult C l i n i c day h o s p i t a l i s located on the main f l o o r and - 15 -includes a large occupational therapy room (weaving, pottery, sewing, car-pentry, l e a t h e r c r a f t , basket-weaving, e t c . ) , adjoined to a r e c r e a t i o n a l therapy room (piano, record player, shuffleboard, ping-pong, and t a b l e games). The r e c r e a t i o n a l therapy room may be subdivided to provide f o r patient meetings, or a quiet place f o r patients. In summer, croquet, v o l l e y b a l l , and badminton are a v a i l a b l e . The program i s planned by both s t a f f and patients and includes organized games, play reading, dancing, pa r t i e s and movies. The day h o s p i t a l s t a f f include two occupation-recreational t h e r a p i s t s , plus a physiotherapist (who i s also trained i n both occupational and r e c r e a t i o n a l therapy), one registered nurse who i s i n charge of the day h o s p i t a l , and f i v e p s y c h i a t r i c nurses. A l l nursing s t a f f p a r t i c i p a t e each morning i n physical treatments which are given i n the treatment block. Day h o s p i t a l patients attend everyday, Monday to Friday, from 8:30 a.m. to 4:30 p.m. The average length of stay i s f i v e weeks, and the patients are usually transferred to the Outpatient Department. Outpatients have interviews with a s o c i a l worker or a p s y c h i a t r i s t on a weekly, bi-weekly, or monthly basis depending on t h e i r needs. I f they require medication, i t i s purchased by the patient, or supplied by the Centre i f the patient cannot a f f o r d i t . Physical treatments f o r outpatients are given with day h o s p i t a l treatments. Outpatients receive treatment as long as they are able to use i t c o n s t r u c t i v e l y , usually s i x months to two years; often a spouse or other family member receives casework at the same time. A S o c i a l Club, run by patients and ex-patients as well as two s t a f f members, and f i v e volunteers from the Canadian Mental Health Association, i s - 1 6 -held every second Tuesday evening with attendance averaging from forty to sixty. Due to the lack of a professionally trained group worker, the Social Club now consists of only "drop-in" a c t i v i t i e s . Referral to the Mental Health Centre i s made via the patient's family physician or a psychiatrist. Following the i n i t i a l interviews and a diagnostic conference, a decision is made about the applicant's s u i t a b i l i t y for treatment, and the applicant i s either referred to a more suitable agency, (e.g., Family Service Agency), or accepted for treatment. The plan for treatment is made at this time. There is no charge for treatment; however, patients may be required to purchase medication, hire a housekeeper and other incidental expenses. I f a patient i s in financial straits, a social worker may arrange for social assistance or for a housekeeper while a mother i s in day hospital. Within six months after the opening of the Mental Health Centre, the Director realized that a special form of service needed to be developed to provide a sustaining form of psychiatric care for those patients who were being maintained in the community on medication, and who did not have the ego strength to develop further insight, and improve adaptation through psychotherapeutic or intensive casework services. At this time, about one-half of the patients attending the Adult Clinic had been discharged within the year from either the Provincial Mental Hospital or Crease Cl i n i c . The majority of these patients had been returned to the community as a result of successful chemotherapy. Thus in August, 1 9 5 ?» a sustaining service c l i n i c , known as the Largactil C l i n i c , was organized to meet one evening during the month, staffed - 17 -by one psychiatrist, one social worker, and one public health nurse. The plan was to have each patient seen once a month by either a psychiatrist or a social worker for a brief re-assessment, reassurance, and regulation of medication. A Social Club was organized in April, 1957» through the initiative of other patients attending the Adult Clinic and the participa-tion of the staff and volunteer members of the C. M. H. A. The Social Club and Largactil Clinic (later changed to the Sustaining Clinic) were soon scheduled on the same evening, in an effort to give the Sustaining Service patients more opportunity for social participation, with the hope that they could be maintained on a social rather than a medicinal basis. It was ag-reed that although any patient attending the Clinic might attend the Social Club, patients attending for regular interview therapy would not attend the Sustaining Clinic at the same time. A year after its establishment, the Sustaining Clinic was duplicated by the participation of a psychiatrist and a social worker from the mental hospital. Accordingly, two groups of appro-ximately twenty-five patients each were seen one evening a month on alternate Tuesdays between 6 : 0 0 p.m. and 9 : 0 0 p.m. The Sustaining Clinic is backed up by regular outpatient clinic services if they become necessary, such as aptitude testing for job place-ment, assistance in finding work or accommodation, emotional first-aid (e.g. support, reassurance, information-giving, etc.) in times of crisis, and day hospital service for psychotic relapse. Method of Study The Adult Clinic offers service to two types of individual: (l) the person living in the community who is saved from going to a mental - 18 -hospital by intensive and rapid treatment; (2) the person who, on leaving the mental hospital, has not recovered sufficiently to live a normal life, but who has received as much help as the hospital can give. The present study is concerned with the Sustaining Clinic, a service designed to aid in the rehabilitation of this latter group. In recent years in British Columbia a series of theses have been completed on social services directed to the rehabilitation of mentally-ill persons. A number of these are particularly concerned with the patient's transition from the hospital to the community. For example, "Vista", as a rehabilitation resource for women without families to return to, was sur-veyed by Sophie Birch. Currently, Mrs. Helen Jones is completing a study of the C. M. H. A. Social Centre as a social-recreational resource for the discharged patient, and Mrs. Beatrice Booth is examining foster home care for the mentally i l l . These studies are relevant to the present one in that they illustrate how different programs attempt to meet the needs of different types of discharged mental patients. At the date of writing, the Sustaining Clinic has been in opera-tion for three years, and it is reasonable to believe that this can be con-sidered a period sufficiently long to determine its contribution toward the re-establishment of the patients. In consultation with the appropriate staff, forty cases were selected for close examination, this being about the maximum number of cases that could be examined with the intensiveness that was required. The problems presented by these persons and the treatment offered to them, it can be assured, are representative of the Sustaining Service group as a whole. - 19 -The purpose of the study is to evaluate the contribution of the therapeutic team (of which the social worker is a part) toward the rehabi-litation of this difficult group of patients, most of whom require long-term follow-up care. To emphasize the focus on the appropriate type of patients, the method is (l) examining the problems of the sample group of patients, and (2) reconstructing the treatment services given to them; thus, establishing how far this meets their needs. The treatment is evaluated by comparing the patient's functioning at the time of referral with his present functioning or his functioning at the time of discharge. In an effort to describe the patient's adjustment in meaningful terms, a number of points are summed up under the headings of degree of (a) impairment, (b) emotional distress, and (c) social tension, and three rating scales for these are compiled. The unit files at the Mental Health Centre are unusually compre-hensive. Unlike the files of many multi-disciplinary agencies, all entries made by the psychiatrists, social workers, nurses, and psychologists appear on the same narrative sheet, and are arranged in chronological order. Such a record gives an integrated picture of the total treatment services offered to the patient, and the contribution made by each discipline. The psychi-atrist's contribution to the narrative sheet generally includes the findings of the physical examination, a social history obtained from the patient, the psychiatrist's comments concerning the patient's general appearance and be-haviour, his pre-occupations, complaints, and insight, as well as a diag-nosis and prognosis. The nurse records the type and amount of medication given to the patient. The social worker contributes social history - 20 -information on the patient as obtained from r e l a t i v e s and other i n t e r e s t e d persons, and a summarized account of subsequent contacts with the patient, members of the family, and other members of the h o s p i t a l treatment team. The psychologist's c o n t r i b u t i o n includes the r e s u l t s of psychometric t e s t s , including the patient's i n t e l l i g e n c e r a t i n g , aptitudes, degree of mental d e t e r i o r a t i o n and a personality evaluation. The " p r i n c i p l e t h e r a p i s t " sum-marizes a l l contacts with the patient and members of the family, and records the r e s u l t s of Progress Conferences. Results of X-rays, basal metabolism t e s t s and other laboratory t e s t s are included i n the reports of the various technicians. On the i n s i d e cover of the patient's f i l e are two basic data sheets: one giving the medical and s o c i a l information on admission, and another g i v i n g the same data at discharge. A l l correspondence r e l a t i n g to the patient i s attached to h i s f i l e . A l l t h i s material was examined f or the sample cases; and where information was lacking or ambiguous, i t was discussed with the appropriate s t a f f . CHAPTER I I THE PATIENTS AND THEIR PROBLEMS: AN ILLUSTRATIVE REVIEW The Sustaining C l i n i c could hardly be expected to deal r e a d i l y with the myriad array of s i t u a t i o n s that confront these patients i n t h e i r everyday l i v i n g . A l l the patients have had a long h i s t o r y of mental i l l -ness dating back many years p r i o r to t h e i r f i r s t h o s p i t a l i z a t i o n . They have suffered from states of anxiety and v u l n e r a b i l i t y , trtiose roots are to be found i n ea r l y childhood. They have exploited archaic mechanisms which are dormant i n every human being, i n the hope of decreasing anxiety and maintaining t h e i r own i n d i v i d u a l i t y , but mostly they have f a i l e d . They have struggled between the world of r e a l i t y and the world of symptoms. 1 Paleologic thinking as one wr i t e r has termed i t , and what can be c a l l e d " d e - s o c i a l i z a t i o n " have characterized t h e i r behaviour. They have regressed, but have not re-integrated at a lower l e v e l . They have accepted t h e i r i l l -ness, but t h e i r i l l n e s s has not accepted them. They have been placed i n a mental h o s p i t a l , and gradually t h e i r anxiety has subsided as the r e s u l t of the protected environment and the few demands placed on them. Electrotherapy and medication have repressed t h e i r symptoms. At t h i s point they succeed i n making a tenuous adjustment to r e a l i t y by decreasing t h e i r needs - sometimes to an almost unbelievable A r i e t i , Silvano, I n t e r p r e t a t i o n of Schizophrenia. Robert Brunner, New York, 1955, p. 186. - 22 -extent. They are discharged from the mental hospital and are referred to the Sustaining Clinic, hut they are not well. They do things haphazardly and half-heartedly, and cannot exploit their full potentialities. The reduction of spontaneous activity confers on them a certain awkwardness and inappropriateness. Their lack of experi-ence in dealing with people increase their fears. When they succeed in eva-ding their "schizoid" attitudes and in doing a few active things, the old sensitivity tends to come back, and tremendous anxiety is experienced. The early uncanny experiences add a particular coloring to their present expe-riences. The persons they have to deal with are, symbolically speaking, other parents, and they have never learned to deal adequately with parents. The world appears to them to be populated by millions of authorities, ready to criticize them. Symbolically, every interpersonal situation is a repro-duction of the old parent-child relationship» a compulsive attitude quite often compels them to make this reproduction more similar to the original situation than is actually required. Furthermore, in spite of their detach-2 ment, they maintain the image of themselves as the "bad child"; but to be a bad child now means to be incapable, inadequate, worthless. Their awk-wardness seems to prove to them that they are really inadequate. The com-petitive spirit of contemporary society, where everybody is supposed to assert himself or to show how good he is, makes their predicament worse. Handicapped as they are, it is no wonder that they fail. Any additional Sullivan, Harry Stack, The Interpersonal Theory of Psychiatry. W. W. Norton, New York, 1953. 