Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Family care homes for mental patients : a comparative review of family care programs as rehabilitation… Booth, Beatrice 1961

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1961_A5 B6 F2.pdf [ 4.46MB ]
Metadata
JSON: 831-1.0105998.json
JSON-LD: 831-1.0105998-ld.json
RDF/XML (Pretty): 831-1.0105998-rdf.xml
RDF/JSON: 831-1.0105998-rdf.json
Turtle: 831-1.0105998-turtle.txt
N-Triples: 831-1.0105998-rdf-ntriples.txt
Original Record: 831-1.0105998-source.json
Full Text
831-1.0105998-fulltext.txt
Citation
831-1.0105998.ris

Full Text

FAMILY CARE HOMES FOR MENTAL PATIENTS A Comparative Review of Family Care Programs as R e h a b i l i t a t i o n Aids, and Some Local A p p l i c a t i o n s .  by BEATRICE BOOTH  Thesis Submitted i n P a r t i a l F u l f i l m e n t of the Requirements f o r the Degree of MASTER OF SOCIAL WORK i n the School of S o c i a l Work •  Accepted as conforming to the standard 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 presenting  t h i s thesis i n p a r t i a l fulfilment of  the requirements for an advanced degree at the  University  of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference  and study.  I further  agree that permission for extensive copying of t h i s thesis for scholarly purposes may  be granted by the Head of  Department or by his representative.  my  It i s understood  that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission.  Department of The University of B r i t i s h Columbia, Vancouver B, Canada.  iii ABSTRACT  The goal o f treatment i s the r e s t o r a t i o n of the mental p a t i e n t t o the community. This study has sought to show that family care i s a u s e f u l device f o r r e h a b i l i t a t i o n , both f o r the person f o r whom r e t u r n t o independent l i v i n g i s expected, and as a means o f p r o v i d i n g a more s a t i s f a c t o r y way of l i f e than the h o s p i t a l environment f o r the person who w i l l continue to need s u p e r v i s i o n . The method used was t o survey the development of family care i n Europe, Canada and the United States, and to compare various c h a r a c t e r i s t i c s of U. S. programs i n New Jersey, Wisconsin, Michigan, C a l i f o r n i a , Idaho, Maryland, Kentucky and Minnesota. A report of the Veterans Administ r a t i o n , Washington, D. C. was examined, and a study was also made of s p e c i a l features of f o s t e r care programs i n the Veterans Administration H o s p i t a l at Bedford, Massachusetts, and St. Cloud, Minnesota. A general assessment was made of e x i s t i n g arrangements f o r boarding home care of mental p a t i e n t s I n B r i t i s h Columbia, with s p e c i a l reference to community resources a v a i l a b l e , i n order t o determine the r e l a t i v e merits o f boarding home placement versus family care. I n t h i s connection the f i l e s of a l l p a t i e n t s placed i n boarding home care by one f u l l - t i m e s o c i a l worker a t the P r o v i n c i a l Mental H o s p i t a l , Essondale, B. C , between J u l y 1, 1959 and August 31, I960 (comprising 20 p a t i e n t s i n a l l ) were c l o s e l y examined to e s t a b l i s h the main c h a r a c t e r i s t i c s of the group and t h e i r community adjustment. In the concluding chapter, as a r e s u l t o f the various comparisons made, i t was p o s s i b l e to draw up a check l i s t of c r i t e r i a which could serve as a guide i n s e t t i n g up and developing future family care programs. The check l i s t i n summary comprises the f o l l o w i n g p o i n t s : (1) o r i e n t a t i o n of h o s p i t a l employees and the community to the program; (2) preparation o f the p a t i e n t ; (3) s u f f i c i e n t number of s o c i a l workers to operate the program; (4) sponsors s u i t e d t o the task of caring f o r p a t i e n t s ; ( 5 ) adequate p h y s i c a l standards i n the home; (6) p r o v i s i o n of medical s e r v i c e s f o r p a t i e n t s ; (7) p r o v i s i o n of c l o t h i n g and money f o r i n c i d e n t a l expenses and comforts allowance f o r p a t i e n t s without means; (8) encouragement o f appropriate s o c i a l a c t i v i t i e s ; (9) homes o f varying s i z e s to meet the needs of d i f f e r e n t p a t i e n t s ; (10) l o c a t i o n of the home w i t h i n access of community f a c i l i t i e s f o r the b e n e f i t o f p a t i e n t s . The broad conclusion i s that the p r o v i s i o n of adequate s e r v i c e s w i l l u l t i m a t e l y depend on the assumption by the community of the r e s p o n s i b i l i t y f o r the r e h a b i l i t a t i o n of.the mentally i l l .  iv  Acknowledgments I wish to extend my thanks to a l l those whose help made t h i s study p o s s i b l e . I am e s p e c i a l l y gratef u l to Dr. Leonard Marsh of the School o f S o c i a l Work, U n i v e r s i t y of B r i t i s h Columbia, as guide, philosopher and f r i e n d ; my thanks also go to Dr. J . E. Boulding, C l i n i c a l D i r e c t o r of East Lawn U n i t , P r o v i n c i a l Mental H o s p i t a l , Essondale, B. C , and to members of the s o c i a l service s t a f f . I f u r t h e r wish to express my a p p r e c i a t i o n of the kind I n t e r e s t and assistance of s o c i a l service personnel i n h o s p i t a l s and mental hygiene services i n the United States.  TABLE OF CONTENTS Chapter I .  Mental I l l n e s s and R e h a b i l i t a t i o n  A d e f i n i t i o n of mental h e a l t h . The goal of r e h a b i l i t a t i o n . Post-discharge needs of mental h o s p i t a l p a t i e n t s ; s o c i a l f a c t o r s ; economic f a c t o r s ; medical f a c t o r s . The "family care" approach. Focus of study  Page  1  Chapter I I . Family Care — Some Features of American Plans Compared Goals of family care. S e l e c t i o n of the p a t i e n t . Finding the homes. Standards of the homes. Size of accommodation. Financing of programs and rates of a s s i s t a n c e . Group and community a c t i v i t i e s . Growth of family care Chapter I I I . Current Arrangements i n B r i t i s h  21  Columbia  The a l t e r n a t i v e o f boarding home placement. F a c i l i t i e s f o r treatment. The h o s p i t a l and the c l i n i c . Community resources. Discharge to boarding home care — a r e p r e s e n t a t i v e group from East Lawn u n i t . S e l e c t i o n and a n a l y s i s o f the group. The home s  .45  Chapter IV. Family Care as an A i d i n R e h a b i l i t a t i o n The goal of treatment and the r o l e of the s o c i a l worker. Family care as a therapeutic device. Boarding homes versus family care. C r i t e r i a f o r family care. Conclusion  67  Appendix A. L e t t e r addressed to Chiefs of S o c i a l Service i n U. S. Departments o f Hygiene and. Veterans A d m i n i s t r a t i o n Hosp i t a l s , requesting information on family care programs . . . 8 3 Appendix B. Bibliography  8 4  TABLES IN THE TEXT Table I Table I I  D i s t r i b u t i o n of p a t i e n t s according to age and average length of h o s p i t a l i z a t i o n . . . 5 9 F i n a n c i a l status of p a t i e n t s 61  V  FAMILY  C A R E HOMES F O R M E N T A L  PATIENTS  FAMILY CARE HOMES FOR MENTAL PATIENTS Chapter I Mental I l l n e s s and R e h a b i l i t a t i o n In recent years i t has become the fashion to t a l k of mental h e a l t h r a t h e r than mental i l l n e s s . Although i n Canada there are numerous a s s o c i a t i o n s concerned w i t h the problems of s p e c i f i c i l l n e s s e s such as the Canadian A r t h r i t i s  and Rheumatism Society, and  the  Canadian Diabetic A s s o c i a t i o n , to name but two, the org a n i z a t i o n concerned with promoting the prevention  of  mental I l l n e s s and i n t e r p r e t i n g to the community the needs of the mentally  i l l i s named the Canadian Mental Health  A s s o c i a t i o n , whose formation grew out of the founding of the Mental Hygiene movement i n the United  States.  Various c r i t e r i a have been suggested to define mental h e a l t h , one of them being normal behaviour. t h i s i n i t s e l f presents d i f f i c u l t i e s .  Behaviour that i s  considered normal i n one c u l t u r e or community may regarded as quite abnormal i n another.  But  be  In one of the busy  s t r e e t s of a f a i r - s i z e d c i t y i n India the w r i t e r has seen a man  dressed i n flowing black robes, with l o c k s of h a i r  f a l l i n g w e l l below the shoulders  (rather l i k e the popular  conception of one of the twelve apostles) wandering amidst  the  t r a f f i c , o b l i v i o u s to e v e r y t h i n g around him,  another i n d i v i d u a l , who  and  appeared to be i n good p h y s i c a l  c o n d i t i o n , r o l l i n g a l o n g the sidewalk i n s t e a d o f w a l k i n g i n the accepted f a s h i o n .  The former was absorbed i n  m e d i t a t i o n , while the' l a t t e r may some a c t o f penance;  have been p e r f o r m i n g  but no one p a i d the s l i g h t e s t  a t t e n t i o n to e i t h e r o f them.  In a western c i t y ,  the  " a p o s t l e " would be regarded as h i g h l y e c c e n t r i c , i f not with s e r i o u s s u s p i c i o n , w h i l e the man  who  chose to r o l l  i n s t e a d o f walk would be p i c k e d up by the p o l i c e i n short order.  What t h e r e f o r e i s "normal"? Sol  W. G-insburg, i n an a r t i c l e on "The Mental  H e a l t h Movement and i t s T h e o r e t i c a l Assumptions" p u b l i s h e d i n 1 9 5 5 i n a volume of essays e n t i t l e d Community Programs f o r Mental Health, d e p l o r e s the l a c k of an adequate d e f i n i t i o n o f mental h e a l t h .  He remarks t h a t  early  attempts to d e f i n e mental h e a l t h merely i d e n t i f i e d i t w i t h absence of mental i l l n e s s ; y e t , except i n cases of verysevere d i s o r d e r , there i s no c l e a r d i v i d i n g l i n e  between  mental h e a l t h and mental illness."*" People a l s o began i d e n t i f y i n g mental h e a l t h w i t h "happiness", " m a t u r i t y " and so on, which only added to the  ^Ginsburg, S o l W., "The Mental H e a l t h Movement and i t s T h e o r e t i c a l Assumptions", K o t i n s k y , Ruth, and Witmer, Helen L., Community Programs f o r Mental Health, The Commonwealth Fund, Harvard U n i v e r s i t y P r e s s , Massachusetts, 1 9 5 5 .  -3-  confusion.  Thus, i n one a r t i c l e mental h e a l t h i s des-  c r i b e d as "the a b i l i t y to meet and handle problems, to make choices and d e c i s i o n s , to f i n d s a t i s f a c t i o n i n accepting tasks, to do jobs without t r y i n g to avoid them or pushing them on to others, to carry on without undue dependency on others, to l i v e e f f e c t i v e l y and  satis-  f a c t o r i l y with others without c r i p p l i n g complications, to enjoy l i f e and to be able to lo.ve and be loved, "^  This  p r e s c r i p t i o n , f o r a k i n d of "gracious l i v i n g " seems an attempt to define the mature i n d i v i d u a l , and one wonders how long one could go on adding to the l i s t of s u i t a b l e attributes. The author p r e v i o u s l y quoted p r e f e r s to adopt a comparatively criteria.  simple i f somewhat u n s c i e n t i f i c set of  These are "the a b i l i t y to hold a job, have a  family, keep out of t r o u b l e w i t h the law and enjoy usual o p p o r t u n i t i e s f o r pleasure." that those who  the  We might then consider  are unable to f u l f i l l these basic c r i t e r i a  are s u f f e r i n g from some form of mental d i s o r d e r . D i a g n o s t i c a l l y , a d i f f e r e n t k i n d of d e f i n i t i o n i s possible.  Thus, mental i l l n e s s has been described as "a  range of p s y c h i a t r i c d i s o r d e r and m a n i f e s t a t i o n , w i t h b i o l o g i c a l , p h y s i o l o g i c a l and p s y c h o l o g i c a l causative ,'  Knee, Ruth I r e l a n , and Lamson, Warren C , "Mental Health and Mental I l l n e s s " , S o c i a l Work Year Book I960. New York, N a t i o n a l A s s o c i a t i o n of S o c i a l Workers. 1  -4-  f a c t o r s which l e a d to acute or chronic p h y s i c a l , emotional, and/or behavioural d i s a b i l i t i e s and c o n d i t i o n s unfavourable to mental h e a l t h . "  1  In medico-legal p r a c t i c e the mentally disordered have been d i v i d e d i n t o two broad groups.  The f i r s t group  i s comprised by the mentally d e f e c t i v e (those whose minds never f u l l y developed) and the second by the mentally  ill  (those whose minds developed normally and then became a f f e c t e d by some d i s o r d e r l a t e r i n l i f e . ) has p r a c t i c a l value.  This  distinction  The term "mentally retarded" i s now  more g e n e r a l l y used than "mentally d e f e c t i v e . " There are varying degrees of r e t a r d a t i o n from the m i l d l y retarded, sometimes r e f e r r e d to as morons, down to the severely retarded, or i d i o t s , who are c h i e f l y nursing problems. The causes of mental r e t a r d a t i o n , though numerous, are on the whole w e l l understood as a r e s u l t of medical and n e u r o l o g i c a l research.  On the other hand, the causes of  mental i l l n e s s as a f u n c t i o n a l d i s o r d e r —  that I s , where  there i s no evidence of organic b r a i n impairment — s t i l l obscure.  are  C e r t a i n schools of medical thought see the  explanation of mental i l l n e s s i n e a r l y traumatic childhood experiences, while others b e l i e v e that mental i l l n e s s be due to bio-chemical f a c t o r s , as yet not f u l l y  may  identified.  Intensive research i n the l a t t e r f i e l d of enquiry i s now taking place.  I b i d . , p.  383.  -5-  The Goal of R e h a b i l i t a t i o n Part of .the basic philosophy of s o c i a l work i s b e l i e f i n the worth of every i n d i v i d u a l , i n h i s p o t e n t i a l f o r growth and change, and i n h i s r i g h t to f i n d h i s most s a t i s f y i n g s o c i a l adjustment f o r himself and the community; and, f u r t h e r , that the community has r e s p o n s i b i l i t y toward the i n d i v i d u a l i n a s s i s t i n g him i n making t h i s optimum adjustment.  1  This philosophy i s affirmed i n the d e f i n i t i o n  of r e h a b i l i t a t i o n adopted by the National Council on R e h a b i l i t a t i o n (U.S.), i n 1943.  This postulates " r e s t o r -  a t i o n of the handicapped to the f u l l e s t p h y s i c a l , mental, s o c i a l , v o c a t i o n a l and economic usefulness of which he i s capable." (also U.S.)  The National A s s o c i a t i o n of S o c i a l Workers i n i t s statement on Goals of P u b l i c S o c i a l  P o l i c y published i n May,  1958,  maintains that I t i s  p o s s i b l e to a s s i s t the handicapped i n d i v i d u a l i n achieving a maximum of independent f u n c t i o n i n g ( i n terms of s e l f care, productive work, r e c r e a t i o n a l a c t i v i t y , and r e l a t i o n s h i p s ) through a program of co-ordinated  social rehabili-  t a t i o n s e r v i c e s which help the i n d i v i d u a l i n terms of h i s own needs and l i f e s i t u a t i o n , to develop and use h i s a c t u a l c a p a c i t i e s to best advantage. " R e h a b i l i t a t i o n comprises those medical, p s y c h o s o c i a l , educational, and v o c a t i o n a l s e r v i c e s t o , or i n behalf of, an I n d i v i d u a l  See e.g., Philosophy, Concepts and P r i n c i p l e s of S o c i a l Work, The U n i v e r s i t y of B r i t i s h Columbia, School of S o c i a l Work. (Mimeographed.) x  -6-  w i t h a p h y s i c a l or mental impairment that w i l l enable him to r e a l i z e h i s p h y s i c a l , mental, s o c i a l , and v o c a t i o n a l potential."  1  These are broadly-based goals.  To what extent i s  the community prepared to accept them f o r the mentally ill?  During the l a s t three decades i n Canada, a number  of s o c i a l s e c u r i t y measures d i r e c t e d towards the welfare of the aged, the b l i n d and the d i s a b l e d have been i n t r o duced, while great s t r i d e s forward have been made i n the prevention and cure of diseases such as t u b e r c u l o s i s and poliomyelitis.  But p u b l i c r e c o g n i t i o n of the needs of  the mentally i l l ,  and progress i n the conquest of mental  i l l n e s s , have moved at a much slower pace. A B r i t i s h w r i t e r has stated that "one out of twelve people i n t h i s country w i l l be admitted to a mental h o s p i t a l during t h e i r l i f e - t i m e .  Nearly one-half of our  h o s p i t a l beds are being used f o r the treatment of mental illness."  2  Robert S. DeRopp, i n an i l l u m i n a t i n g book on Drugs and the.Mind, published i n 1 9 5 7 , emphasizes the g r a v i t y of t h i s s i t u a t i o n i n the United States, remarking t h a t mental i l l n e s s f i l l s more h o s p i t a l beds than cancer, heart  G o a l s of P u b l i c S o c i a l P o l i c y , N a t i o n a l A s s o c i a t i o n of S o c i a l Workers, New York, 1 9 5 8 , p. 24. 1  Chiesman, W.E.,"Return to Work", i n Ling, Thomas M., and O'Malley, C.J.S., R e h a b i l i t a t i o n , London, B a l l l e r e , T i n d a l l & Cox, 1 9 5 8 . (The above i s a much quoted f i g u r e i n U. S., Canada and B r i t a i n . I t could do w i t h some careful interpretation.) 2  -7-  disease, and t u b e r c u l o s i s combined.  But i n s p i t e of the  f a c t that schizophrenia i s the g r e a t e s t of a l l p u b l i c h e a l t h problems, the sums spent on research (even i n the United States) i n t o the causes and cure of the disease are scarcely equal to the cost of a s i n g l e j e t bomber. No other major ailment i s so completely ignored.  