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Post-discharge needs of mental patients without family resources : a study of a group of women who were… Kern, George Herman 1959

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POST-DISCHARGE HEEDS OF MENTAL PATIENTS WITHOUT FAMILY RESOURCES A study of a group of women who were formerly long-term patients at P r o v i n c i a l Mental H o s p i t a l , B. C , 1957 — 1958 hy GEORGE HERMAN KERN 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 1959 The U n i v e r s i t y of B r i t i s h Columbia i v ABSTRACT This study surveys the personal circumstances and s i t u a t i o n s upon discharge, of young women who have been i n the P r o v i n c i a l Mental Hos p i t a l a niimber of years, and have no home to which to return* I t was found that nine out of ten patients without usable family resources have problems of such a nature on discharge as to require the services of a s o c i a l worker. Their problems include obtaining work or maintenance to meet t h e i r basic needs of food, c l o t h i n g , and s h e l t e r . They a l s o need personal assistance and encouragement i n obtaining employment, making new friends and acquaintances, and p a r t i c i p a t i n g i n r e c r e a t i o n a l a c t i v i t i e s . The method used was to compile pertinent information from the h o s p i t a l f i l e s of patients aged t h i r t y - f i v e and under, who l e f t on "probationary discharge to s e l f " during a given one-year period ( a c t u a l l y , J u l y 1, 1957 "to June 5 0 , 1958)«„ Eighteen patients were found t o meet t h i s c r i t e r i a , whose cases could be studied extensively. The f i n d i n g s suggest that the average patient without family resources has come from a home i n which there has been much s t r e s s , and i s l i m i t e d i n educational, v o c a t i o n a l , and s o c i a l s k i l l s (e.g., l a c k of friends and acquaintances, r e l a t i o n s h i p s with the opposite sex, e t c . ) . S o c i a l workers, both at the h o s p i t a l and i n welfare agencies throughout B r i t i s h Columbia, were a c t i v e i n ' h e l p i n g approximately 90 percent of these patients meet t h e i r needs. Such help included making arrangements f o r finances, job f i n d i n g , accommodation f i n d i n g , t r a n s p o r t a t i o n , and providing emotional support. Only 56 percent of these patients were able to make an adjust-ment that d i d not r e s u l t i n re-admission to the h o s p i t a l : which suggests that follow-up, and a f t e r - c a r e programs should be strengthened to include more extensive use of hostels (such as the V i s t a i n Vancouver), and of family care programs. The p o s s i b i l i t y of smaller l o c a l centres f o r p s y c h i a t r i c care i s another idea that merits consideration, to avoid prolonged separation from the community i n which the patient i s to r e t u r n . In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It i s understood that copying or publication of this thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The University of B r i t i s h Columbia Vancouver $, Canada. • i i TABLE OF CONTENTS Chapter I . R e h a b i l i t a t i o n of the Mentally 111 Page H o s p i t a l i z a t i o n as a phase of i l l n e s s . Evolution of community r e s p o n s i b i l i t i e s . Mental h o s p i t a l s and the s o c i a l s e r v i c e s . S o c i a l Work i n the p s y c h i a t r i c h o s p i t a l . Discharge needs of mental patients and the concept of r e h a b i l i t a t i o n 1. Chapter I I . The Non-Family Patient Method of study. Primary f a c t s . Medical and s o c i a l diagnosis. Previous h o s p i t a l i z a t i o n . R e s p o n s i b i l i t y f o r probationary discharge • Conclusions 21. Chapter I I I . The Discharge S i t u a t i o n Employment. Income and f i n a n c i a l resources. Friends and s o c i a l contacts. S o c i a l s e r v i c e s . An assess-ment of the discharge s i t u a t i o n f o r the sample group 38• Chapter IV. The Non-Family Patient and Her Future The woman without a family. Services to supply the d e f i c i e n c i e s . P r o f e s s i o n a l and community contributions. R e h a b i l i t a t i o n and research. L i m i t a t i o n s ; f u r t h e r studies needed ' 61. Appendices: A. Sample Schedule Form. B. Bibliography i i i TABLES IN THE TEXT Page Table 1. Age D i s t r i b u t i o n of Patients 26 Table 2 . N a t i v i t y of Patients 26 Table 3 . M a r i t a l Status of Patients 26 Table 4« Educational Attainment of Patients 28 Table 5» P s y c h i a t r i c Diagnosis of Patients,. 29 Table 6 . Reasons f o r not L i v i n g with Relatives 36 Table 7» Occupation of Women at Time of Admission and A f t e r Discharge 44 Table 8. Referrals made to other Agencies to F a c i l i t a t e Discharge Planning. 51 • V ACKNOWIiEDGMEHTS I wish to express my appreciation and thanks to those whose i n t e r e s t and support have made t h i s study possible,, I p a r t i c u l a r l y acknowledge with gratitude the counsel and d i r e c t i o n given by the fol l o w i n g persons: Dr. Leonard C. Marsh and Mrs. Mary Tadych of the School of S o c i a l Work, Un i v e r s i t y of B r i t i s h Columbia; Dr. I. Kenning, Miss Dorothy Begg, and Mr. Jack E l l i s of the P r o v i n c i a l Mental H o s p i t a l , Essondale, B r i t i s h Columbia. POST-DISCHARGE MEEDS OF MENTAL PATIENTS WITHOUT FAMILY RESOURCES CHAPTER I REHABILITATION OF THE MENTALLY ILL I t i s often argued that no one can enjoy a complete l i f e t i m e with perfect mental health* Mental i l l n e s s , however, w i l l be thought of as i n v o l v i n g a disturbance of s u f f i c i e n t i n t e n s i t y and duration as to require a person ,s admittance to a p s y c h i a t r i c h o s p i t a l . The U.S. National I n s t i t u t e of Mental Health reports that i n 1954 the number of persons found i n state mental h o s p i t a l s was 340 per 100,000 i n the general population,-- This i s 0 . 3 4 $ of the population 9. The t o t a l number of mentally i l l i s c e r t a i n l y greater, however, considering that h o s p i t a l i z a t i o n i n a state i n s t i t u t i o n i s often only a l a s t r e s o r t used f o r the most extremely disturbed people* There are an uncounted number cared f o r i n out-patient c l i n i c s , or by p r i v a t e p r a c t i t i o n e r s , and many a l s o are making a marginal adjustment with the a i d of a s o c i a l agency or are bearing t h e i r i l l n e s s without assistance*; Many informed sources maintain that one out of every ten persons w i l l at some time require p r o f e s s i o n a l assistance i n dealing with h i s everyday personal problems. Another source 2 mentions that mental i l l n e s s s t r i k e s one family i n f i v e i n the community."* Much the same s i t u a t i o n e x i s t s i n Canada, On December 3 1 , 1936 J[ Noyes, Arthur P., and Kolb, Lawrence C. , Modern C l i n i c a l P s y c h i a t r y . "" F i f t h E d i t i o n , W.B. Saunders Company, P h i l a d e l p h i a , 1958. P. 6 8 . 2: Province of B r i t i s h Columbia, Department of P r o v i n c i a l Secretary, Mental Health Services Annual Report. 1957* Queen's P r i n t e r , V i c t o r i a , B.C. . P. Q 57 . « 2 -1 there were 71 ,000 patients r e c e i v i n g p s y c h i a t r i c care i n mental hospitals*"" This i s nearly 0*42$ of the e n t i r e Canadian population* In B r i t i s h Columbia on March 51» 1957 there were 6,279 mental p a t i e n t s i n residence i n 2 the P r o v i n c e ^ i n s t i t u t i o n s * " " Of these, 226 were h o s p i t a l i z e d at Crease C l i n i c at Essondale and 5*553 were h o s p i t a l i z e d i n the P r o v i n c i a l Mental 3 H o s p i t a l at Essondale*'*' At the P r o v i n c i a l Mental H o s p i t a l 176 were under the age of twenty-five, 1,784 were i n the age bracket twenty-six to f i f t y , 4 and 1,766 were age f i f t y and over* At f i r s t i t may seem s u r p r i s i n g that so few patients h o s p i t a l i z e d at the P r o v i n c i a l Mental H o s p i t a l are under the age of twenty-five* One would suppose, however, that those under t h i s age are given opportunity f o r treatment a t the Crease C l i n i c , i n the C h i l d Guidance C l i n i c s , and Mental Health Centre* A l s o , the younger people are responding to newer treatments e a r l y i n the course of i l l n e s s ; and t h i s i s evidence that the population 5 i n long-term treatment u n i t s tend to be an aging population* Not so long ago the layman's conception of a mentally i l l person was that he would have to spend the remainder of h i s l i f e i n a p u b l i c mental h o s p i t a l , were h i s i l l n e s s so severe that h o s p i t a l i z a t i o n were required* The a c t u a l f a c t i s that patients have been discharged from these 1_ G i l b e r t , J * E*, The Mental Health S i t u a t i o n i n Canada Today* Reprinted from Medical Services,Journal, Canada, Volume XIV, Number 7 , July-August, 1958* P. 478* 2 *' „ * Mental Health Services Annual Report. 1957* I b i d * , P* Q 21* j£ Loca C i t . i I b i d * , pp* Q 157^ -Q 159. 5* Personal Communication with S o c i a l Service Supervisor of East Lawn Un i t , Mr. Jack E l l i s . same hospitals for many years. It is entirely true that admission rates have shown steady increases throughout the years, hut, only recently, discharge rates have shown a slight increase over the admission rates. This, of course, is not due to one factor alone, hut to a number of causes. Increased knowledge has been gained regarding mental illness, and improved treatment techniques have been devised, notably in the areas of psychiatry, social work, psychology, and pharmacology. What is the actual situation in British Columbia today? Roughly one-third of the patient population is being discharged from the Provincial Mental Hospital annually 1 During the fiscal year from April 1, 1956 to March 51» 1957 there were 1,148 patients discharged in f u l l from the total 1 resident population of 5»555*~" The disposition of these discharges is even more significant. Prom this total of 1,148 patients discharged, 885 went home, three went to a general hospital, 206 went to another mental.hospital, 2 and.56 were discharged under "other1* circumstances."" More will be said later about the residual classification, "other", as i t is in many ways the theme of this thesis. It may be noted that 5 8 6 , or 54$» of a l l that were discharged were under thirty-five years of age". Hospitalization a phase of illness t The foregoing statistics clearly indicate that mental illness incapacitate many persons only during a temporary period in their lifetime. Hospitalization, then, is not necess-arily a permanent l i f e plan for a person should he become mentally i l l s Tne evidence is that most patients admitted to the Provincial Mental 1 Province of British Columbia, Department of Provincial Secretary, ~ Mental Health Services Annual Report. 1957. Ibid., p. Q 140. 2 Lqc. c i t . 2 Ibid., pp. Q 142—Q 145. Hospital become s i c k while l i v i n g at home, are then h o s p i t a l i z e d , and then return to t h e i r home when they are b e t t e r . This obviously, i s exactly the same pattern as f o r most other i l l n e s s e s . As with other i l l n e s s e s there are some that are more permanently i n c a p a c i t a t i n g than others, and therefore some patients w i l l need some form of h o s p i t a l i z a t i o n f o r very long, i n d e f i n i t e periods of time. Included i n t h i s group are persons f o r whom scienoe as yet does not have s u f f i c i e n t , 1 knowledge to help them make even a s o c i a l recovery.— An example of such a person would be one who i s severely disorganized due to extensive, i r r e v e r s i b l e b r a i n damage. The f a c t remains, however, that p a t i e n t s r e q u i r -i n g permanent h o s p i t a l i z a t i o n are not the bulk of patients admitted to mental h o s p i t a l s ; most patients are h o s p i t a l i z e d only temporarily. Other p a t i e n t s , f o r one reason or another, do not r e t u r n home a f t e r t h e i r i l l n e s s ; indeed, some have no home i n which to r e t u r n . This c e r t a i n l y does not mean that they must remain i n h o s p i t a l permanently. This i s the group of patients selected f o r the present study. Evolution of Commuuity R e s p o n s i b i l i t i e s . In a sense, people have always been concerned about the mentally i l l . Because of t h e i r unusual behaviour, which u n t i l comparatively recent times was thought to be beyond human understanding, the mentally i l l were viewed with a l l sorts of s u p e r s t i t i o n * T h e i r h e a l t h i e r contemporaries a l l too often viewed them as being possessed with s p i r i t s , demons, and d e v i l s * P r e v a i l i n g a t t i t u d e s throughout h i s t o r y tended to place mentally i l l persons f a r apart from the human race* Sometimes they were placed i n temples and worshipped—as though t h e i r behaviour was that of d i v i n e inspiration;* J[ A s o c i a l recovery r e f e r s to the s i t u a t i o n i n which a p a t i e n t , although s t i l l evidencing mild symptoms of mental i l l n e s s , i s able to h o l d a job, enjoy f r i e n d s , and so on. The q u a l i t y of t h i s adjustment i s s t i l l impaired by i l l n e s s , however* More frequently they were associated with the forces of e v i l , and execution 1 i n the most hideous of manners was deemed r i g h t and proper*— Even with the spread of more enlightened philosophies regarding the d i g n i t y of the i n d i v i d u a l , people were a l l too quick to have the mentally i l l removed from t h e i r midstV Gradually the mentally i l l were placed i n various i n s t i t u t i o n s ; j a i l s , workhouses, poorhouses, and other receptacles f o r humanity, Por the most part, conditions i n these i n s t i t u t i o n s were a p p a l l i n g , and the person so confined was kept i n chains and t r e a t e d much l i k e a w i l d beast. I n the l a t t e r part of the eighteenth century, there was some movement toward the development of welfare measures* As pointed out by Sutherland, these followed " i n the wake of progressive forces released by the p o l i t i c a l and s o c i a l revolutions i n America and Prance (1776 and x 2 1789/•H~ Alb e r t Deutsch presents an i n t e r e s t i n g account of the s e t t i n g i n which P h i l i p p e P i n e l undertook h i s great reforms i n the treatment of the 1 mentally i l l at the B i c e r t e Asylum i n Paris;*• P i n e l was given the post of Superintendent at that i n s t i t u t i o n by two of h i s f r i e n d s , Thouret and Cabanis, both of whom were elevated to the top of the P a r i s h o s p i t a l system 4 by the French revolutionary government. This was i n 1792 when the French Revolution was at i t s height* The same year P i n e l shattered a l l present t r a d i t i o n s by removing the chains from the p a t i e n t s , and thus introduced the method that was l a t e r designated as "moral treatment"* t Deutsch, A l b e r t , The Mentally 111 i n America; A H i s t o r y of Their Care and Treatment from C o l o n i a l Times, Doubleday, Doran and Company, Ine*, Garden C i t y , New York, 1937* P* 1* 2 Sutherland, Robert Murray, 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, Vancouver, B, C*, 1954. P. 3« j£ Deutsch, Op* c i t * , pp* 88—92, 4 I b i d , , p, 89* £ I b i d . , pp. 88—89. - 6 -The method of "moral treatment" was the use of humane procedures i n c a r i n g f o r the mentally i l l . I t r e f e r s to the then popular concepts of p r o v i d i n g patients with calm r e t r e a t i n the country and p r o t e c t i o n from 1 severe p h y s i c a l abuses."" The time was r i p e f o r reform and the r i s e of the era of moral treatment at the end of the eighteenth century. Working quite independently at the same time were Tuke, i n England; Rush, i n America; and C h i a r u g i . • ,.,2 i n Italy»r* Not only were chains and shackles removed from the mentally i l l , but other p r a c t i c e s such as b l o o d l e t t i n g were questioned, and abolished 1 i n at l e a s t one i n s t i t u t i o n . L e g i s l a t i o n was f i n a l l y enacted i n the nineteenth century f o r the public p r o v i s i o n and r e s p o n s i b i l i t y f o r a l l severely mentally i l l persons. "Moral treatment" was not marked by continuous progress, however. In North America during the f i r s t three decades of the nineteenth century, i t was not uncommon f o r mentally i l l persons to be s o l d at p u b l i c auction along with paupers;.- In some areas where l o c a l communities took r e s p o n s i b i l i t y f o r the care of the poor, confused people were often taken and "dumped" i n neigh-4 bouring towns i n the hope that someone else would care f o r them> The 1840»s saw the influence of Dorothea Lynde Dix, whose s o c i a l reforms gradually spread i n t e r n a t i o n a l l y . At the age of forty-one she was appalled by the conditions of the mentally i l l i n the j a i l at East Cambridge, Massachusetts, and was moved to such f e r v o r that f o r the next f o r t y years J_ Loc. c i t . 2 Deutsch, Op., c i t . . pp. 94—95. ?L L o c * c i t a A I b i d . , p. 124. she t r a v e l l e d through, the United States, B r i t a i n , Canada, and many European countries as "the apostle of the insane"; her gospel being the humane treatment f o r the mentally i l l . I t has been s a i d that wherever she t r a v e l l e d , a new mental h o s p i t a l was b u i l t * A f u r t h e r step toward state r e s p o n s i b i l i t y f o r the mentally i l l occurred during the nineteenth century, Horace Mann, i n addressing the Massachusetts State L e g i s l a t u r e i n 1828 declared "the insane are the wards .1 -of the state".*" During Mann's time, however, "state care" implied l i t t l e more than that the duty of the state was to provide s p e c i a l asylum, or c u s t o d i a l , care to those who required i t * The t h i r d decade of the nine-teenth century witnessed a strange phenomenon. Because of an unfortunate s e r i e s of events a large number of people at that time believed that ninety percent of the mentally i l l could be cured with the methods then a t t h e i r 2 3 disposal."