2 Arieti, OP. cit.. pp. 47 - 50 . - 23 -failure increases their feelings of inadequacy and predisposes them to subsequent failures. To avoid disappointment they withdraw into a stronger armour, with more defensive mechanisms. Fantasies replace their need for action. Often when they are confronted with a situation which does require some action, they convince themselves that it is not neces-sary or xrorth while to act. A Sample Group of Patients Of the forty patients selected for assessment in this study, twenty-four were referred directly from the mental hospital to the Mental Health Centre. Of these twenty-four, sixteen were transferred directly to the Sustaining Clinic. The other sixteen patients were referred to the Mental Health Centre by their doctors. Five had never been hospitalized in a mental institution; eight had not been hospitalized within the year prior to their referral; and three had been hospitalized within the year. Out of this group of sixteen, only two were referred directly to the Sustaining Clinic. Of the forty cases studied, twenty-seven are females and thirteen, male. By marital status, twenty-four are married or had been married. The majority of the patients, twenty, are between the ages of thirty and forty; ten are between the ages of forty and fifty; nine are over fifty and one is under thirty. Thirty-three of the forty Sustaining Service patients live in primary family relationships; seventeen live with a spouse; ten live with parents; and six with a sibling or a son or daughter. Six live alone. The one woman who is employed as a domestic and living in, lives in a kind of - 24 -substitute family constellation. In regard to education, twenty-seven have completed up to grade ten or grade twelve. Ten have an education between grade seven and grade nine. Only three have an education below grade seven, and of these, two are men aged thirty-three and thirty-eight• and the other a woman aged sixty. Five have extra training: two women have completed business courses, one has a B. A., and one has taken part of a course at an Art Academy. The only man who has training beyond grade twelve is a third year university student who, because of his illness, is unable to pursue his education any further. Of the twenty-seven female cases examined, nine are married and occupied as housewives. Three are widows: one is receiving a Disabled Veteran's Allottfance, one is employed as a saleslady and doing exceptionally well, and one is receiving free accommodation from her mother and supporting herself from her savings. Three are separated: one receives $125 a month from her estranged husband and is working, usually as a saleslady; one is employed as a clerk; and one is living on Social Assistance, working only occasionally and always at unskilled jobs. The one divorced woman is employed in a photo studio. Six of the eleven unmarried women rely on Social Assistance for economic support. Two, however, were able to support themselves for a short period before going on Social Assistance, and one continues to work part-time occasionally. One of the single women is supported by her parents, but works occasionally at unskilled jobs. Of the four self-supporting single women, three have relatively stable work. One is employed as a domestic and receives the low salary of $25 a month plus room and board; one is employed as a sewer - 25 -i n a c l o t h i n g factory, i s frequently being l a i d o f f , and receives the low salary of $ 9 6 a month. Two receive s a t i s f a c t o r y s a l a r i e s ; one as a stenog-rapher and one as a s k i l l e d worker i n a school supply factory. However, as a r e s u l t of t h e i r paranoid ideas, one changes her jobs constantly while the other f i g h t s c ontinually with her co-workers. In summary, nine of the twenty-seven female patients are housewives; eight are employed; seven are unem-ployed and i n r e c e i p t of S o c i a l Assistance; two are unemployed and supported or p a r t i a l l y supported by t h e i r parents; and one i s i n r e c e i p t of a pension. Of the eight married men, f i v e are employed; none of t h e i r jobs have a high income or carry high p r e s t i g e . One i s r e t i r e d and i n r e c e i p t of an old age pension. Two are unemployed and supported or p a r t i a l l y sup-ported by t h e i r working wives. Of the f i v e single men, one i s employed as a truck d r i v e r , one i s i n r e c e i p t of a Disabled Person's Allowance, and one works occasionally at manual jobs, l i v i n g the rest of the time on Unemploy-ment Insurance and his savings. The other two s i n g l e men are unemployed and supported by t h e i r parents. Of the s i x unemployed men, only one i s uncon-cerned by h i s unemployment. The sources of economic support of the f o r t y patients are summed up as follows: f i f t e e n are employed and self-supporting, fourteen are un-employed, nine are housewives and are supported by t h e i r husbands, and two are i n r e c e i p t of pensions. Of the fourteen who are unemployed, eight are on S o c i a l Assistance, and s i x are supported or p a r t i a l l y supported by t h e i r wives or parents. The T r a n s i t i o n Problems The analysis of the diagnoses of the patients studied reveals - 26 -that twenty-nine are schizophrenic, six have depressive reactions (one in a schizoid personality); three have anxiety reactions (two in schizoid per-sonalities and one in an inadequate personality); and two are manic-depres-sives. Excluding the five who have never been hospitalized in a mental institution, the thirty-five who had, spent an average of three years there. These patients are far from "normal" if efficient day-to-day living is the practical test. In the community, a person is responsible for the scheduling of his activities, he must awaken himself, get to his meals, arrange for trans-portation to x»7ork, and be there on time. After work he provides for the use of leisure time and must judge the amount of rest he will have. In treatment as a patient, he is called in the morning, conducted to meals, scheduled for activities or work, checked on attendance and on the use of his leisure time. He has little responsibility for decision making, planning, and implementation of his ideas. He is assigned to groups. Participation is voluntary only within narrow limits; he is expected to participate be-cause it is a part of treatment, not because he feels it is his right or social obligation. When he goes and where he goes is noted and reported by nurses and aides. Even his presence in bed is checked at regular intervals. The longer the patient remains in a mental hospital the more indoctrined he becomes with these institutional habits, and the more imbued he becomes with following a simple regime instead of thinking for himself. However, this constant supervision cannot be carried on into the community life of the patient. A long period of hospitalization thus presents many problems to the - 27 -patient upon discharge. He must not only perfect skills that have fallen into disuse, but he must learn new ones. He must also discontinue prac-ticing many of the habits and way of thinking acquired while in the hospi-tal. Personal Behaviour The problems faced, though they are not necessarily verbalized or even realized by the Sustaining Service patients, fall into three areas: 1. Relationships with others - Co-operation and sharing with authority figures; co-operation and sharing with peers; acceptance by others; and ability to take responsibility. 2. Attitudes toward self - Self confidence; insight; and health attitudes. 3. Personal behaviour - Speech and conversation; eating habits; personal cleanliness; dress and personal appearance; money or budgeting; work habits; and use of leisure time. The area of personal behaviour looms large as a problem because it is here that the person's incompetence arouses the strongest feelings of anger and frustration in other people. Much of these patients' personal behaviour follows no set pattern, thus interfering with the routine estab-lished by family or social structure. For example, Catharine's mother reports that: Catharine does not get up until some time between 10:00 a.m. and 1:00 p.m. She is s t i l l uncommunica-tive with her mother and cannot be depended on to carry out routine household duties. However, when she feels like it she will do a bit of work. Cat-harine's stepfather has said either he or she will have to leave if her present behaviour continues. Many of the patients present an appearance which the layman would - 28 -dub "feebleminded", and which is a clear, outxfard sign of mental illness. The vacant stare, the silly grin, the slow movements, characterize these people. In a society where physical attractiveness is highly esteemed, careless, untidy persons are at a disadvantage. They are seldom sought out as friends, and are eliminated as a potential means of gaining prestige and popularity. Because casualness or downright sloppiness is perhaps more acceptable in men, it is the untidy, carelessly groomed woman who most suffers the pangs of unpopularity and ridicule. Accordingly personal ap-pearance is one of the means by which the patient's adjustment can be measured. Time and time again the therapist will note either, that the patient is neatly groomed and appropriately dressed - a sign of improve-ment - or else unkempt, disheveled and peculiarly attired, a sign that he 1 or she is "slipping". For example, when Miss O'Connor , a fifty-year old single lady, began attending the Sustaining Clinic, she would usually arrive with no make-up on, her hair uncombed, and wearing a grubby cotton house-dress. Granted this lady had little money; yet eighteen months after the initial contact, her appearance had improved immensely. She began to wear a bit of lipstick which brightened her pale, drawn face, her hair was neatly done, and her clothes though not expensive were clean and more appropriate to the occasion than the cotton house-dress. Unfortunately, Miss O'Connor s t i l l retains many residual schizophrenic symptoms and her twelve years of hospitalization show in her vacant stare, in her slow deliberate movements, and in her lack of spontaneity in action and expression. Miss Lake, a thirty-year old woman, is a similar example. She has an This name and all others that appear in this study are fictitious. - 2 9 -income sufficient to permit her to buy attractive clothes. However, her combinations are most unflattering. Miss Lake: tends to be indifferent in her personal grooming -tousled hair, dirty nails, dirty clothes. She is prone to ruffles, bows, pleated skirts, and costume jewellery, and it is a bit overpowering when one of her outfits has a l l of these attributes. Her standard footwear is a pair of high heeled shoes worn with white ankle socks. Added to this she has a silly grin and a withdrawn "nothingless" manner which is immediately associated with mental illness, and which discourages people from trying to make social contact with her. The leisure time pursuits of these patients are stereotyped and demand littl e emotional involvement. Because of their feelings of inferi-ority and fear of failure, the patients tend to be spectators of, rather than participants in, social activities. Because of the poverty of their relationships, their spare-time activities are generally solitary ones. Sarah Stone's use of her leisure time typifies the restricted nature of these patients' activities: Sarah Stone is quiet and restrained in her verba-lizations. She s t i l l remains inappropriate in her affect, a residual schizophrenic feature which she will no doubt always have. She lives a very res-tricted existence with her mother, going out to shop for food about three times a week, and the odd time going to $1.49 Day. In the evenings she spends her time watching television. About once a month she goes to a movie. Many of the problems of these patients are manifested in their work habits: problems with authority figures, relationships with peers, lack of vocational skills, passive-aggressive tendencies, and lack of con-fidence. None of the forty patients hold high-paying jobs. None are pro-fessional people; and only one is self-employed. All hold jobs that carry - 30 -relatively low prestige. Their income is low or barely subsistent. The social status and standard of living of the married female patient is de-pendent on her husband's occupation, and is, therefore, usually higher than the single female patient or the male patient. But even here the income and standard of living fall below the average. One might speculate on the effect of the wife's illness on the husband's occupation and income, as it could quite conceivably adversely affect the husband's work. Because of the patient's narcissism, lack of satisfactory personal relations and low frustration tolerance, he is generally disturbed in rela-tion to his work situation. He lacks the powers of concentration required for sustained effort, is over-sensitive to criticism and unable to accept rules and routine, expects praise and recognition out of a l l proportion, and blocks on learning new skills. In relation to the learning process, the patient fails to judge what is relevant, fails to identify due to his poor development of object relations and is unable (because he is unwilling) to foresee the consequences of his behaviour. As a result, he relies heavily upon denial and an avoidance of involvement, and feels insecure, sensitive, anxious, and full of grievances. Mr. Rogers is an example of the type of patient who is unable to stick to his job because of his low frustration tolerance level and his ina-bility to accept rules and routine. This case also illustrates the rever-sal or roles that takes place \tfithin the family, with the patient assuming the expressive role, and his wife, the instrumental role. Mr. Rogers is a fifty-two year old married man with a diagnosis of chronic schizophrenia and post-lobotomy syndrome. He is a former executive - 31 -of a large business concern. Since his first hospitalization in 195- the family's standard of living has dropped considerably. His wife and two teen-age children have adapted to the unfortunate change in circumstances rather gracefully. Mrs. Rogers has obtained a job as a receptionist and enjoys her work. Mr. Rogers works only occasionally and has gradually assumed responsibility for the housework. One evening at the Centre, Mr. Rogers in-formed the social worker that he had quit his job as a nigh watchman at an appliance warehouse, a position he had held for exactly one month. He rationalized his termination of employment by saying that he could not sleep during the day, that he was becoming anxious and irritable, that he was upsetting the family routine by the awkward hours he worked, and that he found the long nights exceedingly boring and lonely. Mr. Rogers is concerned about his employment, but has shown himself to be incapable of holding down the types of jobs he can get. At the same time he is aware of the fact that he will never be able to maintain a managerial type of job such as he had before his first hospitalization. These patients' seriously impaired ability for work, play, and love is often the result of inferiority feelings. The isolation and suffering caused by the sense of inferiority is based (usually) upon fancied defects, or upon the emotional reactions to defects which of themselves are not isolating. This is one of the most