Dr.  DeRopp argues: every v i c t i m of p o l i o m y e l i t i s r e c e i v e s the b e n e f i t of $28.20 worth of research funds per year, every v i c t i m of cancer $27.57, every v i c t i m of t u b e r c u l o s i s $26.80.  But the schizophrenic, despised and r e j e c t e d by  the p u b l i c , only has spent on him a mere $4.15 of research money. Not so many years ago, treatment of p a t i e n t s i n a l a r g e number of mental h o s p i t a l s was based on the concept t h a t , owing to t h e i r removal from r e a l i t y , there was no necessity to provide them w i t h the comforts enjoyed by people s u f f e r i n g from p h y s i c a l i l l n e s s .  I t v/as also  b e l i e v e d t h a t , owing to t h e i r mental c o n d i t i o n , they could, not respond to sympathetic understanding and. s o c i a l contacts.  Because of the i n a c c e s s i b i l i t y of many of these  h o s p i t a l s , p a t i e n t s were removed from r e l a t i v e s and f r i e n d s , and apt to be f o r g o t t e n .  In f a c t , mental h o s p i t a l s came  to be regarded as a convenient means of removing the mentally i l l person from the community r a t h e r than as  DeRopp, Robert S., Drugs and the Mind. New York, St. Martin's Press, 1957, p. 174. i  -8-  i n s t i t u t i o n s d i r e c t e d towards t h e i r care. But the o l d a t t i t u d e s are slowly changing, and the basic worth and d i g n i t y of the i n d i v i d u a l i s coming to be recognized i n the mental p a t i e n t as w e l l as i n the p a t i e n t s u f f e r i n g from p h y s i c a l i l l n e s s .  I n recent years,  through autobiographical accounts o f those who have been p a t i e n t s i n mental h o s p i t a l s , through d i s c u s s i o n i n magazines and newspapers, on the radio and T.V., the p u b l i c has become i n c r e a s i n g l y aware of the problems and extent of mental i l l n e s s . Great advances have been made i n the treatment of mental i l l n e s s , i n c l u d i n g the development of p s y c h i a t r i c out-patient c l i n i c s , mental h e a l t h centres, c h i l d guidance c l i n i c s , the use o f psychotherapy, physiotherapy, and i n s u l i n and shock treatment.  Jhe t r a n q u i l i z i n g drugs,  reserpine and chlorpromazlne, o r i g i n a l l y Introduced i n 1952, and i n wide use by 1956, have had remarkable r e s u l t s i n the treatment o f mental i l l n e s s , and a whole battery of new and improved medications has developed since that time.  R e f e r r i n g to t h e i r e f f e c t on h o s p i t a l discharge  r a t e s Dr. DeRopp states? "Following the widespread use o f these new drugs, i n 1956 f o r the f i r s t time i n approximately 200 years o f the h i s t o r y o f p u b l i c mental h o s p i t a l s i n the United States, instead of the expected increase o f 10,000 p a t i e n t s , there was a r e d u c t i o n of over 7,000 patients.  I n New York there was a 23% increase i n d i s -  charges from state mental h o s p i t a l s between A p r i l 1955  -9-  and A p r i l 1956.  I t would be a mistake to a t t r i b u t e t h i s  to the drugs alone.  Coincident with the use of drugs,  there has been an increased a p p r o p r i a t i o n f o r personnel. A l s o , the drugs, by suppressing many of the symptoms of p s y c h i a t r i c i l l n e s s and by modifying  behaviour, permit  the healthy forces i n the p a t i e n t and the s o c i a l i z i n g forces i n the h o s p i t a l to f u n c t i o n .  P a t i e n t s become more  communicative and r e h a b i l i t a t i v e procedures are more p o s s i b l e The new  conception  of the mental h o s p i t a l i s an  i n s t i t u t i o n p r i m a r i l y concerned w i t h the r e h a b i l i t a t i o n of the p a t i e n t on a team-work b a s i s , r a t h e r than a place f o r the custody of the mentally  ill.  Thus i n the  Physician's Manual of the B. C. P s y c h i a t r i c Service i t i s stated that a mental h o s p i t a l i s not a place of c u s t o d i a l care, but a s p e c i a l l y created environment i n which mentally i l l p a t i e n t s can adjust, and a place where they can receive treatment according to t h e i r needs.  Patients w i l l  continue  to need t o t a l push therapies i n v o l v i n g the cooperation  of  the p h y s i o t h e r a p i s t , the occupational t h e r a p i s t , the recr e a t i o n t h e r a p i s t and the s o c i a l worker, and a l l other forms of psychotherapy.  The problems of mental disease  will  never be solved by any one group of p r o f e s s i o n a l workers, and cooperation and coordination of a l l groups, both prof e s s i o n a l and otherwise, I b i d . , p.  467.  are e s s e n t i a l i n the p s y c h i a t r i c  -10-  program. Increasing of  emphasis  i s being  placed  on t h e  relation  i n d i v i d u a l a t t i t u d e s t o t h e s t r u c t u r e and o p e r a t i o n  institutions. "The  Thus S a u l  Recovered P a t i e n t  published  H.  Fisher  i n an a r t i c l e  entitled  R e t u r n s t o t h e Community"  recently  i n Mental Hygiene  remarks  that h o s p i t a l organization,  that  o f the s o c i a l  peutic  i t h a s been  shown  the r o l e s o f the i n d i v i d u a l s  i n t h e h o s p i t a l , and t h e f u n c t i o n i n g parts  of  s t r u c t u r e have  course o f the p a t i e n t  of the v a r i o u s  a bearing  on t h e  subthera-  and c a n e x p l a i n many o f t h e  2 symptoms p a t i e n t s  show i n h o s p i t a l .  Dr. Maxwell along Unit  these l i n e s  Jones has  f o r some y e a r s a t t h e I n d u s t r i a l N e u r o s i s  a t t h e Belmont  in his highly  c a r r i e d o u t an e x p e r i m e n t  Hospital  significant  i n England.  book on t h i s work ^ t h a t  I s made t o a b s o r b t h e p a t i e n t where s o c i a l roles the  and v o c a t i o n a l  peutic  healthy  community  a p p l i c a t i o n by  B.  "unit  an attempt  community",  r o l e s are provided  community  explains  him.  These  t o what i s f o u n d i n  outside.  The  thera-  v i e w s t r e a t m e n t as l o c a t e d n o t i n t h e  s p e c i a l i s t s o f c e r t a i n shocks, drugs o r  interpretations, 1  i n t o the  a p p r o x i m a t e a s f a r as p o s s i b l e  relatively  Dr. J o n e s  but i n the normal  C. P r o v i n c i a l H e a l t h  Services  interactions of Physician's  healthy  Manual.  1951.  F i s h e r . S a u l H., "The R e c o v e r e d P a t i e n t R e t u r n s t o t h e Community , M e n t a l H y g i e n e . O c t o b e r , 1958. 2  ^ J o n e s , M a x w e l l , The I n c . , New Y o r k , 1953.  Therapeutic  Community. B a s i c  Books  -11-  community l i f e .  Tensions associated w i t h various  roles  can be worked out while s t i l l i n h o s p i t a l and i n t h i s sense the u n i t i s a t r a n s i t i o n a l community.  Jones  believes that i t i s p o s s i b l e to change s o c i a l a t t i t u d e s i n r e l a t i v e l y d e - s o c i a l i z e d p a t i e n t s with severe character d i s o r d e r s , provided that they are treated together i n a therapeutic  community.  The i m p l i c a t i o n s of t h i s  f o r developed community resources, such as appropriate boarding u n i t s , i s r e f e r r e d to a t f u r t h e r points i n t h i s thesis. Post-discharge Needs of Mental H o s p i t a l P a t i e n t s . New community a t t i t u d e s and advances i n s c i e n t i f i c knowledge of the treatment of mental i l l n e s s have changed the focus of mental h o s p i t a l s from p r i m a r i l y c u s t o d i a l i n s t i t u t i o n s to centres where the a v a i l a b l e resources are brought together and concentrated upon the r e h a b i l i t a t i o n and, where p o s s i b l e , discharge of the p a t i e n t . Following upon the use of new t h e r a p i e s , e s p e c i a l l y the t r a n q u i l i z i n g drugs, h o s p i t a l discharge rates are increasing r a p i d l y .  But the task of r e i n t e g r a t i n g p a t i e n t s  i n t o the community remains to be solved.  What are some  of the problems faced by the mental p a t i e n t on h i s return to community l i f e ?  I t w i l l be h e l p f u l to l i s t these  under three headings. S o c i a l Factors. i t a stigma.  Mental i l l n e s s s t i l l c a r r i e s with  The p u b l i c i s apt to regard the mental  -12-  patient As  as b e i n g  a result,  e i t h e r dangerous o r "queer", o r b o t h .  the p a t i e n t himself  t h a t he h a s r e c e i v e d this the by  in itself patient  treatment  his  forms a b a r r i e r t o communication,  believes h i s illness  community  efficiency contact.  will  I f he r e t u r n s  i n a changed world,  obliged  his  to adjust  patterns  a  to h i s family,  w i t h them a g a i n  will  too w i l l During  of h i s family  may  contact  w i t h him, o r formed  of living  so t h a t  t h e y a r e u n w i l l i n g t o have  As  Or t h e f a m i l y  that  other  He may  schizophrenic,  become s u s p i c i o u s ,  u n w i l l i n g to p a r t i c i p a t e i n s o c i a l Economic F a c t o r s . he may  supporting  again  himself,  living  the p a t i e n t , may  i n forming r e l a t i o n s h i p s with easily  such  f o r him.  a residual effect of h i s illness,  difficulty  new  s i t u a t i o n may h a v e b e e n  more e s p e c i a l l y t h e r e c o v e r e d  hospital  he  t o a d i f f e r e n t way o f l i f e .  arrangements a r e necessary  and  from  a n d how t o  w h i l e h i s own f a m i l y  contributing factor i n h i s illness  people.  i n hospital,  or lost  return.  great  "accepted"  contact.  y e a r s o f h o s p i t a l i z a t i o n , members  have d i e d ,  him  n o t be  since  be I m p a i r e d by r e m o v a l  n e e d t o r e - l e a r n how t o l i v e  be  will  the p a t i e n t has spent a l o n g p e r i o d  social  live  t o admit  i n a mental h o s p i t a l ;  t h o s e w i t h whom he comes i n t o If  i s afraid  have  other  frustrated,  activities.  When t h e p a t i e n t l e a v e s t h e  be f a c e d  w i t h the- p r o b l e m o f  and perhaps h i s f a m i l y .  He may  have  -13-  l o s t h i s s p e c i a l work s k i l l s  through  in  hospital,  and  have h a d  to  l e a r n new  techniques.  he  he  ing  will  has  l o s t h i s place  especially will so a  find  i f he  will  necessary.  not  the  Perhaps a p e r i o d of  retrain-  Through h i s h o s p i t a l i z a t i o n  reinstatement reached  difficult.  This w i l l  the middle-aged b r a c k e t  f o r employment  i t a hard  be  doubly  when e v e n  task to  the  be  difficulties  illness  still  pective  e m p l o y e r t h a t he h a s  recruitment  c o n f r o n t s him.  the  Should  stigma  he  tell  of mental h i s pros-  been a mental p a t i e n t  r i s k unfavourable  r e a c t i o n t o t h i s news, o r s h o u l d  say n o t h i n g  i t , and  about  t r y to account  as  b e s t he  h i s p e r i o d o f absence from the l a b o u r market.  are very  real  asking every  may  still  and  be  ment.  The  can These  discharged mental p a t i e n t  some r e s i d u a l  effects  i n need o f r e g u l a r m e d i c a l  w h i c h he  he  day.  Factors.  suffer  Yet  and  questions which d i s c h a r g e d mental p a t i e n t s  Medical  in  men,  older applicants. Added t o t h e s e  are  and,  experience,  i n competition with'younger  o r where employment p o l i c i e s d i s c o u r a g e  for  he  i n i n d u s t r y o r o t h e r employment,  s o - c a l l e d normal worker f i n d s  of  while  opportunity  i n v i e w o f l a c k o f r e c e n t employment  has  accepted  l a c k o f use  such  c a r e may  lives,  not  be  of h i s  Illness  c o n s u l t a t i o n and  available  or a l t e r n a t i v e l y  such  i n the  treat-  community  facilities  may  -14-  t>e available but the patient unable to pay t h e i r cost. It has been estimated that the cost to the patient of t r a n q u i l i z i n g drugs along may run as high as t h i r t y to f i f t y d o l l a r s a month.  Few patients are able to con-  tinue on medication without outside assistance.  A  further factor i s the tendency on the part of some patients to deny t h e i r i l l n e s s by refusing to seek medical advice or to take medication prescribed.  For these  patients some kind of community supervision i s necessary i f t h e i r health i s to be maintained. Louis Leveen and David d r i v e r have described, i n a recent a r t i c l e i n Social Casework, the operation of the Gateways Health Centre established i n Los Angeles, C a l i f o r n i a , i n 1954 by the Jewish Committee f o r Personal Service.^.  This i s a combined h o s p i t a l and mental health  centre, o f f e r i n g p s y c h i a t r i c treatment and r e h a b i l i t a t i o n f a c i l i t i e s , both to. people l i v i n g i n the community and to discharged mental patients. Executive centre.  Mr. Priver i s Assistant  Director, and Mr. Leveen a caseworker at the Outlining some of the d i f f i c u l t i e s that the  mental patient has to face i n h i s return to the community, they point out that long-term h o s p i t a l i z a t i o n i n any setting reactivates a person's dormant dependency needs. When he i s mentally  i l l this problem can be p a r t i c u l a r l y  severe.  the mental h o s p i t a l patient who  Frequently  ' Leveen, Louis, and Priver, David, "A RehabilitationCentre f o r the Discharged Mental Hospital Patient", Social Casework, December, 1959. 1  -15-  returns to the community suffers from i n t e n s i f i e d f e e l i n g of insecurity and extreme lack of confidence from which h i s 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 person who has been discharged  from a mental h o s p i t a l i s further compli-  cated because,'in most cases, there i s s t i l l a residue of the mental i l l n e s s .  Unlike others who experience  emotional problems and whose defences are s t i l l  intact,  the person who returns to the community from the state 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 Is so  complete that he needs help i n a l l the v i t a l areas of living —  job placement, l i v i n g arrangements, and so on.  The"Family Care" Approach. To a s s i s t those patients ready f o r discharge  from  hospital who have no homes to which they can return or where emotional factors i n the family s i t u a t i o n would be detrimental to the patient's mental health, family care has proved a useful means of reintegration into community l i f e .  I t has been described as "a specialized  plan f o r the extramural care and treatment of mentally i l l and mentally  d e f i c i e n t patients who have received  the maximum benefits of h o s p i t a l i z a t i o n but are not ready to return to t h e i r own homes or to t h e i r i n d i v i d u a l places i n the community."  1  Thus, patients referred f o r  "^Family. Care Program. State of C a l i f o r n i a , Department of Mental Hygiene. (Mimeographed.)  -16-  family care are believed to have made s u f f i c i e n t progress i n hospital to l i v e outside the i n s t i t u t i o n , but are considered not yet capable of managing on t h e i r own without some help and supervision. Family care has a two-fold purpose; to provide a more happy, stimulating and s o c i a l i z i n g experience than i s obtainable i n h o s p i t a l for long-term patients who w i l l continue to need care for an i n d e f i n i t e period, and to provide a stepping stone f o r the convalescent patient f o r whom i t i s hoped there w i l l be an eventual return to f u l l and independent  living.  self-responsibility  There i s also the added  advan-  tage to the hospital that the discharge of patients no longer i n need of the hospital environment w i l l make more hospital beds and s t a f f services available f o r the treatment of acute cases. There i s nothing new about the p r i n c i p l e of family care.  As f a r back as 1792 i n England, a group of Quakers  discussed the advantages of an i n s t i t u t i o n f o r the care of mental patients i n which a family atmosphere predominated.  As a result of the adoption of ideas presented  by William Tuke, an i n s t i t u t i o n known as "The Retreat" was established near York i n 1796.  Among the p r i n c i p a l  objects of the founders was the provision of a family environment f o r patients as shown i n the n o n - i n s t i t u t i o n a l character of the building and i t s surroundings, emphasis  -17on employment and exercise as therapeutic measures, and the treatment of p a t i e n t s as guests rather than inmates.^" Almost a hundred years l a t e r , Dr. S. Weir M i t c h e l l , an American n e u r o l o g i s t , i n an attack on i n s t i t u t i o n a l medical o f f i c e r s d e l i v e r e d at the f i f t i e t h annual meeting  of the American Medico-Psychological A s s o c i a t i o n ,  was saying: to  "There i s another f u n c t i o n you t o t a l l y  fail  f u l f i l l and t h i s i s by papers i n l a y j o u r n a l s , to  preach down the idea that i n s a n i t y i s always dangerous, to  show what may be done i n homes, or by boarding out  the  quiet insane, and to teach the needs of h o s p i t a l s  u n t i l you educate a p u b l i c which never reads your r e p o r t s , and i s absurdly ignorant of -what your p a t i e n t s need." I t i s i n t e r e s t i n g to speculate how f a r he would  still  f e e l compelled to say t h i s today. Family care of the mentally i l l and the mentally d e f e c t i v e i s s a i d to have i t s o r i g i n s i n Gheel, Belgium, as e a r l y as the end of the s i x t h century, and i s u s u a l l y a t t r i b u t e d to the shrine of an I r i s h p r i n c e s s named Dymphha  The shrine was celebrated f o r i t s miraculous  cures of mental i l l n e s s , p i l g r i m s journeying to i t from  Deutsch, A l b e r t , The Mentally 111 i n America, Doubleday, Doran and Company Inc., Garden C i t y , New York, 1937, p. 93. p  M i t c h e l l , S. Weir, F i f t i e t h Anniversary Address, Transa c t i o n s of the American Medico-Psychological A s s o c i a t i o n , 1894, as quoted by Deutsch, A l b e r t , I b i d . , p. 116.  -18-  long distances i n the hope of being restored to s a n i t y . The Church assumed the r e s p o n s i b i l i t y f o r the housing of these p a t i e n t s , and, as the numbers increased, many were placed w i t h sympathetic p r i v a t e f a m i l i e s .  As  the work grew, i t became subject to l o c a l governmental r e g u l a t i o n s ; but, a f t e r t h i s s i t u a t i o n had p r e v a i l e d f o r f i f t y or s i x t y years^ i t became apparent that family care i n Gheel was meeting a nation-wide need.  The n a t i o n a l  government took over r e s p o n s i b i l i t y f o r the program, and the present h o s p i t a l f a c i l i t i e s were e s t a b l i s h e d .  Thus  the h o s p i t a l assumed the s c i e n t i f i c care of p a t i e n t s l i v i n g w i t h f a m i l i e s i n d i r e c t response to a community need f o r help i n a s i t u a t i o n which had been developing f o r several hundred years.  Today there are thousands of  p a t i e n t s l i v i n g i n homes i n Gheel and nearby v i l l a g e s . This form of f a m i l y care has come to be known as the colony system.  Although the shrine at Gheel and the  t r a d i t i o n s of care f o r mental p a t i e n t s i n f a m i l i e s could not be d u p l i c a t e d elsewhere,  the general p a t t e r n was  adopted at the colony e s t a b l i s h e d at Dun-sur-Auron i n France as e a r l y as  1893.  France, Germany, Switzerland and Scotland i n t r o duced family care i n the l a t t e r p a r t of the nineteenth  C r u t c h e r , Hester B., Foster Care f o r Mental P a t i e n t s . The Commonwealth Fund, New York, 1944, pp. 96-103. 1  -19-  century, Denmark has had t h i s system i n use f o r approxi-' mately t h i r t y - f i v e years, while Sweden and Czechoslovakia have made use of family care f o r about twenty-five'years. With the exception of the colony at Dun-sur-Auron, p a t i e n t s have been placed d i r e c t l y from the h o s p i t a l to which they were committed, and no importance has been attached to the development o;f: a colony system. Family care, o r f o s t e r home care, was f i r s t i n t r o duced i n t o the United States i n 1885 i n the Commonwealth of Massachusetts,  and was l a t e r developed  i n other s t a t e s .  The u t i l i z a t i o n of f a m i l y care d e c l i n e d f o r a time because s t a t e a d m i n i s t r a t i o n s made improper use of - thisdevice i n order to reduce h o s p i t a l c o s t s .  Thus p a t i e n t s  were sometimes placed i n f o s t e r care who could not p o s s i b l y b e n e f i t from such a program since they were a c t u a l l y too i l l to leave h o s p i t a l .  Modern-day experience  with family care i n the United States dates from the nineteen-thirties.  1  In Canada, family care has not been developed as f a r as i n Europe and the United States, although Ontario, and Saskatchewan now have planned f o s t e r - c a r e programs. A l l provinces have used some type of boarding home care  •^Pugh, • Edward N., A Study of the Family Care Program. Veterans A d m i n i s t r a t i o n H o s p i t a l . Waco, Texas"! (Mimeographed. ) ' ' ' '  -20-  from time to time, but i t has never been developed on a l a r g e scale due to f i n a n c i a l cost and l a c k of s t a f f to operate the program.  1  Focus of study. The purpose of t h i s t h e s i s i s to examine family care as a u s e f u l device f o r the r e h a b i l i t a t i o n of d i s charged mental p a t i e n t s , who have no homes to which they can go, but who need some s u p e r v i s i o n on t h e i r r e t u r n to community l i f e .  A f t e r surveying current  l i t e r a t u r e on the subject, a t h r e e - f o l d method of enquiry has been followed.  (1) The development of family care  i n Europe, Canada and the United States has been reviewed, and some features of U, S. programs compared; (2)  A general assessment of current arrangements f o r  boarding home care i n B r i t i s h Columbia has been made, w i t h s p e c i a l reference to the community resources a v a i l able to discharged mental p a t i e n t s ; (3)  A small sample  of cases discharged to boarding-home care from the P r o v i n c i a l Mental H o s p i t a l , Essondale, B. C , over a p e r i o d of fourteen months, has been c l o s e l y examined. Through these l i n e s of enquiry i t has been sought t o e s t a b l i s h basic c r i t e r i a f o r a sound family-care program.  Goodwin, Harold George, Foster Care f o r the Mentally 111. Master of S o c i a l V/ork Thesis, U n i v e r s i t y of B r i t i s h  Columbia, I 9 6 0 .  Chapter II Family Care —  Some Features of American Plans Compared  Family care i s designed to meet the needs of two p r i n c i p a l groups of patients.  The f i r s t group consists  of long-term patients whose I l l n e s s i s of a chronic nature.  They have shown progress i n h o s p i t a l to the  point where i t i s considered that t h e i r behaviour Is s u f f i c i e n t l y s t a b i l i z e d f o r them to derive benefit from l i v i n g In home surroundings under some supervision, but marked Improvement i s not anticipated.  The second and  smaller group comprises patients recovering from the acute stages of i l l n e s s f o r whom family care i s seen as a stepping-stone to f u l l s e l f - r e s p o n s i b i l i t y , though* a high l e v e l of adjustment  i s not necessarily  expected.  1  In New Jersey, family care was f i r s t conceived of as an extension of hospital care to relieve  overcrowding  but gradually the custodial aspect gave way to therapeutic considerations and the family care program was regarded as one of several channels by which certain patients might be assisted i n a more complete Integration 2  into community l i v i n g . ^Crutcher, Hester B., Foster Home Care f o r Mental Patients. The Commonwealth Fund, New York, 1944. S t a t e of New Jersey, Family Care Manual. Division of Mental Health and Hospitals, New Jersey Department of I n s t i t u t i o n s and Agencies, July 1, 1959. 2  -22-  In i t s family care manual the State of Wisconsin, D i v i s i o n of Mental Hygiene, states that placement Is an extension of the therapeutic or r e h a b i l i t a t i v e plan f o r the patient and under no circumstances i s family care to be used as a substitute form of custodial care."'' In contrast the Michigan Department of Mental Health notes that the focus of the family care program has varied i n accordance with the needs of the department.  The program was i n i t i a t e d i n 1942.  In the beginning,  emphasis was placed on patient r e h a b i l i t a t i o n , (I.e. a t r a n s i t i o n period i n which the patient i s helped to readjust to community l i v i n g i n a c a r e f u l l y selected home under hospital supervision before moving on to convalescent status or discharge) but over the years the focus has changed from time to time i n accordance  with  the amount of personnel available to select appropriate patients, f i n d suitable homes, supervise patients placed therein, interpret the program to the community, and a s s i s t the family care therapists i n developing s k i l l i n working with p a t i e n t s .  2  I t is-pointed out that \^hen  i t i s necessary to place large numbers of patients with l i t t l e or no Increase i n s t a f f , patients of the "custodial"  Family Care Manual. State Department of Public Welfare, D i v i s i o n of Mental Hygiene, Wisconsin. September, i960. (Mimeographed.) Michigan Department of Mental e a l t h . Family Care Program. December 19. I960. (Mimeographed.') 2  H  -23-  type are  selected  and  numbers o f p a t i e n t s  homes t h a t  are  sought  can  i n order  l e a s t minimal  supervision possible,  of necessity,  amounting to l i t t l e  that  the  patients  means t h a t  there  receive  and  back a g a i n .  to place  or length  degree to which t o t a l i n the  S e l e c t i o n o f the Patients planning  by  the  supervision,  more t h a n m a k i n g  the  family  with therapeutic  sure This  home,  m a k i n g an intent  effort  regardless  The  degree  i s commensurate w i t h  the  s t a f f understands, accepts,  and  program.  Patient. are  usually  referred f o r family  p s y c h i a t r i s t to the  social  department a f t e r a c a r e f u l review o f the determine whether o r not  there  longer  in hospital.  should  be  The  are mental o r  patient's physical  stabilized.  His  adjustment  w h e t h e r he  mixes w e l l w i t h the  other  seclusive,  w h e t h e r he  or  cooperates w i t h the  i s quiet  staff  or  care  service  case  symptoms w h i c h i n d i c a t e a n e e d t o keep t h e  well  care  of h o s p i t a l i z a t i o n .  to which each i s s u c c e s s f u l  participates  such  most h o s p i t a l s a r e  a l l patients  of diagnosis  t o make a t  movement i n s u c h a p r o g r a m  h o s p i t a l and  But  large  adequate p h y s i c a l care.  is little  e x c e p t between t h e  accommodate  to physical  patient condition on  patients  the or  ward, remains  combative, whether  resists  authority,  he  are a l l  - 2 4 -  factors  t o be c o n s i d e r e d .  patient  i s able  dressing, success all  to look  looking  a f t e r h i s clothes,  i n c a r r y i n g out d a i l y  who a r e s u i c i d a l ,  excluded  from  care  and h i s m e a s u r e o f i n the h o s p i t a l  to adjust  effect.  placement as i s the case  Hospital,  Bedford,  i n t h i s matter.  Veterans Administration program,  with  care to t h i s  i t I s i n t e r e s t i n g t o note that the  Veterans Administration shows f l e x i b i l i t y  life.  v i o l e n t or destructive are  something i n t h e i r r e g u l a t i o n s  Ikwever,  will  t o home  a l c o h o l i c and t h e d r u g a d d i c t , most f a m i l y  manuals h a v i n g  care  tasks  be i n d i c a t i o n s o f h i s a b i l i t y  family  to which the  a f t e r h i s own n e e d s i n b a t h i n g ,  Patients  the  The e x t e n t  their  In a l e t t e r  hospital explaining  Chief  Massachusetts, to another  their  S o c i a l Worker r e m a r k s  that  a l t h o u g h t h e y do n o t c o n s i d e r  patients  recently  assaultive, patients  who a r e a l c o h o l i c s , o r  patients  w i t h an a d d i c t i o n p r o b l e m , a s g o o d f a m i l y  prospects,  y e t they have I n f a c t  placed  have h a d t h e s e p r o b l e m s t o v a r y i n g t h i n g about t h e i r consideration.  patients  d e g r e e s when  s i t u a t i o n seemed t o w a r r a n t  been  care  who every-  family  care  1  T h i s h o s p i t a l makes a p o i n t people  who have  family  i n family  care  planning  of involving  staff  p r i m a r i l y through the use  ^Copy o f l e t t e r f r o m R e b e c c a Glasmann, C h i e f , S o c i a l Work S e r v i c e , V e t e r a n s A d m i n i s t r a t i o n H o s p i t a l , B e d f o r d , Massachusetts, dated January 1 5 , 1 9 5 9 , to Chief S o c i a l Worker, V e t e r a n s A d m i n i s t r a t i o n H o s p i t a l , Downey, I l l i n o i s .  -25-  of a family care board which i s an approving body f o r p o t e n t i a l family care homes, f o r p a t i e n t s being placed, and f o r other a d m i n i s t r a t i v e problems p e r t i n e n t to the program.  This board c o n s i s t s of the family care workers,  s t a f f supervisors, c h i e f s o c i a l worker, ward p h y s i c i a n of the p a t i e n t concerned, the c h i e f of p r o f e s s i o n a l s e r v i c e s , the c l i n i c a l psychologists and other s t a f f personnel who have played a p a r t i c u l a r r o l e i n the p a t i e n t ' s hospitalization. The  s o c i a l worker to whom the p a t i e n t i s r e f e r r e d  u s u a l l y has a number of interviews with the p a t i e n t t o determine h i s f e e l i n g s about going to a family care home, and to assess h i s readiness  to leave the h o s p i t a l .  She may also i n t e r v i e w h i s r e l a t i v e s t o e x p l a i n the need for  family care.  During t h i s period she w i l l have d i s -  cussions w i t h the nursing and other ward .staff about the p a t i e n t ' s general behaviour.  P a t i e n t s who have become  used to h o s p i t a l l i f e are o f t e n f r i g h t e n e d at the thought of l e a v i n g the s e c u r i t y o f the i n s t i t u t i o n . time —  Some need  o f t e n several month's--- to adjust t o t h i s new  idea, and i n f a c t a few can never b r i n g themselves to the point when they can leave the h o s p i t a l . v  No p a t i e n t  who does not wish to be discharged should be obliged t o go to a f o s t e r home against h i s w i l l .  I n I t s Family  Care Manual, New Jersey s p e c i f i c a l l y s t a t e s :  "The  -26-  indlvidual  shall  be g i v e n  a p p r o v e o f t h e home.  the r i g h t  No one s h a l l  t o approve o r d i s be p l a c e d  i n a family  c a r e program a g a i n s t h i s w i s h e s . " In a d d i t i o n to the i n d i v i d u a l patient, patient  various devices towards wanting  casework w i t h the  have b e e n u s e d t o m o t i v a t e t h e t o go t o a f o s t e r home.  Cali-  fornia  r e p o r t s t h e use o f p a t i e n t group meetings t o h e l p  orient  potential family  The  p a t i e n t s t o t h e program.  a p p r o a c h i s one o f i n f o r m i n g  patient  for  placed  some o f t h e s e  about f a m i l y nearby  care.  family  care  t e l e v i s i o n before the  and i n t e r e s t i n g t h e  and a l s o o f d i s p e l l i n g h i s f e a r s a b o u t  Successfully  patients returned  meetings to help  placement.  to t h e i r hospitals  correct  misconceptions  A t one s t a t e h o s p i t a l p a t i e n t s homes a p p e a r e d o n  from  closed-circuit  b o t h p a t i e n t s and employees t o d i s c u s s  program."'' The  in  care  Veterans Administration,  i t s report entitled  Psychotic  F o s t e r Home P r o g r a m f o r Improved  Patients describes  a number o f m e a s u r e s w h i c h  have been s u c c e s s f u l l y t r i e d . c o n t i n u i n g group program w i t h This  W a s h i n g t o n , D. C.,  i s an open-ended group  One h o s p i t a l m a i n t a i n s f o s t e r home c a r e  a  candidates.  so t h a t p a t i e n t s may  come  S t a t e o f C a l i f o r n i a , Department o f M e n t a l Hygiene, F a m i l y C a r e ; T e c h n i q u e a n d A c h i e v e m e n t , September i 9 6 0 . (Prepared f o r the Monthly Report t o the Governor.)  -27-  and go as they please.  Other h o s p i t a l s t e s t the p a t i e n t '  a b i l i t y to adjust on the outside by g i v i n g him day passes then week-end passes o r longer, to stay i n the f o s t e r home before f i n a l placement I s made.  I n one h o s p i t a l  the p a t i e n t i s stimulated to accept f o s t e r home care by having him f i r s t v i s i t f o s t e r homes with the f o s t e r home worker.  The s o c i a l worker t r i e s f r e q u e n t l y to take the  p a t i e n t to homes where there are other p a t i e n t s who have been i n the ward w i t h him.  H o s p i t a l s have i n v i t e d back  f o r a v i s i t some of the p a t i e n t s who have been successf u l l y placed i n f o s t e r homes.  I n the course of conver-  s a t i o n with t h e i r o l d "buddies" the homes i n which they are now l i v i n g w i l l I n e v i t a b l y be discussed.  Sometimes  a f o s t e r mother i s brought to the h o s p i t a l to meet s t a f f members or p a t i e n t groups i n order to describe her home and the p a t i e n t who may be l i v i n g there, w i t h the object of spreading g r e a t e r knowledge about the program to the h o s p i t a l s t a f f and p a t i e n t s . Several h o s p i t a l s have separate cottages  housing  about twenty or twenty-five p a t i e n t s , where candidates f o r foster-home l i v i n g r e s i d e .  Here home conditions are  stimulated, and the occupants are exposed i n varying degrees, to the r e s p o n s i b i l i t i e s which go w i t h more independent l i v i n g i n the community.  Volunteers have  -28-  been used as companion t h e r a p i s t s to promote p a t i e n t i n t e r e s t i n f o s t e r home care.  I t i s reported that they  have been s i n g u l a r l y h e l p f u l i n s t i m u l a t i n g p a t i e n t s t o accept t h i s type of l i v i n g .  1  Finding the Homes. The work of f i n d i n g the f o s t e r home and e v a l u a t i n g the sponsor u s u a l l y devolves upon the h o s p i t a l s o c i a l worker.  Sometimes the family care s u p e r v i s o r a t the  h o s p i t a l assesses the sponsor i n an i n i t i a l i n t e r v i e w , and subsequently the s o c i a l worker v i s i t s the sponsor i n the home to g a i n her own impressions o f the family situation.  The s u p e r v i s o r and the s o c i a l worker are then  able t o combine t h e i r views i n making an assessment. Where t h i s i s a new program to be introduced, the support of many community groups and volunteers may be needed.  I t i s also necessary to b r i n g the o b j e c t i v e s  of the program to the a t t e n t i o n of the p u b l i c through the medium of a r t i c l e s i n the press, through radio and T.V. announcements and so on. Veterans A d m i n i s t r a t i o n H o s p i t a l , Bedford, Massachusetts, have not f e l t that homefinding has been a p a r t i c u l a r problem over the years.  