* This i d e a , plus other developments, l e d to a wave of asylum and h o s p i t a l b u i l d i n g i n the western world© Although many events t r a n s p i r e d the ultimate outcome was toward l a r g e , c e n t r a l i z e d care f o r the mentally i l l This most often being on the state or p r o v i n c i a l l e v e l . _! Deutsch, On. c i t . . p. 229 2 I t i s hoped that u l t i m a t e l y at l e a s t 90 percent of the mentally i l l w i l l be "curable". I t i s unfortunate that t h i s erroneous idea became prevalent i n 1830 because i t l a t e r caused a damaging wave of enlightened pessimism. Even with over another century of tremendous progress, the year 1959 s t i l l can not olaim 90 per cent c u r a b i l i t y of a l l mental i l l n e s s . ^ The events that occurred were few i n number, but widely p u b l i c i z e d . The recurrent mental i l l n e s s of King George I I I of England, who probably suffe r e d from a manic-depressive psychosis, was claimed t o be "cured"'by h i s p h y s i c i a n , Dr. W i l l i s , during periods of rather normal remission of t h i s disease. Widely p u b l i c i z e d s t a t i s t i c a l e r rors and biased reports a l s o l e d to t h i s era of wishful t h i n k i n g . _ Por an i n t e r e s t i n g account of t h i s , the reader i s r e f e r r e d to Deutsch's chapter e n t i t l e d "The Cult of C u r a b i l i t y " . I b i d . , pp. 132—157. The l a t e nineteenth and e a r l y twentieth centuries witnessed many great men emerging i n the newly recognized f i e l d o f p s y c h i a t r y . Men such as K r a e p e l i n , Freud, and B l e u l e r are some of the most s i g n i f i c a n t , and i t was then r e a l i z e d that much could be done i f more knowledge were known. The work of these men helped considerably i n l a y i n g the framework f o r a sound and r a t i o n a l b a s i s f o r tr e a t i n g , ' and l a t e r r e h a b i l i t a t i n g mental p a t i e n t s . This period i s also known f o r the beginning development of the f a c i l i t i e s and techniques f o r p r o f e s s i o n a l t r a i n i n g of s t a f f , the develop-ment of appropriate research techniques; the r i s e of out-patient depart-1 ments, the r i s e of psychopathic hospitals 0"' f o r acute cases, and the beginnings of the employment of p r o f e s s i o n a l s o c i a l workers. Cl o s e l y a l l i e d with treatment and r e h a b i l i t a t i o n of the mentally i l l was the growth of the concept of the prevention of such ailments. The name most c l o s e l y associated with the development of prevention i s that of C l i f f o r d Beers, Mr, Beers, himself once a mental p a t i e n t , founded the Mental Hygiene Movement i n 1909* He set f o r himself the task of developing a working partnership between the p u b l i c and p s y c h i a t r y . His work was e s p e c i a l l y u s e f u l i n that i t , among other things, opened the door " f o r the i n t e g r a t i o n of mental hygiene thought, philosophy, and p r a c t i c e i n t o such d i s c i p l i n e s and f i e l d s as (general) medicine, s o c i a l work, education, 2 r e l i g i o n , and industry,""" Although h i s work s t a r t e d i n the United States, the concept of prevention and maintenance of mental he a l t h soon spread to 1, A psychopathic h o s p i t a l i s defined as "one f o r e a r l y diagnosis and treatment of mental disorders. The patients need not be subject to commitment as insane • • • « The psychopathic h o s p i t a l emphasizes study of the i n d i v i d u a l patient (rather than custody)'. The term i s sometimes used f o r a r e c e i v i n g h o p s i t a l , " Referencet E n g l i s h , Horace B., and E n g l i s h , Ava Oiampney, A Comprehensive D i c t i o n a r y of Psychological and Psychoanalytical Terms, Longmans, Green and Co,, New York, 1958* P« 427 , 2 Sutherland, Op, cit,« P. 5v Canada and other parts of the world. As a r e s u l t , many organizations are now i n existence f u r t h e r i n g these concepts on the basis of community planning. Mental Hospitals and the S o c i a l Services I t i s common p r a c t i c e today f o r p s y c h i a t r i s t s to look to s o c i a l workers f o r help i n the study of p e r s o n a l i t y i n r e l a t i o n to environmental s i t u a t i o n s . Conversely, s o c i a l workers look to p s y c h i a t r i s t s f o r assistance i n understanding d i f f i c u l t problems of at t i t u d e s and behaviour. This i s manifest i n that most e f f i c i e n t l y - o p e r a t e d p s y c h i a t r i c c l i n i c s and h o s p i t a l s employ s o c i a l workers and most e f f i c i e n t l y - o p e r a t e d s o c i a l agencies employ p s y c h i a t r i c consultants. With the growth of humanitarian understanding has come an i n t e r n a t i o n a l movement to b u i l d mental h o s p i t a l s , but many reformers have had to press f o r s o c i a l a c t i o n i n t h i s area© The r e a l i z a t i o n of the s o c i a l needs as w e l l as the i n d i v i d u a l need, however, i s s t i l l incomplete. As Dr. Cordon Hamilton has w r i t t e n , "there i s always a p o l a r i t y i n s o c i a l planning — to look at so c i e t y from the basis of the whole and from the basis of the i n d i v i d u a l " . I t was at t h i s point that p s y c h i a t r i s t s and s o c i a l workers joined forces and s t a r t e d to operate as a team i n mental h o s p i t a l s . Gradually from t h i s has developed v i t a l i n t e r e s t i n a f t e r - c a r e , i . e . i n the circumstances which face parents when they leave h o s p i t a l s , or complete i n s t i t u t i o n a l treatment. Lois French writes* "The f i r s t unorganized beginnings of t h i s 'focussing* or drawing together of • • • psychiatry and s o c i a l work are d i f f i c u l t t o t r a c e . . . . Before our present day type of s o c i a l work was organized, psychiatry here and there had f o r li Hamilton, Gordon, Theory and P r a c t i c e of S o c i a l Case Work. Second E d i t i o n , Revised, Columbia U n i v e r s i t y Press, New York, 1954* P« 15» - 10 * probably a century done a kind of s o c i a l work under the name of a f t e r - c a r e . • • .As f a r back as 1860 there appeared, i n annual reports of c e r t a i n state h o s p i t a l s , r e c o g n i t i o n of the need for. consideration of the s o c i a l problems at the time of a patient's discharge. Such reports a l s o show that some ' s o c i a l i n v e s t i g a t i o n ' was done by the doctors themselves, p a r t i c u l a r l y of patients placed i n boarding homes."JL» Z. The physicians who made these e a r l y e f f o r t s to help patients a f t e r they had l e f t the mental h o s p i t a l found that they were faced with a lack of knowledge i n helping with s o c i a l problems. Sh o r t l y a f t e r the turn of the twentieth century, Dr. W i l l i a m Mabon of the Manhattan State H o s p i t a l s a i d , "After-care should be . • • c l o s e l y connected with h o s p i t a l s . . . . The f i e l d workers, whether physicians of laymen, should have had s p e c i a l t r a i n i n g i n s o c i a l service and should know something 3 about i n s a n i t y . 1 ^ " The f i r s t record of s o c i a l s ervice departments i n p s y c h i a t r i c h o s p i t a l s seems to be the year 1905* I t was i n 1905 that the s o c i a l service departments were formed i n the n e u r o l o g i c a l c l i n i c s of Massachusetts General H o s p i t a l , Bellevue H o s p i t a l , and C o r n e l l C l i n i c i n New York C i t y . The f i r s t time a s o c i a l worker was a f f i l i a t e d with a State mental h o s p i t a l was i n A p r i l , 1906, and was known as " a f t e r - c a r e agent". This f i r s t worker was a graduate of the New York School of Philanthropy ( l a t e r c a l l e d New York School of S o c i a l Work), was employed by the State C h a r i t i e s A i d and worked i n the Manhattan State H o s p i t a l . The f i r s t s o c i a l workers i n mental h o s p i t a l s were a l s o known as " f i e l d workers" t h e i r duties being to "attend c l i n i c s , v i s i t homes of p a t i e n t s , and 1 French, Lois Meredith, P s y c h i a t r i c S o c i a l Work. The Commonwealth Fund, " New York, 1940. P. 33. •iv-2 One can trace the a f t e r - c a r e movement f u r t h e r back than 1860. The name f i r s t associated with the movement i s Dr. Idndpainter who put forward t h i s idea i n 1829 i n Germany. The purpose sought was "to provide adequate f i n a n c i a l , medical and moral assistance to patients discharged from mental h o s p i t a l s " . See Deutsch, Op. cit.» p. 289. £ French, 0j>. c i t . * p. 246. - 11 -cooperate with the Board of Education*' 1^- By May, 1914 there were workers employed i n eleven state hospitals."" One of the e a r l y pioneers i n p s y c h i a t r i c s o c i a l work was Miss Mary C. J a r r e t t , who was appointed d i r e c t o r of s o c i a l s e r v i c e i n the sp r i n g of 1913 at the newly formed Boston Psychopathic Hospital* She defined the f u n c t i o n of her department by saying the s o c i a l s e r v i c e depart-ment was organized to a s s i s t i n the study and treatment of mental disease, and treatment was "construed i n i t s "broadest sense to mean r e s t o r a t i o n of 5 capacity f o r normal l i v i n g or p r o v i s i o n f o r the greatest p o s s i b l e comfort*"^ Most of, the duties the e a r l y p s y c h i a t r i c s o c i a l workers, l i k e Miss J a r r e t t , set f o r themselves remain as standard p r a c t i c e today, although many refinements and experimentation i n procedure has taken place since then* S p e c i a l duties connected with the outpatient work were "taking the s o c i a l h i s t o r y of new p a t i e n t s , a s s i s t i n g i n discovering and d e a l i n g with s o c i a l problems, seeing that the f a m i l y of the p a t i e n t understood the p h y s i c i a n , s d i r e c t i o n s , a c t i n g as a l i a s o n agent between the p h y s i c i a n and A s o c i a l workers i n the community*""^ Miss J a r r e t t , as e a r l y as 1914, saw part of her duties as t r a i n i n g new workers* She accepted students on her s t a f f from the Simmons College School of S o c i a l Work, and a l s o took an a c t i v e i n t e r e s t i n developing of a t r a i n i n g course f o r p s y c h i a t r i c s o c i a l workers at Smith College i n 1918—1919. I t was a l s o Miss J a r r e t t who, i n 1920, helped with the formation of an organization c a l l e d the P s y c h i a t r i c ± I b i d * , p* 35* 2 Loc* c i t * 1" I b i d * * p. 3 8 . £ I b i d * , p. 39* - 12 -S o c i a l Workers Club, the forerunner of the American A s s o c i a t i o n of • 1 P s y c h i a t r i c S o c i a l Workers;**" The need f o r t r a i n e d workers became very apparent during the time of World Wax I , and t h i s need has p e r s i s t e d constantly since then* despite the f a c t that many schools of s o c i a l work have since been organized* In Canada, the f i r s t course f o r p s y c h i a t r i c s o c i a l workers was inaugurated , 2 at the U n i v e r s i t y of Toronto i n 1919*" Br* Adolph Meyer, a p s y c h i a t r i s t , i n 1922 gave added impetus to the trend of studying patients i n r e l a t i o n to t h e i r s o c i a l environment* Dr, Meyer i n s i s t e d on the study of the environment from whence the patient came and to which he might return*-^ His works a l s o had the impact of s t r e s s i n g the psychosocial aspects of human behaviour and t h i s g r e a t l y influenced the p r a c t i c e of p s y c h i a t r i c s o c i a l work* This close a s s o c i a t i o n of s o c i a l work with psychiatry was instrumental i n s h i f t i n g the emphasis of s o c i a l workers during the 1920*s i n t h e i r approach to s o o i a l problems of human beings* Sutherland s t a t e s : "Their focus of concern s h i f t e d from the broader environ-mental f a c t o r s underlying s o c i a l i l l s t o the developing of casework techniques a r i s i n g from a deeper understanding of i n d i v i d u a l p e r s o n a l i t y afforded by dynamic psy c h i a t r y . There was a gradual modification from an exclusive i n t e r e s t i n external problems toward i n c l u s i o n of treatment of p e r s o n a l i t y d i f f i c u l t i e s , " ! The Great Depression of the 1930*s brought with i t many s o c i o -economic problems f o r large numbers of i n d i v i d u a l s * Paced by the st r e s s of unemployment and d e s t i t u t i o n , s o c i a l workers returned to many o f t h e i r 1 I b i d . , p. 296 . 2 Sutherland, Op,, c i t , , p, 8, ^ French, Op,, c i t , , p, 33» 4 Sutherland, Og. c i t . , p, 9« - 13 -s o c i o l o g i c a l approaches to s o c i a l need, f o r the emphasis on r e s o l v i n g p e r s o n a l i t y and f i n a n c i a l d i f f i c u l t i e s , while important, d i d not solve the urgencies that were present* In l a t e r years there has been a growing blend of the two approaches s Concern with f a m i l i e s and communities as w e l l as i n d i v i d u a l s has a l s o influenced psychiatry considerably* P s y c h i a t r i s t s nowadays c h a r a c t e r i s t i c a l l y go beyond the i n d i v i d u a l patient i n terms of diagnosis and treatment* Their concern i s moving "to the complex weave of the i n t e r r e l a t i o n s of i n d i v i d u a l , family, and wider community* Perhaps the types of problems patients b r i n g to s o c i a l workers today are not fundamentally d i f f e r e n t from those at other times i n h i s t o r y * C e r t a i n l y not those of patient readjustment a f t e r discharge* The h i s t o r i c a l beginnings of s o c i a l work i n mental h o s p i t a l s was concerned with the patient's readjustment to l i f e away from the h o s p i t a l , and t h i s i s s t i l l a very important consideration to present-day s o c i a l workers* Unfortunately, patients s t i l l s u f f e r a stigma when l e a v i n g such a h o s p i t a l and employers, family, and acquaintances often needlessly mistrust the exwnental patient* The patient often needs considerable help and emotional support i n making h i s re-adjustment, and s o c i a l workers s t r i v e to help the patient meet t h i s need* Experience has shown that frequently when such help i s not given, the patient often s u f f e r s a relapse due to s o c i a l handicaps* Socio-economic d i f f i c u l t i e s are often present 1* I f the patient i s indigent, arrangements must be made t o overcome t h i s problem, e i t h e r through s o c i a l assistance or employment, and o c c a s i o n a l l y s o c i a l assistance i s a f i r s t step toward the patient being again employable*: 1_ Ackerman, Nathan W», The.Psychodynamics of Family L i f e * Basic Books, " Inc., New York, 1958. P. 11* - 14 -S o c i a l workers are also concerned with the family s i t u a t i o n s of patients* Attempts are made t o o f f e r help to f a m i l i e s at various stages of h o s p i t a l i z a t i o n * Perhaps the f i r s t contact with a r e l a t i v e w i l l he p r i o r to the patient's admission to h o s p i t a l , or s h o r t l y a f t e r he i s 1 received*"" Usually a s o c i a l h i s t o r y i s recorded at t h i s time and some i n t e r p r e t a t i o n i s given t o the r e l a t i v e as to what can be achieved or expected of h o s p i t a l i z a t i o n * I d e a l l y , there i s contact with both the patient and h i s family throughout a l l aspects of h o s p i t a l i z a t i o n , and both are prepared f o r the day when the patient returns to h i s home* But some patients have no home i n which to return* Some are homeless a f t e r a long p e r i o d i n the hospital'* Other homes are so d i s -organized that i t i s unwise f o r a patient to r e t u r n there* S t i l l other patients might f i n d i t advantageous to leave the h o s p i t a l and e s t a b l i s h themselves i n geographical communities other than the ones from which they came* Perhaps t h e i r o r i g i n a l communities may have deep-seated bias against the p a t i e n t f o r actions and behaviour he committed before being h o s p i t a l i z e d * Por a l l p r a c t i c a l purposes such a patient has no fa m i l y resources he can use* These are the s i t u a t i o n s which make what w i l l be r e f e r r e d to i n t h i s study as a "non-family p a t i e n t " • What more should we know about such people? What s p e c i a l assistance do they need on l e a v i n g the h o s p i t a l and i n making a subsequent adjustment, and how can the s o c i a l worker provide, d i r e c t l y or i n d i r e c t l y , t h i s s p e c i a l assistance* S o c i a l Work i n the P s y c h i a t r i c H o s p i t a l In each state or province, when a mental h o s p i t a l has been b u i l t , an almost u n i v e r s a l pattern has developed* The h o s p i t a l was f i l l e d t o capacity almost as soon as the doors were opened^ In most places the 1_ Berkman, Tessie D., P r a c t i c e of S o c i a l Workers i n P s y c h i a t r i c Hospitals  and C l i n i c s * American A s s o c i a t i o n of P s y c h i a t r i c S o c i a l Workers, Inc*, New York, 1953V Pp« 35—36* number of patients f a r exceeded the supply of adequate s t a f f y Quality of s e r v i c e , however, i s as important as quantity of service*. Each profes s i o n , psychology, medicine, s o c i a l work, and nursing has struggled 1 2 to develop i t s own standards of p r o f e s s i o n a l p r a c t i c e and codes of e t h i c s . — Por s o c i a l workers the relevance of t h i s i s that a program of high q u a l i t y means bett e r care f o r p a t i e n t s , decrease i n length of t r e a t -ment required, reduction i n number of re-admissions, and improved p u b l i c 4 relations.- I n the p s y c h i a t r i c h o s p i t a l there are f i v e main functions with which the s o c i a l s ervice department should engage i t s e l f _ ; These are: (1) the p r a c t i c e of s o c i a l casework and group work; (2) p a r t i c i p a t i o n i n program planning and p o l i c y formulation; (3) p a r t i c i p a t i o n i n the develop-ment of s o c i a l and hea l t h programs i n the community; (4) p a r t i c i p a t i o n i n : the educational program f o r p r o f e s s i o n a l personnel;;, and, (5) s o c i a l research i n c l u d i n g (a) follow-up studies of groups of p a t i e n t s , and (b) evaluative studies of the effectiveness of the a c t i v i t y of the s o c i a l work department. The p r o f e s s i o n a l p r i n c i p l e s upon which s o c i a l workers base t h e i r work with c l i e n t s , as put f o r t h by the American A s s o c i a t i o n of 1^  O f f i c i a l documents on t h i s subject from both the American A s s o c i a t i o n of S o c i a l Workers, and the Canadian As s o c i a t i o n of S o c i a l Workers are u t i l i z e d as the source material f o r the above'. 2 Standards f o r the P r o f e s s i o n a l P r a c t i c e of S o c i a l Work, American ~" A s s o c i a t i o n of S o c i a l Workers, New York, 1951** _3_ A Statement of Standards to be Met by Medical and P s y c h i a t r i c S o c i a l  Service Departments i n H o s p i t a l s , C l i n i c s and Sanatoria, Canadian As s o c i a t i o n of S o c i a l Workers, Ottawa, 1 9 5 2 « £ The Canadian A s s o c i a t i o n believes that the s o c i a l s e r v i c e department i n the p s y c h i a t r i c h o s p i t a l should include a l l of the s o c i a l workers with i n the i n s t i t u t i o n , arid i t s d i r e c t o r should be responsible only to the h o s p i t a l ' s top administrator. e 16 -S o c i a l Workers, are* "If*. Firm f a i t h i n the d i g n i t y , worth and c r e a t i v e power of the i n d i v i d u a l * 2 * Complete b e l i e f i n h i s r i g h t to hold and express h i s opinions and to act upon them, so long as by so doing he does not i n f r i n g e upon the r i g h t s of others* 3« unswerving conviction of the inherent, i n a l i e n a b l e r i g h t of each human being to choose and achieve h i s own destiny i n the framework of a progressive, yet s t a b l e , s o c i e t y * " These p r i n c i p l e s hold good f o r mental patients as they do f o r others, but they are often hard to i n t e r p r e t * N a t u r a l l y the patient i s c l o s e l y examined regarding such matters as impairment of judgement and mental competency? nevertheless, the patient must be encouraged to exercise a l l the self-determination of which he i s capable* This again i s not an easy task* In mental h o s p i t a l s , s o c i a l workers are u s u a l l y responsible to the medical superintendent v i a the d i r e c t o r of the s o c i a l s e r v i c e depart-ment* This i s c e r t a i n l y the case i n the p a r t i c u l a r s e t t i n g i n which t h i s study occurs* In such a s e t t i n g , a c l e a r d i v i s i o n of f u n c t i o n must e x i s t between the various p r o f e s s i o n a l d i s c i p l i n e s . The physicians must assume the p s y c h i a t r i c and medical r e s p o n s i b i l i t y f o r each patient*, s o c i a l work r e s p o n s i b i l i t i e s remain to be e s t a b l i s h e d between the D i r e c t o r of S o c i a l Service and the C l i n i c a l D i r e c t o r of the h o s p i t a l ^ — ( U s u a l l y i n a mental h o s p i t a l , the senior p s y c h i a t r i s t appointed by the Medical Superintendent, f o r the purpose of e s t a b l i s h i n g and supervising the o v e r - a l l medical program)'* In the s t a f f - a n d - l i n e management, these general p o l i c i e s are transmitted down to the ward physicians and s o c i a l workers who t r e a t i n d i v i d u a l p a t i e n t s * I t i s within t h i s framework that i n d i v i d u a l p r a c t i t i o n e r s of d i f f e r i n g d i s c i p l i n e s collaborate on the s p e c i f i c d e t a i l s of t h e i r work* How f a r t h i s may require development f o r discharge - 17 -planning w i l l be considered i n the concluding s e c t i o n of t h i s study. Discharge Needs of Mental Patients and the Concept of R e h a b i l i t a t i o n R e h a b i l i t a t i o n , as defined by the National Council on R e h a b i l i -t a t i o n , New York, has been frequently quoted. In t h e i r terms i t i s the 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 they are capable."