important, most frequent and most serious of all factors in the personality make-up of these patients. The Feelings of Inferiority From the time when the first person shivered in fear before the threatening forces of nature and compared his puniness with the incalculable power of the universe, man has been subject to disagreeable sensations de-pendent upon his awareness of the discrepancy between his fantasy of power and his relative helplessness in the hands of natural forces. Having - 32 -reconciled himself to this with the aid of various devices - religions, philosophies, inventions, regional conquests over nature, and the l i k e -he encounters the same discomfort i n comparing himself with other men, stronger, quicker, or more astute than himself. This i s especially true of the tiny infant and the growing child, who perceive parents as omnipotent gods, toward whom inferiority feelings f i r s t develop. Later this may be assuaged by compensations of dependency and by the growth process i t s e l f , and, depending on the family security, i t may be the brothers and sisters who then excite envy by comparison. Or he may grow up to be mature and reasonably self-confident. Ideally the results of such comparisons with one's fellow-beings are an intellectual adjustment of one's given powers to one's given tasks in the most productive way possible with a minimum of dissatisfaction. But in actuality, the occasional surrender to painful fantasies of relative i n -competence and weakness probably replace productiveness to a lesser or greater extent i n everyone. I t is easy to see how-these arise from envy» and from the omnipotent ambitions of infancy; but realizing these things does not make anyone totally immune from them. The expressions " i n f e r i o r i t y feelings" coined by psychiatrists, social xrorkers and psychologists during the past few decades are seized upon as technical designations dignifying any unworthy and disquieting emotion they are supposed to describe, and i n -dicating i t as a unique phenomenon in the self-diagnosed individual (and perhaps a few others). The fact i s everyone i s inferior i n some sense. The mature or sensible person is aware of this, without pain or handicap. He has developed "positives" i n his own individuality. - 33 -It is,therefore, no distinction and no credit to one to recognize one's inferiority feelings. To pity oneself because one lacks something that someone else has is an unflattering way of viewing the situation. The clinical fact is that whether they proclaim it proudly or deny it vigo-rously, the patients attending the Sustaining Clinic do suffer constantly and sometimes acutely with feelings of inadequacy, diffidence, self-dissatis-faction, so-called hypersensitiveness, and a pervading discouragement because of such feelings. To call these merely "a sense of inferiority" is not enough. They should be called an illusion or an alibi of inferiority; they may disguise envy, hate, guilt feelings, and other emotions which in turn arise from fundamental misconceptions and self-mismanagement. Their feelings of inferiority consciously center on comparisons of themselves with other individuals. Usually these comparisons are ori-ginally of tangible, visible things - that is, physique, intelligence, and popularity. As a child, the typical patient probably compared himself, his little body, his physical equipment, with that of his omnipresent and omni-potent parents; later, also, with siblings and playmates. Necessarily he is constantly aware of discrepancies in size, in height and weight, in strength. His obvious inferiorities are associated with his obvious depen-dency and subservience. Since what Father and Mother say "goes", he is early taught without xrords that "might makes right". These primary feelings of inferiority are ordinarily submerged in oblivion in the majority of persons. They usually become completely uncon-scious. But in these patients the childish anxieties are revived, and add to their intensity a few years later by unfavourable comparisons made by - 34 -someone in authority: "John is not so bright as his sister", remarks his mother to a visitor. "George is unusually awkward and clumsy for his age." "Daughter, it's a good thing you're smart in school, because you certainly are the homeliest child on earth." Such comments are deadly. They often crush the child's hopes, efforts and self-respect completely. They rarely stimulate, because the authority of their source makes them incontrovertible. Peter Owens' reaction to his parents1 unfavorable comparisons of himself with other individuals is typical: Mr. Owens, a thirty-one year old single man, was referred to the Mental Health Centre by his physician in 195-• ne had been hospitalized twice in Crease Clinic for a total period of seven months. His last hospitalization was three years prior to his referral. At the time of referral, Mr. Owens' chief complaints were those of inner depression, a general feeling of uselessness, and physical complaints such as weight loss, poor appetite and insomnia. He was in a highly dependent yet pressured position in his family as the hand maid of an aged and dominant grandfather. Three years later the social worker reported that Mr. Owens' situation was virtually unchanged. Peter Owen continues to live at home with his parents, and while apparently needing this dependent relationship feels very sensitive about it . Each day he goes downtoxm and wanders about, primarily as a means of being able to feel that he is doing something. He has overcompensated for his homely appearance by always being immacu-lately dressed and well-groomed. Tonight he re-vealed in some detail the sense of helplessness he feels at being unemployed, being supported by his family and so on. His maternal grandfather was a very successful business tycoon and his mother con-tinually reminds him of this vxith statements like, "Your grandfather never had anything to begin with, he really had to work to get what he got. And he made lots of ^ noney and was a big success ... Peter, - 35 -you have been given every opportunity to get ahead, and look at you, you're no place." It is little wonder Peter feels inferior. He is coming much closer to being able to bring out many of his own feelings and concerns, especially in the sense of wanting to receive support and reassurance around them. He is very hostile toward his parents and deceased grandfather, but learned at an early age to control the expression of these aggressive feelings. This man's problems revolve around emancipation and employment. His inferi-ority feelings stem from the unfavorable comparisons made between his grandfather's and his father's intellectual and professional attainments and his own rather average endowments. He has such tremendous feelings of inferiority that he is afraid of gaining employment for fear he will not succeed. He is very shakey in the masculine role. A failure in the job si-tuation would reinforce Mr. Owens' conception of himself as an inadequate person. There are other, less obvious ways in which the parents have built up inferiority feelings in these patients. One is by constantly exhibiting their own inferiority feelings. Some parents are incessantly complaining of their misfortunes, comparing their acquisitions and opportunities with those of their neighbours, voicing their enviousness and unhappiness and disappointments. They may go further and berate themselves, or they may scowl and sneer at their envied friends. More frequently they complain that their neighbours dislike them, that their friends have lost interest in them, do not return their social overtures, do not appreciate their ef-forts. Still other parents of these patients excite inferiority in their - 36 -children by delinquencies. The child feels much more keenly than his parents the social disapprobation which they incur. An alcoholic father or a divorced mother may serve as a burden of bitterness to the children throughout their lives. "I have always f e l t as i f I must apologize for my father," remarked one female patient. Finally there are certain physical conditions of which no one needs to speak - nor can the organic inferiority remain unknown to the pa-tient. He knows because he can see himself in the eyes of strangers; he knows because the cruel taunts of the l i t t l e animals about him - glad to find someone their inferior and someone to torture - w i l l not l e t him for-get. This group includes speech defects, birth-marks on the face, dental deformities, crippled limbs, deformed bodies, cleft palate and hare-lip. So obvious are these things and so disfiguring that they permit of l i t t l e real protection from exceedingly great mental pain. Miss Tanya Beriosova, a striking looking thirty-five year old woman i s an example of this: She is a shy person with something of a Slavic accent. She suffered from c l e f t palate a l l her childhood and teen years and had i t corrected only at eighteen. Her inferiority feelings o r i -ginated from this defect. She was intensely sen-sitive about her speech, and about the laughing and teasing of other children. She talks of simi-la r sorts of feelings at work, the cruel jokes of fellow employees and so on. She feels treatment has helped her overcome some of this sensitivity, although she i s timorous about the future. The Dynamic History The history of these patients reveals that in childhood their an-xiety was of such tremendous intensity that no sufficient self-esteem and sense of self-identity could be built and that certain trends of - 37 -psychological development prevailed over others. Although it was the mother who contributed most in producing their maladjusted condition, usually both parents failed them, often for different reasons. Frequently the combina-tion was as follows: A domineering, nagging and hostile mother, who gave the patient no chance to assert himself, was married to a dependent, weak man, too weak to help the child. A father who did not dare protect the child because of the fear of losing his wife's sexual favors, or simply because he was not able to oppose her strong personality, was just as crippling to the patient as the mother was. Occurring less frequently was the opposite com-bination: A tyrannical father was married to a weak mother, who had solved her problems by unconditionally accepting her husband's rules. These rules did not allow her to give enough love to the child. At times, one parent died or was away because of divorce, separation, war, etc., and the child was completely at the mercy of the destructive parent, generally the mother. The history of Mr. McLeod illustrates the type of home situation to which many of these patients were exposed: William McLeod was horn in Glasgow, Scotland in 192-, and was brought up under very poor family circumstances. He was the third of seven boysi The father was an irresponsible alcoholic who did not show much concern for his wife or his sons. The mother was an overprotective, controlling woman who wallowed in self-pity, forever complain-ing of her plight. She only loved the patient when he was better than the other children in the neighbourhood. She imbued him with ambition and a fear of failure by constantly telling him that when he grew up he would have to be successful and rescue his "poor mother". She early instilled in him a feeling that the family was deprived and inferior. She taught him to compare himself un-favourably with others. William went to school until he was fourteen - 38 -and was apparently the best in his class. He has many mental conflicts about being brought up in the slum district. Whenever he looked out the window he would see drunks and bums on the street. Consequently, he has always been afraid of gangs and fights. Due to his mother's nagging and com-plaining, William early decided that he wanted to make something of himself. However, at the age of fourteen, he and an older brother beat up their father, who was attacking their mother, and threw him out of the house. The father was not seen after this, and William had to quit school and go to work to support the family. He worked at various unskilled jobs, and joined the Navy when he was eighteen. As can be seen, in these very unhealthy home atmospheres, a state of intense relatedness exists between the pre-psychotic patient and his parents, especially the mother. The child is actually overwhelmed with feel-ings, but this relatedness, these feelings, are extremely anxiety-provoking and destructive. Although it is true that the disturbance originates on account of the patient's personality, it soon becomes more complicated or a two-way stream. The patient, who at this period (from the end of the first to the end of the fifth year of life) is intensely emotional and often overactive in his behaviour, causes out-of-proportion anxiety to the already over-anxious parent. The parent expresses her anxiety in the form of hostility toward the child, who will then be more adversely affected. He will respond with behaviour which will be even more objectionable to the parent. Furthermore, the mother often feels guilty for her hostility and this guilt-feeling in-creases her anxiety. A circular process of ominously vast proportions thus originates. Because of the intensity of these experiences, the pre-psychotic - 39 -patient finds d i f f i c u l t y i n organizing effective defenses. It is his awkwardness in developing these defenses which i s often a prelude to the later psychotic disorder. The patient growing in an atmosphere of expo-1 sure to anxiety tries nevertheless to preserve the good image of the parent. In the majority of cases the good image of the parent cannot be preserved. In such instances, the patient remains to an extent conscious of the bad qualities of his parents. Even he, however, represses in large measure their worst characteristics. In the majority of cases the child represses the fact that he was hated, falsely accused or the innocent tar-get of h o s t i l i t y . He remains, nevertheless, with the feeling that the pa-rents are bad, and he harbours hostile thoughts of them. At the same time he thinks he should love them and therefore he feels guilty. Often he a l -ternates in believing in his own values and in those of his parents. When he prefers his own he feels guilty; i f , on the other hand, he follows the orders and values of his parents he feels crushed, victimized, compelled to surrender. Mr. McLeod1 s constant conflict about x-xhether to remain the "good" child and do as his mother wished, or to assert himself and risk losing her love, i s an il l u s t r a t i o n of this. After the war William Mcleod l e f t the Navy, and at his mother's insistence returned home to li v e with her. From the age of twenty-one to twenty-seven he xtforked during the day and went to night school. He found i t very d i f f i c u l t to study be-cause of the poor home environment. The mother, on the one hand, encouraged him to study, and, on the other, berated him for the poor wage he x^ as earning. A r i e t i , OP. c i t . . pp. 48 - 56. - 40 -At the age of twenty-seven, William broke away from his mother and emigrated to Canada. However, two years later she' joined him, and urged him to obtain his senior matriculation and enter univer-sity. He did this, only to realize that, after having spent years struggling to better himself, he had no goals of his own. Often the child is afraid that people can read his thoughts, see his hostility for his parents and will punish him. Even normal young chil-dren have the feeling that adults know their thoughts or "steal their thoughts". In pre-psychotic children, this impression is enhanced by their fear that the parents may know the feelings of hostility they harbour for them. Since the child is in constant expectancy of disapproval, and tries desperately to anticipate possibilities of disapproval in the futile attempt to avoid them, he becomes very sensitive to the slightest sign of the oncoming reproach. This sensitivity to disapproval persists until it is covered by other defenses. The patient is never able to tolerate even minor frustrations, because frustrations mean disapproval from other human beings. Like other children, the pre-psychotic patient, too, attempts to find ways of relating to others which will decrease his anxiety. Often he learns that complying, as the person with the compliant, dependent character does, or that being aggressive and hostile, like the hostile person pays. His parents may not accept either compliance or hostility. Then only by detaching himself emotionally can he avoid further attacks on his self-esteem. Furthermore, by detaching himself emotionally, i t is easier for him to tolerate his own image of the bad child and to accept the partially conscious bad images of the parents. Moreover, the hostility for them - 41 -produces less guilt feeling. Thus, very often, but not in all cases, the patient develops the character changes which are found in a person with a schizoid personality. He becomes aloof, cold, inactive. Lack of warm social contacts induces in these children a rich fantasy life, and excessive brooding about certain subjects, one of them being their own sex identity. The most common cause of this uncertainty is the fact that the child who is rejected by both parents tends also to reject both parents and, therefore, has difficulties in identifying himself vixth either one of them. Mr. McLeod's blurred masculine identification can be explained in this way: Mr. McLeod hated his father with whom he refused to identify; at the same time his conception of a masculine person is a "rough and tough type" like his father. Mr. McLeod is very ambivalent about gratifying his intense dependency needs because he feels that to be dependent is to be feminine. His dependency needs have never been satisfied because of the early responsibilities forced upon him. He has problems with authority figures. His inadequacy in the masculine role and his lack of success have reinforced his early inferiority feelings. While in the Navy, he was greatly threatened by homosexual tendencies. His first heterosexual experience was sodomy to preserve the girl's vir-ginity. He had previously practised sodomy and mutual masturbation with an older brother. In 195-» Mr. ilicLeod married a nurse who sup-ported him through his year at college. She is a cold, mothering person, five years older than himself. The marriage focuses many of the diffi-culties he has on sexual identification. He is very hostile toward his mother and his wife, both of whom are cold, controlling women. However, his hostility has never been openly expressed except in his phobia that he will choke his wife. In addition to this confusion and uncertainty about his own sex, - 42 -the pre-psychotic patient has, to an exaggerated degree, that feeling of omnipotence common even in normal children. The normal child has feelings of ominpotence and lives in a world which he thinks exists for him only; but whereas a child who has normal relations with his parents is gradually "corrected" by them with their approach to reality, because he wants to accept their reality, the pre-psychotic child cannot depend on his parents for this correction. The reality which they show him, the reality of the world, is their unpleasant reality. The patient is reluctant to give up these feelings of omnipotence; when he succeeds in losing them, to a more or less conscious degree he s t i l l has the desire to go back to them. Toget-her with this tendency toward the feeling of omnipotence, there is the ten-dency toward a unique, or very subjective outlook. The child has tendencies to use his own language, with expressions he has coined. All these tenden-cies, which are called autistic, are more or less suppressed and repressed but become conscious again during the psychosis. Mr. Mcleod's thinking i l -lustrates this feeling of omnipotence and the tendency toward a subjective outlook: Mr. McLeod has a fantasy life as rich as Walter Matty's. In childhood, he spent hours daydreaming that he was a prince and that people vied with each other to cater to his wants. In his late teens he became concerned with magical thinking and was very anxious about the possible effects of magic in card tricks. Prior to his hospitalization, William felt that the teachers and students were looking at him unduly in classes. He began to think he might be exerting some sinister influence over them. Mr. McLeod is very pre-occupied with his mental conflicts and elaborates upon them extensively. He feels he is an actor on the stage of life but he is not really aware of the part he is playing, whereas everyone else knows what role he is playing and fits - 43 -into the situation ideally. At times he has f e l t he was the centre of the universe. At other times, he does not clearly understand where reality f i t s into l i f e . He becomes pre-occupied xcLth fantasies of l i f e , and tries to explain these thoughts on what he calls a pleasure pain and experiment principle. Some of these tendencies could have been corrected at least par-t i a l l y i f the child had been exposed to some healthy influences, l i k e close relations with friends and distant relatives. Unfortunately, in many cases the personalities of the parents of pre-psychotic patients are such as not to encourage extra-family social intercourse, so that the "ingrown family" i s constituted. Compensatory interpersonal contacts are lacking, and the children are dependent for psychological development on their unfit parents, even more than children usually are dependent on parents. Poverty in Relationships It i s thus understandable why so many of the people attending the Sustaining Clinic appear aloof, detached, less emotional than the ave-rage person, less concerned and less involved. Actually, at an unconscious level many are very sensitive, but they have learned to avoid anxiety in two ways: f i r s t , by physical distance from situations which are apt to arouse anxiety and, second, by repressing emotions. This physical distance is main-tained by avoiding interpersonal relations or avoiding doing things which w i l l evoke an unpleasant reaction from other people. Often, they would like to do things, but they s t i l l remember from early childhood that action does not pay because i t provokes a storm of intense and threatening emotional responses in the surrounding adults. Anticipation of actions means a n t i c i -pation of a repetition of these emotional storms. They, therefore, become - 44 -underactive. In some cases the parents have actually encouraged them not to do things; doing nothing meant being a good child, "because" what the child did was "always bad". As a result, many patients have a deeply-rooted pessimism about the outcome of their actions. There appear to be exceptions as some seem to be relatively active. On close observation they reveal, hovjever, that they do things because they cannot resist the pressure of somebody who pushes them. This occurs not only in childhood and adolescence but even later on, when the patient has to se-lect a profession, clothes, marital partners, apartment, furniture, etc. More often than not, this pressure is exerted not directly, but in a subtle way. The patients protect themselves from this invasion with further de-tachment. These patients tend to comply in a perfunctory way. They go through the motions of the imposed act, but without being emotionally i n -volved. They prefer to do this because they have learned that this i s the best way to avoid anxiety. If they succeed in being emotionally uninvolved, their resentment and h o s t i l i t y remains deeply repressed. When they become psychotic, the resentment and the hostility may be displaced toward non-parental figures who may become the persecutors. Undue suspiciousness is one of the commonest and most serious barriers to the establishment of satisfying relationships. Paranoid i s a technical word, so apt, however, that i t has been taken over into popular speech. No other word so well describes, with implications of their mental unsoundness, such patients as the man who eternally suspects and accuses an innocent wife of i n f i d e l i t y , the student who is sure the teachers - 4 5 -discriminate against him, the merchant who suspects a plot among his com-petitors. In contrast to the healthy person, the paranoid individual is forever tortured by suspicions, doubts, fears, constructions, and resolu-tions of self-defence. • His delusions burn into his soul, and he becomes obsessed with his bitterness and plans for defence and revenge. He tries in innumerable ways to prove them or to disprove them and accumulates masses of useless data as evidence of the persecutor's intentions. Miss Tanya Beriosova, who has already been mentioned in connection with inferiority feelings, is a good example of a paranoid individual. Her undue suspicious-ness aroused the hostility of co-workers and interfered with her work per-formance. Miss Beriosova's employer, Mr. Keller, contacted the Sustaining Clinic because she was creating a disturbance at work. She felt that the other girls in the factory were making "snide remarks" concer-ning her appearance, her spinsterhood and her mental illness. At first, there was no basis for her thin-king this. However, she became so hostile and accu-sative toward her co-workers that they did begin to talk about her. This served to reinforce Tanya's paranoid thinking and she retaliated by verbal and physical combat. Mr. Keller declared her behaviour kept the place in a state of constant turmoil. The Clinic gained the impression that Mr. Keller wanted to fire Tanya but felt guilty about doing so because she is a capable worker and because he realizes she is sick. When the social worker arrived at Tanya's flat, Tanya was lying in her unmade bed wearing a filthy duster. The room was dirty and reeked of her body odor. Tanya expressed hostility toward her co-wor-kers because of their derogatory remarks about her. She had delusions that they were going to attack her, and that she should k i l l herself. The worker encouraged Tanya to admit herself to the Day Hospi-tal. After receiving some support and reassurance that she would be vjell cared for, Tanya docilely allowed herself to be taken to the Mental Health Centre. - 46 -Frequently the paranoid symptoms appear not in actual delusions but in what are called "ideas of reference"; everything that happens is interpreted by the victim as having special reference to him; an article in the newspaper, the chance words of a passer-by, the peculiar sound of an automobile horn, all of these have some special meaning related to him alone. In spite of the frequency of illness it is also true that some of the patients acquire a certain insight into their personality. From time to time they perceive the validity of their paranoid ideas. They recognize that their detachment is a very unsatisfactory solution and in-deed they are justified in feeling that way. Some reach a pseudo-solution by denying a great part of their life, but by doing so they may make that part of their life which they continue to live more awkward and unstable. Frequently their unconscious hostility and resentment increase; their emotional and social isolation are never complete enough to protect them entirely from anxiety; on the other hand, they harbour secret desires to reconnect themselves with that emotional and social life from which they have tried to detach themselves. Their lack of emotion is not due to simple repression of feelings; it is also a reaction-formation to too much sensitivity, not only to the sensitivity of the preceding intense relatedness to the parents, but also to the sensitivity which s t i l l exists at an unconscious or preconscious level. Frequently the dreams and fantasies of these patients transport them into an adventurous life, and often storms of affect. With their actions, on the other hand, these patients try to be as static as possible. - 4? -Often, if they act, they will be very impersonal and will try to avoid communication by direct contact. As already mentioned, they succeed without apparent difficulty in decreasing their needs to an almost un-believable extent. In summary, the Sustaining Clinic patients are people who have never acquired the degree of social skill they need for shifting their perspectives through taking successive culturally determined roles when they are under stress. In other words, they have not succeeded in es-tablishing themselves firmly in their culture. They do not share their anxieties, conflicts, suspicions or loneliness with others because they lack the techniques for doing so. They may be overtrained in dependence and made reaction-sensitive in the process to the approval and censure of other persons; but they have been kept so consistently on the receiving end of this relationship that they are incapable of checking on the vali-dity of their own interpretations by taking the roles