They have used such  devices as s t i m u l a t i n g r e f e r r a l s through agencies such as the Red Cross, the Family Service Agency and the  Foster Home Program f o r Improved Psychotic P a t i e n t s Veterans A d m i n i s t r a t i o n , Washington, D.C., January i960.  -29-  State D i v i s i o n of Child Guardianship, helpful.  which have been  Newspaper p u b l i c i t y has also been used.  They  have found that a surprisingly successful method of obtaining suitable homes has been through answering advertisements  f o r room and board situations.  Here they  encountered much less resistance than was expected when i t became known that a home and care was needed f o r a mental patient.  Many of t h e i r r e f e r r a l s have come from  people already engaged i n family care a c t i v i t i e s as caretakers.  1  A report received from the State of C a l i f o r n i a Bureau of SocialWork confirms that the best r e c r u i t e r s are the caretakers themselves, who r e f e r t h e i r friends. The patients also interest others i n the questioncof family care.  In C a l i f o r n i a , f i e l d workers are responsible  for investigating and c e r t i f y i n g homes.  However, although  certain physical standards are required of the home, of much more Importance i s the evaluation of the caretaker's own q u a l i f i c a t i o n s .  Homes are of a l l types with a wide  range of c a p a b i l i t i e s among the caretakers.  Many care-  takers make good use of the services of s o c i a l workers, and are creative, imaginative and understanding ing patients to move back into the community.  Copy of l e t t e r from Rebecca Glasmann. P. 24.)  i n assistSome are  (See reference  -30-  especially  helpful  undertaking  to p a t i e n t s seeking  training,  while  o t h e r e q u a l l y good  a r e more s u c c e s s f u l w i t h p a t i e n t s who over  a period of  years.  time  task of  w o r k e r more m a n a g e a b l e and  spent  in travel,  within a reasonable  These may  be  a f i f t y mile  and  sponsor  emergency  call  friendliness, an a b i l i t y  radius.  f o r the  expected  to cooperate  that  sponsor  other than  reimbursement  hospital. the  hospital.  sponsor  w i t h the  should  an  necessary. are  warmth,  of mental  social  illness,  worker i n  I t i s Important  some f i n a n c i a l  security  care of p a t i e n t s .  unconsciously  i n f l u e n c e the  i n t a k i n g an o v e r - o p t i m i s t i c v i e w o f a p a t i e n t  whose symptoms i n d i c a t e  that  homes  not u s u a l l y  of security  acceptance  f o r the  n e e d may  the  excessive  but  o f the p a t i e n t .  s h o u l d have  Otherwise f i n a n c i a l sponsor  o f the  understanding,  f o r the w e l f a r e  care  T h i s a l s o g i v e s the p a t i e n t  s o c i a l w o r k e r be  planning the  to a v o i d  d i s t a n c e of the  a greater feeling  Qualities  and  s u p e r v i s i o n by  q u i t e c l o s e to the h o s p i t a l  outside  caretakers  require  i t i s a d v i s a b l e t h a t the  s h o u l d be  the  may  or  1  I n o r d e r t o make t h e social  employment  New  t h a t he  Jersey's Family  sponsor  n e e d s t o be Care Manual  s h o u l d have the f i n a n c i a l  returned  to  stipulates resources  to  ^ P e r s o n a l L e t t e r from Miss L e x i e Cotton, S u p e r v i s i n g P s y c h i a t r i c S o c i a l Worker I I , D e p a r t m e n t o f M e n t a l H y g i e n e , S t a t e o f C a l i f o r n i a , December 2 1 , I960.  -31-  meet the cost of necessary improvements to the home, i f any, and that the sponsor should be able to meet the i n i t i a l expense of maintaining i n d i v i d u a l s through the p e r i o d of e a r l y operation. Standards of the Homes. Requirements of the home vary from one program to another. for  The f o l l o w i n g are the b a s i c requirements  family care homes as s t a t e d i n the f a m i l y care  brochure f o r prospective caretakers of State H o s p i t a l North, Orofino, Idaho: 1. "The sponsors w i l l be of s u i t a b l e character, temperament, and p h y s i c a l h e a l t h to be able and w i l l i n g to provide adequate care, comfort, and understanding o f t r a i n e e s on leave of absence, and to work c o o p e r a t i v e l y with the s o c i a l worker and the h o s p i t a l f o r the best i n t e r e s t s of the t r a i n e e .  Other members of the f a m i l y  must be agreeable to the program. 2. The sponsor must have a net income from an already e x i s t i n g source which i s r e g u l a r , dependable, and s u f f i c i e n t to maintain a comfortable standard o f l i v i n g . 3. The homes must meet minimum housing standards, and l o c a l , c i t y o r county h e a l t h , f i r e and zoning ordinances. 4. Each;\trainee s h a l l be provided an opportunity to share i n f a m i l y l i f e , s h a l l be provided w i t h three meals per day, and i n d i v i d u a l beds."  1  Family Care Brochure, Superintendent, State H o s p i t a l North, Box 672, Orofino, Idaho.  -32-  The regulation stating that trainees' bedrooms may not be above the f i r s t f l o o r i s probably designed to meet the needs of placement primarily i n r u r a l d i s t r i c t s where wooden buildings are more common and f i r e hazards greater. cable i n a c i t y  Such a rule would scarcely be p r a c t i area.  Scope of Accommodation. In the e a r l i e r phases of family care, especial emphasis was directed to the p o s i t i o n of the patient i n the family c o n s t e l l a t i o n .  In Maryland, f o s t e r care f o r  mental patients was f i r s t introduced at the S p r i n g f i e l d State Hospital i n 1935.  Writing about the Maryland  plan i n 1954, Henrietta B. DeWitt explains that not more than two patients are placed i n one home because i t i s f e l t that a family cannot absorb more than two people Into i t s pattern of l i v i n g without e f f e c t i n g drastic changes i n the design of family relationships. It i s believed that the patient should not be placed i n a p o s i t i o n of unfavourable competition of the family.  with other members  Thus, the placement of an elderly woman  i n a home where there Is already a grandmother might jeopardize the therapeutic advantage to be gained from the s i t u a t i o n because the patient would have a r i v a l with whom she would not be able to contend. considered  I t i s even  that the placement of two patients of the  -33-  same age and sex might not be advisable as t h i s would tend to set them apart as "the p a t i e n t s " r a t h e r than a i d i n g t h e i r acceptance as i n d i v i d u a l s .  1  However, t h i s concept i s now by no means accepted as v a l i d by many other s t a t e s .  I n New Jersey homes of  a l l s i z e s are used because i t i s b e l i e v e d that although some p a t i e n t s do b e t t e r i f they are the only person i n the home, others improve i f they are with a l a r g e r group. Some homes have twenty-five o r t h i r t y boarders, but i n many cases the homes are u s u a l l y shared with welfare clients.  Many l a r g e r homes are used because the communal  type of l i v i n g seems to f u r t h e r the r e s o c i a l i z a t i o n process and to be an e x c e l l e n t intermediate step to encourage independence, g e t t i n g along w i t h others, and f i n a l d i s charge from the i n s t i t u t i o n . "open-door".  Most h o s p i t a l s today are  The f a c t that the p u b l i c has come into the  h o s p i t a l means t h a t the p a t i e n t s themselves are d i f f e r e n t . Very few need the e a r l i e r p r o t e c t i o n and close r e l a t i o n ship which was very much a p a r t of e a r l i e r f a m i l y care 2  programs. In Kentucky, the Department of Health i s authori z e d to place two or three p a t i e n t together; i n Wisconsin -"-DeWitt, H e n r i e t t a , The Foster Care Placement of State Mental H o s p i t a l P a t i e n t s ; Maryland Plan, 1954~ o  Personal L e t t e r from Mrs. Eleanor Engelbrecht, Psychi a t r i c S o c i a l Work Consultant, State of New Jersey, Department of I n s t i t u t i o n s and Agencies, dated January 6, 1961.  -.34-  numbers are l i m i t e d to four.  I n C a l i f o r n i a not more  than s i x p a t i e n t s may be placed I n one home, as i s the case i n Massachusetts (although Commonwealth l e g i s l a t i o n permits up to ten retarded persons.) Financing of Programs and Rates of Assistance. There i s considerable v a r i a t i o n among the d i f f e r e n t states i n the methods of f i n a n c i n g family care programs; also i n the rates p a i d f o r the support of p a t i e n t s i n homes.  The cost of support i s o f t e n shared between the  h o s p i t a l i n s t i t u t i o n s concerned and c a t e g o r i c a l p u b l i c a s s i s t a n c e programs.  I n New Jersey, as i n Kansas and  the State of Minnesota, i n p a r t i c u l a r , much emphasis i s placed on the c o o r d i n a t i o n of r e l i e f planning with categorical assistance.  1  The maximum t o t a l monthly payment  f o r an I n d i v i d u a l from a mental h o s p i t a l i n f a m i l y care i n New Jersey i s |85.00 a month f o r room and board, plus |7.00 f o r medical and dental s e r v i c e s , $4.50 f o r personal i n & i d e n t a l s , $2.00 f o r personal laundry, and $1.50 f o r dry cleaning and c l o t h i n g maintenance.  Clothing i s  furnished on an "as needed" b a s i s by the i n s t i t u t i o n . The maximum t o t a l per diem f i g u r e chargeable  to the county  Is $3.29 f o r an i n d i v i d u a l i n f a m i l y care, $2.79 being f o r room and board, and the remainder itemized to be a l l o c a t e d to the various a d d i t i o n a l expenses as l i s t e d above. Personal L e t t e r from Mrs. Eleanor  Engelbrecht.  State of New Jersey, Family Care Manual.  -35-  In Wisconsin the cost to the state of the superv i s i o n and maintenance of any patient boarded out must not exceed the average per capita cost of h i s maintenance i n the state h o s p i t a l or colony.  The county of  his l e g a l settlement i s charged with certain of these 1 expenses i n accordance with statute. In Idaho the Division of Mental Health pays a maximum rate of |72.00 per month per patient i n family care.  These patients do not qualify f o r assistance from  the State Department of Public Assistance, which administers the categorical programs of o l d age assistance, a i d to the blind, a i d to dependent children, and a i d to the t o t a l l y and permanently disabled.  Neither i s assistance  obtainable from the county commissioners who only grant 2  assistance i n cases of desperate need. In Massachusetts payment f o r a state-supported patient i n a boarding home must not exceed $4.00 per day, though remuneration f o r a p r i v a t e l y supported patient i s 3 not subject to l i m i t a t i o n . The Michigan Department of Mental ^ e a l t h divides family care homes into classes, rates paid being i n Family Care Manual.Wisconsin, I960. Idaho Department of Health, Thermofax copy of National Institute of Mental Health Project, received from T.R. Mager, Chief, Social Service Department, March 20, 1961. 3 Family Care Manual prepared by Family Care Committee of the Massachusetts Mental Health, Social Workers Association, 1951. 2  -36-  accordance with  t h e number o f p a t i e n t s i n t h e home.  A  Class  I home i s a p p r o v e d f o r one t o two p a t i e n t s , a  Class  I I home f o r two t o f o u r p a t i e n t s , a n d a C l a s s I I I  home f o r f i v e  o r more p a t i e n t s .  Present  r a t e s f o r each  c l a s s o f home p e r p a t i e n t a r e $2.45 p e n day f o r C l a s s I ,  $2.30 f o r C l a s s I I , a n d $2.05 f o r C l a s s I I I .  In i t s  1961-1962 b u d g e t t h e D e p a r t m e n t h a s r e q u e s t e d  a sub-  stantial  increase  i n boarding  r a t e s have n o t k e p t pace w i t h rates requested  home r a t e s rising  since  costs.  The new  a r e $3.20 p e r day f o r a C l a s s  $2.75 f o r C l a s s I I , a n d $2.35 f o r C l a s s I I I . The the  Veterans Administration  tirely  own.-  This r e s t r i c t s  I home,  1  i s not able  e x p e n s e i n c u r r e d by v e t e r a n - p a t i e n t s  than t h e i r  these  family  t o pay  i n homes  care  other  almost en-  t o t h o s e p a t i e n t s who a r e i n r e c e i p t o f compen-  s a t i o n o r pension,  a n d who a r e a b l e  t o pay i n whole o r  2 i n p a r t the expenses According  to a report describing the family  program a d m i n i s t e r e d Hospital,  Bedford,  to  caretakers  family  Until  incurred.  by t h e V e t e r a n s  Massachusetts,  care  Administration  t h e r a n g e o f payment  i s $25.00 t o $35.00 p e r week.  r e c e n t l y $25.00 was t h e e x p e c t e d f e e , b u t t h i s i s  rapidly  c o m i n g up t o $30.00 a s a n a v e r a g e .  M i c h i g a n Department o f M e n t a l H e a l t h , P r o g r a m , December 19, I 9 6 0 .  A  s needed,  Family  Care  2 Pugh, Edward N., A Study o f t h e F a m i l y C a r e P r o g r a m . V e t e r a n s A d m i n i s t r a t i o n H o s p i t a l , Waco, T e x a s . (Mimeographed. ) '  -37-  payment o f $40.00 t o $45.00 i s n o t c o n s i d e r e d e x o r b i tant  I f the p a t i e n t r e q u i r e s s p e c i a l  nursing  service,  rigid  In C a l i f o r n i a  diet,  care  such as  or specialised supervision.  c a r e t a k e r s a r e p a i d $100.00 p e r month  f o r e a c h p a t i e n t , w h i c h may  be from  the funds  Department o f M e n t a l  H y g i e n e , p a t i e n t ' s own  combination  from  o f funds  state d i f f i c u l t y dation,  different  sources.  i s being experienced  particularly  1  o f the  funds,  or a  In t h i s  i n s e c u r i n g accommo-  i n t h e u r b a n areas,, b e c a u s e o f t h e  h i g h e r f o s t e r home r a t e s p a i d by some o t h e r p r o g r a m s such  as those  tration. report fifty  f o r c h i l d r e n and f o r t h e v e t e r a n s  Social  adminis-  workers i n t h e Department o f Hygiene  that t h e i r  competitors  p e r c e n t more i n some  are paying  communities  as much a s for similar  2 placement's. In B r i t i s h  Columbia,  care are i n the middle the  range.  Department o f W e l f a r e  w i t h an a d d i t i o n a l ance f o r those  in a later  $10.00 p e r month f o r c o m f o r t s  Affairs  chapter,  resources.  The  allowDepart-  a l s o p l a c e s some p a t i e n t s i n  homes u n d e r s u p e r v i s i o n , payment b e i n g made  Copy o f l e t t e r Letter  As n o t e d  p a y s up t o $85.00 p e r month  p a t i e n t s without  ment o f V e t e r a n s boarding  r a t e s p a i d f o r b o a r d i n g home  from  from  Miss  Rebecca Glasmann.  Lexie  Cotton.  from  -38-  the  veteran's  own  resources.  War  V e t e r a n s A l l o w a n c e , whose maximum Income i s $90.00  a month f i n d d i f f i c u l t y dation  i n competition  W e l f a r e r a t e , and p a t i e n t s on h i g h e r Group and  in  the  accommo-  $85.00 D e p a r t m e n t  i n competition  with  on  of  other  veteran  pensions.  Community A c t i v i t i e s .  an  g r o u p s and  increasing part  resocialization  selves organize problems,  the  disability  Individuals, playing  patients  i n o b t a i n i n g adequate  with  also  Needy v e t e r a n  and  their  community  i n helping  process, own  while  agencies  the mental the  patient  patients  groups to d i s c u s s  also assist  are  them-  mutual  i n promoting a wider under-  standing, o f m e n t a l i l l n e s s . A number o f a c t i v i t i e s i n v o l v i n g p a t i e n t s , caretakers, reported it  volunteers  from t h e  i s learned  State  that  and of  i n San  community ^ o r g a n i z a t i o n s California. Francisco  For  vocational planning  needs of the m e n t a l l y  instance,  employers to  course  c a r r y i n g her  enthusiasm  fellow-patients.  t o b r u s h up  ill.  office  She  s i x male p a t i e n t s u s e d the  Francisco  "therapeutic  in a  training,  f o r t h i s undertaking  I n a n o t h e r San  State of C a l i f o r n i a , r e p o r t , I960.  her  to  the  became s u f f i c i e n t l y i n t e r e s t e d t o e n r o l l  night-school  are  a patient helped  San  of  Francisco  1  "educate" a group o f  herself  family  home t o  home a  her  group  community".  Department o f M e n t a l  Hygiene  -39-  approach In assuming a r e s p o n s i b l e their  own  social  of patients, caretaker of  the  c o n d u c t by  later  i n the  of  patients welfare  family  care.  social  Two  s t a t e h o s p i t a l s to h e l p  subject  In  committee  w o r k e r and  i n an  inservice  O a k l a n d two  family  for a local  one  the care  community  general  work. caretaker-and-patient-picnlc  whose j o b s course of  the  and  were a l s o  to  b r i n g out  i n one  family  o f t e n make them d i f f i c u l t  discussions  regular  in their their  able  of dealing  d a y ' s work. own  g r o u p s on  r o l e i n the  to  o f h o u s e h o l d and  family  care  Caretakers' news and  caretakers  had  the  subject  mental  care  caretakers  connected w i t h the At  one  on  family  care  to  consider  ways  and  Family source  of  everyone  program.  hospital volunteers  recruitment  They  common p r o b l e m s  prepared  for  of  program.  C l a r i o n w h i c h became a s t a t e - w i d e  information  the  The  p a t i e n t management and The  in  fathers  t o meet i n  "compare n o t e s " a b o u t  w i t h them.  city  e d i t e d a d e p a r t m e n t a l p u b l i c a t i o n named t h e  the  the  training  p e r s o n n e l on  c o u n c i l , d o i n g r e c e p t i o n i s t and  C a l i f o r n i a helped  in  to  patients visited  nursing  worked as v o l u n t e e r s  A  health  the  discussions.  