~ Mental i l l n e s s f o r most patients i s a severe handicap, and large numbers who are w e l l enough to be released from the h o s p i t a l carry, to some degree, r e s i d u a l e f f e c t s of t h e i r i l l n e s s . Even those who are fortunate enough not to have a residuum of i l l n e s s often must have considerable assistance to r e a l i z e t h e i r f u l l 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. What i s meant by "discharge"? As the term i s used i n h o s p i t a l parlance, i t r e f e r s to the time when a patient severs h i s p h y s i c a l ties with the h o s p i t a l , and leaves to r e - e s t a b l i s h himself elsewhere. Unfortunately, i n many mental h o s p i t a l s , the term can take on a number of d i f f e r e n t meanings'. A patient i s u s u a l l y admitted to a mental h o s p i t a l on the basis 2 of a w r i t t e n agreement c a l l e d a commitment'."" The commitment may be e i t h e r voluntary or one made by court order and signed by a magistrate. The voluntary commitment i s an agreement that the patient himself s i g n s , should h i s own request f o r admission to a mental h o s p i t a l be granted. The voluntary 1_ Johnson, Emily A l i c e , The S o c i a l Problems of Discharged Mental Patients  Referred to a P u b l i c Assistance Agency i n 1954. 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, Vancouver, B. Co, 1956© P. 6. 2 An exception to t h i s i s the r a r e l y used device of admitting a person as a "guest" of the h o s p i t a l , and no formal agreement i s made. T h i s , however, i s most often used as a temporary device u n t i l a more formal arrangement i s made. • 18 ~ patient may a l s o demand and receive h i s release from h o s p i t a l under terms outlined i n the agreement. The patient h o s p i t a l i z e d under court order i s usually released at the d i s c r e t i o n of the medical superintendent, unless a s p e c i a l "detainer" i s added whereby release must a l s o meet with approval of the court. Discharge always occurs when the commitment i s closed and no longer e x i s t s . Most h o s p i t a l s , however, f i n d i t advantageous to a l l concerned to allow the patient to leave the h o s p i t a l on a t r i a l b a s i s , to determine the extent of h i s adjustment before a c t u a l l y "discharging" or terminating the commitment. Another way i n which t h i s might be used i s i n instances when an overnight v i s i t to family and f r i e n d s i s used f o r therapeutic purposes. The o l d term f o r these types of separations, a term everyone understood, was parole. In recent years, however, the term "parole" was unfortunately thought by some to be an undesirable word. In i t s place a whole host of terms are now used to designate parole periods. Some of these are to mention only a few; " t r i a l v i s i t " , "temporary leave", "convalescent status", "furlough", "terminal leave", and "discharge on probation" (as contrasted with "discharge i n f u l l " ) . To confound the term "discharge" even f u r t h e r , mental h o s p i t a l s and courts often add a q u a l i f y i n g word a f t e r i t . The intent i s to make a statement regarding the competency of the patient when terminating the commitment. Thus, there are terms l i k e the f o l l o w i n g i n common usage. "discharged, recovered", "discharged i n f u l l , able", "discharged,improved", "discharged, unimproved", "discharged i n f u l l , unable", and so on. Depend-i n g on which state or province i s r e f e r r e d t o , there may be c i v i l connotations attached to the q u a l i f y i n g phrase a f t e r the word "discharged". These connotations can sometimes a f f e c t a patient's l e g a l r i g h t to buy or rent property, contract f o r marriage, be responsible f o r cr i m i n a l a c t i o n s , - 19 -and so f o r t h * Another controversy t h i s w r i t e r has witnessed i s a medico-l e g a l one, i f a court of law or designated magistrate by committing a patient to a mental h o s p i t a l thus removes h i s l e g a l and c i v i l r i g h t s , can the medical p r o f e s s i o n restore these on discharging a patient? The answers are by no means u n i v e r s a l l y i n agreement. Discharge, however, i s regarded as important, and i s commonly determined by medical s t a f f meetings, rather than by one i n d i v i d u a l medical p r a c t i t i o n e r . A l l of the patients selected f o r the sample of the present study were on a parole or "probationary discharge" status before e i t h e r being discharged i n f u l l or re-admitted to the h o s p i t a l . No attempt was made to s e l e c t p atients e x c l u s i v e l y i n one of the foregoing c l a s s i f i c a t i o n s , nor was i t necessary to do so© No non-family patient i s released d i r e c t l y from the area of the h o s p i t a l studied without f i r s t s e r v i n g a probationary p e r i o d , and maximum probationary period at the B r i t i s h Columbia P r o v i n c i a l Mental Hospital at Essondale i s s i x months. H o s p i t a l i z a t i o n may mean many things to a mental p a t i e n t . Probably the great majority v e r b a l l y state they want to leave the h o s p i t a l , but many f i n d that " g e t t i n g out" i s not always a pleasant matter. Many s u f f e r a s o r t of "separation anxiety" when the time comes f o r them to leave, e s p e c i a l l y when they have been i n an i n s t i t u t i o n f o r many months or years, as had a l l the patients who are studied here. Patients i n such a s e t t i n g are completely dependent on the h o s p i t a l f o r food and s h e l t e r . Many are clothed by the h o s p i t a l as w e l l . Forced i n t o group l i v i n g , most have made an adjustment to a f a i r l y r i g i d routine i n such matters as when meals are served, when to a r i s e i n the morning, when to r e t i r e at night, what type of clothes to wear, and so on. In other words, there are l i t t l e demands f o r the p a t i e n t to take on more m 20 m than p a r t i a l r e s p o n s i b i l i t y f o r h i s d a i l y a f f a i r s . Other patients often become h i s c l o s e s t f r i e n d s while he i s i n the hospital© "Outside" becomes indeed another world. Thus| on l e a v i n g the h o s p i t a l , the patient must change h i s way of l i v i n g d r a s t i c a l l y . There are such matters as housing, employment, f r i e n d s , and r e c r e a t i o n to consider. His behaviour and personal conduct i s a lso more important, as often what i s t o l e r a t e d i n the h o s p i t a l i s not t o l e r a t e d elsewhere. A l l human beings tend to r e s i s t change, e s p e c i a l l y when i t means a complete change i n one's way of l i f e . Many patients who "want to leave the h o s p i t a l " , f i n d i t d i f f i c u l t when making the change because imminent, and they may at t h i s stage develop resistances and ambivalences, Needs on discharge must be distinguished from services on discharge, although ser v i c e s offered are intended to be r e l a t e d to need. Some of the more common needs of patients are a place to l i v e , food to eat, clothes to wear, employment, finances, emotional support from f r i e n d s , s a t i s f a c t i o n from one's a c t i v i t i e s , and so on. When a patient leaves the h o s p i t a l , resources must be present to meet h i s needs i f he i s to survive and sustain himselfV The d e t a i l s of t h i s story are developed i n the chapters which follow© CHAPTER I I  THE NON-FAMILY PATIENT 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 1 Psychological Medicine are both located at Essondale, B. C."~ The difference between the P r o v i n c i a l Mental Hospital and Crease C l i n i c i s that the former may accept a l l kinds of mentally i l l p a t i e n t s , but u s u a l l y accepts p a t i e n t s where i l l n e s s has been present f o r a considerable length of time and f a i r l y long-term treatment i s i n d i c a t e d . Of the two i n s t i t u -t i o n s , although t h e i r functions over-lap, the Mental H o s p i t a l tends to 2 accept patients whose i l l n e s s i s chronic or recurrent."" Patients are admitted to t h i s i n s t i t u t i o n on an i n d e f i n i t e commitment, terminated at the d i s c r e t i o n of the medical superintendent. The P r o v i n c i a l Mental H o s p i t a l i s divided i n t o u n i t s , each with a c e r t a i n amount of autonomy. The "Centre Lawn" b u i l d i n g with a capacity of approximately 500 beds i s the reception u n i t f o r new patients and also contains semi-acute treatment f a c i l i t i e s . Both male and female patients are housed i n the Centre Lawn Un i t . The "West Lawn" Unit contains 1^  The e a r l y methods of earing f o r mental patients i n the Province of B r i t i s h Columbia and the establishment and h i s t o r y of the P r o v i n c i a l Mental Ho s p i t a l are very well described elsewhere. For the reader i n t e r e s t e d i n t h i s aspect of the s e t t i n g , i t i s suggested reference be made to the theses of Richard J . Clark and Robert M. Sutherland. F u l l t i t l e s of these references are l i s t e d i n the Bibliography (Appendix B.). 2 Crease C l i n i c of Psychological Medicine i s designed as an acute t r e a t -ment centre. Commitment, e i t h e r by voluntary admission or by court order, must be terminated at the end of four calendar months. Patients sent to t h i s i n s t i t u t i o n generally have a bet t e r prognosis f o r t h e i r i l l n e s s , and concentrated services are o f f e r e d . - 22 -approximately 900 beds and i s f o r male long-term patients,"* The "East Lawn" Unit has a capacity of approximately 1200 beds and i s f o r female long-term p a t i e n t s . The East Lawn Unit contains i t s own s o c i a l s e r v i c e department and medical s t a f f . A l l patients l e a v i n g East Lawn between J u l y 1, 1957 "to June 3 0 , 1958 were studied i n r e l a t i o n to the c r i t e r i a described i n the fo l l o w i n g pages. I t was found that most patients l e a v i n g the P r o v i n c i a l Mental Hos p i t a l have f a m i l i e s to whom they return'. I t was obviously not f e a s i b l e to study the enti r e h o s p i t a l population, and the choice to study the female non-family patients i n the East Lawn B u i l d i n g was made, on the basi s of several considerations. F i r s t , patients who have been h o s p i t a l i z e d f o r long periods of time — normally f o r seve r a l years — would be more l i k e l y to be without adequate family resources when they are ready to leave the h o s p i t a l . This hypothesis was not proved e n t i r e l y t r u e : the greatest majority of women patients apparently returned to t h e i r r e l a t i v e s . The proportion of non-family patients was greater f o r t h i s group, however, than f o r the t o t a l h o s p i t a l population being discharged. Only those non-family patients under age t h i r t y - f i v e were studied. Nineteen of these patients were found from the t o t a l of 234 patients from a l l age groups discharged on probation from the East Lawn Unit. This i s 8,t percent of the t o t a l , and the f i g u r e would be higher i f the age l i m i t had not been set i n obtaining the sample group, _[ The North Lawn Unit was rec e n t l y b u i l t and has a capacity of 257 beds. I t was o r i g i n a l l y intended as a u n i t f o r mental patients with i n f e c t i o u s diseases, such as tu b e r c u l o s i s . Within a short distance of the P r o v i n c i a l Mental H o s p i t a l and Crease C l i n i c i s the Home f o r the Aged, Port Coquitlam, The Home f o r the Aged i s also part of the P r o v i n c i a l Govern-ment's Mental Health Services, and serves to reduce the s e n i l e p p u l a t i o n i n the Mental H o s p i t a l , e s p e c i a l l y i n the reception and treatment of newly r e f e r r e d g e r i a t r i c cases. This oompaxes with 4*9 percent of a l l patients discharged from the h o s p i t a l to "other" circumstances (see page 3). The second reason f o r studying the East Lawn Unit only i s that t h i s u n i t has had by f a r l e s s p r o f e s s i o n a l s t a f f turnover than the other u n i t s during the time under consideration. The t h i r d reason i s that with the resource of the V i s t a i n Vancouver, a community l i v i n g arrangement f o r female mental p a t i e n t s r e -e s t a b l i s h i n g themselves i n the community, findings of t h i s study could be compared with the study of Sophie B i r c h . Johnson describes the V i s t a as "an a u x i l i a r y service of 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 and was o r i g i n a t e d to meet the need of p a r t i c u l a r women patients who are ready to leave h o s p i t a l , but who have no resources of family, f r i e n d s , and finances to see them through the i n i t i a l p eriod while obtaining employment 2 and accommodation. "~" Since t h i s study chose to review only patients under age t h i r t y -f i v e from the East Lawn Unit who have been discharged on a probationary status, no s t a t i s t i c s are a v a i l a b l e of how many non-family patients are s t i l l h o s p i t a l i z e d . I t could w e l l be that patients with f a m i l y resources have a better chance of being considered f o r t r i a l away from the h o s p i t a l than those who do not. T h i s , however, could w e l l be the subject of a comparative t h e s i s . Method of Study The p r i n c i p a l area of study i s the discharge s i t u a t i o n of the non-family p a t i e n t . By discharge s i t u a t i o n i s meant the circumstances i n B i r c h , Sophie. An A i d i n the R e h a b i l i t a t i o n of Mental H o s p i t a l 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, Vancouver, B. C., 1953. j? Johnson, Op. c i t . . p. 18. « 24 *». which the patients were l i v i n g upon l e a v i n g the h o s p i t a l . Some a t t e n t i o n i s given to services o f f e r e d a f t e r the patient l e f t the h o s p i t a l and to subsequent changes i n circumstances, unfortunately much of t h i s information was not a v a i l a b l e i n many of the h o s p i t a l f i l e s , therefore, most of the following pages are concentrated on the immediate discharge s i t u a t i o n as such. This study i s divided i n t o two f a i r l y d i s t i n c t areas. The f i r s t , (expanded upon i n Chapter l l ) i s an attempt to secure a d d i t i o n a l information regarding what constitutes a non-family p a t i e n t . To determine t h i s , such matters as age, m a r i t a l status, place o f b i r t h , occupation, length of h o s p i t a l i z a t i o n , and s o c i a l and medical diagnosis are reviewed. The second area, (which constitutes the bulk of Chapter I H ) i s the study of the patient's circumstances on lea v i n g the h o s p i t a l , and what s o c i a l services he required to meet h i s needs. Some of the types of problems studied i n t h i s area include the person to whom the patient was responsible during the probationary period, housing, employment, f i n a n c i n g , s o c i a l i z a t i o n , and a 1 q u a l i t a t i v e d e s c r i p t i o n of the patient's success i n these endeavours."" The sample that was sought was f o r a one-year period, ( a c t u a l l y from J u l y 1, 1957 to June 3 0 , 1958) . From the h o s p i t a l ' s weekly b u l l e t i n of population changes, an extensive l i s t of names was obtained of patients who had been discharged on probation from the East Lawn Unit. Ruling out those patients age t h i r t y - f i v e and over was done by consulting a master card f i l e of patients i n which t h e i r birthdates were l i s t e d . A s t a f f member was consulted to r u l e out names on the l i s t where i t was known that the patient had returned to a family s i t u a t i o n . The 1 See also Appendix A. ~ 25 -1 remainder of the names were checked with each patient's h o s p i t a l f i l e s . The assembly of material was organized on the l i n e s of the schedule appended i n Appendix A« Most of the information gathered on the schedules was taken d i r e c t l y from the h o s p i t a l f i l e s , except i n two or three instances when information was gathered d i r e c t l y from the s o c i a l worker who worked d i r e c t l y with the p a t i e n t . No d i r e c t contact was made with any of the p a t i e n t s . The purpose of the f o l l o w i n g material i s to present a sketch of the non-family patient as a person, and i n r e l a t i o n to t h e i r personal c i r -cumstances at time of discharge. A number of important personal and s o c i a l c h a r a c t e r i s t i c s are not measured, such as appearance to others, s o c i o -c u l t u r a l background, concept of s o c i a l r o l e s and h a b i t s * Such information can hardly be judged without seeing the patient i n person, and t h i s u n f o r t -unately was not possible* But where recorded, such information i s incorpor-ated i n the s o c i a l diagnosis* Primary Facts The ages of t h i s group of patients ranged from twenty to t h i r t y -f i v e years, the median age being 30*5 years, and more of the group being over t h i r t y than under t h i s age (Table l ) . This i s not s u r p r i s i n g , i n view of the f a c t s already set f o r t h * For patients being discharged from the East Lawn Unit, a group of "long-term" or continued-care p a t i e n t s , the median age would i n a l l p r o b a b i l i t y be much higher had no maximum age l i m i t been set f o r the sample group* 1_ The case records of p a t i e n t s , or u n i t f i l e s , are a comprehensive compilation of the impressions and services of p r o f e s s i o n a l s t a f f members who have contact with the patients* The f i l e includes ward notes of physicians, dental reports, records of nursing and treatment s t a f f s , notations by the s o c i a l workers, and psychological reports. In a d d i t i o n there i s a separate correspondence f i l e * Each time a patient i s r e -admitted a f t e r being discharged i n f u l l a new f i l e and "case" i s es t a b l i s h e d . There are many patients who each have more than one f i l e i n t h e i r name* • 26 * Table 1* Age D i s t r i b u t i o n of Patients Age, i n years Number of Patients 20 to 23 3 24 to 27 4 28 to 31 3 32 to 35 8 T o t a l 18 Table 2 : N a t i v i t y of Patients Place of B i r t h Number of Patients B r i t i s h Columbia 9 Saskatchewan 4 A l b e r t a 3 Quebec 1 Foreign born 1 T o t a l 18 Table 3 : M a r i t a l Status of Patients M a r i t a l Status Number of Patients Single 15 Divorced 2 Widowed 1 T o t a l 18 - 27 -A l l the patients except one were Canadian horn (Table 2 . ) . Hot having a home i n which to return a f t e r leaving the mental h o s p i t a l c e r t a i n l y can not be a t t r i b u t e d to immigration, i n s p i t e of the high post-war immigration r a t e . Half of the patients were born and l i v e d most of t h e i r l i v e s i n the Province i n which t h i s study took place. Nine out of ten of these patients without adequate family resources were born and l i v e d most of t h e i r l i v e s i n the three Western Canadian provinces. The majority of the patients were s i n g l e . Most had never married, but two were divorced and one was widowed (Table 3)» Prom t h i s i t may be concluded that f o r 83 percent, the only home these patients had was t h e i r parental home. Seventeen percent had an established home of t h e i r own, but had l o s t i t through m a r i t a l d i f f i c u l t y and misfortune. Education and Occupation Education of these patients ranged a l l the way from only Grade I to u n i v e r s i t y (Table 4 ) . At the top l e v e l , one was a school teacher *rith a '•normal school" education, unfortunately "normal school" was not f u r t h e r defined i n the recorded m a t e r i a l . Of the remaining three with education beyond Grade XII, one had one year of U n i v e r s i t y and the other two had some pro f e s s i o n a l t r a i n i n g (nursing, commercial a r t ) . The median number of school years completed, however, remains at Grade vTII. In North American s o c i e t y t h i s i s considered a basie or minimum amount of education a person needs f o r most types of s k i l l e d employ-ment, and i s considered inadequate even f o r many u n s k i l l e d jobs. _1 Between the years 1946 to 1954* 1,111,000 persons migrated to Canada, nearly 6 .7 percent of the e n t i r e Canadian population. (Corbett, David C , Canadian Immigration P o l i c y . U n i v e r s i t y of Toronto Press, Toronto, 1957• P. 167) . - 28 -Table 4* Educational Attainment of Patients Number of School Grade Patients 1-6 5 7 - 9 7 10*12 2 Beyond Grade 12 4 T o t a l 18 Wilensky and Lebeaux s t a t e , "Because work i n modern s o c i e t y demands 1 greater a b i l i t i e s , education i s becoming the main b a r r i e r to opportunity*""" This statement i s c e r t a i n l y true, and i s r e f l e c t e d i n this.study i n n o t i c i n g that most of the patients held u n s k i l l e d and s e m i - s k i l l e d jobs both before and a f t e r discharge from the mental h o s p i t a l . There i s a f a i r l y obvious connection between the Grade Y H I median here and the u n s k i l l e d jobs these patients h e l d . The people with t r a i n i n g beyond Grade X U i t may be added, d i d not return to p r o f e s s i o n a l occupations, but d r i f t e d i n t o l e s s - s k i l l e d types of employment. This i s f u r t h e r r e f e r r e d to i n employment i n Chapter 3, where the discharge s i t u a t i o n i s discussed. Medical and S o c i a l Diagnosis Diagnosis, as the term i s used here, r e f e r s to the c l a s s i f i c a t i o n of an i n d i v i d u a l on the basis of observed c h a r a c t e r i s t i c s . Within the: terms of t h i s broad d e f i n i t i o n , two types of diagnoses are s i n g l e d out f o r 1_ Wilensky, Harold L«, and Lebeaux, Charles N,, I n d u s t r i a l Society and "~ S o c i a l Welfare, R u s s e l l Sage Foundation, New York, 1958, P, 109. « 29 «• presentation. These are ( 1 ) . the p s y c h i a t r i c medical diagnosis, and ( 2 ) . the s o c i a l diagnosis of these p a t i e n t s . 