of persons whose conduct frightens or puzzles them. Such patients are left in a personal crises with only the relatively inept techniques of private fantasy, furtive observation and unwarrantable inference at their disposal. The initial disorganization which develops render these socially unskilled and immature persons s t i l l more inadequate and isolated, while their increasing isolation tends in its turn to reduce yet further their opportunities for the effective per-sonal interaction upon which social adequacy must depend. Thus the pa-tients' behaviour may describe a descending spiral from comparative inad-quacy to complete ineffectuality, and sometimes to complete inaction. - 48 -Reduced to its simplest terms, the common tendency of the members of this Clinic is an inability to get along well with other people. This is almost too much simplified, because it might be applied to all of us at times, and to many criminals and "insane" all of the time. But this lack of social adaptability is of a special kind. These people sometimes appear to want to mix with the herd. Other times they obviously do not want to and they never do - successfully, at any rate. They may make ges-tures, go through the motions, even become extremists in social manoeuvres, but "the pane of glass is always there". How does this make them appear? Well, variously, according to the combination of traits and reactions. Some of them are more or less seclusive, quiet, reserved, serious-minded, unsociable, and eccentric; others are timid, shy, very fine-grained, sensitive. Still others are dull, apparently stupid, indifferent, often quite pliable; while some are stubborn, morose and grouchy, and all too frequently suspicious and envious. These are the problems of the Sustaining Clinic patients. After gaining an understanding of the patient's difficulty and its etiology, the treatment team formulates a plan of service. The mode of treatment depends upon the extent and degree to which the patient is impaired in his adapta-tion to reality, his ability to deal with people, arrange his affairs, and take consistent responsible action. The social worker as part of the professional team, brings to the solutions of the problems created by the stress and strain of mental illness and readjustment into community life, the same techniques and skills that characterize social work in general. In essence the social worker's - 49 -contribution is based upon an understanding of the dynamics of human be-haviour, upon an ability to translate this understanding as it applies to the individual patient, upon a thorough knowledge of the community resources which can be brought to bear on the patient, and upon special competence in guiding him toward maximal adjustment to his illness in the light of the limitations it imposes. The social worker's focus is on preserving and in-creasing the strengths of the patient(and family members) during this transitional phase from the hospital to the community. Unlike the psychiatrist whose function imposes upon him the obli-gation to exercise authority, the social worker can remain free from the need to prescribe to any line of action and from emotional entanglement. The social worker's approach is governed by an attempt to see the patient as a human being, to move at his own pace, and to make his own decisions toward a goal that he is helped to set for himself. Such an approach can only be carried out when it is rooted in a genuine appreciation of the intrinsic worth and dignity of the human being regardless of the stage of his illness or the degree of incapacity it produces. For the patient such an approach assumes particular significance in the light of an illness that tends to undermine his feelings of usefulness and status. This ap-proach, removing as it does the threat of control, compulsion, or censure, tends to minimize the patient's feeling of helplessness produced by the illness. It enables him to view his problem more realistically and to feel free to ask for help in its solution, convinced that he wants and needs such help and that he will not be forced into a line of action con-trary to his needs and desires. - 5 0 -Like the patient, members of his family frequently need help; help in coping with the uncertainties, deprivations, and anxieties evoked by the patient's behaviour. A r e a l i s t i c recognition of the d i f f i c u l t i e s and strains imposed by these patients, coupled with an awareness of the importance of satisfactory family relationships for the patient's well-being, place on the social worker an obligation to render such help as may be necessary to maintain the "normal" functioning of the family as a unit and the provision of a healthful milieu for the patient. CHAPTER III TREATMENT SERVICES OFFERED BY THE SUSTAINING CLINIC A person referred to the Mental Health Centre begins with an introductory interview, usually with a psychiatrist but sometimes with a social worker. The purpose of the interview is to obtain a history of the person, determine the present complaints and symptoms and assess the person's functioning and degree of impairment. Following this there is an intake conference. On the basis of an assessment, the person is assig-ned to a service which the treatment team thinks will be most beneficial for the patient. Treatment services at the Mental Health Centre include a day hospital, therapeutic interviews conducted on a weekly or bi-monthly basis, and a Sustaining Service. There are frequent progress conferences when the treatment team reviews each case and formulates future treat-ment plans including transfer to another service i f this is thought neces-sary. Accompanying most of the referrals from the Provincial Mental Hospital and Crease Clinic is a complete assessment of the patient, inclu-ding a social history, a description of the patient's illness and symptoms, a summary of the treatment given, and a prognosis which helps determine the type of service which will be most useful to the patient. Invariably the patient referred to the Sustaining Service is a severely damaged individual who is fearful of involving himself in a more _ 52 -intensive type of treatment. He is assigned to a treatment team consisting of a psychiatrist, a social worker, and a Public Health nurse. The patient v i s i t s the Mental Health Centre on a specified Tuesday each month. He i s met at the desk by the Public Health nurse, who introduces him to the other patients and to the occupational therapists and the volunteers who are i n charge of the Social Club. Later the patient i s seen by a psychiatrist or social worker for brief re-assessment, reassurance, and regulation of medi-cation. This interview usually lasts about twenty or thirty minutes. At i t s conclusion the patient receives his medication, and is free to leave or remain and participate i n the Social Club. The Sustaining Clinic applies the concept of the "principal thera-p i s t " . E ach patient i s assigned to a team. However, he is seen on a regu-lar basis by one of the members of the team, (e.g., a psychiatrist or a social xrorker). If the patient i s being seen by a social worker and problems arise concerning medication, he is referred to the psychiatrist. On the other hand, i f the patient seen regularly by the psychiatrist complains of tension in the home or some other social problem, he is referred to the social worker. The Two Forms of Casework Treatment The social worker as part of the professional team, brings to the solutions of the problems created by the stress and strain of mental illness and readjustment into community l i f e , the same techniques and s k i l l s that 1 characterize social work in general. According to Florence Hollis, there Hollis , Florence, "Personality Diagnosis in Casework," Ego Psy-chology and Dynamic Casework. Parad, Howard, editor, Family Service Associ-ation of America, New York, 1958, p. 84. - 5 3 -are only two major forms of casework treatment: supportive treatment and the development of self-awareness. Her definition of the former is "treat-ment that aims to improve the ego's functioning of the person without sub-stantial increase in the ego's understanding of previously hidden aspects of the self." She defines the development of self-awareness as "treatment that holds as a major aim the improvement of the individual's functioning by seeking to better the ego's direction of behaviour through enabling the ego to gain more accurate and more complete understanding of previously hidden aspects of the individual's own feelings and behaviour." 1 Florence Hollis believes that both these forms of treatment have the aim of improving the individual's functioning. She thinks social wor-kers have confused themselves quite unnecessarily in the past by pretending that supportive treatment did not have the aim of improving adaptive pat-terns, but rather was concerned only with maintaining current adaptive patterns. She is convinced that considerably improvement in adaptive pat-terns occurs as the result of using purely supportive measures. It might be added that social workers tend to confuse themselves by trying to define certain types of casework, particularly "insight development", as those that bring about so-called "basic changes" in the personality. It x«rould be more fruitful to describe the nature of the change the social worker is seeking and the means by which he seeks to obtain i t . In supportive treatment the change sought is one that may occur either without the client's awareness of change in functioning, as such, or with his better evaluation of the reality situation but without substantial increase in his knowledge of himself. The improved functioning is brought about by environmental changes, by the effects of catharsis, by the in-fluence of an encouraging, anxiety-relieving relationship with a caseworker, and by better perception of external reality. At the Sustaining Clinic, the joint aim of the social xrorker and the psychiatrist is to help the patient develop by dealing with everyday realities, by being a steady available support in cases of stress. Insight serves mainly as a means of emotional contact. It should be added that insight, by removing some areas of resistance, can aid in the forward move-ment of these patients, but in general i t serves mainly as a means of rela-tionship rather than a tool of understanding for the patient. In some cases, it must be realized, insight could have an adverse effect on the patient by undermining some of the defensive aspects of his symptoms. Because of their immaturity and narcissism, these patients are reluctant to accept responsi-bility for their acts. In many cases, they are poorly motivated in their wish to change. Acting on the pleasure principle, and employing concepts of omnipotence and denial, some are not pushed to adapt to reality. The point about motivation which should be stressed is that a per-son, to benefit successfully from treatment, should have an appreciable abi-lity to see that in a fundamental sense his problem is of his own making. If the defense of externalizing (projecting) is too strongly entrenched, the patient may be inaccessible to insight about his needs and attendant conflicts. In other xrords, the therapist must keep in mind the psychoanaly-tic principle that emotional problems arise from an inner struggle and not because of an environmental situation, though the latter may have a preci-pitating effect. Motivation, therefore, has to do both x^ ith the patient's - 55 -willingness to accept help and with his ability to see the forces that operate within himself as the cause of his anxieties and difficulties in relationships. One of the most salient features in the treatment of these patients is concerned with the re-education of the patient, in the sense of helping him adopt patterns of behaviour that will improve his social functioning. With the chronic semi-psychotic, readjustment appears to be best achieved through his deliberate application of way and means of behaving that have been given to him by a constructive, accepting person, rather than the in-dividual arriving at a more mature level of functioning in response to emo-tional growth from within himself. This readjustment in itself promotes further growth. A comparison may be made between the treatment of the neurotic patient and the psychotic: With the former, the therapist reaches the patient through open recognition and acceptance of his feelings, while with the psychotic, a deliberately educative approach is seen as being ef-fective once a good relationship has been established. The relationship between the worker and the patient is the main method of developing and strengthening the impaired capacity for feelings for others. Through identification with the worker, dealing with the "meat and potatoes" of everyday living, the patient can develop new identifica-tions. He can gradually accept controls and attitudes more appropriate to reality. The patient's aptitudes and potentialities must be carefully as-sessed so that realistic goals may be reached. A major requirement of these patients is their need for a steady, constant relationship over a long period of time. Ego growth and integration requires time, as it does in - 56 -normal development. Many of these patients, because of their d i f f i c u l t y i n forming relationships, are not ideally suited for insight therapy. However, insight can often be given to the patient by confronting him with a particular reality situation; the therapist may point out how the patient failed to cope with i t adequately - whether the failure was a' result of conflict of needs or ina b i l i t y to understand reality. In short, confrontation may serve the purpose of c l a r i f i c a t i o n and of showing how emotional d i f f i c u l t i e s occur. Most of these patients require what might be called "developmental therapy" - a therapy of relationship. It i s in this area, where the need is great and other resources for help are meager, that the social worker with a psychoanalytic orientation has a great deal to contribute in a de-cisive fashion. But in the end, the therapist's best tool for successful treatment of these patients i s persistence. The Process of Treatment: A Case Illustration Though no one single form of treatment i s espoused by the Sus-taining Clinic teams, an examination of the records reveals the pattern of treatment that i s being developed. This has been reconstructed from the sample group experience; and is