for administrative  office  f o r m i n g a house  Including  program  role in relation  o f new  interested  homes, p r o v i s i o n o f  themselves specific  -40-  needs f o r c e r t a i n p a t i e n t s glasses,  and  the  s u c h as  p r o v i s i o n of  transportation  P l a n s f o r a much-needed f a m i l y p a t i e n t s were d e v e l o p e d by Los  Angeles  cooperation  the mental h e a l t h  hospitals  and  developed  i n the  the  sheriff, San  of  several  a family  Diego area  parent h o s p i t a l .  The  free c l a s s i f i e d  association.  by  the  Miss J. L u c i l l e Department o f P u b l i c  that  Poor,  Circle  i t s purpose the  patient. lines centre  to  social  the  difference  elsewhere  to discharged  the  patients,  awaiting  was  F.  from  neighbourhood three  Service  homes  Consultant,  Minnesota,  o f the  i s conducted along  in this  and  have w r i t t e n  i n Minneapolis which  Canadian Mental Health  i s that  program  first  St. Paul, Circle  county  association  rehabilitation  I n many ways t h i s  described  hospital  F club  the  agencies  some d i s t a n c e  Community  Welfare,  Thomas Wals, D i r e c t o r o f the  at  care  a d v e r t i s i n g i n the  were l o c a t e d  as  the  community  mental h e a l t h  result  account of  adolescent  group i n  a s s o c i a t i o n , the  nev/spapers w i t h t h e  Mr.  home f o r  a volunteer  including  placed  care  for patients.  area.  With the  the  c l o t h i n g and-eye-  Association thesis.  One  an  has  returning similar social important  c l u b a d m i t s as members, i n a d d i t i o n t h o s e p a t i e n t s who  discharge  plans,  are  or p a t i e n t s  still  in  whom i t  -41-  i s considered  could derive e s p e c i a l b e n e f i t from an  outside s o c i a l experience.  The volunteers are club  members along with the p a t i e n t s , the c h i e f requirement being that when they attend the program, they do so p r i m a r i l y to enjoy themselves, and to be concerned that those around them have a pleasant s o c i a l  experience.  The authors of t h i s account remark that when refreshments are o f f e r e d " i t i s i n t e r e s t i n g to see p a t i e n t s serving p a t i e n t s , volunteers serving p a t i e n t s and p a t i e n t s serving volunteers.  A v i s i t o r could not d i f f e r e n t i a t e  between unpaid workers, s t a f f members and p a t i e n t s . . . . The p a t i e n t s begin having d i f f e r e n t s e l f Images and a r e s u l t develop a new  role.  as  More l a s t i n g r e l a t i o n s h i p s  begin to emerge on a behaviour r a t h e r than a v e r b a l level." The club was e s t a b l i s h e d w i t h the help of many volunteer and p r o f e s s i o n a l groups, and the support of the State Department of P u b l i c Welfare, the  State  Department of Vocational R e h a b i l i t a t i o n and  the  Minneapolis  Council of Churchwomen.  ment of P u b l i c Welfare was.interested  The State Departbecause discharged  p a t i e n t s suffered from an apparent l a c k of welcome on the part of the community. R e h a b i l i t a t i o n , who  The Department of Vocational  o f f e r e d a money grant, showed  -42-  i n t e r e s t because they considered i t was a poor investment to r e t r a i n a p a t i e n t whose s o c i a l i s o l a t i o n might adversely a f f e c t h i s e f f i c i e n c y during t r a i n i n g or h i s l a t e r work performance on the job, and might l e a d through recurrence of symptoms to a r e t u r n t o h o s p i t a l .  The  Council of Churchwomen, who provided o f f i c e and r e c r e a t i o n space i n one of the downtown churches, was i n t e r ested because of t h e i r i d e a l s of s e r v i c e to mental patients.  This was a r e a l community e f f o r t .  The weld-  ing together of these various community resources made the formation of the club p o s s i b l e . Growth of Family Care. In order to give some i n d i c a t i o n of present status and recent development of f a m i l y care i n the United States, a few s t a t i s t i c s may u s e f u l l y be quoted.  In  New Jersey, at the present time, there are approximately 500 p a t i e n t s i n care, u t i l i z i n g 200 homes.  The p a t i e n t i  c l i e n t e l e i s drawn from f i v e i n s t i t u t i o n s f o r the mentally i l l and f i v e f o r the r e t a r d e d .  1  In Kentucky 320 p a t i e n t s  have been placed i n homes other than t h e i r own since 2  June, 1958.  I n C a l i f o r n i a there are at present approxi-  mately 1,700 p a t i e n t s i n 498 family care homes.  Patients  include a l l ages from two years (mentally retarded) and up. 1  2  ''  L e t t e r from Mrs. Eleanor Engelbrecht.  Is Yours an Understanding Community?, Kentucky Department' "of C e n t a l Health, H.L-. McPheeters,- Commissioner, August, I960.  -43-  A l l p a t i e n t s are ambulatory except retarded c r i b p a t i e n t s . It i s interesting  1  to note the g r a d u a l i n c r e a s e p  i n placements i n C a l i f o r n i a . e a r l i e r year-end are:  f o r some mentally  The  t o t a l s f o r three  placement of p a t i e n t s i n f a m i l y care  1950  - 1951  ...  367  1951  - 1952  ...  536  ...  665  1952 - 1953 In Michigan  i n December I960,  1,205  mentally i l l  and m e n t a l l y r e t a r d e d p a t i e n t s were i n c a r e .  In the  1961-1962 budget a request has been made to r a i s e t o t a l placements from the c u r r e n t l e v e l of 1,205 Increase of  to 1,580,  an  375.^  In the Veterans A d m i n i s t r a t i o n there has been a steady i n c r e a s e i n the number o f p a t i e n t s r e s i d i n g f o s t e r homes as shown below: 1955  in  797  1956  1,011  1957  1,249  1958  1,554  1959  1,946  ^-Letter from Miss L e x i e Cotton, p Family Care Program, State of C a l i f o r n i a , Department of Mental Hygiene (mimeographed and undated.) -Michigan Department o f Mental Program.  Health, Family  Care  -44-  These f i g u r e s are obtained from a Veterans A d m i n i s t r a t i o n report on F o s t e r Home Care published i n January, 1959.  According to advice r e c e i v e d from Mr. Roger  Cumming, D i r e c t o r , S o c i a l Work Service, Veterans A d m i n i s t r a t i o n , Department o f Medicine and Surgery, Washington, D. C , the f i g u r e f o r those i n care as a t January, i960 i s 2,375.  From v a r i o u s r e p o r t s received, both from state departments o f hygiene and from the Veterans Administ r a t i o n , i t i s apparent that f o s t e r home care could be s u b s t a n t i a l l y increased i f a d d i t i o n a l funds and s t a f f were a v a i l a b l e t o handle placements.  This b r i e f  reviev; o f the growth o f some family care programs i n the U. S. i n d i c a t e s that although the programs are not on a large s c a l e , there has been a steady increase i n p a t i e n t placements during the l a s t t e n years.  Chapter I I I Current Arrangements i n B r i t i s h Columbia B r i t i s h Columbia, i n common w i t h the m a j o r i t y of Canadian provinces, has no e s t a b l i s h e d program f o r family care of mental p a t i e n t s , but t h i s province does have a very a c t i v e program of supervised boarding home placement.  I n order to b r i n g more c l e a r l y i n t o focus  the s i t u a t i o n of the p a t i e n t who may be r e f e r r e d f o r boarding home care, i t i s advisable to review b r i e f l y the treatment s e r v i c e s a v a i l a b l e f o r the mentally  ill,  the p r o v i n c i a l I n s t i t u t i o n s e s t a b l i s h e d f o r the care of mental p a t i e n t s , and admission and discharge procedures. F a c i l i t i e s f o r Treatment. Vancouver General H o s p i t a l accepts p a t i e n t s who are not acutely i l l i n i t s p s y c h i a t r i c ward, as a l s o does the Royal J u b i l e e H o s p i t a l i n V i c t o r i a , while selected p a t i e n t s l i v i n g i n Vancouver and surrounding m u n i c i p a l i t i e s can o b t a i n treatment at the Burnaby Mental Health Centre, which operates a Children's C l i n i c , Adult C l i n i c and Day H o s p i t a l .  Patients i n  need of longer term treatment i n the more acute stages of i l l n e s s can be admitted to the Crease C l i n i c of P s y c h o l o g i c a l Medicine o r the P r o v i n c i a l Mental H o s p i t a l ,  -46-  both s i t u a t e d a t Essondale.  I n a d d i t i o n the P r o v i n c i a l  Government has e s t a b l i s h e d a number o f Homes f o r the Aged ( f o r the care of mentally i l l persons age s i x t y f i v e and over) at Port Coquitlam (adjacent to the P r o v i n c i a l Mental H o s p i t a l ) and other homes a t Vernon and Terrace (the l a t t e r home being f o r male p a t i e n t s only).  P a t i e n t s may a l s o , of course, receive treatment  from p r i v a t e medical p r a c t i t i o n e r s and p r i v a t e psychiatrists. The P r o v i n c i a l Mental H o s p i t a l and the Crease C l i n i c of P s y c h o l o g i c a l Medicine are administered under separate a c t s o f the l e g i s l a t u r e \  but the work o f the  two i n s t i t u t i o n s i s c l o s e l y i n t e g r a t e d .  Crease C l i n i c  i s the acute treatment centre where the maximum p e r i o d a p a t i e n t may receive treatment i s f o u r months, although the average stay i s about eight weeks.  P a t i e n t s are  discharged from the c l i n i c and immediately admitted to the h o s p i t a l i f i t becomes evident that they w i l l need a longer time f o r treatment than the s t a t u t o r y four month p e r i o d .  The h o s p i t a l accepts both acute and  chronic cases f o r an i n d e f i n i t e time, terminated a t the d i s c r e t i o n of the medical superintendent. P a t i e n t s can enter both i n s t i t u t i o n s on a committal or voluntary b a s i s .  For ordinary committal to the  "^Mental H o s p i t a l s A c t , Province o f B r i t i s h Columbia, 1940, and C l i n i c s of P s y c h o l o g i c a l Medicine Act, Province of B r i t i s h Columbia, 1948.  -47-  h o s p i t a l the s i g n a t u r e o f two  d o c t o r s who  p a r t n e r s and a judge or m a g i s t r a t e  are not  i s r e q u i r e d , as w e l l  as t h a t o f a r e l a t i v e , or someone e l s e knowing the circumstances  of the case i f no r e l a t i v e i s a v a i l a b l e ,  but f o r committal  to the c l i n i c  judge o r m a g i s t r a t e  the s i g n a t u r e o f the  i s not necessary.  For  admission  on a v o l u n t a r y b a s i s , only the s i g n a t u r e o f the p a t i e n t and a p h y s i c i a n i s r e q u i r e d .  A p a t i e n t who  enters  e i t h e r the h o s p i t a l o r the c l i n i c v o l u n t a r i l y may  obtain  his  d i s c h a r g e a f t e r f i v e days of the r e c e i p t i n w r i t i n g  of  a request f o r t h i s made by the p a t i e n t to the m e d i c a l  superintendent. P a t i e n t s are d i s c h a r g e d from the Crease in f u l l ,  Clinic  as i s the case w i t h v o l u n t a r y p a t i e n t from the  h o s p i t a l , but committed p a t i e n t s from the h o s p i t a l are u s u a l l y d i s c h a r g e d on s i x months p r o b a t i o n which can be renewed, i f necessary.  During the p r o b a t i o n a r y p e r i o d  the p a t i e n t can be r e t u r n e d to the h o s p i t a l a t the d i s c r e t i o n of the medical  superintendent  mental h e a l t h d e t e r i o r a t e , without new  committal  papers.  should h i s  the n e c e s s i t y f o r  P a t i e n t s f r e q u e n t l y go on l e a v e  from h o s p i t a l to r e l a t i v e s or f r i e n d s w i t h the of  the medical  superintendent,  permission  t h i s being sometimes on  a t r i a l b a s i s p r e p a r a t o r y to d i s c h a r g e .  1  "^Information r e g a r d i n g a d m i t t i n g and d i s c h a r g e procedures i s based on S e c t i o n 3 o f the B r i t i s h Columbia Mental H e a l t h S e r v i c e s P h y s i c i a n s Manual, 1 9 5 1 .  -48-  The H o s p i t a l and the C l i n i c . The P r o v i n c i a l Mental H o s p i t a l and the Crease C l i n i c are s i t u a t e d i n b e a u t i f u l and extensive parkl i k e grounds on a h i l l s i d e overlooking the Fraser about twenty miles from the C i t y of Vancouver.  River  East  Lawn i s the women's long-term treatment u n i t of the h o s p i t a l , the other u n i t s comprising Centre Lawn, which i s the admitting b u i l d i n g and semi-acute t r e a t ment centre f o r male and female p a t i e n t s , and V/est Lawn, the long-term treatment u n i t f o r male p a t i e n t s . The Crease C l i n i c has i t s own s o c i a l service department, as do each of the h o s p i t a l u n i t s r e f e r r e d to above. S o c i a l service s t a f f have contacts with p a t i e n t s on a continuing b a s i s to help resolve emotional conf l i c t s , deal with many day to day problems which may be causing p a t i e n t s anxiety, work with r e l a t i v e s i n the community to i n t e r p r e t the p a t i e n t ' s i l l n e s s and what i s best f o r h i s r e h a b i l i t a t i o n , i n c o n s u l t a t i o n with the p s y c h i a t r i s t and other p r o f e s s i o n a l s t a f f , formulate discharge plans based on the i n d i v i d u a l needs of the p a t i e n t , help the p a t i e n t to accept  separation  from the h o s p i t a l , and maintain a program of a f t e r - c a r e  -49-  during the s i x months probationary p e r i o d , sometimes longer i f necessary.  I t should be pointed out that  h o s p i t a l s o c i a l workers from Essondale are only able to give a f t e r - c a r e s e r v i c e t o those p a t i e n t s w i t h i n d a i l y reach of the h o s p i t a l ; those l i v i n g i n more d i s t a n t areas of the province are r e f e r r e d to the l o c a l p r o v i n c i a l s o c i a l welfare branches f o r follow-up care. The h o s p i t a l has no s p e c i a l funds a l l o c a t e d to i t f o r a family care program, but through the cooperation o f municipal and p r o v i n c i a l ( d i s t r i c t ) s o c i a l welf a r e o f f i c e s , s e l e c t e d p a t i e n t s are placed i n care under the normal program f o r supervised boarding homes. P r i v a t e placements may be arranged f o r p a t i e n t s w i t h money o f t h e i r own, o r r e l a t i v e s prepared to maintain them i n care, but f o r those without resources, a r e quest i s made to a municipal or d i s t r i c t s o c i a l welfare o f f i c e f o r boarding home placement on p u b l i c  (social)  assistance. I f the d i s t r i c t o r municipal welfare o f f i c e "accepts" the p a t i e n t , a s u i t a b l e vacancy i s sought among i t s l i c e n s e d boarding homes.  As soon as one i s  a v a i l a b l e the h o s p i t a l s o c i a l service department i s so informed.  Before the request i s made f o r boarding care  the p a t i e n t ' s preferences as to the d i s t r i c t where he  -50would l i k e to be r e h a b i l i t a t e d are ascertained, and when the boarding home vacancy becomes a v a i l a b l e , the p a t i e n t : i s u s u a l l y taken to see the home so that he can form an o p i n i o n as to whether o r not he would l i k e to l i v e there.  I f the p a t i e n t f e e l s t h i s p a r t i c u l a r home  i s not a place where he could be happy, another vacancy i s sought elsewhere. The rate paid f o r p a t i e n t s on s o c i a l assistance i n boarding home care i s up to $85.00 a month, w i t h an a d d i t i o n a l amount up to $10.00 a month f o r comforts allowance.  A r e c i p i e n t o f s o c i a l assistance i n board-  ing home care i s permitted t o r e t a i n l i m i t e d resources f o r h i s own u s e but i n t h i s case he i s not provided 1  w i t h comforts allowance u n t i l he has used up h i s own funds. Supervision o f mental p a t i e n t s who are l i v i n g on s o c i a l assistance i n l i c e n s e d boarding homes may be given by the h o s p i t a l s o c i a l worker, or be taken over by the p r o v i n c i a l o r m u n i c i p a l s o c i a l welfare o f f i c e concerned, o r i n some cases there may be j o i n t supervision.  Arrangements are also made f o r each p a t i e n t  to receive medical care, e i t h e r through a l o c a l p h y s i cian or hospital out-patient c l i n i c .  Every e f f o r t I s  ''"Department of S o c i a l Welfare, B.C. Admission Form (Licensed Boarding Home o r P r i v a t e H o s p i t a l ) . "The Department of S o c i a l Welfare does not p a r t i c i p a t e i n hosp i t a l clearance plans f o r p r i v a t e cases: i . e . where cash assets i n the case of a s i n g l e person are more than $250. or f o r a married person more than $500. o r where f u l l payment w i l l be made by o t h e r s . "  -51-  made to place the p a t i e n t i n a home where a familyatmosphere predominates,  and where the p a t i e n t w i l l f i n d  the other p a t i e n t s and the sponsor congenial to him. Community Resources. As has been pointed out e a r l i e r i n t h i s t h e s i s , the mental p a t i e n t who i s discharged from h o s p i t a l u s u a l l y needs help i n most areas of l i v i n g .  The p a t i e n t  who i s placed i n a supervised l i v i n g s i t u a t i o n has h i s needs f o r food, s h e l t e r and some companionship met, but without a s s i s t a n c e he may s t i l l remain i s o l a t e d i n the l i t t l e world of h i s boarding home.  The stigma of mental  i l l n e s s is' apt to undermine h i s confidence i n meeting new people and i n p a r t i c i p a t i n g i n the many, s o c i a l a c t i v i t i e s provided by community agencies.  