1). P s y c h i a t r i c diagnosis; The function of a medical diagnosis has three e s s e n t i a l aims: a) To i n d i c a t e the s i t e of disease, b) To i n d i c a t e the causes, and c) To i n d i c a t e the nature of the f u n c t i o n a l disturbances. In psychiatry, however, i t i s seldom that a complete diagnosis can be made i n t h i s sense with the present information 2 a v a i l a b l e about these d i s e a s e s , - The term " p s y c h i a t r i c diagnosis", then, r e f e r s to a statement c l a s s i f y i n g a person i n r e l a t i o n to a s p e c i f i c mental disorder. Table; 5«• P s y c h i a t r i c Diagnosis of Patients P s y c h i a t r i c Diagnosis Incidence Schizophrenia paranoid type simple type hebephrenic type u n d i f f e r e n t i a t e d type 8 1 1 3 11 Chronic Brain Syndrome associated with epilepsy associated with metabolism associated with s p a s t i c paraplegia 2 1 1 4 Sociopathic P e r s o n a l i t y Disturbance a n t i s o c i a l r e a c t i o n 1 i_ T o t a l 18 18 I t i s i n t e r e s t i n g to note that only three major p s y c h i a t r i c e n t i t i e s are represented i n t h i s group of patients (Table 5 ) , Two f a i r l y common p s y c h i a t r i c i l l n e s s e s are not represented at a l l ; psycho-neurosis, J[ Mayer-Gross, W,, S l a t e r , E l i o t , and Roth, Martin, C l i n i c a l P s y c h i a t r y . C a s s e l l and Company Ltd., London, 1954* P» 6 . 2' Loc. c i t . - 30 -and manic-depressive psychosis. Schizophrenia was the p s y c h i a t r i c diagnosis of 72.2 percent of the patients* For a group of "chronic", or continued* care, p a t i e n t s , as are a l l East Lawn Pa t i e n t s , t h i s may be considered a t y p i c a l sample* This idea i s strengthened by the statements of Noyes and Kolb: "Schizophrenia i s one of the most frequent forms the major psychoses, c o n s t i t u t i n g from 15 to 20 percent of the f i r s t admissions to p u b l i c h o s p i t a l s f o r mental diseases* Because the disorder tends to c h r o n i c i t y and i n many instances does not shorten l i f e i t w i l l be found that 60 percent of thepopulation of state h o s p i t a l s i s made up of schizophrenic patients*"-L Regarding the nature of schizophrenia, Noyes and Kolb s t a t e : "While i t i s r e l a t i v e l y easy to describe some of the more s t r i k i n g c h a r a c t e r i s t i c s of schizophrenia, no d e f i n i t i o n of t h i s mental i l l n e s s has yet received u n i v e r s a l assent* Although one of the commonest of serious mental disorders, i t s e s s e n t i a l nature i s probably the l e a s t understood," — Although w r i t i n g i n the year 1911, Eugen B l e u l e r has given one of It A the c l a s s i c a l accounts of t h i s i l l n e s s * B l e u l e r was impressed by the s p l i t t i n g , or disorganization of the thought processes, and the s p l i t t i n g between thought and emotion—hence, h i s term "schizophrenia" ( l i t e r a l l y meaning s p l i t - m i n d ) . In h i s book, Dementia Braecox or the Group of  Schizophrenias, he presents a d e t a i l e d account of the person's a l t e r e d thought a s s o c i a t i o n s , a f f e c t i v i t y (mood), ambivalence, and r e l a t i o n to r e a l i t y . In the t o t a l of 26 accessory symptoms that he l i s t s are included such phenomena as h a l l u c i n a t i o n s , delusions, and stupors* 2 Noyes and Kolb, 0p_. c i t . , p. 391. 2 I b i d . , p. 381. £ B l e u l e r , Eugen, Dementia Praecox or the Group of Schizophrenias, ( T r a n s l a t i o n ) , I n ternational U n i v e r s i t i e s Press, New York, 1950* _. There are many excellent volumes w r i t t e n on the subject of schizophrenia. The reader i s e s p e c i a l l y r e f e r r e d f o r a more complete account of t h i s i l l n e s s to the works by B l e u l e r , Leopold B e l l a k , Silvano A r i e t i , W.F, McAuley, and David Shakow. Complete l i s t i n g of these books are found i n the Bibliography (Appendix B). - 31 -Organic b r a i n damage was a f a c t o r to be considered i n other cases. As i n d i c a t e d i n Table 5» (with q u a l i f y i n g phrases) was the p s y c h i a t r i c diagnosis f o r four p a t i e n t s . The term, Chronic B r a i n Syndrome, per se, i s so vague that i t means l i t t l e without being f u r t h e r q u a l i f i e d . Many of the textbooks on psychiatry do not l i s t i t as a separate e n t i t y . Henderson and G i l l e s p i e l i s t i t under the heading "Organic Reaction-Types". They s t a t e : "The organic reaction-type as a whole comprises the f o l l o w i n g changes: (1) In the i n t e l l e c t u a l sphere there i s impairment of compre-hension, interference with elaboration of impressions, defects i n o r i e n t a t i o n and r e t e n t i o n , d i f f i c u l t y i n a c t i v a t i o n of memories and marked f l u c t u a t i o n of the l e v e l of a t t e n t i o n . (2) A f f e c t i v e disorder i n the form of emotional i n s t a b i l i t y , the patient laughing or weeping without s u f f i c i e n t cause, and often i n an explosive way. (3) Character-change i n the form of conduct f o r e i g n to the patient's natural d i s p o s i t i o n , e.g., indecent behaviour i n a h i t h e r t o s e l f - r e s p e c t i n g i n d i v i d u a l . " ! . With the Chronic B r a i n Syndrome, there i s u s u a l l y a q u a l i f y i n g phrase. The q u a l i f y i n g phrase may include anything from alcoholism to epile p s y . The t h i r d c l a s s i f i c a t i o n that appeared i n t h i s study was Socio-pathic Disturbance, a n t i s o c i a l r e a c t i o n . This, too has tended to be an ambiguous c l a s s i f i c a t i o n . The term i s used f o r c l a s s i f y i n g persons "who, though nei t h e r insane nor i n t e l l e c t u a l l y d e f e c t i v e , behave s o c i a l l y i n an abnormal way." - I t t r a d i t i o n a l l y encompasses many (though not a l l ) c r i m i n a l s , delinquents, and sexual deviates. The term "moral i n s a n i t y " _J_ Henderson, S i r David, and G i l l e s p i e , R.D., A Eext-Book of Psychiatry, Seventh E d i t i o n , Oxford U n i v e r s i t y Press, London, 1.951 • P» 4 4 0 . 2 Mayer-Gross, S l a t e r , and Roth, Op. c i t . . p. 91* - 32 -was f i r s t used f o r t h i s e n t i t y , and was coined by Pri c h a r d i n the year 1 1835*"~ A term r e p l a c i n g "moral i n s a n i t y " was psychopathic p e r s o n a l i t y * The trend now i s to c a l l i t sociopathic disturbance* S o c i a l diagnosis: Turning to the s o c i a l diagnosis of the p a t i e n t s , there i s even more d i f f i c u l t y i n precise c l a s s i f i c a t i o n * S o c i a l Work as yet does not enjoy the advantages of being able to c l a s s i f y s o c i a l pathologies i n one or two short phrases. There are some moves i n t h i s d i r e c t i o n , however, as discernable patterns are beginning to emerge i n at l e a s t two areas? 2 namely, unmarried parenthood,"" and the "hard-core" or multi-problem family* But i n the present state of our knowledge, the s o c i a l diagnosis i s a s e r i e s of d e s c r i p t i v e statements s e t t i n g f o r t h the c l i e n t *s problems i n the s o c i a l and c u l t u r a l context i n which they occur, and the a b i l i t y of the c l i e n t , through h i s strengths and weaknesses, to slove the d i f f i c u l t y , Mary Richmond has s a i d : "Most types (of s o c i a l diagnosis) w i l l have to in c l u d e , i n add i t i o n to a general d e s c r i p t i o n of the d i f f i c u l t y , a statement of those p e c u l i a r i t i e s of circumstance and p e r s o n a l i t y which d i f f e r e n t i a t e s the case under review from a l l others. Then should come an enumeration of the causal f a c t o r s , so f a r as known, i n the order of t h e i r importance* I t i s a help to clearness of thinking to set them down, at t h i s e a r l y stage of treatment, to be only t e n t a t i v e * And l a s t should come the • . . a p p r a i s a l of the assets f o r reconstruction discovered i n the course of the i n q u i r y --those within our c l i e n t , within h i s immediate family, and outside," 3. Some d i s t i n c t i o n should be made at t h i s point between a s o c i a l diagnosis and a s o c i a l evaluation. Dr. Gordon Hamilton makes t h i s d i s t i n c -t i o n quite c l e a r i n the following statements: 1_ Loc. c i t * 2, Gordon, Henrietta L,, Casework Services f o r Children: P r i n c i p l e s and  P r a c t i c e s , Houghton M i f f l i n Company, Boston, 1956, pp* 224—256* j£ Richmond, Mary E l l e n , S o c i a l Diagnosis. R u s s e l l Sage Foundation, New York, 1917. P. 360. "Diagnosis and evaluation are complementary i n t e l l e c t u a l processes d i r e c t e d toward e l i c i t i n g the meaning of a case; both begin at intake and continue to be used with varying emphasis throughout treatment . . • •What i s the matter?* c a l l s f o r a diagnostic formulation. At intake, a l s o , we make some estimate of the person's capacity or incapacity, readiness or unreadiness to use help, c u l t u r a l factors,, and so on, and these s o c i a l judge-ments are known as 'evaluation', . When the i n t e r p r e t a t i o n i s di r e c t e d , not toward d e f i n i n g the problem, but toward analyzing how the person i s meeting the problem, the r e s u l t would appear to be an evaluation r a t h e r than a diagnosis . . . Diagnosis i s concerned with causal i n t e r - a c t i o n ; evaluation with s o c i a l purpose . , • Diagnosis i s to problem and s i t u a t i o n , as evaluation, both of personal p o t e n t i a l i t y and s o c i a l resources, i s to treatment," — A l l i n the present sample had the presenting problem of being ready to leave the mental h o s p i t a l , and di d not have a family w i l l i n g and able to provide accommodation. Al s o , the f a m i l i e s were extremely l i m i t e d i n a b i l i t y t o f u r n i s h f i n a n c i a l means f o r the patients to l i v e elsewhere. In examining the diagnostic s i t u a t i o n c l o s e r , i t was found that a l l eighteen patients had d i f f i c u l t y i n r e l a t i o n to t h e i r parents. S i x , or one-third, were from broken homes, i . e , , homes broken through divorce, separation, desertion, death, and so on. Another s i x were from very large f a m i l i e s , ( e i g h t s i b l i n g s , and over) or had some background of poverty and neglect. An example of t h i s was one patient who was from a family of ten, l i v i n g i n a three-room shack where "the parents fought c o n t i n u a l l y " . This p a r t i c u l a r patient l e f t the parental home at the age of t h i r t e e n . The remaining s i x patients had a v a r i e t y of family d i f f i c u l t i e s of s i m i l a r e f f e c t . Six patients had, p r i o r to admission, exercised f a u l t y judgement i n t h e i r r e l a t i o n s h i p to men, or tended to be promiscuous. Two had been unmarried mothers, one having two i l l e g i t i m a t e pregnancies, the other having three. One of the unmarried mothers was subsequently s t e r i l i z e d , J[ Hamilton, Op_. c i t . , pp, 232, 216. - 34 -medically. Homosexuality was a diagnostic f a c t o r with another two p a t i e n t s . I t can he seen that most, i f not a l l , of these patients were from f a m i l y backgrounds where there had been considerable s o c i a l pathology. Almost h a l f (eight patients) developed symptoms of an "acting-out" nature, manifested i n the sexual behaviour j u s t described. I t i s i n t e r e s t i n g to note, however, that from the large poverty-s t r i c k e n f a m i l i e s , most members of these f a m i l i e s were not considered to be mentally i l l to the extent of needing to go to h o s p i t a l . Yet, such a family could be of very l i t t l e help i n a s s i s t i n g a patient who has been mentally i l l to become re-established i n any community. In a l l of the eighteen cases there appeared no way of modifying the fami l y influences and r e l a t i o n s h i p s by any means other than separation. I t i s noted, indeed, that some of these patients had on previous occasions attempted to l i v e i n t h e i r own homes, but with unsuccessful r e s u l t s . Previous H o s p i t a l i z a t i o n The number of times these eighteen patients had been h o s p i t a l i z e d f o r mental i l l n e s s ranged from one admission to f i v e admissions. The median number of admissions was 2.5. Nine, or one-half, of the patients had been at one time or another admitted to the Crease C l i n i c of Psychological Medicine, and had been given extensive treatment there. The other h a l f had been h o s p i t a l i z e d only at the P r o v i n c i a l Mental H o s p i t a l . Length of h o s p i t a l i z a t i o n ranged from nine months to f i f t e e n years. The median number of years h o s p i t a l i z e d was 2.5* The e f f e c t s of such long periods of hospitalization.have already been r e f e r r e d t o ; but t h e i r e f f e c t s are easy to a n t i c i p a t e . Many had become dependent on the h o s p i t a l as a way of l i f e ; moreover, a f t e r being away from family and f r i e n d s f o r long periods of time, emotional t i e s which may never have been very t i g h t were now often very much weakened. R e s p o n s i b i l i t y f o r Probationary Discharge The p r a c t i c e i n most mental h o s p i t a l s i s to discharge p a t i e n t s , wherever p o s s i b l e , to a r e l a t i v e , guardian, or to some person who i s supposed to keep the h o s p i t a l advised of the patient's progress. Usually t h i s i s a written contract signed by the person who i s taking the p a t i e n t , and the contract i s made at the time the patient leaves the h o s p i t a l . Frequently such contracts include a clause s t a t i n g that the responsible person w i l l return the patient at h i s or her own personal expense, should t h i s become necessary. In p r a c t i c e t h i s procedure i s not always followed. Quite often, no word i s received from the person responsible unless some emergency arises« Patients are also frequently returned by a peace o f f i c e r , or by h o s p i t a l transportation. Just what proportion of people assuming r e s p o n s i b i l i t y f o r mental patients a c t u a l l y keep the h o s p i t a l advised of the pati e n t ' s progress at p e r i o d i c i n t e r v a l s , and the reasons f o r i t , could w e l l be the t o p i c of a s p e c i a l study. Many mental h o s p i t a l s with a shortage of s t a f f must i n e v i t a b l y be more concerned with patients presently i n t h e i r care than with those who have l e f t , unless a s p e c i f i c s i t u a t i o n i s brought to the att e n t i o n of the s t a f f . T h i s , of course, does not hold true where there i s a s o c i a l worker a s s i s t i n g a discharged p a t i e n t , but a l l patients do not have the b e n e f i t of a s o c i a l worker when they leave the h o s p i t a l , A recent survey made by the S o c i a l Service O f f i c e of the East Lawn Unit revealed that only 40 percent of patients discharged on probation between June 30, 1957 to December 31» 1957 were assigned to a s o c i a l w o r k e r W i t h a l a r g e r s t a f f , t h i s percentage would be greater, 1 Information received from the S o c i a l Service s t a f f , (December 5, 1958)« - 36 -Of the present sample, sixteen of the eighteen patients were discharged on probation "to themselves". In other words, there was no r e l a t i v e , f r i e n d , or guardian h e l d responsible f o r t h e i r well-being. The Department of Indian A f f a i r s took r e s p o n s i b i l i t y f o r another p a t i e n t , while the l a s t one was released to a cousin (but accommodation was arranged e l s e -where) . An attempt was made to f i n d s p e c i f i c reasons why these patients were not re t u r n i n g to l i v e with r e l a t i v e s . These are c l a s s i f i e d i n Table 6. Table 6t Reasons f o r not L i v i n g with Relatives Reason Number of Patients Emotional f r i c t i o n between r e l a t i v e s and pat i e n t 12 Relatives unable 3 No employment i n r u r a l B.C. 1 No r e l a t i v e s a v a i l a b l e (death, f o r e i g n country) 2 T o t a l 18 I n a b i l i t y of r e l a t i v e s to help the patients sometimes over-lapped with emotional tension i n the family and v i c e versa, therefore, parts of t h i s c l a s s i f i c a t i o n are somewhat a r b i t r a r y . Some of the patients abso-l u t e l y refused to consider l i v i n g with t h e i r r e l a t i v e s , but yet were con-sidered well enough to leave the h o s p i t a l . - 37 * Conclusions ' A composite p i c t u r e of the non-family patient studied here can be presented as follo w s . Such a patient i s a s i n g l e woman 3O2 years of age, born i n B r i t i s h Columbia, has a Grade T i l l education, i s employed as an u n s k i l l e d laborer, has many emotional tensions w i t h i n her own f a m i l y , has been h o s p i t a l i z e d at l e a s t twice and has spent over two and a h a l f years i n the mental h o s p i t a l with paranoid schizophrenia. She has hardly any f r i e n d s and i s l e a v i n g the mental h o s p i t a l responsible only to h e r s e l f and what help she may receive through s o c i a l workers. Chapter 3 o u t l i n e s many- of the si t u a t i o n s i n which she may f i n d h e r s e l f . CHAPTER I I I THE DISCHARGE SITUATION Patients l e a v i n g a mental h o s p i t a l are not a race apart from other people. They use many of the same s o c i a l resources as others, when they are i n need. They often seek a i d from such f a c i l i t i e s as the National Employment Service, S o c i a l Assistance Departments, commercial re c r e a t i o n , hoarding houses, housekeeping rooms, apartments, and so on. However desirable or not i t may be, many use the same beer p a r l o r s . That they seek i n t h i s way to be "ordinary people" i s the way i t should be» Yet, f o r many homeless p a t i e n t s , the use of such resources i s not enough. Some s p e c i a l f a c i l i t i e s are often needed. Among the most important i s the personal element which can be given by s o c i a l workers w e l l acquainted with helping people i n need, who understand p s y c h i a t r i c i l l n e s s e s , and who know the routines to be-followed i n many s o c i a l agencies and i n s t i t u t i o n s . This i s a l l the more relevant i f there i s marked personal d i f f e r e n c e . In spite of the common fa c t o r s among homeless p a t i e n t s , they are i n t h i s respect a very heterogeneous group. One task of g i v i n g d i f f e r e n t i a l help to many can not be discharged unless there i s enough s t a f f f o r i n d i v i d u a l interviews. Por those who are planning to l i v e i n the Greater Vancouver area, some are fortunate enough to be able to use the f a c i l i t i e s of the V i s t a — . 