illustrated by a typical case. The f i r s t stage of treatment is the establishment of a strong  relationship. This stage takes considerably longer with these patients than with other people, because the patient, rather than having had satis-factory relationships, has had experience of a negative nature. He expects - 57 -1 rejection and misunderstanding and tends to cast the social worker in the negative role. For this reason during the i n i t i a l period, establishing a contact with the patient is more important than gathering specific h i s t o r i -cal data. Always the aim i s to prevent the patient from relapsing into a psychosis. In the following case, i t took the social worker fifteen months to form a working relationship with the patient, Mrs. Foster. Mrs. Foster was referred to the Mental Health Centre by her private physician in August, 1957. She has been hospitalized twice for a total period of six months, her last hospitalization was three years ago. She has a diagnosis of schi-zophrenia and lacks self-reliance. Mrs. Foster was born in 192-. She i s a t a l l , slim, plain-looking woman with greying hair. Her appearance and manner are inconspicuous. At the time of her referral, she was separated from her husband, fifteen years her senior, and an alcoholic. She was lonely, uneasy in her social relationships, discontented with her job., and anxious over the responsibility of supporting herself and her son. On the recommendation of a psychiatrist and a social worker, Mrs. Foster was assig-ned to the Sustaining Service where she i s seen on a monthly basis. The tone of the early interviews was as follows: For the f i r s t fifteen months, Mrs. Foster was pleasant but superficial during the interviews. Most of them were spent complaining about her job and her many responsibilities. She worried about everything: the quality and quantity of her work, the care she was giving her son, the thought of becoming unemployed or sick. She had In this section, the term 'social worker' w i l l be used instead of 1 therapist 1. - 58 -no insight into the fact that her anxiety arose from her need to feel secure. She was hostile to the world in general because of her fear that something unfortunate would befall her. At one point, when anticipating a job pro-motion (she is employed as a clerk) she became very anxious and sought reassurance from the so-cial worker that she could assume this new, more diversified job involving more responsibility. Allowing her to ventilate her anxiety and reas-suring her that she could do the job relieved her and bolstered her confidence. The social worker must avoid being case in the role of the "bad" parent (i.e., being either too restricting or too indulgent). This is par-ticularly difficult with this type of patient because he continually attempts to recreate in all interpersonal relationships suitable structures by which to maintain his defensive behaviour. Therapy has to break into this pat-tern through the use of a constructive relationship that does not repeat the client's past experiences. Mrs. Foster's overwhelming need to feel secure was partly met by regular, monthly contacts with one therapist who listened sympathetically to her complaints and gave her gifts (i.e., medica-tion). It is often difficult for the worker to respond positively to the personality of these patients, which have many unattractive assets. The social i-rorker's great difficulty with Mrs. Foster was in accepting her, in spite of her great dependency needs (she could do nothing on her own), and her many illegitimate complaints. The volley of feeling which the patient levels at the worker may touch off the latter's own anxieties, and make it difficult to maintain objectivity. The indifferent or destructive treatment accorded to the patient's family often adds to the worker's problem of remaining objective. To help combat the onslaught on his own personality, - 59 -the worker needs to have a high degree of self-awareness so that he knows what i s operating in the relationship. Typically, the patients are particularly sensitive to the a t t i -tudes of others. Because they expect rejection, the social worker needs to continually communicate consideration and concern. He may need to take active steps in reaching out to the patient, such as following up missed appointments as in the case of Mrs. Foster, or making a home v i s i t to the patient i f he is i l l . Some f a c i l i t y in using the patient's "lingo" i s usually helpful. In the main, the social worker's activity takes the form of demonstrating attitudes rather than verbalizing that the patient has a problem within himself which the worker wants to help him with. To such a patient any focussing on personal problems at this point may be inter-preted by him as rejection. Discussion is in the main centered on tangible, everyday crises. This is well illustrated by the Foster case. In January, 1958. Mrs. Foster was very upset because, as the result of her husband's unemploy-ment, she had to assume support of her son without his aid. Thus, the interview x-ias spent discussing budgeting and cheaper rent. In March, 1958. Mrs. Foster reported that the sister who was looking after her daughter was sick, and that she might have to begin caring for her daughter, also. Foster home care for the daughter was discussed as Mrs. Foster was unable at that point to assume any more responsibility. She was encouraged to contact the Centre i f any c r i s i s arose. One phase of the social worker's activity deals with the patient's fears of revealing himself. His expressions of guilt about inadequacy need to be met, not by denial that i t exists but by recognition that these feelings are hard on the patient. The patient may test the social worker - 6o -during this period by apparent digressions about someone else's problem. Once he is sure of the worker's attitude, he may feel secure enough to re-veal himself. If he i s s t i l l too fearful to trust his way of relating to the worker, i t w i l l be characteristic of his manner of relating generally, and w i l l in i t s e l f provide significant diagnostic material. By November, 195°> Mrs. Foster had sufficient trust i n the social worker that when an emotional c r i s i s arose in her personal l i f e , she sought his aid. Mrs. Foster requested this special interview because she f e l t depressed, lonely, and had lost control of her emotions because her "boyfriend" of three years had j i l t e d her. At the beginning of the interview she poured out her feelings of loss and loneliness. Later, she related this present episode to incidents i n her childhood when she had been rejected or abandoned. At this point she recognized that the present rejection only partly explained her anxiety and loneliness: she realized the problem was an internal one and she requested help with i t . The second stage i s seen as the period of imitation and i d e n t i f i -cation. It i s at this stage particularly that the worker assumes the parent role and may need to continue reaching out to the patient i n a variety of ways. In some cases including the Foster one, the patient i s able gradually to move from complaining about his situation to permitting the worker to know more f u l l y his feelings, attitudes and behaviour. In March, 1959, a special interview was precipitated by the fact that Mrs. Foster's boss c r i -ticized her in front of her co-x«rorkers: Mrs. Foster complained bitterl y about her boss and asked for a letter stating that for medical reasons she should be transferred to another department. The social worker refused to do this, but encouraged her to express her feelings about being c r i t i c i z e d . Mrs. Foster poured forth her feelings, and i t became - 61 -apparent that she had a need to be constantly praised in order to maintain her confidence, that she associated criticism with rejection, and that she was unable to defend herself against criticism for fear of precipitating greater retaliation. Another incident a few months later illustrates Mrs. Foster's progress: Mrs. Foster reported that her sister wanted to adopt her daughter who was to start school in September. Mrs. Foster was ambivalent about the adoption, but after several discussions, concluded that she x-jas unable to assume res-ponsibility for her daughter, and that i t would be in the daughter's best interests i f she was formally adopted by her sister. Thus, she pro-ceeded xtfith the adoption. It i s at this stage that reality may be held up to the patient by pointing out that certain patterns of behaviour are not helping him achieve his goal. It is necessary, therefore, for the social worker to exert great care in making demands for more r e a l i s t i c behaviour. If these demands are made too frequently or at inappropriate times, the patient may be unable to tolerate them and resort to his usual withdrawn or destructive patterns. An assessment of the patient's l i f e situation as to whether he can obtain sufficient gratification of healthy needs to give up his old pat-tern i s very important. During this period when demands are being placed on the patient, he w i l l need considerable support and approval from the social worker. For example, from November 1958 to March 1959. Mrs. Foster was under great stress: her "boyfriend" j i l t e d her, her boss c r i t i c i z e d her, and her son refused to accept her discipline. She also had financial d i f f i c u l t i e s , and was very lonely. During this period the social worker concentrated on those roles which Mrs. Foster x-ras performing - 62 -satisfactorily. She was commended on the quality of her work, and on her participation in the Social Club. She was congratulated on the way in which she managed her responsibilities and on her a b i l i t y to budget. She was encouraged to develop friend-ships with co-workers, and when she was invited by a co-xrorker to go to Seattle for a holiday, the wor-ker, as the "good" parent, gave his consent. She was also urged to take a firm, consistent stand with her son. The techniques used during this period may be prohibition of acting out, exploration of inadequacy feelings, encouragement of social and occupational a c t i v i t i e s , and granting of valid dependency gratification. The emphasis i s always on specific r e a l i t y problems. In April, i 9 6 0 , the social worker, who was now consistently perceived as the good parent, dis-couraged Mrs. Foster from sharing a suite with another patient, Mrs. Neal. The worker recognized Mrs. Foster's feelings of loneliness and her dependency needs, but pointed out the reality of the situation. Mrs. Foster admitted that Mrs. Neal's bellicose, domineering manner would be exasperating after a long day's work, and gave up the idea. A useful technique when appropriate i s the giving of rewards in the form of praise. Direct advice may be given but is usually couched as a suggestion and the ultimate decision i s generally l e f t up to the patient. During this period the patient may be able to imitate the social xrorker's method of mas-tering, even when his psychic structure i s such that he cannot internalize a mature way of functioning. The more mature patient may be able to incor-porate to some extent the social worker's attitudes.. This period i s of considerable duration, and i t may last from one to several years, depending on the degree of disturbance the patient mani-fests. With Mrs. Foster, the second stage of treatment lasted eighteen - 63 -months, from November 1958 to May i960. Certain environmental factors may interfere with the treatment of these patients such as inability to obtain employment, family rejection, low income, and family neurotic interaction. Changes of therapists interfere with the treatment of these patients because of their need for a consistent parent figure. The third stage occurs when the patient discovers there is real  gain for himself in controlling his behaviour, when he experiences how much he likes himself, and when he obtains positive responses from others. This experience encourages him to practice his new ways of relating while the worker stands by, giving him support and approval long enough for the pa-tient to feel comfortable in the use of his new patterns of behaviour. A distressing episode in May i960, proved to Mrs. Foster that she had the inner strengths to withstand major crises without relapsing into a psychosis. Her ability to cope with this situation was primarily the result of confidence gained through successfully dealing with other traumatic incidents, such as adopting out her daughter and divorcing her husband. In May, i960, Mrs. Foster's son, Randy, ran away from home with another boy, broke into a house and stole $140. She managed the courtroom visits very well, when her son was placed on probation, she moved to a new neighbourhood where he could make new friends. With the help of the social worker she began to set limits on him which she actually enforced. During this period the social worker supported her in her courtroom visits and in her periods of helplessness; and he praised her in her efforts to prevent her son from further delinquencies. The patient is motivated by successes rather than needing to rely so heavily on the social worker's support and direction. The patient must be prepared - 64 -for ups and downs that are bound to occur, but he can take comfort for the future in the fact that he is experiencing fewer downs. At the end, when termination is discussed, the patient may-regress temporarily to his old behaviour pattern, to illustrate to the social worker that he is not ready to terminate. This may be a valid indi-cation of unreadiness, or may be an attempt to test the worker's confidence in his ability to manage his own life. Widely spaced appointments, reas-surance of the worker's interest and continued availability in times of stress are helpful mechanisms to deal with this problem. If the patient is actually ready to terminate, his general adjustment will be the best indicator once he has tried to function on his own. By December, i 9 6 0 , all was going well at the Foster home: Randy, the son, was doing well in school, was active in sports, and well-behaved and obedient at home. Mrs. Foster was off medication, and had obtained a new job with a higher salary and more prestige. Three months later, Mrs. Foster reported that she was happier and more relaxed than she had ever been. In fact, she even talked about being well enough to be discharged. The main treatment