Further, as  a part of h i s i l l n e s s , he tends to withdraw from s o c i a l contacts. To help w i t h t h e , s o c i a l r e h a b i l i t a t i o n of the mental p a t i e n t , the volunteers of the Canadian Mental Health A s s o c i a t i o n operate a s o c i a l centre i n the C i t y of Vancouver.  This provides both s o c i a l a c t i v i t i e s and  p r o f e s s i o n a l c o u n s e l l i n g . A l l those admitted to the centre must at some time have been mentally i l l , but the teenager, the aged, the a l c o h o l i c , the drug, addict and the psychopath are excluded.  P a t i e n t s may apply  -52-  directly as t h e and  o r be  Crease  the  r e f e r r e d by h e a l t h o r g a n i z a t i o n s Clinic,  the P r o v i n c i a l Mental  Burnaby M e n t a l  through  community  Health Centre.  agencies  such  such  Hospital,  Some a r e  as t h e F a m i l y  referred  Service  1 A g e n c y , and The social he  others through d i r e c t o r o f the  worker.  psychiatrists.  centre i s a  professional  With the p e r m i s s i o n of the p a t i e n t ,  c o n t a c t s t h e h o s p i t a l where t h e p a t i e n t r e c e i v e d  treatment. directly Mental asked the  private  In the  case  o f p a t i e n t s who  d i s c h a r g e d from  Hospital,  the  to c a r r y the  centre.  patients,  The  Crease  social  w h i c h may  where n e c e s s a r y ,  Provincial is  gives c o u n s e l l i n g to  o f an o n g o i n g  employment, m a r i t a l c o n f l i c t s patient,  o r the  the p a t i e n t i s a t t e n d i n g  director also  day-to-day d i f f i c u l t i e s  been  worker a t the h o s p i t a l  case w h i l e  though not  Clinic  have  and  nature, arise  regarding  over  so on,  housing,  referring  to the a p p r o p r i a t e  the  community  resource. The situated the  city.  c e n t r e has  on a m a i n bus  a t t r a c t i v e premises route  i n the western  From n i n e o ' c l o c k u n t i l  d r o p - i n program which i s not -"-Chud, B., Cross S o c i a l  conveniently  five  organized.  part of  there i s a A  library,  D i r e c t o r , F i r s t Annual Report o f the C e n t r e , V a n c o u v e r , B. C , I960.  White  -53-  magazines, games, a r e c o r d - p l a y e r and T.V. are prov i d e d , while t e a , c o f f e e and cookies are a v a i l a b l e when needed. evenings  There a r e o r g a n i z e d a c t i v i t i e s  a week.  To arrange  three  these programs the p a t i e n t s  form t h e i r own e x e c u t i v e , and, w i t h the h e l p o f s t a f f , p l a n such a c t i v i t i e s as games, dancing, t i o n s , and o t h e r entertainment.  bingo,  expedi-  An a r t c l a s s i s conduct-  ed on an i n f o r m a l b a s i s on one evening d u r i n g the week. No attempt i s made to have every evening pied.  occu-  I t i s hoped t h a t p a t i e n t s w i l l use the centre  as a b r i d g e t o o t h e r community a c t i v i t i e s  so t h a t ,  a f t e r a time, they w i l l no l o n g e r need the f a c i l i t i e s and  support which the centre p r o v i d e s .  In f a c t , the  o b j e c t i v e s o f the centre have been r e a l i z e d . do move on to become absorbed  Patients  i n o t h e r community  so t h a t membership i s always changing.  interests  A number o f  younger p a t i e n t s p l a c e d i n boarding homes use the centre i n the e a r l i e r stages o f d i s c h a r g e . A s i m i l a r centre has been opened by the Canadian Mental  H e a l t h A s s o c i a t i o n v o l u n t e e r s i n North Vancouver,  and l a t e r i t i s hoped t h a t i t may be p o s s i b l e t o open other c e n t r e s  elsewhere.  Burnaby Mental  H e a l t h Centre operates a s o c i a l  c l u b one evening a week i n c o n n e c t i o n with the A d u l t o r  -54-  Sustaining C l i n i c , where p a t i e n t s may receive l i n g and take part i n s o c i a l a c t i v i t i e s .  counsel-  However, the  number of p a t i e n t s accepted f o r t h i s s e r v i c e i s quite l i m i t e d , the Centre being reserved f o r those p a t i e n t s w i t h a good chance f o r f u l l r e h a b i l i t a t i o n . P a t i e n t s who are seeking employment may be r e f e r r e d to the S p e c i a l Placements D i v i s i o n o f the N a t i o n a l Employment Service, which gives s p e c i a l a s s i s t ance i n job f i n d i n g to persons s u f f e r i n g from some p h y s i c a l or mental handicap.  The National Employment  Service, i n t h i s case, requests a medical and s o c i a l assessment from the h o s p i t a l , and also an employment h i s t o r y , which i s only given w i t h the p a t i e n t ' s w r i t t e n permission,  ome p a t i e n t s refuse to make use o f t h i s  a  service which i n v o l v e s admitting they have received treatment i n a mental hospital,, p r e f e r r i n g t o contact p r i v a t e employment agencies o r prospective employers directly. Two half-way houses, the V i s t a f o r women and the Venture f o r men are maintained by the h o s p i t a l .  Each  can accommodate seven p a t i e n t s at any one time.  These  are boarding homes where p a t i e n t s may stay f o r a period up to three o r four weeks while they are making arrangements f o r employment and accommodation.  In some  -55-  instances the homes are used to t e s t out the p a t i e n t ' s p o t e n t i a l i t y to adjust to community l i f e . are unable to f i n d employment may assistance,  while  for  others  Those who  be r e f e r r e d f o r s o c i a l  who have demonstrated that  a protected l i v i n g arrangement i s s t i l l needed, a boarding home placement i s sought.  v  "hile staying at  the V i s t a or the Venture, p a t i e n t s are s t i l l "on from the h o s p i t a l and the  leave"  clinic.  L i m i t i n g the stay of p a t i e n t s i n these homes to three or four weeks i s occasioned by the necessity to have accommodation a v a i l a b l e f o r new p a t i e n t s about to be discharged,  but t h i s short p e r i o d of stay i s  scarcely adequate f o r the p a t i e n t to make the necessary adjustment to l i v i n g outside the h o s p i t a l .  Additional  f a c i l i t i e s are d e s i r a b l e so that the half-way house can provide accommodation f o r p a t i e n t s f o r several months. The p a t i e n t could then stay i n the home f o r a f u r t h e r p e r i o d of adjustment a f t e r employment was Discharge to Boarding Home Care —  obtained.  A Representative  Group  from East Lawn U n i t . The p a t i e n t population of the u n i t i s approximately 1200,  although t h i s n e c e s s a r i l y v a r i e s from day to day  i n accordance with admissions and discharges.  An "open  door" p o l i c y i s followed, except f o r a small number of  -56-  closed wards f o r the severely d i s t u r b e d or d e t e r i o r a t e d . A l l p a t i e n t s who  are w e l l enough, and p h y s i c a l l y able,  have some job to do i n the h o s p i t a l such as work i n the laundry, nurses' homes, k i t c h e n s , c a f e t e r i a s , the educational centre, l i b r a r y , p r i n t i n g shop, beauty shop and a u d i o - v i s u a l centre.  A rehabilitation officer in  the u n i t i s responsible f o r p l a c i n g p a t i e n t s i n the various p o s i t i o n s to be f i l l e d , on a therapeutic basis i n so f a r as i s p o s s i b l e .  P a t i e n t s do not receive pay  f o r work done i n h o s p i t a l . Most p a t i e n t s have "grounds p r i v i l e g e s " which give them the r i g h t to come and go as they please  during  c e r t a i n hours of the day w i t h i n the confines of the h o s p i t a l property, to wander about the gardens, v i s i t the tuck shop or the r e c r e a t i o n centre.  Patients  may  attend occupational therapy, i n d u s t r i a l therapy, music therapy and so on, i n accordance with the treatment plan. The women spend much of t h e i r spare time i n the day rooms reading, c h a t t i n g , sewing, k n i t t i n g , p l a y i n g cards and games.  There are also many organized  recreat-  i o n a l a c t i v i t i e s such as dances, f i l m s , sports and p i c n i c s i n summer. The Canadian Mental Health A s s o c i a t i o n has i t s  -57-  own o f f i c e i n the h o s p i t a l grounds.  Volunteers  visit  the p a t i e n t s on the wards, operate the restaurant a t the r e c r e a t i o n centre, run the apparel shop where c l o t h i n g they have c o l l e c t e d i s d i s t r i b u t e d t o p a t i e n t s i n need, e s p e c i a l l y to those who are ready f o r discharge, and organize various forms of entertainment. There i s p r o v i s i o n f o r a s o c i a l work s t a f f at East Lawn of f i v e s o c i a l workers and a supervisor, but on account of s t a f f shortages and absence of workers on educational leave, i t i s not always p o s s i b l e to maint a i n the f u l l complement.  The work involved i n the  s e l e c t i o n , placement and s u p e r v i s i o n of p a t i e n t s i n boarding home care i s d i s t r i b u t e d among a l l the s o c i a l workers i n the u n i t , no one worker being e x c l u s i v e l y assigned to t h i s area of a c t i v i t y . S e l e c t i o n and A n a l y s i s of the Group. For the purposes of t h i s study, the f i l e s of a l l p a t i e n t s who were placed i n boarding home care by one f u l l - t i m e s o c i a l worker between J u l y 1, 1959, and August  31,  I960  were examined i n order to determine  the main c h a r a c t e r i s t i c s o f the group.  Six months  a f t e r the l a s t p a t i e n t i n the group was discharged on probation, a check was made to a s c e r t a i n how many had returned to h o s p i t a l , and how many were s t i l l  outside.  -58-  Of the twenty p a t i e n t s placed, s i x t e e n had a diagnosis of schizophrenic r e a c t i o n of some kind, eleven of these being schizophrenics of the paranoid type.  Of the remaining four, one was a manic depressive,  one had a diagnosis of p e r s o n a l i t y pattern disturbance, s c h i z o i d p e r s o n a l i t y , one (age seventy-five) had a diagnosis of chronic b r a i n syndrome associated with c e r e b r a l a r t e r i o s c l e r o s i s , and the remaining p a t i e n t was an e p i l e p t i c and high grade moron.  Her diagnosis  was b r a i n syndrome w i t h convulsive d i s o r d e r with psychotic reaction. M a r i t a l status of the p a t i e n t s was as f o l l o w s : s i n g l e seven, married three, separated four, divorced one, widowed f i v e . The f o l l o w i n g t a b l e shows d i s t r i b u t i o n of p a t i e n t s according to age group with average number of years spent i n h o s p i t a l (not n e c e s s a r i l y continuously).  -59-  TABLE I D i s t r i b u t i o n of P a t i e n t s according to Age and Average Length of H o s p i t a l i z a t i o n .  .Age group i n years  No. of persons  Average l e n g t h of h o s p i t a l i z a t i o n i n years  35 - 45  6  6.5  45 - 55'  8  7.4  55 - 65  4  11.7  65 - 75  2  11.5  I t w i l l be noted from the above t a b l e that the m a j o r i t y of the group of twenty p a t i e n t s vrere i n the middle-aged bracket w i t h long periods of h o s p i t a l i z a t i o n . The average age of the group was 55.8 years and the median age 50.5 years.  The average number of years  of h o s p i t a l i z a t i o n wag 8.3 years and the median nine years.  The shortest continuous p e r i o d spent i n the  u n i t f o r p a t i e n t s with one h o s p i t a l i z a t i o n was eight months and the longest eighteen years. The educational l e v e l of the p a t i e n t s was as  -60-  f o l l o w s : nine had a t t a i n e d Grade 12 and one Grade 11, three had a t t a i n e d Grade 8, and seven Grade 6 or l e s s . I n the Grade 12 and 11 group, comprising ten p a t i e n t s , seven had taken up to one year's a d d i t i o n a l business or p r o f e s s i o n a l t r a i n i n g , but only f i v e had shown a continuous record of employment p r i o r to the onset of mental i l l n e s s .  Two of these were schoolteachers, one  w i t h twenty years teaching experience and the other w i t h ten. the group.  These were the only p r o f e s s i o n a l members of In the lower educational c a t e g o r i e s ,  comprising h a l f the number of p a t i e n t s , one p a t i e n t , a widow, r e g u l a r l y was employed i n a f a c t o r y f o r some years p r i o r to he'r marriage, but a f t e r the death of her husband, had l i v e d on s o c i a l a s s i s t a n c e continuously f o r several years u n t i l her admission to h o s p i t a l i n 1959 f o l l o w i n g an acute p s y c h o t i c episode.  The remain-  ing p a t i e n t s could show no h i s t o r y of steady, employment, appearing to have d r i f t e d from one u n s k i l l e d job to another.  - 6 1 -  TABLE I I F i n a n c i a l Status of P a t i e n t s .  Description No f i n a n c i a l resources of any kind or v e r y " l i m i t e d resources which s t i l l l e f t the p a t i e n t e l i g i b l e f o r social assistance.  No. of Persons  1 2  S u f f i c i e n t means f o r maintenance i n the community f o r a few months only and f o r cost of r e - t r a i n i n g .  2  C a p i t a l of -from $ 4 , 0 0 0 to $ 6 , 0 0 0 , enough f o r maintenance f o r l i m i t e d period.  2  Regular pensions from Old Age Assistance or Workman's Compens a t i o n , teacher's pension, other pension plus some c a p i t a l .  4  I t w i l l be seen that only 2 0 per cent of the group had a permanent income, 6 0 per cent had no r e sources whatever, while the remaining 2 0 per cent had s u f f i c i e n t means f o r t h e i r support f o r l i m i t e d periods only.  -62-  From the f o r e g o i n g review o f the twenty p a t i e n t s i n the group, some predominant c h a r a c t e r i s t i c s emerge. S i x t e e n p a t i e n t s o r 80 p e r cent o f the group had a d i a g n o s i s o f s c h i z o p h r e n i a , the m a j o r i t y being schizophrenics.  paranoid  T h i s type o f p a t i e n t has h i s own  s p e c i a l d i f f i c u l t i e s i n the area o f s o c i a l  relation-  s h i p s , s i n c e he p r o j e c t s h i s f e e l i n g s o f h o s t i l i t y on to o t h e r s , t e n d i n g to blame them f o r h i s own  shortcomings.  This generates an a t t i t u d e o f s u s p i c i o n on h i s p a r t which complicates ially  h i s r e l a t i o n s h i p s with o t h e r s ,  i n the area o f employment.  espec-  Thus, he i s q u i t e  l i k e l y t o leave h i s j o b because o f imaginary  grievances,  o r be f i r e d because of h o s t i l e behaviour t o h i s s u p e r i o r s or f e l l o w workers. The f i v e p a t i e n t s ( t w e n t y - f i v e percent group) who had shown a steady to the onset  o f the  employment r e c o r d ,  prior  o f i l l n e s s , had a l l a t t a i n e d an e d u c a t i o n a l  l e v e l o f Grade 11 o r 12, p l u s a d d i t i o n a l t r a i n i n g .  The  employment r e c o r d o f the remainder was poor. t h i r t e e n o f the p a t i e n t s had m a r r i e d .  Excluding  the f i v e widows, on whose m a r i t a l adjustment t h e r e i s not adequate i n f o r m a t i o n , none o f the remaining had  s u c c e s s f u l marriages.  eight  One was d i v o r c e d , f o u r were  separated, and of the remaining three, one decided against going back to her husband, while the husbands of the other two were u n w i l l i n g to have t h e i r wives home again.  S i e d i f f i c u l t y i n the area of s o c i a l n C  relationships i s one of the c h a r a c t e r i s t i c s of the mental p a t i e n t , a h i s t o r y of m a r i t a l maladjustment i s to be expected i n t h i s group.  The p o s s i b l e connection  between low educational status and mental i l l n e s s suggests a u s e f u l area f o r f u r t h e r research,  although 1  some studies have already been made i n t h i s f i e l d . The Homes. The twenty p a t i e n t s were placed i n ten d i f f e r e n t homes.  The two homes f u r t h e s t from the h o s p i t a l were  at White Rock, about twenty-five miles d i s t a n t , three were i n the C i t y of Vancouver, two were i n New Westmins t e r , two i n Burnaby and one i n Port Coquitlam.  Thus  a l l the homes were l e s s than an hour's d r i v e of the h o s p i t a l , and could be r e a d i l y reached i n an emergency. Numbers of boarders i n the homes ranged between one and t h i r t e e n . f i v e and s i x .  But average numbers were between  Some homes catered e x c l u s i v e l y f o r  mental p a t i e n t s while others received both mental Hollingshead, August B., and R e d l i c h , Frederick C , S o c i a l Class and Mental I l l n e s s , New York, John Weley and Sons Inc.  -64-  and welfare c l i e n t s . Most p a t i e n t s shared rooms w i t h one o r two other boarders. varied.  Standards of t a s t e and comfort  The home w i t h the highest standards was  chosen by a p r i v a t e p a t i e n t , whose means enabled h e r to pay a rate of $125.00 a month.  This home also had  male boarders placed by the Department o f Veterans Affairs.  I n a l l homes where p a t i e n t s from East Lawn  were l i v i n g on s o c i a l a s s i s t a n c e , women boarders only were received. The homes a l l had t e l e v i s i o n .  I n some homes  boarders had t h e i r own lounge; i n others i t was shared w i t h the f a m i l y .  The i n t e r e s t taken by the sponsors  i n t h e i r boarders v a r i e d a good d e a l .  