1 a s p e c i a l h o s t e l f o r female mental patients•"" The V i s t a operates as an 1 A s i m i l a r h o s t e l e x i s t s f o r male p a t i e n t s . I t i s c a l l e d the Venture. - 39 -a u x i l i a r y s e r v i c e of the P r o v i n c i a l Mental Ho s p i t a l and Crease C l i n i c , I t was or i g i n a t e d to meet the need of p a r t i c u l a r women patients who are ready to leave the h o s p i t a l , but have no resources of family, f r i e n d s , and finances to see them through the i n i t i a l period while obtaining employment and accommodation. The V i s t a f i r s t came i n t o being i n January, 1944 through the e f f o r t s of Mr, E, E, Winch, M,L,A,, a f t e r hearing the p l i g h t of one patient without family resources and tak i n g the patient i n t o h i s own home to l i v e . The V i s t a i s a large house i n a r e s i d e n t i a l area i n the C i t y of Vancouver, In March, 1947 Mr. Pearson, P r o v i n c i a l Secretary, speaking f o r the Executive Council agreed to take over V i s t a , and since t h i s time i t has been under the administration of the B r i t i s h Columbia P r o v i n c i a l Government, I t presently has accommodation f o r nine p a t i e n t s , and the average length of time a patient stays i n V i s t a i s three or four weeks. Occasionally there i s a waiting l i s t , the average wait being two or three weeks, sometimes there are vacancies. There i s a matron and an as s i s t a n t housekeeper who are i n charge of i t s d a i l y operation. In a d d i t i o n to the s o c i a l workers, the matron and housekeeper a l s o o f f e r h e l p f u l suggestions to the patients regarding the implementation of t h e i r discharge plans. The V i s t a accepts patients on the basis of a medical r e f e r r a l which i s made by the h o s p i t a l p h y s i c i a n i n charge of the pa t i e n t ' s case. The c r i t e r i a on which a patient i s r e f e r r e d to V i s t a , according to B i r c h , i s : a) "patients who have no f a m i l i e s or whose f a m i l i e s are i n t e r e s t e d but are not i n a p o s i t i o n t o a s s i s t a c t i v e l y i n the r e h a b i l i t a t i o n , b) patients whose f a m i l i e s have rej e c t e d them completely, c) patients f o r whom i t i s f e l t - 40 -inadvisable to r e t u r n to t h e i r f a m i l i e s because of u n s a t i s f a c t o r y p h y s i c a l environment and poor family r e l a t i o n s h i p s , d) patients f o r whom i t i s thought that therapeutic value can be derived from a v i s i t p r i o r to t h e i r r eturning to homes beyong the c i t y or j u s t f o r a holiday from the h o s p i t a l , and e) patients who go to V i s t a f o r observation to a s c e r t a i n i f they can hold t h e i r 1_ improvement before proceeding with plans f o r t h e i r r e h a b i l i t a t i o n . Good accommodation i s the f i r s t e s s e n t i a l to a patient's adjust-ment i n any society; f o r the type of patients studied here, t h i s i s f r e -quently the primary problem of r e h a b i l i t a t i o n . Moreover, i t a f f e c t s employment; f o r many patients from Essondale, a Vancouver address i s of 2 utmost importance while a job i s being sought. Many employers are s t i l l very s k e p t i c a l of h i r i n g patients who can give only a mental h o s p i t a l as t h e i r place of residence. As rents are u s u a l l y payable i n advance, temporary 1 s h e l t e r i s paramount u n t i l the patient becomes f i n a n c i a l l y independent. The use of the V i s t a , then i s d i r e c t l y h e l p f u l when a patient can be employed soon a f t e r discharge. Another use of the V i s t a i s that i t provides patients with a short period of convalescence i n a large c i t y , and at the same time they are s t i l l i n a protected environment. Seven of the eighteen patients studied here used the V i s t a as a resource, before f i n d i n g accommodation and employment. This i s almost h a l f , and i t provided an e x c e l l e n t service f o r these p a t i e n t s . Three other;. _1 Information gained from B i r c h . Op. c i t . , pp« 12—14, 34, and from — consultation with the P r o v i n c i a l Mental H o s p i t a l s o c i a l workers. 2 B i r c h , I b i d . . p. 18. _. Loc. c i t . £ Loc. C i t . - 41 -patients were discharged d i r e c t l y to r u r a l B r i t i s h Columbia, p o s s i b l y f o r t h i s reason V i s t a was not used as a resource i n these instances* I t i s not known why the remaining eight d i d not use the services of t h i s h o s t e l . Most of the patients studied d i d not have established roots i n any community. This being the case, i t i s not s u r p r i s i n g that several of them changed t h e i r circumstances f a i r l y quickly a f t e r leaving the h o s p i t a l . Six patients l i v e d at t h e i r place of employment as domestic servants. This i s one-third of the e n t i r e group, and was the most frequent type of accommodation (and employment) that was found. Two of the s i x d i d not stay as domestics i n a home. One found employment as a h o t e l chambermaid, and l i v e d at the same h o t e l . Two ( i n c l u d i n g a former domestic) l i v e d i n h o t e l s , but t h i s d i d not prove too s a t i s f a c t o r y as was evidenced from t h e i r subsequent s o c i a l mal-adjustments. One changed employ-ment, and l i v e d with f r i e n d s i n a p r i v a t e house i n r u r a l B r i t i s h Columbia on a board-and-room b a s i s , and found employment as a waitress. Pour patients found accommodation i n commercial boarding houses.Only three or so l i v e d i n pr i v a t e homes. One of these was helped i n f i n d i n g accommodation i n r u r a l B r i t i s h Columbia by the Department of Indian A f f a i r s , and very b r i e f information was given to the h o s p i t a l . The second l i v e d f o r a time with a distant r e l a t i v e , but t h i s ended i n re-admission to the h o s p i t a l . The t h i r d l i v e d i n the home of her employer (but was not employed i n the home). Information i s not recorded regarding the type of s h e l t e r i n which two of the patients were l i v i n g (although the addresses were a v a i l -a b l e ) . No information at a l l i s recorded f o r s i x regarding how accommodation was found. Nine patients (one-half of the group) were instrumental i n f i n d -i n g t h e i r own accommodations, and four received d i r e c t assistance from s o c i a l workers i n f i n d i n g s h e l t e r ( i . e . , s o c i a l workers d i r e c t l y contacting l a n d l o r d s ) . Regrettably, more e f f o r t s should have been taken to interview - 42 -» the s o c i a l workers regarding how accommodation was found when the informa-was being gathered, and t h i s remains an unfortunate oversight* I t must be pointed out, however, that s o c i a l workers, when a c t i v e with a case, are always s a t i s f i e d that a patient has an abode upon l e a v i n g the h o s p i t a l ; t h i s i s h o s p i t a l p o l i c y . In a d d i t i o n , the doctor i n charge of a p a t i e n t ' s case also has the r e s p o n s i b i l i t y to see that patients have some arrange-ments made f o r s h e l t e r . For therapeutic reasons, though, patients may be permitted (and i n some cases, encouraged) to f i n d t h e i r own s h e l t e r ; t h i s , however, i s done with adequate safeguards. For example, patients may be l i v i n g at the V i s t a while looking f o r more permanent accommodation, and t h e i r a c t i v i t i e s i n t h i s respect supervised by the s o c i a l worker assigned to the p a t i e n t . Employment Upon being discharged on probation, one-third, (or s i x ) patients became employed as domestic servants i n p r i v a t e homes. Only f o u r of these s i x patients stayed with t h i s type of work, however. One of the two that changed became a h o t e l chambermaid f o r awhile, the other changed f i r s t to waitress then "orchard" work, (probably f r u i t picking) i n r u r a l B r i t i s h Columbia© Two found t h e i r immediate employment as restaurant waitresses, and a t h i r d patient a l s o had a s p e l l at t h i s type of work. Only one on l e a v i n g the h o s p i t a l was able to secure a job as s k i l l e d as a c l e r k i n an o f f i c e : Another became a s a l e s g i r l i n a store. Two were not considered employable, or at best very marginal workers and a c t u a l l y found no employ-ment. Another was considered employable at the time of l e a v i n g the h o s p i t a l , but i t was not learned whether she f i n a l l y gained employment, as she was r e f e r r e d to another agency. Others found employment which sounds casual i n - 43 -nature — as "baby - s i t t i n g " , "working i n a bowling-alley", and "photography work". Employment i s apt to be a neglected area — c e r t a i n l y judged by d e s c r i p t i o n a l inadequacies. There i s a l l too c l e a r evidence here, however, of low-grade and perhaps discouraging employment prospects. As f a r as the information goes, the comparison between the p a t i e n t s ' f i r s t job on probationary discharge from the h o s p i t a l with t h e i r occupation p r i o r to admission to the mental h o s p i t a l i s l i s t e d i n Table 7« In the greatest majority of cases, the patients e i t h e r returned to e s s e n t i a l l y the same kin d of work, or to lower grade work than before. _ 44 •* Table 7* Occupations of Women at Time of Admission and A f t e r Dischargee Patient Occupation at Time of Admission F i r s t Occupation A f t e r Discharge 1 None Not employable 2 Marginal employment Unemployed 3 Marginal employment No information 4 Domestic service Domestic service 5 Domestic service Domestic service 6 Laundress "Bowling-alley worker" 7 P r a c t i c a l nurse Domestic service 8 P r a c t i c a l nurse C l e r k - t y p i s t 9 Seamstress Domestic service '10 Factory work Unemployed 11 Food packer Baby s i t t i n g 12 Waitress Domestic service 13 Waitress Domestic service 14 S a l e s c l e r k S a l e s c l e r k 15 Nurse's aide Hotel chambermaid 16 Nurse's aide, teacher Questionable employability 17 F i l i n g c l e r k F i l i n g c l e r k 18 Commercial a r t i s t "Photography work". - 45 -In concluding t h i s s e c t i o n i t i s noted that most of these patients are employable. Eight of these patients were discharged on probation between January 1* 1958 and June 30, 1958; a time when the unemployment i n B r i t i s h Columbia was high, y e t , i n s p i t e of t h i s , most were able to f i n d some kind of employment. The f a c t must also be remembered that these are patients who have been h o s p i t a l i z e d both f o r a long time and many on a number of d i f f e r e n t occasions. Several patients were r e f e r r e d by the h o s p i t a l s o c i a l workers to the National Employment Service, but only two were able to obtain jobs through t h i s method. I t must be remembered, however, that there are a v a r i e t y of ways a patient may obtain employment. Although not stated as such i n the h o s p i t a l records, patients often use such resources as answering newspaper c l a s s i f i e d advertisements, d i r e c t l y contact prospective employers and sometimes use p r i v a t e employment agencies. I t i s al s o a well-known f a c t that many job vacancies never come to the a t t e n t i o n of the National Employ-ment Serv i c e , e s p e c i a l l y during times of widespread unemployment. Patients are often encouraged to look f o r jobs on t h e i r own, and many do j u s t t h i s while e i t h e r staying at a h o s t e l such as the V i s t a , or while l i v i n g away from the h o s p i t a l ( i n a boarding home) and r e c e i v i n g s o c i a l a s s i s t a n c e . On Other instances the h o s p i t a l s o c i a l worker may discuss the employment prospects with a p a t i e n t , and thus provide a l i t t l e v o c a t i o n a l counseling, but the patient i s then l i k e l y to be encouraged to make h i s (or her) own contacts. Income and F i n a n c i a l Resources No patient i n t h i s group had f i n a n c i a l resources of her own enough to maintain h e r s e l f without a job, or maintenance from f r i e n d s or r e l a t i v e s ; s o c i a l assistance would be her only hope. Only one patient - 46 f had a small amount of money saved, and then t h i s proved inadequate to meet her needs.~ Only three of the p a t i e n t s , while not l i v i n g with r e l a t i v e s , d i d receive some f i n a n c i a l support from them* As noted e a r l i e r , several of these patients changed t h e i r c i r -cumstances often. Some were s e l f - s u p p o r t i n g f o r a while, and some of the others who were r e f e r r e d to other a s s i s t a n c e - g i v i n g agencies were employed f o r b r i e f periods. Friends and S o c i a l Contacts The lack of information on r e c r e a t i o n a l i n t e r e s t s , f r i e n d s and s o c i a l contacts generally may be i n d i c a t i o n of the deprived l i v e s of these women, or of the l a c k i n g program i n the i n s t i t u t i o n , but i t i s c e r t a i n l y a regrettable gap i n the s o c i a l information. For f i v e of the eighteen p a t i e n t s , no information at a l l i s recorded regarding f r i e n d s and s o c i a l contacts during the probationary discharge period. The information that was obtained i n t h i s area i s impossible to c l a s s i f y . In hone of the cases studied was a formal r e f e r r a l a c t u a l l y made to a s o c i a l group work agency or other r e c r e a t i o n agency. One p a t i e n t , on her own, d i d frequent the A l c o h o l i c s Anonymous re c r e a t i o n center, but also engaged i n other forms of commercial entertainment. Others found casual acquaintances i n beer p a r l o r s . One "occasionally engaged i n sports". Several had some close f r i e n d s . Others "tended to be s e c l u s i v e " and d i d not seek f r i e n d s outside of the places they vrere l i v i n g . Several "enjoyed t e l e v i s i o n " . 1_ Obviously, a woman who i s h o s p i t a l i z e d f o r a long period of time, i s unable to earn money, except under very unusual circumstances. Most mental h o s p i t a l s , i n c l u d i n g Essondale, charge a minimum monthly fee against any f i n a n c i a l resources a patient may have. A f t e r ' a long period o f - h o s p i t a l i z a t i o n these charges have generally taken most of a patient's money. The remainder i s u s u a l l y spent by the patient f o r small luxuries such as tobacco, cosmetics, snacks, and other small items. In many instances* the s o c i a l workers counseled patients regard-i n g t h e i r s o c i a l contacts* At no time d i d the workers e i t h e r a c t i v e l y p a r t i c i p a t e with the patients i n s o c i a l s i t u a t i o n s * or make r e f e r r a l s to agencies f o r t h i s purpose* There are several reasons why t h i s i s a d i f f i c u l t s i t u a t i o n to assess. S o c i a l contacts (intimate f r i e n d s h i p s , casual acquaintances) constantly change i n q u a l i t y and content} therefore, are much more intangi b l e than concrete s i t u a t i o n s l i k e housing, employment, and finances. In casework s i t u a t i o n s , patients are seldom seen during non-working hours when they are more apt to s o c i a l i z e and engage i n r e c r e a t i o n . Perhaps a p a r t i a l remedy would be use of the " l i f e - s p a c e " 2 technique"" with patients on probationary discharge. The technique i s to be with patients during d i f f i c u l t c r i s i s s i t u a t i o n s , and to give help the moment i t becomes needed. This, however, involves knowing the patient i n more than j u s t an o f f i c e - i n t e r v i e w type s i t u a t i o n . The purposes of the l i f e -space interview being "to a i d the ego i n moments of ( l ) acute f r u s t r a t i o n , f u r y , g u i l t , or panic; (2) to throw support around thesgo when i t i s faced by sudden v i o l e n t r e t r e a t from r e l a t i o n s h i p ; and (3) to help a (person) steer h i s way s a f e l y through some complicating and confusing ' s o c i a l and 1 behavioural t r a f f i c jams' and decision-making c r i s i s . " This i s a v a l -uable technique, but would involve a s o c i a l s e r v i c e s t a f f many times l a r g e r than presently e x i s t s i n the East Lawn Unit at the P r o v i n c i a l Mental H o s p i t a l . This i s only stated as f a c t . I t i s not being advocated that workers a c t i v e l y p a r t i c i p a t e with i n d i v i d u a l patients on l e s s than a p r o f e s s i o n a l b a s i s . S o c i a l workers, l i k e other people, c e r t a i n l y need a l i f e of t h e i r own a f t e r working hours. 2 Wineman, David, "The Life-Space Interview", S o c i a l Work* Journal of the National A s s o c i a t i o n of S o c i a l Workers, v o l . 4, no. 1, January, 1959. PP* 3—13 • 3_ Ibid.