considerations for the therapeutic handling of 1 this type of patient is well summarized by Melitta Schmideberg: As the aim in treating the borderline patient is to strengthen the ego and its control over the id, we must be careful not to weaken the existing de-fences by interpretations, by encouraging the un-conscious material to emerge indiscriminately as in free associations and uncontrolled fantasying, or Schmideberg, Melitta, "The Borderline Patient," American Hand-book of Psychiatry. Arieti, editor, Basic Books, Hew York, 1959. vol. 1, p. 413. - 65 -by being unduly tolerant of pathological manifes-tations and impulsive behaviour. Moreover, we should develop the existing defences. In part i -cular, setting limits, developing volition, fore-thought, responsibility, and consideration for others, stressing consequences, socializing the patient, and giving him values force him to deve-lop defences. Values and standards are of posi-tive emotional significance; they are as important for normal development as the fulfilment of mate-r i a l or sensual needs. They fashion the persona-l i t y and form an important part of i t . Values, ideals, and standards act as levers that check primitive impulses, and thus further repressions and other defence mechanisms, but they also give positive satisfaction that compensates the instin-ctual frustration. This type of treatment is successful in rehabilitating the patient, especially when i t i s combined with social work services to the family. The aim of the social worker in working with the family is to help them accept the patient and his limitations. This is done by clarifying the nature of the patient's illness to the family, by helping the family lower their expec-tations regarding the patient's performance, and by giving advice as to how to behave toward the patient. At the same time the social worker accepts the family's negative feelings concerning the patient's irresponsible and detached behaviour, and supports the family in i t s attempts to re-integrate the patient into the family. Some of the patients, after one or two years contact with the Sus-taining Clinic, are able to assume responsibility for their behaviour. During this time, many are able to develop a number of sufficiently close relationships that they no longer feel isolated in the community. The con-fidence gained through having "weathered this stormy transitional" period gives them the courage to seek out new interests and a c t i v i t i e s . - 66 -An Evaluation of the Treatment It is difficult to measure the kinds of results achieved by the 1 Sustaining Clinic. In essence, "no progress" is progress. Because the patients are so severely damaged and so vulnerable to further illness, the first aim of the Sustaining Clinic is to prevent the patient from regressing to the point where he has to be hospitalized. At the same time, attempts are made to improve the patient's functioning so that he can obtain greater enjoyment from his emotions, achieve more satisfying social relationships, and assume greater responsibility for his behaviour. One of the simplest ways of evaluating the effectiveness of the Sustaining Clinic is by determining the number of patients who have been readmitted to Crease Clinic or the Provincial Mental Hospital. On this basis, the Clinic has been successful. Only six of the forty patients were hospitalized while attending the Sustaining Service, and the longest period of hospitalization was four months. Nine patients relapsed and were ad-mitted to the Day Hospital; one was admitted on three different occasions and three were admitted on two different occasions. Another way of evaluating treatment is by comparing the patient's functioning at the time of referral with his present functioning or his functioning at the time of discharge. Three rating scales have been used in an effort to describe the results of treatment in meaningful terms, instead of the traditional terms "recovered, improved, and unimproved". In the present study no attempt is made to evaluate the specific contribution made by the social worker in the rehabilitation of the patient. Rather, this account is concerned with the total treatment service, including the social xrorker's contribution, to the particular kind of patient for whom it is designed. - 67 -1 The three ratings may be summed up as follows: 1. Impairment - a performance scale. 2. Emotional Distress - a scale of subjective discomfort. 3. Social Tension - a scale of relationship. Schedule A. Criteria Used for Rating Degree of Illness or Improvement Degree IMPAIRMENT (Performance) EMOTIONAL DISTRESS (Subjective Discomfort) SOCIAL TENSION (Relationships) 1. None effective emotions enjoyed single and social satisfactions 2. Minimal pre-illness functioning symptoms appear only under pressure structured relationships 3. Mild impaired under pressure symptoms present -mild constricted relationships 4. Moderate maintains self at lower level symptoms present -marked unsatisfying relationships 5. Severe supervised loss of control marked social conflict The f i r s t rating i s a simple adaptation from the American  Psychiatric Association Manual. Rating scales 2 and 3 were devised by Dr. McNair, Director of the Mental Health Centre. - 68 -Table 1. Comparative Ratings of Samnle Group. at Referral and at Discharge Degree Impairment Emotional Distress Social Tension At Referral At Discharge At Referral At Discharge At Referral At Discharge Males 1 None - - - - - -2 Minimal 1 3 - 2 - 1 3 Mild 2 5 1 7 2 6 4 Moderate 5 3 8 1 9 5 Severe 5 2 3 2 2 Females 1 None - 1 - - - -2 Minimal 1 8 - 2 - 1 3 Mild 6 10 6 15 6 17 4 Moderate 10 10 10 11 8 5 Severe 10 4 i i - 10 1 - 69 -Judging by the ratings, the patients' condition, grouped in terms of impairment, emotional distress, and social tension alike, was moderate to severe at the time of referral. At the time of discharge (or at the date of this study) their functioning had improved to the point where i t was mild or minimal. The degree of improvement was about equal for men and xromen. On the whole, equal progress was achieved in a l l three areas. In summary, this type of treatment, removing as i t does, the threat of control, compulsion, or censure, tends to minimize the patient's feelings of helplessness and i n f e r i o r i t y . A positive reality relationship between the worker and the patient is the main method of developing and strengthening the latter's impaired capacity for feelings for others. Through identification with the worker, the patient can gradually accept controls and attitudes more appropriate to reality. The treatment pro-vides emotional and practical support aimed at strengthening the patient's necessary defences and f i l l i n g some of his basic needs, so that his feelings of isolation and infer i o r i t y are diluted. It is a type of treatment that is appropriate to the Sustaining Clinic patient in view of his low rehabili-tation potential. CHAPTER IV THE SUSTAINING CLINIC AS A BRIDGE TO THE COMMUNITY The focus of this study has been the contribution made by the Sustaining Clinic for its appropriate class of patients. This has been done by (l) examining the problems of a sample group of these patients, and by (2) reconstructing the treatment services given to them; thus estab-lishing how far this meets their needs.• Therapeutic effort, to be valid and effective, must be related to the needs of the patient and to the specific conditions surrounding his illness. But, as this material illustrates, it is often difficult to se-parate the part of the problem which belongs to the patient and the part that is related to his being a member of a family unit. The influences that push him tox^ ard illness and the influences that lead him toward health are intertwined. While these factors are known to be psychological, social, economic, and medical, in actuality it is difficult to make clear-cut dis-tinctions between them and other elements which contribute to stress and breakdown in mental health. The review of the cases under study demonstrates that each pa-tient has many difficulties and concerns which are contributing elements in his illness. Treatment in hospital may have improved his psychiatric syn-drome, but a period of hospitalization can create further difficulties for him in his social environment outside the hospital. For most patients, the - 71 -transition from the hospital to the community is a long one, fraught with many threatening real and fantasied.problems. Many patients may improve in hospital only to return to - what is for them - a sick environment. Not all environmental situations are correctable or amenable to modification, and it may be destructive to have the patient return to the environment where he first became i l l . The patients, because of the residual aspects of their illness, are unable to face all the complications and responsibilities that healthy people take in their stride. Confronted with distressing situations, they tend to relapse into illness, which, in a sense, offers them escape from unbearable stresses. There is evidence, recognized by the staff at the Mental Health Centre, that the patients attending the Sustaining Clinic are unable, for a variety of reasons, to benefit from more intensive therapy. For many of these patients any contact beyond a brief monthly interview is so fright-ening they will terminate treatment. Though they crave a close relation-ship with someone who will understand and accept them, their fear of rejec-tion and loss of power through lowering their defences is great. Thus, the therapist, because of the very nature of his patient's personality, is forced to deal with everyday reality problems. He helps the patient main-tain a kind of equilibrium through being a constant support in cases of stress, through setting limits, through information-giving, through manipu-lation of the environment, and through being a figure for identification. No hope is held out, of making changes in the basic personality structure of the patient. - 72 -Readmission rates indicate that the Sustaining Clin i c has been, on the whole, successful i n i t s aim of maintaining the patient at his pre-referral level of functioning; six (or fifteen per cent) of the patients studied returned to the mental hospital during the three years the Clinic has been in operation. This corresponds with results recorded in studies 1 2 done by Donald Carmichael and Elsie Kris . Carmichael found the relapse rate of patients attending four Aftercare Clinics in New York City to be fifteen to twenty per cent during a three year period. Kris, studying one of the New York Aftercare C l i n i c s , found the relapse rate (of 250 patients over a two year period) to be ten per cent. However, in view of the Sustaining Clinic patient's severe im-pairment, intense emotional distress, and unsatisfying social relationships, mere maintenance through medication and brief monthly contacts is not enough. This i s not to negate the importance of tranquilizing drugs be-cause without them the Sustaining Clinic patients would probably s t i l l be in a mental hospital. However, sustaining the patient is but one step in the total rehabilitation of the mentally-ill person. The staff of the Sus-taining Clinic are aware of this, and have evolved a pattern of treatment that has helped improve the functioning of the majority of the patients. The rating scales reveal that the patient' condition, grouped in terms of impairment, emotional distress, and social tension, X\ras on the average Carmichael, Donald, "Community Aftercare Clinics and Fountain House," Rehabilitation of the Mentally 111. Greenblatt and Simon, editors, Washington, D. C , American Association for the Advancement of Science, 1959. PP. 157 - 173. 2 Kris, Elsie, "Patients Maintained in the Community on Tran-quilizing Drugs, Rehabilitation of the Mentally III, pp. 191 - 199* - 73 -moderate to severe at the time of referral. At the time of discharge (or at the date of the present study) their functioning had improved to the point where it was in general mild or minimal. The degree of improvement was about equal for men and women. On the whole, equal progress was achi-eved in all three areas. However, the patients after demonstrating their ability to use more intense treatment services, are seldom transferred to it . This is primarily due to staff shortages, not reluctance on the part of staff. It would cost the provincial government very little to increase the staff at the Adult Clinic to the point where these patients could receive bi-monthly or weekly interviews, for some of whom this might be beneficial. The bene-fits of the Sustaining Service would be extended if the Social Club, asso-ciated with the Clinic, offered a variety of special interest and problem-centered groups. However, a professionally trained group worker would be required to organize these services. The Sustaining Clinic in the Network of Social Agencies The goal in the development of social welfare resources is to en-sure in the community a network of facilities for meeting the needs which individuals are unable to meet themselves. The process of social action is the mobilization of group efforts in the interests of social welfare. Some of the needs of the patients at the Sustaining Clinic are distinctive and require specialized facilities; some of these needs are the common needs of other sick or disturbed persons. There are a wide range of community resources significant for mental health. Certain of them are primarily directed to the population as - ?4 -a whole or to large segments of i t , with a view to helping people develop and maintain maximum capacity to cope with the ordinary problems of life. Examples of such agencies are the Vancouver City Social Service Department, the Outpatient Department at the Vancouver General Hospital, and Gordon and Alexandra Neighbourhood Houses. The clientele of these agencies is not con-fined to people with emotional or behavioural problems, though such people are included. The Vancouver City Social Service Department offers finan-cial assistance to those applicants who pass a "means" test. The Outpatient Department at the Vancouver General Hospital provides medical services for low-income groups. The Neighbourhood Houses provide social, educational, and recreational programs for people from many segments of the community. Then, there are agencies designed primarily for people with emo-tional or behavioural problems such as the Family Service Agency and the Mental Health Centre. The Family Service Agency is not designed to provide service for people with a low rehabilitation potential (e.g., the Sustaining Clinic patients). The Adult Clinic of the Mental Health Centre is the one agency in metropolitan Vancouver offering a comprehensive rehabilitative program for the mentally-ill patient. Its Day Hospital has four goals: (l) The Day Hospital makes possible early discharge from the hospital of patients who can establish living arrangements outside. (2) Patients may maintain therapeutic con-tact with a hospital setting for a longer time without tying up a much needed hospital bed. (3) The Day Hospital is helpful in preventing the hospitalization of relapsing patients. (4) It is helpful in preventing -75 -the hospitalization of new acute cases. The Outpatient Department offers therapeutic interviews on a weekly, bi-weekly, or monthly basis depending on the needs of the patient. Treatment usually lasts from six months to over two years: often a spouse or other family member receives casework at the same time. The Psychiatric Outpatient Department at the Vancouver General Hospital offers a similar service. The Social Club at the Adult Clinic is organized only for drop-in activities two evenings a month. Unfortunately, the Social Club is not open every day, nor are there any special interest or problem-centered groups as there are at the C. M. H. A. Social Centre. Finally, there are facilities designed exclusively for discharged mental patients. These facilities have already been mentioned in the first chapter, and include follow-up care by a social worker from the mental hos-pital, foster home care, Venture, Vista, the C. H. H. A. Social Centre, and the Sustaining Clinic. 