Some sponsors  d i d l i t t l e beyond p r o v i d i n g adequate food, s h e l t e r and s u p e r v i s i o n , so that i n these homes p a t i e n t s were l a r g e l y dependent on each other, o r on a few v i s i t s w i t h r e l a t i v e s and f r i e n d s , f o r companionship and r e c r e a t i o n . Other sponsors took considerable trouble i n promoting s o c i a l a c t i v i t i e s and community contacts f o r p a t i e n t s , and i n encouraging p a t i e n t s who f e l t ready to seek work. The s o c i a l worker u s u a l l y v i s i t e d the p a t i e n t on a weekly basis d u r i n g the f i r s t month u n t i l she  -65-  became After  assured this  monthly  that  gradually  schedule.  However,  needed  course  the  of  reassured. the  to  of  former  urgent  consultation had  perhaps  decision  until  were  unusual  the  times they  behaviour visits  patients  during  became  by  the  more  Indicating might  social  patient  the  required  lead  psychiatrist after  " s i z e d up" that  a  dependent  sometimes  These  the  to  should  to  the  worker, be  a  and  returned  hospital. After  found  that  the  of  s i x months  the  h o s p i t a l owing  thirteen  had  maintaining of  been  extended  several  two  symptoms.  situation  to  or  with  " s e t t l e d down".  extremely  visits  reported  had  became  visited  week  Emergency  sponsor  a  be  first  return  to  patient  visits  sometimes  if  the  the  five  office  to  recurrence outside.  themselves  work,  one  in  patients  was  a  to  contribute  were  widow  so  useful  refused  towards  her  to  the  sponsor  that  she  was  made,  seven of  Of  i t  had  was  returned  symptoms,  these,  while  four  were  f u l l - t i m e employment. single  given  the a  one  have  support. in  had  Two  age  thirty-  returned  thirty-five  and  to  women,  who  age  d o m e s t i c .employment,  woman w h o s e h u s b a n d  was  patients,  forty-six respectively,  obtained  placed,  a  remained  employed  and  twenty  check  was  a  who  return  She  made  f u l l - t i m e job  had  married  her  home w h e r e  to  home  or  herself  she there  was after  -66-  her probationary p e r i o d expired.  Some p a t i e n t s made a  good adjustment from the s t a r t , while others tended to be r e s t l e s s , s e c l u s i v e , quarrelsome  or complaining.  One paranoid p a t i e n t who had shown good progress i n h o s p i t a l , r a p i d l y d e t e r i o r a t e d i n the boarding home, wrote accusing l e t t e r s to the sponsor, refused to dress or bathe h e r s e l f , o r to eat the food provided, and was soon returned to h o s p i t a l . home s e t t l e d down h a p p i l y .  Other p a t i e n t s i n the  Another p a t i e n t "panicked"  as soon as she was out of h o s p i t a l , demanding to be returned the next day. With help from the s o c i a l worker, she was g r a d u a l l y able to overcome her f e a r of l i v i n g outside the h o s p i t a l , and i s one of those p a t i e n t s who are now s e l f - s u p p o r t i n g . I t was not p o s s i b l e to determine what l e d to the breakdown of those p a t i e n t s who needed to come back to h o s p i t a l , but the s o c i a l worker considered that i n most cases f a i l u r e to take the medication p r e s c r i b e d was an important c o n t r i b u t i n g f a c t o r . drugs cannot i n themselves  Although t r a n q u i l i z i n g  cure mental i l l n e s s , they are  of great value i n c o n t r o l l i n g psychotic symptoms.  It is  therefore of e s p e c i a l importance that p a t i e n t s l i v i n g i n boarding homes should be r e g u l a r l y supervised i n the t a k i n g of these medications.  Family  Care  Human l i f e society to a  IV  a s a Means  to  Rehabilitation  within  t h e medium o f  i s lived  o r "communities".  a mental  hospital  breakdown  society. article  i s the social  1  program  i s the degree  people  enough, doubly the  but as Teicher difficult  negative  illness. supervised the  points  Social test  o r middle  Worker"  of  i tsuccessfully being.  This  psychi-  restores  i s true  out, the process i s patient  o r half-way ways  mental  such as  houses,  t o cope  because o f  towards  or i t s variations  homes  recent  f o rany treatment  i n t h e community  care",  boarding  intermediate  t o which of well  In a  r e h a b i l i t a t i o n of the  f o rthe psychiatric  attitudes  "Family  the acid  justification  to a state  so b e c a u s e o f  has r e i t e r a t e d  Welfare,  comes  normally i n  of the Psychiatric  i n Canadian  -The o n l y  does  to function  Teicher  o n "The R o l e  treatment  o r woman who  f o rtreatment,  patient.  i l l  T h e man  i n h i sability  As Morton  published atric  CHAPTER  with  i s one o f this  problem.  T e i c h e r , M o r t o n I . , "The R o l e o f t h e P s y c h i a t r i c S o c i a l Worker", C a n a d i a n W e l f a r e . March 1952.  -68-  Within the l a s t few decades, great advances have been made i n the treatment o f the mentally  s i c k through  the use o f many new techniques and t h e r a p i e s , but, when the p a t i e n t ' s i l l n e s s i s s u f f i c i e n t l y i n remission f o r him to leave h o s p i t a l , r e j e c t i n g community a t t i t u d e s may undo much of the progress he made there.  Social  i s o l a t i o n o f the p a t i e n t can contribute t o a recurrence of symptoms and to an e a r l y re-admission  to h o s p i t a l .  The f o s t e r home provides a s e t t i n g where the p a t i e n t can f e e l secure and welcome, and where, with the help of the s o c i a l worker and the sponsor, and f e l l o w members of the household, he can f i n d s a t i s f a c t i o n i n everyday l i v i n g . Some of the p h i l o s o p h i c a l and p r a c t i c a l assumpt i o n s of s o c i a l work include r e c o g n i t i o n and acceptance of each i n d i v i d u a l as a s e l f - r e s p e c t i n g person no matter what h i s state of h e a l t h ; r e c o g n i t i o n of the r i g h t o f every person to a "health and decency" standard of l i v i n g and to o p p o r t u n i t i e s to experience s a t i s f y i n g human r e l a t i o n s h i p s ; r e c o g n i t i o n that the r i g h t o f the i n d i v i d u a l and of s o c i e t y are i n t e r - r e l a t e d ; r e c o g n i t i o n that progress i n s o c i a l welfare a r i s e s from broad communi t y understanding, as w e l l as c r e a t i v e c o n t r i b u t i o n s by i n d i v i d u a l s and p r o f e s s i o n a l groups.  1  "'"Sutherland, Robert M., The R e h a b i l i t a t i o n of Disdharged Mental P a t i e n t s , Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1954, p. 78.  -69-  The s o c i a l worker's approach towards helping the p a t i e n t e f f e c t a more s a t i s f a c t o r y s o c i a l adjustment i s of a two-fold nature.  He may  apply c e r t a i n p s y c h o l o g i c a l  methods to decrease the p a t i e n t ' s emotional s t r e s s and c o n f l i c t s ; or he may,  with the consent of the p a t i e n t ,  intervene to change the environment.  Dr. R, F, Tredgold,  i n a book on mental i l l n e s s published i n 1958, Bridging the Gap,  entitled  emphasizes the f a c t that the p s y c h i a t r i c  s o c i a l worker i s t r a i n e d to help people involved i n domestic, occupational and personal problems associated w i t h p o t e n t i a l p s y c h i a t r i c breakdown, and to help those who have been i n h o s p i t a l to adjust themselves to community l i f e on d i s c h a r g e .  1  This assistance can  be  given i n countless ways, not only by p r a c t i c a l measures such as h e l p i n g p a t i e n t s to obtain s u i t a b l e jobs and to make use of a v a i l a b l e s o c i a l s e r v i c e s , but also i n l e s s t a n g i b l e ways -g  e.g..by r e s t o r i n g broken s o c i a l con-  t a c t s , encouraging s e l f - c o n f i d e n c e , or by merely lending a sympathetic ear to the p a t i e n t ' s troubles u n t i l confidence i s e s t a b l i s h e d . Family Care as a Therapeutic Device. This t h e s i s has pointed out some of the s p e c i a l needs of mental p a t i e n t s , p a r t i c u l a r l y i n the p r o v i s i o n of employment and t r a i n i n g , economical l i v i n g accommod a t i o n , adequate s o c i a l a s s i s t a n c e , medical s e r v i c e s , T r e d g o l d , R. F., Bridging the Gap, London, 1958, pp. 1 7 0 - 1 7 1 . 1  Christopher Johnson,  -70-  and o p p o r t u n i t i e s f o r s o c i a l l i f e .  A t t e n t i o n has been  p a r t i c u l a r l y focused on the needs of mental p a t i e n t s ready f o r discharge from h o s p i t a l , who have no homes to which they can go, but are s t i l l unable to manage without some s u p e r v i s i o n .  This has l e d to a c o n s i d e r a t i o n  of the family care home as a therapeutic l i v i n g s i t u a t i o n to meet the needs of t h i s s p e c i a l group of p a t i e n t s . The r e l a t i v e merits of f a m i l y care and boarding homes can also be b e t t e r assessed by reference to t h i s experience. The review of f o s t e r care f o r mental p a t i e n t s makes i t c l e a r that i t has been i n use i n Europe f o r several c e n t u r i e s , and also has a longer h i s t o r y i n the United States than might be at f i r s t supposed. Although introduced there i n 1885,  i t i s only w i t h i n  the l a s t t e n years o r so that i t has been widely  taken  up i n North America. From t h i s experience several gains and "leads" are already evident.  Many techniques have been used i n  the motivation of the p a t i e n t towards l e a v i n g h o s p i t a l , and i n f u r t h e r i n g the r e s o c i a l i z a t i o n process through the use of group a c t i v i t i e s .  Emphasis has-been placed  on i n t e g r a t i n g h o s p i t a l and community services i n the i n t e r e s t of the p a t i e n t .  Family care i s seen not only  -71-  a s a means o f p r o v i d i n g a more s a t i s f a c t o r y way o f life  f o r t h e p a t i e n t who w i l l  manage o n h i s own, b u t a l s o has  a good p r o s p e c t In  to assist  never  been used  be a b l e t o  t h e p a t i e n t who  o f a r e t u r n t o independent  Canada, f a m i l y c a r e h a s n o t been  developed,  Hospital  probably  living.  widely  t h o u g h s u p e r v i s e d b o a r d i n g home p l a c e m e n t h a s i n most p r o v i n c e s .  at Essondale,  As t h e P r o v i n c i a l  British  C o l u m b i a , h a s one o f t h e  most a c t i v e p r o g r a m s o f b o a r d i n g home p l a c e m e n t , was  chosen f o r t h e study  patients to  (from  these p a t i e n t s s u f f e r e d illness,  paranoid  diagnosis.  this  o f a r e p r e s e n t a t i v e group o f  t h e E a s t Lawn u n i t ) r e c e n t l y  b o a r d i n g home c a r e .  Mental  discharged  The g r e a t e s t p r o p o r t i o n o f from  some form  schizophrenia being  of schizophrenic the predominant  The m a j o r i t y o f t h e m a r r i e d p a t i e n t s h a d  u n s a t i s f a c t o r y m a r i t a l r e l a t i o n s h i p s which p r e c l u d e d return to their marital partners. had of  no f a m i l i e s  t o whom t h e y  t h e group had a low l e v e l  Most o f t h e p a t i e n t s  c o u l d go, w h i l e of education,  employment r e c o r d w i t h a few e x c e p t i o n s was  60 p e r c e n t  while  consistently  65 p e r c e n t o f t h e p a t i e n t s were  poor.  Although  living  outside the h o s p i t a l  after  b a t i o n a r y p e r i o d had e x p i r e d , only  their  still  t h e s i x months p r o 20 p e r c e n t o f t h e  -72-  total in  group had succeeded i n e s t a b l i s h i n g themselves  full  employment.  I t proved d i f f i c u l t  to determine  why some p a t i e n t s had succeeded w h i l e o t h e r s Examination o f these experience,  both suggest that  t o be p e r f e c t e d  for assessing  f o r b o a r d i n g home o r f a m i l y applied  cases,  and o f comparative  further techniques patients  care;  i n the h o s p i t a l before  failed.  need  who a r e s u i t a b l e  a n d t h e s e must be  the patient  leaves.  1  A l t h o u g h many f a c t o r s a r e t a k e n i n t o c o n s i d e r a t i o n i n referring  a patient  symptoms, a b i l i t y ability  to look  to get along  a f t e r personal  tain psychological in  f o r care,  the p a t i e n t ' s  such as r e m i s s i o n o f with fellow  n e e d s , and so on,  f a c t o r s w h i c h may b r i n g a b o u t  adjustment  experiment within has  cerfailure  t o t h e home may be o v e r l o o k e d .  In M i n n e s o t a , one o f t h e V e t e r a n s Hospitals  patients,  Administration  ( a t S t . Cloud) i s c a r r y i n g out a unique i n s e t t i n g up a c e n t r a l i z e d m o t i v a t i o n  i t s existing hospital f a c i l i t i e s .  a two-fold  purpose:  (1) to motivate  2  clinic  The c l i n i c suitable  Mr. Eugene E l m o r e , i n an a n a l y s i s o f a g r o u p o f g e r i a t r i c p a t i e n t s , h o s p i t a l i z e d f o r mental i l l n e s s i n the Home f o r t h e Aged, P o r t C o q u i t l a m , B. C , h a s d e v i s e d a number o f r a t i n g s c a l e s f o r a s s e s s i n g t h e r e a d i n e s s o f patients f o r discharge. He c o n s i d e r s t h a t f a m i l y c a r e i s a u s e f u l r e s o u r c e f o r quiet, c h r o n i c p a t i e n t s ; and c o u l d a l s o be d e v e l o p e d f o r s e n i l e p a t i e n t s who no l o n g e r need i n s t i t u t i o n a l c a r e . E. Elmore, D i s c h a r g e P l a n n i n g i n t h e Homes f o r t h e Aged, M a s t e r o f S o c i a l Work T h e s i s , U n i v e r s i t y o f B r i t i s h Columbia, 1 9 5 9 . ^ F a m i l y Care o f P a t i e n t s , P l a n f o r M o t i v a t i o n C l i n i c , Veterans A d m i n i s t r a t i o n H o s p i t a l , ^ t . Cloud, Minnesota.  -73-  patients, the  who  are  r e l u c t a n t to  h o s p i t a l , t o d e s i r e a new  vide  a testing period  ready to  leave  and  leave  who  of  ( 2 ) to  pro-  seemingly  psychotic.  By  those p a t i e n t s  r e f e r r e d f o r placement are  c l i n i c a l team, w h i c h makes t h e  Accepted patients  are  final  screened  h o u s e d i n a s p e c i a l ward where treatment according  to  detailed plan  by  group  individual community  ability  get  to  plan  vocational  t o new  tunities  e.g.  with others,  and  extent  i n general  strength  social  work  to the  The  patient's  assign-  ability  supportive  placement  the  oppor-  available.  Those p a t i e n t s who  show s u s t a i n e d  progress  are  moved t o a n o t h e r ward f o r a more i n t e n s i f i e d p r o g r a m motivation The  to  super-  i t seeks to determine  in relation  or  programs,  contact, of  a  counselling.  s i t u a t i o n s , new  situations requiring  patient's  team —  i s d i r e c t e d toward t e s t i n g the  adjust  required;  the  special service  e x p e r i e n c e s and  along  vision  formulated  psychotherapy,  therapeutic  by  selection.  each i n d i v i d u a l r e c e i v e s  ments,  who  fail. Patients  a  are  superficially  t h i s means i t i s h o p e d t o e l i m i n a t e might  security  environment;  f o r others  not  the  and  preparation  whole g e n e r a l  towards r e l e a s e  atmosphere of  this  of  from h o s p i t a l .  ward i s  organized  -74-  to  ; s i m u l a t e as n e a r l y as p o s s i b l e l i f e  hospital.  P a t i e n t s s e l e c t e d are expected  increasing ability own a f f a i r s . use  t o show  t o assume r e s p o n s i b i l i t y  f o r their .  The p a t i e n t s a r e g i v e n l a t i t u d e  o f passes,  visiting  outside the  funds,  visits  into  i n the  t h e community,  p r o s p e c t i v e f a m i l y c a r e homes, a l o n e  or with  team members, a n d i n t h e g e n e r a l h a n d l i n g o f t h e i r affairs. of  P a t i e n t s a r e encouraged to use the p r i n c i p l e  self-government  on b o t h wards as a means o f s t i m u l a t -  ing  them t o a c c e p t  and  i n making d e c i s i o n s f o r themselves. The  for  responsibility  t o be f u l l y  hospitals  f o r determining  a d v a n t a g e from  a useful  a f a m i l y care placement.  there are obvious  r o l e s here  Homes v e r s u s  Boarding  Family  This  approach i n other  the p a t i e n t ' s a b i l i t y  w i t h the p a t i e n t and i n u t i l i z i n g  Boarding  behaviour,  assessed, but  r e p o r t e d so f a r h a v e been e n c o u r a g i n g .  "motivation c l i n i c " suggests  Both i n l i a i s o n  community  f o r social  to gain  resources,  workers.  Care.  home p l a c e m e n t h a s g e n e r a l l y been  as a n a l t e r n a t i v e in  f o r t h e i r own  c l i n i c has n o t been I n o p e r a t i o n l o n g enough  t h e m e r i t s o f i t s program  results  own  used  t o a f a m i l y c a r e home, and, i n f a c t ,  some i n s t a n c e s i t may  even approximate to a f a m i l y  -75-  care s i t u a t i o n .  Experience i n B r i t i s h Columbia has  demonstrated that supervised boarding home placement can be a move along the road to s e l f - r e s p o n s i b i l i t y and independence i n the community.  The f i r s t step i n  t h i s d i r e c t i o n i s u s u a l l y a part-time job, which not only gives the man o r woman the absorption of work i n i t s e l f , but enables the p a t i e n t to contribute towards h i s support i n the home. However, present s o c i a l a s s i s t ance r e g u l a t i o n s i n B r i t i s h Columbia place obstacles i n the way of t h i s mode o f r e h a b i l i t a t i o n f o r the boarding home p a t i e n t .  As already mentioned, the rate paid f o r  s o c i a l assistance r e c i p i e n t s i n need of boarding home care i s up to  $85.00  per month, but the general  social  assistance rate f o r one person responsible f o r h i s own l i v i n g arrangements i n the community i s only month.  $66.00  per  Thus, as soon as a p a t i e n t ' s earnings reach  t h i s f i g u r e , he i s no longer e n t i t l e d to s o c i a l a s s i s t ance, which means he i s u s u a l l y o b l i g e d to f i n d a room f o r himself elsewhere. To c i t e an example, one member of the group of twenty p a t i e n t s from East Lawn, with a long h i s t o r y of mental i l l n e s s , was discharged f i v e other p a t i e n t s resided.  to a boarding home where She made an e x c e l l e n t  adjustment i n the home, soon showing i n i t i a t i v e i n  -76-  seeking was  part-time  successful  work i n a c a f e  i n this,  working time.  I n t h i s way she i n c r e a s i n g l y c o n t r i b -  her monthly earnings  She  But t h e time  jumped f r o m  she was no l o n g e r was o b l i g e d  eligible  came when  $60.00 t o $75.00, so f o rsocial  assistance.  to e s t a b l i s h h e r s e l f i n a housekeeping  room, w h i c h m i g h t be a " p r o m o t i o n " f o r a n o r m a l but  She  e a c h month e x t e n d i n g h e r  u t e d t o w a r d s h e r own s u p p o r t .  that  washing d i s h e s .  f o r her i t could  be d a n g e r o u s ,  since  person;  she s t i l l  n e e d e d t h e s u p p o r t a n d p r o t e c t i o n w h i c h t h e home p r o vided.  This  i s a n anomaly  n e e d s t o be r e c t i f i e d , self-supporting,  i n the regulations  so t h a t p a t i e n t s  which  who h a v e become  b u t u n a b l e t o a f f o r d t h e b o a r d i n g home  r a t e , may c o n t i n u e  to reside  i n t h e home i f t h e y so  desire. Although the present b o a r d i n g home c a r e met  arrangements f o r s u p e r v i s e d  f o r discharged  with a considerable  mental p a t i e n t s  measure o f s u c c e s s ,  this  of placement n e c e s s a r i l y has i t s l i m i t a t i o n s . doubtful care  i f they  program.  should  circumscribed  in  i t s choice  method  It i s  be a s u b s t i t u t e f o r a f a m i l y  Under t h e p r e s e n t  is  have  system,  by D e p a r t m e n t o f W e l f a r e  the h o s p i t a l regulations,  o f home, c o n t r o l o f s u p e r v i s i o n ,  and i n  -77-  making f i n a n c i a l arrangements f o r the p a t i e n t . The h o s p i t a l s o c i a l worker, through h i s s p e c i a l i z e d t r a i n i n g and experience and h i s close contact w i t h the p a t i e n t i n h o s p i t a l , best understands the needs of the p a t i e n t .  The h o s p i t a l s o c i a l worker, i n consulta-  t i o n w i t h h i s department, i s the person best q u a l i f i e d to s e l e c t the home, to supervise both the p a t i e n t and the sponsor of the home, and to introduce or encourage appropriate s o c i a l and group a c t i v i t i e s .  I t i s the  h o s p i t a l s o c i a l worker who can most e a s i l y detect a recurrence o f the p a t i e n t ' s former symptoms so that these may be brought to the a t t e n t i o n of the p s y c h i a t r i s t at the e a r l i e s t opportunity.  Perhaps a r e t u r n to  h o s p i t a l , a change of medication, o r a change to another home, may be i n d i c a t e d .  Under present conditions of  boarding home placement i n B r i t i s h Columbia, s u p e r v i s i o n may take several forms.  I t may be c a r r i e d out by the  h o s p i t a l s o c i a l worker, i t may be taken over by the municipal or p r o v i n c i a l worker, o r i t may be a j o i n t undertaking.  However cooperative the other municipal  or p r o v i n c i a l department may be, t h i s method of working i s not as s a t i s f a c t o r y as where the h o s p i t a l worker has f u l l r e s p o n s i b i l i t y f o r supervision. V/hen the h o s p i t a l i s dependent upon the a v a i l a b l e  -78-  boarding home v a c a n c i e s o f f e r e d by another department, the placement, though adequate, may i n i t s e l f be a compromise.  The h o s p i t a l worker may have p r e f e r r e d a  different setting for his patient,  but h i s choice i s  l i m i t e d by the v a c a n c i e s p r e s e n t e d .  F u r t h e r , when the  h o s p i t a l i s i n a p o s i t i o n t o choose the home and e v a l u a t e the  sponsor, a c l o s e r working r e l a t i o n s h i p i s l i k e l y t o  develop between the h o s p i t a l s o c i a l worker and the sponsor than i n the present s i t u a t i o n ; under t h i s , the h o s p i t a l s o c i a l worker s u p e r v i s e s a p a t i e n t which- has  been l i c e n s e d by the Department o f Welfare  for s o c i a l assistance care.  i n a home  r e c i p i e n t s i n g e n e r a l i n need o f  The sponsor n a t u r a l l y f e e l s that h e r c h i e f  r e s p o n s i b i l i t y i s to the department which has l i c e n s e d her home.  I n s p i t e o f these d i f f i c u l t i e s ,  the success  achieved c e r t a i n l y r e f l e c t s the c l o s e degree o f coopera t i o n which e x i s t s between t h e h o s p i t a l s o c i a l  service  s t a f f and the S o c i a l Welfare Branch. C r i t e r i a f o r Family Care. The  Veterans A d m i n i s t r a t i o n ,  in' i t s r e p o r t  Washington, D. C ,  on i t s f o s t e r home program, to which  r e f e r e n c e has a l r e a d y been made i n Chapter I I , suggests a number o f ways i n which a f o s t e r care program may be initiated.  I t i s p o i n t e d out that  special  attention  -79-  should be p a i d towards o r i e n t i n g the e n t i r e h o s p i t a l s t a f f towards the program so that they understand i t s f u n c t i o n and the r o l e they may play i n i t .  Not only  can members o f the s t a f f help i d e n t i f y p a t i e n t s who might b e n e f i t from family care, but they can promote community I n t e r e s t i n i t by d i s c u s s i n g i t with r e l a t i v e s and f r i e n d s .  The community also needs to be o r i e n t e d  to the program, which can be done through p u b l i c a t i o n of a r t i c l e s i n the newspapers, t a l k s on the radio and T. V., l e c t u r e s to community groups, and so on. In conclusion, the j o i n t evidence of the comparat i v e studies examined i n t h i s survey, and a review o f the e x i s t i n g arrangements f o r boarding home care i n B r i t i s h Columbia, make p o s s i b l e a check l i s t of basic c r i t e r i a f o r a sound family care program.  The w r i t e r  would suggest the f o l l o w i n g : (1)  O r i e n t a t i o n of h o s p i t a l employees and the community  to the program. (2)  Preparation of the p a t i e n t :  i f p o s s i b l e through  motivation techniques and s c i e n t i f i c a l l y planned t e s t i n g periods:  i f not, at l e a s t by general c o u n s e l l i n g and  s o c i a l work i n t e r v i e w s . (3)  S u f f i c i e n t number of s o c i a l workers to p a r t i c i p a t e  i n the e v a l u a t i o n and preparation o f p a t i e n t s f o r home  -8ocare, and (4)  f i n d i n g the homes, and s u p e r v i s i n g  the p a t i e n t  the sponsor i n the home. Sponsors who are p e r s o n a l l y  c a r i n g f o r mental p a t i e n t s ,  s u i t e d to the task o f  and who have the a b i l i t y  to cooperate with the s o c i a l worker.  Some degree o f  f i n a n c i a l s t a b i l i t y o f the sponsor i s a l s o necessary. (5)  Adequate p h y s i c a l  standards i n the home; and pro-  v i s i o n o f s u f f i c i e n t and s u i t a b l e food. (6)  P r o v i s i o n of medical services f o r patients. .  (7)  Provision  of c l o t h i n g , money f o r i n c i d e n t a l ex-  penses and comforts allowances, f o r p a t i e n t s  without  means. (8)  Encouragement o f a p p r o p r i a t e  patients,  both w i t h i n  social activities f o r  the home and i n the o u t s i d e  community. (9)  Homes o f v a r y i n g  s i z e s to meet the needs o f d i f f e r e n t  patients. (10)  Location  transportation of  o f the home w i t h i n  easy access o f p u b l i c  and community f a c i l i t i e s f o r the b e n e f i t  patients. I t goes without saying  t h a t no program w i l l be  adequate without s u f f i c i e n t funds.  There i s danger t h a t  such a program could be s e i z e d upon as a measure o f administrative  economy to make more beds a v a i l a b l e f o r  -Si-  new  cases, without due  regard  to the  capacity  p a t i e n t to b e n e f i t from home placement, and regard  to the p r o v i s i o n of a t h e r a p e u t i c  patient. and  the  The  program cannot be  the  without  due  m i l i e u f o r the  served by money alone,  check l i s t brought t o g e t h e r above may  an a i d i n the p l a n n i n g  of  serve as  or d e v e l o p i n g o f f u r t h e r programs  of t h i s k i n d . Conclusion. The  broad c o n c l u s i o n  u s e f u l device for  f a c t o r y way  care" i s a  i n the r e h a b i l i t a t i o n of the m e n t a l l y 111  a l s o as a means of p r o v i d i n g a more s a t i s -  of l i f e  the p a t i e n t who situation.  than the h o s p i t a l environment f o r  w i l l need a continued s u p e r v i s e d  Anyone who  living  has v i s i t e d a boarding home where  "inmates" s i t i n t h e i r rooms, s t a r i n g i n t o space,  awaiting how  "family  the p a t i e n t f o r whom r e t u r n to independent l i v i n g , i s  the g o a l ; and  the  i s that  the d i v e r s i o n of the next meal, w i l l r e a l i z e  a home placement can become a t o t a l f a i l u r e i n pro-  v i d i n g a s a t i s f y i n g and concerned.  useful l i f e  f o r the i n d i v i d u a l  I t i s not merely enough to p l a c e  a patient  i n a home where p h y s i c a l standards are adequate.  The  p a t i e n t needs to be encouraged i n many a c t i v i t i e s  to  aid  in his resocialization.  In t h i s process the warmth,  —  -82-  understanding and i n g e n u i t y of the g r e a t e s t The  o f the sponsor a r e f a c t o r s  importance.  p r o v i s i o n o f adequate s e r v i c e s f o r the r e -  i n t e g r a t i o n o f the p a t i e n t i n t o community l i v i n g  will  u l t i m a t e l y depend on the acceptance by the community o f the r e s p o n s i b i l i t y f o r such s e r v i c e s , and on t h e i r a b i l i t y t o welcome the p a t i e n t back again i n t o t h e i r midst.  There has been much d i s c u s s i o n o f the r e h a b i l i -  t a t i o n o f the mental p a t i e n t ; but the community  itself,  which, f o r so long, has consigned the m e n t a l l y i l l to the  s e c l u s i o n o f mental h o s p i t a l s , must a l s o p l a y i t s  part i n r e h a b i l i t a t i o n . be done i n h e l p i n g  There i s a s o c i a l work  job.to  s e t up adequate family, care,  and i n  i n t e r p r e t i n g i t to the "community" i n i t s many g u i s e s .  -83-  APPENDIX A Form of l e t t e r addressed to Chiefs of S o c i a l Service i n U, S. State Departments of Hygiene, or Veterans A d m i n i s t r a t i o n H o s p i t a l s , requesting  informa-  t i o n on family care programs.  Address Date Mr. Chief of S o c i a l Service, State Department of Hygiene, or Veterans A d m i n i s t r a t i o n H o s p i t a l , Address. Dear Mr. I am a student a t the U n i v e r s i t y of B r i t i s h Columbia completing my s o c i a l work degree, and have chosen as the subject of my MSW t h e s i s "Family Care Homes f o r Mental P a t i e n t s . ' In t h i s connection I am anxious to obtain p a r t i c u l a r s regarding family care programs f o r mental p a t i e n t s i n the United States, and I wonder whether you would be kind enough to give me some information as to what arrangements you have i n f o r p a t i e n t s discharged from mental h o s p i t a l s who are not considered capable of managing on t h e i r own without some s u p e r v i s i o n , and who have no r e l a t i v e s to whom they can r e t u r n . I f any surveys have been completed as to the type of p a t i e n t r e f e r r e d f o r care or the type of home, t h i s would be very h e l p f u l , or any published or mimeographed m a t e r i a l r e l a t i n g to general p o l i c i e s . Any information you could l e t me have i n t h i s connection would be very much appreciated. Thanking you, Yours very  truly,  -84APPENDIX B Bibliography B. C. P r o v i n c i a l Health Services P h y s i c i a n ' s Manual, 1951. C a l i f o r n i a , State Department of Mental Hygiene, Family Care Program (mimeographed), Family Care. Technique and Achievement, September, I960 (prepared f o r the Monthl y Report to the Governor), personal l e t t e r from Miss Lexie Cotton, Supervising P s y c h i a t r i c S o c i a l Worker I I , dated December 21, I960. Chiesman, W. E., "Return to Work", i n Ling, Thomas M., and O'Halley, C. J . S., R e h a b i l i t a t i o n , London, B a i l l e r e , T i n d a l l & Cox, 1958. Chud, B., D i r e c t o r , F i r s t Annual Report of the White Cross S o c i a l Centre, Vancouver, B. C , I960. Crutcher, Hester B., Foster Care f o r Mental P a t i e n t s , The Commonwealth Fund, New York, 1944. De Ropp, Robert S., Drugs and the Mind, New York, St. Mart i n ' s Press, 1957. Department of S o c i a l Welfare (B. C ) , Admission Form Licensed Boarding Home o r P r i v a t e H o s p i t a l ) S.W. 151-0. Deutsch, A l b e r t , The Mentally 111 i n America, Doubleday, Doran and Company Inc., Garden C i t y , New York, 1937. De Witt, H e n r i e t t a B., The F o s t e r Care Placement of State Mental H o s p i t a l P a t i e n t s : Maryland P l a n , 1954 (mimeographed). '. Elmore, Eugene, Discharge Planning i n the Homes f o r the Aged, Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1959. F i s h e r , Saul H.. "The Recovered P a t i e n t Returns to the Community , Mental Hygiene, October, 1958. Foster Home Program f o r Improved P s y c h o t i c P a t i e n t s , Veterans A d m i n i s t r a t i o n , Washington, D. C , January, I960.  -85-  Ginsburg, Sol V/., "The Mental Health Movement and I t s T h e o r e t i c a l Assumptions", published i n Kotinsky, Ruth, and Witmer, Helen L., Community Programs f o r Mental Health, The Commonwealth Fund, Harvard U n i v e r s i t y Press, Massachusetts, 1 9 5 5 . Glasmann, Rebecca, Chief, S o c i a l Work Service, Veterans A d m i n i s t r a t i o n H o s p i t a l , Bedford Massachusetts, copy of l e t t e r dated January 1 5 , 1 9 5 9 , to Chief S o c i a l Worker, Veterans A d m i n i s t r a t i o n H o s p i t a l , Downey, I l l i n o i s . Goals of P u b l i c S o c i a l P o l i c y , National A s s o c i a t i o n of S o c i a l Workers, New York, 1 9 5 8 . Goodwin, Harold George, F o s t e r Care f o r the Mentally 1 1 1 , Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, i 9 6 0 . Hollingshead, August B., and R e d l i c h , F r e d e r i c k C , S o c i a l Class and Mental I l l n e s s , New York, John Weley and Sons, Inc. Idaho, Family Care Brochure, State H o s p i t a l North, Orofino, Idaho, National I n s t i t u t e of Mental Health P r o j e c t (thermofax copy), Idaho Department of Mental Health, r e c e i v e d from T. R. Mager, Chief, S o c i a l Service Department, March 2 0 , I96I. Jones, Maxwell, The Therapeutic Community, Basic Books Inc., New York, 1 9 5 3 . Kentucky, Is Yours an Understanding Community? Kentucky Department of Mental Health, H. L. McPheeters, Commissioner, August, i 9 6 0 . Knee, Ruth I r e l a n , and Lamson, Warren C , "Mental Health and Mental I l l n e s s " , p u b l i s h e d i n S o c i a l Work Year Book i 9 6 0 , New York, National A s s o c i a t i o n of S o c i a l Workers. Leveen, Louis, and P r i v e r , David, "A R e h a b i l i t a t i o n Centre f o r the Discharged Mental H o s p i t a l P a t i e n t " , S o c i a l Casework, December, 1 9 5 9 . Massachusetts, Family Care Committee of the Massachusetts Mental Health, S o c i a l Workers A s s o c i a t i o n , 1 9 5 1 , Family Care Manual (corrected f o r 1 9 6 1 ) .  -86-  Mental H o s p i t a l s Act, Province of B r i t i s h Columbia, 1940. and. C l i n i c s of P s y c h o l o g i c a l Medicine Act, Province of B r i t i s h Columbia, 1948. Michigan Department of Mental Health. Family Care Program December 19, I960 (mimeographed). Minnesota, Family Care of P a t i e n t s . Plan f o r M o t i v a t i o n C l i n i c . Veterans A d m i n i s t r a t i o n H o s p i t a l , St. Cloud, Minnesota. M i t c h e l l , S. Weir, F i f t i e t h Anniversary Address. Trans' a c t i o n s of the American Medico-Psychological A s s o c i a t i o n , as quoted by A l b e r t Deutsch i n The Mentally 1 1 1 i n America. New Jersey, Family Care Manual, D i v i s i o n of Mental Health and H o s p i t a l s , New Jersey Department of I n s t i t u t i o n s and Agencies, J u l y 1, 1 9 5 9 . Personal l e t t e r from Mrs. Eleanor Engelbrecht, P s y c h i a t r i c S o c i a l Work Consultant, State of New Jersey, Department of I n s t i t u t i o n s and Agencies, dated January 6, 196-1. Philosophy. Concepts and P r i n c i p l e s of S o c i a l Work. The U n i v e r s i t y of B r i t i s h Columbia, School of S o c i a l Work (mimeographed.) Pugh, Edward N., A Study of the Family Care Program. Veterans A d m i n i s t r a t i o n H o s p i t a l . Waco. Texas. Sutherland, Robert M., The R e h a b i l i t a t i o n of Discharged Mental P a t i e n t s . Master of S o c i a l Work Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1 9 5 4 . Teicher, Morton I . , "The Role of the P s y c h i a t r i c S o c i a l Worker", Canadian Welfare, March, 1 9 5 2 . Tredgold, R. F., Bridging the Gap. Christopher Johnson, London, 1 9 5 8 . Wisconsin, Family Care Manual. State Department of P u b l i c Welfare, D i v i s i o n of Mental Hygiene, Wisconsin.  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0105998/manifest

Comment

Related Items