« p. 13. I - 48 -S o c i a l Services Intake services such as case h i s t o r y recording and he l p i n g patients adjust within the h o s p i t a l s e t t i n g are important, but the services most relevant to t h i s present study are those r e l a t i n g to d i s -charge. S o c i a l work a c t i v i t i e s i n a mental h o s p i t a l include preparing patients f o r probationary discharge, as w e l l as p a r t i c i p a t i o n i n helping them a f t e r l e a v i n g the i n s t i t u t i o n , A v a r i e t y of services were undertaken with these eighteen patients by the East Lawn s o c i a l workers. The f i r s t step taken was an assessment and evaluation of the patient's circumstances. In some instances, reports were sought from other agencies, when the patient was not ret u r n i n g to the Greater Vancouver area. The two agencies outside of t h i s geographical region where r e f e r r a l was made were the S o c i a l Welfare Branch and the Department of Indian A f f a i r s , Counseling patients i n i n d i v i d u a l interviews regarding t h e i r plans was frequently undertaken. R e f e r r a l s , i n some cases, were made to s o c i a l assistance agencies f o r f i n a n c i a l h e l p . R e f e r r a l s , i n other cases, were made to the National Employment Serv i c e , and to the 1 P r o v i n c i a l Mental Health C entre. -Casework services were o f f e r e d i n a v a r i e t y of ways. Emotional support was a frequent o b j e c t i v e . C l a r i f i c a t i o n to the patient of her s i t u a t i o n , and helping the patient t e s t r e a l i t y were other o b j e c t i v e s , 1 The P r o v i n c i a l Mental Health Centre i s a d i v i s i o n of the Province's Mental Health Services, and i s located i n Burnaby, B r i t i s h Columbia. I t functions as an out-patient treatment c l i n i c and also as a "day h o s p i t a l " (that i s , patients come to the c l i n i c f o r a day, receive treatment, and then return to t h e i r own homes i n the evening). S h o r t l y a f t e r coming i n t o existence i t quic k l y developed a large c l i e n t e l e from people l i v i n g i n the Greater Vancouver area. With such a large demand f o r services i t i s d i f f i c u l t f o r the Mental Health Centre to operate extensively i n the follow-up and af t e r - c a r e of patients discharged from the P r o v i n c i a l Mental H o s p i t a l . I t was, however, a c t i v e l y p r o v i d i n g out-patient treatment to one patient studied i n t h i s sample. - 49 -Seeing r e l a t i v e s of patients f o r the purpose of assessing and seeking t h e i r readiness and a b i l i t y to support the patient was also undertaken by s o c i a l workers, when t h i s a c t i o n was i n d i c a t e d . In one case, the s o c i a l worker made extensive use of c o l l a t e r a l contacts; seeing former employers, i n t e r -viewing h o t e l clerks and landladies, and so on. Of the eighteen patients studied, a l l had been seen by a s o c i a l worker at one time or another during the time they were h o s p i t a l i z e d at Essondale, The majority ( f i f t e e n ) received s o c i a l work assistance i n pre-paration f o r probationary discharge. The s p e c i a l circumstances of the other three are note worthy. One was b e l i e v e d unable to make a s o c i a l adjustment away from h o s p i t a l , and services were not o f f e r e d , the patient was neverthe-l e s s released by the medical s t a f f . The second was "awaiting assignment"' to a s o c i a l worker i n preparation f o r discharge, but was released by the medical s t a f f before a worker could interview the p a t i e n t . She was returned to the h o s p i t a l a f t e r being away seven months. The t h i r d was o f f e r e d services while being on escape from the h o s p i t a l , and her status was then changed to " d i s -charge on probation". Twelve, or two-thirds, of the patients were formally r e f e r r e d to other agencies f o r help i n f a c i l i t a t i n g t h e i r discharge.plans. Two of these twelve were r e f e r r e d to more than one agency. Six patients were ref e r r e d to the National Employment Service f o r job placement (Table 8 ) , Only two of these s i x patients found employment as a r e s u l t of r e f e r r a l to t h i s agency, however. Three of the remaining four found employment through other means. Two patients were r e f e r r e d to r u r a l d i s t r i c t s of the S o c i a l Welfare Branch f o r assistance i n job placement, accommodation f i n d i n g , and r e s o l v i n g other s o c i a l d i f f i c u l t i e s . As soon as the S o c i a l Welfare Branch accepted t h e i r cases, the h o s p i t a l s o c i a l workers closed t h e i r case i n the h o s p i t a l , » 50 ~ although the patients were s t i l l c l a s s i f i e d as being discharged on pro-bation, t h i s status being e f f e c t i v e f o r s i x months. Unfortunately, no information regarding the p a t i e n t s ' adjustment was returned to the hospital; therefore, no evaluation of the p a t i e n t s ' adjustment can be made. One patient was r e f e r r e d to the Department of Indian A f f a i r s f o r placement i n r u r a l B r i t i s h Columbia. L i t t l e was known about the type of placement, and what information that was secured was made known when the patient had to be returned to the h o s p i t a l . One patient was r e f e r r e d to the Mental Health Centre f o r casework and p s y c h i a t r i c services a f t e r she l e f t the h o s p i t a l . Since the Mental Health Centre i s part of the P r o v i n c i a l Mental Health Services, t h i s r e f e r r a l amounted to an inter-departmental t r a n s f e r , and the patient's case i s s t i l l a c t i v e . Three patients were r e f e r r e d to the Vancouver C i t y S o c i a l Service Department f o r f i n a n c i a l assistance and accommodation f i n d i n g . As with the S o c i a l Welfare Branch, the h o s p i t a l s o c i a l service case was immediately closed upon the s o c i a l assistance agency's acceptance of i t , and there was l i t t l e communication between the two agencies regarding the patients a f t e r they had l e f t the h o s p i t a l . The usual procedure being to provide d e t a i l e d information to the s o c i a l assistance agencies i n the l e t t e r of r e f e r r a l . Regarding one p a t i e n t , considerable contact was maintained between the h o s p i t a l s o c i a l worker and a children's agency regarding the patient's i l l e g i t i m a t e c h i l d r e n . The p a t i e n t , i n t h i s instance, would not release her c h i l d r e n f o r adoption, and t h i s posed somewhat of a problem both from the standpoint of the c h i l d r e n and from the standpoint of the p a t i e n t . The patient could not provide a home f o r her c h i l d r e n while i n the mental h o s p i t a l , nor could she do so immediately on discharge. Her desires were often u n r e a l i s t i c regarding her c h i l d r e n from the standpoint of what she could o f f e r them. - 51 -Table 8: Referrals Made to Other Agencies to F a c i l i t a t e '  Discharge Planning Agency- Number of Referrals National Employment Service 6 S o c i a l Welfare Branch ( r u r a l ) 2 Vancouver C i t y Social Service 3 Department of Indian A f f a i r s 1 Catholic Children's A i d Society 1 Mental Health Centre 1 T o t a l H (a) (a) Two patients were r e f e r r e d to more than one agency. The fourteen r e f e r r a l s were f o r twelve of the p a t i e n t s . I t i s noticed that no r e f e r r a l s were made by the h o s p i t a l s o c i a l workers f o r these patients to be seen by group work and r e c r e a t i o n agencies. One patient, however, made her own contact with A l c o h o l i c s Anonymous, and p a r t i c i p a t e d f o r a while i n that agency's r e c r e a t i o n program. The patient that made t h i s contact was not diagnosed as an a l c o h o l i c , but e v i d e n t l y thought she had a drinking problem. The discharge s i t u a t i o n s of these eighteen patients may be summarized as follows: Less than h a l f used the services of the V i s t a i n Vancouver i n meeting t h e i r needs f o r accommodation. Becoming employed as domestic servants solved the problems of both housing and employment f o r one-third of the p a t i e n t s . One-half found t h e i r own l i v i n g accommodations l a r g e l y through t h e i r own e f f o r t s , but were e i t h e r placed i n a p o s i t i o n to - 5 2 -do t h i s f o r themselves by the s o c i a l workers assigned to them, or by providing evidence to the doctor i n charge of t h e i r case that they would have a place to stay on discharge. Most of the patients are employable, even though they have been h o s p i t a l i z e d f o r a considerable length of time, but most found employment on discharge as u n s k i l l e d , or s e m i - s k i l l e d l aborers. None of the patients had adequate finances of t h e i r own to sustain themselves without e i t h e r employment or s o c i a l assistance. Many of the patients were counseled regarding s o c i a l i z a t i o n and r e c r e a t i o n . Due to l a c k of recorded information regarding t h i s area, i t i s impossible to f u l l y evaluate the extent of t h i s counseling. There was no d i r e c t p a r t i c i p a t i o n by s o c i a l workers i n helping these patients s o c i a l i z e i n groups f o l l o w i n g discharge. Casework counseling and r e f e r r a l s to other agencies constituted the bulk of s o c i a l work a c t i v i t y , although some work with c o l l a t e r a l s was done i n i s o l a t e d instances. The counseling a c t i v i t i e s included g i v i n g the patients emotional support and encouragement, and helping them t e s t t h e i r r e a l i t y s i t u a t i o n s . Assessment of the Discharge S i t u a t i o n P u l l i n g together the threads of t h i s survey we can now say that t h i s s p e c i a l discharge s i t u a t i o n i s that of si n g l e women of l i m i t e d education and employment s k i l l s who have considerable pathology i n t h e i r s o c i a l back-grounds. A l l eighteen patients had s u f f e r e d from p s y c h i a t r i c conditions which had been thought to have reached a more or l e s s chronic s t a t e . This i s evidenced i n that most of these patients had been h o s p i t a l i z e d on at l e a s t two or more occasions and were patients i n a long-term, or continued care u n i t of the mental h o s p i t a l . The majority had previously received t r e a t -ment i n the short term units of Crease C l i n i c and Centre Lawn, before being t r a n s f e r r e d to the East Lawn B u i l d i n g . The average peri o d of h o s p i t a l i z a t i o n - 5 3 -was 2 . 5 years. Only three major p s y c h i a t r i c e n t i t i e s were represented: schizophrenia, chronic b r a i n syndrome, and sociopathic p e r s o n a l i t y d i s -turbance-anti-social r e a c t i o n . 7 2 . 2 percent were schizophrenics. A l l had shown improvement i n t h e i r mental conditions, presumably enough to warrant consideration f o r discharge. Unfortunately, the recorded material d i d not elaborate, to any great extent, on the r e s i d u a l of mental i l l n e s s these patients s t i l l had at time of discharge. Presumably, too, they also had the capacity to cope with t h e i r s o c i a l s i t u a t i o n with the assistance of s o c i a l workers when they were discharged from the h o s p i t a l . Pre-discharge planning and assessment took place between the s o c i a l workers and f i f t e e n of these patients (one was o f f e r e d services a f t e r an unauthorized leave, and two others were discharged on probation on approval of plans to the doctor; t h e i r cases not being a c t i v e with s o c i a l s e rvice at time of d i s -charge). T h e i r emotional needs were a l s o taken i n t o c a r e f u l consideration. This includes such things as f e a r of l e a v i n g the h o s p i t a l , and f e a r o f the unknown. The h o s p i t a l s o c i a l workers are e s p e c i a l l y aware of such anxieties patients may have, and often deal with t h i s by d i s c u s s i n g the r e a l i t i e s of the patient's prospective s i t u a t i o n . The e a r l y h i s t o r i e s of these patients are s i g n i f i c a n t . Some came from large poverty-stricken f a m i l i e s , others from homes that were broken through death, separation, and desertion. Yet others had been the victims of parental neglect. These factors undoubtedly had an adverse influence on the p a t i e n t s * p e r s o n a l i t y and mental i l l n e s s . I t was a l s o found that a l l eighteen had disturbed r e l a t i o n s h i p s with t h e i r parents, manifested i n such reactions as f e a r of parents, continual arguments, and so on. Por those who d i d have homes, they e i t h e r refused to r e t u r n , or such a plan was considered to be anti-therapeutic. - 54 -A l l eighteen patients had made a marginal s o c i a l adjustment p r i o r to admission to the mental h o s p i t a l . Bow much of t h i s was due to mental i l l n e s s , o r to what extent the mental i l l n e s s was due to the s o c i a l adjustment i s d i f f i c u l t to answer* One would suspect, however, that the mental i l l n e s s and s o c i a l adjustment i s c l o s e l y interwoven, and an improve-ment i n one area would note improvement i n the other as w e l l . The most s t r i k i n g area of marginal s o c i a l adjustment p r i o r to admission was i n sexual r e l a t i o n s h i p s * This was true f o r at l e a s t h a l f of the patients* This included promiscuity, unmarried motherhood, and homosexuality* Others tended to be withdrawn and had few f r i e n d s * The general conclusion that must be drawn i s that t h i s i s a group of r e l a t i v e l y unstable, u n s k i l l e d young women who are le a v i n g the mental h o s p i t a l , They are to assume the major r e s p o n s i b i l i t y f o r t h e i r actions* As the discharge s i t u a t i o n s i n d i c a t e , most are employable. The majority had no f i n a n c i a l resources on discharge. In the l i g h t of these f i n d i n g s , these women have s p e c i a l needs, only a part of which can be met i n any i n s t i t u t i o n a l s e t t i n g . Apart from the basic needs of food, s h e l t e r , and c l o t h i n g , which are apparent, they have other needs which stem from t h e i r s o c i a l background and long h i s t o r y of mental i l l n e s s . They need the s a t i s f a c t i o n s which can be obtained from performing a c t i v i t i e s (such as work) that are u s e f u l to themselves and others* They need congenial surroundings, people at home, work, and recreation i n whom they can become i n t e r e s t e d and who w i l l take an i n t e r e s t i n them. On the whole, t h i s has been l a c k i n g i n t h e i r past. Psychosis, by d e f i n i t i o n , involves a d i s t o r t i o n of r e a l i t y . Con-s i d e r i n g the long duration, and s e v e r i t y , of t h e i r psychoses, i t i s only l o g i c a l to assume that these women need s p e c i a l safeguards i n continuing - 55 -to see t h e i r l i v e s i n true perspective. They have a need to exercise e s p e c i a l l y good judgement i n personal, s o c i a l , and economic matters. This i s e s p e c i a l l y so i n l i g h t of peoples a t t i t u d e s i n the everyday world. Mental i l l n e s s i s s t i l l a stigma (despite the growth i n advanced t h i n k i n g ) , and e c c e n t r i c i t y on the part of these women could well add to t h e i r problems. On the other hand, i f t h e i r judgement remains strong, they can w e l l be the ones to prove, both to themselves and others, that mental i l l n e s s need not be a stigma. Another, s p e c i a l need some of these women encountered was that of e s t a b l i s h i n g residency i n the m u n i c i p a l i t y i n which they chose to l i v e . This was true of the women from r u r a l l o c a l i t i e s who wished to become estab-l i s h e d i n the Greater Vancouver area. In most instances, a temporary job and a place to stay would s a t i s f y the residence requirements i n those instances where s o c i a l assistance was needed, and residency could not be established. Discharge s i t u a t i o n s of pa t i e n t s : One-third of the patients solved both t h e i r employment and housing needs by accepting jobs as domestic servants immediately upon lea v i n g the h o s p i t a l . The remainder obtained s h e l t e r i n commercial boarding homes, h o t e l s , l i g h t housekeeping rooms, and a few i n private homes. The employment they obtained was mostly u n s k i l l e d or semi-s k i l l e d work. I t was noted that ( s i g n i f i c a n t l y ) one-third of the patients were re f e r r e d to the National Employment Service f o r assistance i n obtaining a job, but only two of the eighteen a c t u a l l y received t h e i r f i r s t employment on discharge from t h i s agency. Few i n d i c a t i o n s appeared here as to why t h i s s i t u a t i o n should e x i s t , but t h i s , i n i t s e l f , would i n d i c a t e a need to explore i n more d e t a i l the p r a c t i c e of r e f e r r i n g t h i s type of patient to such an agency. - 56 -What t h i s study d i d show, however, was that at l e a s t t h i r t e e n , or 72.2 percent of the p a t i e n t s , were a c t u a l l y h i r e d by employers* This i s a s i g n i f i c a n t percentage, considering the " c h r o n i c i t y " (or a l l e g e d c h r o n i c i t y ) of these p a t i e n t s , and also remembering t h e i r lack of f a m i l y resources. Although the c a t e g o r i c a l type of employment i s known, i t would be extremely h e l p f u l to have more information regarding the q u a l i t a t i v e aspects of the patient's employment; that i s , how s a t i s f a c t o r y was the job to the p a t i e n t , how w e l l d i d the patient perform her duties, what was the salary that was paid, and so on. This i s d e f i n i t e l y a gap i n recording, and not due to a lack of s e r v i c e s . S o c i a l workers at the P r o v i n c i a l Mental H o s p i t a l enable patients to use newspaper advertisements and to make a p p l i c a t i o n f o r employment. Frequently t h i s "enabling" takes the form of p r o v i d i n g transportation to prospective employers, helping patients f i n d renewed encouragement a f t e r r e j e c t i o n from a prospective employer, and so on. The matron and house-keeper at the V i s t a a l s o help encourage patients i n f i n d i n g employment, and o f f e r suggestions. The most common type of employment these women engaged i n was domestic s e r v i c e . In view o f the l a c k of s p e c i f i c information, i t i s possible to indulge i n some speculation about t h i s type of work. House-keepers are d i f f i c u l t to obtain, even during times of widespread unemploy-ment, and because of the nature of t h i s type of work, few controls are possible as to the amount of time spent on the job, the way i n which d i r e c t i o n s are given, and so on. There i s also the element of i n t e r -personal r e l a t i o n s h i p s between employer and employee which i s more important f o r t h i s type of work than f o r many other types. Another speculation i s that p o s s i b l y these patients were looking f o r a family, considering t h e i r -57-own lack of one, and the acceptance of such a job may be based on quite subtle f a c t o r s . S t i l l another speculation i s that some of the domestic servant jobs were a form of family care, although the women d i d receive wages. In f a c t , i t was learned from the s o c i a l workers at the P r o v i n c i a l Mental H o s p i t a l , that some women patients without f a m i l i e s are a c t i v e l y encouraged to take a domestic service job, so that they w i l l then be l i v i n g i n a family s i t u a t i o n ; such a job ( i f the r i g h t s i t u a t i o n i s found) i s thought t o be hig h l y therapeutic. Sometimes the s o c i a l worker must " s e l l " t h i s type of s i t u a t i o n to a pa t i e n t . Not very much information was found regarding the patients 1 s o c i a l i z a t i o n and r e c r e a t i o n a l a c t i v i t i e s . I t i s pos s i b l e to speculate that the other problems these patients possessed seemed greater than t h e i r s o c i a l and r e c r e a t i o n a l needs, a l s o , more information could be obtained easier i n the other areas. In no instance was mention made of r e f e r r a l to a s o c i a l group work agency, or to a r e c r e a t i o n agency such as a community centre. I t i s possible to speculate f u r t h e r , regarding the s o c i a l group work agencies. There are very few of them i n existence, and those that do ex i s t s e l e c t t h e i r c l i e n t e l e within very narrow, r i g i d l y defined, geographic borders. The need f o r s p e c i a l forms of r e c r e a t i o n may be a l l e v i a t e d to some extent i n the near f u t u r e . The Canadian Mental Health A s s o c i a t i o n w i l l be opening a s o c i a l centre i n Vancouver soon f o r people who have been mentally i l l . One way of determining a patient's success i n considering i^hether return to the h o s p i t a l f o r f u r t h e r treatment has been necessary. Eight, of the eighteen patients were returned f o r t h i s reason. This i s 42.2. per-cent. This i s contrasted with the r e t u r n rate of 26.3 percent of a l l - 58 -patients l e a v i n g t h i s u n i t . The p r i n c i p a l reason, that i s , return of symptoms of p s y c h i a t r i c i l l n e s s , i s not f u l l y elaborated upon' i n