2ach attempts to meet a particular need of the dis-charged patient or provides a service for a particular type of discharged patient. Patients referred for follow-up care from the mental hospital usually have a high rehabilitation potential but are returning to unsatis-factory home situations. Follow-up care rarely extends beyond six months after discharge. Venture and Vista offer a temporary protected environment to employable patients who lack family and friends. Foster home care is designed primarily for the chronic, non-recoverable patient who requires little supervision and who can live in the community in controlled - 76 -conditions. The C. M. H. A. Social Centre offers organized and "free" social activities for discharged patients whose central problem is diffi-culty in establishing social contacts. As can be seen, the crux of rehabilitation of the mentally i l l is the array of services which must be integrated to do the job. Disablement of a human being is a complex thing; the person is himself complex; and the society in which he finds himself is complex, too. To achieve rehabilitation of mental handicaps, to "reable" the individual takes the combined efforts of a number of disciplines in a number of different social agencies. The Sustaining Clinic alone does not suffice. As more and more patients leave the hospitals, many of them after a hospitalization of at least several years' duration, questions related to modern drug therapy assume progressively greater importance. One of the main purposes in establishing the Sustaining Clinic, formerly known as the Largactil Clinic, was to regulate the medication of discharged mental pa-tients. The ultimate benefit to humanity from tranquilizing drugs will depend on how social workers and psychiatrists solve the social problems and meet the social needs of the patients discharged on medication. The results of this study suggest that no drug can alter the social and econo-mic pressures which proved to be the underlying causes of illness in these patients. Such therapy can help insulate the discharged patient from the stresses caused by rejection, ignorance and prejudice, but the stresses are s t i l l there. Only the community itself can remove them. Social workers can help in the process by interpreting to the community the problems, -77 -needs, and capacities of the discharged mental patient. Interpretation to the Community In the past, the attitude of society toward patients suffering from mental illness was one of hopelessness, an attitude that is reflected even today in the type of provisions made for their care. I f the advances of psychiatry and social work are to benefit such patients in the future, i t i s essential that steps be taken to modify this attitude. Social workers in mental health settings have ample opportunity to observe the close relationship existing between substandard social con-ditions and the incidence of mental i l l n e s s . Cognizant of the impact of social pressures upon health, the hardships imposed by lack of suitable fa-c i l i t i e s for care of the mentally i l l , and the end results in human misery they create, the social worker must assume greater responsibility for cal-li n g these situations to the attention of the community and for suggesting, whenever possible, ways and means of providing remedies. In fact, such activity i s in line with, and cannot be separated from, the social worker's total effort to marshal a l l the forces in the patient's environment to serve his best interests. In these efforts toward providing adequately for human needs, the professional team in the mental health setting can be of v i t a l influence. Working together, the team can influence community attitudes through inter-pretation of the individual patient, the problems confronting him, and the measures necessary for his maximal rehabilitation. Although i t is true that many patients returning to the community after mental illness may have residual handicaps, these handicaps do not preclude the existence of real - 78 -potentialities which should be recognized and utilized as f u l l y as possible. Social work has a responsibility to re-orientate the community so that i t w i l l accept the mental patient and react more tolerantly to his be-haviour. The public must learn to respond to the patient's disordered func-tioning without depriving him of a l l positive social roles and must take the trouble to help him maintain a sense of personal destiny and self-control in the presence of i l l n e s s . Rehabilitation is achieved only when the patient i s accepted by the citizens of the community. Ability or d i s a b i l i t y i s a characteristic of the relationships which a person establishes with his environment; they either f i t each other well or they do not. It i s no more nearly correct to say that the round peg does not f i t the square hole, than i t i s to say that the square hole does not f i t the round peg - neither, of course, f i t s the other. Fortunately, the f u t i l e argument is ending as to whether the environment of the chronic psychotic i s unsuited to the needs of the patient or the patient i s unsuited to his environment. There are signs of recognition that periods of decom-pensation signify that each has become unsuited to the other. Thus, at the same time that techniques are being perfected to help the patient keep him-self adapted to his environment, programs should be developed to create an environment in which the patient can l i v e without undue stress. The Sus-taining Cli n i c with i t s two-way process of rehabilitation - that of modi-fying the patient in some degree, and modifying the environment, such as home and work circumstances, as far as possible - has as i t s goal the increase i n the patient's capacity to pursue l i f e . The Sustaining Clinic is an essential aspect of the patient's - 7 9 -t r a n s i t i o n from the h o s p i t a l to the community and the coordination of h i s o v e r a l l post-hospital career. There i s evidence that i t reduces relapse rates and helps patients remain i n the community longer at higher l e v e l s of adjustment. This i s done by regulation of medication and regular thera-peutic contacts. The Sustaining C l i n i c i s appropriate f o r i t s type of patients: the severely damaged patient with a low r e h a b i l i t a t i o n p o t e n t i a l who i s maintained i n the community on medication. 'The service would not be p a r t i c u l a r l y b e n e f i c i a l to a l l types of discharged patients. I t does not, nor i s i t intended to, meet the needs of the chronic patient r e q u i r i n g boarding or f o s t e r home care, the discharged patient xtfithout accommodation, or the patient whose primary problem i s a f i n a n c i a l or a vocational one or i n the realm of s o c i a l r e l a t i o n s h i p s . The Sustaining C l i n i c i s one of the bridges between the patient's i l l n e s s and h i s community. - 80 -Appendix A Schedule B - St a t i s t i c a l Data on the Male Sample Group Name Age on Admission Marital Status Formal Education Economic Status Length of Hospitalization Mr. A. 69 married Grade 9 unemployed, * 0.A.S, 6 years Mr. B. 54 married Grade 10 employed l/4 year Mr. Rogers 51 married Grade 12 unemployed 5 years Mr. C 50 married Grade 10 employed 1/3 year Mr. D. 43 married Grade 9 employed l/4 year Mr. E. 41 married Grade 10 employed l/4 year Mr. Mcleod 33 married 3rd yr.un. unemployed l / 2 year Mr. F. 30 married Grade 10 employed n i l Mr. G. 36 single Grade 5 unemployed 2 and l/4 years Mr. H. 35 single Grade 10 unemployed, D.P.A. 6 years Mr. I. 30 single Grade 6 unemployed n i l Mr. Owens 30 single Grade 10 unemployed 2/3 year Mr. J. 28 single Grade 9 employed n i l * Old Age Security ** Disabled Persons Allowance - 81 -Appendix B Schedule C - Sta t i s t i c a l Data on the Female Saraole Grouo Name ^ge on Marital Formal Economic Length of Admission Status Education Status Hospitalization Mrs. A. 54 Married Grade 8 Housewife 1 and 3/4 years Mrs. B. 50 Married Grade 10 Housewife 2/3 year Mrs. C. 45 Married Grade 9 Housewife l / 2 year Firs. D. 45 Married Grade 8 Housewife n i l Mrs. E. 43 Married Grade 12 Housewife 1 year Mrs. F. 40 Married Grade 9 Housewife 1 year Mrs. G. 34 Married Grade 12 Housewife 3/4 year Mrs. H. 31 Married Grade 11 Housewife 2 years Mrs. I. 31 Married Grade 11 Housewife 1 and 1/2 years Mrs. J. 57 Widowed Grade 6 D.V.A. pension n i l Mrs. K. 54 Widowed Grade 10 employed 2 years Mrs. L. 46 Widowed Grade 9 unemployed 1 and 1/2 years Mrs. M. 35 Separated Grade 10 unemployed, S.A. 4 and l / 2 years Mrs. Foster 35 Separated Grade 12 employed l / 2 year Miss N. 34 Divorced Grade 12 employed 5 years Mrs. 0. 33 Separated Grade 11 employed 1 year Miss A. 54 Single Grade 8 employed 7 years Miss B. 47 Single Grade 12 unemployed, S.A. 4 years Miss O'Connor 47 Single Grade 12 unemployed, S.A. 12 years Miss C 47 Single B. A. employed 14 years Miss D. 38 Single Grade 11 employed 1 year Miss Beriosova 35 Single Grade 8 employed 1 year Miss Stone 34 Single Grade 12 unemployed, S.A. 13 years Miss E. 31 Single Grade 8 unemployed, S.A. 3 and 1/2 years Miss Lake 30 Single Grade 10 unemployed 9 years Miss F. 29 Single Grade 12 unemployed, S.A. 2 and l / 2 years Miss Catherine G . 29 Single Grade 12 unemployed, S.A. 1 and 1/2 years - 82 -Appendix C. BIBLIOGRAPHY Books A r i e t i , Silvano, Interpretation of Schizophrenia. Robert Brunner, New York, 1955. Cameron, Norman, The Psychology of Behaviour Disorders. Houghton-Mifflin, Cambridge, 1947. Fenichel, Otto, The Psychoanalytic Theory of Neurosis. Norton, New York, 1945. Greenblatt, M i l t o n , and Benjamin Simon, e d i t o r s , R e h a b i l i t a t i o n of the  Mentally 111, American Association f o r the Advancement of Science, Washington, D. C., 1959. Meyer, Henry J . , and Edgar F. Borgatta, An Experiment i n Mental Patient  R e h a b i l i t a t i o n , R u s s e l l Sage Foundation, New York, 1959. Myers, Jerome, and Bertram Roberts, Family and Class Dynamics i n Mental I l l n e s s , John Wiley and Sons, New York, 1959. Noyes, Arthur, and Lawrence Kolb, Modern C l i n i c Psychiatry, Saunders, Philad e l p h i a , 1959. Parad, Hoisrard, e d i t o r , Ego Psychology and Dynamic Casework. Family Service As s o c i a t i o n of America, New York, 1958. Pattison, Harry A., The Handicapped and t h e i r R e h a b i l i t a t i o n . Charles C. Thomas, S p r i n g f i e l d , I l l i n o i s , 1957* Robinson, Reginald, David Demarche and Mildred Wagle, Community Resources  i n Mental Health. Basic Books Inc., New York, i 9 6 0 . S u l l i v a n , Harry Stack, The Interpersonal Theory of Psychiatry. W. W. Norton, New York, 1953. A r t i c l e s Aarons, Z. Alexander, "The Therapeutic Function of a Community P s y c h i a t r i c Training C l i n i c , " S o c i a l Casework, V o l . XL11, No. 3» March 196l , Family Service Association of America, New York. Andriola, Joseph, "Casework Treatment i n a Home Setting of Patients Released from Mental Hospitals," S o c i a l Casework, V o l . XXXV111, No. 9, November 1957. F.S.A.A., New York. - 83 -Beckenstein, Dr. Nathan, "The Importance of Mental Hospital Aftercare Programs to Treatment," Mental Health Bulletin, Vol. 15, No. 1, (Special supplement to Canada's Mental Health Bulletin). Birch, Sophia, "An Aid in the Rehabilitation of Mental Hospital Patients," Master of Social Vfork Thesis, University of British Columbia, Vancouver, 3. C , 1953. Jackson, Edgar, Mildred Brandon, Patricia Morgan, John How, and Jean Eaton, "A Project on Resocialization of Patients i n a Mental Hospital, Social  Casework, Vol. XL11, No. 2, February, 196l , F.S.A.A., New York. Johnson, Emily Alice, "The Social Problems of Discharged Mental Patients Referred to a Public Assistance Agency in 1954," Master of Social  Work Thesis, University of British Columbia, Vancouver, B. C., 1956. Kris, Elsie B., Irene Hitchman, and Elsie Jockel, "New Drug Therapy and the Rehabilitation of Mental Patients," Social Work, Vol. 2, No. 4 , October, 1957. National Association of Social Workers, New York. Leveen, Louis and David Priver, "A Rehabilitation Center for the Discharged Mental Hospital Patient," Social, Casexrork. Vol. XL, No. 10, December, 1959. F.S.A.A., New York. Sabat, Charlotte, "The Mental Patient Released on a T r i a l V i s i t , " Social  Casework, Vol. XXXV111, No. 2, February 1957, F.S.A.A., New York. Schmideberg, Melitta, "The Borderline Patient," American Handbook of Psy-chiatry , Silvano A r i e t i , editor, Vol. 1, 1959. Basic Books, Nextf York. Sutherland, Murray Robert, "The Rehabilitation of Discharged Mental Patients," Master of Social Work Thesis. University of British Colum-bia, Vancouver, B. C., 1954. 

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