terms of causation. Perhaps much more information regarding p s y c h i a t r i c i l l n e s s i s needed before i t can be stated why symptoms should return i n one pat i e n t , and not i n another. The idea i s h e l d , though, that poor s o c i a l conditions are a con t r i b u t i n g f a c t o r i n the development of p s y c h i a t r i c symptoms. Experience of others has shown that wise and i n t e l l i g e n t planning by s o c i a l workers with patients can do much i n reducing the re-admission r a t e . I t was noted that i t was exceptional f o r a patient to be seen r e g u l a r l y by a s o c i a l worker from the h o s p i t a l during the f u l l s i x months of the probationary period. I t would seem that a c t i v e services were term-inated a f t e r the patient's basic needs were being met; that i s , a f t e r she was employed, was apparently s a t i s f i e d with her l i v i n g accommodations, and did not express a need to discuss emotional aspects of her s i t u a t i o n . Because change of employment, and residence was not uncommon f o r these p a t i e n t s , and also because the re-admission rate i s higher f o r the women not l i v i n g with t h e i r own f a m i l i e s than i t i s f o r the women returning to t h e i r own homes, there i s a good case f o r more intensive follow-up s e r v i c e s . Regular v i s i t s during the f u l l probationary period would undoubtedly y i e l d much q u a l i t a t i v e information that would be of value i n helping future patients who are not returning to t h e i r own home. Perhaps one reason why more follow-up of the patients i s not being done i s due to shortage of s o c i a l workers, and a large demand f o r services from patients s t i l l i n the h o s p i t a l . Shortage of pr o f e s s i o n a l s o c i a l workers i s not a problem r e l a t e d only to Essondalej i t i s a problem that faces p r a c t i c a l l y every s o c i a l agency. The p o l i c y at the P r o v i n c i a l Mental H o s p i t a l - 59 -i s to keep caseloads small enough so that a high q u a l i t y of service may be given, but as a r e s u l t of t h i s , patients often have to wait f o r the services of a s o c i a l worker unless there i s a question of urgency involved* I t i s , therefore, understandable that the c l o s i n g of a c t i v e services i s made at a time when i t i s believed the patient i s w e l l - s i t u a t e d enough to function independently. When cases are r e f e r r e d to s o c i a l assistance agencies (namely, the S o c i a l Welfare Branch, the Department of Indian A f f a i r s , and the Vancouver C i t y S o c i a l Service Department), the tendency i s f o r those agencies to take major r e s p o n s i b i l i t y f o r the patient on acceptance of the case. Such r e f e r r a l s are made by l e t t e r or conference i n advance of the patient leaving the h o s p i t a l when the s o c i a l s ervice department has been a c t i v e with the p a t i e n t . When a c t i v e services are closed by the h o s p i t a l s o c i a l workers, the option of furth e r consultative help to the ac t i v e agency i s always given i n the r e f e r r a l l e t t e r . For example, i f a case i s r e f e r r e d to the Vancouver C i t y S o c i a l Service Department, and i f the case requires the services of a h o s p i t a l worker to see the patient f o r the maximum time of s i x months (the probationary period) with the C i t y S o c i a l Service Department pro-v i d i n g f i n a n c i a l help only. Such safeguards are needed; as Emily Johnson has pointed out, the C i t y S o c i a l Service Department can not continue s e r -v i c e when patients become employed and are no longer i n need of f i n a n c i a l 1 assistance."" In counting the number of patients discharged on probation from the East Lawn Unit during the year studied ( J u l y 1, 1957 to June 3 0 , 1958) , 2 i t was found that 234 patients were so discharged. In a s p e c i a l study J_ Johnson, 0p_. c i t . t p. 69 2 The count was made through use of the ho s p i t a l ' s weekly b u l l e t i n s showing changes of census. - 60 -by the East Lawn S o c i a l Service Department i t was found that s o c i a l workers were a c t i v e with 40 percent of the patients discharged on probation from J u l y 1, 1957 to December 31, 1957» This present study shows that 88 .9 per-cent of the non-family patients that were discharged on probation were a s s i s t e d by s o c i a l workers during t h i s same period of time. This would imply that there i s more of a recognized need f o r the assistance of a s o c i a l worker f o r "homeless" women going to the outside world. I t i s s i g n i f i c a n t , too, that a i l eighteen patients studied had been seen by a s o c i a l worker at one time or another during t h e i r p e r i o d of h o s p i t a l i z a t i o n . The conclusion drawn from t h i s i s that the whole group generally have more pressing and urgent s o c i a l d i f f i c u l t i e s on discharge than the average patient population. CHAPTER 17  THE NON-FAMILY PATIENT AND HER FUTURE When t h i s study began, there was no way of t e l l i n g i n advance what the proportion of non-family patients would be i n r e l a t i o n to the t o t a l number of patients i n the u n i t being studied. I t was a s u r p r i s e there were only nineteen under the age of t h i r t y - f i v e * As expected, much time and e f f o r t were spent by s o c i a l workers with t h i s group, and t h i s 2 type of patient was most frequently r e f e r r e d to s o c i a l service*"" One d e f i n i t e conclusion that emerges i s that there i s presently a l a r g e r pro-portion of non-family patients on s o c i a l s e rvice caseloads than the pro-portion of such patients i n r e l a t i o n to the general population of the East Lawn Unit of the h o s p i t a l * Further Implications of the Findings: Three d i f f e r e n t ways, or perspec-t i v e s can be used to study these f i n d i n g s * They can be r e l a t e d t o : (a) the i n d i v i d u a l patient who does not return home; (b) the community i n which the patient i s to l i v e ; and, (c) the programs of the P r o v i n c i a l Mental Health H o s p i t a l . (a) The Patient's Standpoint: What does i t mean to leave a mental h o s p i t a l a f t e r being there f o r a long time, and when one has no home to which to go? Without money, i n most cases no personal f r i e n d s on the 'outside", these patients needed a place to stay and enough income to 1_ As stated e a r l i e r i n the text, one patient was discharged on probation f o r only one day, hence, only eighteen were studied i n d e t a i l . 2 This f a c t , undoubtedly, influenced the writer's e a r l i e r t h i n k i n g that great numbers of non-family patients existed. - 62 -eat. There was also the d i f f i c u l t y of finding new friends as people are often needlessly fearful of ex-mental patients becoming violent (employers oftentimes believe this, too). Certainly much courage i s needed to do this, and more personal decisions w i l l have to be made, such as taking responsibility for r i s i n g on time for a job, and actually competing with others who have not been distressed with mental i l l n e s s . The social workers at the hospital w i l l see to i t that the patient has transportation to where he can l i v e , at least temporarily, perhaps the Vista i n Vancouver i s a p o s s i b i l i t y . ( 3 8 . 9 percent used the Vista). A solution i n solving this problem that was used in one out of three instances was for the patient to take a job as a domestic servant i n a private home. Perhaps the newspaper want-ads were the quickest way of finding such a job, or perhaps both private and public employment agencies were used. In some instances, emotional needs of patients are met i n such a setting — e.g. need for the security of a family situation. • Much i s uncertain. Maybe the employers w i l l be dissatisfied with the patient's work and dismissal comes suddenly, and after a short period of time. A new job must quickly be found i n order to eat and have li v i n g accommodations. Possibly arrangements for emergency social assist-ance must be made in this event. The thought of having a social worker f u l l y acquainted with a l l of the details, and who can be contacted readily to help make emergency arrangements would be very comforting indeed. At best, the non-family patient has r e a l i s t i c anxieties about very basic needs that the average patient with home and family does not have. Even in the event that a boarding home or foster family i s used, with social assistance temporarily removing financial insecurity, there i s - 63 -often a concern "by the patient whether she w i l l l i k e the people with whom she i s to stay, and wonder i f f r i e n d s can be made out of such "strangers". I f previous home l i f e has been d i s t a s t e f u l , w i l l t h i s be the same? I t i s hardly a s u r p r i s e that the re-admission rate (mentioned e a r l i e r ) i s higher f o r non-family patients than f o r patients with homes. Yet, with adequate assistance and knowledge on the part of the s o c i a l worker, the re-admission rate can be kept reasonably low. (b) The Community i n which the Patient i s to L i v e : Most people have homes. But there are two kinds, (a) the "parental" home, (Home i n which you are spouse or breadwinner). Then there are (b) homes where you are welcome and homes where you are not. I f a person doesn't have one, i t i s n a t u r a l to wonder why. Unfortunately the a t t i t u d e s of employers, co-workers, and others toward the patients was not recorded to any great extent. Yet, i f such a question were asked such a p a t i e n t , i t would be d i f f i c u l t to give a t r u t h f u l answer without r e v e a l i n g circumstances about which there i s much emotion. Again, most people are not acquainted with the severe forms of mental i l l n e s s . Acquaintances, and others, are often dismayed by b i t s of unusual behaviour. This can only aggravate the s i t u a t i o n f o r the p a t i e n t . The people i n the average B r i t i s h Columbia community, however, would probably take the a t t i t u d e that mental patients not "cured" would be best o f f to remain i n the h o s p i t a l . There i s also a f e e l i n g that mental h o s p i t a l s should "look a f t e r " t h e i r people when they are "out", and the average per-son i n contact with ex-patients thinks that the h o s p i t a l should be the l o g i c a l agency to make the d e c i s i o n i f more treatment i s required. I t i s well recognized that there are varying l i m i t s as to how much mental i l l n e s s any community w i l l t o l e r a t e before a c t i o n i s taken - 64 -to remove the person. This i s c e r t a i n l y brought f o r t h i n Chapter One i n the reasons f o r e s t a b l i s h i n g mental h o s p i t a l s i n the first p lace, and at public expense. Recent thinking, however, i s that every community has 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 — and that f u r t h e r i n t e r p r e t a t i o n 1 of t h i s f a c t must be made to the general population,"" Psychotics who are not too disturbed are sometimes better o f f away from the mental h o s p i t a l , 2 given the r i g h t (or favorable) s i t u a t i o n , (c) The Programs of the P r o v i n c i a l Mental H o s p i t a l ; I t would seem that i t i s the non-family patient that puts the h o s p i t a l ' s programs to the most severe t e s t s . Because of the severe discharge problems these patients encounter, the treatment programs are put to more of a t e s t i n terms of l a s t i n g adequacy. The concern here, however, i s more with the discharge programs as such, than with the treatment programs. Many argue that no great d i s -t i n c t i o n should be made between intake programs, treatment programs, and discharge programs. In p r i n c i p l e , perhaps, t h i s i s c o r r e c t . Yet, i t seems to t h i s w r i t e r , discharging a patient from long-term treatment means that a d r a s t i c change i n environment occurs. Patient resources should be checked again at t h i s time, and implemented as necessary. Patients with f a m i l i e s often can expect t h e i r responsible r e l a t i v e s to do much o f t h i s . For example, c l o t h i n g needs, transportation needs, s h e l t e r , finances, and the l i k e are no great problem. What are considered small, but important, d e t a i l s most often do 1_ Information gained from members of the s o c i a l s e r v i c e s t a f f at the P r o v i n c i a l Mental H o s p i t a l , Essondale, B . C., on A p r i l 13 , 1959« 2 I b i d . - 65 -not get recorded. As a general rule, patients are never taken to the front door of the hospital and discharged on the spot, when l e f t entirely to their own resources. An apparel shop exists to outfit patients with suitable clothes and lack of relative responsibility to provide this i s the only criterion used i n determining a patient !s e l i g i b i l i t y for this service. The Apparel Shop i s operated by volunteers i n conjunction with the Canadian Mental Health Association's programs. Similarly, financial need i s met to a limited extent, although mental hospitals do not enjoy budgets to the extent that anything approach-ing social assistance can be offered. Based on patient need, a small cash gratuity i s given a patient when leaving the hospital. The amount i s usually five or ten dollars. The ward physician i s the person who must approve a l l gratuities, although ward nurses and social workers may recommend to the doctor that a gratuity be granted. The gratuity i s granted as a temporary measure when i t i s certain that the patient w i l l have income from either a job, or from social assistance. Information is not available to state conclusively that the eighteen patients studied here received apparel and gratuities. Because of the circumstances described, i t i s assumed that most, i f not a l l , received th i s . Thus, from the standpoint of dollars and cents, i t costs more to discharge a non-family patient, i n that many necessities have to be pro-vided, than one with a family (albeit, this i s cheaper than providing indefinite in-patient care). Social workers have access to the hospital's fleet of automobiles to transport patients to areas adjacent to the hospital, or to transportation to more distant l o c a l i t i e s . On cases where a social worker i s active, patients are taken via this means to places inhere they are to l i v e , to the - 66 -National Employment Service (after referral has heen made in advance) to look for work, and so forth. In the case of the non-family patient, i t i s again suspected that more use was made of this service, than for the average patient being discharged on probation. A detail such as trans-portation, however, is another one of the points not considered a major item for recording i n most social agencies. Because of a l l of the many reasons mentioned, a non-family patient requires much time, effort, and professional s k i l l to relocate from the mental hospital to any community. It follows, therefore, that with a limited staff and available services at a premium, plus from the humane standpoint, that every effort should be made to make the patient's rehabilitation a success. When failure occurs after the patient i s away for only a short time, and the discharge procedure i s repeated a number of times, this can be damaging. Selection of suitable patients for rehabilitation, when such choices have to be made, i s important. To spend time that results i n failure i s hardly j u s t i f i e d . Patients must be well enough to leave the hospital i n the f i r s t place. Secondly, the discharge situation, i t s e l f , must be adequate and certain enough not to produce anxieties i n a patient to the extent that this w i l l become a contributing factor i n a return of psychiatric symptoms of sufficient intensity to require re-admission. The findings show that severe mental illness existed with these patients over a long period of time, the average hospitalization being 2.5 years. The Grade Eight average educational level also suggests that these patients are only f i t t e d for the lowest and most uncertain kinds of employment. Therefore, the challenge i s great i n helping these patients find a suitable discharge situation. The question might well be raised, for example, whether this group cotild benefit from programs such as - 67 -vocational r e - t r a i n i n g , or whether more emphasis should be placed on care-f u l l y selected forms of employment where the p o s s i b i l i t y of termination of employment wouldn't pose such a d i r e threat to the t o t a l well-being of the p a t i e n t . The f i n d i n g s also r e f l e c t that follow-up could be more care-f u l l y undertaken with.these p a t i e n t s . There are d e f i n i t e gaps i n the recorded material where gaps should not occur. More should be known about the conditions under which these patients are l i v i n g . Seldom di d an evaluation of t h i s appear. For patients returning to r u r a l B r i t i s h Columbia, quite another s i t u a t i o n occurs. Often other agencies are involved such as the S o c i a l Welfare Branch and the Department of Indian A f f a i r s . Information was not always made known to the h o s p i t a l regarding what help was given during the probationary period, nor i f the r e f e r r a l was i n the best i n t e r e s t or not. Better communication between such community agencies and the h o s p i t a l i s in d i c a t e d . The re-admission r a t e of the non-family patient being as high as 42.2 percent, while a l l other patients being re-admitted i n the same u n i t i s at 26.3 percent, suggests that even stronger e f f o r t s be used i n h e l p i n g the homeless p a t i e n t . I t would be i n t e r e s t i n g to note, i f another study were done using experimental and c o n t r o l groups, i f the re-admission rate of such patients could be reduced through more follow-up s e r v i c e s . P r o f e s s i o n a l and Community Contributions At t h i s point consideration should be given to some prevalent ideas about state-supported mental h o s p i t a l s , and the implications f o r the discharged p a t i e n t . One view put f o r t h by Dr. Ivan Belknap, and gaining much support, - 68 -questions the whole concept of (retaining) the large, centralized hospitals (of which the Provincial Mental Hospital at Essondale, B.C. is an example.) Br. Belknap has said: "One of the curious things in the history of attempts to improve the numerous abuses in • . . (state hospitals) has been the failure of reformers to ask whether a. large-scale, centralized, and partly self-sufficient institution is in fact able to function effectively in the treatment of the mentally i l l . These features of the hospital were perhaps once conducive to a short-run economy in the care of paupers, but what relation do they have to modern concepts in the treatment of the mentally ill?"_L Dr. Belknap and others are, in other words, favoring the abolition of the large, centralized, mental hospitals. In the place of such hospitals, i t is advocated that small, local, treatment centres be established, much on the same principle as are secondary (high) schools. The argument frequently put forth by advocates of this plan, is that by so doing, the patient in smaller centres may be kept closer to the family unit. It would seem that the implication of this idea for many of the non-family patients studied here would have both negatives and positives. The negatives, obviously, would be around the fact that patients would then be close to an unwanted family situation; one that is unhealthy and unmodifiable. Another negative is that many ideas such as sheltered workshops, are not practicable unless sufficient numbers of patients can be involved. This is a small problem in large, urban areas such as the Greater Vancouver area, but may be a sizable problem in rural British Columbia. The positive aspect of this idea would be that the non-family 1_ Belknap, Ivan, Human Problems of a State Mental Hospital, McGraw-Hill Book Company, Ine, New York, 1956. P. 2 0 5 , - 69 -patient, because, of the lack of having ties with people away from the hospital, could develop such ties easier i n a smaller, less centralised setting. An idea, once prevalent, was the desirability of placing psychiatric workers in community social agencies• Community, i n this sense, referring to various geographic l o c a l i t i e s , regions, or d i s t r i c t s . This i s not the issue i t once was, considering that modern psychological principles are now part of standard training for social workers, teachers, nurses, and physicians. Yet, something s t i l l can be said for the idea of making administrative changes within the hospital administrative structure for changing the present ward-centred type of assignment of patients to professional staff i n the large mental hospital that would serve people from the various geographic regions, Por example, certain psychiatrists and social workers would work only with patients from, say, region one, rather than with caseloads where a l l geographic regions are represented. Ideally, the staff would extend themselves into the regions they serve on regular v i s i t s , and become thoroughly acquainted with their regions. The non-family patient, then, would be assigned immediately, on entering the hospital, to staff representing the region where future l i v i n g accommodations may be sought. Using this idea, public health departments and social agencies also could become more acquainted with the hospital, and on various v i s i t s to the institutional setting, could become well-acquainted with the patients long before the time of discharge occurs. This would help eliminate the evils i n referring patients to complete strangers, i n strange regions, 1_ This is s t i l l valid thinking with respect to d i s t r i c t offices where heavy, generalized caseloads prevail. S t i l l another idea would he to establish specialized departments that care only for discharged mental patients. An example of this plan i s presently i n effect i n the State of California. In 1938, "after-care" services were organized i n the California Bureau of Extramural Care by 1 the State Department of Mental Hygiene.— In 1950, this department employed about 100 social workers, and workers in this department main-tained liaison between the patient and the psychiatric and social work staffs of the mental hospital where the individual had received i n -2 patient treatment. Within such a system as thi3, no patient could become "lost" after leaving' the mental hospital. The disadvantage of this idea, however, l i e s i n the fact that yet another state agency i3 established, and the patient may have just one more additional organization to deal with, plus the others he may have, i n order to obtain needed services. The same advantages and objections as the foregoing plan would exist were a private agency, or foundation, established to provide ser-vices to discharged mental patients. Rehabilitation and Research The problem of having long-term patients without a home in which to return i s certainly not a phenomenon peculiar to British Columbia. This writer has experienced the same problem elsewhere. Every large state and provincial mental hospital probably has i t s share of such patients. Unfortunately, there does not seem to be studies comparable to this one; therefore, i t i s d i f f i c u l t to compare the findings presented here with similar situations elsewhere. 1_ Berkman, 0p_. c i t . . p» 46. 2 Loc. C i t . . ' - 71 -The g e n e r a l t o p i c o f r e h a b i l i t a t i n g the m e n t a l l y i l l has r e c e i v e d a great d e a l o f a t t e n t i o n i n r e c e n t t i m e s , however* I t i s not a new p r o b l e m , as mentioned i n Chapter One, f o r the r a t i o n a l e f o r b r i n g -i n g i n s o c i a l workers t o s t a t e h o s p i t a l s as e a r l y as 1905 was to h e l p w i t h " a f t e r - c a r e " * That i s t o s a y , the d i s c h a r g e s i t u a t i o n s o f p a t i e n t s always has been regarded as i m p o r t a n t , a l t h o u g h f o r v a r i o u s reasons s e r v i c e s se ldomly have been adequate t o meet the d i s c h a r g e need o f p a t i e n t s * The S t a t e of Oregon i s p r e s e n t l y engaged i n r e s e a r c h f o r the purpose o f d e v e l o p i n g a c o o r d i n a t e d program f o r r e h a b i l i t a t i n g m e n t a l p a t i e n t s . "The Oregon Study o f R e h a b i l i t a t i o n o f M e n t a l H o s p i t a l P a t i e n t s " , has i t s headquarters i n Sa lem, Oregon, and i s under the d i r e c t o r -s h i p o f D r . John James, The p r o j e c t , "encompasses a c o o r d i n a t e d e f f o r t between community and h o s p i t a l i n the r e h a b i l i t a t i o n o f a wide v a r i e t y o f p a t i e n t s . . . The D i v i s i o n o f V o c a t i o n a l R e h a b i l i t a t i o n , P u b l i c W e l f a r e , P u b l i c H e a l t h , and the S t a t e H o s p i t a l a r e the c o o p e r a t i n g s e r v i c e a g e n c i e s . " ! T h i s r e s e a r c h i s p r e s e n t l y i n p r o g r e s s , the t e s t p e r i o d b e i n g from S e p t -ember 1, 1957, through August 51» 19&0. The a n a l y s i s and p r e p a r a t i o n o f r e p o r t s w i l l be made d u r i n g the s i x - m o n t h s ' p e r i o d o f September 1, 1960 , 2 through F e b r u a r y , 1 9 6 1 . " I t i s hoped t h i s r e s e a r c h w i l l uncover f u r t h e r i m p l i c a t i o n s f o r the n o n - f a m i l y p a t i e n t s , as w e l l as f o r a l l c l a s s e s o f p a t i e n t s . The S t a t e o f M i n n e s o t a i s a l s o c o n d u c t i n g an e x t e n s i v e r e s e a r c h program i n the f o l l o w - u p o f mental p a t i e n t s . The name o f t h i s p r o j e c t i s : "Minnesota F o l l o w - u p Study" and i s under the d i r e c t o r s h i p o f D r . Joseph C. 1_ I n f o r m a t i o n o b t a i n e d from p e r s o n a l correspondence w i t h members o f the Oregon Study o f R e h a b i l i t a t i o n o f M e n t a l H o s p i t a l p a t i e n t s (September 24 , 1958) . 2 L o c . C i t . - 72 -Lagey, Work has been j u s t r e c e n t l y s t a r t e d on the p r o j e c t , and the plans axe to study a l l patients f o r f i v e years a f t e r the patients leave 1 Moose Lake State H o s p i t a l , - There i s no information presently a v a i l a b l e regarding t h e i r f i n d i n g s , but again, when the r e s u l t s are made a v a i l a b l e , there probably w i l l be implications regarding non-family patients,, I t • i s i n t e r e s t i n g to note that one of the hypotheses made by the people engaged i n the Minnesota study i s that "a better and more enduring post-h o s p i t a l adjustment w i l l be possible f o r a patient who returns to h i s own 2 home and i s genuinely needed i n the home" -Limitations of the Present Study - Further Studies Weeded The primary intent of t h i s study has been to survey the needs of long-term female mental patients who e i t h e r d i d not have a home, or could not return to a home, upon l e a v i n g a mental h o s p i t a l . Within the time a l l o t t e d f o r t h i s study, i t i s now apparent that many gaps i n information appear. Many of these gaps i n information could be closed, but not without time-consuming e f f o r t . A look backward over the pages makes i t c l e a r that these patients have indeed a d i f f i c u l t s i t u a t i o n i n l i f e . For various reasons they have been, over a period of years, i n and out of the mental h o s p i t a l on a number of occasions. This survey has t r i e d to see these patients as persons who, oh being judged well enough to leave the mental h o s p i t a l by the s t a f f p s y c h i a t r i s t s , have become established elsewhere. S t a t i s t i c a l information regarding the patients was r e a d i l y a v a i l a b l e i n the h o s p i t a l f i l e s , as was * » 1_ Informa-tion obtained from personal correspondence with members of the Minnesota Follow-up Study (September 26, 1958)• 2 Loc. C i t . - 73 -also background information. This included such information as birthdates, marital status, nativity, social and medical history, and so on. After the patients l e f t the hospital, the recorded material was scarce i n disclosing how these patients became established, and what methods were used. One of the gaps not mentioned, for example, was answers to the question of how many employers a patient interviewed before obtaining a job, and what effect refusal of a job had on such a patient. Undoubtedly, much more of this information could have been obtained by questioning the social workers more carefully about thi s , and also by requesting additional follow-up reports i n instances where referrals had been made, especially the referrals to agencies located away from the Greater Vancouver area. This also suggests that a more careful job could have been undertaken in drafting the schedule that was used i n obtaining information (Appendix A). Even with this, perhaps, the actual interviewing of patients would have yielded even more accurate information regarding their circumstances. The size of the sample group is an obvious limitation. Prom only eighteen cases, the conclusions that can be drawn must necessarily be guarded. Were the study extended over a five-year period, rather than a one-year period, more cases would be obtained, and, therefore, a more comprehensive picture would emerge. It was mentioned earlier that there was no way of knowing i n advance how many such patients existed, therefore, limitations as to age and time were set that now, i t i s seen, were unnecessary. As a suggestion, should the circumstances of the non-family patient be studied again, the limitations of age and time should be less r i g i d l y applied,. - 74 -The Future of the Non-Family Patient The findings r e f l e c t that s i x out of ten non-family patients w i l l remain out of the mental h o s p i t a l , and w i l l take some part i n the d a i l y a f f a i r s of the B r i t i s h Columbia population. More than l i k e l y , most of these patients w i l l remain as s i n g l e people. The question could w e l l be r a i s e d regarding how many of them could function otherwise; that i s , how many could s a t i s f a c t o r i l y perform the r o l e s of mothers and wives? I t was learned, nevertheless, that one p a t i e n t , a f t e r being away from the h o s p i t a l f o r the f u l l six-month probationary discharge period, was engaged to be married. Perhaps, too, the r e s p o n s i b i l i t i e s these patients must assume f o r themselves, has therapeutic aspects f o r those who can meet t h i s challenge s u c c e s s f u l l y . Considering the s t r e s s f u l s o c i a l backgrounds, and the long backgrounds of mental i l l n e s s , success i s c e r t a i n l y a great achievement• The r o l e of the s o c i a l worker i s also exacting i n h e l p i n g these people with such d i f f i c u l t circumstances achieve the independence and s e l f -s u f f i c i e n c y they say they so greatly d e s i r e . As has been seen, a great many s o c i a l resources are often needed f o r these p a t i e n t s , and these resources must be used i n the best possible way to help the p a t i e n t . Many measures are presently being taken to strengthen the programs r e l a t i n g to the mentally i l l . The concept of v o c a t i o n a l r e h a b i l i t a t i o n i s one such measure that i s becoming i n c r e a s i n g l y important. In the United States, vocational r e h a b i l i t a t i o n programs f o r the mentally i l l are now l a r g e l y financed by the Federal Government. The P r o v i n c i a l Mental Hospital has had a " r e h a b i l i t a t i o n o f f i c e r " assigned to i t s s t a f f , and i t could well be that much more w i l l be done t o prepare patients - 75 -v o c a t i o n a l l y through t r a i n i n g programs both while they are i n the h o s p i t a l , and a f t e r they are discharged. The use of domestic service jobs to provide patients with some measure of family care may we l l be the forerunner of a comprehensive family care program. Such a program i s c e r t a i n l y needed, and e s p e c i a l l y f o r many of the type of patients as the women who were studied here. The Canadian Mental Health A s s o c i a t i o n i s a l s o engaged i n developing programs f o r the ex-mental p a t i e n t . This organization has operated i n B r i t i s h Columbia since June, 1953>"White Cross Open Door Service", which i s an information centre on mental health topics and 1 personal problems i n the area of emotional disturbance. The service i s free of charge and persons consulting t h i s agency are re f e r r e d to the proper f a c i l i t i e s , with assistance offered to put such persons i n touch with that f a c i l i t y . In a d d i t i o n to the o f f i c e i n Vancouver, other B r i t i s h Columbia branches are located i n V i c t o r i a , Nanaimo, and T r a i l . Another three branches are expected to be i n operation within the coming year. The s o c i a l club soon to be opened f o r ex-mental patients (mentioned e a r l i e r ) i s part of a p i l o t project to o f f e r d i r e c t services to these people. The majority of people interviewed i n conjunction with t h i s study expressed a need f o r such a f a c i l i t y . As a f i n a l word, new methods i n psychiatry, and psycho-pharmacological therapy i n p a r t i c u l a r , have opened the doors of the mental h o s p i t a l much wider f o r the long-term p a t i e n t s . In the changing world of today, i t i s now more important than ever to maintain the human element i n a s s i s t i n g patients. S o c i a l workers, therefore, can and are doing much 1. Information gained through personal correspondence with the Canadian Mental Health As s o c i a t i o n , B r i t i s h Columbia D i v i s i o n . - 76 -t o h e l p t h e f o r m e r l o n g - t e r m p a t i e n t * A s more becomes known r e g a r d i n g t h e s e p a t i e n t s , a n d a s more t e c h n i q u e s a r e d e v i s e d t o a s s i s t t h e m , t h e b e t t e r a n d more u s e f u l c i t i z e n s t h e s e p e o p l e w i l l b e c o m e . T h i s s u r v e y r e g a r d i n g t h e c i r c u m s t a n c e s o f t h e l o n g - t e r m n o n - f a m i l y p a t i e n t , t h e n , i s a n o t h e r e f f o r t i n t h e d i r e c t i o n o f a d d i n g t o t h e k n o w l e d g e t h a t i s s o d e s p e r a t e l y n e e d e d . - 77 -APPENDIX A SCHEDULE 1. Name ( F i l e number) 2. Age 2a. F l a c e of b i r t h 3 . M t x r i t a l S t a t u s 4. E d u c a t i o n 5. O c c u p a t i o n 6 . D i a g n o s i s (Medical and S o c i a l ) 7. Length of H o s p i t a l i z a t i o n DISCHARGE SITUATION A . Discharged t o whom? ( o . g . , S e l f , F r i e n d , To a community r e s o u r c e ( n u r s i n g home, e t c . ) . t o an employer , e t c . ) B . H o u s i n g Type of accommodation ( a l s o l o c a t i o n , and how f i n a n c e d ) . 1. B o a r d i n g house 2. Apartment (By s e l f , s h a r i n g , e t c . ) 3 . H o t e l 4. P r i v a t e house (own, r e n t i n g , anyone e l s e i n home?) 5. Other 6 . Was S o c i a l S e r v i c e i n s t r u m e n t a l i n f i n d i n g accommodation? 7. Comments C. Employment 1. Type 2. P r e v i o u s job or new? 3 . Unemployed? ( I s p a t i e n t employable?) 4. Was S o c i a l S e r v i c e i n s t r u m e n t a l i n h e l p i n g p a t i e n t f i n d employment D. Reason f o r not l i v i n g w i t h r e l a t i v e s . Schedule — page 2 E. Success of Probationary Discharge S i t u a t i o n 1. Is patient s t i l l out of the Hospital? 2. Reason f o r r e t u r n 3. How many times has retur- been necessary i n the past F. S o c i a l i z a t i o n 1. Nature and type of f r i e n d s 2. Nature and type of r e c r e a t i o n 3. Comments — Degree of s o c i a l work p a r t i c i p a t i o n i n helping patient s o c i a l i z e G. F i n a n c i a l S i t u a t i o n 1. Ou s o c i a l assistance 2. Self-supporting 3. Has adequate finances without work 4. Other H. Summary of S o c i a l Services Administered and comment about b e n e f i t s derived therefrom. I - 79 -APPENDIX B. BIBLIOGRAPHY A Statement of Standards to be Met by Medical and P s y c h i a t r i c S o c i a l  Service Departments i n Ho s p i t a l s ! C l i n i c s and Sanatoria. Canadian As s o c i a t i o n of S o c i a l Workers, Ottawa, 1952. Ackerman, Nathan W., The Psychodynamics of Family L i f e . Basic Books., Inc., New York, 1958. A r i e t i , Silvano, I n t e r p r e t a t i o n of Schizophrenia. Robert Brunner, Inc., New York, 1955. Bellak, Leopold, Schizophrenia: A Review of the Syndrome, Logos Press, New York, 1958. Belknap, Ivan, Human Problems of a State Mental H o s p i t a l , McGraw-Hill Book Company, Inc., New York, 1956, Berkman, Tessie D., P r a c t i c e of S o c i a l Workers i n P s y c h i a t r i c Hospitals  and C l i n i c s , American Asso c i a t i o n of P s y c h i a t r i c S o c i a l Workers, Inc., New York, 1953. B i r c h , Sophie, An A i d i n the R e h a b i l i t a t i o n of Mental H o s p i t a l 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, Vancouver, B. C , 1953* B l e u l e r , Eugen, Dementia Praecox or the Group of Schizophrenias. ( T r a n s l a t i o n ) , I nternational U n i v e r s i t i e s Press, New York, 1950, Clark, Richard James, Care of the Mentally 111 i n B r i t i s h Columbia, 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, Vancouver, B. C , 1947-Corbett, Da,vid C., Canadian Immigration P o l i c y . U n i v e r s i t y of Toronto Press, Toronto, 1957. Deutsch, A l b e r t , The Mentally 111 i n America: A Hist o r y of T h e i r Care and  Treatment from C o l o n i a l Times, Doubleday, Doran & Company, Inc., Garden C i t y , New York, 1937« French, Lois Meredith, P s y c h i a t r i c S o c i a l Work. The Commonwealth Fund, New York, 1940. G i l b e r t , J . E., "The Mental Health S i t u a t i o n i n Canada Today", The Medical  Services Journal, (Canada), Volume XXV, Number 7» July-August, 1958. - 80 -Gordon, Henrietta L., Casework Services f o r Children: P r i n c i p l e s and  P r a c t i c e s , Houghton M i f f l i n Company, Boston, 1956. Hamilton, Gordon, Theory and Pra c t i c e of S o c i a l Case Work, Second E d i t i o n , Revised, Columbia U n i v e r s i t y Press, New York, 1954. Henderson, S i r David, and G i l l e s p i e , R.D,, A Text-Book of Psychiatry, Seventh E d i t i o n , Oxford Uni v e r s i t y Press, London, 1951* Johnson, Emily A l i c e , The S o c i a l Problems of Discharged Mental Patients  Referred to a P u b l i c Assistance Agency i n 1954. 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, Vancouver, B. C,, 1956, Mayer-Gross, W,, S l a t e r , E l i o t , and Roth, Martin, C l i n i c a l Psychiatry, C a s s e l l and. Company, Ltd., London, 1954* McAuley, W.F., The Concept of Schizophrenia, P h i l o s o p h i c a l L i b r a r y , New York, 1954, Noyes, Arthur P,, and Kolb, Lawrence C,, Modern C l i n i c a l Psychiatry, F i f t h E d i t i o n , W.B. Saunders Company, Ph i l a d e l p h i a , 1958, Province of B r i t i s h Columbia, Department of P r o v i n c i a l Secretary, Mental Health Services Annual Report, 1957, Queen's P r i n t e r , V i c t o r i a , B. C« Richmond, Mary E l l e n , S o c i a l Diagnosis, Russell Sage Foundation, New York, 1917. Shakow, David, The Nature of De t e r i o r a t i o n i n Schizophrenic Conditions, Coolidge Foundation, New York, 1946. Sutherland, Robert Murray, The R e h a b i l i t a t i o n o f 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, Vancouver, B. C., 1954* Standards f o r the Pr o f e s s i o n a l P r a c t i c e of S o c i a l Work. American A s s o c i a t i o n of S o c i a l Workers, New York, 1951. Wilensky, Harold L,, and Lebeauz, Charles N,, I n d u s t r i a l Society and  S o c i a l Welfare, Russell Sage Foundation, New York, 1958. . 

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